Margarita Dubko

Comparable Efficacy of Abatacept Used as First-line or Second-line Biological Agent for Severe Juvenile Idiopathic Arthritis-related Uveitis.

Objective. Abatacept (ABA) has recently been proposed as second-line treatment in patients with juvenile idiopathic arthritis (JIA)–associated uveitis refractory to anti–tumor necrosis factor-α (anti-TNF) agents, but little is known about its efficacy as a first-line approach. The aim of the present study was to compare the safety and efficacy of ABA as a first-line biological agent (ABA-1) with that of ABA as a second-line treatment after 1 or more anti-TNF agents (ABA-2), in patients with severe JIA-related uveitis. Methods. In this multicenter study, we collected data on patients with severe JIA-related uveitis treated with ABA as a first-line or second-line biological agent. Changes in frequency of uveitis flares/year and ocular complications before and after ABA treatment, clinical remission, and side effects were recorded. Results. Thirty-five patients with a mean age of 10.8 years were treated with ABA for a mean period of 19.6 months. In 4 patients, ABA administration was discontinued, owing to inefficacy on arthritis in 3 cases and allergic reaction in 1. Thirty-one patients, 14 in the ABA-1 group and 17 in the ABA-2 group, completed the 12-month followup period; of these, 17 (54.8%) had clinical remission. The mean frequency of uveitis flares decreased from 4.1 to 1.2 in the ABA-1 group (p = 0.002) and from 3.7 to 1.2 in the ABA-2 group (p = 0.004). Preexisting ocular complications improved or remained stable in all but 5 patients, all in the ABA-2 group. No significant difference was found between the efficacy of the 2 treatment modalities. ABA confirmed its good safety profile. Conclusion. ABA, used as first-line biological treatment or after 1 or more anti-TNF agents, induces a comparable improvement in severe refractory JIA-related uveitis.

A128: Hierarchical Clustering Methodology for Exploration of Proteomic Profile in Tears: Seeking for Markers of Uveitis Associated With Juvenile Idiopathic Arthritis

Uveitis often is the only initial clinical manifestation of JIA for years. There are no reliable markers of JIA‐associated uveitis and impossibility to overcome ocular barriers impede diagnosis and treatment leading to blindness. During the last years the number of proteins identified in tears increased from 200 (Herber et al., 2001) of only 17 (Zhou et al., 2003) different molecular weights (MW) to 491 (de Souza et al., 2006) with 80 chemokines, cytokines, and growth factors (Sack et al., 2005). Objective of the study is to reveal protein markers of JIA‐associated uveitis in tears using high‐resolution mass‐spectrometry and hierarchical clustering methodology.

Identification of the best cut-off points and clinical signs specific for early recognition of macrophage activation syndrome in active systemic juvenile idiopathic arthritis

Macrophage activation syndrome (MAS) – is a severe life-threatening hematological condition, mostly complicated systemic juvenile idiopathic arthritis (SJIA). Early detection of MAS can lead to appropriate therapeutic interventions and change the outcomes. There are no strict criteria for early MAS detection in SJIA. Currently applied HLH criteria can determinate only advanced stage of MAS, which lead to delay diagnosis, late start of specific treatment and associated with poor outcomes. There are several sets of preliminary criteria of MAS in SJIA.

A130: Is the CCR5‐delta32 Mutation Protective Against Systemic‐Onset Juvenile Idiopathic Arthritis?

The CCR5 protein is a chemokine receptor, and is known to be expressed on T cells, macrophages, dendritic and microglia cells. It is believed that different prevalence of HLA and CCR5‐ delta32—a 32 base pair deletion in the coding region—in various ethnic groups is associated with the severity and prevalence of chemokine‐mediated autoimmune diseases, systemic‐onset Juvenile Idiopathic Arthritis (soJIA) being among them (Del Rincon et al., 2003). Since the end of the last century the protective role of the CCR5‐delta32 mutation against JIA is discussed (Hinks et al., 2010), though it seems the role of this mutation is less simple than was hitherto thought. The purposes of the study was to compare the prevalence of the CCR5‐delta32 mutation in children with and without soJIA, to assess the association of this mutation with the severity of the disease and thus to evaluate its protective role.

Proteomic Profile of Tears for the Diagnosis of Uveitis Associated with Juvenile Idiopathic Arthritis: Setting Targets to Achieve Results

The paper presents epidemiologic and pathophysiological aspects of the problem statement for early recognition of Uveitis (Uv) associated with Juvenile Idiopathic Arthritis (JIA) in terms of the proteomic profile of tears as well as the results of an attempt to solve this problem by means of the Tandem Mass-Spectrometry (TMS). The solution of this problem is of the highest relevance due to revolutionary changes in treatment strategies after introducing highly effective biologics. Content analysis of literature reviews reveals the following: 1. the incidence of JIA-Uv in the Northwest Federal District of Russian Federation averages 0.5-0.7 per 100 000 of children with the prevalence being ten-fold higher than incidence, 2. without Methotrexate treatment 4-7 years after the diagnosis of JIA-Uv cataract is revealed in 35-40% of children and in 5% – glaucoma as well, 3. even with Methotrexate in 28-40% of children the complications of JIA-Uv inevitably will be revealed with blurred vision in 10-36% of children, 4. timely diagnosis of JIA-Uv and adequate treatment reduce the risk of complications by 4% per year, 5. current medical care system reveals in one third of children already the complications of JIA-Uv. Revelation in tears of the motif mode for protein interaction network, triggering mobilization/inhibition of cells which moderate Uv would contradict the traditional point of view on existing natural anatomic and physiologic barriers, isolating the intraocular space, but however seems to be possible since JIA is a systemic disease and Uv leads to damage of the blood-retinal barriers. To reveal protein biomarkers of JIA-Uv tears of 31 children aged 2-17 years were studied: 17 – chronic JIA-Uv, 4 – JIA without Uv, 4 – idiopathic Uv, 3 – systemic vasculitis, 3 – healthy children. We used the current clinical guidelines and standards to diagnose the pathology and TMS with hierarchical clustering methodology for protein identification: nano C18 column attached to Shimadzu nano LC coupled in-line to LTQ Orbitrap XL tandem mass spectrometer, data-dependent 4-event scan method, a survey FT-MS parent scan followed by sequential data dependent FT-MS/MS scans on the three most abundant peptide ions. Proteins were identified from the mass spectra results with Proteome Discoverer 1.2 software for protein database search using the International Protein Index (IPI) and Human Protein Database. Quantification was conducted using SIEVE 2.0 after normalization to albumin keeping in mind the validity of proportional change of its concentration after stimulation of lacri-mation. Data from SIEVE were exported to IPA (Ingenuity Pathway Analysis) for filtering. The extracellular proteins selected in Ingenuity were further analyzed for disease relation and networks formation. TMS revealed more than 3000 proteins in tears and 300 of them have been considered to be the first row candidates to be biomarkers of JIA-Uv. The top two proteins, lactoferrin and lipocalin were upregulated over ten-fold in children with Uv. Pathway analysis placed these proteins into the inflammation-related IL-1 and TNF-α related networks which also included proteins involved in the development of endothelial dysfunction, inflammation and retinopathy. In addition, IL-23, which was previously linked to Uveitis, was found to be upregulated. Taken together, our proof-of-principle study presents a novel and yet untested approach for detection of early biomarkers of Uveitis and identified several candidate proteins.

Evaluation of the efficiency and safety of tocilizumab therapy in patients with systemic-onset juvenile idiopathic arthritis: results of a retrospective follow-up

Objective: to study the efficiency and safety of tocilizumab (TCZ) therapy in patients with systemic-onset juvenile idiopathic arthritis (sJIA). Patients and methods. The retrospective study included 48 children with active sJIA in whom TCZ therapy was initiated because of the inefficiency of using different anti-rheumatic drugs. The investigators studied the time course of changes in the main indicators of sJOA activity, as well as the possibility of achieving remission in accordance with the Wallace criteria (2004). Results and discussion. The main demographic characteristics of the study group (median [25th and 75th percentiles]) included the age of the patients (9.9 [5.0; 12.7] years) and the duration of TCZ therapy (27.0 [5.9; 89.7] months). 40 (83.3%) patients achieved remission; the median of its achievement was 138.5 [56.0; 255.0] days. The patients who had achieved remission had milder sJOA: hepatosplenomegaly, pulmonary and cardiac involvements, and macrophage activation syndrome were less frequently observed. At baseline, they also had higher hemoglobin values and a lower erythrocyte sedimentation rate, and decreased levels of leukocytes, granulocytes, C-reactive protein (CRP), lactate dehydrogenase (LDH) and ferritin. The main predictors for achieving remission, which were estimated using the analysis of sensitivity and specificity, as well as Cox regression models, were CRP ≤82.0 mg/l (OR – 7.9; HR – 1.17); ESR ≤32 mm/h (OR – 17.0; HR – 0.85), ferritin ≤273 ng/ml (OR – 56.5; HR – 2.6), hemoglobin >113 g/l (OR – 17.0; HR – 1.33), LDH ≤676 U/l (OR – 113.6; HR – 3.2), platelets >335⋅109 /l (OR – 5.0; HR – 2.5), and a decline in white blood cells two weeks after the first infusion by more than 11% (OR – 13.0; HR – 6.0) and in granulocytes by more than 12% (OR – 14.0; HR – 4.7). Conclusion. Children with a less severe course of sJIA more promptly reached remission during TCZ therapy. Male gender, high inflammatory activity, previous glucocorticoid therapy, long time to achieve remission, and TCZ dosing regimen deviations were the main factors for an exacerbation of sJOA. Male sex, signs of the high disease activity, preceding CS treatment, long time to achievement of inactive disease and treatment protocol deviations increased risk of sJIA flare.

THU0226 Outcomes of Treatment of Juvenile Idiopathic Arthritis Related Uveitis with TNF-Alpha Inhibitors

Background Uveitis is the inflammation of the uvea by definition, but for a rather long time the term “uveitis” was used to identify inflammation in any part of the eye (retinitis, chorioretinitis, scleritis, episcleritis). According to some authors one of the most common causes of uveitis in childhood is Juvenile Idiopathic Arthritis (JIA). Patients with JIA associated uveitis are usually asymptomatic at early stages. In 20–30% of cases uveitis may occur a few years before joint manifestation. As the result of those two factors we often see the delay in the treatment or not adequate treatment. Early and aggressive treatment of JIA associated uveitis can help better control inflammation and can help to eliminate inflammation before development of irreversible ophthalmic pathology. Objectives The goal of the study was to evaluate the efficacy of two anti-TNF-alpha biological agents: Adalimumab (ADA, humanized monoclonal anti-TNF-alpha antibody) and Infliximab (INF, chimeric monoclonal antibody that binds both circulating and membrane-bound TNF-alpha receptors) in the treatment of uveitis, associated with Juvenile idiopathic Arthritis (JIA). The incidence of eye involvement in JIA can be as high as 10–20%. Methods Thirty-seven children with aggressive forms of JIA with uveitis who failed immunosuppressive agents were enrolled in the study. The age of the patients at the beginning of anti-TNF-alpha treatment ranged from 5 to 17 years. All patients were divided into two groups: one group received ADA (40 mg sc every 2 weeks), and the other group was received INF (iv 5–6 mg/kg at week 0–2-6 and after every 8 weeks). Duration of treatment was 3–48 months. The efficacy of treatment was assessed by reduction of flare-ups, reduction of topical and systemic steroids, immunosuppressive drugs and reduction of activity of uveitis. Results In ADA group the remission was observed in 61% of cases, reduction of number of flare-ups was in 18% and in 14% we saw worsening of the disease due to discontinuation of non-biological drug. In INF group remission was in 78% and in 22% of the cases no improvement. The remission of uveitis was achieved in 0.5 - 4 months from the starting of ADA. Topical steroids was tapered within 1.5–3 months and none of the patient required regional injections of steroids. Therapy with ADA permitted to cease non-biological immunosuppressive agents, especially in children who received simultaneously 2 non-biological agents. Conclusions Our experience in ADA treatment of uveitis shows good result in control of uveitis independent from the severity of the disease and despite it was used as a first-, second- or third-line agent among the biologics. The speed of remission in patients with JIA associated uveitis treated with ADA and INF depends on the severity of uveitis, the time between the beginning of the disease and administration of immunosuppressive therapy. This study needs to be continued to enroll more patients and to increase the follow-up time to evaluate the long-term efficacy and safety of anti-TNF-alpha agents in JIA associated uveitis. Disclosure of Interest None declared

AB0876 Achievement Remission in Different Juvenile Idiopathic Arthritis Categories during Adalimumab Therapy: Data of Retrospective Analysis

Background Juvenile idiopathic arthritis (JIA) is a chronic rheumatic disease with onset before 16 years. According ILAR classification there are several categories based on number of joints, clinical and laboratorial features. Patients with JIA without systemic features who fall or not tolerated to methotrexate (MTX) or sulfasalasine (SSZ) usually treated by biologics, especially TNFα-inhibitors. Currently only 2 TNFα-inhibitors approved in JIA: etanercept and adalimumab (ADA). Objectives The aim of study was to evaluate the efficacy of ADA in children with JIA without systemic features and ability to induce remission. Methods In the retrospective observation study were included 53 children (67.9% girls) with active JIA without systemic features, who were resistant to previous therapy with MTX alone (or SSZ in enthesytis-related arthritis) or with combination with other non-biologic DMARDs and were treated with subcutaneous ADA injections every 2 weeks. The onset age was 3.9 (1.7–7.8) years, the interval between onset of JIA and start of ADA was 4.2 (0.3–15.2). Uveitis was detected in 32 (60.3%) patients. According number of active joints and clinical features all patients were divided into 3 groups: oligoarthicular course (OA) – 4 active joints or less, polyarthricular course (PA) – 5 active joints or more and enthesitis-related arthritis (ERA) with any active joints. We evaluated routine clinical and laboratorial test for JIA and ability and time to achieve inactive disease, according to C. Wallace criteria (2004). Results Number of active joints (NAJ) and erythrocyte sedimentation rates significantly decreased, while levels of C-reactive protein, WBC, Hb and platelets still unchanged. In 12 months after start of ADA median of NAJ was equal 0. During the trial 44 (84.6%) patients reached the status of inactive disease (ID) according the C. Wallace criteria in median time 122.0 (36.5–220.0). We have not found any significant differences of initial JIA parameters between patients who achieved and not achieved status of ID. We have found differences in JIA groups in achievement ID: patients with OA similar to PA faster and frequently get into remission than patients with ERA (p=0.03, Log-Rank test, OA vs ERA). During the trial 26 (50.0%) have experienced the flare throw the median time 551.0 (317.0–809.0) days after 1st ADA injection. Patients with flare had less NAJ [1.0 (0,0; 2,0) vs 4.0 (1,0; 8,0), p=0.007]. The main predictors of JIA flare during the ADA trial were calculated with Cox-regression models: JIA duration ≥4 years before start of ADA (HR=2.4, p=0.055), presence of concomitant uveitis (HR=4.8, p=0.0008) and discontinuation of MTX (HR=3.2, p=0.19). During the trial 1 SAE was detected: disseminated tuberculosis in patient who received ADA near 3 years (unrecognized family contact). Conclusions In our study the efficacy of ADA was shown. Further trials required for evaluation long-term outcomes. Disclosure of Interest None declared

SAT0261 Different Treatment Strategies for Chronic Non-Bacterial Osteomyelitis: The Experince of 52 Patients

Background Chronic non-bacterial osteomyelitis (CNO) is a heterogenous group of immune-mediated inflammatory bone diseases, often co-exist with other rheumatic diseases. There are no approved treatments for CNO except non-steroid anti-inflammatory drugs (NSAID). The efficacies of methotrexate (MTX), sulfasalazine, pamidronate (PAM), anti-IL1 and TNFα-inhibitors (TNFα-inh) were shown in different reports. Objectives The aim of study: to compare the efficacy of non-randomized different treatment approaches in pediatric patient CNO cohort. Methods 52 children (25 M and 27 F) with CNO has average age at the onset of disease 8.4 years (5.4÷11.0), the number of foci - 3.0 (2.0÷6.0, incl. multifocal cases in 80.8%), fever at the onset – 38.5%, spine involvement - 34.6%, positive family autoimmune diseases (AID) history - 7.7%, concomitant AID - 67.3%. NSAID was the first-line treatment for non-vertebral cases, as well as PAM for vertebral involvement. Second-line treatment includes MTX, PAM and TNFα-inh. Dynamics of pain, patients (PVAS) and physicians (MDVAS) assessment and ability to each medication to achieve remission of CNO activity we evaluated. Results According to the NSAID, MTX, SSZ, PAM and TNFα-inh groups next data were registered: PVAS: -14.2% (p=0.05), -50.0% (p=0.04), -23.1 (p=0.89), -83.3% (p=0.0001), -73.6% (p=0.0007); pain: -21.9% (p=0.01), -18.6% (p=0.13), +36,4 (p=0.89), -79.7% (p=0.00016), -74.1%, (p=0.0015); MDVAS: -13.8% (p=0.13); -56.4% (p=0.09), +30.8% (p=0.89), -74.7%, (p=0.0001), -82.1 (p=0.0015) respectively. The ability of each treatment strategy to achieve the CNO remission was 52.6%, 44.4%, 57,1%, 88.8% and 73.3% respectively (log-rank test, p=0,001, figure). TNFα-inh usually used as second-third line treatment in cases where other options, especially PAM were fall. Conclusions The most effective treatment approaches for CNO were PAM and TNFα-inh. The randomized controlled trials for assessment efficacy and safety of these medications is mandatory to confirm these results. Disclosure of Interest None declared

Comparison of different treatment approaches in chronic non-bacterial osteomyelitis.

Chronic non-bacterial osteomyelitis (CNO) is a heterogenous group of immune-mediated inflammatory bone diseases, which often co-exist with other rheumatic diseases. There are no approved treatments for CNO, except non-steroid anti-inflammatory drugs (NSAID). The efficacy of methotrexate (MTX), sulfasalazine, pamidronate (PAM), anti-IL1 and TNFα-inhibitors was shown in different reports, but there are some concerns about safety of pamidronate due to long-term accumulation and persistation in bone. The aim of our study was to compare the efficacy of non-randomized different treatment approaches in pediatric patient cohort with CNO.