Sibel Zehra Aydin

The Psoriatic Arthritis Registry of Turkey: results of a multicentre registry on 1081 patients.

Objective. The aim was to assess the characteristics of PsA, find out how well the disease is controlled in real life, demonstrate the treatments and identify the unmet needs. Methods. The PsA registry of Turkey is a multicentre Web-based registry established in 2014 and including 32 rheumatology centres. Detailed data regarding demographics for skin and joint disease, disease activity assessments and treatment choices were collected. Results. One thousand and eighty-one patients (64.7% women) with a mean (S.D.) PsA duration of 5.8 (6.7) years were enrolled. The most frequent type of PsA was polyarticular [437 (40.5%)], followed by oligoarticular [407 (37.7%)] and axial disease [372 (34.4%)]. The mean (S.D.) swollen and tender joint counts were 1.7 (3) and 3.6 (4.8), respectively. Of these patients, 38.6% were on conventional synthetic DMARD monotherapy, 7.1% were on anti-TNF monotherapy, and 22.5% were using anti-TNF plus conventional synthetic DMARD combinations. According to DAS28, 86 (12.4%) patients had high and 105 (15.2%) had moderate disease activity. Low disease activity was achieved in 317 (45.7%) patients, and 185 (26.7%) were in remission. Minimal disease activity data could be calculated in 247 patients, 105 of whom (42.5%) had minimal disease activity. The major differences among sexes were that women were older and had less frequent axial disease, more fatigue, higher HAQ scores and less remission. Conclusion. The PsA registry of Turkey had similarities with previously published registries, supporting its external validity. The finding that women had more fatigue and worse functioning as well as the high percentage of active disease state highlight the unmet need in treatment of PsA.

What does evidence-based medicine tell us about treatments for different subtypes of psoriatic arthritis? A systematic literature review on randomized controlled trials

Abstract Objective PsA is a heterogeneous disease with various subtypes of joint manifestations, which can affect the homogeneity of randomized controlled trials (RCTs). The aim of this systematic literature review was to evaluate the inclusion criteria, demographics and outcomes of RCTs to see whether the whole spectrum of PsA was represented. Methods Medline, EMBASE and Cochrane databases were screened for RCTs on the efficacy of any treatment for PsA up to 4 October 2016 to investigate the inclusion criteria, demographics, outcomes and efficacy. Results Two thousand and sixty-eight abstracts were identified at screening; 76 articles and 52 conference proceedings were included in the final analysis. The main inclusion criteria always included the number of active joints and never axial symptoms, enthesitis nor dactylitis. Only 10 studies provided information about subtypes, of which symmetrical polyarthritis was the main subtype. Mean (s.d.) tender and swollen joints were between 7.8 and 35.8 (1.8–22.1) and between 5.2 and 25.2 (1.5–16.2), respectively. All studies had responses in joint counts as their primary outcome. Responses in enthesitis and dactylitis were usually secondary or tertiary outcomes. Response in BASDAI was among the outcomes in four studies. The comparison of efficacy in polyarticular vs oligoarticular disease was given in three studies, whereas no information was available for DIP joint disease or arthritis mutilans. Conclusion There is evidence in the literature to guide clinicians on how to treat PsA patients with polyarticular disease, but there is a gap in knowledge about the other subtypes. Protocol registration The study protocol is registered at PROSPERO (CRD42017053907).

Greater magnitude of entheseal microdamage and repair in psoriatic arthritis compared with ankylosing spondylitis on ultrasound

Objectives AS and PsA share clinical and immunological features centred on enthesitis. However, a strong association between PsA and preceding injury has been recognized. The aim of this study was to test the hypothesis that the entheseal damage seen by US is commoner in PsA patients than in AS patients. Methods Seventy-nine AS and 85 PsA patients had US scans of 1640 entheses to calculate entheseal inflammation (hypoechogenicity, thickening and Doppler) and damage scores (calcifications, enthesophytes and erosions). Regression modelling was done to evaluate the effect of diagnoses on outcomes, controlling for age, gender, BMI, clinical enthesitis, HLA-B27, and anti-TNF use. Results Both inflammation and damage scores on US were correlated with BMI (r = 0.392; r = 0.320) and age (r = 0.308; r = 0.538) (P < 0.001), and men had higher inflammation scores than women [12.3 (7.5) vs 8.9 (7.3), P = 0.001]. In multivariate analysis, despite similar (anti-TNF-treated patients) or slightly less inflammation (anti-TNF-naïve patients) in the PsA group, they had 4.22 times more US damage than their counterparts with AS. The difference was even higher in the anti-TNF-naïve patients (5.6 times). Conclusion On US assessment, PsA patients have greater entheseal insertion damage scores compared with AS, suggesting potential differences in tissue repair, immunobiology or response to injury at insertions.

Axial psoriatic arthritis: the impact of underdiagnosed disease on outcomes in real life

Psoriatic arthritis (PsA) may affect different joints, including the spine. The prevalence of spinal involvement is variable depending on the definition and a subset of patients have been identified in cohorts that do not have clinical features of axial disease and yet have imaging findings. Still, there is not a consensus on how and when to screen axial disease. In this study, we aimed to investigate factors associated with being underdiagnosed for axial psoriatic arthritis (axPsA) and its impacts on outcomes. Disease features and outcomes of axPsA according to the physician (n = 415) were compared with patients with imaging findings only (sacroiliitis fulfilling the modified New York criteria, n = 112), using data from a real-life PsA registry. Patients with imaging findings only were more frequently women (83/220 (37.7%) vs 29/122 (23.8%); p = 0.008). This group also had higher peripheral disease activity (imaging only vs clinical AxPsA: mean (SD) tender joint count 5.3 (6.1) vs 3.3 (4.7), swollen joint count 1.9 (2.9) vs 1.2 (2.4); p < 0.001 for both comparisons) and was less often treated using TNF inhibitors (16.1 vs 38.2%; p < 0.001) than patients who were classified as axPsA. Patient-reported outcomes were similar in both groups. PsA patients, especially women with more severe peripheral disease, have a higher risk of being underdiagnosed for axPsA. The severity of peripheral symptoms may be a risk factor to mask the spinal features of PsA.

SAT0353 Geographical differences in psoriatic arthritis: a transatlantic comparison

Background The environmental and genetic factors play a crucial role in the pathogenesis of psoriatic arthritis (PsA) which may cause a difference in disease characteristics for patients from different geographical regions. Objectives The aim of the study was to explore the disease characteristics, treatment choices and comorbidities in patients with PsA in different countries to see the impact of geographic factors. Methods PsArt-ID (Psoriatic Arthritis- International Database) is a prospective, multicentre registry in PsA, which was initially developed in Turkey in 2014, with participation of Canada since 2015 and Italy since 2017. Patients with PsA are consecutively registered to this registry with the aim of investigating the real-life data. Patient characteristics across Turkey (n=1283) and Canada (n=119) are compared for this analysis.Abstract SAT0353 – Table 1 The demographics and clinical characteristics in two countries TURKEY CANADA p value Female* 827/1283 (64.5) 60/119 (50.4) 0.002 Age (years) 47 (36–56.7) 49 (34–61) <0.001 BMI (kg/m2) 27.47 (24.5–31.2) 29 (23.7–33.5) 0.013 At onset age for PsA 36 (29–49.7) 39 (30–48) 0.058 Smoking (package/years) 10 (3–19.7) 14.5 (5–26.25) 0.007 Education years 8 (5–12) 15 (13–16) <0.001 SJC 2 (1–5) 2 (1–7) 0.461 TJC 4 (2–8) 6.5 (2–17) 0.340 TEP 2 (1–2) 1 (1–2) 0.021 BSA 5 (1–13.75) 1 (0–5) <0.001 BASDAI 37 (20–54) 38 (22–58) 0.027 Pt GA 45 (20–60) 31 (12–70) <0.001 PGA 30 (20–50) 34 (18–66) <0.001 Pain VAS 40 (20–60) 33 (18–78) <0.001 TJC: tender joint counts; TEP: tender entheseal points; BSA: body surface area; PtGA: patient global activity; PGA: physician global activity. All data were given n/total n (percentage (%))* or median (first-third percentiles).Abstract SAT0353 – Figure 1 The distribution of the treatment choices in Turkey and Canada, excluding patients with new diagnosis at the time of recruitment. DMARD: Disease-modifying anti-rheumatic drug; anti-TNF: anti-tumour necrosis factor. All data were given n/total n (percentage (%). Results Canadian patients were older at the time of recruitment (Table). They also were more frequently smokers, had higher duration of education and higher BMI than patients in Turkey. Patients in Canada had more frequent polyarthritis (66.7% vs 39.6%, p<0.001), DIP joint disease (34.2% vs 16%, p<0.001), dactylitis (38.1% vs 29%, p=0.037) nail involvement (55.9% vs 45.7%, p=0.008) and higher number deformed joints (29.3% vs 20.7%, p=0.035) whereas Turkish patients had oligoarthritis more often (37.6% vs 24.8%, p=0.016). For disease activity, tender and swollen joint counts were similar for whereas the skin activity was higher in Turkish patients. There were no major differences between countries regarding treatment choices with similar frequencies of patients on biologic therapies (34.5% vs 30.2%, p=0.339) (figure 1). Although the numbers were very low, there was more frequent cancer in Canada than Turkey (4.3% vs 1.4%, p=0.022) whereas all the other comorbidities were similar. Conclusions Geographical differences have impacts on the disease features in PsA, which may be due to genetic, environmental and cultural differences. The treatments are comparable suggesting a similar approach by the physicians. Disclosure of Interest None declared

SAT0063 A prospective study on comparison of composite indices with ultrasound for detecting remission and prediction of flare in 2 years

Background Treat-to-target (T2T) approach suggests using a composite index when following patients with rheumatoid arthritis (RA) without identifying which one to use. Objectives In this prospective study we aimed to compare the accuracy of different indices for RA patients in remission taking Ultrasound Global Synovitis Score (GLOESS) as a gold standard and their predictive value for flares in 2 years. Methods RA patients who were considered to be in clinical remission according to the clinician were recruited. Disease activity was assessed using DAS28-CRP, CDAI, SDAI and RAPID-3 and 38 joints per patient were scanned by US and scored according to GLOESS. The total GLOESS scores were calculated for 38 joints and also for 28 joints by excluding the MTP joints. The number of joints with ≥2 GLOESS was calculated. Flare data was collected in 3 subsequent visits in the following 2 years, whenever available. Results Ninety-six consecutive patients (80.2% females) were recruited. Patients were more frequently categorized as being in remission using DAS28 (80%) compared to CDAI (50%), SDAI (45.2%) and RAPID 3 (37.5%). Patients that were in remission according to CDAI had lower GLOESS scores on 28 joints (p=0.05) and had less joints with ≥2 signals (p=0.04) (table). For SDAI patients in remission had significantly less number of joints with grade 3 signals (p=0.03) and tend to have lower GLOESS scores on 28 joints as well as lower number of joints with ≥2 signals (p=0.06). None of the US scores were able to differentiate different disease states according to DAS28-CRP or RAPID. Flare data was available in 76 patients, 22 of whom had flares. Patients that had flare had higher GLOESS scores on 28 joints at baseline (p=0.05) and tend to have higher number of joints with grade 3 signals (p=0.06). Although numerically higher, none of the clinical indices were able to predict flares based on remission status (remission vs non remission: CDAI: 22.5% vs 36.1, p=0.2; SDAI: 22.9 vs 36.8, p=0.2; DAS28: 25.4% vs 50%, p=0.1; RAPID3: 20% vs 34.8%, p=0.2).Table 1. The distribution of US-GLOESS according to different categories by indices GLOESS 38 joints GLOESS 28 joints Joint counts ≥ score 2 Joint counts with score 3 mean±SD mean±SD mean±SD mean±SD DAS-28  Remission (n=77) 10.9±7.5 7.8±7.2 3.5±3.1 0.7±1.3  LDA (n=11) 14.5±6.6 10.0±5.4 4.9±3.0 0.9±1.4 VMDA (n=5) 9.6±6.2 5.4±3.5 3.0±2.3 0.80±1.7 CDAI  Remission (n=48) 10.0±6.9 6.9±6.2 3.02±2.7 0.60±1.0  LDA (n=48) 12.7±7.7 9.1±7.2 4.3±3.3 0.94±1.5 SDAI  Remission (n=42) 9.9±6.6 6.6±5.9 2.9±2.6 0.5±0.9  LDA (n=50) 12.4±7.8 9.1±7.5 4.2±3.3 0.9±1.5  MDA (n=1) 13.0 4.0 5.0 0 RAPID  Remission (n=36) 10.3±6.2 6.7±4.6 3.1±2.6 0.5±0.8  Low activity (n=28) 9.6±5.8 6.6±4.6 2.7±2.2 0.3±0.7  MDA (n=30) 14.0±9.4 10.7±9.7 5.1±3.9 1.4±1.9  HDA (n=2) 15±1.4 8.5±2.1 5±1.4 0 LDA: Low disease activity MDA: Moderate disease activity HDA: High Disease activity. Conclusions Our results show that CDAI is superior then other clinical indices to assess remission in RA. US has the superiority over clinical indices to predict flares and 28 joint GLOESS is superior to 38 joints. Disclosure of Interest None declared

SAT0582 Psoriasis Symptom Inventory is a Valid Patient-Reported Instrument for the Assessment of Skin Severityin Psoriatic Arthritis

Background Skin involvement in psoriatic arthritis (PsA) has significant impacts on health-related quality of lives in addition to the joint involvement. Due to this impact, its important to assess the severity of psoriasis to fully capture disease activity in PsA. In this study we aimed to test the validity of “Psoriasis symptom inventory” (PSI) in a cohort of patients with PsA. Methods PsART (Psoriatic Arthritis Registry of Turkey) is a prospective, multicentre, nationwide study in Turkey on patients with PsA. Patients are consecutively recruited to this registry, if they are diagnosed as PsA, regardless of any other disease characteristics. In this registry, PSI data was available in 237 patients. For the PSI the following items were scored on a scale between 0-4, by the patient: itching, redness, scaling, burning, stinging, cracking,flaking and pain. The PSI score was calculated as a sum of these items and ranged between 0-32. The correlations between PSI and other outcome measures were investigated. Results The mean (SD) age and BMI were 44.7 (12.3) and 28.7 (5.6), respectively. Sixty-six percent of the patients were female. The duration of psoriasis in this group was 167.3 (124.2) months. Mean (SD) PSI scores were 6.7 (6.7) with a range of 0-32. PSI scores were found to be significantly correlated to patient (R=0.338) and physician global assessments (R:0.342), fatique (R=0.226), pain (R=0.334) (p<0.001 for all comparisons) and HAQ (R=0.198; p=0.007). PSI was also correlated to body surface area involved, measured by the physician (R=0.256, p=0.07). Conclusions PSI has a good construct validity in comparison to other clinical assessment tools. Due to its high feasibility, PSI can be a useful tool to investigate and record the severity of psoriasis in PsA in clinical practice. Disclosure of Interest None declared

AB0829 Demographics of Patients with New-Onset Psoriatic Arthritis: Real Life Data from an Inception Cohort: Table 1.

Background Psoriatic arthritis is a complex disease with a wide range of manifestations. In this inception cohort of PsA patients we aimed to identify the initial manifestations as well as disease activity characteristics and compare with an unselected group of patients with longstanding disease. Methods PsART (Psoriatic Arthritis Registry of Turkey) is a prospective, multicentre study in Turkey on patients with PsA. Patients are consecutively recruited to this registry. Patients who have been newly diagnosed with PsA have been identified, and their characteristics were compared with longstanding disease. Results Within 746 patients recruited, 111 (14.9%) had a new diagnosis for PsA. Patients in the inception cohort were significantly younger than the rest of the cohort (p=0.03) (table). Females were 53.2% of the inception and 66.8% of the non-inception cohort (p=0.007). For types of joint patterns, 14.4% of the inception cohort had only axial involvement whereas this was seen in 8.2% for the other group (p=0.05). The other joint patterns were comparable among groups. Both groups had similar tender and swollen joint counts, BASDAI and BASFI. Patient (p=0.002) and physician global assessments (p<0.001), fatigue (p=0.02), duration of morning stiffness (p=0.02) and CRP (p=0.05) were higher in the inception cohort. Female patients had higher patient global assessment and fatigue scores despite similar physician global assessment, swollen and tender joint counts, BASDAI, BASFI and CRP with males in non-inception cohort. For the inception cohort, there were no differences between the 2 genders.Table 1. Disease characteristics of the groups Inception cohort Non-inception cohort Whole group Females Males Whole group Females Males n 111 59 52 635 424 211 age 42.5 (12.3) 44.4 (12.5) 40.4 (11.7) 45.5 (12.9) 46.7 (13) 43.1 (12.4) SJC 2.7 (3.4) 2.5 (3.2) 3 (3.6) 1.6 (2.8) 1.5 (2.8) 1.6 (2.7) TJC 4.1 (4) 3.8 (3.7) 4.5 (4.2) 3.4 (4.7) 3.5 (4.8) 3.4 (4.2) BASDAI* 4.5 (2.4) 4.3 (2.2) 4.8 (2.5) 3.7 (3.8) 3.8 (4.3) 3.5 (2.6) BASFI* 3.2 (2.4) 3 (2.3) 3.4 (2.4) 2.8 (2.7) 2.7 (2.7) 2.8 (2.7) Patient global* 4.9 (2.5) 4.7 (2.3) 5.1 (2.6) 3.9 (2.3) 4 (2.3) 3.5 (2.4) Physician global* 4.2 (1.9) 4 (1.6) 4.4 (2.1) 3.1 (2.1) 3.1 (2) 3 (2.2) fatigue* 4.9 (2.5) 5 (2.3) 4.9 (2.7) 4.2 (2.6) 4.5 (2.5) 3.7 (2.8) CRP (mg/lt) 13. 4 (23.4) 9.5 (16.5) 18 (29.1) 8.7 (16.2) 8.6 (16.1) 9 (16.5)* Data given on a scale between 0–10. There were missing data. The number of cases with available information are: BASDAI: 434, BASFI: 413; patient global assessment: 493; physician global assessment 440, fatigue: 506, CRP: 717, tender joint count: 677, swollen joint count: 672. Conclusions More patients present with sole axial involvement at the beginning, which may explain the higher disease activity agreed by the patient and the physician despite similar tender and swollen joint counts. Females may have a different perception of the disease with worse patient global assessments and fatigue in longstanding disease. Disclosure of Interest None declared

AB0827 Hydroxychloroquine Does not Increase Psoriasis in Psoriatic Arthritis: Time on Drug Analysis Based on Real Life Data

Background Antimalarials have been reported to worsen preexisting psoriasis, therefore is commonly avoided by the clinicians in the treatment of psoriatic arthritis (PsA). With the lack of any solid evidence, this precludes the potential use of hydroxychloroquine (HQ) as a part of the treatment. Objectives We aimed to analyze PsA patients who are treated with HQ, identify the time on drug and reasons of discontinuation of HQ. Methods PsART (Psoriatic Arthritis Registry of Turkey) is a prospective, multicentre, nationwide study in Turkey on patients with PsA. Patients are consecutively recruited to this registry, if they are diagnosed as PsA, regardless of any disease characteristics. From the registry, patients who have ever used HQ were identified including the time on HQ, whether they still continue to treatment, and the reasons of discontinuation in case of a withdrawal. Results Until December 2014, 746 patients were recruited. 114 patients (15.3%) were either currently using or have been used HQ previously. 51.8% of these patients were currently using HQ (fig 1). The distribution of joint patterns were 50.9% polyarthritis, 30.7% oligoarthritis, 2.6% monoarthritis, 13.2% distal interphalangeal joint involvement, 26.3% axial disease, including patients who had combinations of different patterns. Joint patterns were not different among patients who had ever used HQ or not. The duration of HQ treatment was 41.4 (SD:38.4) months among current users vs 45.6 (SD:51.2) months in withdrawers. The reason of discontinuity could be identified in 44/55 among non-users. Within these 44 patients the most frequent reason was inefficacy (n=25) and incompliance of the patient (n=7). Retinopathy was observed in 5 patients. Liver function test abnormalities, pregnancy, hyperpigmentation of the skin, step down for being in remission and nausea were observed in 1 case each and were reported to be the reason of stopping the treatment. There were only 2 cases who had to discontinue treatment because of an increase in psoriatic lesions. One of these patients used HQ for one month and the other patient for 21 months. Conclusions These data show that only 2/114 patients had an increase in psoriatic lesions in PsA in a mean duration of 3.5 years due to the HQ treatment suggesting that HQ is a safe treatment choice in PsA. The efficacy and added benefits of HQ in terms of reducing cardiovascular risk factors cannot be enclosed with this registry. Disclosure of Interest None declared