Martina Frodlund

Associations between antinuclear antibody staining patterns and clinical features of systemic lupus erythematosus: analysis of a regional Swedish register

Objective Antinuclear antibody (ANA) analysis by immunofluorescence (IF) microscopy remains a diagnostic hallmark of systemic lupus erythematosus (SLE). The clinical relevance of ANA fine-specificities in SLE has been addressed repeatedly, whereas studies on IF-ANA staining patterns in relation to disease manifestations are very scarce. This study was performed to elucidate whether different staining patterns associate with distinct SLE phenotypes. Design Observational cohort study. Setting One university hospital rheumatology unit in Sweden. Participants The study population consisted of 222 cases (89% women; 93% Caucasians), where of 178 met ≥4/11 of the 1982 American College of Rheumatology (ACR-82) criteria. The remaining 20% had an SLE diagnosis based on positive IF-ANA (HEp-2 cells) and ≥2 typical organ manifestations at the time of diagnosis (Fries’ criteria). Outcome measures The IF-ANA staining patterns homogenous (H-ANA), speckled (S-ANA), combined homogenous and speckled (HS-ANA), centromeric (C-ANA), nucleolar (N-ANA)±other patterns and other nuclear patterns (oANA) were related to disease manifestations and laboratory measures. Antigen-specificities were also considered regarding double-stranded DNA (Crithidia luciliae) and the following extractable nuclear antigens: Ro/SSA, La/SSB, Smith antigen (Sm), small nuclear RNP (snRNP), Scl-70 and Jo-1 (immunodiffusion and/or line-blot technique). Results 54% of the patients with SLE displayed H-ANA, 22% S-ANA, 11% HS-ANA, 9% N-ANA, 1% C-ANA, 2% oANA and 1% were never IF-ANA positive. Staining patterns among patients meeting Fries’ criteria alone did not differ from those fulfilling ACR-82. H-ANA was significantly associated with the 10th criterion according to ACR-82 (‘immunological disorder’). S-ANA was inversely associated with arthritis, ‘immunological disorder’ and signs of organ damage. Conclusions H-ANA is the dominant IF-ANA pattern among Swedish patients with SLE, and was found to associate with ‘immunological disorder’ according to ACR-82. The second most common pattern, S-ANA, associated negatively with arthritis and organ damage.

Smoking and pre-existing organ damage reduce the efficacy of belimumab in systemic lupus erythematosus

OBJECTIVES Belimumab is the first biologic drug approved for Systemic Lupus Erythematosus (SLE). Here, we aimed to investigate the effects of belimumab on clinical and serologic outcomes, and sought to identify predictors of treatment response in three Swedish real-life settings. METHODS Fifty-eight patients were enrolled at initiation of belimumab and followed longitudinally for up to 53months. Surveillance outcomes included the SLE Disease Activity Index 2000 (SLEDAI-2K), 100mm Visual Analogue Scales for Physicians Global Assessment (PGA), fatigue, pain and general health, and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Assessment of treatment response included the SLE responder index (SRI). B lymphocyte stimulator (BLyS) levels were determined using ELISA. RESULTS SLEDAI-2K (median baseline score: 8.0; IQR: 4.0-13.8), PGA and corticosteroid use decreased during therapy, and patients reported improvements on fatigue, pain, and general health (p<0.0001 for all). SDI scores remained stable (p=0.08). Patients with baseline SDI scores >1 showed decreased probability and prolonged time to attain SRI response (HR: 0.449; 95% CI: 0.208-0.967), as did current smokers compared with non-smokers (HR: 0.103; 95% CI: 0.025-0.427). In contrast, baseline BLyS levels ≥1.2ng/mL predicted increased probability and shorter time to attain SRI response (HR: 2.566; 95% CI: 1.222-5.387). CONCLUSIONS Disease activity and corticosteroid usage decreased, patient-reported outcomes improved, and no significant organ damage was accrued during follow-up. Smoking and organ damage predicted reduced treatment efficacy. These findings might contribute to a better selection of patients who are likely to benefit from belimumab.

Osteopontin is associated with disease severity and antiphospholipid syndrome in well characterised Swedish cases of SLE

Objective The variety of disease phenotypes among patients with SLE challenges the identification of new biomarkers reflecting disease activity and/or organ damage. Osteopontin (OPN) is an extracellular matrix protein with immunomodulating properties. Although raised levels have been reported, the pathogenic implications and clinical utility of OPN as a biomarker in SLE are far from clear. Thus, the aim of this study was to characterise OPN in SLE. Methods Sera from 240 well-characterised adult SLE cases classified according to the American College of Rheumatology (ACR) and/or the Systemic Lupus International Collaborating Clinics (SLICC) criteria, and 240 population-based controls were immunoassayed for OPN. The SLE Disease Activity Index 2000 (SLEDAI-2K) was used to evaluate disease activity and the SLICC/ACR Damage Index (SDI) to detect damage accrual. Results Serum OPN levels were in average raised fourfold in SLE cases compared with the controls (p<0.0001). OPN correlated with SLEDAI-2K, especially in patients with a disease duration of <12 months (r=0.666, p=0.028). OPN was highly associated with SDI (p<0.0001), especially in the renal (p<0.0001), cardiovascular (p<0.0001) and malignancy (p=0.012) domains. Finally, OPN associated with coherent antiphospholipid syndrome (APS; p=0.009), and both clinical and laboratory criteria of APS had significant positive impact on OPN levels. Conclusions In this cross-sectional study, circulating OPN correlates with disease activity in recent-onset SLE, reflects global organ damage and associates with APS. Longitudinal studies to dissect whether serum OPN also precedes and predicts future organ damage are most warranted.

High Anti-Dsdna Content in Sle Immune Complexes is associated with Clinical Remission Following Belimumab Treatment

Background Systemic lupus erythematosus (SLE) is considered driven by immune complexes (IC), and autoantibodies are supposed to participate in IC formation. Thus, the fraction of autoantibodies participating in IC formation merits interest as a diagnostic and/or prognostic marker. We have developed a technique to quantify autoantibody content in IC (Sohrabian et al. Ann Rheum Dis 2015;74(Suppl 1):A74). Objectives To evaluate quantification of autoantibodies in IC as a measure of disease activity and prognosis for response in belimumab-treated SLE patients. Methods Fifty-five SLE cases classified according to the ACR criteria were treated with belimumab and followed for one year. High disease activity was defined as SLE Disease Activity Index 2000 (SLEDAI-2K) ≥10, or as low levels of complement factors C3 and/or C4. Treatment responses were recorded using the SLE Responder Index (SRI), or as a value 0 for modified SLEDAI-2K with suppression of autoantibody and complement data (clinical remission). Low disease activity was also recorded as Lupus Low Disease Activity State (LLDAS). Response data were recorded at 3, 6 and 12 months. IC were purified from sera by binding to C1q-coated beads, and thereafter eluted. Autoantibody levels were determined in unmodified serum and in solubilised IC with addressable laser bead immunoassay (FIDIS Connective, Theradiag, Paris) for autoantibodies against dsDNA, histones, ribosomal P antigen, proliferating cell nuclear antigen (PCNA), SSA/Ro60, SSA/Ro52, SSB, Sm, U1RNP and the Sm/RNP complex. Autoantibody levels in serum and in IC were compared with Mann-Whitneys U test between patients with high and low disease activity at baseline and between patients with and without treatment response during the follow-up period. Results Antibodies against dsDNA, SSA/Ro60 and Sm/RNP were found in 65%, 54% and 43%, other antibodies with lower percentages. Low complement levels were associated with high serum anti-dsDNA (p=0.003) and anti-ribosomal P antigen (p=0.008) levels, whereas high SLEDAI-2K associated with high anti-dsDNA (p=0.02) and anti-Sm/RNP (p=0.047) levels. Serum levels of antibodies against SSA/Ro60, SSB and SSA/Ro52 were lower in patients attaining LLDAS after 6 months (p=0.02, 0.051 [trend] and 0.04, respectively); these associations were stronger for corresponding IC fractions (p=0.01, 0.005, and 0.002, respectively). Baseline levels of anti-dsDNA and anti-histones in IC associated with clinical remission ever during the follow-up period (p=0.003 and p=0.05). Low levels of anti-Sm and anti-Sm/RNP in serum but not in IC associated with clinical remission at month 6 (p=0.02 and 0.04 respectively), and for Sm/RNP also at month 3 (p=0.04). Serum levels of all antibodies except SSA/Ro52 declined during the first 6 months, most prominently for dsDNA, histones ribosomal P, PCNA and Sm/RNP (p<0.0001 for all). Levels of antibodies in IC declined only for dsDNA (p=0.048). Conclusions Autoantibody levels in serum and in IC show different associations to disease activity and to treatment response. High baseline anti-dsDNA levels in IC were most strongly associated with clinical remission, and decreased during belimumab treatment. Belimumab effect might primarily relate to autoantibodies in IC. Disclosure of Interest None declared

Novel gene variants associated with cardiovascular disease in systemic lupus erythematosus and rheumatoid arthritis

Objectives Patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) have increased risk of cardiovascular disease (CVD). We investigated whether single nucleotide polymorphisms (SNPs) at autoimmunity risk loci were associated with CVD in SLE and RA. Methods Patients with SLE (n=1045) were genotyped using the 200K Immunochip SNP array (Illumina). The allele frequency was compared between patients with and without different manifestations of CVD. Results were replicated in a second SLE cohort (n=1043) and in an RA cohort (n=824). We analysed publicly available genetic data from general population, performed electrophoretic mobility shift assays and measured cytokine levels and occurrence of antiphospholipid antibodies (aPLs). Results We identified two new putative risk loci associated with increased risk for CVD in two SLE populations, which remained after adjustment for traditional CVD risk factors. An IL19 risk allele, rs17581834(T) was associated with stroke/myocardial infarction (MI) in SLE (OR 2.3 (1.5 to 3.4), P=8.5×10−5) and RA (OR 2.8 (1.4 to 5.6), P=3.8×10−3), meta-analysis (OR 2.5 (2.0 to 2.9), P=3.5×10−7), but not in population controls. The IL19 risk allele affected protein binding, and SLE patients with the risk allele had increased levels of plasma-IL10 (P=0.004) and aPL (P=0.01). An SRP54-AS1 risk allele, rs799454(G) was associated with stroke/transient ischaemic attack in SLE (OR 1.7 (1.3 to 2.2), P=2.5×10−5) but not in RA. The SRP54-AS1 risk allele is an expression quantitative trait locus for four genes. Conclusions The IL19 risk allele was associated with stroke/MI in SLE and RA, but not in the general population, indicating that shared immune pathways may be involved in the CVD pathogenesis in inflammatory rheumatic diseases.

PS7:132 Smoking reduces the efficacy of belimumab in mucocutaneous lupus

Background Belimumab is a biologic agent approved for the treatment of systemic lupus erythematosus (SLE). Recently, we demonstrated decreasing SLE activity during belimumab treatment in patients from three Swedish clinical settings. In the present study, we aimed to investigate the effects of belimumab on mucocutaneous and articular SLE in relation to smoking status. Methods Sixty-two patients with active SLE treated with belimumab between 2011 and 2017 were enrolled. We assessed the mucocutaneous disease using the mucocutaneous SLEDAI-2K and the cutaneous lupus erythematous disease area and severity index (CLASI). Musculoskeletal activity was evaluated by the arthritis SLEDAI-2K descriptor and the 28-joint count. Results At baseline, 44/62 (71.0%) patients had a mucocutaneous SLEDAI-2K score 2 or more (mean mucocutaneous SLEDAI-2K: 2.3; range 0–6; n=62). The mean baseline CLASI activity was score: 8.4 (range: 0–39; n=33). We observed decreased mucocutaneous SLEDAI-2K scores at month 6 (p<0.001) and month 12 (p<0.001) compared to baseline. CLASI activity scores also decreased from baseline to month 6 (p<0.001) and 12 (p<0.001). No significant worsening in CLASI damage scores was observed at either month 6 or 12. Patients with a baseline mucocutaneous SLEDAI-2K score 2 or more with a history of current or previous exposure to tobacco smoking (n=17) displayed a more than six times higher probability of poor response to belimumab compared to never smokers (n=22) (OR: 6.4; 95% CI: 1.5–27.4; p=0.012). We observed decreased SLEDAI-2K scores for the arthritis domain both at month 6 (p<0.001) and 12 (p<0.001). From baseline to month 6, the mean tender joints count decreased from 5.7 to 2.7 (p=0.010), and the swollen joints count from 3.6 to 0.7 (p<0.001); the decreases were sustained through month 12 (p=0.001 for both counts). No impact of smoking habits on treatment outcomes in relation to articular SLE was observed. Conclusion In line with previous reports, belimumab treatment was effective in limiting mucocutaneous and articular symptoms in patients with SLE. A history of past or current smoking was found to reduce the efficacy of belimumab in mucocutaneous manifestations. Further survey on the impact of smoking on the efficacy of belimumab at a mechanistic level is merited.

Smoking reduces the efficacy of belimumab in mucocutaneous lupus

ABSTRACT Objectives: Recently, we demonstrated a negative impact of smoking on belimumab efficacy in patients with systemic lupus erythematosus (SLE). Here, we particularly investigated clinical effects of belimumab and a potential impact of smoking in mucocutaneous and articular SLE. Methods: We surveyed 62 SLE patients treated between 2011 and 2017. Evaluation included the mucocutaneous descriptors of SLEDAI-2K (rash, alopecia, mucosal ulcers; mcSLEDAI-2K), CLASI, the arthritis SLEDAI-2K descriptor (arSLEDAI-2K) and the 28-joint count. Results: mcSLEDAI-2K and CLASI activity decreased from baseline to month 6 and 12 (P < 0.001 for all). No worsening in CLASI damage was observed. Current or previous smokers displayed a higher probability of unchanged/worsened mcSLEDAI-2K compared to never smokers (OR: 6.4; 95% CI: 1.5–27.4; P = 0.012), also after adjustment for antimalarial agents. arSLEDAI-2K scores had decreased at month 6 (P < 0.001) and 12 (P < 0.001). Likewise, tender and swollen 28-joint counts had improved at month 6 (P = 0.010 and P < 0.001, respectively) and 12 (P = 0.001 for both). We observed no impact of smoking on belimumab efficacy in articular SLE. Conclusion: We observed a negative impact of smoking on the efficacy of belimumab in mucocutaneous SLE. In contrast, no impact of smoking on belimumab efficacy was seen in patients with articular manifestations.

Immunoglobulin A anti-phospholipid antibodies in Swedish cases of systemic lupus erythematosus: associations with disease phenotypes, vascular events and damage accrual: IgA anti-APL antibodies and clinical events in Swedish cases of SLE

Immunoglobulin (Ig) G‐ and IgM‐class anti‐cardiolipin antibodies (aCL) and lupus anti‐coagulant (LA) are included in the 1997 update of the American College of Rheumatology (ACR‐97) systemic lupus erythematosus (SLE) criteria. Despite limited evidence, IgA‐aCL and IgA anti‐β2‐glycoprotein‐I (anti‐β2GPI) were included in the 2012 Systemic Lupus International Collaborating Clinics criteria. The present study aimed to evaluate IgG‐/IgA‐/IgM‐aCL and anti‐β2GPI occurrence in relation to disease phenotype, smoking habits, pharmacotherapy, anti‐phospholipid syndrome (APS) and organ damage among 526 Swedish SLE patients meeting ACR‐97. Patients with rheumatoid arthritis (n = 100), primary Sjögren’s syndrome (n = 50) and blood donors (n = 507) served as controls. Anti‐phospholipid antibodies (aPL) were analysed by fluoroenzyme‐immunoassays detecting aCL/anti‐β2GPI. Seventy‐six (14%) SLE cases fulfilled the Sydney APS‐criteria, and ≥ 1 aCL/anti‐β2GPI isotype (IgG/IgA/IgM) occurred in 138 SLE patients (26%). Forty‐five (9%) of the SLE cases had IgA‐aCL, 20 of whom (4%) lacked IgG‐/IgM‐aCL. Seventy‐four (14%) tested positive for IgA anti‐β2GPI, 34 (6%) being seronegative regarding IgG/IgM anti‐β2GPI. Six (1%) had APS manifestations but were seropositive regarding IgA‐aCL and/or IgA anti‐β2GPI in the absence of IgG/IgM‐aPL and LA. Positive LA and IgG‐aPL tests were associated with most APS‐related events and organ damage. Exclusive IgA anti‐β2GPI occurrence associated inversely with Caucasian ethnicity [odds ratio (OR) = 0·21, 95% confidence interval (CI) = 0·06–0·72) and photosensitivity (OR = 0·19, 95% CI = 0·05–0·72). Nephritis, smoking, LA‐positivity and statin/corticosteroid‐medication associated strongly with organ damage, whereas hydroxychloroquine‐medication was protective. In conclusion, IgA‐aPL is not rare in SLE (16%) and IgA‐aPL analysis may have additional value among SLE cases with suspected APS testing negative for other isotypes of aPL and LA.

103 Smoking and pre-existing organ damage reduce the efficacy of belimumab in systemic lupus erythematosus

Background and aims Belimumab is the first biologic drug approved for Systemic Lupus Erythematosus (SLE). Here, we aimed to investigate the effects of belimumab on clinical and serologic outcomes, and sought to identify predictors of treatment response in three Swedish real-life settings. Methods Fifty-eight patients were enrolled at initiation of belimumab and followed longitudinally for up to 53 months. Surveillance outcomes included the SLE Disease Activity Index 2000 (SLEDAI-2K), 100 mm Visual Analogue Scales for Physician’s Global Assessment (PGA), fatigue, pain and general health, and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Assessment of treatment response included the SLE responder index (SRI). B lymphocyte stimulator (BLyS) levels were determined using ELISA. Results SLEDAI-2K (median baseline score: 8.0; IQR: 4.0–13.8), PGA and corticosteroid use decreased during therapy, and patients reported improvements on fatigue, pain, and general health (p<0.0001 for all). SDI scores remained stable (p=0.08). Patients with baseline SDI scores>1 showed decreased probability and prolonged time to attain SRI response (HR: 0.449; 95% CI: 0.208–0.967), as did current smokers compared with non-smokers (HR: 0.103; 95% CI: 0.025–0.427). In contrast, baseline BLyS levels≥1.2 ng/mL predicted increased probability and shorter time to attain SRI response (HR: 2.566; 95% CI: 1.222–5.387). Conclusions Disease activity and corticosteroid usage decreased, patient-reported outcomes improved, and no significant organ damage was accrued during follow-up. Smoking and organ damage predicted reduced treatment efficacy. These findings might contribute to a better selection of patients who are likely to benefit from belimumab.