V. Pacucci

Citrullination and autoimmunity

Autoimmune diseases are characterized by the bodys own immune system attack to the self-tissues, a condition enabled, in predisposed subjects, by the reduction of self-tolerance. A central role has been recently recognized to post-translational modifications, since they can promote generation of neo-(auto)antigens and in turn an autoimmune response. During the last years great attention has been paid to citrullination, because of its role in inducing anti-citrullinated proteins/peptide antibodies (ACPA), a class of autoantibodies with diagnostic, predictive and prognostic value for Rheumatoid Arthritis (RA). Nonetheless, citrullination has been reported to be a process present in a wide range of inflammatory tissues. Indeed, citrullinated proteins have been detected also in other inflammatory arthritides and in inflammatory conditions other than arthritides (polymyositis, inflammatory bowel disease and chronic tonsillitis). Moreover, environmental exposure to cigarette smoke and nanomaterials of air pollution may be able to induce citrullination in lung cells prior to any detectable onset of inflammatory responses, suggesting that protein citrullination could be considered as a sign of early cellular damage. Accordingly, citrullination seems to be implicated in all those para-physiological processes, such as cells death pathways, in which intracellular calcium concentration raises to higher levels than in physiologic conditions: hence, peptidylarginine deiminases enzymes are activated during apoptosis, autophagy and NETosis, processes which are well-known to be implicated in autoimmunity. Taken together, these data support the hypothesis that rather than being a disease-dependent process, citrullination is an inflammatory-dependent condition that plays a central role in autoimmune diseases.

Flare, Persistently Active Disease, and Serologically Active Clinically Quiescent Disease in Systemic Lupus Erythematosus: A 2-Year Follow-Up Study

Objective Several indices have been proposed to assess disease activity in patients with Systemic Lupus Erythematosus (SLE). Recent studies have showed a prevalence of flare between 28–35.3%, persistently active disease (PAD) between 46%–52% and serologically active clinically quiescent (SACQ) disease ranging from 6 to 15%. Our goal was to evaluate the flare, PAD and SACQ rate incidence in a cohort of SLE patients over a 2-year follow-up. Methods We evaluated 394 SLE patients. Flare was defined as an increase in SLEDAI-2K score of ≥4 from the previous visit; PAD was defined as a SLEDAI-2K score of ≥4, on >2 consecutive visits; SACQ was defined as at least a 2-year period without clinical activity and with persistent serologic activity. Results Among the 95 patients eligible for the analysis in 2009, 7 (7.3%) had ≥1 flare episode, whereas 9 (9.4%) had PAD. Similarly, among the 118 patients selected for the analysis in 2010, 6 (5%) had ≥1 flare episode, whereas 16 (13.5%) had PAD. Only 1/45 patient (2.2%) showed SACQ during the follow-up. Conclusion We showed a low incidence of flare, PAD and SACQ in Italian SLE patients compared with previous studies which could be partly explained by ethnic differences.

Evaluation of the Patient Acceptable Symptom State (PASS) in Italian Patients Affected by Systemic Lupus Erythematosus: Association with Disease Activity Indices

Objectives The aim of this study was to evaluate the discriminant capability of the patient acceptable symptom state (PASS) according to disease activity, in a cohort of Italian patients affected by systemic Lupus erythematosus (SLE). Methods Consecutive SLE patients were enrolled. At each visit, the patients underwent a complete physical examination and the clinical/laboratory data were collected in a standardized, computerized, and electronically-filled form. The evaluation of serum complement C3 and C4 levels and determination of autoantibodies was obtained. Disease activity was assessed with the SLEDAI-2K and ECLAM, while chronic damage was measured with the SLICC. Finally, PASS was assessed in all patients by asking to answer yes or no to a single question. Results One hundred sixty-five patients were enrolled (M/F 12/153; mean age 40.4±11.8 years, mean disease duration 109.1±96.2 months). No patients refused to answer, suggesting the acceptability of PASS. A total of 80% of patients rated their state as acceptable. The patients with an acceptable status had significantly lower mean SLEDAI-2K and ECLAM scores than the others [1.8±2.7 versus 3.4±2.3(P=0.004); 0.7±0.9 versus 1.4±1.1(P=0.0027)]. No significant differences were observed when considering chronic damage, evaluated with SLICC. Conclusions In the clinical practice, SLE patients assessment performed by using complex disease activity indices such as SLEDAI-2K and ECLAM, could be time consuming. In our study, for the first time, we used PASS, a quick and easily comprehensible tool, to evaluate the patients’ status, this single question seems to be able to discriminate patients with different disease activity, especially when this is determined by musculoskeletal involvement.

The role of disease activity score 28 in the evaluation of articular involvement in systemic lupus erythematosus.

Objectives. To evaluate the application of Disease Activity Score 28 (DAS28) to assess joint involvement in Systemic Lupus Erythematosus (SLE). Methods. Sixty-nine SLE patients, complaining of joint symptoms, and 44 rheumatoid arthritis (RA) patients were enrolled. In SLE patients disease activity was assessed with SLEDAI-2K. DAS28 was calculated in all the patients. Results. Thirty SLE patients (43.5%) showed clinical signs of arthritis. Mean DAS28 was 4.0 ± 1.4, 22 patients (31.9%) had low disease activity, 29 (42.0%) moderate, and 18 (26.1%) high. We dichotomized SLE patients according to the presence (Group 1) or absence (Group 2) of articular involvement according to SLEDAI-2K: 56.3% of the patients of the second group had a moderate/high activity according to DAS28. We compared SLE patients with 44 RA patients (M/F 9/35, mean age 55.6 ± 14.5 years; mean disease duration 140.4 ± 105.6 months). No significant differences were found regarding the values of DAS28 between SLE and RA patients. On the contrary, the values of tender and swollen joint count were significantly higher in RA compared to SLE patients (P = 0.0002 and P = 0.0001, resp.). Conclusions. We suggest the use of the DAS28 in the assessment of joint involvement in SLE patients.

AB0036 Association between synovitis and inflammatory citokines serum levels in a cohort of patients affected by primary knee osteoarthritis

Background Osteoarthritis (OA) is characterized by progressive loss of cartilage, deterioration of subchondral bone and mild synovial inflammation. Classified for a long time as a non-inflammatory arthropathy, a growing number of evidences has suggested that OA course could be driven by systemic and localized inflammation. In particular, serum levels of Interleukin (IL)-6 have been associated with higher prevalence of osteophytes in older adults with knee OA. Furthermore, high levels of other inflammatory cytokines have been identified in serum and synovial fluid of OA patients. Objectives In the present cross-sectional study, we aimed at analyzing the correlation between articular inflammatory state, reflected by ultrasonographically-detected synovitis, and the serum levels of 27 cytokines, chemokines and growth factors in a cohort of primary knee OA. Methods We consecutively enrolled 47 patients (M/F 16/31, mean age ±SD 63.8±7.8 years, mean onset interval ±SD 70.0±78.6 months) affected by knees OA according to clinical and radiographic ACR criteria. Patients were excluded if they had received non-steroidal anti-inflammatory drugs or other analgesics within the 2 days before enrollment. Pain was assessed with a 100-mm visual analogue scale (VAS), and the Lequesne algo-functional index was used to measure the OA severity. BMI was registered. Each patient underwent ultrasonographic (US) assessment of both knees performed by a single operator. According with OMERACT definitions, we assessed the presence of synovial effusion, synovial hypertrophy and power Doppler. These elementary lesions were scored according to a semi-quantitative scale (0 = absent, 1 = mild, 2 = moderate and 3 = severe), the sum of them allows obtaining a total score of the patients inflammatory state (0–18). Finally, blood samples for laboratory assays were obtained and commercially available multiplex bead based immunoassay kits (Human 27-plex, Bio-Rad laboratories, Hercules, CA) were used to measure concentrations of IL-1β, IL-1RA, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12, IL-13, IL-15, IL-17, FGF-Basic, G-CSF, GM-CSF, interferon-γ, IP-10, MCP-1, MIP-1α, MIP-1β, PDGF, RANTES, TNF, VEGF. Results At the study enrollment, OA patients showed a mean±SD US synovitis score of 4.4±2.7, a mean±SD VAS pain rating of 53.3±16.6 mm (range 18–90 mm), a mean±SD Lequesne index of 10.2±4.2 (range 1.5–19), a mean±SD BMI of 26.8±4.2 (range 20–34.7). Positive correlations among US synovitis score and serum levels of IL-6 (r=0.3, p=0.01), IL-2 (r=0.3, p=0.01), IL-5 (r=0.3, p=0.01), IL-7 (r=0.3, p=0.03), MIP-1b (r=0.3, p=0.01), VEGF (r=0.3, p=0.02) were found. Moreover, US synovitis score positively correlated with Lequesne index (r=0.4, p=0.004) and BMI (r=0.4, p=0.04). Conclusions The results of the present study confirmed that OA may be associated with systemic inflammatory changes, as demonstrated by the positive correlation between US synovitis and several inflammatory cytokines serum levels. Disclosure of Interest None declared

FRI0328 A Complete Remission Lasting at Least One Year Influences The Outcome in Patients Affected by SLE: Results from A Large Monocentric Cohort

Background The achievement of complete remission is one of the most important goal in the management of patients with Systemic Lupus Erythematosus (SLE). Even though a definition of remission has been proposed (complete absence of any clinical and serological sign or symptom of activity) and the concomitant acceptable treatment (including antimalarial drugs only) has been identified, however the minimum lapse of time is still controversial. This issue is of primary importance in a disease characterized by a relapsing-remitting course. Several cut-off have been suggested, ranging from 1 to 5 years. Objectives The primary end-point of the present study was to analyze the frequency of complete remission lasting at least 1 year in a large monocentric SLE cohort. Furthermore, we aimed at evaluating its association with different clinical and serological parameters and its impact on the chronic damage accrual. Methods Data on Caucasian SLE patients, diagnosed according to the ACR Classification Criteria for SLE, were collected. We included in the present analysis SLE patients evaluated at least twice per year during the last 5 years. The frequency of complete remission, defined as an SLE Disease Activity Index 2000 (SLEDAI-2k) =0, was assessed in glucocorticoid-free and immunosuppressant-free patients. Antimalarial drugs were the only SLE-related acceptable treatment. Results Our database includes 658 SLE patients evaluated at least once. From these patients non-Caucasian were excluded, resulting in 622 patients. Among these, 179 (M/F 13/166, mean age 46.3±12.7 years, mean disease duration 173.9±101.9 months) fulfilled the above-reported selection criteria. During the 5-year follow-up, 27 patients (15.1%) experienced a complete remission lasting for at least 1 year, with a mean duration of 37.5±15.8 months. Notably, six patients experienced a prolonged complete remission lasting 5 years (4.6%). There were no significant differences in terms of demographic characteristics between patients achieving and those not achieving remission. Patients in remission showed a significantly lower frequency of renal involvement (29.0 vs 18.4, P=0.04) and low C3 and C4 (14.8% vs 36.8%, P=0.0005; 14.8% vs 33.5%, P=0.0002, respectively). There were no other differences in terms of clinical and laboratory features. The frequency and the severity of chronic damage, evaluated by SLICC Damage Index (SDI), resulted significantly lower in patients achieving remission (11.1% vs 51.9%, P<0.000001; 0.48±0.8 vs 0.8±1.2, P=0.03, respectively). The length of the remission status did not influence the chronic damage. At the multivariate analysis, no independent factors were associated with remission; conversely, low C3 resulted a risk factor for absence of remission (OR=0.15, 95% CI 0.03–0.06). Conclusions In the present SLE cohort, a complete remission lasting at least 1 year has been identified in 15% of patients. The remission status, regardless of its duration, is associated with a lower chronic damage, in terms of frequency and severity. These results suggest that the achievement of a state of remission lasting at least one year may represent a favorable prognostic factor in patients with SLE. Disclosure of Interest None declared

THU0397 Safety and Survival of Rituximab Treatment in Systemic Lupus Erythematosus Versus Rheumatoid Arthritis Patients: A 10 Years Observational Study

Background The anti-CD20 monoclonal antibody rituximab (RTX) is an effective treatment option for patients with systemic lupus erythematosus (SLE) refractory to conventional therapies. The safety of this drug has been widely analyzed in randomized controlled clinical trials in patients with rheumatoid arthritis (RA); on the contrary, there are few data on patients with SLE. Objectives We aimed to evaluate the safety and survival of treatment with RTX in patients with SLE and RA in a 10 years observational study. Methods We evaluated the clinical history and laboratory data of patients with SLE (1997 ACR revised criteria) and RA (2010 revised EULAR/ACR criteria) treated with RTX in the period between 2003 and 2013. In all the patients RTX was administered intravenously (IV) according to two different protocols: 1000 mg IV on days 1 and 14, or 375 mg/m2 on days 1, 8, 15, and 22. Each protocol provided for additional cycles of treatment after an interval of at least 6 months. All patients in both groups received oral acetaminophen (1000 mg), methylprednisolone (125 mg IV), and chlorphenamine (10 mg IV) 30 minutes before each infusion to prevent infusion-related adverse events. Written informed consent was obtained from all patients enrolled in the study. In particular, we analyzed the following parameters: duration of therapy, number of cycles, interval between them, infusion-related (IR) and other adverse events leading to discontinuation of RTX treatment. Statistical analysis was performed using the Mann-Whitney test and Fishers exact test; the risk was calculated by dividing the number of events by the number of cases. Results Thirty-three patients with SLE (2M/31F, mean age 41.9±12.1 years, mean disease duration 183.6±74.4 months) and 80 RA patients (15M/65F; mean age 57.5±12.2 years; disease duration 151.2±81.6 months) were treated with RTX. SLE patients were significantly younger compared with RA patients (P<0.0001). SLE patients underwent a total of 87 cycles of therapy (2.6 cycles/patient), compared to 235 in patients with RA (2.93 cycles/patient). The mean duration of treatment was higher in SLE patients than in those with RA (32.7±19.4 months versus 25.5±16.9 months, P=NS). The assessment of the safety profile showed a risk of infusion reactions (IR) significantly higher in patients with RA compared with SLE [12.5% (10/80) versus 3% (1/33); P=0.0007]. In all cases, these events were mild and did not require hospitalization. These IR occurred in 72.7% of cases (8/11) during the first cycle. Concerning other adverse events, only one patient with SLE (3%) developed an infectious disease that caused treatment discontinuation (Legionella Pneumophila pneumonia). No infectious events resulted in treatment discontinuation in patients with RA. Conclusions The results of our study highlight the long-term safety of treatment with RTX in patients with SLE and RA, with a low risk of infusion-related as well as infectious adverse events. The lower incidence of infusion-related AEs in the SLE patients might be related to the higher-dosage steroid therapy they received during the week before RTX infusion. Finally, physicians should be aware that IR adverse events are more likely to occur during the first cycle of therapy. Disclosure of Interest None declared

FRI0431 Evaluation of Self Reported Fatigue in Adult Patients with Systemic Lupus Erythematosus: Association with General Health

Background Systemic Lupus Erythematosus (SLE) is a multifactorial autoimmune disease characterized by a wide range of clinical manifestations. Fatigue represents a frequent symptom reported by SLE patients, mainly at the disease onset, with impact on the quality of life. The assessment of fatigue could be difficult. The Functional Assessment of Chronic Illness version 4 Therapy (FACIT-F) questionnaire has been validated in chronic diseases to assess fatigue in adult patients. Objectives We aimed at assessing the fatigue, by using FACIT-F questionnaire, in a monocentric cohort of SLE patients. Moreover, we evaluated possible associations with others clinical manifestations, laboratory parameters, disease activity and chronicity indices, and, general health (GH) index. Methods In 1 month period, we enrolled consecutive SLE patients, fulfilled the 1997 American College of Rheumatology (ACR) revised criteria. Clinical and laboratory data were collected in a standardized, computerized and electronically filled form, which included demographics, past medical history with date of diagnosis, comorbidities, and previous and concomitant treatments. We assessed the disease activity and chronic damage by using SLEDAI-2K and SDI, respectively. The GH (range 0-100) was assessed. Finally, all the patients completed the FACIT-F, a 13-item questionnaire that assesses self-reported tiredness, weakness, and difficulty conducting usual activities due to fatigue. A five-point intensity type of rating scale (from “not at all” to “very much”) is used. Final scores are the sum of responses and range from 0 to 52; higher scores indicated less fatigue. Results One hundred-nine SLE patients (11M/98F; mean ± SD age 40.7±11.5 years; mean disease duration 130.2±93.5 months) were evaluated. We obtained a mean SLEDAI-2K of 1.9±2.9 and a mean SDI of 0.4±0.7; moreover, the GH was 64.6±19.2. The assessment of FACIT-F showed a mean value of 34.6±11.8; all the patients showed the involvement of at least one item. The item more frequently involved in this cohort was the tiredness, identified in 91.7/% of the patients. A significant correlation between the FACIT-F values and GH was identified (P<0.0001; R=0.65). No significant associations have been identified between FACIT-F and SLEDAI-2K or SDI. Moreover, SLE patients with joint involvement showed a mean FACIT-F values lower than patients without (30.6±11.1 versus 35.4±11.8, P=0.05). Conclusions In the present study the use of FACIT-F demonstrated the presence of involvement of at least one items in all the evaluated patients, with the item related to the tiredness involved in up to 90% of patients. Moreover, the fatigue was significantly associated with the health status, evaluated by GH. The absence of correlation with disease activity suggest the need to evaluate this specific finding also in patients without signs of active disease. Disclosure of Interest None declared

AB0667 Clinical and immunological features in a monocentric cohort of 305 italian patients affected with systemic lupus erythematosus

Objectives To analyze the clinical and immunological features of an Italian cohort of systemic lupus erythematosus (SLE) patients referring to a unique center, and to evaluate their association with specific pattern of disease. Methods Three hundred five consecutive patients followed from September 2008 to July 2011, were evaluated. All the patients satisfied the 1987 revised criteria of the American College Rheumatology. At each visit, the patients underwent a complete physical examination, and the clinical and laboratory data were collected in a standardized, computerized, and electronically-filled form, which included demographics, past medical history with date of diagnosis, comorbidities, and previous and concomitant. Disease activity was assessed using SLEDAI and ECLAM, while chronic damage was measured with SLICC. Patients were divided into subcathegories according with age at onset: <14 years (group 1), 15-50 years (group 2), >50 years (group 3). Results At first we evaluated clinical and laboratory features at time of disease onset. Group 1 patients showed more frequently thrombocytopenia (P=0.006) and less frequently arthritis (P=0.028) compared with group 2 patients. Nonetheless, group 1 patients showed less frequently anti-Ro/SSA compared with group 2 and 3 (P=0.04 and P=0.006, respectively). LAC positivity was more prevalent in group 2 patients (P=0.03). Renal involvement was less frequent in group 3 patients (P=0.04). At time of the first visit, mean disease duration was 12.3±18.6 months. Patients with older than 50 years had a significantly lower frequency of renal involvement than those below 50 years (P=0.003, OR=0.14, 95% CI 0.03-0.6). Presence of anti–dsDNA antibodies was associated with renal involvement (P=0.035, OR=1.9, 95% CI 1-3.64) and with neuropsychiatric involvement (P<0.05, OR=2.59, 95% CI 0.97-7). The presence of anti-2GPI antibodies was associated with hematologic manifestations (P=0.01, OR=1.9 95% CI 1.2-5.7). Anti-2GPI and anti-CL (P=0.04, OR=0.5, 95% CI 0.3-0.6) resulted protective for cutaneous involvement (P=0.006, OR=0.3, 95% CI 0.15-0.74). Anti-La/SSB were associated with hematologic involvement (P=0.03, OR=2.45, 95% CI 1-5.7). No differences in clinical and immunological features were observed when dividing the patients according to gender. Conclusions Our cohort seems to have similar clinical and immunological features when compared with other European cohorts, but Italian patients seem to have a more frequent hematologic involvement and a less frequent neuropsychiatric. We confirm the association between anti-dsDNA antibodies with renal involvement and anti-La/SSB antibodies with cutaneous manifestations. Interestingly, thrombocytopenia was a relatively frequent manifestation at disease onset in younger patients, while renal involvement seems to be a less frequent manifestation at disease onset in older patients. Disclosure of Interest None Declared

AB0395 Evaluation of the organ damage detected by systemic lupus international collaborating clinics/american college of rheumatology (slicc/acr) damage index. a monocentric cross-sectional study on 349 patients affected by systemic lupus erythematosus.

Background The survival and outcome of patients affected by Systemic Lupus Erythematosus (SLE) have improved dramatically over the past 50 years in terms of mortality and morbidity rates. However, the activity of disease and the long-term therapy could be associated with the development of a chronic damage Objectives To evaluate organ damage using SLICC/ACR damage index (SDI) in a large monocentric and well-characterized cohort of patients affected by SLE and to investigate its correlation with clinical, demographic and laboratory features. Methods Consecutive patients affected by SLE (revised ACR criteria) referring to a Lupus Clinic, were enrolled to perform a cross-sectional analysis. At each visit, the patients underwent complete physical examination, and the clinical and laboratory data were collected in a standardized computerized electronically-filled form. Chronic damage was evaluated in all the patients by using SDI. Results In our study, 349 SLE patients (M/F 25/324; mean age at the onset ± SD 29.2±12 years, mean age ± SD 42.7±12.4 years, mean disease duration ± SD 164.9±105.2 months) were enrolled. A SDI value ≥ 1 was observed in 125 patients (35.8%), with a mean SDI value of 1.7±0.9 (range 1-5). Patients with SDI ≥ 1 showed significant higher mean values of age (38.8±11.3 vs 49.7±11.3) and disease duration (135.6±93.1 vs 217.5±105.4) compared with patients without chronic damage. Musculoskeletal was the system most frequently involved (41 patients, 33%), followed by neuropsychiatric manifestations and malignancies, both registered on 24 patients (19%) and the renal involvement (19 pts,15%). Interestingly, neuropsychiatric manifestations were significantly associated with the presence of anticardiolipin antibodies (P=0.0005) and the occurrence of thrombotic events (P=0.0006). Moreover, regarding the development of malignancies, the most frequently types detected in the present cohort were thyroid and mammalian carcinoma (29.2% and 20.8% respectively), according with the higher incidence of disease in female subjects. Conclusions A mild chronic damage, significantly associated with age and disease duration, involving primarily musculoskeletal system, was detected in the present monocentric, large cohort of SLE patients. Moreover, the role of anticardiolipin antibodies in the neuropsychiatric manifestations was underlined. These results confirm that the tight monitoring and the new available therapeutical options allow a better long-time control of disease, with consequent survival improvement. Disclosure of Interest None Declared