Search

Background Rheumatoid arthritis (RA) is a risk factor for the development of fragility fractures, but there is little quality data on its prevalence. Conversely, osteoporosis is one of the most frequent comorbidities of RA. Objectives To determine the prevalence of vertebral fractures in postmenopausal women with RA and to analyse their characteristics and associated risk factors. Methods We included 346 postmenopausal women diagnosed with RA according to the ACR/EULAR 2010 criteria in 19 Spanish Rheumatology Departments, randomly selected from the registry of RA patients in each center, recruited during 2018. Lateral radiographs of the dorsal and lumbar spine were obtained from all patients, to evaluate morphometric vertebral fractures. Expert rheumatologists identified vertebral fractures and classified them into mild (grade 1: reduction of height of 20-25%), moderate (grade 2: reduction of 26-40%) and severe (grade 3: reduction > 40%), according to the Genant grading scale. The spinal deformity index (SDI) was calculated by assigning numbers 1, 2 and 3 to each fractured vertebra and adding the total score of each patient. The study variables were: a) age, body mass index (BMI), b) factors related to RA: time of evolution, FR, ACPA, and c) fracture risk factors: prior fragility fracture, parental hip fracture, glucocorticoids, smoking, alcohol intake ≥3 units daily, secondary osteoporosis and time since menopause. Results The mean age was 66.8 (SD: 10.1) years and the median evolution of the disease, 8.00 [RIQ: 3.00-15.5] years. 77.2% (n: 267) and 75.7% (n: 252) had FR and ACPA +, respectively. The mean duration of the postmenopausal period was 15.0 (SD: 9.6) years. 23.4% (n: 79) of patients had at least one vertebral fracture; 10.7% (n: 36) had a single fracture and 12.7% (n: 43), multiple fractures. The most fractured vertebrae were D12, L1 and L2 (fractured in > 5% of patients). The median SDI was 3 [RIQ: 2-5]. The vertebrae with the highest mean IDE were D8, D10, D11 and L1 (all mean IDE ≥ 2).An association was found between the presence of vertebral fractures and age, height, postmenopausal period, time of disease progression, glucocorticoid treatment and parental hip. No linear association was found between SDI and age, time of evolution of the disease, BMI and time since menopause. Conclusion One out of every 4 postmenopausal women with RA has at least one vertebral fracture. Vertebrae of the dorso-lumbar hinge are the most frequently involved and the magnitude of the spinal deformity is relevant. Vertebral fractures are related to the time of evolution of RA and to the risk factors for fracture. Disclosure of Interests Carmen Gomez Vaquero: None declared, Dacia Cerda: None declared, Cristina Hidalgo: None declared, JA Martinez Lopez: None declared, Luis Marcelino Arboleya Rodriguez: None declared, Javier Aguilar del Rey: None declared, Silvia Martinez Pardo: None declared, Inmaculada Ros: None declared, Xavier Suris Speakers bureau: Lilly, Pfizer, MSD, Dolors Grados: None declared, Chesus Beltran: None declared, Evelyn Suero-Rosario: None declared, Inmaculada Gomez Gracia: None declared, Asuncion Salmoral: None declared, Irene Martin-Esteve: None declared, Helena Florez: None declared, Antonio Naranjo: None declared, Santos Castaneda Consultant for: Amgen, BMS, Pfizer, Lilly, MSD, Roche, Sanofi, UCB, Soledad Ojeda Grant/research support from: AMGEN, Speakers bureau: AMGEN, S Garcia Carazo: None declared, Alberto Garcia-Vadillo: None declared, Laura Lopez Vives: None declared, A Martinez-Ferrer: None declared, Helena Borrell: None declared, Pilar Aguado: None declared, Raul Castellanos-Moreira Speakers bureau: MSD, Lilly, Nuria Guanabens Consultant for: Advisory Boards from Amgen, Alexion and UCB, Speakers bureau: Fees and lectures from Eli Lilly

The prevalence of antiphospholipid antibodies (aPL) in the general population is 1%. Not all asymptomatic patients with aPL antibodies have the same risk for thrombosis, and consequently routine prophylaxis with acetylsalicylic acid (ASA) is not justified in terms of risk-benefit in all asymptomatic carriers. Based on current evidence, primary prevention is indicated only in high-risk groups including the following: a) in patients with anticardiolipin antibodies (aCL) at persistently high titers, repeatedly positive lupus anticoagulant (LA) or aCL positivity, LA and anti-beta2 glycoprotein I (triple positivity) regardless of titer; b) in situations of high thrombotic risk due to the concomitant presence of other thrombotic risk factors (hypertension, immobilization, surgery, etc.); c) in the presence of a systemic autoimmune disease, particularly systemic lupus erythematosus, and d) during pregnancy. Prophylactic treatment in these patients is based on the use of ASA. In specific situations, low-molecular-weight heparin and hydroxychloroquine are also useful.

Objective To review and summarize the information available on the effectiveness and safety of biological therapies in refractory Felty's syndrome (FS). Methods We describe a case of FS with severe neutropenia and recurrent bacterial infections unresponsive to disease-modifying antirheumatic drug treatment and long-term administration with granulocyte colony-stimulating factor, in which treatment with rituximab (RTX) was useful and resulted in a sustained neutrophil response. Current evidence on the use of biological therapies in FS is also analyzed through a systematic review of the English-language literature, based on a PubMed search. Results Available data on the use of biological therapies in refractory FS are based only on several case reports and are limited to the use of RTX and some anti-tumor necrosis factor α agents (etanercept, infliximab, and adalimumab). Including the case described here, data are available on 8 patients treated with RTX. A sustained increase in the absolute neutrophil count (>1500/mm 3 ) was observed in 62.5% (5/8) of these patients after 1 cycle of treatment. In most of them, the hematological response was accompanied by a parallel improvement in biological markers of inflammation and other clinical manifestations of FS (arthritis, recurrent infections, systemic symptoms, etc). After a median follow-up of 9 months (range, 6-14), only 1 of these patients relapsed and neutropenia reappeared; in this patient, retreatment was rapidly effective. No significant adverse events related to RTX therapy were reported. Experience with anti-tumor necrosis factor agents is limited to 6 patients, none of whom presented any sustained increase in neutrophil count. Conclusions Although it is not yet possible to make definite recommendations, the global analysis of all cases reported to date only supports the use of RTX as a second-line therapy in patients with refractory FS.

Objective To investigate the frequency and type of giant cell arteritis (GCA)-related ischemic complications in a series of patients with GCA who, for a substantial period of time (i.e., at least 3 mo), lacked vascular symptoms and presented with apparently isolated polymyalgia rheumatica (PMR). Methods Retrospective follow-up study of an unselected population of 167 patients with GCA diagnosed from 1985 to 2014. Results In all, 18 patients (11%) developed GCA on a background of a prior history of PMR. They were diagnosed as having isolated PMR because they did not have clinical evidence of GCA at diagnosis and exhibited a prompt and complete response to low-dose steroid therapy. However, during the course of treatment, 17 patients later experienced an arteritic relapse with the development of typical craniofacial symptoms, and one patient developed signs of upper extremity vascular insufficiency, resulting in the diagnosis of large-vessel GCA. The median time to GCA diagnosis from the initiation of low-dose steroid therapy was 9 ± 14.4 mo (range: 3−39). At the time of GCA diagnosis, severe ischemic complications were observed in 50% (9/18) of the patients. Of these patients 22% (4/18) were considered to have “true” occlusive disease (i.e., permanent visual loss, stroke, and/or limb claudication). Late inflammation of the aorta and its branches occurred in 4 (22%) of the patients during long-term follow-up. Conclusion Patients with GCA presenting with apparently isolated PMR have a significant risk of developing transient or permanent disease-related ischemic complications; these complications occurred in 50% of the cases.

Objective To review and summarize published information on the effectiveness and safety of rituximab (RTX) in adult patients with refractory neuropsychiatric systemic lupus erythematosus (NPSLE). Methods We describe a patient with persistently active NPSLE, despite conventional therapy, who responded dramatically to RTX. Current evidence on the therapeutic use of RTX in this complex situation is also analyzed through a systematic review of the English-language literature, based on a PubMed search. Results Available data on the use of RTX in refractory NPSLE come from a large number of case reports and some open-label studies. Including our case, 35 patients have been well documented. A complete or partial therapeutic response was achieved in 85% of patients after 1 cycle of treatment. A positive correlation between serological markers of disease activity and clinical outcome has also been demonstrated in some of these patients. Clinical improvement was accompanied by a significant reduction in the daily dose of oral corticosteroids. Relapse after RTX treatment was noted in 45% of cases (median 9.5 months; range, 4-33 months). Infections were observed in 29% of patients. Conclusion Evidence for the effectiveness of RTX as induction therapy in NPSLE is based solely on several case reports and noncontrolled trials. Although it is not yet possible to make definite recommendations, the global analysis of these cases supports the off-label use of RTX in cases of severe refractory NPSLE.