H. Yarkan

Ankylosing Spondylitis: HLA-B*27-Positive Versus HLA-B*27-Negative Disease

Purpose of ReviewWe review our current knowledge about the clinical features of patients with ankylosing spondylitis (AS) who possess HLA-B*27 versus those who lack this gene.Recent FindingsERAP1 association is present only in HLA-B*27+ patients, but other genetic associations are similar between the two groups. A genetic study supports the existence of an HLA-B27-independent common link between gut inflammation and AS. It is unusual to observe familial occurrence of primary AS among families of northern European extraction that show no segregation of HLA-B*27, psoriasis, or IBD.SummaryAlthough there are many similarities among AS patients possessing HLA-B*27 versus those lacking this gene, the former group has a younger age of onset, a shorter delay in diagnosis, a better clinical response to tumor necrosis factor inhibitors, a greater familial occurrence, a greater risk for occurrence of acute anterior uveitis, and a lower risk for occurrence of psoriasis and IBD. ERAP1 association is present only in HLA-B*27+ patients, but other genetic associations are similar between the two groups. It is unusual to observe occurrence of primary AS among families of northern European extraction that show no segregation of HLA-B*27, IBD, or psoriasis. A recent genetic study supports the existence of an HLA-B*27-independent common link between gut inflammation and AS.

Phenotype Differences in HLA-B27 Positive Versus Negative Patients with Ankylosing Spondylitis in a Population That Show Relatively Weaker Association with HLA-B27

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THU0314 Radiologic activity is the major determinant for physicians while deciding active disease in takayasu arteritis

Background There are no valid follow-up parameters in the assessment of disease activity in Takayasu arteritis (TA). Objectives We investigated the impact of incorporation of vascular imaging into ITAS in the assessment of disease activity in TA. Methods 52 patients who fulfilled the ACR criteria were included in the study. PGA, Kerr et al.s criteria and ITAS2010/ITAS-A scores were evaluated in all patients in serial visits. All the patients were followed using 3–6 monthly B-mode/Doppler ultrasonography (USG) and 6–12 monthly magnetic resonance angiography (MRA). Radiological activity (Rad) was defined based on the presence of any of the 3 parameters including new vessel involvement by any technique (5 points),increase in vessel wall thickness on USG (3 points) and vessel wall edema on MRA (3 points).Then we incorporated these scores with ITAS-A to obtain a composite disease activity index (ITAS2010-A-Rad) (Table 1). Active disease was defined as ITAS-A-Rad >4 points. Results Total 410 visits of 52 TA patients (mean age 50.7 yrs, F: 92.3%, mean follow-up duration:6.4±2.9 yrs) were evaluated. Radiological assessment was done in 359 visits (by USG in 271 and by MRA in 190). Patients were categorized as having active disease in 194 visits (47.4%) according to PGA and 72 visits (17.5%) according to Kerr et al. criteria.The agreement between them was fair (66%, κ: 0.29). Radiological activity was determined in 105 out of 359 visits (29.2%). The total agreement between radiological activity and Kerr at al. criteria was 83% (κ: 0.58). It was found to be 76% (κ: 0.52) between radiological activity and PGA. Mean ITAS-A-Rad scores were found to be significantly higher in visits with active disease compared to visits with inactive disease according to both PGA and Kerr et al. criteria (Table 2). The ITAS-A-Rad was significantly correlated with all the other activity parameters including ITAS2010, ITAS-A, and APRs. There were 43 visits with new vessel involvement by any radiologic technique; all visits included patients with active disease based on both PGA and Kerr et al. criteria. Whereas in 50% of these visits, patients had normal CRP, and %49 had normal ESR. The agreement between ITAS2010 and PGA was fair (69%, κ: 0.38).When APR was added (ITAS-A), it did not improve (68%, κ: 0.34). But the agreement between ITAS-A-Rad and PGA (72%, κ: 0.50) and also Kerr et al. criteria (82%, κ: 0.56)was found to be moderate. Interestingly, when only USG (ITAS-A-USG) or only MRA (ITAS-A-MRA) was used, the agreement with PGA was remained unchanged (73%, κ: 0.45 and 76%, κ: 0.52, respectively). When responsiveness to change of ITAS-A-Rad score was evaluated by serial visits of patients, it was found that the mean value of the score was discriminative for activity according to PGA in 9 of 11 visits (Figure 1).Table 1. The definition of ITAS-A-Rad Score Clinical ITAS2010 0– Laboratory APR ESR 0 for ESR<20 1 for 21–39 2 for 40–59 3 for >60 mm/h 0–3 CRP 0 for CRP≤5 1 for 6–10 2 for 11–20 3 for >20mg/l Radiology Radiological activity New vessel involvement with any radiological method 5 B-mode Doppler USG Progression on vessel wall thickness 3 MRA Presence of vessel wall edema 3 Total ITAS-A-RAD Score ITAS-A-Rad Score >4 –> Activity. Conclusions The results of this study suggest that ITAS-A-Rad may be used to be a valuable foIlow-up parameter in the assessment of disease activity. Disclosure of Interest None declared

AB1120 Comparison of Long-Term Drug Survival of Tumor Necrosis Factor Inhibitors in Patients with Rheumatoid Arthritis, Ankylosing Spondylitis and Psoriatic Arthritis: A Single Center Turkish Experience Over a Decade

Background The studies from different national biologics registries provide data on long term efficacy and safety of tumor necrosis factor inhibitors inhibitors (TNFi) for the treatment of rheumatic diseases in diverse patient populations. The data in this regard is lacking in Turkish population. Objectives To assess and compare the long term drug survival rates of TNFi in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic Arthritis (PsA) and to identify potential reasons for treatment discontinuation. Methods The analysis included all the patients treated with TNFi at our center since 2004. Persistence on anti-TNF in patients who were lost to follow-up were analyzed using the national prescription database. Patients with no prescription over the last 6 months were considered to have discontinued the treatment. The date of the last prescription was accepted as the date of discontinuation. These patients were tried to be contacted by phone to identify the reason for discontinuation. Kaplan-Meier plots and log rank tests were used to assess drug survival. Results Of the 351 patients in the study 222 had AS (26.1% females, mean age: 44.3±11.7 years, mean disease duration: 20±9.9 years, HLA-B27:(+): 71.1%), 96 had RA (78.2% females, mean age: 53±13.9 years, mean disease duration: 15.1±7.7 years, RF (+): 59.1%, anti-CCP (+): 67.9%) and 32 had PsA (62.2% females, mean age: 47±14.2, mean disease duration: 12.2±8.7). Etanercept (ETA) was started in 123 (35.1%) patients, infliximab in 116 (33.1%), adalimumab (ADA) in 98 (28%) and golimumab (GOL) in 13 (%3,7). Over an observational period of up to 10 years, biologic treatment was discontinued in 198 (56.4%) patients, of whom 137 (69%) were switched to another TNFi. Drug survival rate for all of the three anti-TNF-α agents is 48.6% for AS, 37.5% for RA, and 40.6% for PsA. Median drug survival time in AS was 67.4 (95% CI, 58.5-76.3) and seemed to be longer than in RA (51.6 months, 95%CI 37.8-65.4) and PsA (45.5 months, 95% CI 30.0-61.0). No difference was observed between different TNFi within the same disease category. In patients with RA, female patiens had a longer drug survival than male patients. The reasons for discontinuation were inefficacy in 86 patients (44.3%), adverse events in 45 (23.2%) (tuberculosis in 2 patients, malignancy in 4 patients), remission in 10 (5.2%) and other or unclear reasons in 55 (29.3%). During the observational period four patients died, one due to lymphoma which developed during anti-TNF therapy, one due to metastatic germ cell tumor which developed one year after the cessation of antiTNF therapy, two due to possibly not related to the anti-TNF therapy. Conclusions Our single center study indicate generally similar long term drug survival rates for TNFi within a disease category. The trend for a better long term drug survival in this study is in line with some previously published. Disclosure of Interest G. Can: None declared, S. Capar: None declared, P. Cetin: None declared, D. Solmaz: None declared, G. Kenar: None declared, H. Yarkan: None declared, S. Akar: None declared, M. Birlik: None declared, I. Sari: None declared, F. Onen: None declared, N. Akkoc Grant/research support from: Pfizer UCB, Consultant for: Pfizer UCB Abbvie MSD BMS, Speakers bureau: Pfizer UCB Abbvie MSD

FRI0229 Evaluation of Patient Acceptable Symptom State in Patients with Axial Spondylarthritis; Similar Thresholds for Radiographic and Non-Radiographic Subgroups

Background The Patient Acceptable Symptom State (PASS), a single-question outcome, has been defined as an absolute level of patient well-being. A few studies have assessed PASS in patients with ankylosing spondylitis (AS), but it is not known whether the results of those studies apply also to the group of non-radiographic (nr) axial spondylarthritis (axSpA) Objectives To estimate the PASS values for disease activity and several patient reported outcomes both in the whole group of axSpA and in the two subgroups of AxSpA. Methods This single-center cross-sectional analysis included patients fulfilling the ASAS criteria for axSpA, who have been registered in our local database. All patients responded to the global yes/no question for PASS. A variety of other outcome measures in regard with global scales, disease activity, functional status, health status and quality of life were collected at the same time. The thresholds at which patients rated themselves in PASS for disease activity (BASDAI and ASDAS) and for each of the assessed patient self-reported outcome measures were estimated using the 75th centile (25th centile for SF 36)estimation and receiver operating characteristic (ROC) analyses in the whole group, as well as in each subgroup of axSpA. Contributors which can affect PASS were evaluated with logistic regression analysis. Results The analysis was based on 356 axSpA patients (261 AS, 95 nr-axSpA) with a mean age of 42.2±12.0 years and mean disease duration of 14.7±10.8 years. Of the patients with axSpA, 271 (%76.1) considered themselves in PASS (76.6% in AS, 74.7% in nr-axSpA). PASS thresholds for disease activity and all other assessed outcome measures were shown in table and there were not significant difference between AS and nr-axSpA group. PASS cut-off points for BASDAI, BASFI and HAQ identified by the 75th percentile method were slightly higher than those determined by the ROC analysis, but similar for the rest of the outcome measures. The patients with an acceptable status had significantly lower mean disease activity scores and good results with the all outcome measures. PASS had no relationship with age, sex, disease duration and education (years) in logistic regression analysis. Of the axSpA patients with BASDAI (≥4), 61.4% and those with ASDAS (>3.5), 50% rated themselves in PASS, whereas 5.5% of the patients with a BASDAI score <2, and 4.5% of those with ASDAS <1.2 were not in PASS. Conclusions PASS thresholds for disease activity and outcome measures were similar to the figures previously reported in some studies with no apparent difference between patients with AS and nr-axSpA. However, more than half the Turkish axSpA patients considered themselves in PASS, which needs to be evaluated in further studies. Disclosure of Interest None declared

AB0804 Increased Carotid Intima-Media Thickness in Psoriatic Arthritis Patients Compared with Systemic Lupus Erythematosus Patients and Healthy Controls: Table 1.

Background Patients with psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE) are at increased risk of atherosclerosis. An increased carotid intima-media thickness (IMT) is considered to be a marker of early atherosclerosis. Objectives The aim of this study was to investigate carotid IMT in patients with PsA and compare it with those in patients with SLE and healthy controls. Methods Non-diabetic patients with PsA and age and body mass index (BMI) matched, non-diabetic patients with SLE, and healthy controls were included in this study. Bilateral carotid IMTs were evaluated by using B-mode ultrasonography in PsA patients and compared with those in SLE patients and healthy controls. Results There were 42 PsA patients (30 female, 12 male; mean age: 45.36±8.9 years) who fulfilled CASPAR criteria and 38 patients (37 female, 1 male; 41.2±13.0 years) who fulfilled the 1982 revised American College of Rheumatology (ACR) criteria for SLE. Thirthy healthy hospital workers (27 female, 3 male; mean age 41.2±6.8 years) were recruited as healthy controls. The frequency of hiperlipidemia was found to be significantly higher in patients with PsA than SLE patients and healthy controls (p<0.001) but hypertension was more common in SLE patients (p=0.002). While serum CRP levels were higher in PsA patients than control patients and healthy controls, SLE patients had higher ESR levels than the both control groups (p<0.001). The mean carotid IMT was found to be higher in PsA patients (0.76mm ±0.15) in comparison with the SLE patients (0.58±0.11) and healthy control group (0.57±0.12) (p<0.001).Table 1. B-mode ultrasonography results in the study subjects Averaged CCA IMT (mm) Right CCA IMT (mm) Left CCA IMT (mm) PsA patients (n=42) 0.76±0.15* 0.72±0.12* 0.79±0.18* SLE patients (n=38) 0.58±0.11 0.56±0.12 0.60±0.12 Healthy controls (n=30) 0.57±0.12 0.55±0.12 0.59±0.15 Data are mean ± SD (*p<0.001 for PsA patients vs SLE patients and healthy controls). CCA: common carotid artery. Conclusions This study shows that carotid IMT measurements are higher in PsA patients than SLE patients and healthy controls. A higher hyperlipidemia frequency and male predominancy in PsA patients may be partly responsible for the increased carotid IMT compared with SLE patients. Disclosure of Interest None declared

AB0764 Gender Differences in Axial Spondyloarthritis

Background Gender differences in demographic and clinical features of ankylosing spondylitis (AS) has consistently been demonstrated in several cohorts but there is little knowledge of those of axial spondyloarthritis (axSpA) as a whole group and of nonradiographic axial spondyloarthritis (nr-axSpA). Objectives The aim of this study was to assess the gender differences in axSpA. Methods Demographic and clinical data in our local axSpA database were evaluated and compared between male and female patients. Subgroup analyses in patients with AS/radiographic axSpA (r-axSpA) and nr-axSpA were also performed. Results There were 438 patients with axSpA [279 male (64%)], who fulfilled the ASAS classification criteria (Table 1). 349 out of them were classified as having AS/r-axSpA [236 male (68%)] and 89 as having nr-axSpA [43 male (48%)]. In female patients with axSpA, age of disease onset and age of diagnosis was older and delay of the diagnosis was longer compared with male patients (p<0.05). Peripheral arthritis and dactilitis were seen more in females (p<0.05) but entesitis was more frequent in males. At the time of diagnosis, BASDAI was higher in females (p<0.05); but BASMI scores (p<0.05) and CRP (p<0.05) were higher in males. Although neck pain was more common in female axSpA patients; cervical rotation disability and BASMI score assessments were worse in males (Table 1). When subgroup analysis was performed, females with nr-axSpA were found as having worse BASDAI (p<0.05) and BASFI scores (p<0.05) and males with AS as having higher CRP levels (p<0.05) and worse BASMI scores (p<0.05). Conclusions This study demonstrated that AS/r-axSpA was more prevalent among men but the prevalence of males and females in patients with nr-axSpA was similar. While subjective disease activity parameters were higher among women with axSpA as well as in those with nr-axSpA, men with axSpA experienced higher objective disease activity parameters and more restricted spinal mobility as well as in those with AS/r-axSpA. However, objective disease activity and spinal mobility scores were similar between women and men with nr-axSpA. Disclosure of Interest None declared

AB0766 Comparing Iphone Compass Application with Inclinometer and Universal Goniometer for the Assessment of Cervical Rotation in Patients with Ankylosing Spondylitis

Background Cervical rotation reflects restriction of mobility in axial disease in ankylosing spondylitis (AS) and it can be assessed in several approaches based on the use of either an inclinometer, a goniometer or a tape measure. New generations of smartphones are equipped with a gyroscope and an accelerometer which in combination with a smartphones operating system or specific software applications can be used for various inclinometric functions. Objectives The aim of the study was to assess the reliability and validity of using iphone built in compass application, as compared to using inclinometer and universal goniometer in the assessment of cervical rotation patients with AS. Methods The study sample included 30 AS patients (8 females, 22 males) with a mean age of 46.8 (±12.2). BASMI scores were obtained from patient charts. The mean BASMI score of AS patients was 37.6 (±30.6). Two examiners measured cervical rotation of each patient using iPhone4 compass application and also inclinometer and universal goniometer, twice with each method. A cap with a velcro patch on top and an iphone case with a Velcro patch on the bottom were used to stabilize the iphones position during measurements. Intra-rater and inter-rater reliability were examined with intra-class correlation coefficients (ICC). The agreements between the methods facing one another, were assessed by Bland-Altman method. Results We observed an excellent intra and inter-rater reliability in the whole study sample for all three methods (Table 1 and Table 2). Bland-Altman analysis showed a good agreement between the iphone and inclinometer methods with a mean difference (bias) of -5.6 for examiner 1 (95% CI -7.6 to -3.6) and -6.3 for examiner 2 (95% CI -8.8 to -3.8). Upper and lower limits of agreement were 4.9 (95% CI 1.4 to 8.3) and -16.2 (95% CI −19.6 to -12.7) for examiner, and 6.6 (95% CI 2.3 to 10.9) and -19.3 (95% CI -23.5 to -15.0) for examiner 2. Mean differences according to Bland-Altman analysis between the iphone and universal goniometer measurements were 2.3 for examiner 1 (95%CI -0.4 to 5.2) and 4.1 for examiner 2; between the universal goniometer and inclinometer were -8.0 for examiner 1 (95% CI -11.2 to -4.8) and -10.4 for examiner 2. Conclusions IPhone compass application is a simple and accessible way of measuring cervical rotation in patients with AS. Measurements acquired with iphone show excellent intra and inter-rater reliability and a good agreement with inclinometer and universal goniometer, with slightly lower values than obtained with inclinometer, and slightly higher values than with universal goniometer. Disclosure of Interest None declared

FRI0227 The Burden of Axial Spondyloarthritis: A Comparison of the Radiographic and Non-Radiographic Groups

Background Axial spondyloarthritis (axSpA) represents the whole clinical spectrum of ankylosing spondylitis (AS) including those at the non-radiographic (nr) stage of the disease. Although the disease burden associated with radiographic axSpA (classically known as AS) has been extensively studied, the burden associated with nr-axSpA is less well known. Objectives To assess and compare the burden of radiographic and nr-axSpA Methods This cross-sectional, observational study included consecutive AxSpA patients with varying disease severity, who attended our outpatient clinic between April 2014 and December 2014. During the visits, the following questionnaires were applied by trained health professionals:BASDAI, BASFI, HAQ-S, SF-36, ASQoL,Work Productivity and Activity Impairment (WPAI) and Work Productivity Survey (WPS). Results A total of 381 AxSpA patients (279 AS) were analyzed. Nr-axSpA group, were younger (39.4 vs 43.1, p=0.007), more likely to be female (54% vs 33%, p<0.001), had a shorter disease duration (10.1 vs 16.0 years, p<0.001) and lower CRP (5.9 vs 13.2, p<0.001) and less common use of biologics (41.2% vs 26.5, p=0.008) despite higher BASDAI scores (Table). Broadly similar results were found for the other clinical outcome measures. Of all the axSpA patients, 58% were employed, with non-manual (25%), mixed (19%) and manual works (14%). Only 1.1% of the patients could not work due to arthritis. Patients with nr-axSpA reported more work productivity loss at workplace and at home over the last month, but the difference was significant only for household activities. Subgroup analysis showed that this difference was only found in females. Table 1. Clinical variables related to disease burden in study participants. Data are presented as mean ± SD, unless otherwise stated Variable AS (n=279) nr-axSpA (n=102) P value BASDAI (0–100) 33.2±21.8 39.5±23.1 0.014 BASFI (0–100) 30.5±24.1 29.4±24.6 0.711 HAQ-S 0.7±0.6 0.8±0.6 0.606 SF36 PCS 41.3±9.3 39.2±10 0.111 SF36 MCS 46.1±10.5 43.3±11.4 0.060 ASqoL 5.6±5.4 6.2±5.6 0.331 Work productivity and impairment index (refers to the last week)  Absenteeism (%)* 8.7±25.5 12.3±30.3 0.374  Presenteeism (%)* 33.8±25.0 37.1±25.9 0.401  Overall work impairment (%)* 33.4±29.7 36.6±32.9 0.476  Daily activity impairment, (%) 33.5±22.9 34.6±23.6 0.672 Work productivity survey (refers to the last month)  Days of work missed* 1.4±4.6 3.0±6.6 0.090  Days with productivity at work reduced by ≥50%* 2.6±6.3 4.6±8.2 0.090  Rate of SpA interference on work productivity* 3.2±2.3 3.8±2.6 0.109  Days of household work missed 2.5±5.6 4.8±7.6 0.010  Days with household productivity reduced by ≥50% 3.1±2.1 3.6±2.3 0.048  Days with outside help 2.7±6.5 2.8±5.9 0.815  Rate of SpA interference with household work productivity (0-10 ) 3.1±2.1 3.7±2.3 0.052* Assessed in employed patients only. Conclusions Patients with AS and nr-AxSpA demonstrate similar degree of disease burden and prodcutivity, with a greater impairment of household work in females. Low rate of inability to work due to arthritis in this population with a relatively high prevalence of anti-TNF use may be a reflection of the effectiveness of such therapies. Disclosure of Interest None declared