Vincenzo Venerito

Cytokine Signatures in Mucocutaneous and Ocular Behçet’s Disease

Behçet’s disease (BD) is a multi-systemic inflammatory disorder consisting of recurrent oral aphthosis, genital ulcers, and chronic relapsing bilateral uveitis; however, many other organs may be affected. Several pro-inflammatory cytokines, mainly derived from Th1 and Th17 lymphocytes, seem to be involved in different pathogenic pathways leading to development of the clinical manifestations. On this basis, the primary aim of our study was to compare a core set of pro-inflammatory cytokines between patients with BD and healthy control (HC). The secondary goal was to evaluate potential correlations between these putative circulating biomarkers, the status of disease activity, and the specific organ involvement at the time of sample collection. Fifty-four serum samples were collected from 46 BD patients (17 males, 29 females, mean age 45.5 ± 11.3 years), and 19 HC (10 males, 9 females, mean age 43 ± 8.3 years). Twenty-five serum cytokines (APRIL/TNFS13, BAFF/TNFSF13B, sCD30/TNFRSF8, sCD163, Chitinase3-like1, gp130/sIL-6Rb, IFNb, sIL-6Ra, IL-10, IL-11, IL-19, IL-20, IL-26, IL-27 (p28), IL-28A/IFN-lambda2, IL-29/IFN-lambda1, IL-32, IL-34, IL-35, LIGHT/TNFSF-14, Pentraxin-3, sTNF-R1, sTNF-R2, TSLP, and TWEAK/TNFSF-12) were simultaneously quantified using a Bio-Rad cytokine bead arrays. Serum concentration of sTNF-R1 (p < 0.01) and sTNF-R2 (p < 0.01) resulted higher in both active and inactive BD than HC, while Chitinase3-like1 (p < 0.05) and gp130/sIL-6Rb (p < 0.01) serum levels were significantly higher in inactive BD, and IL-26 (p < 0.01) in active BD than HC. No differences were observed between inactive and active BD group. In addition, we observed that gp130/sIL-6Rb, sIL-6Ra, IL-35, and TSLP serum levels were significantly enhanced in patients with mucocutaneous manifestations plus ocular involvement (MO-BD) compared to subgroup with only mucocutaneous involvement (M-BD). Our findings may suggest a signature of IL-6, tumor necrosis factor-α as well as of Th17 response in BD patients due to increased levels of gp130/sIL-6Rb, sTNF-R1, sTNF-R2, IL-26, respectively. This evidence could contribute to improve the knowledge regarding the role of these citokines in the induction of specific BD clinical features.

Ten-Year Retention Rate of Infliximab in Patients with Behçet’s Disease-Related Uveitis

ABSTRACT Purpose: To evaluate the 10-year drug retention rate of infliximab (IFX) in Behçet’s disease (BD)-related uveitis, the effect of a concomitant use of disease modifying anti-rheumatic drugs (DMARDs) on drug survival and differences according to the lines of biologic treatment. Methods: Cumulative survival rates were studied using the Kaplan-Meier plot, while the Log-rank (Mantel-Cox) test was used to compare survival curves. Results: Forty patients (70 eyes) were eligible for analysis. The drug retention rates at 12-, 24-, 60- and 120-month follow-up were 89.03%, 86.16%, 75.66% and 47.11% respectively. No differences were identified according to the use of concomitant DMARDs (p = 0.20), while a statistically significant difference was observed in relation to the different lines of IFX treatment (p = 0.014). Visual acuity improved from baseline to the last follow-up visit (p = 0.047) and a corticosteroid-sparing effect was observed (p < 0.0001). Conclusions: IFX retention rate in BD-uveitis is excellent and is not affected by concomitant DMARDs.

Management of Small Vessel Vasculitides.

Inflammation mediated by cells of the immune system and necrosis are the most striking features observed at the histologic level in patients with vasculitides, clinical entities classified according to pathologic findings involving different organs, to etiology, or to size of vessels involved. Small vessel vasculitides (SVV) are a peculiar group of systemic disorders electively involving small intraparenchymal arteries, arterioles, capillaries, or venules and leading to different levels of vascular obstruction, tissue ischemia and risk of infarction; they can be divided into anti-neutrophil cytoplasmic antibody-associated vasculitides and immune complex vasculitides. Despite the significant advances in understanding the whole disease process and pathophysiology of SVV, strong efforts are still needed to draft, share and spread guidelines in the therapeutic management of these protean disorders. After an accurate evaluation of different open or double-blind trials and cohort studies in this review, we analyze the actual medical tools suggested for treating granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, Henoch-Schönlein purpura, cryoglobulinemic vasculitis, anti-glomerular basement membrane disease and hypocomplementemic urticarial vasculitis.

Long-term effectiveness and safety of switching from originator to biosimilar infliximab in patients with Behçet’s disease

Behçet’s disease (BD) is a chronic multisystem inflammatory disorder clinically characterized by the “triple symptom complex,” consisting of recurrent oral aphthosis, genital ulcers, and chronic relapsing bilateral uveitis [1]. Besides this classical clinical pattern, other organs and systems including gastrointestinal tract, musculoskeletal, cardiovascular, and central nervous system may also be involved [2, 3]. The management of BD is often challenging due to its protean clinical features, therefore treatment should be individualized to each patient according to the type and severity of organ involvement [4]. The effectiveness of tumor necrosis factor (TNF) blockers, especially the monoclonal antibody anti-TNF-a infliximab (IFX), for all severe BD manifestations resistant to conventional therapy, has pointed out the critical role of this cytokine in its pathogenesis [5–8]. However, the impending patent expiration and the relatively high costs of anti-TNF agents, have paved the way for biosimilar drugs development, the first of which has been the biosimilar IFX CT-P13. The efficacy and safety of biosimilar IFX has been evaluated in different inflammatory conditions, and approved for all indications of the reference product in several countries [9]. In spite of this, it is still debated whether the biosimilar IFX performs equally to the originator when patients treated with reference IFX are switched to biosimilar in routine care, as small differences in immunogenicity might influence tolerability and outcomes [10]. For this reason, biosimilars remain a hot topic in rheumatology, and some physicians are cautious about their application in clinical practice. To the best of our knowledge, there are scanty data on biosimilar IFX employment in BD [11], some of them with conflicting results, advising caution with regard to the automatic replacement of reference IFX in sustained remission patients [12]. Based on a retrospective chart survey, in the present study we report our experience with biosimilar IFX CT-P13 in patients affected by BD, who were switched from originator IFX. Thirteen patients diagnosed with BD according to the International Study Group criteria or the International Criteria for BD initially treated with originator IFX were switched to biosimilar IFX CT-P13 from March 1st 2017 to May 31st 2017. Retrieved data including gender, ethnicity, age at diagnosis, HLA-B51 haplotype, clinical manifestations for which originator IFX was started, as well as age and concomitant immunosuppressive drugs at switch were collected (Table 1). The study was approved by the local ethics committee according to the Declaration of Helsinki principles. After obtaining informed consent from all patients, originator IFX was replaced with biosimilar CT-P13 at a dosage of 5 mg/kg every 8 weeks. Clinical assessment was done at the last follow-up visit under originator IFX, subsequently after starting biosimilar, every 3 months, and in case of disease relapse, during a whole follow-up period of 12 months. To assess disease activity accurately, the BD current activity form (BDCAF) was used at each examination during the treatment. BDCAF is a tool for the assessment of BD activity, which scores the history of clinical features including mucocutaneous lesions, joint, blood vessel, gastrointestinal, eye involvement, and central nervous system complications, which present over the 4 weeks prior to the day of assessment. The occurrence of adverse events was Giuseppe Lopalco and Vincenzo Venerito equally contributed to this work.

SAT0616 Ten-year retention rate of infliximab in patients with behÇet’s disease-related uveitis

Background To date, a few studies have reported the long-term efficacy of Infliximab (IFX) in Behçet’s disease (BD)-related uveitis.1,2 Nevertheless, it is known that TNF-α inhibitor drugs may lose their efficacy over time due to the formation of anti-drug antibodies, causing secondary failure and influencing the retention rate of these agents.3 In this regard no previous study has specifically investigated IFX retention-rate in BD-related uveitis. Objectives To evaluate the 10 year drug retention rate of IFX in BD-related uveitis, the effect of a concomitant use of disease modifying anti-rheumatic drugs (DMARDs) on drug survival and differences according to the lines of biologic treatment. Methods Cumulative survival rates were studied using the Kaplan-Meier plot, while the Log-rank (Mantel-Cox) test was used to compare survival curves. Results Forty patients (70 eyes) were eligible for analysis. The drug retention rates at 12-, 24-, 60- and 120 month follow-up were 89.03%, 86.16%, 75.66% and 47.11% respectively. No differences were identified according to the use of concomitant DMARDs (p=0.20), while a statistically significant difference was observed in relation to the different lines of IFX treatment (p=0.014). Visual acuity improved from baseline to the last follow-up visit (p=0.047) and corticosteroids-sparing effect was observed (p<0.0001) Conclusions IFX retention rate in BD-uveitis is excellent and is not affected by concomitant DMARDs References [1] Keino H, Okada AA, Watanabe T, et al. Long-term efficacy of infliximab on background vascular leakage in patients with Behçet’s disease. Eye (Lond)2014;28(9):1100–6. [2] Keino H, Okada AA, Watanabe T, et al. Efficacy of Infliximab for Early Remission Induction in Refractory Uveoretinitis Associated with Behçet Disease: A 2-year Follow-up Study. Ocul Immunol Inflamm2017;25(1):46–51. [3] Fabbroni M, Cantarini L, Caso F, et al. Drug retention rates and treatment discontinuation among anti-TNF-α agents in psoriatic arthritis and ankylosing spondylitis in clinical practice. Mediators Inflamm2014;2014:862969. Disclosure of Interest None declared

SAT0307 Impact of the modified rheumatic disease comorbidity index(MRDCI) on drug survival of first line anti-tnfΑ drugs in patents affected with psoriatic arthritis in real life setting

Background Psoriatic Arthritis (PsA) is a chronic condition resulting in significant physical disability and, in many cases, accelerated mortality. Studies have shown that patients with PsA suffer also from associated comorbidities, including cardiovascular diseases, obesity and metabolic syndrome, diabetes, osteoporosis, malignancy and depression; these could also play a role in determining discontinuation from therapy, especially if anti-TNFα drugs are prescribed. Objectives Our study’s goal is to demonstrate the impact of comorbidities on drug survival of first line anti-TNFα treatment in a cohort of patients affected with PsA. Methods We retrospectively assessed 208 patients, (136 female, 72 male) mean age (±SD) 51.35±12.34 years, fulfilling the CASPAR criteria for PsA who underwent first line anti-TNFα therapy in two centres for a mean duration of 23.34±15.50, from 2011 to 2016. Disease characteristics were registered at first entry. To evaluate the burden of comorbidities we used the modified Rheumatic Disease Comorbidity Index (mRDCI),1 a validated score including lung illnesses, cardiovascular diseases, stroke, hypertension, gastrointestinal disorders, diabetes, fractures, depression, obesity, kidney diseases and cancer. The mRDCI was scored at baseline as well. Drug retention was analysed using Kaplan-Maier curves. Cox regression models were used to estimate the inference of mRDCI and several disease characteristics on drug discontinuation. Goodness of fit of the final model was assessed comparing Cox-Snell residuals to Nelson-Alen cumulative hazard function. Results Drug persitence in first line therapy was significantly higher in patients with mRDCI <4 (70.43%) than in those with mRDCI ≥4 (45.45%). Compared to mRDCI ≥4, those with mRDCI <4 showed significantly higher drug survival rate (p=0.018). Multivariate Cox model showed that mRDCI ≥4 (HR 1.94) and female gender (HR 2.39) were strong predictors of drug discontinuation. Nelson–Alen hazard function followed very closely Cox-Snell residuals showed final model fitted well the data except for large values of time.Abstract SAT0307 – Figure 1 Drug survival in first-line anti-TNFα treatment assessed by Kaplan-Meier and comparison among patients with mRDCI <4 and mRDCI ≥4.Abstract SAT0307 – Figure 2 Nelson-Alen Hazard function and Cox-Snell residual Conclusions This study shows that an high mRDCI at baseline negatively impacts the persistence on first line anti-TNFα treatment in patients affected with PsA in real life setting; hence Rheumatologists should take into account comorbidities in the management of PsA and in admninistering anti-TNFα therapy as these may condition the persistence on therapy. Reference [1] Staetgens, et al. Content and construct validity of the Rheumatic Diseases Comorbidity Index in patients with gout. Rheumatology2015Sep;54(9):1659–1663. Disclosure of Interest None declared

AB0709 Switching from originator infliximab to biosimilar infliximab: efficacy and safety in a cohort of patients with established behÇet’s disease

Background Infliximab (IFX) has been proved to be effective in several organ involvement of Behçet’s Disease (BD). A recent report1 describing rapid loss of efficacy of biosimilar IFX after switching from originator IFX suggests the necessity to exercise caution regarding the automatic substitution of originator IFX with biosimilar IFX in patients achieving remission with originator IFX. Objectives The purpose of the present study was to describe our experience with biosimilar IFX CT-P13 in patients affected with BD, who were switched from originator IFX. Methods Retrieved data including demographic characteristics, clinical manifestations and previous treatments were collected. All patients met the ISG and/or ICBD classification criteria for Behçet’s Disease. In order to evaluate disease activity, the BD Current Activity Form (BDCAF) has been evaluated before starting biosimilar, at three, six and nine months after switching to CT-P13. The occurrence of adverse events was also recorded. Wilcoxon matched-pairs signed-ranks test was carried out to evaluate differences between BDCAF distributions pre-switch and either at three, at six and at nine months after switching. Results Thirteen caucasian adult BD patients (mean age 39.77±7.46 years) with a mean disease duration of 12.54±4.21 years, underwent IFX treatment at licensed dosage for a period of 117.66±48.01 months. After 106.92±46.37 months of treatment with originator IFX, all of them were switched to CT-P13 biosimilar IFX. At 3 months after switching, none of them had discontinued CT-P13 biosimilar IFX treatment. No significant difference was noticed between BDCAF mean score assessed at switch and 3 months after switching (p=0.15). At 6 months follow up, 2/13 patients (15.38%) discontinued CT-P13 biosimilar IFX treatment, both for recurrence of mucocutaneous involvement. One out of 2 patients who discontinued CT-P13 IFX had previously experienced a disease flare under originator IFX therapy, requiring a modification of ongoing therapy. BDCAF mean score assessed before and 6 months after switching were not significantly different (p=0.81). Nine months after switching 2 out of the remaining 11 patients were lost at follow up. Once more, no difference was shown between BDCAF mean score assessed at switch and at 9 months follow up (p=0.85). No adverse events occurred during the observed period. Female n(%) 3 (23.08%) Age at Onset (mean±SD) 27.15±10.02 Clinical Manifestations n(%) Uveitis 10 (76.92) Oral Aphtosis 9 (69.23) Genital Aphtosis 7 (53.85) Cutaneous Involvement 7 (53.85) Concomitant Treatment n(%)* Colchicine 5 (38.46) csDMARDs 4 (30.77) Corticosteroids 1 (7.69)Abstract AB0709 – Figure 1 Conclusions Despite the short follow up period, these data suggest that switching BD patients from originator IFX to CT-P13 seems to be effective and safe; only a small percentage of patients experienced relapse of symptoms, whereas a significant modification of BDCAF pre-switch and post-switch was not noticed. Although encouraging, these results need to be confirmed over a longer follow up period and on larger cohorts of patients. Reference [1] Cantini F, et al. (2017) Rapid loss of efficacy of biosimilar infliximab in three patients with Behcet’s disease after switching from infliximab originator. Eur J Rheumatol4 (4):288–290 Disclosure of Interest None declared

Update on the Medical Management of Gastrointestinal Behçet’s Disease

Behçets disease (BD) is a multisystemic disorder of unknown etiology mainly defined by recurrent oral aphthosis, genital ulcers, and chronic relapsing bilateral uveitis, all of which represent the “stigmata” of disease. However, many other organs including the vascular, neurological, musculoskeletal, and gastrointestinal systems can be affected. The gastrointestinal involvement in Behçets disease (GIBD), along with the neurological and vascular ones, represents the most feared clinical manifestation of BD and shares many symptoms with inflammatory bowel diseases, such as Crohns disease and ulcerative colitis. Consequently, the differential diagnosis is often a daunting task, albeit the presence of typical endoscopic and pathologic findings may be a valuable aid to the exact diagnosis. To date, there are no standardized medical treatments for GIBD; therefore therapy should be tailored to the single patient and based on the severity of the clinical features and their complications. This work provides a digest of all current experience and evidence about pharmacological agents suggested by the medical literature as having a potential role for managing the dreadful features of GIBD.

AB0037 Serum cytokine signature in mucocutaneous and ocular behÇet's disease

Background Behçets disease (BD) is a multi-systemic inflammatory disorder consisting of recurrent oral aphthosis, genital ulcers, and chronic relapsing bilateral uveitis. However, many other organs including the vascular, gastrointestinal, neurological, and musculoskeletal systems can be affected. Pathogenetically, both innate and adaptive immunity have shown to play a pivotal role, and several proinflammatory cytokines derived from Th1 and Th17 lymphocytes seem to be involved in different pathogenic pathways leading to development of the clinical manifestations. Objectives The primary aim of our study was to compare a core set of proinflammatory cytokines between patients with BD and healthy control (HC). The secondary aim was to evaluate potential correlations between these putative circulating biomarkers, the status of disease activity, and the specific organ involvement at the time of sample collection. Methods Fifty-four serum samples were collected from 46 BD patients (17 males, 29 females, mean age 45,5±11,3 years), and 19 HC (10 males, 9 females, mean age 43±8.3 years). Twenty-five serum cytokines (APRIL/TNFS13, BAFF/TNFSF13B, sCD30/TNFRSF8, sCD163, Chitinase3-like1, gp130/sIL-6Rb, IFNb, sIL-6Ra, IL-10, IL-11, IL-19, IL-20, IL-26, IL-27 (p28), IL-28A/IFN-lambda2, IL-29/IFN-lambda1, IL-32, IL-34, IL-35, LIGHT/TNFSF-14, Pentraxin-3, sTNF-R1, sTNF-R2, TSLP and TWEAK/TNFSF-12) were simultaneously quantified using a Bio-Rad cytokine bead arrays. Results Serum levels of Chitinase3-like1, gp130/sIL-6Rb, IL-11, IL-26, sTNF-R1, sTNF-R2 were significantly higher in BD patients than in HC. Specifically, serum concentration of sTNF-R1 (p<0.01) and sTNF-R2 (p<0.01) resulted higher in both active- and inactive-BD than HC, whilst Chi-tinase3-like1 (p<0.05) and gp130/sIL-6Rb (p<0.01) serum levels were significantly higher in in-active-BD, and IL-26 (p<0.01) in active-BD than HC. No differences were observed between inactive- and active- BD group. In addition, comparing cytokines levels in patients affected by mucocutenous manifestations with (MO-BD) or without (M-BD) ocular involvement we observed that gp130/sIL-6Rb, sIL-6Ra, IL-35, and TSLP serum levels were significant enhanced in MO-BD compared to M-BD subgroup. Conclusions Our findings showed a signature of IL-6, TNF-α as well as of Th17 response in BD patients due to increased levels of gp130/sIL-6Rb, sTNF-R1, sTNF-R2, IL-26 respectively. This evidence could contribute to improve the knowledge regarding the role of these citokines in the induction of specific BD clinical features References Lopalco G, Lucherini OM, Vitale A, Talarico R, Lopalco A, Galeazzi M, et al. Putative Role of Serum Amyloid-A and Proinflammatory Cytokines as Biomarkers for Behcets Disease. Medicine (Baltimore) (2015) 94(42):e1858. Lucherini OM, Lopalco G, Cantarini L, Vitale A, Rotondo C, Lopalco A, et al. Correlation between serum amyloid-A and serum levels of proinflammatory cytokines in patients with Behçets disease. Pediatric Rheumatology Online Journal (2015) 13(Suppl 1):P6. Turan B, Pfister K, Diener PA, Hell M, Möller B, Boyvat A, et al. Soluble tumour necrosis factor receptors sTNFR1 and sTNFR2 are produced at sites of inflammation and are markers of arthritis activity in Behçets disease. Scand J Rheumatol (2008) 37(2):135–41. Disclosure of Interest None declared

AB0041 Serum Amyloid A Stimulates The Induction of Inflammatory Mediators in Monocytes from Behçet's Disease Patients: A Proof of Concept Study

Background Behcets disease (BD) is a complex inflammatory disorder characterised by an abnormal innate and adaptive immune response leading to hyper-activation of pro-inflammatory mediators. Recurrent oral aphthous, genital ulcers and chronic relapsing bilateral uveitis are the hallmarks of the disease. Serum amyloid-A (SAA) is a biomarker of inflammation recently associated to BD, and pro-inflammatory stimuli including IL-6, IL-1 and TNF are known to be involved in the SAA production. Moreover, several innate immune cells such as neutrophils, monocytes and macrophages have been reported to produce pro-inflammatory cytokines also through inflammasome activation after SAA stimulation. Objectives The purpose of this study was to investigate the involvement of SAA in the pathogenesis of Behçets disease Methods Monocytes obtained from heparinised venous blood of Behçets disease patients (BD, n=14) and healthy controls (HC, n=7) were stimulated or not with SAA, and serum cytokine levels of IL-1β, IL-18, IL-6 and TNF-α were analysed in the medium using a multiplex bead analysis. Statistical approaches included two-tailed Mann-Whitney test (for two non-parametric groups) and Students t-test (for two parametric groups) were used for statistical comparisons between groups. Correlations were calculated using Spearmans correlation (two-tailed p-value) analysis. Results BD monocytes showed an increased IL-1β (p=0.0017), TNF-α (p=0.0003) and IL-6 (p=0.0003) secretion after SAA stimulation. No differences were observed in the amounts of pro-inflammatory cytokines production between HC and BD. We also found that IL-1β levels positively correlated with IL-6 (r=0.842, p<0.001), and TNF-α (r=0.889, p<0.001), whilst TNF-α levels positively correlated with IL-6 (r=0.894, p<0.001) levels. Moreover, also IL-18 showed a positive trend with no significant differences between the two groups Conclusions These findings suggest that SAA can promote inflammatory mediators production thereby contributing to the inflammatory manifestations typically observed in BD. References Hatemi G, Yazici Y, Yazici H. Behçets syndrome. Rheum Dis Clin North Am 2013; 39:245–611. Vitale A, Rigante D, Lopalco G, Brizi MG, Caso F, Franceschini R, Denaro R, Galeazzi M, Punzi L, Iannone F, Lapadula G, Simpatico A, Marrani E, Costa L, Cimaz R, Cantarini L. Serum amyloid-A in Behçets disease. Clin Rheumatol. 2014. Lopalco G, Lucherini OM, Vitale A, Talarico R, Lopalco A, Galeazzi M, Lapadula G, Cantarini L, Iannone F. Putative Role of Serum Amyloid-A and Proinflammatory Cytokines as Biomarkers for Behcets Disease. Medicine (Baltimore). 2015 Oct;94(42):e1858. Uhlar CM, Grehan S, Steel DM, Steinkasserer A, Whitehead AS. Use of the acute phase serum amyloid A2 (SAA2) gene promoter in the analysis of pro- and anti-inflammatory mediators: differential kinetics of SAA2 promoter induction by IL-1 beta and TNF-alpha compared to IL-6. J Immunol Methods 1997;203:123–30. Disclosure of Interest None declared