anti-TNF Inhibitors Research Articles

A RARE AND UNDER RECOGNIZED CAUSE OF PNEUMONITIS

TYPE: Case Report TOPIC: Diffuse Lung Disease INTRODUCTION: Anti-TNF inhibitors are increasingly known to cause both infective (re-activation of TB, opportunistic or atypical infections) and inflammatory pulmonary complications. The exact mechanism for inflammatory complications is still unclear. CASE PRESENTATION: A 52-year-old female, ex-smoker with background history of Crohn’s disease and arthropathy presented with type 1 respiratory failure and markedly raised inflammatory markers (CRP 339mg/L and Ferritin 13,189mcg/L). She had been on long-term Methotrexate and Prednisolone 20mg. She became unwell after she had her third infliximab maintenance infusion. A CT pulmonary angiogram (high D-Dimer - 1961), showed a segmental pulmonary embolus along with diffuse ground glass reticulation with subpleural sparing in the lower lobes (NSIP pattern-fig 1). She was positive for RF, Anti-CCP and HLA-B27 but had negative ANA/ENA profile. She was suspected to have infliximab induced pneumonitis and infliximab was stopped. She was treated with high dose oral Prednisolone 60mg/day with gradual taper over a period of 3 months. The lung function showed normal spirometry with reduced gas transfer. Her interval CT scan in 3 months whilst on oral prednisolone of 5mg/day showed resolution of pneumonitis along-with simultaneous clinical improvement. DISCUSSION: In this case, temporal relation to the introduction of Infliximab and excellent response to the steroids and cessation of the offending agent point towards this rare diagnosis of Anti-TNF induced pneumonitis. CONCLUSIONS: Anti-TNF induced acute lung injury is an under recognised cause of pneumonitis and should be suspected, after excluding other causes as clinico-radiological features are non-specific. Patients should be reminded about potential pneumotoxicity when starting infliximab therapy. Fig -1 DISCLOSURE: Nothing to declare. KEYWORD: INFLIXIMAB

Differential efficacy of TNF inhibitors with or without the immunoglobulin fragment crystallizable (Fc) portion in rheumatoid arthritis: the ANSWER cohort study.

Rheumatoid factor (RF) binds to the fragment crystallizable (Fc) portion of immunoglobulin. It could bind to the Fc portion of anti-TNF inhibitors (TNFi) and attenuate the clinical efficacy. We tried to determine whether the therapeutic efficacy of TNFi with Fc might be lower than that of TNFi without Fc in rheumatoid arthritis (RA) patients with high titres of RF. The Kansai Consortium for Well-being of Rheumatic Disease Patients (ANSWER) cohort is an observational multi-center registry of patients with RA in the Kansai district of Japan. RA patients treated with TNFi were included and divided into two groups based on the structural characteristics between TNFi with Fc (infliximab, adalimumab, golimumab, and etanercept) and TNFi without Fc (certolizumab pegol). Patients were classified into 4 groups according to RF titre quartiles. The sequential disease activity score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR) was compared by Mann-Whitney U test between TNFi with and without Fc in each RF titre group. Multiple linear regression analysis was used to analyze the effect of TNFi without Fc for the change of DAS28-ESR adjusted after potential confounders. A total of 705 RA patients were classified into four groups (RF1; RF 0-15.0IU/mL, RF2; 15.0-55.0, RF3; 55.0-166, RF4; 166-7555). In RF4, RA patients treated with TNFi without Fc had a significantly lower DAS28-ESR than those treated with TNFi with Fc [3.2 (2.3-4.2) vs. 2.7 (2.0-3.0)] after 12months. This effect of TNFi without Fc for the change of DAS28-ESR after 12months treatment retained in multivariate analysis in RF4. TNFi without Fc may be more efficacious than TNFi with Fc in RA patients with high RF titres.

P529 Evolution of COVID19 serology in a real-life population of IMID patients. Results of the BELCOMID study: BELgian Cohort study of COVID-19 in Immune Mediated Inflammatory Diseases (IMID)

BackgroundImmunomodulators (IMM) and Targeted Immune-Modulating Therapies (TIMT) such as anti-TNF, anti-interleukins and Janus Kinase inhibitors, for treatment of Immune Mediated Inflammatory diseases (IMID) could theoretically interfere with the cytokine storm and humoral immune response against COVID19 infection and vaccination. We investigate seroprevalence and evolution of SARS-CoV2 antibodies in relation to previous vaccination and/or exposure to COVID19 and ongoing IMID-treatment in a Belgian, real-life population of IMID patients.MethodsA cross-disciplinary, prospective, observational cohort study was set up at two university hospitals. All patients with IMIDs of the gut (Crohn’s disease, ulcerative colitis), joints (rheumatoid, psoriatic or spondyloarthritis) and skin (psoriasis, hidradenitis suppurativa, atopic dermatitis) visiting the respective clinics were asked to participate. Patients had to fill out an electronic survey (REDCap®, based on WHO-ISARIC) and blood samples were drawn for serology testing (anti-Spike(S) and anti-viral Nucleocapsid(N) protein antibody IgG, Abbott). Results at baseline, prior to the national vaccination program and at 6 months follow-up are presented. R version 4.0.2 was used for statistical analyses.ResultsAt baseline 2165 IMID patients consented to take part. In 3.2% SARS-CoV2 anti-N seroconversion was confirmed. Of the anti-N seroconverted patients 72.9% reported a positive PCR test prior to inclusion.At 6-months follow-up, data of 1853 IMID patients was collected. Of these, 81.7% were fully and 14.4% partially vaccinated. Seroconversion for anti-N antibodies was confirmed in 2.5% of all participants and seroconversion for anti-S antibodies in 90.8%. In 5.1% (61/1483) of fully vaccinated IMID patients no seroconversion in anti-N nor anti-S antibodies was found.Chi Square analyses show, at 6-months follow-up, no significant association between anti-S seroconversion rate and treatment with systemic steroids (RiskRatio 1.22, 95%CI 0.38–3.9, P=0.99), TIMT (RiskRatio 0.57, 95% CI 0.3–1.1, P=0.12), IMM (RiskRatio 1.65, 95% CI 0.85–3.19, P=0.19) or combination treatment IMM/TIMT (RiskRatio 1.60, 95% CI 0.75–3.4, P=0.32).Appearance of COVID19 symptoms followed the epidemiological curve in Belgium (Fig1). ConclusionIn this real-life IMID cohort, the number of COVID19 cases confirmed by PCR prior to vaccination was low. Seroconversion rate for anti-N antibodies was lower at 6-months follow-up, suggesting decrease in antibody titre over time. Full COVID19 vaccination led to a high anti-S antibody seroconversion rate. Nonetheless, 5.1% of fully vaccinated patients showed no antibody seroconversion. So far, no significant association between anti-S antibody seroconversion and IMID treatment was noted.

Impact of Th17/tregfoxp3 Cells Ratio on Rheumatoid Arthritis Patients Receiving Anti Tnf- Therapy-.

In order to determine the correlation between disease activity of RA with the Th17/TregFoxp3 cells ratio in patients undertherapy with Anti-TNF-alpha which is the aim of present study, Ninety-seven patients with RA and healthy control groups were included in this case control study, eighty-four patients divided into four groups; 25 patients receiving only MTX; 18 patients receiving monotherapy (anti- TNF); 26 patients receiving combined therapy (MTX + anti-TNF); 15 patients with RA not receiving any drug (positive control). Other thirteen healthy people considered as negative control were enrolled in this study. Patients with RA were attending Basrah General Hospital, Rheumatology Unite, Biological Therapy Center for receiving anti-TNF therapy. Flowcytometry was used for measuring TregFoxp3 and Th17 markers and DAS-28 score was used for measuring RA disease activity. Anti TNF inhibitors (Infliximab and Etanercept) were measured as well. Other inflammatory and hematological parameters were also measured (ESR, total WBC, Lymphocytes, monocytes and neutrophil counts). Resulted, DAS-28 as disease activity score was significantly correlated with Th17/ TregFoxp3 ratio and with the TH17 cells count. Statistically, Th17/ TregFoxp3 ration was not correlated with BMI, morning stiffness, and duration of the disease. In a Conclusion, Th17/Treg Foxp3 ratio correlated significantly with DAS-28 as RA disease activity. The lower Tregs Foxp3 frequency, the higher the DAS score reflecting higher disease activity. In combined therapy group, disease activity was found lower than other patient groups indicating for the effect of this combination between MTX and anti-TNF. Herein, we demonstrated that the main advantage of this combined therapy in RA patients was the reversion of Th17 cell expan­sion

P21 My eye was cloudy at first and I can see it is melting away!

P21 My eye was cloudy at first and I can see it is melting away!

Association of polymorphisms in promoter region of TNF-α-238 and -308 with clinical outcomes in patients with immune-mediated inflammatory diseases on anti-TNF therapy.

The hypothesis of the study was that polymorphisms in promoter regions -238 and -308 of TNF-α could be associated with different clinical outcomes in inflammatory bowel diseases (IBD) and immune-mediated rheumatic diseases (IMRD). The aim was to examine the possible association of both polymorphisms with concentration of C-reactive protein (CRP) and fecal calprotectin (fCAL), onset of the remission and development of the ADA in patients on therapy with anti-TNF inhibitors. The prospective study was done in patients with IBD and IMRD on infliximab (IFX) or adalimumab (ADM). Patients were genotyped for TNF-α-238 and -308 polymorphisms. The concentration of CRP, fCAL, IFX or ADM and antibodies to drugs were measured according to manufacturer's instructions and followed-up for 6 or 12months. Out of all patients (N = 112), number of patients in remission did not differ according to genotypes (for IBD patients P = 0.509 vs 0.223; for IMRD patients P = 0.541 vs 0.132 for TNF-α-238 and -308, respectively). Initial CRP concentration was higher in IBD patients with TNF-α -308 GG than GA/AA genotypes in patients who failed to achieve remission [11.8 (4.4-39.6) vs 3.1 (1.5-6.5), P = 0.033]. In IBD patients with remission, fCAL concentration after at least 6months of therapy was higher in TNF-α-308 GG than in GA genotype [52 (25-552) vs 20 (20-20) µg/g, P = 0.041]. Our results showed the association of TNF-α-308 GG genotype with a higher concentration of CRP and fecal calprotectin in patients with inflammatory bowel diseases on IFX or ADM therapy. Clinical remission and development of antibodies to anti-TNF drugs were not associated with TNF-α-238 and -308 polymorphisms.

COVID-19 mRNA Vaccine Short-Term Safety in Patients With Inflammatory Bowel Disease

COVID-19 mRNA Vaccine Short-Term Safety in Patients With Inflammatory Bowel Disease

S2406 A Rare Clinical Case of Ulcerative Colitis Presenting With Unexpected Pulmonary Findings

Introduction: Inflammatory bowel disease, as Ulcerative Colitis and Crohn’s, are disorders of chronic inflammation of the gastrointestinal tract associated with extraintestinal manifestations in 10.4% of affected patients. Pulmonary involvement is rare and often overlooked. Respiratory changes can include small airways, vascular diseases or serositis, and other lung findings can develop in the course of IBD, but only few reports have demonstrated uncommon pleural manifestations. Case description/methods: Case of a 47 y/o woman with Ulcerative Colitis on Mesalamine and Infliximab evaluated at ER with shortness of breath and night sweats. Referred compliance to medications, and still experienced abdominal pain and occasional bloody diarrhea. Vital signs were normal, asides from oxygen desaturation of 75%. Physical examination with diminished breath sounds and chest Xray showed bilateral pleural effusions, worse on right side. Patient was admitted for thoracentesis which yielded 1L of pleural exudative fluid. Culture, cytology, fungal and tuberculosis analyses were negative. Chest CT revealed mediastinal diffuse non calcified nodules, and bronchoscopy with biopsy was notable for macrophages with negative cytology. Due to effusion recurrence, thoracoscopy with pleural biopsy was done revealing necrotizing granulomas. Rarely, necrobiotic nodules have been described in IBD, and workup for tuberculosis and rheumatologic conditions were requested, all with normal results. Low dose steroids were started, and 4 month follow up chest CT still showed lung nodules. Bronchoscopy was performed again, with biopsy positive for non-caseating granulomas, compatible with sarcoidosis. In some cases, sarcoidosis can develop after anti TNF inhibitors, as Infliximab, mostly if used in rheumatological pathologies, less common in IBD. Pleural sarcoidosis is rare and effusions are usually exudates, as in this case. Therefore, Vedolizumab was started with optimized steroids resulting in marked pulmonary improvement and complete remission of UC. Discussion: Pleural involvement by IBD or associated conditions like sarcoidosis is a rare extraintestinal presentation since only few cases have been reported. Although uncommon, unilateral, exudative pleural effusions can be directly related to both conditions. It is important to establish awareness and early identification of this manifestation that can be life-threatening to provide adequate management and treatment plans, avoid further complications and provide a better standard of care.

Immunologic Parameters for Disease Activity in Rheumatoid Arthritis.

This study aimed to determine the correlation of disease activity of rheumatoid arthritis (RA) with Th17/regulatory T cell (Treg) and Forkhead box protein 3 (Foxp3) cells ratio in patients under therapy with anti-tumor necrosis factor (TNF)-α. Totally, 84 patients with RA and 13 healthy controls were included in this case-control study. The patients were divided into four groups to receive only methotrexate (MTX) (n=25), monotherapy (anti-TNF) (n=18), and combined therapy (MTX+anti-TNF) (n=26); however, one group received no medications (n=15) and was regarded as a positive control. Other 13 healthy controls that were considered negative controls were also enrolled in this study. Patients with RA were attending Basrah General Hospital, Rheumatology Unit, Biological Therapy Center for receiving anti-TNF therapy. Flow cytometry was used for measuring Treg/Foxp3 and Th17 markers, and the DAS-28 score was utilized to measure RA disease activity. Anti-TNF inhibitors (e.g., infliximab and etanercept), as well as other inflammatory and hematological parameters (e.g., erythrocyte sedimentation rate, total white blood cells, lymphocytes, monocytes, and neutrophil counts), were also measured in this study. DAS-28 as a disease activity score was significantly correlated with Th17/Treg/Foxp3 ratio and the Th17 cells count. Statistically, Th17/Treg/Foxp3 ratio was not correlated with body mass index, morning stiffness, and duration of the disease. Th17/Treg/Foxp3 ratio correlated significantly with DAS-28 as an RA disease activity. The lower Treg/Foxp3 frequency led to the higher DAS score reflecting higher disease activity. In the combined therapy group, disease activity was found lower than that in other patient groups indicating the effect of this combination on the relationship between MTX and anti-TNF. This study demonstrated that the main advantage of this combined therapy in RA patients was the reversion of Th17 cell expansion.

In Silico Identification and Evaluation of Natural Products as Potential Tumor Necrosis Factor Function Inhibitors Using Advanced Enalos Asclepios KNIME Nodes.

Tumor necrosis factor (TNF) is a regulator of several chronic inflammatory diseases, such as rheumatoid arthritis. Although anti-TNF biologics have been used in clinic, they render several drawbacks, such as patients’ progressive immunodeficiency and loss of response, high cost, and intravenous administration. In order to find new potential anti-TNF small molecule inhibitors, we employed an in silico approach, aiming to find natural products, analogs of Ampelopsin H, a compound that blocks the formation of TNF active trimer. Two out of nine commercially available compounds tested, Nepalensinol B and Miyabenol A, efficiently reduced TNF-induced cytotoxicity in L929 cells and production of chemokines in mice joints’ synovial fibroblasts, while Nepalensinol B also abolished TNF-TNFR1 binding in non-toxic concentrations. The binding mode of the compounds was further investigated by molecular dynamics and free energy calculation studies, using and advancing the Enalos Asclepios pipeline. Conclusively, we propose that Nepalensinol B, characterized by the lowest free energy of binding and by a higher number of hydrogen bonds with TNF, qualifies as a potential lead compound for TNF inhibitors’ drug development. Finally, the upgraded Enalos Asclepios pipeline can be used for improved identification of new therapeutics against TNF-mediated chronic inflammatory diseases, providing state-of-the-art insight on their binding mode.

Assessment of Treatment in Inflammatory Bowel Disease Patients Using Steroid Assessment Tool (SAT) in a Tertiary Center from Romania

Background and aims: The evolution of inflammatory bowel diseases was significantly improved during the last decade by the new therapeutic options. Classical medications as corticosteroids and 5-aminosalycilates (5-ASA) are still highly used. In order to evaluate the pattern of corticosteroid usage we used a dedicated online tool-the steroid assessment tool. Our purpose was to evaluate if this tool can permit a change in the therapeutic habits and an improvement of quality of care. We succeeded to outline a therapeutic profile for a series of IBD patients in a tertiary centre from Romania. Methods: Two consecutive assessments were made using an online tool named Steroid Assessment Tool (SAT). Corticosteroid pattern of use and all previous and current treatments were registered and analyzed. Also the epidemiological and clinical data were collected and analyzed. The statistical analysis was performed using SPSS® software. Results: Results showed that most of our IBD patients (90%) had been treated with 5-ASA, with 29.2% of CD patients and 54.3% of UC patients currently using 5-ASA. Also, we had more CD patients (78%) than UC patients (56.5%) treated with anti-TNF inhibitors. The rate of thiopurine use was small (2.3%) and of anti-integrin therapy, interleukin 12/23 inhibitors as well. The rate of corticosteroid use was 34% in 2019 and in 2020 it dropped to 25% while the rate of corticosteroid excess was 20.4% in 2019 with a statistically significant decrease in 2020 (p=0,01) when it was 5.95%. Discussion: We managed to draw a therapeutic profile of IBD patients in a tertiary IBD centre from Romania using an online tool named SAT. We noticed that the majority of patients were treated with 5-ASA. Even though 5-ASA are not recommended by recent therapeutic guidelines as treatment for CD, we have 29.2% of CD patients treated with this class of drugs, a rate smaller than other reports but still outside guidelines. In the same time, we have a higher rate of anti-TNF agents use compared to other studies, but a lower rate of thiopurine use. Corticosteroid use was higher the other reports, but we succeeded to lower the rate of corticosteroid use and the rate of corticosteroid excess.Conclusions: The therapeutic profile and habits of prescription in a tertiary IBD centre were analyzed twice using an easy-to-use online tool. The results obtained in our first evaluation led to a change in the therapeutic management, improving our adherence to guideline’s recommendations.

P440 First results of the BELCOMID study: BELgian Cohort study of COVID-19 in Immune Mediated Inflammatory Diseases (IMID)

BackgroundIt has been suggested that 100% of SARS-CoV2 infections leads to development of specific IgG antibodies that remain detectable for a long period of time. Targeted Immune-Modulating Therapies (TIMT) such as anti-TNF, anti-interleukins and Janus Kinase inhibitors (JAKi) for treatment of Immune Mediated Inflammatory diseases (IMID) could theoretically interfere with cytokine storm and humoral immune response against COVID19. We investigate the seroprevalence of SARS-CoV2 IgG in relation to previous exposure to COVID19 and ongoing IMID treatment in a Belgian, real-life population of IMID patients.MethodsA cross-disciplinary, prospective, observational cohort study was set up at two university hospitals. Between 17/12/2020 and 29/02/2021, all patients with IMIDs of the gut (Crohn’s disease (CD), ulcerative colitis (UC)), joints (rheumatoid arthritis, psoriatic arthritis, spondyloarthritis) and skin (psoriasis, hidradenitis suppurativa, atopic dermatitis) visiting the respective clinics were asked to participate. Both patients under conventional treatment and/or TIMT were included. Patients were asked to fill out an electronic survey (REDCap®, based on WHO-ISARIC) and blood samples were drawn for serology testing (SARS-CoV-2 IgG Abbott – Architect kit®). Statistical analyses were performed with SPSS26.ResultsIn total 2166 IMID patients consented to take part. Of these, 1913 responded to the survey, including 218 dermatology patients, 415 rheumatology patients and 1217 IBD patients (64.7% CD, 34.3% UC, 1% undifferentiated colitis). There were 372 patients (19.5%) who reported having experienced symptoms suggestive of COVID19 (Fig. 1). Fatigue (61.3%), headache (48.1%), throat ache (46.9%) and dry cough (38.7%) were most frequent. Gastrointestinal symptoms such as diarrhoea or abdominal pain were present in less than 20.0% (Fig. 2). Ninety-six IMID patients (5.04%) had a positive SARS-CoV2 PCR test on nasal or throat swab. In 44/96 (45.8%) anti-SARS-CoV2 IgG seroconversion was confirmed. There was no significant difference in seroconversion rate between patients treated with TIMT compared to conventional therapy (P=0.192). Of the seroconverted group, 75.0% were treated with TIMT. The interval between reported positive PCR date and serology test date ranged from 3 to 24 weeks with a mean of 10 weeks. Of all survey responders, 25 were hospitalized for respiratory symptoms since 01/02/2020, six of these had positive SARS-CoV2 PCR. ConclusionPrevalence of COVID19 symptoms and number of confirmed COVID19 cases by PCR in this cohort of IMID patients remain low regardless of treatment modality. There was no significant difference in SARS-CoV2 IgG seroconversion rate between TIMT or conventional treatment in patients with positive PCR.

P666 Frequency and outcome of SARS-CoV2 infection in patients with inflammatory bowel disease on different biological therapy

BackgroundSince almost its 1 year outbreak declared by the World Health Organization on 11th March 2020, COVID-19 pandemic still cannot be controlled successfully. Inflammatory bowel disease potentially elevates the risk of infections, independently from the age, while disease activity and medical treatment(s) can increase the risk as well. Based on international data, in total, 4% receives the infection. Furthermore, 1.8% of the patients on biologic therapy needs intensive therapeutic care and 1% passes away.MethodsThis was an observational, questionnaire based study, carried out in Hungary, between February and March 2021. Our questionnaire consisted of 45 questions, that surveyed the impact of the pandemic among IBD patients, and the severity and outcome of the infection. Participants were on biologic therapy. Our aim was to determine the frequency and outcome of SARS-CoV2 infection in patients with inflammatory bowel disease on different biological therapy.ResultsIn total, 387 respondents completed the questionnaire, and 47 participants (12%) developed COVID-19 infection. 66.9% of them were receiving anti-TNF inhibitor, 16.8% vedolizumab, 12.1% ustekinumab, and 4.1% tofacitinib. Based on our cohort, different biologic therapies didn’t elevate the risk of infection (p=0.3486), nor the hospitalization rate (p=0.277). No one was in ICU or ventilator, and nobody passed away. Furthermore, 38.3% suspended the current biologic therapy, but it didn’t decrease the rate of hospitalization (p=0.533), however, it didn’t cause flare-ups either in the primary disease (p=0.415). Based on our cohort, neither vitamin supplementations meant protection against the infection (p=0.117), only regular mask wearing seems to protect patients with IBD (p=0.009).ConclusionBased on our cohort, more IBD patients develop the infection in Hungary, compared to international data, however, the outcome of the infection is more favourable. It seems, that the different biological treatments don’t affect the infection rate, and neither elevates the hospitalization rate. In generally, there is no need to suspend the current biologic therapy, however, it should be a matter of individual judgment. After all, we claim that mask-wearing still seems to be the most effective form of prevention.

POS0048 SEROPREVALENCE OF ANTI-SARS-COV-2 ANTIBODIES IN RHEUMATIC PATIENTS TREATED WITH BIOLOGICAL AND TARGETED THERAPY LIVING IN LOMBARDY, ITALY (MAINSTREAM PROJECT)

Background:Emerging observational data have shown that rheumatic patients seem not to be more susceptible to SARS-CoV-2 infection neither to worse outcomes. However, the true prevalence of COVID19 is still unknown due to the high proportion of subclinical infection. In this scenario, measuring the seroprevalence of SARS-CoV-2 may be crucial to improve the knowledge about the impact of COVID19 in rheumatic patients.Objectives:To estimate in a COVID19 high-endemic area (Lombardy, Italy) the prevalence of anti-SARS-CoV-2 antibodies in a large cohort of patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) treated with biologic (b-) or targeted synthetic (ts-) disease modifying drugs (DMARDs).Methods:A seroprevalence cross-sectional study was conducted in the period between 4th May and 16th June 2020, including patients with confirmed RA or SpA treated with b- or tsDMARDs. Patients were tested for anti-SARS-CoV-2 IgG, IgM and IgA antibodies against main viral antigens (nucleoprotein [N], spike 1 [S1], receptor-binding domain [RBD]) using ELISA. These data were compared with those observed in the healthy population in the same period and region. Patients also answered a questionnaire on history of symptoms consistent with COVID19, risk factors and comorbidities. Serological response to RBD was evaluated according to symptom severity (asymptomatic, minor, or major [respiratory and fever >37.5°C] symptoms).Results:The study population included 300 patients (62% females, mean age 53 years, 20% over 65 years old) diagnosed with RA (56%), psoriatic arthritis (23%), or ankylosing spondylitis (21%), treated with anti-TNF (57%), abatacept (20%), anti-IL6 (11%), or JAK inhibitors (5%). Four patients (1.3%) referred a prior diagnosis of COVID19 defined by nasopharyngeal swab. Immunoglobulin titers were evaluated resulting in 9%, 13.6%, and 13.3% positive patients for IgG, IgM and IgA, respectively (Table 1), with no significant difference to the healthy population. Among seropositive patients, 55.3% were asymptomatic, 16% had minor and 19.6% major symptoms, 7.1% were hospitalized. No deaths or admission to intensive care units occurred. IgM, IgG and IgA titers to RBD were higher in patients with both minor and major symptoms compared with asymptomatic ones (Figure 1). No differences were found between seronegative and seropositive patients in relation to age, sex, rheumatic diagnosis, and treatments with b- or tsDMARDs. A relative lower risk of seropositivity was observed in patients receiving concomitant methotrexate (RR 0.49, 95% CI 0.25-0.94; p 0.04), while an increased risk was associated with obesity (RR 2.33, 95% CI 1.26-3.79; p 0.019) and presence of at least 2 comorbidities (RR 1.94, 95% CI 1.11-3.15; p 0.037). Corticosteroids use was numerically more frequent in seropositive than seronegative patients (18% vs 14%).Conclusion:This study confirms that, even in a cohort of rheumatic patients, the spread of SARS-CoV-2 infection is much greater than that observed by capturing only swab-diagnosed COVID19 cases. The underlying rheumatic disease and ongoing therapy with b/ts-DMARDs do not seem to impact SARS-CoV-2 antibody positivity, which conversely seems to be proportional to the intensity of COVID19 symptoms and less frequent in patients receiving concomitant methotrexate. The project was co-financed by Lombardy Region 2014-2020 Regional Operational Programme under the European Regional Development Fund.Table 1.Prevalence of specific anti-SARS-CoV-2 antibodies.AntibodiesPosivite(n)Seroprevalence (%)(95% CI)IgG279%(6.2 – 12.7)IgG anti-N268.6%(5.9 – 12.3)IgG anti-RBD206.6%(4.3 – 10)IgG anti-S1186%(3.8 – 9.2)IgM4113.6%(10.2 – 18)IgM anti-N3511.6%(8.5 – 15.7)IgM anti-RBD258.3%(5.7 – 12)IgA4013.3%(9.9 – 17.6)IgA anti-N3712.3%(9.0 – 16.5)IgA anti-RBD258.3%(5.7 – 12)IgG+IgM237.6%(5.1 – 11.2)IgG+IgM+IgA227.3%(4.9 – 10.5)IgG+IgA248%(5.4 – 11.6)IgG/IgM/IgA5618.6%(14.6 – 23.4)Figure 1.Antibody levels (S/Co) against SARS-CoV-2 RBD.Disclosure of Interests:None declared.

MiRNAs as potential biomarkers of treatment outcome in rheumatoid arthritis and ankylosing spondylitis.

Common autoimmune, inflammatory rheumatic diseases including rheumatoid arthritis and ankylosing spondylitis can lead to structural and functional disability, an increase in mortality and a decrease in the quality of a patient's life. To date, the core of available therapy consists of nonsteroidal anti-inflammatory drugs, glucocorticoids and conventional synthetic disease-modifying antirheumatic drugs, like methotrexate. Nowadays, biological therapy including anti-TNF, IL-6 and IL-1 inhibitors, as well as antibodies targeting IL-17 and Janus kinase inhibitors have been found to be helpful in the management of rheumatic conditions. The review provides a summary of the current therapy strategies with a focus on miRNA, which is considered to be a potential biomarker and possible answer to the challenges in the prediction of treatment outcome in patients with rheumatoid arthritis and ankylosing spondylitis.

Loss of response and frequency of adverse events in patients with ulcerative colitis and Crohn's disease when switching from the original infliximab to its biosimilars

To define the frequency of adverse events and loss of the response in patients with ulcerative colitis (UC) and Crohn’s disease (CD), treated with original medicine infliximab (IFX) “Remicaide” and its biosimilars. We included 154 patients with IBD: 78 UC patients (50.6%) и 76 CD patients (49.4%), treated with original medicine IFX Remicade and its biosimilars. In our study we did not include patients, who previously underwent induction treatment with IFX and its biosimilar. Among 78 UC patients, IFX was cancelled in 25 (32.0%) patients and they were switched to the other anti-TNF inhibitor or medicine with the another mechanism of action; in patients group, treated with biosimilar – 16 (20.5%) and 9 (11.5%) patients, who were interchanged biosimilar and/or original IFX. Among 76 CD patients IFX was cancelled in 20 (26.3%) patients: 11 (14.5%) patients in group, treated with similar trade name biosimilar, 8 (10.5%) patients, who were interchanged biosimilar and/or original IFX and 1 patient (1,3%), receiving original IFX. We found no difference in the secondary loss of response and adverse events in patients with CD and UC, switched from original IFX to biosimilar (p=0.6257 and p=0.6635, correspondingly). The frequency of the secondary loss of response or adverse events in patients with UC and CD, switched from original IFX to IFX biosimilar, was similar (p>0.05). Approximately 30% of IBD patients, receiving IFX biosimilar, will be switched to the other anti-TNF therapy or medicine with the another mechanism of action because of secondary loss of response or adverse events.

Vaccine targeting TNF epitope 1–14 do not suppress host defense against Mycobacterium bovis Bacillus Calmette-Guérin infection

Anti-TNF inhibitors are efficacious in the treatment of chronic inflammatory diseases such as rheumatoid arthritis (RA), Crohn's disease (CD), juvenile idiopathic arthritis (JIA), and ankylosing spondylitis (AS). However, more and more clinical case reports revealed that anti-TNF inhibitors could increase the risk of viral, fungal, and bacterial (especially intracellular) infection. In this study, based on Immune Epitope Database (IEDB) online B cell epitope prediction and the knowledge of TNF three dimensional (3D) structure we developed a novel vaccine (DTNF114-TNF114) that targeting TNF epitope 1–14, which produced antibodies only partially binding to trans-membrane TNF (tmTNF), therefore partially sparing tmTNF-TNFR1/2 interaction. Immunization with DTNF114-TNF114 significantly protected and prolonged the survival rate of mice challenged with lipopolysaccharide (LPS); and in the mCherry expressing Mycobacterium bovis Bacillus Calmette-Guérin (mCherry-BCG) infection model, DTNF114-TNF114 immunization significantly decreased soluble TNF (solTNF) level in serum, meanwhile did not suppress host immunity against infection. Thus, this novel and infection concern-free vaccine provides a potential alternative or supplement to currently clinically used anti-TNF inhibitors.

Optimization of culture conditions for high-level expression of soluble and active tumor necrosis factor-α in E. coli

Anti-TNF inhibitors exert their therapeutic effect by inhibition of the excessive amounts of TNF-α within the body. Recombinant TNF-α should be produced in a soluble refolded form to investigate the effectiveness and efficiency of anti-TNF-α compounds. In this research, the designed cassette was subcloned in the pET28a expression vector and expressed in E. coli BL21 (DE3). The identity of the protein was confirmed through SDS-PAGE and Western blotting. After optimizing expression conditions, protein purification was performed using native Ni-NTA affinity chromatography. The biological activity of the soluble recombinant TNF-α was investigated using MTT assay. Also, the affinity of an anti-TNF-α agent, Altebrel, was investigated against the expressed protein through ELISA. Optimization of TNF-α expression conditions represented that the highest expression could be achieved at 37 °C using 0.5 mM IPTG 6 h post-induction. The recombinant protein represented an inhibitory effect on the L929 murine fibroblast cell line and was successfully detected by Altebrel in ELISA. Binding kinetics were also studied using Cimzia as an anti-TNF-α molecule and 7.2 E−13M was calculated as the equilibrium dissociation constant value (KD). The significant expression level of the recombinant protein in the soluble form, its high purity, and assessment of its biological activity showed that the expressed protein could be used in tests of ELISA and MTT to assess the activity of anti-TNF-α agents.

O21 A rare case of anti-TNF induced panniculitis

Case report - IntroductionPanniculitides comprise a heterogeneous group of inflammatory diseases involving the subcutaneous fat. They remain the most challenging areas for clinicians. Skin biopsy is commonly needed to confirm diagnosis. Because there are many underlying aetiologies for panniculitis, detailed history and thorough investigations are needed. We present a case of A 20-year male who was admitted with painful lumps treated initially as cellulitis/abscess but turned to be neutrophilic panniculitis on skin biopsy. Extensive workup failed to reveal underlying aetiology. Eventually Imradli (AntiTNF) was thought to be the culprit and therefore was kept on hold with no recurrence of panniculitis.Case report - Case descriptionA 20-year-old, Asian Malawian. Moved to the UK at the age of 6. He was diagnosed with Ankylosing spondylitis in November 2016. Initially received Naproxen followed by (Humira) with good clinical response. He was switched to biosimilar Imradli in Nov 2019. He was admitted with 2–3 weeks history of progressive right hip and buttock pain, 1 week of very tender erythematous swelling of the right buttock but without fever or weight loss. He reported mild weakness of lower limbs. Physical examination revealed 5x 8 cm swelling on Right buttock, Rest of examination was unremarkable. He was reviewed by neurology team who arranged MRI spine and brain, EMG and lumbar puncture which all came back as unremarkable excluding the possibilities of myelitis and myositis. Initially thought to be abscess/cellulitis but absence of fever/inflammatory response, abnormal CT finding and no response to antibiotics made it less likely. While the Right buttock erythema/swelling started to resolve, he developed two new migratory erythematous lesions appearing around the left buttock and lower lumbar spine. Working diagnosis of panniculitis was made which was confirmed on biopsy. Due to lack of response to NSAIDs, colchicine or oral steroids, a 3rd biopsy of the freshest lesion was performed to exclude deep-seated infection.Investigations –FBC, U&ES, LFT, CRP, CK, ACE - all were unremarkableASO titre <200, serology for Borrelia and TPHA negative.Viral, parasitic, and Autoimmune screen were unremarkable.CXR clear, MRI/CT: extensive subcutaneous inflammatory changes in the right buttock with sacral oedema.PET-CT – showed resolving inflammatory changes in the right flank, FDG intake in C6 and SI joints presumed secondary to ankylosing spondylitis and sacroiliitis.The underlying cause of panniculitis remains uncertain. Anti TNF was kept on hold and the patient was followed up with no evidence of recurrence of panniculitisCase report - DiscussionPanniculitis (inflammation of subcutaneous fat) is a relatively uncommon condition. It has various aetiologies including infection, trauma, inflammation, and malignancy. Skin biopsy can give valuable information including microbiological studies if infectious panniculitis was suspected. However, clinical correlation and careful consideration of the differential diagnosis is needed in many cases.The diagnosis can be quite challenging as in this case where all investigations and skin biopsy could not point towards the underlying aetiology. Although anti-TNF inhibitors are commonly used in treating a wide range of autoimmune conditions. But their use can lead to the development of secondary autoimmune diseases, such as cutaneous vasculitis, lupus-like syndrome, and interstitial lung disease, paradoxically induced by anti-TNF-α agents. Llamas-Velasco and Requena, reported the first case of panniculitis induced by etanercept injection in a 62-year-old woman with severe psoriasis who developed an erythematous, slightly painful nodule on the skin of the anterior abdominal wall.Adalimumab induced lupus panniculitis was reported in a Rhu-lupus patient. Although the lesions stopped progressing after cessation of adalimumab, they remained unchanged for two more years. The mechanism for adalimumab-induced CLE is uncertain.Although there is not enough data about autoimmunity with biosimilars, we think secondary autoimmune conditions could similarly be induced by biosimilar as illustrated in this case. Anti-TNF induced cutaneous panniculitis is considered most likely although uncertain. If anti-TNF drug-induced, this should gradually resolve but can be slow (4–6 months). Corticosteroids have been added for an anti-inflammatory response, but there was little benefit which might point to a different pathogenetic mechanism.NSAIDs has helped to keep his AS relatively stable during the COVID-19pandemic. During the last review, the patient expressed his wishes to go back on biologic. But the question remains whether he will a have a recurrence of panniculitis or not?Case report - Key learning points1/Anti-TNF inhibitors sometimes cause secondary autoimmune conditions like cutaneous vasculitis, lupus-like syndrome, but there is not enough data regarding biosimilar induced autoimmunity.2/This case illustrates the high importance of having a tissue diagnosis. (whenever there is an issue, the diagnosis would be in the tissue).3/There is still uncertainty whether a recurrence of panniculitis might occur or not if the patient went again on biologics.

Characteristics of Chikungunya virus infection in patients with established rheumatoid arthritis.

The aim of this study is to describe both clinical and treatment needs in six patients who had a previous diagnosis of rheumatoid arthritis (RA) and were infected with Chikungunya virus (CHIKV). We report RA patients who acquired CHIKV infection, treated from the Fundación Valle del Lili Hospital, Cali, Colombia, between August 2014 and September 2015. Data of demographic information, clinical and laboratory findings, DAS28 score, dose of glucocorticoids (GC), or conventional or DMARD use was collected before, during CHIKV infection, and 6months of follow-up. Five women and one man were analyzed, with an average age of 66years, who had been receiving low doses of GC (4mg of prednisolone/day on average). Two patients were being treated with methotrexate (MTX) and etanercept, one with MTX and other with etanercept, with an average DAS28 of 2.00 at the last control consultation. At the time of CHIKV infection, they presented an average DAS28 of 3.98, requiring more than double their usual dose of GC (average dose 8.75mg/day of prednisolone). One patient required a change from etanercept to adalimumab and three others started rituximab, tocilizumab, and tofacitinib as second-line medication. A case series of patients with RA in remission are presented, who when contracting CHIKV infection developed exacerbation of their underlying disease, which in general was difficult to control. An increase in the doses of GC and change or induction to the use of second-line medications (anti-TNF, anti-CD20, or Janus kinase inhibitor) were required. Key Points • The clinical outcome of RA patients with CHIKV infections is not well known. • A group of RA patients, who were in clinical remission, were affected during the 2014-2015 CHIKV epidemic and treated in a hospital in southwestern Colombia, and had severe reactivation of their RA. • Some patients with RA in remission and who had CHIKV infection required an increase in the glucocorticoid, in addition to starting second-line medications (anti-TNF, anti-CD20, or Janus kinase inhibitor) or their modification.