Search

Objectives To assess factors influencing the choice and effectiveness of biological disease-modifying antirheumatic drugs (DMARDs) following failure of rituximab (RTX) in rheumatoid arthritis (RA), taking patient profile into account. Methods In a retrospective, multicenter study, data about RA patients starting a new biologic during the year after RTX discontinuation were collected at baseline (when the biologic was introduced after RTX), and during follow-up (3, 6, and 12 months). Characteristics of patients receiving tocilizumab (TCZ), abatacept (ABA), or a TNFα inhibitor (TNFi), EULAR response, and retention rate were compared using multidimensional factorial analysis for patient profiles and multivariate analysis including propensity score built on the patient profile. Results Among 152 patients analyzed (37.5% TCZ, 31.6% ABA, 30.9% TNFi), sex, disease characteristics and activity, concomitant DMARDs or glucocorticoids, and previous use of RTX and TNFi were similar at baseline. Patients receiving ABA were slightly older. Multimorbidity index was higher but not significantly different. Multidimensional factorial analysis showed a distinct profile of patients receiving ABA, characterized by older age, more men, more smokers, more comorbidities, and higher anti-cyclic citrullinated peptide antibody. At 1 year, drug retention was higher for ABA than TNFi after adjustment for disease duration, concomitant DMARDs, glucocorticoids, and propensity score (P = 0.04). Tolerance and serious infections were similar among groups. Conclusions The profile of patients receiving ABA following failure of RTX differed from TNFi and TCZ using multidimensional factorial analysis. After adjustment for propensity score, drug retention rate remained higher with ABA than TNFi.

Introduction Higher cardiovascular risk found in rheumatoid arthritis or psoriatic arthritis is largely due to systemic inflammation. In osteoarthritis (OA), occurrence of systemic inflammation has already been sometimes reported, but the possible association between OA and increased cardiovascular risk remains unclear. In this meta-analysis, we aimed to assess the incidences of myocardial infarction (MI) and stroke, and the cardiovascular risk factors in OA patients. Methods We searched PubMed, EMBase, and the Cochrane Library to find references of interest up to June 2018. MI and stroke incidence were calculated using meta-proportion analysis. Differences in cardiovascular risk factors between OA patients and controls were expressed as standardized mean differences using the inverse of variance method. Results The reviewed studies reported 227 MIs in 3550 OA patients (incidence, 7.5%; 95% CI: 3.0–13.8%) and 616 MIs among 12,444 control subjects (incidence, 6.0%; 95% CI: 2.8–10.3%). Meta-analysis of the three longitudinal studies revealed a significantly increased MI risk among OA patients (RR = 1.22; 95% CI: 1.02–1.45). We also found a significantly increased stroke risk in OA patients (RR = 1.43; 95% CI: 1.38–1.48). Concerning cardiovascular risk factors, OA patients exhibited a pro-atherogenic lipid and glycemic profile including high levels of fasting glucose, total cholesterol, and LDL cholesterol and a high body mass index. Concerning atherosclerosis markers, OA patients exhibited a higher risk of metabolic syndrome, and increased pulse wave velocity. Conclusion Our meta-analysis results revealed higher cardiovascular risk in OA patients. This highlights the importance of cardiovascular risk factor management in OA.

International audience

Background Barriers and facilitators to physical activity in inflammatory arthritis can be assessed through the Inflammatory arthritis FAcilitators and Barriers (IFAB) questionnaire. The objective was to measure the correlation between IFAB and self-reported physical activity levels. Methods This was an international, multicentric, cross-sectional study in 2019–20. Consecutive spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) patients completed the 10-item IFAB, which ranges from − 70 to 70 with lower scores indicating more barriers. Physical activity was measured by the IPAQ-S questionnaire, steps per day collected by smartphone, and psychological readiness to change by stages of behaviour change. Spearman correlations and multivariable linear regression were calculated. Results Of 245 patients included, 150 were analysed: 69 (46%) axSpA, 63 (42%) RA, 18 (12%) PsA. Mean age was 48.6 years (standard deviation, SD 17.1), mean disease duration 11.7 (10.1) years and 60% were women. Barriers to physical activity were moderate: mean IFAB, 6 (SD 19.2); 39 (26%) patients scored less than − 5, corresponding to significant barriers. The mean physical activity was 2837 (SD 2668, median 1784) MET-minutes per week. The IPAQ-S questionnaire was correlated with the IFAB (rho 0.28, p p Conclusion Perceived barriers and facilitators to physical activity were correlated with physical activity, indicating that targeting patients with high barriers and low facilitators to physical activity could be an effective option to improve physical activity levels. Trial registration ClinicalTrial NCT04426747. Registered 11 June 2020 - Retrospectively registered.

To assess, by means of a questionnaire, the effectiveness of a therapeutic education session on rheumatoid arthritis patients’ knowledge about methotrexate. Retrospective study of data collected in routine care. STROBE guidelines were used. Rheumatoid arthritis patients treated with methotrexate had a therapeutic education session conducted by a rheumatology nurse at time 0 and 6 months after. They completed a questionnaire to assess their knowledge about methotrexate before the first therapeutic education session and 6 and 12 months after. A score from 0 to 100 was calculated based on 20 questions. A total of 66 patients were enrolled (50 women), with a mean age of 57 years, median disease duration of 4 years, and methotrexate treatment duration of 2 years. The knowledge score improved 6 months after the first therapeutic education session and was unchanged at 12 months. Significant improvement was observed in knowledge about the need for contraception, the contraindication of trimethoprim, the maximum dose not to be exceeded, reduction in alcohol consumption, and the value of combining folic acid with methotrexate. Knowledge about the risk of hypersensitivity pneumonitis did not improve. Skills related to the need for and timing of laboratory testing and contraception were evaluated using two role-playing situations. None of the skills improved. A therapeutic education session improves patients’ knowledge about methotrexate at 6 months.

There is growing interest in the alterations in body composition (BC) that accompany rheumatoid arthritis (RA). The purpose of this review is to (i) investigate how BC is currently measured in RA patients, (ii) describe alterations in body composition in RA patients and (iii) evaluate the effect on nutrition, physical training, and treatments; that is, corticosteroids and biologic Disease Modifying Anti-Rheumatic Disease (bDMARDs), on BC in RA patients. The primary-source literature for this review was acquired using PubMed, Scopus and Cochrane database searches for articles published up to March 2021. The Medical Subject Headings (MeSH) terms used were ‘Arthritis, Rheumatoid’, ‘body composition’, ‘sarcopenia’, ‘obesity’, ‘cachexia’, ‘Absorptiometry, Photon’ and ‘Electric Impedance’. The titles and abstracts of all articles were reviewed for relevant subjects. Whole-BC measurements were usually performed using dual energy x-ray absorptiometry (DXA) to quantify lean- and fat-mass parameters. In RA patients, lean mass is lower and adiposity is higher than in healthy controls, both in men and women. The prevalence of abnormal BC conditions such as overfat, sarcopenia and sarcopenic obesity is significantly higher in RA patients than in healthy controls; these alterations in BC are observed even at an early stage of the disease. Data on the effect treatments on BC in RA patients are scarce. In the few studies published, (a) creatine supplementation and progressive resistance training induce a slight and temporary increase in lean mass, (b) exposure to corticosteroids induces a gain in fat mass and (c) tumour necrosis factor alpha (TNFα) inhibitors might be associated with a gain in fat mass, while tocilizumab might be associated with a gain in lean mass. The available data clearly demonstrate that alterations in BC occur in RA patients, but data on the effect of treatments, especially bDMARDs, are inconsistent and further studies are needed in this area.

International audience; Objectives: To compare the prevalence and correlates of metabolic syndrome (MetS) stratified by body mass index (BMI) categories in rheumatoid arthritis (RA) and spondyloarthritis (SpA).Methods: The age- and sex-standardized prevalence of MetS was calculated by BMI categories and compared between RA and SpA patients before starting first biologic, and controls. The determinants of metabolic syndrome in patients without obesity were investigated.Results: MetS was observed in 28% of RA (21/75), 22.5% of SpA (18/80), 19% of controls (187/998). The age- and sex-standardized prevalence of MetS was not significantly different between RA 19% (95% CI: 11-27%), SpA 26% (95% CI: 16-36%) and controls 16% (95% CI: 14-18%). When stratified by BMI, the standardized prevalence of MetS was less frequent in obese RA patients (15%, 95% CI: 4-27%) compared to obese controls (48%, 95% CI: 40-55%) or to obese SpA (36%, 95% CI: 26-45%). In normal-weight RA patients, MetS standardized prevalence was 16% (95% CI: 7-25%) compared to 5% (95% CI: 0-11%) in SpA, and 6% (95% CI: 4-8%) in controls. In non-obese SpA, MetS was associated with abdominal obesity, visceral fat mass and cardiovascular risk. In non-obese RA patients with metabolic syndrome, body composition did not differ from metabolically healthy RA patients.Conclusions: MetS is not uniform among patients with similar BMI. In RA, MetS was less frequent in obese patients, and unlike SpA, was not associated with body fat composition in non-obese patients. Differences between RA and SpA for metabolic health suggest various pathophysiological mechanisms.

Rheumatoid arthritis (RA) is associated with a decrease in lean mass and stability or even an increase in fat and ectopic adipose tissue. A few data are available on body composition changes under treatment, and data are still controversial. Body composition was assessed before initiation of biologic disease-modifying antirheumatic drug (bDMARD) and after 6 and 12 months of stable treatment. Eighty-three RA patients were included (75% of women, mean age 58.5 &plusmn, 10.8 years) of whom 47 patients treated with TNF inhibitor (TNFi), 18 with non-TNF-targeted biologic (Non-TNFi), and 18 with conventional DMARD (cDMARD) alone. In the TNFi group, total lean mass, fat-free mass index, and skeletal muscle mass index significantly increased at 1 year. An increase in subcutaneous adipose tissue (SAT) without change for the visceral or body fat composition was associated. These changes were associated with an improvement in strength and walking test. In non-TNFi or cDMARD groups, no significant changes for body composition or muscle function were observed at 1 year. However, no significant differences for treatment x time interaction were noted between group treatments. In active RA patients starting first bDMARD, treatment with TNFi over 1 year was associated with favorable changes of the body composition and muscle function.

To investigate the physiopathology of pain in chronic inflammatory rheumatic diseases (CIRDs), we assessed the prevalence of migraine and neuropathic pain in 499 patients with CIRDs. We studied 238 patients with rheumatoid arthritis, 188 with spondyloarthritis (SpA), 72 with psoriatic arthritis (PsA), and 1 unclassified. Migraine was diagnosed according to IHS migraine diagnostic criteria. Neuropathic pain was diagnosed when patients scored at least 3 on the DN4 questionnaire. Participants completed a validated self-assessment questionnaire. Migraine prevalence was 34% (165/484), and it was highest in PsA. Risk factors for migraine were a high level of anxiety, female sex, young age, and TNF-alpha inhibitor treatment (OR = 1.90 (1.13&ndash, 3.25)). Besides, high disease activity was a risk factor in SpA. Blood CRP level was not significantly associated with migraine. Of 493 patients with CIRDs, 21.5% had chronic pain with neuropathic characteristics. Compared to the French general population, these patients had significantly higher prevalences of migraine (two-fold) and neuropathic pain (three-fold). This study showed that migraine and neuropathic pain frequently occurred in patients with rheumatic diseases. Therefore, upon reporting residual pain, these patients should be checked for the presence of migraine or neuropathic pain, despite adequate clinical control of rheumatic disease.

Background The use of eHealth tools (eg, the internet, mobile apps, and connected devices) in the management of chronic diseases and for rheumatoid arthritis is growing. eHealth may improve the overall quality of care provided to patients with chronic diseases. Objective The primary objective of this study was to describe eHealth use by patients with rheumatoid arthritis in France. The secondary objectives were to identify associations between patient demographics and disease characteristics and the use of eHealth tools, and assess their expectations of eHealth. Methods In this cross-sectional, multicenter study, patients with rheumatoid arthritis, according to the 2010 ACR/EULAR classification criteria, were recruited from 5 university hospitals (Bordeaux, Clermont-Ferrand, Limoges, Montpellier, and Toulouse). Patients completed an anonymous self-questionnaire, including demographic data, evaluating their eHealth use (ie, access, support, frequency of use, type of use, and reason for use). The rheumatologist in charge of each patient completed an independent medical questionnaire on disease characteristics, activity of rheumatoid arthritis, and treatments. Data were collected between December 2018 and July 2019. Results Questionnaires were completed by 575 participants, with a mean age of 62 (SD 13) years, 447 (77.7%) of whom were female. Overall, 82.2% (473/575) of the participants had access to eHealth through a computer (402/467, 86.1%), tablet (188/467, 40.2%), or smartphone (221/467, 47.3%). Of these, 36.4% (170/467) of the participants used the internet for health in general, and 28.7% (134/467) used it specifically for rheumatoid arthritis–related reasons. All these 134 patients used eHealth to learn about disease pathology, and 66.4% (89/134) of them used it as a tool to help monitor rheumatoid arthritis. Most patients (87/125, 69.6%) had a paper file, 19.2% (24/125) used a digital tool (spreadsheets, 10/125, 8%; mobile app, 9/125, 7.2%; or website, 5/125, 4%), and 24.8% (31/125) did not use any tools for monitoring. Few patients (16/125, 12.8%) used tools for treatment reminders. About 21.6% (27/125) of the patients using eHealth used a specific app for rheumatoid arthritis. Univariate analysis showed that age, education level, employment status, treatment, comorbidities, membership of a patient association, and patient education program were associated with eHealth use for rheumatoid arthritis. Multivariate analysis showed that membership of a patient association (odds ratio [OR] 5.8, 95% CI 3.0-11.2), use of biologic disease-modifying antirheumatic drugs (OR 0.6, 95% CI 0.4-1.0), and comorbidities (OR 0.7, 95% CI 0.6-0.8) remained associated with eHealth use for rheumatoid arthritis. Recommendation by a doctor (225/330, 68.2%), ease of use (105/330, 31.8%), and data security (69/330, 20.9%) were factors favoring the use of eHealth. Conclusions To date, few patients have used eHealth for disease management. The use of a reliable and validated eHealth tool for rheumatoid arthritis could therefore be promoted by rheumatologists and could optimize therapeutic adherence.

Objective To compare, in real‐life settings, the retention rates of initial anti‐tumor‐necrosis factor (TNF) treatments (etanercept [ETN], adalimumab [ADA] and infliximab [IFX]) used as first‐line biotherapy for axial spondyloarthritis (axSpA), and evaluate treatment switches to another anti‐TNF inhibitor in the event of treatment failure. Methods We analyzed the medical records of all SpA patients (Assessment in Ankylosing Spondylitis International Working Group axial criteria) treated with ETN, IFX or ADA between 2001 and February 2015. Drug retention rates were calculated using the Kaplan‐Meier method and compared by means of the Cox extended model. Sub‐analyses were performed according to discontinuation reasons. Results Of the 249 SpA patients analyzed (135 radiographic cases, 114 non‐radiographic), 102 received ETN, 62 ADA, and 85 IFX. In total, 103 discontinued treatment. The retention rates of IFX, ADA and ETN were 67%, 59% and 56% after 3 years; 62%, 42% and 47% after 5 years; 55%, 42% and 24% after 8 years; 53%, 42% and 12% after 10 years, respectively. In multivariate analyses, the predictive factors for retention were: low BASDAI score (hazard ratio [HR]: 1.02 [1.01‐1.04]), high C‐reactive protein levels (HR: 0.98 [0.97‐0.99]), concomitant disease‐modifying therapy (HR: 0.4 [0.21‐0.75]), and radiographic SpA (HR: 1.5 [1.0‐2.52]). In total, 61 patients switched to another anti‐TNF therapy. No difference was observed among the three anti‐TNF therapies regarding median retention duration, although the retention rate proved higher for treatment switches from one monoclonal antibody to another. Conclusion The retention rate in SpA patients proved high, with retention for IFX superior to that of ETN.

Objective To compare, in real-life conditions, the retention rates of anti-tumor necrosis factor (anti-TNF) treatment (etanercept [ETN], adalimumab [ADA] and infliximab [IFX]) initiated as first-line biotherapy for rheumatoid arthritis (RA) and to evaluate, in case of failure, the switch to another anti-TNF or a non-anti-TNF biological. Methods Monocentric retrospective cohort including all patients with RA starting a first anti-TNF between 2001 and 2015. Results Among the 346 patients analyzed, 201 received ETN, 82 ADA and 63 IFX. The first anti-TNF was interrupted in 151 cases. The retention rates were 82.8%, 67.6%, 46.5%, 28.1% and 22.5% at 1, 2, 5, 10 and 15 years, respectively, with a median retention duration of 52.8 (18.9–136.2) months (ETN: 59.3 [19.1–NA), ADA: 79.9 [19.3–136.2] and IFX: 37.2 [17.5–134.5], P = 0.49). The predictive factors of discontinuation were active RA (Disease Activity Score of 28 joints – C-reactive protein [DAS28-CRP] hazards ratio [HR]: 1.22 [1.03–1.45]), inflammatory syndrome (erythrocyte sedimentation rate HR: 1.01 [1.0–1.02]; CRP HR: 1.00 [1.00–1.01]), absence of methotrexate treatment (HR: 0.60 [0.43–0.83]), and corticosteroid use (HR: 1.91 [1.31–2.78]). The patients who switched to another anti-TNF treatment had an inferior retention than those who switched to a non-anti-TNF treatment (HR: 0.39 [0.17–0.87], P = 0.02). Conclusion In real life, there was no difference in retention among the three anti-TNF agents, and 25% of patients continued them at 15 years. After failure of an anti-TNF, the switch to a non-anti-TNF biotherapy showed better retention.

Fibromyalgia (FM) is a confounding factor for diagnosing and assessing rheumatic disease activity. This study sought to assess the extent of this syndrome in rheumatism patients at a French rheumatology department.This monocentric epidemiological study enrolled all patients consulting due to rheumatoid arthritis (RA), spondyloarthritis (SpA), or connective tissue disease (CTD). FM diagnosis was confirmed or excluded according to the rheumatologist opinion and the 1990 American College of Rheumatology (ACR) criteria.We enrolled 691 patients, including 451 women (65.3%), with a mean age of 55.8 years (18-93). Of the enrolled patients, 325 presented with RA, 298 SpA [59 psoriatic arthritis (PsA), 137 ankylosing spondylitis (AS), 64 non-radiographic SpA (nr-SpA), and 38 peripheral SpA], and 71 CTD. The rheumatologist established FM diagnosis in 97 patients (14%), while 55 (8%) fulfilled the 1990 ACR criteria. The frequency of FM was lower in RA patients (4.9% by 1990 ACR criteria; 7.7% by expert opinion) compared to SpA (11.1% by 1990 ACR, p0.05; 17.5% by expert opinion, p0.003) and CTD (11.3% by 1990 ACR, non-significant; 28.2% by expert opinion, p0.001). In the SpA subgroups, FM was more common in the nr-SpA than in PsA or AS (23.9%, 9.6%, and 6.4%, by 1990 ACR, p = 0.001; 37.3%, 13.5%, and 7.2%, by expert opinion, p0.001).FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in non-radiographic axial SpA, thus raising questions about the specificity of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by increased mortality associated with cardiometabolic disorders including dyslipidaemia, insulin resistance, and cachectic obesity. Tumour necrosis factor inhibitors and interleukin 6 receptor blocker licensed for the treatment of RA decrease inflammation and could thus improve cardiovascular risk, but their effects on body composition and metabolic profile need to be clarified. We investigated the effects of tocilizumab (TCZ), a humanized anti-interleukin 6 receptor antibody, on body composition and metabolic profile in patients treated for RA. METHODS: Twenty-one active RA patients treated with TCZ were included in a 1 year open follow-up study. Waist circumference, body mass index, blood pressure, lipid profile, fasting glucose, insulin, serum levels of adipokines and pancreatic/gastrointestinal hormones, and body composition (dual-energy X-ray absorptiometry) were measured at baseline and 6 and 12 months of treatment. At baseline, RA patients were compared with 21 non-RA controls matched for age, sex, body mass index, and metabolic syndrome. RESULTS: Compared with controls, body composition was altered in RA with a decrease in total and appendicular lean mass, whereas fat composition was not modified. Among RA patients, 28.6% had a skeletal muscle mass index below the cut-off point for sarcopaenia (4.8% of controls). After 1 year of treatment with TCZ, there was a significant weight gain without changes for fat mass. In contrast, an increase in lean mass was observed with a significant gain in appendicular lean mass and skeletal muscle mass index between 6 and 12 months. Distribution of the fat was modified with a decrease in trunk/peripheral fat ratio and an increase in subcutaneous adipose tissue. No changes for waist circumference, blood pressure, fasting glucose, and atherogenic index were observed. CONCLUSIONS: Despite weight gain during treatment with TCZ, no increase in fat but a modification in fat distribution was observed. In contrast, muscle gain suggests that blocking IL-6 might be efficient in treating sarcopaenia associated with RA

Epub ahead of print; Rheumatoid arthritis (RA) has a negative impact on muscle mass, and reduces patient's mobility and autonomy. Furthermore, RA is associated with metabolic comorbidities, notably in lipid homeostasis by unknown mechanisms. To understand the links between the loss in muscle mass and the metabolic abnormalities, arthritis was induced in male Sprague Dawley rats (n=11) using the collagen-induced arthritis model. Rats immunized with bovine type II collagen were compared to a control group of animals (n=11) injected with acetic acid and complete Freund's adjuvant. The clinical severity of the ensuing arthritis was evaluated weekly by a semi-quantitative score. Skeletal muscles from the hind limb were used for the histological analysis and exploration of mitochondrial activity, lipid accumulation, metabolism and regenerative capacities A significant atrophy in tibialis anterior muscle fibers was observed in rats with arthritis despite a non-significant decrease in the weight of the muscles. Despite moderate inflammation, accumulation of triglycerides (P

Statin-associated muscle symptoms (SAMSs) vary considerably in frequency and severity, with a spectrum extending from myalgia with normal creatine kinase (CK) levels or asymptomatic hyperCKemia to potentially life-threatening rhabdomyolysis and necrotizing autoimmune myopathy. Myalgia with CK elevation is the most common presentation. Onset is usually within 1 month after statin initiation or dosage intensification, and the symptoms can be expected to resolve within a few weeks after treatment discontinuation. The mechanism of muscle injury combines statin accumulation within muscles, which varies with the type and dosage of the drug; muscle fragility; abnormalities in statin transport or liver metabolism; drug-drug interactions; and genetic susceptibility. HMG-CoA reductase inhibition in muscles by statins exerts pleiotropic effects that can affect energy metabolism, induce mitochondrial dysfunction, modify lipid oxidation, promote apoptosis and cell membrane lysis, alter muscle protein synthesis, or trigger an autoimmune process. Statins are used to treat several chronic conditions and comorbidities, including inflammatory rheumatic diseases, which are associated with an increased cardiovascular risk. When the cardiovascular risk is high or very high, statin therapy is indispensable and has a very favorable risk/benefit ratio. Otherwise, the risks should be weighed against the benefits before reinitiating statin therapy, and a different statin or lower dosage should be used. If statin therapy cannot be successfully reintroduced, other classes of lipid-lowering drugs should be considered. Severe SAMSs with major weakness and marked CK elevation should suggest the rare eventuality of necrotizing autoimmune myopathy and prompt an anti-HMGCR antibody assay and muscle biopsy to ensure that immunosuppressant therapy is started rapidly if needed.

This article belongs to the Special Issue Polyunsaturated Fatty Acids Intake and Human Health; Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by a high prevalence of death due to cardiometabolic diseases. As observed during the aging process, several comorbidities, such as cardiovascular disorders (CVD), insulin resistance, metabolic syndrome and sarcopenia, are frequently associated to RA. These abnormalities could be closely linked to alterations in lipid metabolism. Indeed, RA patients exhibit a lipid paradox, defined by reduced levels of total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol whereas the CVD risk is increased. Moreover, the accumulation of toxic lipid mediators (i.e., lipotoxicity) in skeletal muscles can induce mitochondrial dysfunctions and insulin resistance, which are both crucial determinants of CVD and sarcopenia. The prevention or reversion of these biological perturbations in RA patients could contribute to the maintenance of muscle health and thus be protective against the increased risk for cardiometabolic diseases, dysmobility and mortality. Yet, several studies have shown that omega 3 fatty acids (FA) could prevent the development of RA, improve muscle metabolism and limit muscle atrophy in obese and insulin-resistant subjects. Thereby, dietary supplementation with omega 3 FA should be a promising strategy to counteract muscle lipotoxicity and for the prevention of comorbidities in RA patients.

The paper by Ferdowsi et al , reported a 23-item composite damage index to quantify organ damage in systemic sclerosis (SSc).1 In this index, sicca symptoms (item 3) play an important role (weight score=3). Actually, sicca symptoms are frequently reported by patients with SSc (7.5%–68%) and could be due to a fibrosis process of the salivary glands (SGs).2–4 In recent years, ultrasonography (US) of the parotid and submandibular glands has been widely used for identifying SG modifications in patients with primary Sjogren’s syndrome (pSS). In order to assess modifications in the SG echostructure in patients with SSc and compare them with those of patients with pSS or controls with sicca symptoms, we prospectively enrolled patients with SSc fulfilling the American College of Rheumatology/European League against Rheumatism (ACR/EULAR) 2013 classification criteria, patients with pSS according …

Background Modifications in ultrasonographic aspect of major salivary glands have been reported in patients with primary Sjogren Syndrom (pSS) with good diagnostic accuracy. Sicca symptoms are frequently observed in Systemic sclerosis (SSc). Objectives To assess the ultrasonographic echostructure of major salivary glands in patients with SSc and compare the modifications with those of patients with pSS or controls with sicca symptoms. Methods We performed a monocentre case-control study between 2014 and 2017 in the universitary hospital of Clermont-Ferrand (France). Patients with SSc and pSS were fullfilling the American College of Rheumatology/European League against Rheumatism (ACR/EULAR) 2013 and the ACR 2012 classification criteria respectively. Controls patients were complaining of sicca symtoms but did not meet the ACR 2012 criteria. Bilateral parotid and submandibular glands ultrasound (US) were performed in all patients by the same operator blinded to the diagnosis. Inhomogeneity of each of the 4 major salivary glands in B-Mode was graded using the Jousse-Joulin scoring system (scale of 0 to 4) as previously described.[1] The highest grade among the 4 glands was retained as suggestive of Sjogren Syndrom if ≥ 2. Results A total of 108 patients were included: SSc (n=25), pSS (n=48) and controls (n=35). Among the 48 patients with pSS, 12 were receiving hydroxychloroquine, 4 an immunosuppressor, 77% had antinuclear antibodies at a significant level (≥1/640), 26 (54%) anti-SSA antibodies, 14 (29%) anti-SSB antibodies, 40/45 (89%) had a labial salivary biopsy suggestive of pSS (Chisholm and Mason score ≥3). Comparing the pSS and the control groups, performance of a US echostructure grade ≥ 2 for the diagnosis of pSS was good: Se=75%, Sp=91.4%, positive predictive value= 92.3%, negative predictive value= 72.7%. Among the 25 SSc patients, 7 had immunosuppressor therapy, 8 had a localized SSc. Shirmer’s test ≤ 5 mm in 5 minutes was present in 9/18 (53%), unstimulated salvary flow ≤ 0.1 mL/minute in 8/14 (57.1%). In the SSc group, 12 patients had an US echostructure grade 0, 6 grade 1, and 7 patients (28%) had an US echostructure grade of ≥ 2: US score=3 (n=5), US score=4 (n=2). Anti-SSA antibodies were found in 1/7 patients with an US echostructure grade ≥ 2 and 2/18 patients with US echostructure grade 0 or 1. Conclusion Nearly one third of patients with SSc have US echostructure changes suggestive of Sjogren Syndrom regardless of the presence of anti-SSA antibodies. References [1] - Cornec D, Jousse-Joulin S, Pers JO, et al. Contribution of salivary gland ultrasonography to the diagnosis of Sjogren’s syndrome: toward new diagnostic criteria? Arthritis Rheum. 2013;65:216-25. Disclosure of Interests None declared

Background:Physical activity is important for patients with inflammatory arthritis (IA), such as spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA). They are more prone to physical inactivity but derive specific benefits from regular physical activity (1,2). It is not easy to modify physical activity level (3). Barriers and facilitators to physical activity can be assessed through questionnaires (4), however, it is important to demonstrate a link between these explanatory elements and physical activity levels.Objectives:To measure the correlation between barriers and facilitators to physical activity, assessed through a simple questionnaire, and self-reported physical activity levels.Methods:This was an international, multicentric, cross-sectional study performed between October 2019 and June 2020 (ClinicalTrial NCT04426747). Consecutive patients were included if they had definite axSpA, RA or PsA, were aged above 18 and able to walk. Barriers and facilitators to physical activity were measured using the 10-item Inflammatory arthritis Facilitators and barriers questionnaire (IFAB) (5). The IFAB ranges -70 to 70 with lower scores indicating more barriers; scores below -5 correspond to significant barriers. Physical activity was measured by the IPAQ-S questionnaire (6). Exploratory analyses used steps per day collected by smartphone, and psychological readiness to change by stages of behavior change. Statistical analysis used Spearman correlation (rho, pResults:Of 245 patients included, 150 had analysable data (69 (46%) axSpA, 63 (42%) RA, 18 (12%) PsA). Mean age was 48.6 years (SD 17.1), mean disease duration 11.7 (10.1) years and 60% were women. The mean score of barriers and facilitators to physical activity was 6.0 (SD 19.2, median 4) (Figure 1). A total of 39 (26%) patients scored less than -5, which could justify a targeted intervention. The mean physical activity was 2837 (SD 2668, median 1784) Metabolic Equivalent of Task min per week. Physical activity was correlated with score of barriers and facilitators to physical activity in linear regression (rho 0.28, pTable 1for abstract: correlation between IFAB questionnaire, each items and level of physical activity with or without extreme valuesItemCorrelation with IPAQ-S min/met/week, rhoCorrelation with stage of behavior change, rhoCorrelation with mean steps per day, rhoTotal IFAB score0.28 ***0.35 ***0.08Item 10.29 ***0.16 *0.16 *Item 20.060.020.05Item 30.080.16 *0.01Item 40.130.09-0.07Item 5-0.090.100.07Item 60.22 **0.25 ***-0.05Item 70.22 **0.20 **0.12Item 80.16 *0.26 ***0.11Item 90.150.33 ***0.11Item 100.090.17 *0.02Social support questions0.140.27 ***-0.03Psychological and knowledge status questions0.22 **0.16 *0.09*=PConclusion:Perceived barriers and facilitators to physical activity are correlated with physical activity. Targeting patients with high barriers and low facilitators to physical activity could be an effective option to improve physical activity levels.References:[1]O’DWYER T., et al. Rheumatology 2014. Vol. 53, n° 10, pp. 1812-1817.[2]OSTHOFF, A et al. 2018. Vol. 77, n° 9, pp. 1251-1260. DOI 10.1136/annrheumdis-2018-213585.[3]MARLEY, J, et al: BMC Musculoskeletal Disorders. 2017. Vol. 18, pp. 482. DOI 10.1186/s12891-017-1836-2.[4]COSTE, N., et al. 2019. DOI 10.1016/j.rehab.2019.07.009.[5]DAVERGNE, T, et al. Rheumatology International 2020. DOI 10.1007/s00296-020-04692-4.[6]LEE, PH, et al. 2011. Vol. 8, pp. 115. DOI 10.1186/1479-5868-8-115.Figure 1.Distribution of the IFAB score Footnote: Y axis: effectifs, X axis: IFAB score (possibles values from -70 to 70)Acknowledgements:I have no acknowledgements to declare.We thank the following coinvestigators: Sylvie Rozenberg, Beatrice Banneville, Rachida Inaoui, Emmanuelle Dernis, Athan Baillet and Catherine Beauvais, and we thank Hervé Servy for expert CRO adviceDisclosure of Interests:None declared

Background:Anti-TNF treatments (TNFi) have shown high efficacy in axial spondyloarthritis (ax-SpA) with inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs). However their effect remains predominantly symptomatic, and their long-term tolerance as well as significant societal cost justify investigation about a potential reduction in drug dosage, or –most feasible and comfortable for the patient– increase in intervals between doses.Objectives:To assess if a progressive and monitored reduction of administered TNFi by increase of intervals between injections results in a comparable proportion of patients remaining after 12 months (m) in low disease activity state despite a decreased cumulative treatment dose received.Methods:Non-inferiority randomized controlled trial, having included adult patients with ax-SpA fulfilling ASAS criteria, already treated by anti-TNF, and in stable low disease activity for at least 6 m (current and at least 6 m old BASDAIResults:398 patients were randomized in 23 French rheumatology units (197 and 201 in the spacing and unchanged groups respectively), and 389 included in analyses (9 did not receive the allocated treatment). Mean (SD) age was 44.3 (12.4) years, 71.2% were males. Mean (SD) BASDAI at inclusion was 1.45 (1.02). TNFi used were etanercept (35.7%), adalimumab (33.9%), infliximab (20.6%), golimumab (9.3%) and certolizumab (0.5%). For the 373 patients with complete follow-up (93.7%), 162/184 (88.0%) had a low disease activity in the “spacing” group vs. 173/189 (91.5%) in the “unchanged” group at 12 m. After multiple imputation for the 16 patients with missing data, the difference of proportion between the two groups was estimated to -4.18% [CI90% -10.0; 1.7], thus confirming the non-inferiority of the “spacing” procedure. In the “spacing” group at 12 m, 134/162 (82.7%) patients in low disease activity were still receiving a lowered TNFi dose.Conclusion:In ax-SpA patients with BASDAIDisclosure of Interests:Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai, Anne Tournadre Speakers bureau: Abbvie, Fresenius, Janssen, MSD, Pfizer, Roche Chugai, Sanofi, Paid instructor for: Fresenius, Consultant of: Abbvie, Fresenius, Lilly, Novartis, Sanofi, Grant/research support from: Fresenius, Novartis, Pfizer, UCB, Marie Christine Picot: None declared, Erika Nogué: None declared, Emmanuelle Dernis Speakers bureau: Roche chugai, UCB, BMS, Novartis, Lilly, Mylan, Pfizer, Celgène, Consultant of: UCB, MSD, BMS, Lilly, Novartis, Philippe Goupille Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi

To see whether the frequency and features of septic arthritis (SA) complicating rheumatoid arthritis (RA) have changed over the last 35years.This retrospective single-center study included all patients hospitalized at the rheumatology department for SA bacteriologically documented by synovial fluid and/or blood culture samples. The periods 1979-2002 (before biotherapies) and 2003-2013 (the era of biotherapies) were compared.Between 1979 and 2013, 64/514 (12.5%) SA presented with a RA - 21/157 (13.4%) in the 2003-2013 period and 43/357 (12.0%) in the 1979-2002 period. Over the past decade, median age of RA SA patients increased (61 vs. 68 years; P0.02) and predominant gender became males (52% vs. 40%). The features of the RA remained unchanged: history (18 vs. 16years), rheumatoid factor (95% vs. 87%), and corticosteroids (91% vs. 81%). Over the last decade 24% (vs. 0; P0.003) of the patients received a biologic DMARD: etanercept (n=2), adalimumab (n=1), rituximab (n=1), tocilizumab (n=1). Proportion of polyarticular infection had decreased strongly (9.5% vs. 37%; P0.02). Proportion of Staphyloccus aureus infections remained stable, but there was a higher incidence of MRSA infections (31 vs. 6%; P0.05). Blood cultures less often tested positive (29% vs. 47%; NS). Case fatality rate had fallen slightly in RA SA (5% vs. 9%; NS), but not in non-RA SA cases (7% vs. 6%; NS).This study brings reassuring findings - in the era of biotherapies, the rate of septic arthritis amongst patients with RA has not increased, and the most severe septic polyarticular forms are on the decline.

Background:Rheumatoid arthritis (RA) patients are at increased risk of infections, some of which could be prevented in part by vaccination (1). Influenza and pneumococcal vaccines are recommended in RA (2). However, vaccination coverage of these patients remains very low. Five years ago, we found in a previous study that vaccination rates in France were 55% for pneumococcal and 60% for influenza vaccines (3).Objectives:The aim of our study was to evaluate the vaccination rate among RA patients, compare it with our previous results, and identify factors associated with non-vaccination.Methods:We conducted a cross sectional multicentric observational study in the rheumatology departments of 5 university hospitals in France. Data were collected from December 2018 to July 2019. Outpatients and hospitalized adult patients with RA according to the ACR/EULAR 2010 criteria were included. Data were collected during a single visit through an anonymous questionnaire completed by the patients. Pearson Chi-squared analysis and multivariable logistic regression were used to compare characteristics of vaccinated versus non vaccinated patients.Results:584 patients (77.9% of women, mean age 61.8±12.6 years old) were included. 81.7% were RF and/or ACPA positive, with a mean RA duration of 15.7±10.5 years, 58.2% were treated with methotrexate (MTX), and 68.6% with a biologic. Vaccination rate against pneumococcal was 78.9% (versus 55% in 2013, pConclusion:Vaccination rate against pneumococcal increased over the last 5 years but remained stable for influenza vaccine in French RA patients. This could be improved with patient’s information and education, especially in patients age under 65, biologic naïve and with a bad opinion about vaccination.References:[1] Doran MF, Crowson CS et al. Arthritis Rheum. 2002 Sep;46(9):2287–93.[2]van Assen S, Agmon-Levin N et al. Ann Rheum Dis. 2011 Mar;70(3):414–22.[3] Hua C, Morel J et al. Rheumatol Oxf Engl. 2015 Apr;54(4):748–50.Disclosure of Interests:Claire Rempenault: None declared, Thomas Barnetche: None declared, Marion Magnol: None declared, Benjamin Castagne: None declared, marine pugibet: None declared, Eleonore Berard: None declared, Marie-Elise Truchetet: None declared, Pascale Vergne-Salle: None declared, Anne Tournadre: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Cédric Lukas: None declared

International audience; The increased cardiovascular risk in RA (rheumatoid arthritis) cannot be explained by common quantitative circulating lipid parameters. The objective of the study was to characterize the modifications in HDL phosphosphingolipidome in patients with RA to identify qualitative modifications which could better predict the risk for CVD. Nineteen patients with RA were compared to control subjects paired for age, sex, BMI, and criteria of metabolic syndrome. The characterization of total HDL phosphosphingolipidome was performed by LC-MS/MS. RA was associated with an increased HDL content of lysophosphatidylcholine and a decreased content of PC (phosphatidylcholine), respectively, positively and negatively associated with cardiovascular risk. A discriminant molecular signature composed of 18 lipids was obtained in the HDL from RA patients. The detailed analysis of phospholipid species showed that molecules carrying omega-3 FA (fatty acids), notably docosahexaenoic acid (C22:6 n-3), were depleted in HDL isolated from RA patients. By contrast, two PE (phosphatidylethanolamine) species carrying arachidonic acid (C20:4 n-6) were increased in HDL from RA patients. Furthermore, disease activity and severity indexes were associated with altered HDL content of 4 PE and 2 PC species. In conclusion, the composition of HDL phosphosphingolipidome is altered during RA. Identification of a lipidomic signature could therefore represent a promising biomarker for CVD risk. Although a causal link remains to be demonstrated, pharmacological and nutritional interventions targeting the normalization of the FA composition of altered phospholipids could help to fight against RA-related inflammation and CVD risk.

Objective To determine whether anti-Ro52 antibodies are associated with ILD in pSS. Methods Retrospective study based on the presence or absence of anti-Ro52 antibodies in patients with pSS. Patients underwent chest HRCT at the time of diagnosis or during follow-up. Results Sixty-eight patients were included. Two groups were defined by the presence (n = 31) or absence (n = 37) of anti-Ro52 antibodies. ILD was significantly higher in the presence of anti-Ro52 (41.9%, n = 13) versus in the anti-Ro52-negative group (16.2%, n = 6; p = 0.019). Multivariate analysis adjusted for anti-SSA/Ro60, anti-SSB antibodies and rheumatoid factor status confirmed that anti-Ro52 antibodies positivity is a predictive factor for ILD (p = 0.01). Nonspecific interstitial pneumonia was the most common pattern of ILD (31.6%). The majority of patients were diagnosed with pSS simultaneously to ILD (52.6%). In the anti-Ro52-negative group, no patients develop ILD after 5 years of follow-up. Conclusion In pSS, the risk of developing ILD is higher in the presence of anti-Ro52 antibodies. In patients with pSS and anti-Ro52 antibodies, a clinical screening and pulmonary functional tests with DLCO is necessary during the follow-up and should comprise chest HRCT if there is a decline in the DLCO or clinical symptoms or inspiratory crackles.

Background Alterations of body composition in Rheumatoid arthritis (RA) may contribute to the development of cardiometabolic disorders. RA patients have a decrease in muscle mass with a preserved or increased fat mass, notably accumulation of ectopic fat in the muscles, witch define the sarcopenic obesity. The mechanisms leading to this sarcopenic obesity phenotype remain poorly understood. Accumulation of intramuscular lipids and the formation of lipotoxic compounds may affect intracellular signalling pathways and energy production, alter protein synthesis and thus promote sarcopenia. Objectives Our objective was to determine if muscular lipotoxicity promotes the development of sarcopenia in joint inflammatory condition, using rats with collagen-induced arthritis. Methods Male Sprague Dawley rats were divided into a control group (CO, n=12) and a collagen-induced arthritis group (CIA, n=11). After 5 weeks, hind leg muscles and epididymal adipose tissue were removed. Tissues were weighed at sacrifice and stored for histological analyses and evaluation of mitochondrial function, lipotoxicity, protein and gene expression levels. Statistical analyses were performed with t-test. Results Animals, adipose tissue and muscle weights tended to be lower in the CIA group. Only EDL muscle weight was significantly lower in the CIA group (p=0.05). Muscle histological analyses showed larger CSA (cross sectional area) in CO group. In the CIA group we observed a nonhomogeneous distribution of muscle fibre CSA with a predominance of small fibres (figure 1). Mean perimeter and mean diameter were also significantly decrease in CIA group but the shape of fibres remained similar between groups. Furthermore, there was an increased expression of MAFBx (a marker of catabolism) mRNA (40%, p=0.04) in the CIA group, while MyoD (a myogenesis marker) mRNA was decreased by 18% (p=0.01), indicating a catabolic state. Lipid content analysis showed an accumulation of intramuscular TAG (x 1.5, p=0.05), as well as an increased expression of cellular fatty acid transporter FATP1 (about 35%, p=0.01) and mitochondrial fatty acid transporter CPT1b (about 27%, p=0.02). Mitochondrial DNA copy number was decreased by 27% in CIA rats (p=0.01) and complex IV activity of mitochondrial respiratory chain also tended to be reduced in CIA group (−20%, p=0.18). Conclusions Collagen-induced arthritis induced fibres alterations in skeletal muscle. The association of increased muscle protein catabolism, mitochondrial dysfunction and fatty acid accumulation in skeletal muscle of animals with arthritis supports the hypothesis that lipotoxicity is involved in sarcopenia development during joint inflammation. Disclosure of Interest None declared

Background The use of TNF-α inhibitors, has considerably improved the treatment of rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA). The most widely used anti-TNFs are infliximab (IFX), adalimumab (ADA), and etanercept (ETN). Their efficacy and safety have been demonstrated in randomised controlled trials, though of short duration and involving a selected patient population differing from those seen in daily practice. Objectives To compare, in real-life settings, the retention rates of anti-TNF treatments (ETN, ADA, or IFX) initiated as first-line biotherapy following their approval in the three clinical indications. Methods Monocentre retrospective cohort involving patients on initial anti-TNF therapy for RA, SpA, or PsA since 2006. Results Anti-TNF treatment was initiated on 228 RA (ETN 160, ADA 45, or IFX 23), 208 SpA (ETN 91, ADA 62, or IFX 55), and 81 PsA (ETN 40, ADA 26, or IFX 15) patients. Treatment retention rates at 1, 3, and 5 years were 82%, 53%, and 44% in PR; 75%, 57%, and 49% in SpA; 75%, 64%, and 51% in PsA, with no differences detected among the pathologies (p=0.96). Retention rates at 1, 3, and 5 years did not differ among the 3 anti-TNFs either for all pathologies included (ETN: 80%, 57%, and 43%; ADA: 80%, 58%, and 51%; IFX 72%, 56%, and 52%; p=0.75) or each pathology alone ( RA : ETN: 83%, 55%, and 41%; ADA: 83%, 51%, and 51%; IFX: 76%, 44%, and 44%, p=0.84; SpA : ETN: 78%, 57%, and 48%; ADA: 78%, 59%, and 46%; IFX: 68%, 55%, and 52%, p=0.81; PsA : ETN: 70%, 60%, and 36%; ADA: 79%, 69%, and 69%; IFX: 80%, 66%, and 53%, p=0.65). Overall, 89 RA, 85 SpA, and 28 PsA patients discontinued treatment for inefficacy (32%) or side effects (SE, 9%)). In RA, predictors for treatment discontinuation were: Disease activity (DAS 28 ESR HR: 1.27 [1.05–1.55]; DAS28-CRP HR: 1.27 [1.03–1.60]), (CRP HR: 1.01 [1.01–1.02]), and corticosteroid intake (HR: 2.05 [1.027–3.32]). Concomitant methotrexate intake tended to decrease the treatment discontinuation risk (HR: 0.64 [0.41–1.01)]. Predictors for treatment discontinuation due to inefficacy were similar (DAS28 ESR, HR: 1.31 [1.05–1.63]; DAS28 CRP, HR: 1.33 [1.04–1.72], CRP HR: 1.02 [1.01–1.03]), corticosteroid intake HR: 3.79 [2.02–7.11]). We were unable to identify any predictors for treatment discontinuation due to SE, though corticosteroid intake was found to be protective (HR: 0.23 [0.07–0.71]). In SpA, the sole predictor for treatment discontinuation identified was increased BASDAI score (HR: 1.02 [1.01–1.04]), while the sole predictor for treatment maintenance was inflammatory syndrome (CRP HR: 0.97 [0.95–0.99]. Similar findings were seen for treatment discontinuation due to inefficacy (BASDAI HR: 1.03 [1.01–1.05)]; CRP HR: 0.98 [0.96–0.99]). We were unable to identify any predictors for treatment discontinuation due to SE. In PsA, active smoking was revealed to be a predictor for treatment discontinuation due to inefficacy (HR: 2.234 [1.02–4.91)]. Conclusions ETN, ADA, and IFX display similar treatment retention rates in RA, SpA, or PsA without between-agent differences. Disclosure of Interest None declared

International audience; Objectives: To analyze the factors associated with fatigue focusing on comorbidities in a large cohort of rheumatoid arthritis (RA). Methods: Cross-sectional analyses were performed on RA patients from the French COMEDRA cohort study, a nurse-led program for comorbidities management. Fatigue was assessed using Question 3 of the Rheumatoid Arthritis Impact of Disease (RAID) score on a 0-10 numerical rating scale (NRS). Fatigue was defined as acceptable if = 5 out of 10. Using univariate and multivariate models, the relationship between fatigue and demographics, social, disease characteristics, comorbidities (cardiovascular, infections, cancer, pulmonary, osteoporosis, and psychiatric disorders), physical activity, quality of life, and treatments was investigated. Results: In total, 962 patients were analyzed. The mean fatigue score was 3.8 +/- 2.7, 40% of patients reported severe fatigue. Patients had an average of 1.8 additional morbid conditions, with anxiety/depression the most common (52%). In univariate analysis, severe fatigue was more frequent in women, in patients not working, and in those with less physical activity. It was associated with disease duration and activity, mHAQ, pain, sleeping and emotional difficulties. Severe fatigue correlated with Multimorbidity index assessing the number of morbid conditions and was associated with obesity, hypertension, COPD, and anxiety/depression. In multivariate models, the risk of severe fatigue was associated with female gender, disease activity, mHAQ, current treatment with NSAIDs and biologics, multimorbidity, obesity and anxiety/depression. Conclusions: Assessment of comorbidities, psychological health and physical activity should be taken into account in order to address frequent RA-related severe fatigue.

Background Corticosteroid therapy can unbalance diabetes, particularly when administered orally, but also during articular infiltration. Corticosteroid infiltrations are an integral part of the therapeutic arsenal in rheumatology. They are utilized to treat congestive articular flare-ups of osteoarthritis or inflammatory rheumatic diseases. Periarticular or ductal pathologies, such as trochanteric bursitis, rotator cuff pathology and carpal-tunnel syndrome, may require the use of these infiltrations. Caution is often required when using corticosteroid infiltrations in diabetics. Objectives The purpose of our study was to evaluate whether or not diabetic patients undergoing a corticosteroid infiltration during hospitalization had a diabetes imbalance. Methods Diabetic patients having undergone a corticosteroid infiltration during hospitalization between 2009 and 2015 were sought. We collected data regarding their rheumatological pathology, glycated hemoglobin (HbA1c), and fasting glycemia on the day of the infiltration, the next day and after 48 hours. Results A total of 114 patients were included in our study. The average age was 72.1±9.4 years. All of them had Type 2 diabetes, and 35 of them were treated with insulin. Average HbA1c was 7.3±0.1%. Overall, 47 (41.2%) patients had an HbA1c below 7%. A total of 31 (27.2%) patients had a diabetes imbalance after infiltration, and 19 of these, who were taking oral antidiabetics, required 48 hours of rapid insulin to balance their glycemia. Overall, 12 patients increased their insulin dose. Out of the 47 patients with good HbA1c, 7 (14.9%) of them had a glycemia imbalance, versus 24 (35.8%) who were unbalanced out of the 67 patients whose HbA1c exceeded 7% (p=0.013). Conclusions Corticosteroid infiltrations can lead to a diabetes imbalance, thus making it necessary to administer a few days of rapid insulin or to increase the insulin dose. A patient whose HbA1c is below 7% has a low risk of unbalancing his/her diabetes after corticosteroid infiltration. Disclosure of Interest None declared

Background Evaluation of sarcopenia is of major relevance because of these clinical repercussions on morbidity and mortality. Although the definition should include both low muscle mass and function, a combination of the 2 criteria was not reported in inflammatory rheumatic diseases (IRDs). Objectives To determine in a cohort of IRDs the prevalence of sarcopenia using established combined criteria (EWGSOP) (1). Methods Sarcopenia defined as both low muscle mass (skeletal muscle index (SMI)

Background Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylsosing spondylitis (SA) are associated with an increased cardiovascular (CV) mortality. Quantitative abnormalities in lipid profiles are insufficient to explain this excess of CV risk and a qualitative approach of HDL composition is required to identify loss of atheroprotective functions and to correctly identify patients at risk. Atheroprotective functions of HDL are directly linked to the structure of HDL mainly composed of phospholipids (PL). Objectives The main objective of this study is to analyze the PL composition of HDL in patients with chronic inflammatory rheumatic diseases and to compare to matched healthy controls. Methods HDL structure was assessed in patients with active RA (ACR criteria), PsA (CASPAR criteria) and SA (ASAS criteria) patients before initiating first biologic and in healthy controls matched for age, sex and body mass index. Dyslipidemia treatment or pathology which could interfere with lipid profile were excluded. Demographics data, disease activity, cardiometabolic profile and plasma samples were collected. HDL particle were isolated from plasma after two step ultracentrifugation using gradient of density. Lipidomics analysis were performed using liquid chromatography coupled with mass spectrometry. Phospholipid composition between patients and controls was compared using multivariate analyses to take into account possible confounding variables determined according to univariate results and clinical relevance (age, tobacco consumption, steroids use). Multidimensional analyses as factorial mixed data analysis (FMDA) were performed to complete these analyses. Results 19 RA, 19 PsA and 12 SA were analyzed (table 1). 220 phospholipids species were identified among which 2 major classes were modified in rheumatic diseases. Phosphatidylcholine (PC) decreased in RA and PsA (p Conclusions Phospholipids composition of HDL is altered in RA and PsA. These alterations could explain a loss of atheroprotective functions and the excess of CV risk observed in RA and PsA patients. Chronic inflammation, through the activation of phospholipase A2 type II which hydrolyze PC into LPC, could modify the structure of HDL phospholipids and thus could impact HDL functionality such as cholesterol efflux, LDL oxidation modulation, anti-inflammatory and vasculoprotective properties. These preliminary data suggest the major role of inflammation in these alterations. References Tselepis AD et al. Atheroscler Suppl. 2002;3(4):57–68. Kontush A, et al. J Lipid Res. 2013;54(11):2950–63. Disclosure of Interest None declared

Background Stress fractures are common in both young and active patients (fatigue fracture) as well as in elderly osteoporotic patients (insufficiency fractures). Objectives The aim of this study was to describe characteristics of stress fractures treated in rheumatology at the Clermont-Ferrand University Hospital, to compare them according to their anatomic location (pelvis, lower limb or feet/ankle) and their diaphyseal or metaphyseal/epiphyseal location. Results Between 01/01/2000 and 12/31/2015, 325 fractures were identified in 227 patients divided in 176 women (including 116 postmenopausal women) and 51 men. Population averaged age was 65.2 years [15–99 years]. 142 (43.7%) fractures occurred at pelvis, 93 (28.6%) at lower limbs and 87 (26.8%) at feet and ankles. The fracture was spontaneous in 63.6% of cases. History of pain was recorded in 92.3% with more frequently (90.3%) mechanical pain. Diagnostic delay was on average 70 days. In 51 patients (22.5%) an orthopedic factor could have promoted stress fracture. 54 patients (23.8%) had a history of chronic inflammatory rheumatism, 28 (12.3%) of cancer, and 20 (8.8%) had chronic renal failure. Among the possible iatrogenic factors, 51 patients (23.4%) received oral corticosteroid therapy, 20 (9.2%) methotrexate, 59 (27%) proton pump inhibitor and 17 (7.8%) serotonin reuptake inhibitor. 49 patients (22.5%) already had vitamin-calcium supplementation, 37 (17%) received biphosphonate therapy. 56.6% were osteoporotic and 29.5% were osteopenic. First-line medical imaging was in 87% conventional radiography, positive in 37%. 106 patients (46.7%) performed bone scan with a sensibility of 99%. MRI sensibility (n=65, 28.7%) was 88% and CT-scan sensibility (n=47, 20.7%) 65.2%. Compared to other sites, pelvic fractures were more frequent (p Pelvic fractures occurred more frequently after fall (p Conclusions In conclusion, pelvic stress fractures are more frequent in a rheumatology department and suggest insufficiency fracture. Stress fracture should be more often suspected when mechanical pain of the pelvis and lower limbs occurs, even spontaneously. Regardless of the site, an assessment of fracture risk factors and bone mineral density evaluation seems necessary. Disclosure of Interest None declared

Background In rheumatoid arthritis (RA), the long lasting effect of rituximab (RTX) on B lymphocyte depletion may influence the choice of biologic after RTX failure but there is currently no specific recommendation about the optimal strategy. Objectives We assessed factors which may have influenced the choice of biologic following failure to RTX in RA patients and analysed the effectiveness of these biologics. Methods A retrospective study of RA patients, who had started a new biologic during the year after RTX discontinuation, was conducted between 2009 and 2016 in 5 French rheumatology centers. We collected at baseline (at the time the biologic was introduced after RTX) and during follow-up (3, 6 and 12 months), data about patients and disease. Characteristics of the patients receiving tocilizumab (TCZ), abatacept (ABA) or anti-TNF following RTX, the EULAR response and retention rate were compared using univariate and multivariate analyses. Results 152 RA patients (117 women, mean age 56.9±13 years) were analysed. RA duration was 14.3 years [IQR 7.8–19.8], mean DAS28 ESR at baseline 4.8±1.3. 57 patients (37.5%) received TCZ, 47 (31%) anti-TNF and 48 (31.2%) ABA following RTX. 87% had received anti-TNF prior to RTX. No significant difference in the biologics prescription profile was noted across centers. At baseline, sex, disease characteristics and activity, use of concomitant DMARDs or prednisone were not different between the 3 groups. There was no difference in the number of cycles or dose of RTX received and the number of previous anti-TNF treatment. Patients receiving ABA were slightly older (59.8 years vs 54 years for TCZ and 57.8 years for anti-TNF, p=0.06). Multimorbidity index (MMI) assessing the number of comorbidities was higher in the group ABA but not significantly (MMI count 2±1.7 for ABA, 1.6±1.5 for TCZ, 1.7±1.4 for anti-TNF, p=0.5). At 3, 6 and 12 months, DAS28ESR was lower in patients with TCZ as compared to those with anti-TNF or ABA (Table) but tender and swollen joint counts did not differ. The EULAR good-or-moderate response rates were similar across groups (Table). After adjustment on age, sex, disease duration, MMI count, number of previous anti-TNF, use of concomitant DMARDs and prednisone, drug retention rate at 1 year was significantly better for ABA compared to anti-TNF (p=0.02) and for TCZ compared to anti-TNF (p=0.04), but no difference was found between TCZ and ABA (p=0.62) (Figure). Conclusions Patients who received ABA following failure of RTX, seem to be older and with more comorbidities. Similar rate of good-or-moderate EULAR response was observed between patients receiving TCZ, ABA or anti-TNF. However, drug retention rate was better with TCZ and ABA compared to anti-TNF after RTX discontinuation. Disclosure of Interest None declared

Background The use of anti-tumor necrosis factor-alpha agents, or anti-TNFs, has greatly improved the treatment of rheumatoid arthritis (RA). The first three anti-TNFs available to us (infliximab, adalimumab, and etanercept) are the most widely used in treating RA. Their efficacy and safety, demonstrated in extensive randomized and controlled trials (RCTs), were not shown to vary significantly when compared indirectly based on randomized studies. Nevertheless, the randomized studies were of short duration and included a selected population that differed from patients treated in daily practice. Objectives To compare, in real-life conditions, the retention rates of the initial anti-TNF treatment (etanercept [ETN], adalimumab [ADA], and infliximab [IFX]) initiated as first-line biotherapy for rheumatoid arthritis (RA) and to evaluate, in case of failure, the switch to another anti-TNF or a non-anti-TNF biological. Methods Monocentric retrospective cohort including all patients with RA starting a first anti-TNF between 2001 and 2015. Results Among the 346 patients analyzed, 201 received ETN, 82 ADA, and 63 IFX. The first anti-TNF was interrupted in 151 cases. The retention rates were 82.8%, 67.6%, 46.5%, 28.1%, and 22.5% at 1, 2, 5, 10, and 15 years, respectively, with a median retention duration of 52.8 [18.9 -136.2] months (ETN: 59.3 [19.1-NA), ADA: 79.9 [19.3–136.2], and IFX: 37.2 [17.5–134.5], p=0.49). The predictive factors of discontinuation were active RA (DAS28-CRP HR: 1.22 [1.03–1.45]), inflammatory syndrome (ESR HR: 1.01 [1.0–1.02]; CRP HR: 1.00 [1.00–1.01]), absence of MTX treatment (HR: 0.60 [0.43–0.83]), and corticosteroid use (HR: 1.91 [1.31–2.78]). The patients who switched to another anti-TNF treatment had an inferior retention than those who switched to a non-anti-TNF treatment (HR: 0.39 [0.17 - 0.87], p: 0.02). p=0.02). Conclusions In real life, there was no difference in retention among the three anti-TNF agents, and 25% of patients continued them at 15 years. After failure of an anti-TNF, the switch to a non-anti-TNF biotherapy showed better retention. Disclosure of Interest None declared

Necrotizing autoimmune myopathy (NAM) is a group of acquired myopathies characterized by prominent myofiber necrosis with little or no muscle inflammation. Recently, researchers identified autoantibodies (aAb) against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) in patients with NAM, especially in statin-exposed patients. Here we report what is to our knowledge the first European cohort of patients with NAM.The serum of 206 patients with suspicion of NAM was tested for detection of anti-HMGCR aAb using an addressable laser bead immunoassay. Forty-five patients were found to be anti-HMGCR positive. Their mean age was 48.9 ± 21.9 years and the group was predominantly female (73.3%). Statin exposure was recorded in 44.4% of patients. Almost all patients had a muscular deficit (97.7%), frequently severe (Medical Research Council [MRC] 5 ≤3 in 75.5%). Subacute onset (

Introduction Les anticorps anti-SSA 52kd sont connus pour etre un facteur de risque de pneumopathie interstitielle diffuse (PID) dans certaines connectivites ou pour etre associes a un moins bon pronostic dans les PID dans sclerodermie systemique et le syndrome des anti-synthetases [1] , [2] , [3] . Aucune etude n’a montre de lien entre les anti-SSA 52kd et le risque de pneumopathie interstitielle dans la maladie de Gougerot-Sjogren primitive (pGS). L’objectif est de savoir si les anticorps anti-SSA 52kd sont un facteur de risque de pneumopathie interstitielle dans pGS. Patients et methodes Etude retrospective monocentrique comparant les patients avec pGS selon la presence ou l’absence d’anti-SSA 52kd repondants aux criteres de classification du Gougerot-Sjogren de 2016 et ayant eu scanner thoracique haute resolution (TDM-HR) de 2005 a 2016. Classification de l’atteinte interstitielle en aveugle par 3 radiologues selon les criteres de l’ATS/ERS : pneumopathie interstitielle commune (PIC), pneumopathie interstielle non specifique (PINS), pneumopathie organisee (PO) pneumopathie interstitielle lymphoide (PIL) ou inclassee. Les patients avec une autre connectivite, un antecedent de radiotherapie thoracique, une prise de medicament pneumotoxique, d’anticorps anti-synthetase, de sarcoidose ou de pneumopathie d’hypersensibilite ont ete exclus. Resultats Cent quatre-vingt-cinq patients ont ete selectionnes. Soixante-huit patients ont ete inclus. Deux groupes ont ete definis selon la presence (anti-SSA 52kd+, n = 31) ou l’absence (anti-SSA 52kd−, n = 37). Le suivi median est identique dans les 2 groupes : 68,4 mois (6–283) dans le groupe SSA 52kd+ versus 88,9 mois (7–270) dans le groupe anti-SSA 52kd−. Les symptomes les plus frequents au diagnostic sont la dyspnee (73 %), la toux (32 %) ou la presence de crepitants a l’auscultation (21 %). La presence d’une atteinte interstitielle pulmonaire est plus frequente dans le groupe anti-SSA 52kd+ (41,9 %, n = 13 versus 16,2 %, n = 6, p = 0,019). Dans le groupe de patients ayant une pneumopathie interstitielle, les epreuves fonctionnelles respiratoires (EFR) sont le plus souvent normales au moment du diagnostic concernant la capacite vitale forcee (CVF = 94,9 %, 52–118 %) avec une alteration discrete de la diffusion alveolo-interstitielle avec une DLCO (63 %, 27–101 %). En analyse multivariee apres ajustement a la presence d’anti-SSA 60kd, anti-SSB ou de facteur rhumatoide, la presence des anticorps anti-SSA Ro52kd est un facteur de risque independant de pneumopathie interstitielle diffuse. Le pattern de pneumopathie interstitielle non specifique (PINS) est le pattern le plus frequemment retrouve (31,6 %). Chez la majorite des patients la pneumopathie interstitielle est presente au diagnostic de pGS (52,6 %). Dans le groupe de patients sans anti-SSA 52kd, aucun n’a developpe d’atteinte interstitielle pulmonaire apres 5 ans de suivi. Conclusion La presence d’anticorps anti-SSA 52kd est un facteur de risque independant de pneumopathie interstitielle diffuse dans la maladie de Gougerot primitive. L’atteinte interstitielle pulmonaire est classiquement presente au diagnostic ou dans les 5 premieres annees de suivi. Chez les patients porteurs d’anti-SSA 52kd, un suivi attentif des signes fonctionnels respiratoires, des crepitants et des EFR avec mesure de la DLCO est necessaire. Si une anomalie est presente, un scanner doit etre realise pour confirmer la pneumopathie interstitielle.

Immune reconstitution inflammatory syndrome is a rare complication of the treatment of Whipple's disease. Here, we report the case of a 65-year-old man treated for Whipple's disease affecting the joints, with positive Tropheryma whipplei PCR in CSF, who developed fever and nodular eruption on the trunk, arms and face in association with biological inflammatory syndrome 10 days after initiation of antimicrobial treatment. Skin manifestations and the patient's general condition improved on corticosteroids (0.5 mg/kg prednisone), but as steroids were gradually tapered, new nodules appeared below a prednisone dose of 10–15 mg. One year after starting treatment, lumbar puncture showed asymptomatic meningitis with negative T. whipplei PCR results which had regressed spontaneously. Two years after the diagnosis, on prednisone 5 mg daily and antimicrobial treatment, the patient had only transient, episodic nodular rash without fever or inflammatory syndrome.

Objective To clarify sex differences in early axial spondyloarthritis (SpA). Methods In total, 475 patients included in the Devenir des Spondylarthropathies Indifferenciees Recentes (Outcome of Recent Undifferentiated Spondylarthropathies) cohort, a prospective multicenter French cohort of patients with early inflammatory back pain suggestive of SpA, and fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial SpA were studied. The clinical and imaging features were compared between sexes and according to the clinical or imaging arm of the ASAS criteria using univariate and multivariate analysis. Results Comparisons between the 239 men and 236 women showed that women had higher disease activity when measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Patient Global Score and higher fatigue and functional scores despite having less radiographic sacroiliitis and magnetic resonance imaging (MRI) inflammation of sacroiliac joints and the spine than men. Disease activity measured by the C-reactive protein (CRP)–based Ankylosing Spondylitis Disease Activity Score was not different between men and women. In contrast to patients classified with the clinical arm, disease activity and functional scores did not differ between women and men with sacroiliitis on imaging scans, except for fatigue and the Ankylosing Spondylitis Quality of Life questionnaire. Women with sacroiliitis had more peripheral involvement and more family history, whereas HLA–B27 positivity, elevated CRP, and MRI inflammation of the spine were associated with male sex. Conclusion Women with early axial SpA according to the ASAS criteria had greater disease activity when measured by the BASDAI and worse functioning despite fewer radiologic abnormalities than men. The differences in disease expression may be confounding factors to establish the diagnosis of SpA and to assess disease activity in women, suggesting that the imaging arm is a pivotal measure in the ASAS criteria.

International audience; OBJECTIVE: It was shown that sodium can promote auto-immunity through the activation of the Th17 pathway. We aimed to compare sodium intake in patients with rheumatoid arthritis (RA) vs. matched controls. METHODS: This case-control study included 24 patients with RA at diagnosis and 24 controls matched by age, gender and body mass index. Sodium intake was evaluated by 24-hr urinary sodium excretion. RESULTS: Sodium excretion was greater for patients with early RA (2,849\textpm1,350 vs. 2,182\textpm751.7mg/day, p = 0.039) than controls. This difference remained significant after adjustment for smoking and the use of anti-hypertensive and nonsteroidal anti-inflammatory drugs (p = 0.043). Patients with radiographic erosion at the time of diagnosis had a higher sodium excretion than those without (p = 0.028). CONCLUSION: Patients with early RA showed increased sodium excretion which may have contributed to autoimmunity.

Objective: The impact of gender on the response and tolerance to abatacept was assessed in a large prospective cohort during 2 years of follow-up. Methods: From the 1017 patients included in the Orencia and Rheumatoid Arthritis registry, disease activity was assessed at baseline, 6, 12 and 24 months. The relationship between the European League Against Rheumatism (EULAR) response, Disease Activity Score 28 (DAS28) remission, rate of adverse events and gender was explored in multivariate analysis. Results: 990 patients, 79.3%female, with at least one follow-up visit were analysed. At baseline, women had longer disease duration, higher disease activity and more often received antitumour necrosis factor (TNF) drugs. The remission was not different between men and women during the follow-up after adjustment on age, disease duration and activity, rheumatoid factor and anti-cyclic citrullinated pyeptide (CCP) positivity, and current disease-modifying antirheumatic drugs (DMARDs), previous TNF blockers and corticosteroids use. The proportion of men and women achieving EULAR good-or-moderate response at any endpoints was similar (52.4% vs 55.5%), as well as time to achieving EULAR response (5.4+/-4.9 vs 5.6+/-5.2 months). Moderate EULAR response was more frequent in women at 6 months (OR=1.80, p=0.02) but was no longer significant at 12 or 24 months. During the follow-up, the DAS28, the tender joint count score and the patient global assessment remained higher in women (p=0.001, 0.04 and 0.06, respectively). Drug retention and safety were comparable. Conclusion: In this large daily practice cohort of established rheumatoid arthritis treated with abatacept, women achieved similar remission and EULAR response than men despite higher disease activity and tender joint count during the treatment course.

To determine the forms and characteristics of rheumatic diseases whose initial presentation mimics septic arthritis. Retrospective study of 398 patients hospitalized between 1979 and 2005 for arthritis diagnosed and treated as septic. In 10 cases, initial presentation of a rheumatic disease was highly suggestive of septic arthritis, and the patient was treated as such. Three had rheumatoid arthritis, 3 spondyloarthropathies, 2 unclassified rheumatic diseases, 1 Wegener granulomatosis and 1 cytosteatonecrosis. Mean time to diagnosis of rheumatic arthritis was 6 months. There were 7 males and 3 females aged from 15 to 77 years. Six had fever, and 3 had leucocytosis. Average ESR was 68 mm/1 h, and C-reactive protein was above 100 mg/l in 6 patients. Five patients had radiological signs suggestive of septic arthritis. Joint fluid count was above 100,000 WBCs/mm(3) in 2/5. Synovial biopsy suggested septic arthritis in 5 out of 6. These cases of pseudoseptic arthritis were indistinguishable from true septic arthritis. Follow-up is required in septic arthritis with negative culture findings to exclude rheumatic disease.

Background No microorganism is identified in 7–35% of cases of septic arthritis. The diagnosis is, therefore, only presumptive. We reviewed our cases of septic arthritis in adult native joints to determine the frequency of negative cultures, disease characteristics and the frequency of misdiagnosis of septic arthritis. Methods This retrospective study included all patients admitted to our department from 1979–2005 with arthritis, diagnosed and treated as septic. Results No microorganism was isolated from synovial fluid or blood samples from 74 out of 398 (19%) patients with presumed septic arthritis. Patients without microorganisms were younger (54 vs 62 years), less likely to have risk factors for septic arthritis (31% vs 41%) and had lower mortality (0 vs 5%) than patients with positive cultures. Long-term outcome was known for 48 patients. A retrospective analysis of all data and long-term outcome concluded that septic arthritis was probable in 18 patients and improbable in 13. Ten of the latter developed rheumatic disease after a mean time of 6 months: rheumatoid arthritis ( n = 3), spondyloarthropathies ( n = 3), unclassified rheumatic disease ( n = 2), Wegener granulomatosis ( n = 1) and cytosteatonecrosis ( n = 1). Fever and signs of inflammation were more frequent and synovial fluid cell counts were higher in patients with improbable septic arthritis. Conversely, radiological signs were more common in patients with probable septic arthritis. Conclusion At least 14% of patients diagnosed with septic arthritis with negative bacteriological results subsequently develop rheumatic disease. This pseudoseptic arthritis is indistinguishable from true septic arthritis. When no microorganism is identified, the diagnosis remains presumptive and follow-up is necessary to screen for other diseases, especially rheumatic diseases.

Inflammatory muscle disease is a term used to designate a heterogeneous group of autoimmune diseases of unknown etiology whose main target is the skeletal muscle. Clinical, histological, and immunopathological criteria are classically used to distinguish polymyositis, dermatomyositis, and inclusion body myositis. Major obstacles to controlled therapeutic trials in patients with inflammatory muscle diseases include the heterogeneity of these diseases, their low prevalence, and the absence of validated evaluation criteria. To date, no such trials are available and the treatment is therefore largely empirical. Glucocorticoids are usually given first. Methotrexate is then added in the event of resistance to, or dependency on, glucocorticoid therapy. Methotrexate may be used from the outset in patients with severe disease in an attempt to decrease the glucocorticoid requirements. However, no controlled trials have been conducted to determine whether first-line methotrexate therapy improves outcomes. Intravenous immunoglobulin infusion is a costly treatment option that is reserved for the following situations: refractory dermatomyositis, based on a trial showing superiority over a placebo; myositis with impaired swallowing; and patients with contraindications to immunosuppressants. In patients who fail second-line treatment, which usually consists of methotrexate plus a glucocorticoid, the diagnosis should be carefully reappraised before other treatment options are considered. These options include methotrexate plus azathioprine and recently introduced drugs such as mycophenolate mofetil and rituximab. Caution is in order when considering TNFα antagonist therapy, as cases of paradoxical exacerbation of the muscle involvement have been reported.

Effect of Corticosteroid Injections on Blood Glucose Levels in Diabetic Patients Sylvain Mathieu;Marion Couderc;Sandrine Malochet-Guinamand;Jean-Jacques Dubost;Anne Tournadre;Martin Soubrier; JCR: Journal of Clinical Rheumatology

Rituximab, a chimeric monoclonal antibody against CD20, very rarely causes lung toxicity. Clinical presentations include lung infiltrates, alveolar hemorrhage, and adult respiratory distress syndrome. Three cases of organizing pneumoinia (formerly called bronchiolitis obliterans with organizing pneumonia or BOOP) have been reported. In our experience, organizing pneumonia occurred in 2 of 25 patients treated with rituximab, for RA and Castleman's disease, respectively. Because organizing pneumonia may be asymptomatic, as illustrated by one of our cases, we recommend obtaining a chest radiograph routinely before rituximab re-treatment.

Resume Le Rituximab est un anticorps monoclonal chimerique anti-CD20, dont la toxicite pulmonaire reste exceptionnelle. De nombreux tableaux cliniques peuvent etre observes, pneumopathie interstitielle, hemorragie intra-alveolaire, syndrome de detresse respiratoire aigue. Trois observations de pneumopathie organisee (PO) auparavant appelee bronchiolite obliterante avec pneumopathie organisee (BOOP) ont ete rapportees. Nous avons observe deux cas chez les 25 patients que nous avons traites par Rituximab. L’une est survenue chez une patiente traitee pour une polyarthrite rhumatoide l’autre chez une patiente traitee pour une maladie de Castleman, Le caractere parfois asymptomatique comme dans une de nos observations, nous semble devoir justifier, avant la readministration de Rituximab, la realisation d’une radiographie pulmonaire.

Objectives. Increased incidence of cardiovascular disease (CVD) has been observed in AS. The reasons of this increase are not fully understood (greater prevalence of traditional cardiovascular risks, consequences of treatment (NSAID) or biological inflammation). The objectives of this study are to assess intima–media thickness (IMT) and arterial stiffness (i.e augmentation index AIx), markers of sub-clinical atherosclerosis in AS patients and to examine the effects of TNF-� inhibitors on arterial stiffness in active AS patients. Methods. Sixty AS patients were enrolled with 60 healthy controls. Their BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and BASFI (Bath Ankylosing Spondylitis Functional Index) scores, ESR and CRP levels were recorded. Subclinical atherosclerosis was assessed by measurement of AIx by pulse wave analysis and IMT by carotid echography. Results. We found significantly increased IMT in the AS group compared with healthy controls. After adjustment for confounding factors, an underlying trend towards increased IMT was still present (P ¼ 0.06). No difference was found in arterial stiffness between the two groups. AS patients, treated or not with anti-TNF-� at baseline, had significantly increased IMT and AIx or a trend towards increase. IMT was positively correlated with tobacco use, WHR and blood pressure but not correlated with CRP level. Despite improvement in markers of disease activity, arterial stiffness was unchanged after 14 weeks of treatment with TNF antagonists. Conclusion. This study shows a trend towards increased subclinical atherosclerosis in AS patients. TNF-� blockade does not seem to improve arterial stiffness in AS patients, but our results lack statistical power.

We report two cases of interstitial lung disease possibly related to TNF alpha antagonist therapy (etanercept) in patients with rheumatoid arthritis. In both cases, pre-existing interstitial lung disease worsened during etanercept therapy. We found 19 previously published cases of interstitial lung disease in patients who were taking TNF alpha antagonists and had no evidence of infection, raising the possibility of a causal link with the medication. The potential pathophysiological mechanisms remain unknown. Caution is in order when using TNF alpha antagonists in patients with pre-existing lung disease. The development or exacerbation of interstitial lung disease in a patient on TNF alpha antagonist therapy should lead to investigations for a cause. Should these investigations prove negative, the treatment must be discontinued.