Mohamed Said

Posterior reversible encephalopathy syndrome in systemic lupus erythematosus: Pooled analysis of the literature reviews and report of six new cases

Introduction Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder which is increasingly recognized to occur in systemic lupus erythematosus (SLE). Objective The purpose of this study was to identify the characteristics of SLE patients with PRES and the associated factors of the poor outcome among them. Methods We investigated SLE patients who developed PRES between 2005–2011 at the Universiti Kebangsaan Malaysia Medical Centre. A comprehensive literature search was done to find all published cases of PRES in SLE. Pooled analysis was conducted to identify the factors associated with poor outcome. Results There were 103 cases of PRES in SLE published in the literature but only 87 cases were included in the analysis in view of incomplete individual data in the remaining cases. The majority of the cases were Asians (74.2%), female (95.4%) with mean age of 26.3 ± 8.8 years. PRES was highly associated with active disease (97.5%), hypertension (91.7%) and renal involvement (85.1%). We found that 79 patients had a full recovery (90.8%) with a mean onset of full clinical recovery in 5.6 ± 4.1 days. On univariate analysis and logistic regression analysis the predictors of poor outcome, defined as incomplete clinical recovery or death, were intracranial hemorrhage, odds ratio (OR) 14 (1.1–187.2), p = 0.04 and brainstem involvement in PRES, OR 10.9 (1.3–90.6), p = 0.003. Conclusion Intracranial hemorrhage and brainstem involvement were the two important predictors of poor outcome of PRES. Larger prospective studies are needed to further delineate the risk of poor outcome among them.

A descriptive study of the factors associated with damage in Malaysian patients with lupus nephritis

Introduction Renal involvement is the most common serious complication in patients with systemic lupus erythematosus (SLE). Objective The objective of this article is to investigate and determine the associated factors of disease damage among lupus nephritis (LN) patients. Methods Medical records of LN patients who attended regular follow-up for at least one year in the Nephrology/SLE Clinic, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), were reviewed. Their Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index scores were noted. Univariate analysis and multivariable regression analysis were performed to determine the independent factors of disease damage in LN. Results A total of 150 patients were included and their follow-up duration ranged from one to 20 years. Sixty (40%) LN patients had disease damage (SDI ≥1). In the univariate analysis, it was associated with age, longer disease duration, antiphospholipid syndrome (APS), higher maximum daily oral prednisolone dose (mg/day), lower mean C3 and C4, higher chronicity index and global sclerosis on renal biopsies (p < 0.05). Patients who received early (≤3 months after the SLE diagnosis) hydroxychloroquine (HCQ), optimum HCQ dose at 6.5 mg/kg/day and achieved early complete remission (CR) were less likely to have disease damage (p < 0.05). After adjustment for age, gender, disease duration and severity, multivariable regression analysis revealed that a higher maximum daily dose of oral prednisolone was independently associated with disease damage while early HCQ and CR were associated with lower disease damage. Conclusion Higher maximum daily prednisolone dose predicted disease damage whereas treatment with early HCQ and early CR had a protective role against disease damage.

FRI0386 Work disability and quality of life among multi-ethnic malaysian systemic lupus erythematosus (SLE) patients

Background Patients with Systemic Lupus Erythematosus (SLE) are at risk of work disability due to the substantial impact of the disease towards their physical and mental health. Objectives To study the prevalence of work disability (WD) and unemployment rate among SLE patients, and their associations with the quality of life (QOL) in National University of Malaysia Medical Centre (UKMMC) Methods This was a cross-sectional study which recruited consecutive SLE patients who attended the Nephrology and Rheumatology clinic at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from March 2017 to July 2017. Information on their current and past employment history were obtained from a customised questionnaire and WD was defined as unemployment or an inability to do paid work due to illness at the time of study or at any time after the diagnosis of SLE being made. The disease characteristics, disease activity and damage were determined from the medical records. The quality of life was measured using SF-36 questionnaires. Statistical analyses were subsequently performed to determine the factors associated with WD. This study was approved by the UKMMC ethics research committee (FF FF-2017–109). Results A total of 197 patients were recruited, and their median age was 37 (32 to 47) years with median disease duration of 12 (8 to 17) years. Majority of them were Malays (n=116, 58.9%), followed by Chinese (n=69, 35%), Indians (n=8, 4.1%) and others (n=4, 2.0%). The prevalence of work disability was 35%(n=69) and the onset of WD was 4 (IQR:1 to 9) years after SLE diagnosis. WD was associated with older age, lower education level, more frequent disease flare, longer disease duration, higher SLICC ACR Damage Index, active disease (SLEDAI 2K and BILAG 2004 and had major organ involvement (lupus nephritis, haematological and neuropsychiatric), all p<0.05. Patients who received plasmapheresis, intravenous methylprednisolone, intravenous immunoglobulin, Mycophenolate Mofetil and calcineurin inhibitors were also associated with WD. Patients with work disability also had significantly impaired QOL with lower SF 36 scores. On multivariate logistic regression analysis, the independent predictors of WD were lower education level, being married and involvement of lupus nephritis, haematological and neurolopsychiatric lupus (NPSLE). Conclusions More than one third of SLE patients had experienced work disability. Lower education level, being married and major organ involvement were the independent predictors for work disability. A larger prospective study is warranted to further delineate the risk factors. References [1] Garris C, et al. Impact of systemic lupus erythematosus on burden of illness and work productivity in the United States. Lupus2013;22:1077–1086. [2] Mok CC, et al. Risk and predictors of work disability in Chinese patients with SLE. Lupus2008;17:1103–1107. Disclosure of Interest None declared

297 Hyperprolactinaemia association with lupus nephritis disease activity

Background and aims Prolactin has been found to be associated with immune regulation in SLE. The aim of this study is to determine the correlation between high prolactin level in comparison with IL – 6 with lupus nephritis disease activity in UKMMC. Methods In this cross-sectional study, the analysis was conducted in SLE patients who attended Nephrology clinic in UKMMC from August 2015 till February 2016 Results Out of 43 patients with lupus nephritis, 27.9% of the patients had raised serum prolactin. The median of serum prolactin level at 0 min was 19.91 ng/ml (IQR: 15.95–22.65 ) for active lupus nephritis that was significantly higher as compared to the median of serum prolactin level 14.34 ng/ml (IQR: 11.09–18.70 ) for patients in remission (p=0.014). The serum prolactin level was positively correlated to SLEDAI (rhos : 0.449, p=0.003 ) and UPCI level in lupus nephritis patients (rhos : 0.241, p=0.032). Assessment of serum IL-6 levels found that the active lupus nephritis patients were having a higher median level of 65.91 pg/ml (21.96–146.14) compared to in remission level of 15.84 pg/ml (IQR: 8.38–92.84), (p=0.039). ROC curve analysis of serum prolactin 0 min and serum prolactin 30 min and IL-6 level for prediction of SLE diseases activity provide the cutoff value of serum prolactin 0 min was 14.63 ng/ml with sensitivity 91.7% and specificity 58.1% and AUC of 0.74 (p=0.015). Conclusions Baseline fasting serum prolactin level was found to be a sensitive biomarker for evaluation of lupus nephritis disease activity.

296 Case series involving obstetrics experiences and outcomes in connective tissue disease patient in universiti kebangsaan malaysia medical centre (ukmmc): a single centre experience

Background and aims Connective tissue diseases (CTD) such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), antiphospholipid syndrome (APS) and others are likely to be worsening during pregnancy. There are poor pregnancy performances because of the abnormal immune system activity. The aim of the study was to observe the obstetrics experiences and the outcomes. Methods A retrospective study was done and a total of 58 cases of pregnancy were taken from year 2010–2015 in Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Results Fifty-eight pregnancies were observed in 44 women where there were fifty pregnancies (86.2%) with SLE, 4 (6.9%) pregnancies with RA and 4 (6.9%) pregnancies with APS. There were 6 (10.3%) pregnancies in active group and 52 (89.7%) pregnancies in remission group. Among the 58 pregnancies, there were 29 (50.9%) birth with no complication, 9 (15.5%) miscarriages, 8 (13.8%) premature babies, 2 (3.4%) stillbirth, 1 (1.7%) intrauterine growth restriction, 1 (1.7%) neonatal death and 7 (12.1%) others (pre-eclampsia, impending eclampsia, oligohydramnios, chorioamnionitis, persistent urinary tract infection, fetal distress and placenta previa). Rate of live birth is affected by type of CTD (x2=6.520, p=0.038) and anti double stranded DNA (x2=6.157, p=0.021). Pregnancy has a significant association with Complement 3 (C3) value (t=2.003, p=0.05). Conclusions This study showed there is a significant relationship between antidsDNA and type of CTD with pregnancy. C3 value also showed significant changes in pre pregnancy and during pregnancy.

AB0293 Carotid Intima Media Thickness and Interleukin -17 Level in Rheumatoid Arthritis Patients

Background Rheumatoid Arthritis (RA) patients are at risk of cardiovascular disease (CVD) and carotid intima media thickness (cIMT) is an excellent marker of subclinical atherosclerosis. However, cIMT and the CVD biomarkers among RA patients with low disease activity and remission are not well studied. Objectives To assess the carotid intima media thickness (cIMT) in RA patients who were in low disease activity state and lacking concomitant co-morbidities potentially influencing cIMT. This study was also aimed to determine the correlation between serum IL-17 with cIMT. Methods Rheumatoid Arthritis patients who were in low disease activity or remission (DAS28<3.2) from Rheumatology Clinic, National University of Malaysia Medical Centre were recruited. Patients with traditional CVD risk factors were excluded. Carotid ultrasound was performed in RA patients and their age and gender-matched healthy controls to determine the cIMT thickness. Serum IL-17 was measured using ELISA method. Results A total of 76 patients were screened and 22 RA patients who were in low disease activity or remission were included. Patients with RA had significantly higher median cIMT, 0.53 (IQR0.13) mm compared to controls, 0.47 (IQR 0.14) mm, p=0.01. In RA patients, the cIMT had significant positive correlation with age (rs=0.84, p=0.00), systolic BP (rs=0.45, p=0.04), waist circumference (rs=0.43, p=0.04), total cholesterol (rs=0.54, p=0.01), BMI (rs=0.45, p=0.04) and serum IL-17 (rs=0.45, p=0.03) but negative correlation with total HDL (rs=-0.43, p=0.05). Conclusions Patients with RA had significantly higher cIMT as compared to healthy controls despite minimal disease activity and lack of traditional CV risk factors, suggesting that the vascular injury due to previous inflammation may not be reversible. Serum IL-17 was also found to be correlated significantly with cIMT, suggesting that it may play a role in atherogenesis among RA patients. References van Sijl AM et al, Carotid intima media thickness in rheumatoid arthritis as compared to control subjects: a meta-analysis. Semin Arthritis Rheum. 2011;40(5):389–97 Targonska-Stepniak B et al. The relationship between carotid intima media thickness and the activity of rheumatoid arthritis. J Clin Rheumatol. 2011;17(5):249–55 Disclosure of Interest None declared

THU0266 Effects of Various Immunosuppressants in the Disease Damage Among Patients with Systemic Lupus Erythematosus (SLE)

Background Various factors have been implicated in the disease damage in SLE. Objectives To investigate disease damage among SLE patients and to determine their association with patient exposure to the various immunosuppressive treatment. Methods A total of 220 SLE patients from the Universiti Kebangsaan Malaysia Medical Centre and Putrajaya Hospital were recruited. Information on the sociodemographic background, lupus characteristics and treatment were obtained from the medical records. Patients were stratified by the Systemic Lupus International Collaborating Clinics/ American College of Rheumatology cumulative disease damage index (SDI ≥ 1= damage). Results Overall, 35% (78/220) patients had disease damage. Those who had ever received hydroxychloroquine (HCQ) were less likely to develop disease damage (37.5% vs 89.3%, p<0.001). Early HCQ treatment (≤3 months from the onset of diagnosis) and receipt of a loading dose of HCQ (6.5mg/kg daily) were less likely to be associated with disease damage [23.2% vs 67.1% and 28 % vs 54%, p<0.001 respectively]. In the HCQ treated group of patients, those with disease damage had a significantly lower cumulative HCQ [189.3 ± 192.2 g vs 314.1 ± 339.4 g, p<0.01]. Those who had a longer duration of corticosteroid treatment tended to develop disease damage (5.1 ± 4.8 years vs 3.8 ± 3.1 years, p=0.057) and more patients who received high dose prednisolone (≥ 1mg/kg daily) developed disease damage (52.2% vs 35.3%, p=0.04). Cyclophosphamide and cyclosporin A use were also associated with disease damage, 78.7% vs 31.7% and 85% vs 41%, p<0.001 respectively. After adjustment of age and major organ involvement of SLE (renal and NPSLE), in the regression analysis, presence of treatment with HCQ (OR 0.12, CI 95% 0.02-0.61, p=0.01) and early treatment with HCQ (≤ 3 months before the onset of SLE) protected against disease damage (OR0.32, CI 95% 0.11-0.91, p=0.03). Cyclophosphamide was an independent risk for disease damage (OR 11.5 CI 95% 3.5-35.6, p=<0.01). These data suggest that the use of cytotoxic agents such as cyclophosphamide and cyclosporine A were probably associated with more severe disease manifestations such as severe lupus nephritis. Conclusions Cyclophosphamide use increased the risk of disease damage whilst early treatment with HCQ protected against disease damage. A larger prospective study is needed to further delineate the contribution of the immunosuppressive treatment towards disease damage among SLE. References M. Petri et al. Predictors of Organ Damage in SLE: The Hopkins Lupus Cohort Arthritis Rheum. 2012 Dec;64(12):4021-8. Disclosure of Interest None Declared

AB0244 Retrospective study on effects of ramadhan month fasting on rheumatoid arthritis patients

Background Rheumatoid arthritis (RA) is a chronic inflammatory disease which affects about 0.5% of adults in Malaysia. Objectives This study aimed to explore the overall effect of Ramadhan fasting onto RA disease activity and identify drug modification, drug side effects and diet changes occurring in Ramadhan. The study was approved by the Ethics Committee of UKMMC. Methods A retrospective case control study was done involving 71 patients who had appointments at the Rheumatology Clinic in UKMMC before Ramadhan and 2 months after Ramadhan, in 2010 and 2011. The fasting cohort (39 patients) and non fasting cohort (32 patients) were compared for RA disease activity (DAS28), intake of medication, side effects and diet before and during Ramadhan. Results In the fasting cohort, the mean for DAS28 before Ramadhan was higher than that after Ramadhan but this was not significant (p>0.05). Clinical symptoms of morning stiffness and fatigue were found in fewer patients after Ramadhan but this was not significant (p>0.05). There was a significant reduction in morning stiffness (x2=13.380, p=0.001) and in functional class (Z=-2.548, p=0.011) after Ramadhan, in the fasting cohort in 2010. The fasting cohort also showed asignificant reduction in the intake of high calorie food (Z=-2.295, p=0.022) in Ramadhan. There was an improvement in medication compliance among the patients, although this was not significant (p<0.05). Conclusions In conclusion, fasting lowers the mean of DAS28 in rheumatoid arthritis patients although this is statistically not significant. During fasting, changes in diet and medication intake do not significantly affect RA disease activity and do not cause significant side effects to fasting patients. Disclosure of Interest None Declared