P. Gallagher

Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis

OBJECTIVES (1) To investigate the demographic and clinical characteristics contributing to the delay from symptom onset to the first visit to a rheumatologist; (2) to compare clinical, radiographic and patient-reported outcome measures of those who saw a rheumatologist early in their disease course with those who were diagnosed later. METHODS All psoriatic arthritis (PsA) patients, fulfilling CASPAR criteria, with an average disease duration of >10 years were invited for detailed clinical evaluation. The total lag time from symptom onset to their first rheumatological encounter was studied. The data were extracted from the referral letters and medical records. Patients were classified as early consulters or late consulters depending on whether they were seen by a rheumatologist within or beyond 6 months of symptom onset. RESULTS 283 PsA patients were studied. Median lag time from the disease onset to the first rheumatological assessment of the cohort was 1.00 years (IQR 0.5-2). 30% (n=86), 53% (n=149) and 71% (n=202) of the cohort were seen by a rheumatologist within 6 months, 1 and 2 years of symptom onset, respectively. PsA patients with low education status (OR 2.09, p=0.02) and Body Mass Index (OR 0.92, p=0.01) were significantly more likely to have a diagnostic delay of >2 years. On multiple stepwise regression analysis, the model predicted significant association of late consulters with the development of peripheral joint erosions (OR 4.25, p=0.001) and worse Health Assessment Questionnaire scores (OR 2.2, p=0.004). CONCLUSIONS Even a 6-month delay from symptom onset to the first visit with a rheumatologist contributes to the development of peripheral joint erosions and worse long-term physical function.

Development of a preliminary composite disease activity index in psoriatic arthritis

Objectives To develop a preliminary composite psoriatic disease activity index (CPDAI) for psoriasis and psoriatic arthritis. Methods Five domains were assessed and specific instruments were employed for each domain to determine the extent of domain involvement and the effect of that involvement on quality of life/function. Disease activity for each domain was then graded from 0 to 3 giving a CPDAI range of 0–15. Patient and physician global disease activity measures were also recorded and an independent physician was asked to indicate if treatment change was required. Bivariate correlation analysis was performed. Factor, tree analysis and standardised response means were also calculated. Results Significant correlation was seen between CPDAI and both patient (r=0.834) and physician (r=0.825) global disease activity assessments (p=0.01). Tree analysis revealed that 96.3% of patients had their treatment changed when CPDAI values were greater than 6; no patient had their treatment changed when CPDAI values were less than 5. Conclusion CPDAI correlates well with patient and physician global disease activity assessments and is an effective tool that clearly distinguishes those who require a treatment change from those who do not.

High Prevalence of Metabolic Syndrome and of Insulin Resistance in Psoriatic Arthritis is Associated with the Severity of Underlying Disease

Objective. To investigate the prevalence of metabolic syndrome (MetS) and of insulin resistance (IR) in an ethnically homogeneous cohort of established psoriatic arthritis (PsA), and to identify clinical associations of MetS and IR in patients with PsA. Methods. A cohort of 283 patients with PsA all meeting ClASsification for Psoriatic ARthritis (CASPAR) criteria was included. All underwent detailed skin and rheumatologic assessments, along with cardiovascular risk factor evaluation. IR was defined as an elevated homeostasis model assessment (HOMA-IR) value of > 2.5. Severe PsA was defined as the presence of 1 or more of the PsA-related radiographic damage features (peripheral joint erosions, osteolysis, sacroiliitis), and PsA requiring tumor necrosis factor inhibitor therapy. Results. The demographic and clinical characteristics of the cohort were mean age 54.6 ± 12 years, 52% female, mean PsA duration 19 ± 9 years. MetS was present in 44% of the studied patients (n = 283). On multiple regression analysis, a significant association of MetS was noted with more severe PsA (OR 4.47, p < 0.001), higher smoking pack-years (OR 1.03, p = 0.02), and worse EQ-5D scores (OR 1.28, p = 0.02). Data on IR were available for 263 patients, and among them, the mean HOMA-IR was 1.43 ± 1.09. Forty-one patients (16%) had IR. On multiple regression analysis, a significant association of IR was noted with more severe PsA (OR 3.49, p = 0.03), later psoriasis age of onset (OR 1.07, p = 0.001), and higher body mass index (OR 1.22, p < 0.001). Conclusion. Among patients with PsA, MetS and IR are highly prevalent, and are independently associated with the severity of underlying PsA.

Ustekinumab for the treatment of refractory giant cell arteritis

Giant cell arteritis (GCA) is the most common form of systemic vasculitis.1 Glucocorticoids are the mainstay of therapy, required in high doses for prolonged periods, with consequent serious complications in 86% of patients.2 There is a critical unmet need for a proven safe and effective immunosuppressive therapy in GCA, as agents such as methotrexate and infliximab have shown disappointing results in GCA.3 ,4 Interleukins 12 (IL-12) and 23 (IL-23) are implicated in Th1 and Th17 responses, respectively, both inflammatory pathways relevant to GCA pathogenesis.5 ,6 A recent case series reported the use of ustekinumab in three patients with Takayasu arteritis.7 The aim of this study was to evaluate the glucocorticoid-sparing efficacy of ustekinumab, an IL-12/IL-23-blocking monoclonal antibody, in patients with refractory GCA. Patients with GCA attending our centre are enrolled in a prospective registry and managed according to standardised …

Striking difference of periarticular bone density change in early psoriatic arthritis and rheumatoid arthritis following anti-rheumatic treatment as measured by digital X-ray radiogrammetry

OBJECTIVES To examine changes in hand BMD as measured by digital X-ray radiogrammetry (DXR-BMD) in early PsA compared with RA patients prior to and 3 and 12 months after introducing an antirheumatic treatment. Further, to identify predictors for hand bone loss at the time of disease presentation. METHODS Recent-onset, active, treatment-naïve patients were recruited. Clinical assessment, hand X-rays and DXR were obtained at 0, 3 and 12 months. Mean DXR-BMD for both hands and changes in DXR-BMD (mg/cm(2)/month) were compared between the two groups. We compared baseline disease characteristics of patients with normal hand DXR-BMD with those with bone loss. Logistic regression analyses were performed to identify predictors of hand BMD loss. RESULTS A total of 64 patients were included. Hand DXR-BMD decreased in RA throughout the study (P = 0.043). Changes in periarticular bone density over 12 months differed between PsA and RA (P = 0.001). Hand bone loss at 3 months was associated with elevated BMI [odds ratio (OR) = 3.59, P = 0.041] and heavier alcohol intake (OR = 1.13, P = 0.035). Diagnosis of RA (OR = 57.48, P = 0.008), heavier alcohol intake (OR = 1.27, P = 0.012) and higher swollen joint count (SJC28) (OR = 1.5, P = 0.036) were independent predictors for hand bone loss in the first year. CONCLUSION Following treatment, we found ongoing hand bone loss in RA and unchanged periarticular bone density in PsA, supporting the hypothesis that different pathomechanisms are involved in hand bone remodelling in PsA. Presence of RA, heavier alcohol intake and higher SJC were identified as independent predictors for hand bone loss over 1 year.

Higher Coronary Plaque Burden in Psoriatic Arthritis Is Independent of Metabolic Syndrome and Associated With Underlying Disease Severity

To examine the effect of metabolic syndrome and psoriatic disease–related variables on coronary plaque burden in psoriatic arthritis (PsA) patients.

Ustekinumab for Refractory Giant Cell Arteritis: A Prospective 52-week Trial☆

OBJECTIVES Giant cell arteritis (GCA) is the most common form of systemic vasculitis. Glucocorticoids are an effective treatment but have significant adverse events and relapses are common. Interleukins 12 (IL-12) and 23 (IL-23) stimulate TH1 and TH17 responses and are implicated in the pathogenesis of GCA. The aim of this study was to evaluate the efficacy and safety of IL-12/23 blockade with ustekinumab in GCA. METHODS We performed a prospective open label study of ustekinumab in patients with refractory GCA. Ustekinumab 90mg was administered subcutaneously every 12 weeks. The primary outcome was the comparison of the median glucocorticoid dose prior to commencement of ustekinumab and at 52 weeks. Secondary outcomes included physician assessed relapse, acute phase reactants, and imaging assessment of large vessel vasculitis (LVV). RESULTS Twenty-five GCA patients received ustekinumab. All patients had failed to taper glucocorticoids despite addition of a median of 1 other immunosuppressive agent. At week 52, median (IQR) daily prednisolone dose decreased from 20 (15, 25)mg to 5 (2.5, 5)mg (p < 0.001). Six patients (24%) stopped prednisolone completely. No patient experienced a relapse of GCA while receiving ustekinumab. Median (IQR) CRP decreased significantly from 12.9 (5.3, 42) to 6 (2.6, 12.5)mg/L (p = 0.006). CT angiography demonstrated improvement of LVV in all patients studied. No unexpected adverse events were observed with ustekinumab. CONCLUSIONS Ustekinumab may be effective for the treatment of GCA and warrants further assessment in a randomized controlled trial.

SAT0319 Description of musculoskeletal symptoms in a cohort of patients with psoriasis

Background The BIOmarkers of COMorbidities (BIOCOM) in Psoriasis (Pso) study is a longitudinal study which aims to identify clinical, genetic or protein biomarker features associated with the development of co-morbidities, notably Psoriatic Arthritis (PsA) in patients with Pso. Pso usually precedes the development of PsA with an average interval of 10 years. Thus, Pso patients are an ideal group in which to study the early events in the evolution to PsA. Objectives Herein we describe the baseline clinical features in this BIOCOM cohort. Based on these features, we categorise patients into groupings which may be helpful during long-term follow-up. Methods Patients are being recruited from the dermatology clinics at St. Vincent’s University Hospital, Dublin. Inclusion criteria included a diagnosis of Pso with disease duration of less than 10 years and an age of 18 years or older. Patients with another serious active medical illness, a previous diagnosis of inflammatory arthritis or those who were receiving systemic immunosuppressant therapy for Pso were excluded Following recruitment, patients were assessed for musculoskeletal (MSK) signs or symptoms: questionnaire detailing history of any MSK complaints including inflammatory back pain, full physical examination including evidence of tender or swollen joints and entheseal tenderness (using the Leeds Enthesitis Index) and routine blood testing including inflammatory markers. If patients had any MSK findings they underwent routine radiographs, MRI scanning or ultrasound scanning as indicated. Patients were then categorised using all information available as follows: Pso only; Pso+: MSK signs or symptoms but insufficient for diagnosis of PsA; PsA (CASPAR): Diagnosis of PsA meeting CASPAR criteria; Other Rheumatic Disease.Abstract SAT0319 – Table 1 Breakdown of Features of Inflammatory Articular Disease MSK Finding(s) No. of Patients (total 96) Tender or Swollen Joint(s) (T/S J) only 41 Enthesitis (E) only 12 Inflammatory Back Pain (IBP) only 10 T/S J and E 20 T/S J and IBP 3 E and IBP 2 T/S J, E and IBP 8 Of these 96 patients, 79 patients had some additional imaging studies. Results To date 190 patients with Psoriasis have been recruited. Of those, 9 were excluded due to a diagnosis of Pso >10 years previously. One was excluded due to a previous diagnosis of JIA Of the remaining 180 patients: 106 were male (58.9%). Mean age was 41.5±14.8 years. Average duration of Pso: 6.1±2.9 years. On examination: 126 (70%) had psoriatic nail disease (pitting, ridges or onycholysis). 84 patients had no musculoskeletal signs or symptoms. The remaining 96 patients had at least one musculoskeletal finding as outlined in table 1 below.Abstract SAT0319 – Table 2 shows how patients were subsequently categorised based on their history, clinical examination, laboratory blood results and imaging. Breakdown of Diagnoses of BIOCOM patients at baseline (180) Pso only 84 Pso+ 64 PsA (CASPAR) 7 Other Rheumatic Disease 25 Conclusions Analysis of patients recruited to date for the BIOCOM-Pso study shows that at baseline at least one third of patients with Pso had non-specific MSK signs and symptoms. Previous studies suggest these patients may be more likely to subsequently develop PsA. By following this cohort prospectively, we hope to better characterise which features are predictive of the development of PsA in patients with Pso. Disclosure of Interest None declared

AB0730 Psoriatic Arthritis Patients with Work Disability Have Worse Quality of Life Compared To Those Who Are Employed

Background Work disability (WD) is an important functional outcome measure in inflammatory arthritis, which has been studied comprehensively in rheumatoid arthritis and ankylosing spondylitis, however limited data is available in psoriatic arthritis (PsA). A variety of WD measurement tools are available, but there are no validated and specific guidelines in PsA [1,2]. Objectives In PsA patients with and without WD: (1) to compare patient-reported outcomes (PROs) and physician-assessed measures and (2) to assess whether there are gender-specific differences associated with WD. Methods Consecutive patients with PsA fulfilling the CASPAR criteria were enrolled. Patients on disability pension, those with early retirement due to arthritis, those unemployed, away from work due to sick leave were considered as having WD. Disease activity measures (TJC/68, SJC/66, ESR, CRP, PASI), economic data, patient-reported outcome measures (HAQ, EQ-5D, SF-36, BASDAI, BASFI, ASQoL, DLQI, pain VAS, average level of fatigue), radiographic damage, medication history and comorbidities were compared between employed and work-disabled patients in both genders using Mann-Whitney pairwise and chi-square test. Results 81 patients completed the economic questionnaire. Thirty-eight (17 male and 21 female) participations of working age had work disability versus forty-three (20 male, 23 female) employed patients. Out of 81 patients, 27 were biologic-naïve and 54 had ever been on biologic agents. We have found no significant differences in disease activity measures or in the number of erosions between work-disabled and employed patients. On the other hand patients with WD had significantly worse self-reported values in both gender groups, especially in females. The total number of comorbidities (p=0.020) and coexistent rheumatic diseases (p=0.025) were significantly higher among patients with WD. Work-disabled patients had more healthcare-related appointments and required more help (p=0.001), including home care and assistance travelling to the hospital. Conclusions Consistent with previous studies, in this cross-sectional cohort we have observed that rates of WD are high (46.9%) among patients with PsA with no difference between males and females. Despite similar disease activity and structural damage measures, patients with WD had worse physical function and overall reduced quality of life compared to employed patients. These differences were more pronounced in females, who had more physical and social limitations related to PsA. References Tillett, W., C. de-Vries, and N.J. McHugh, Work disability in psoriatic arthritis: a systematic review. Rheumatology, 2012. 51(2): p. 275–283. Wallenius, M., et al., Work disability and health-related quality of life in males and females with psoriatic arthritis. Ann Rheum Dis, 2009. 68(5): p. 685–9. Disclosure of Interest None declared

FRI0417 Prevalence of Osteoporosis in An Ankylosing Spondylitis Cohort

Background The Ankylosing Spondylitis Registry of Ireland (ASRI) is a web-based database established in 2013, the objectives of which are to provide descriptive epidemiological data on the ankylosing spondylitis (AS) population in Ireland and to establish a registry for potential future studies of genetics, aetiology and therapeutics. The prevalence of osteoporosis is higher in AS patients than age- and sex-matched controls, with potential for vertebral fractures increased. However, the true prevalence is unknown. There is no data on the prevalence of osteoporosis in an Irish cohort. Objectives To determine the prevalence of low bone mineral density (BMD) in an Irish AS cohort. Methods A standardised detailed clinical assessment was performed on each patient. Disease activity was assessed by Bath AS Disease Activity Index (BASDAI), function by the Bath AS Functional Index (BASFI) and Health Assessment Questionnaire (HAQ) and quality of life by AS Quality of Life (ASQoL). Structured interviews provided patient-reported data. Presence or absence of dual-energy x-ray absorptiometry (DXA) testing and result was recorded. Bone mineral density (BMD) was categorised according to the World Health Organisation criteria into normal BMD, osteopenia or osteoporosis. Statistical analysis was performed using SPSS. Results As of October 2015, 416 patients are enrolled in ASRI: 78.1% males, mean age 47.95 (SD 12.4), mean disease duration 20.9 years (SD 12.2), average delay to diagnosis of 8.8 years (SD 8.3). Mean BASDAI is 3.8 (SD 2.5), BASFI 3.7 (SD 2.7), HAQ 0.53 (SD 0.51) and ASQoL 6.15 (SD 5.5). DXAs have been performed in 24.75% (n=103) of the cohort, of which 39.8% (n=41) have osteopenia and 10.7% (n=11) have osteoporosis. Low BMD is significantly correlated with men and advancing age. There is no association with disease activity or duration. Low BMD is more prevalent in patients treated with one or more biologics compared to those never treated. The self-reported prevalence of osteoporosis is 6.4% (n=27; 19 males). Conclusions There is an elevated prevalence of low BMD in this cohort, with no association with disease severity. The majority of affected patients were unaware, as demonstrated by the low self-reported prevalence. More research and education is needed. Disclosure of Interest None declared