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Systemic lupus erythematosus (SLE) is a highly heterogeneous autoimmune disease characterised by the production of pathogenic autoantibodies against nuclear self-antigens. The anti-inflammatory and tolerogenic cytokine Interleukin-10 appears to play a paradoxical pathogenic role in SLE and is therefore currently therapeutically targeted in clinical trials. It is generally assumed that the pathogenic effect of IL-10 in SLE is due to its growth and differentiation factor activity on autoreactive B-cells, but effects on other cells might also play a role. To date, a unique cellular source of pathogenic IL-10 in SLE has not been identified. In this review, we focus on the contribution of different CD4+T-cell subsets to IL-10 and autoantibody production in SLE. In particular, we discuss that IL-10 produced by different subsets of adaptive regulatory T-cells, follicular helper T-cells and extra-follicular B-helper T-cells is likely to have different effects on autoreactive B-cell responses. A better understanding of the role of IL-10 in B-cell responses and lupus would allow to identify the most promising therapies for individual SLE patients in the future.

Objective To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients. Design Retrospective study. Setting The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository. Population Women with Ob-APS. Methods Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM). Main outcome measures Risk factors for thrombosis and aGAPSS. Results Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089]. Conclusion Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women. Tweetable abstract More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity.

Background:The role of complement in the antiphospholipid (aPL) related pathology has been widely studied in animal models. Antiphospholipid antibodies can induce fetal loss in experimental animals but mice deficient in specific complement components (C4, C3, C5) appear somehow protected. In addition, in pregnant mice injected with aPL, antibody deposition has been found at decidual level causing focal necrosis, apoptosis and neutrophil infiltrates and supporting aPL pathogenetic potential. On the other hand, human studies did find hypocomplementemia associated to pregnancy complications in patients with obstetric antiphospholipid syndrome (APS). These results, however, are not unanimously confirmed and, in addition, some studies only show increased levels of complement activation products (i.e. Bb) and not decreased levels of C3 and/or C4. A recently study focusing on complement level in early pregnancy and before pregnancy showed a significant correlation with pregnancy complications and loss in a large cohort of primary APS.Objectives:To investigate if the simple detection of low C3 and/or C4 could be considered a risk factor for adverse pregnancy outcome in APS and aPL carriers pregnancies.Methods:We performed a multicentric study including patients from 10 Italian and 1 Russian Centers. Data on pregnancies in women with primary APS (n=434) and asymptomatic carriers with persistently positive aPL but not fulfilling clinical criteria for APS (n=218) were retrospectively collected. Serum C3 and C4 levels were evaluated by nephelometry; hypocomplementemia was defined by local laboratory reference values. Statistical analysis was performed using GraphPad.Results:Preconceptional complement levels and gestational outcome were available for 107 (25%) pregnancies in APS out of 434 and for 196 (90%) pregnancies in aPL carriers women out of 218. In pregnancies with low preconceptional C3 and/or C4, a significantly higher prevalence of pregnancy losses was observed (p=0.019). A subgroup analysis focusing on triple aPL positive patients was also performed. Preconceptional low C3 and/or C4 levels were found to be associated with an increased rate of pregnancy loss (p = 0.027) in this subgroup also. Otherwise, adverse pregnancy outcomes in single or double aPL positive women were not related to preconception complement levels (p = 0.44) (Table 1). Of note, all the pregnancy losses in the triple positive group occurred in patients treated with low dose aspirin and low molecular weight heparin from the time of positive pregnancy test.Conclusion:Our findings confirm that decreased complement levels before pregnancy are associated with increased risk of adverse outcome. This has been seen only in in women with triple aPL positivity, indeed single or double positivity does not show this trend. Complement levels are cheap and easy to be measured therefore they could represent a useful aid to identify patients at increased risk of pregnancy loss. test positivity.References:[1]De Carolis S, et al. Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome. Lupus (2012) 21:776–8.[2]Kim MY, et al. Complement activation predicts adverse pregnancy outcome in patients with systemic lupus erythematosus and/or antiphospholipid antibodies. Ann Rheum Dis (2018) 77:549–55.[3]Fredi M, et al. Risk Factors for Adverse Maternal and Fetal Outcomes in Women With Confirmed aPL Positivity: Results From a Multicenter Study of 283 Pregnancies. Front Immunol. 2018 May 7;9:864.Triple aPL positivitySingle or double aPL positivityGestational outcomeLow C3/C4 (n=49)Normal C3/C4(n=17)pLow C3/C4 (n=57)Normal C3/C4(n=165)pTerm live birth (>37w)15 (31%)6 (35%)ns34 (60%)110 (67%)nsPreterm live birth (≤37w)22 (45%)11 (65%)ns15 (26%)38 (23%)nsPregnancy losses (abortion and miscarriages)12 (24%)0 (0%)0.0278 (14%) 17 (10%)nsDisclosure of Interests:None declared

Background:Although guidelines do not recommend antiphospholipid antibodies testing after 60 yo, recent data reported late onset antiphospholipid syndrome (APS).Objectives:To comparatively analyse the clinical, laboratory features and outcomes in 695 cases with primary APS between patients older and younger than 70 yo.Methods:we have performed an international study within the framework of the International Registry of primary APS patients treated with Hydroxychloroquine, HIBISCUS (an ongoing retrospective and prospective register launched in 2016). 28 centres from 17 countries participate. Data about late onset APS were analysed in 695 patients and were obtained from a standardized form registered in the database containing 66 items with respect to demographics, clinical and biological features.Results:Arterial events and especially stroke represented the main initial and recurrent clinical manifestation in 40 primary APS patients older than 70 yo. There were not statistically significant differences with respect to cardiovascular risk factors between the two groups of patients. A significant male predominance, a familial APS history, a higher prevalence of triple positivity, lower complement levels, and anticardiolipin antibodies (aCL) IgA isotype were found in older patients. Low anticoagulation regimens were safe and efficient, with a low relapse rate in older patients.Conclusion:we suggest that the detection of aPL antibodies should be included into the initial screening panel tests in elderly with thrombotic events, especially arterial, in particular those with recurrent stroke and familial APS.Our study further suggests that lower intensity anticoagulation regimens could be a therapeutic option in older APS patients, as no differences in outcomes and relapse rate were found between patients with high and low intensity anticoagulation regimens.References:[1]Grimaud F et al. Rheumatology. 2019;58:1006-10.[2]Goldman-Mazur S et al. Thromb Res. 2019;176:67-73.[3]Hirmerova J et al. 2017;36:167-73.Disclosure of Interests:Cristina Belizna: None declared, Omar Latino: None declared, Ljudmila Stojanovich: None declared, Patrick Saulnier: None declared, Katrien Devreese: None declared, Sebastien Udry: None declared, Natasa Stanisavljevic: None declared, Aleksandra Djokovic Speakers bureau: KRKA, Astra Zeneca, Actavis, Jaume Alijotas-Reig: None declared, Enrique Esteve-Valverde: None declared, Raquel Ferrer-Oliveras: None declared, Angela Tincani: None declared, Laura Andreoli: None declared, Francesca Regola: None declared, Maarten Limper: None declared, Alexander Makatsariya: None declared, Jamilya Khizroeva: None declared, Viktoria Bitsadze: None declared, Cecilia Chighizola: None declared, Francesca Pregnolato: None declared, Maria Orietta Borghi: None declared, Pier Luigi Meroni: None declared

Background:Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the presence of autoantibodies and a variable spectrum of clinical manifestations and disease severity. The 2019 criteria for SLE classification by the American College of Rheumatology and European League against Rheumatism define ANA positivity by immunofluorescence or by an equivalent solid-phase assay as the entry criterion (1). However, the prevalence of ANA positivity and the reliability of solid-phase assays in SLE are still a matter of controversy (2). Furthermore, the significance of ANA negativisation during follow-up is uncertain (3).Objectives:Our aim was to retrospectively analyse data on the frequency of ANA seroconversion during the follow-up in a cohort of SLE patients with renal involvement.Methods:Adult patients independent of age at SLE onset with a follow-up duration of at least 36 months starting from January 2009 (for standardization of ANA measurement) and with at least one ANA measurement per year were included in this retrospective longitudinal study. Data on demographic, clinical and laboratory characteristics of the study population are reported in table 1. ANA have been measured with Hep2 cell immunofluorescence assay.Table 1.Demographic, clinical and laboratory baseline characteristics of the 121 patients suffering from systemic lupus erythematosus (SLE).DemographicsGender,%F (n)93 (112)Age in years,mean±SD41.6±12.6Clinical featuresAge at SLE onset in years,mean±SD28.0±11.9SLE duration in years,mean±SD13.8±9.5SLEDAI,median (min-max)4 (0 – 27)Laboratory profileSerum creatinine mg/dL,median (min-max)0.8 (0.4 – 2)24h urine protein g/24h,median (min-max)0.5 (0 – 13.8)ANA,%pos (n)93 (112)Anti-ENA,%pos (n)49 (59)Anti-dsDNA,%pos (n)43 (51)Results:A total of 121 SLE subjects with renal involvement were enrolled. Mean follow-up ± standard deviation (SD) was 8 ± 2 years. Ten subjects (8.3%) with positive ANA at the beginning resulted ANA negative at the end of the follow-up. These subjects had different initial ANA titres: 1:1280 (n=1), 1:640 (n=2), 1:320 (n=2), 1:160 (n=3) and 1:80 (n=2); 48 subjects (39.7%) showed a decrease in ANA titre. Of the 9 patients (7.4%) that were negative at the beginning of follow-up, 6 remained negative, whereas 3 showed ANA positivity at the end of the follow-up with ANA titres 1:160 (n=2) and 1:320 (n=1). No differences between subjects with and without ANA titre variations in terms of age (p=0.551), disease duration (p=0.786), SLEDAI at the beginning (p=0.453) and at the end of follow-up (p=0.169) were observed. ANA negativisation and titre variations at the end of follow-up did not correlate with any of the treatments taken during follow-up, including a history of cyclophosphamide (p=0.788).Conclusion:In our cohort of patients with SLE and renal involvement, 10% of patients experienced negativisation and around 40% of patients showed a decrease in ANA titre during follow-up, independent of disease characteristics and previous treatment. Further studies are warranted to clarify the underlying mechanisms and clinical significance of ANA seroconversion and titre variation in SLE patients. However, based on our results, ANA positivity seems to be a relatively stable parameter further supporting its use as an entry classification criterion for SLE.References:[1]Aringer M et al. Arthritis Rheumatol. 2019; 71(9):1400-1412.[2]Pisetsky DS et al. Autoimmun Rev. 2019; 18(12):102400.[3]Frodlund M et al. Clin Exp Immunol. 2019. Epub ahead of print.Disclosure of Interests:None declared

Background:IL-10 plays a key role in systemic lupus erythematosus (SLE) pathogenesis, promoting B-cell response. IL10 is mainly secreted by regulatory T-cells, but follicular helper T-cells (TFH), also produce it. We previously identified a subset of CCR6+IL-7R+T-cells in human tonsils providing IL-10-dependent B-cell help. These CCR6+T-cells were able to produce IL-10, inducing IgG production.Objectives:to investigate a possible role of CD4+CCR6+IL7R+T-cells in SLE pathogenesis.Methods:37 patients fulfilling the ACR criteria for SLE have been included. Disease activity was assessed by 2k-SLEDAI. PBMC were analyzed by flow cytometry, using specific lineage markers. CCR6+IL7R+T-cells purified from total PBMC of SLE patients or healthy donors (HD) were co-cultured with autologous CD20+B-cells. IL-10, Il-17, total IgG and anti-dsDNA antibodies titers in patients serum and culture supernatants were assessed by ELISA. Embedded sections of lymph nodes from 8 SLE patients were analyzed by immunofluorescence (IF).Results:IL10 levels were significantly higher in SLE patients (Fig 1A). CD4+CCR6+IL7R+T-cells were significantly increased in SLE, in particular in those with higher disease activity and higher IL10 levels. CD4+CCR6+IL7R+T-cells levels associated with anti-dsDNA positivity. CCR6+IL7R+T-cells of SLE patients induced production of IgG and anti-dsDNA IgG (in anti-dsDNA + patients) from autologous B-cells, providing spontaneous help for autoantibody productionex vivo(Fig 1B-C). The IF study of lymph nodes of SLE patients showed that IL-10-producing CCR6+T-cells were highly abundant and co-localized with B-cells at follicle margins.Fig 1Conclusion:our study revealed a novel population of extra-follicular B-helper T-cells, which produce IL-10 and could play a prominent pathogenic role in SLE. Further studies will clarify if this potentially pathogenic cell population might represent a possible future therapeutic target.References:[1]Facciotti F. J Allergy Clin Immunol. 2016; Geginat J. Semin Immunol. 2019; Tsokos GC. Nat Rev Rheumatol. 2019Tab 1:SLE patients characteristics(n=37)DemographicsFemale/Male, n37/5Age, years, median (IQR)44 (38-49)Disease duration, years, median (IQR)19 (11-26)Lab testsANA86%*anti-dsDNA (%)46% medium/high titre41%Disease activity and clinical manifestations SLEDAI-2K, median (min-max)3.5 (0-24) Moderate/high activity19%Ongoing therapyPrednisone dose mg/day, median (IQR)7,5 mg (2,5 – 20)hydroxychloroquine78%Immunosuppressants87%Fig 2Disclosure of Interests: :Maria Gerosa: None declared, Federica Facciotti: None declared, Paola Larghi: None declared, Roberto Bosotti: None declared, Chiara Vasco: None declared, Nicola Gagliani: None declared, Chiara Cordiglieri: None declared, Elsa Rottoli: None declared, Alessandra Emiliana Penatti: None declared, Lorenza Maria Argolini: None declared, Bhavna Karnani: None declared, Yasushi Kobayashi: None declared, Mauro Bombaci: None declared, Jan Piet Van Hamburg: None declared, Roberta Gualtierotti: None declared, Stefano Gatti: None declared, Sara Torretta: None declared, Lorenzo Pignataro: None declared, Sander W. Tas: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Sergio Abrignani: None declared, Massimiliano Pagani: None declared, Fabio Grassi: None declared, Pier Luigi Meroni: None declared, Richard Flavell: None declared, Jens Geginat: None declared

Background:neonatal lupus syndrome (NLS) is an acquired disease caused by the trasplacental passage of anti-SSA antibodies. Congenital heart block (CHB) represents the most serious manifestation of NLS. The rate of CHB in Anti-SSA positive pregnant women ranges from 1 to 5% in different studiesObjectives:to retrospectively assess the prevalence of CHB in a cohort of anti-SSA positive pregnant women followed in 3 Italian tertiary centersMethods:pregnancies of anti-SSA positive women attending the pregnancy clinic of ASST Pini CTO/Policlinico Mangiagalli, Rheumatology Division of Spedali Civili, Brescia and Rheumatology Division of Ospedale S Matteo, Pavia from 2009 to 2019 were included. Patients underwent monthly clinical examination. Fetal heart rate was assessed weekly by Doppler ultrasound from 14thto 26thgestational week. On week 14 and 26, a fetal echocardiography was performed. A EKG was performed at birthResults:351 prospectively followed pregnancies in 292 anti-SSA/Ro positive women were included. Table 1 reports diagnosis. None of the prospectively followed pregnancies were complicated by complete CHB. Seven additional patients were referred to our clinics after diagnosis of CHB and were subsequently found to be anti-SSA positive, reporting no symptoms of diseases. Considering the 7 additional pregnancies, the incidence of CHB was 1.9%. We observed 3 neonates (0.8%) with cutaneous NLS and 1 case of transient increase of liver enzymes. In another neonate, a 1thdegree A-V block was found after birth. A complete analysis of maternal and fetal outcome was possible in 244 cases (Table 2) and compared with 3158 unselected healthy controls. Among these 244 cases, 65% were taking hydroxychloroquineTable 1.patients diagnosisn%Sjogren’s Syndrome58`20Systemic lupus erythematosus7626UCTD7425Asymptomatic Ro carriers5619Other2810292100Table 2.maternal and fetal outcomehealthy controls N=3158Anti-SSA/Ro ptsN=244P valuePrevious CHB n (%)2 (0.8)Anti-SSB pos n (%)46 (18.8)aPL pos n (%)49 (20)PregnancyLive births3158241Preeclampsia, n (%)43 (1.1)2 (0.8)nsDeliveryDelivery 401 (12.6) /201 (6)35 (15.6) / 14 (6)ns / nsCesarean Section, n (%)897 (29.3)115 (47.5)Conclusion:none of the patients prospectively followed in our centers before and during pregnancy developed complete CHB. If the 7 cases of anti-SSA positivity diagnosed after CHB detection were included in the analysis, the incidence of CHB was comparable to previous reports. Our data suggest that a strict follow up and proper treatment of anti-SSA positive patients with or without an autoimmune disease before and during pregnancy can reduce the risk of NLS. Further studies are warranted to confirm a possible protective role of anti-rheumatic treatments, including HCQReferences:[1]Fredi M. Front Cardiovasc Med. 2019Disclosure of Interests:Maria Gerosa: None declared, Micaela Fredi: None declared, Laura Andreoli: None declared, Cecilia Chighizola: None declared, Lorenza Maria Argolini: None declared, Davide Donzelli: None declared, Tamara Vojinovic: None declared, Véronique Ramoni: None declared, Elisa Bellis: None declared, Laura Trespidi: None declared, Federica Gazzola: None declared, Enrico Ferrazzi: None declared, Sonia Zatti: None declared, Fausta Benvenuti: None declared, Pier Luigi Meroni: None declared, Franco Franceschini: None declared, Carlomaurizio Montecucco: None declared, Rolando Cimaz: None declared, Roberto Caporali Consultant of: AbbVie; Gilead Sciences, Inc.; Lilly; Merck Sharp & Dohme; Celgene; Bristol-Myers Squibb; Pfizer; UCB, Speakers bureau: Abbvie; Bristol-Myers Squibb; Celgene; Lilly; Gilead Sciences, Inc; MSD; Pfizer; Roche; UCB, Angela Tincani: None declared

Background Persistent positivity for anti-phospholipid antibodies (aPL) at medium-high titres is required to diagnose anti-phospholipid syndrome (APS), an autoimmune condition characterised by thrombosis and/or pregnancy morbidity (PM). However, increasing evidence points towards the clinical relevance of low titre aPL in obstetric APS. Objectives This study investigated the association of low titre aPL with PM assessing the efficacy of low-dose aspirin (LDASA) and low-molecular weight heparin (LMWH). Methods Data on pregnancies in women with persistent aPL positivity at any titre were retrospectively collected at a single centre. An association model for repeated measures was applied to quantify the obstetric risk conveyed by low titre and criteria aPL, allowing to: i) evaluate pregnancy outcomes over time using available longitudinal data; ii) account that pregnancies of the same woman are not independent events; iii) consider that women had a different number of pregnancies; iv) estimate the role of several confounders and predictors. The association model envisaged as dependent variable pregnancy outcome as a binary outcome, defined for each pregnancy as “obstetric complication yes versus no” (pregnancy loss before 10 weeks, pregnancy loss after 10 weeks, premature birth before 34 weeks, according to updated APS classification criteria [Miyakis et al]). Results One hundred eleven women were recruited in this study: 160 pregnancies in women with low titer aPL and 178 pregnancies in women eith criteria aPL. According to the association model, women with low titre aPL had a probability of PM of 63% (odds 1.72, 95% CI 1.05–2.80) in case of single positivity and of 79% (odds 3.78, 95% CI 1.96–7.30) in case of double positivity. Criteria aPL conveyed a 2.2-fold higher risk: the probability of PM was 79% in case of single positivity (odds 3.82, 95% CI 2.15–6.80), raising to 89% (8.41, 95% CI 3.99–17.73) for multiple aPL. LDASA-treated women with single low titer aPL positivity had a 16% probability of exeriencing an adverse outcome (odds 0.19, 95%IC 0.08–0.44) while LDASA did not significantly affect the probability of in patients with low titre double aPL positivity (odds 0.42, 95%IC 0.17–1.02). Similarly, LDASA significantly reduced PM among women with single, but not multiple, criteria aPL positivity (odds 0.42, 95% CI 0.19–0.94; odds 0.93, 95% CI 0.39–2.21). Among women treated with LDASA +LMWH, the probability of PM was 14% in case of single low titre aPL positivity (odds 0.17, 95%IC 0.08–0.37) and 28% in case of two low titre aPL (odds 0.38, 95%IC 0.18–0.80). Among women with aPL criteria, treatment with LDASA +LMWH reduced the probability of PM to 28% (odds 0.38, 95%IC 0.21–0.70) in case of a single positive test and, not significantly, to 45% (odds 0.84, 95%IC 0.45–1.55) in case of multiple positivities. Conclusions Low titre aPL are associated with PM; the association treatment with LDASA and LMWH is effective even among women with low titre aPL. The risk of PM and the response to treatment depend upon aPL profile, suggesting the importance of a tailored treatment. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is a chronic autoimmune disease characterised by vascular changes and progressive fibrosis of skin and various internal organs. In SSc a variety of autoantibodies have been detected which are useful for the diagnosis and management of the disease. Some of these autoantibodies are well-established tools strongly associated with SSc (e.g. anti-centromere, anti-topoisomerase I, anti-RNA polymerase III). Other autoantibodies are less frequent and/or less-specific for SSc even if potentially useful to better assess disease subsets and prognosis. Objectives Our goal was to assess the frequency of SSc-related autoantibodies detected using a novel technology as well as to study the associations between these antibodies and clinical features in an Italian SSc cross sectional cohort. Methods Serum samples from 218 consecutive patients with SSc collected at three Italian sites were tested for a variety of autoantibodies (see table 1) using a novel fully automated system utilising bead-based immunoassays (research use only, Inova Diagnostics, San Diego, CA). The Italian cohort included: women 200 (92%), limited cutaneous SSc (lc-SSc) 166 (76%), patients with history of digital ulcers 91 (42%), calcinosis 46 (21%), lung fibrosis 84 (39%), heart involvement 38 (17.4%), pulmonary arterial hypertension 20 (9%), and esophageal involvement 138 (63.3%). Results The prevalence of antibodies is summarised in the table 1 below. Of note, anti-BICD2, anti-CENP-B, and anti-nucleosome antibodies were significantly associated with lc-SSc subtype (p=0.0237, p Conclusions Autoantibodies identified via the novel system in this SSc cohort were found in the expected frequencies and also correlated to clinical features of the patients. The multiparameter approach combined with cluster analysis holds promise for a molecular and more precise stratification of SSc subsets. Disclosure of Interest None declared

Background Cardiovascular (CV) disease is the leading cause of premature death among Systemic Lupus Erythematosus (SLE) patients1. Several studies have analysed the incidence of CV events in SLE patients. However, the majority of them have been conducted in American and North European countries 2–7. At the best of our knowledge, no studies in Italy have considered cumulative incidence and incidence rate of CV events in Italy. Objectives The present study is devoted to estimate the incidence of a first ever CV event in Italian lupus patients from five rheumatologic tertiary units from North, Centre and South Italy and to search for features associated with and potentially causative of the detected differences. Methods Clinical charts of SLE patients consecutively admitted to five Italian rheumatologic centres from November 1 st 2000 and December 31 st 2016 were retrospectively studied. Patients selected were free of CV events at baseline. CV cumulative incidence was evaluated as the proportion of patients who experienced a new CV event over the follow up period. CV incidence rate was expressed as the number of events in the cohort divided by the total number of years at risk. Our incidence was compared with that detected in the Italian general population and those reported in SLE cohorts from other countries. Results The median duration of follow-up was 6 years (IQR=3–11). During the observational period, 39(cumulative incidence=7.6%) of the 511 patients had a first CV event with an incidence rate of 10.4/1000 person-years i.e. 12 times higher than in the general population. The CV cumulative incidence detected in our Italian cohort was similar to that reported in the Spanish cohort, but lower than those from North European and American cohorts. The Italian cohort differed from other SLE cohorts in some traditional risk factors (smoke, hypertension, dyslipidemia) and treatment with aspirin and hydroxychloroquine.(table1) Conclusions Our study confirmed the increased CV risk in SLE compared with the general population. However, the incidence of CV events in our SLE series was lower than that detected in North European and American lupus cohorts. These disparities could be ascribed to the differences in the prevalences of traditional CV risk factors among the distinct cohorts. Nevertheless, our CV cumulative incidence was very similar to that detected in the Spanish cohort, despite their higher frequency of traditional risk factors. For this evidence, the geographic (Mediterranean) origin deserve to be considered. On the other hand, the slight difference detected between our series and Baltimore cohort2(where patients were examined every 3 months) underlines the need of a strict follow-up of the SLE patient. References [1] Cervera R, et al. Medicine (Baltimore)2003. [2] Magder LS, Petri M. Am J Epidemiol2012. [3] Bertoli AM, et al. Lupus2009. [4] Bartels CM, et al. J Rheumatol2014. [5] Gustafsson J, et al. Arthritis Res Ther2009. [6] Hermansen M-L, et al. Rheumatol Oxf Engl2017. [7] Fernandez-Nebro A, et al. Medicine (Baltimore)2015. Disclosure of Interest None declared

Background Rheumatic Diseases (RD) frequently affect women during reproductive age, therefore counselling on family planning is crucial for their quality of life. Children’s outcome is a major topic, but no large studies are available. Objectives To assess the long-term health conditions of children born to women with RD in a large multicentre cohort. Methods 24 Rheumatology Centres distributed the questionnaire (65 multiple-choice and 12 open-answer questions) to consecutive patients (18–55 years) in September 2015. Data were analysed dividing children upon maternal diagnosis: Chronic Arthritides (CA) and Connective Tissue Diseases (CTD). Results Data were collected for 320 children (166 males, 52%) born to 184 mothers (63 CA and 121 CTD). At the time of interview, children had a mean age of 17.1±9.6 years. Preterm delivery ( Conclusions In this long-term follow-up of children born to mothers with RD in this large, multicenter study of randomly interviewed women each AIID did not display a significantly increased frequency as compared to the literature; only coeliac showed a mild increased frequency. Children with LD had a tendency to cluster in the group of mothers with CTD, especially after maternal diagnosis (4/63, 6.3%), with a higher frequency as compared to general paediatric population. No significant relationships between ND/LD and prematurity, intrauterine drug exposure or maternal autoantibodies were identified. Acknowledgements Statistical analysis supported by an unrestricted grant by UCB Pharma. The authors wish to thank Patients Associations and Participants to the survey. Disclosure of Interest None declared

Loss of renal DNase I leads to progression of lupus nephritis. Therefore, we determined if loss of renal DNase I reflects a concurrent loss of urinary DNase I, and whether absence of urinary DNase I predicts disease progression, which thus may reduce the need for renal biopsies. Here, mouse renal DNase I mRNA was determined by qPCR, whereas mouse and human DNase I protein and DNase I endonuclease activity levels were determined by Western blots, and gel and radial zymography assays, respectively, during different stages of the murine and human forms of the disease. Cellular localization of DNase I was analysed by immunohistochemistry, immunofluorescence, confocal microscopy and immune electron microscopy. We further compared DNase I levels in human native and transplanted kidneys to determine if the disease depended on autologous renal genes, or whether the nephritic process proceeded also in transplanted kidneys. We also analysed if DNase I levels in urine samples reflected expression levels in the kidneys, and if the mouse data were translatable to humans. The data indicates that silencing of the renal DNase I gene expression level relates to serious progression of lupus nephritis in murine, human native, and transplanted kidneys. Notably, silencing of renal DNase I correlates with loss of DNase I protein and endonuclease activity in the urine samples. Thus, urinary DNase I levels reflects the renal DNase I expression and activity levels, and may therefore be used as a marker of lupus nephritis disease progression and reduce the need for renal biopsies.

Background Rheumatic Diseases (RD) frequently affect women during reproductive age, therefore counselling on family planning is crucial for their quality of life. Children’s outcome is a major topic, but no large studies are available. This study aimed at assessing the long-term health conditions of children born to women with RD. Methods 24 Italian Rheumatology Centres distributed the questionnaire (65 multiple-choice and 12 open-answer questions) to consecutive patients (aged 18–55) during September 2015. Data were analysed dividing children upon maternal diagnosis: Chronic Arthritides (CA) and Connective Tissue Diseases (CTD). Results Data were collected for 320 children born to 184 mothers (63 CA and 121 CTD). At the time of interview, children had a mean age of 17.1±9.6 years. Pre-term delivery ( The occurrence of an autoimmune/inflammatory disease (AIID) and/or neurodevelopmental disorders (ND)/learning disabilities (LD) is reported in table 1. Twelve children (3.7%) were diagnosed with an AIID, mostly coeliac disease (8/12, 67%). Eleven children (3.4%) were diagnosed as having a ND and/or LD by a Paediatric Neuropsychiatrist. Data of in utero exposure to maternal autoantibodies and/or anti-rheumatic drugs were retrieved for 280 children (87.5%) and a comparison was performed between affected (n=11) and not-affected children (n=258). No association was found with ND/LD and in utero exposure to autoantibodies (ANA, anti-Ro, anti-dsDNA, aPL) or drugs (HCQ,AZA or steroids), neither with sex, preterm birth, birth weight or maternal diagnosis. Conclusions The long-term follow-up of children born to mothers with RD did not raise particular concerns in terms of relevant health problems. In particular, each AIID did not display a significantly increased frequency as compared to the literature. Children with ND/LD had a tendency to cluster in the group of mothers with CTD, especially after maternal diagnosis, with a higher frequency as compared to GPP (7.9% vs 3%). Our data suggest that the development of ND/LD in children of patients with RD cannot be linked exclusively to maternal disease. The results of this study can be reassuring for patients with RD about problems in the offspring possibly related to their disease.

Background Previous study from our group have pointed out a lower number of cardiovascular (CV) events in Italian patients with Systemic Lupus Erythematosus (SLE) than in North European and American ones. This study aims to assess the incidence of the first CV event in a large, multicenter, Italian cohort of patients with SLE and search for differences in disease and traditional risk factors among distinct cohorts. Methods Clinical charts of SLE patients consecutively admitted to five Italian rheumatologic centres from November 1 st 2000 and December 31 st 2015 were retrospectively studied. Patients selected were free of CV events at baseline. CV incidence rate was expressed as the number of events in the cohort divided by the total number of years at risk. CV cumulative incidence were evaluated as the proportion of patients who experienced a new CV event over the follow up period. Our incidence was compared with that detected in the Italian general population and those reported in SLE cohorts from other countries. Results The median duration of follow-up was 6 years (IQR=3–11). During the observational period, 37(cumulative incidence=7.2%) patients had a first episode of CV event with an incidence rate of 10.1/1000 person-years i.e 12 times higher than in the general population. The CV incidence rate and cumulative incidence detected in our Italian cohort was lower than those from North European and American cohorts. The Italian cohort differed from other SLE cohorts in some traditional risk factors (smoke, hypertension, dyslipidemia) and treatment with aspirin and hydroxychloroquine. Conclusion Our results confirmed that Italian lupus patients suffer a high incidence of CV disease compared with general population. However, this incidence was lower than that detected in North European and American lupus cohorts

Background Antiphospholipid antibodies (aPL) are risk factors for Adverse Pregnancy Outcome (APO). In particular, for aPL carriers (patients with aPL positivity with no thrombotic or obstetric history) pregnancy outcome and treatment are still undefined. Objectives To review pregnancy outcome in a large multicenter cohort of aPL carriers patients, according to different serological profile and treatment protocols. Methods We reviewed 69 pregnancies in 61 patients, prospectively followed in 3 Italian centers (1994–2015). Patients with any complication in previous pregnancies or concomitant autoimmune diseases were excluded. aPL profile was defined as the combination of the 3 criteria tests for aPL (Lupus Anticoagulant, anti-cardiolipin, anti-Beta2 Glycoprotein I). APO was defined as: miscarriage ( Results Regarding aPL profile: 44 (64%) were single positive, 16 (23%) were double and 9 (13%) were triple. aPL non-criteria manifestations were present in 6 (9%) and lupus-like manifestations in 5 (7%). Eight pregnancies had a combination treatment with prophylactic low molecular weight heparin (LMWH) plus low dose aspirin (LDA), 37 had LDA alone and 24 had no treatment. We observed 2 thrombotic events (3%, 1 deep venous thrombosis and 1 ischemic stroke) and 6 APO (9%): 3 fetal deaths and 3 pre-term birth ≤34w with PE. We compared 8 complicated (6 APO,2 thrombosis) with 61 non-complicated pregnancies (Table 1). Acquired risk factors (p:0.006), non-criteria aPL (p:0.018) and lupus-like manifestation (p:0.010), triple positive aPL profile (p:0.001) were associated with APO. The combination treatment was also more frequent in APO pregnancies (p:0.005). Conclusions Acquired risk factors,aPL profile (triple positivity), lupus-like and non-criteria aPL manifestations could represent risk factors for pregnancy complications and could determine failure to conventional treatment.These patients may deserve additional treatment, for example LMWH at higher/anti-coagulant dose or immunomodulatory treatment (e.g.hydroxychloroquine, also considering its anti-platelet/anti-thrombotic effects). Disclosure of Interest None declared

Background Rheumatic diseases (RD) predominantly affect young women during reproductive age. Pregnancy, contraception and family planning (FP) are crucial for the quality of life of these patients. Objectives We aimed to investigate 9women9s health9 through a self-reported questionnaire. Answers from patients with connective tissue diseases (CTD) vs chronic arthritis (CA) were compared. Methods 24 centres distributed the questionnaire (65 multiple-choice and 12 open-answer questions) to women with RD (18–45years) regularly attending their outpatient clinics. Results Answers were collected from 249 CTD vs 149 CA patients. Their desire to have children was influenced by RD in 40% of cases: half of them reduced the number of children they wanted (Table 1). 39% CA vs 29% CTD were afraid of being mother because of disability. 24% CTD vs. 18% CA had at least one miscarriage; 21% CTD vs. 2% CA had more than one. 31% CTD and 34% CA were never asked about their desire to have children. 61% CTD vs 70% CA received counselling about contraception, given by a gynaecologist (G) (58% vs 64%), rheumatologist (R) (22% vs 14%) or both (7% vs 9%). 60% in both groups received a counselling before pregnancy: 34% vs 39% from R and G, 14% vs 22% by R. This positively changed family planning in 64% vs 59%. We created a Knowledge Index (based on the average of the normalized performed scores on 6 key questions for different sections): 55% CTD patients vs 44% CA had a medium-high score. A higher score directly correlated with the desire to became pregnant and with a multidisciplinary counselling. Conclusions This survey suggested that CTD have a major impact on FP and family size, possibly mediated by the increased rate of miscarriages as compared to CA. Concerns about reproductive issues could be positively overcome by adequate counselling. Rheumatologists should implement the discussion about FP and the compatibility of drugs with pregnancy in the management of young women with RD, especially those with CTD for whom contraception and pregnancy have particular implications. Acknowledgements Statistical analysis supported by an unrestricted grant by UCB Pharma Thanks to Patients9 Associations and Participants Disclosure of Interest None declared

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown aetiology. The deregulated activation of T follicular helper (Tfh) cells in secondary lymphoid organs may play a pivotal role in the activation of B cells and production of autoantibodies. Both murine and human Tfh cells were shown to be sensitive to extracellular ATP via purinergic P2X7 receptor. P2X7 is a non-selective ionic channel that in the presence of high concentrations of ATP or prolonged stimulation opens to a pore permeable to molecules up to 900 Da and causes cell death. Mice deleted for P2rx7 show a significantly worsened outcome of pristane-induced SLE. Expansion of circulating Tfh (cTfh) cells has been correlated with increased levels of autoantibodies and more severe clinical manifestations in SLE. Objectives Our aim was to investigate the possible role of P2X7 receptor activity in driving cTfh expansion in a cohort of SLE patients. Patients with primary antiphospholipid syndrome (PAPS) and healthy donors (HD) served as normal controls. Methods Forty-two adult patients with SLE (SLEDAI >4), 14 patients with primary antiphospholipid syndrome (PAPS) and 34 sex- and age-matched healthy donors (HD) were included. Circulating Tfh cells were isolated as a CCR7loPD1+ cells. In 32 patients with SLE, we investigated permeability of Tfh cells to Yo-Pro-1 staining over time at FACS upon stimulation with the P2X7 selective agonist BzATP and the presence of a correlation (Spearman9s rho) between Tfh cells expansion and Yo-Pro uptake. We analysed in vitro differentiation of CXCR5+PD1+ Tfh cells and sensitivity of this pathway to BzATP in CD4 naive cells isolated from 4 SLE and 4 healthy donors in the presence of a mixture of Activin A and IL-12, with or without BzATP. Results As previously reported, SLE patients had a significant expansion of the CCR7loPD-1+ cTfh cells [SLE (n=42): 38.3±12.8% versus HD (n=34]): 21.6±4.5%, ****p In vitro generation of Tfh cells from HD naive cells revealed a significant response to inhibition by BzATP, which was not present when SLE naive cells were used. Conclusions The CCR7loPD-1+ cTfh cells are significantly expanded in SLE but not PAPS patients compared to HD. The degree of expansion correlates with diminished sensitivity to P2X7-mediated cell death. This defective regulation is present also within in vitro differentiation of Tfh from naive cells isolated from SLE patients. Our data suggest a selective defect of P2X7-mediated control of Tfh cell generation and expansion in SLE. Disclosure of Interest None declared

Background Raynaud9s phenomenon (RP) can be the first manifestation of systemic sclerosis (SSc) or other connective tissue diseases (CTDs), often preceding an overt disease by years. It is not known if markers of endothelial damage are detectable in those RP patients who subsequently develop a CTD. Objectives We studied RP patients at their first evaluation to correlate the levels of endothelial markers with the subsequent development of an overt disease 36 months later. Methods Eighty-two patients with RP at their first evaluation were recruited. We measured plasma levels of tissue-type plasminogen activator (t-PA) and von Willebrand factor (vWF), two markers of endothelial damage, and interleukin-6 (IL-6), a pro-inflammatory cytokine. Thirty healthy subjects served as healthy controls. Results At baseline, 67 patients showed capillaroscopic normal pattern and 15 patients, of which 11 were very early SSc, had scleroderma pattern. Plasma levels of t-PA, vWF and IL-6 were higher in patients with capillaroscopic normal pattern (p=0.0001) than in normal controls and even much higher in patients with scleroderma pattern (p=0.0001). In patients with capillaroscopic normal pattern and RP of recent onset ( Conclusions Our findings indicate that markers of endothelial damage are elevated in RP patients who subsequently develop SSc or other CTDs, even in the absence of capillaroscopic abnormalities. Disclosure of Interest None declared

Since 1988, the European Consensus Finding Study Group on autoantibodies in rheumatic diseases (ECFSG), also known as the EULAR autoantibody study group, has been distributing sera with unspecified ...

Background Rheumatic diseases (RD) affect women during reproductive age. Children9s outcome is a major topic for counselling on family planning, but no large studies are available. Objectives We aimed at assessing the long-term health conditions of children born to mothers with RD through a self-reported questionnaire. Methods 24 Rheumatology Centers distributed the questionnaire (65 multiple choice and 12 open-answer questions) to consecutive women with RD attending their outpatient clinic during September 2015. Data were compared according to maternal diagnosis (MD) -chronic arthritis (CA) or connective tissue disease (CTD)- and to the timing of pregnancy (before or after MD of RD). Results The survey yielded data about 269 children born to 184 mothers (63 CA, 121 CTD). According to MD, children had a mean age of 17.1 (±9.6 SD) and 14.4 (±9.0 SD) years at the time of interview, and male children were 52/93 (56%) and 91/176 (52%), respectively. Twenty-nine children in the CA group (31.2%) and 64 in the CTDs group (36.4%) were born after MD of RD. Pre-term delivery (before 37 weeks) was observed in 48 cases (17.8%), mostly children born to mothers with CTD (37/48, 77%). Regarding school performance, 12 children (4.5%) repeated one year of school, in 7 cases for indolence, in 3 for learning disabilities (LD)/health problems (HP), in 2 for family problems. Eleven of these children were born before MD. Overall, 9 children (3.3%) were diagnosed with a LD and 53 children were affected by HP requiring either hospitalization or evaluation by a Specialist (Table). Three children (1%) were affected by autoimmune disease. Conclusions The long-term follow-up of children born to women with RD is reassuring of an outcome similar to that of the general pediatric population (GPP). Autoimmune diseases are not frequent. Problems seem to cluster in children born to CTD, especially after MD, with a higher frequency of LD (6.3% vs 2.5–3.5% of GPP), but no particular pattern of exposure to maternal autoantibodies nor drugs was observed. Acknowledgements Statistical analysis supported by an unrestricted grant by UCB Pharma Thanks to Patients Associations and Participants to the survey Disclosure of Interest None declared

Background There are many differences in clinical manifestations, assessment and management of Juvenile Idiopathic Arthritis (JIA) between childhood and adults9 arthritis onset. The transition from pediatric to the adult care emphasizes a lot of aspects that need to be addressed. Objectives To describe the long-term outcome of JIA. Methods Two-hundred and forty patients affected by JIA and referred to a transition care rheumatology tertiary centre were considered between 1999 and 2016. The outcome assessment included disease activity, medications, number of prosthesis implantation, pregnancy, mortality, social integration (mobility, employment status and educational level). Results Seventy-four (30.8%) males and 166 (69.2%) females were included; 53 (22.1%) patients were lost in follow up. Subtypes of JIA at disease onset included 101 oligoarthirtis (42.1%), 67 polyarthritis (27.9%), 43 systemic arthritis (17.9%), 7 psoriatic arthritis (2.9%), 22 enthesitis related arthritis (9.2%). Forty-eight (20%) patients had persistent uveitis. Ninety-three implant prosthesis and 14 arthodesis were recordered. The average disease duration was 20 years, the median age of the patients was 27 (18–57) years. Five deaths (2.1%) occurred in this cohort. At follow up 117 (48.7%) had low active disease activity, 70 (29.2%) had moderate disease activity, 14 (5.8%) had a high disease activity, 24 (10%) were on remission ON medication and 15 (6.3%) OFF medication. Among patients still on medication, 59 (24.6%) were treated with oral steroids, 18 (7.5%) with csDMARDs and 169 (70.4%) with bDMARDs. Seventy-five (31.3%) patients had a higher educational level (university), 195 (81.3%) had an employment, 128 (53.3%) had a driving license. Twenty-one (8.8%) pregnancies were registered. The transition age was considered after age of sixteen years old. In this contest, it was important the multidisciplinary approach of each patient that was realized with the collaboration of other specialists (ophthalmologist, orthopedic, dermatologist, obstetric, psychologist). Conclusions In the era of biologic therapy there was an important improvement in a lot variables of the long-term outcome of JIA. One-hundred-eighty-seven (77.9%) patients were still in tight control, not only because of the continuation of the biological therapy but also because of the multidisciplinary care carried out even during remission. JIA often persists over the adulthood. The long term follow up and care of these patients has to be conducted by a rheumatologist expertized in JIA in collaboration with other specialists. Disclosure of Interest None declared

Background Microvascular damage plays a critical role in the initiation and perpetuation of systemic sclerosis (SSc). A comprehensive approach should investigate both superficial and deep layers of peripheral microcirculation. In addition to nailfold videocapillaroscopy (NVC), a well-established technique to evaluate outer skin layer vessels, power Doppler ultrasound (PDUS) has been recently used to study microcirculation in the inner levels [1]. Objectives To study the severity of microvascular involvement in patients with SSc by using both NVC to measure capillary density (outer layer at the nailfold area) and PDUS to detect perfusion (deeper layers at the nailfold and pulp area). Methods 100 SSc consecutive patients fulfilling the 2013 EULAR classification criteria were enrolled. PDUS was performed at the 3rd and 4th finger of the dominant hand after exclusion of ulnar artery occlusion (UAO). In case of UAO non-dominant hand was examined. Ultrasound investigation was performed with Esaote MyLab 70 XVG by means of linear array transducer (10–22 MHz). Power Doppler settings were standardized (Doppler frequency 14.3 MHz, Gain 55%, PRF 750 Hz). PDUS measurements included sagittal scan of nailbed and fingertip qualitatively graded from 1 (no signal) to 4 (marked hyperemia) [2], and resistivity index (RI) of ulnar and radial proper digital arteries. Capillary density (number/mm) was calculated by NVC with magnification 200X performed on two images of the same digits examined by PDUS. Results 100 SSc patients, 87 (87%) women, 86 (86%) limited cutaneous SSc, median age 62.2 years old, median disease duration 8 years were evaluated. 7 (7%) patients had UAO. Concordance between fingertip and nailbed perfusion as assessed by PDUS is reported in Table 1. Concordance between fingertip and nailbed perfusion as assessed by PDUS is equal to 0.7398. The lower 97.5% confidence interval limit is 0.6433. Association between capillary density, and fingertip and nailbed perfusion as assessed by PDUS is shown in Table 2. Conclusions To our knowledge, this is the first study to correlate NVC and PDUS finding in SSc patients. Fingertip and nailbed PDUS grade concordance was found to be satisfactory. The mean capillary density tends to be greater with respect to grade 1. This is particularly evident comparing grade 4 and grade 1. As such, these two imaging techniques provide different and potentially complementary information on SSc-related peripheral microvascular involvement. There is potential clinical utility in these observations that has yet to be unlocked fully. References Lescoat A et al. Arthritis Care Res. 2016;Epub ahead of print. Newman JS et al. Radiology. 1996,198:582–584. Disclosure of Interest None declared

Background To date the evaluation of the disease activity and the monitoring of the therapeutic response of patients affected by Paget9s disease of bone is based only on clinical and hematological data. However, in clinical practice the management of these patients is still challenging. Previous angiographic and histological studies have revealed that the accelerated bone turnover is associated with an increased blood flow and hypervascularity, suggesting a role of high-resolution sonography with power-Doppler (PD) and color- Doppler (CD) in Paget9s disease. Our preliminary data demonstrated that this technique shows not only the alterations of the pagetic bone profile, but also the hypervascularization of the osteoperiosteal-layer, both at the diagnosis and during follow-up. Objectives To validate the PD technique as a useful tool not only for the diagnosis of Paget9s disease of bone but also for the evaluation of the disease activity and for the monitoring of the therapeutic response. Methods Forty-three consecutive patients affected by Paget9s disease of bone and treated with neridronate were followed up over the last ten years. Patients were classified in eight clinical patterns defined by the presence of bone alkaline phosphatase elevation over the normal range (BAP+), bone pagetic pain as visual analogue scale ≥30 (VAS+) and PD alterations of osteoperiosteal vascularization (PD+). Data were analyzed by Fisher exact test (two tails) to assess the associations between BAP+, VAS+ and PD+ at different times during follow up: before the start of the therapy, after the first, the second and the third neridronate cycle of therapy, and at the end of all cycles. Results At any time BAP+ and VAS+ were not associated. A trend of association between VAS+ and PD+ could be observed only after the first neridronate cycle. In contrast, the association between BAP+ and PD+ was statistically significant before the therapy, at the end of all cycles of therapy and after the second one, but not after the first one. Conclusions The lack of association between VAS+ and PD+ or BAP+ may be due to the difficulty of the patients in identifying and quantifying the pagetic pain, and suggests the weakness of the clinical criteria in defining the disease activity. Otherwise, PD technique proves to be a fast, reliable and not expensive tool, which is also very useful for monitoring/achieving better control of Paget9s disease of bone. References Adami S., et al. Italian guidelines for the diagnosis and treatment of Paget9s disease of bone. Reumatismo, 2007; 59(2):153–168. Singer F.R., et al. Paget9s Disease of Bone: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2014; 99(12):4408–4422. Mastaglio C., et al. Characterization of Osteocortical-Periosteal Layers by High-Resolution Sonography Using a Doppler Technique in Paget9s Disease of Bone. JDMS, 2008; 24(3):136–144. Disclosure of Interest None declared

The classification of the anti-phospholipid syndrome (APS) is based on the occurrence of arterial/venous thrombotic events and/or pregnancy complications with no identifiable causes in the persistent presence of medium/high titres of anti-phospholipid antibodies (aPL) detectable by solid phase (anti-cardiolipin – aCL or anti-beta2 glycoprotein I – ab2GPI) tests and/or PL-dependent functional coagulation assays (lupus anticoagulant – LA). These classification criteria are currently also used as diagnostic tools. aPL represent a risk factor, consequently the presence of two/three positive diagnostic laboratory tests is a valuable parameter to stratify the patients at highest risk for developing the syndrome/recurrences. The syndrome displays a protean clinical picture depending on the involved tissue/organ. The majority of the clinical (criteria) manifestations are clearly related to vascular ischemic events. However some manifestations apparently cannot be supported by a thrombotic mechanism and alternative pathogenic pathways have been suggested. This is the case for thrombocytopenia, central nervous system involvement such as movement disorders and cognitive abnormalities, and APS nephropathy. Heart valve disease, skin ulcers and livedo reticularis are also frequent events in APS patients and their relationship with vascular thrombosis is unclear. Still debated is the suggestion to include these manifestations as additional clinical diagnostic criteria. The possibility to use all these criteria for ranking the patients as having a definite (standard clinical criteria) or probable APS (non classification criteria) is also debated. The revised criteria for obstetric morbidity comprise otherwise unexplained pregnancy loss. Some of the obstetric criteria might display low sensitivity/specificity for APS. In particular the attribution to aPL of a pregnancy wastage early on gestational course requires the exclusion of a myriad of ethiologies. Conversely, the rate of late foetal losses is very low, making this criterion rather specific. Placenta-mediated obstetric complications provide another critical field: pre-eclampsia and intra-uterine growth restriction are relatively common. To enhance the specificity for APS, the classification criterion included only cases requiring delivery before 34 weeks of gestation. Medium/high aPL titres and double/triple laboratory tests positivities confer a higher risk for pregnancy complications but recent data seem to suggest that also persistent low aPL titres can be predictive for a negative pregnancy outcome. This finding has been recently explained by the availability of large amounts of b2GPI in tissues of the reproductive system. Even though classification criteria have allowed uniformity in APS diagnosis, there still remain some controversies. The field of the laboratory classification criteria is even more in progress. Epitope profiling for anti-b2GPI antibodies is quite promising since the characterization of reactivity against the domain 1 of the molecule appears to display a higher specificity for APS and stronger predictive value than the antibodies against the whole molecule. However, anti-domain 1 assay is less sensitive and cannot replace the standard test at the moment. Antibodies against prothrombin (PT) have been reported to be associated with both the vascular and the obstetric APS, in particular when the antibodies are detectable against a solid phase complex of PT with phosphatidylserine (PS) (the so called anti-PS/PT assay). However a clear evidence for their usefulness in the clinical diagnosis and risk stratification for APS patients as well as their true pathogenic role is still debated. Disclosure of Interest None declared

Background Vascular involvement is a hallmark of systemic sclerosis (SSc) and it is responsible for some of the most common complications of the disease such as Raynaud9s phenomenon (Rp), digital ulcers (DUs) and pulmonary arterial hypertension. I.V. iloprost (ILO), a prostacyclin analogue, has been shown to be effective in reducing Rp severity, DUs healing and preventing [1]. Objectives To assess the acute effect of ILO on acral circulation as assessed by nailfold videocapillaroscopy (NVC) and 22-MHz Power Doppler ultrasound (PDUS). Methods 44 SSc consecutive patients fulfilling the 2013 EULAR classification criteria were enrolled. Each patient was evaluated before and immediately after I.V. ILO administration (0.5–2.0 ng/Kg/min for 6 consecutive hours). PDUS was performed at the 3rd and 4th finger of the dominant hand after exclusion of ulnar artery occlusion (UAO). In case of UAO non-dominant hand was examined. Ultrasound investigation was performed with Esaote MyLab 70 XVG by means of linear array transducer (10–22 MHz). Power Doppler settings were standardized (Doppler frequency 14.3 MHz, Gain 55%, PRF 750 Hz). PDUS measurements included sagittal scan of nailbed and fingertip qualitatively graded from 1 (no signal) to 4 (marked hyperemia) [2], and resistivity index (RI) of ulnar and radial proper digital arteries. Capillary width (sum of capillary width/mm) was calculated by NVC with magnification 200X performed on two images of the same digits examined by PDUS. Results The study population included 44 SSc patients, 40 (90.9%) women, 35 (79.5%) limited cutaneous SSc, median age 60.2 years old and median disease duration 8 years. 19 (43.2%) had history of DUs, among them 15 had experienced more than one DUs and 1 had active DU at the moment of evaluation. Semiquantitative perfusion score of sagittal scan of nailbed and fingertip pre- and post-therapy are shown in Table 1. Changes in RI and capillary width pre- and post-infusion are reported in Table 2. Conclusions A statistically significant post-infusion rise in RI, fingertip and nailbed PDUS grade were found. Capillary width was also increased, but it was not statistically significant. As such, these novel results indicate that ILO, alongside its clinical effect, is able to enhance vascularization even at the most peripheral levels. References Pope J et al. Cochrane Database Syst Rev. 2000;(2):CD000953. Newman JS et al. Radiology. 1996,198:582–584. Disclosure of Interest None declared

Background Vasculopathy is considered a primary pathogenic event in systemic sclerosis (SSc) and it substantially contributes to prominent features of the disease such as digital ulcers (DUs). History of DUs (HDUs) has been shown to correlate with disease severity, new cardiovascular events, new DUs and overall poor prognosis [1]. Microvascular abnormalities as assessed by nailfold videocapillaroscopy (NVC) and power Doppler ultrasound (PDUS) have been demonstrated to be predictive of new DUs occurrence [2,3]. Objectives To study the severity of microvascular involvement at the 3rd and 4th finger of the dominant hand in patients with SSc with or without HDUs as assessed by NVC and 22-MHz PDUS. Methods 100 SSc consecutive patients fulfilling the 2013 EULAR classification criteria were enrolled. PDUS was performed at the 3rd and 4th finger of the dominant hand after exclusion of ulnar artery occlusion (UAO). In case of UAO non-dominant hand was examined. Ultrasound investigation was performed with Esaote MyLab 70 XVG by means of linear array transducer (10–22 MHz). Power Doppler settings were standardized (Doppler frequency 14.3 MHz, Gain 55%, PRF 750 Hz). PDUS measurements included sagittal scan of nailbed and fingertip qualitatively graded from 1 (no signal) to 4 (marked hyperemia) [4], and resistivity index (RI) of ulnar and radial proper digital arteries. Capillary density (number/mm) was calculated by NVC with magnification 200X performed on two images of the same digits examined by PDUS. Results 100 SSc patients, 87 (87%) women, 86 (86%) limited cutaneous SSc, median age 62.2 years old, median disease duration 8 years were evaluated. 7 (7%) patients had UAO. 33 (33%) had HDUs among them 23 had experienced more than one DUs and 2 had active DUs at the moment of evaluation. Semiquantitative perfusion score of sagittal scan of nailbed and fingertip were not significantly associated with the presence of HDU. RI and capillary density were significantly different in the two groups as shown in the table below: Conclusions A significant lower RI of ulnar and radial proper digital arteries reported in patient with HDUs is novel. By contrast PDUS grading of nailfold and fingertip were not significantly different in patients with or without HDUs. The finding of a significant lower capillary number assed by NVC in patients with HDUs is consistent with previous results [2]. Adequately longitudinal studies exploring the predictive value of PDUS parameters are required to fully ascertain its role in SSc. References Mihai C et al. Ann Rheum Dis. 2016;75(4):681–6. Cutolo M et al. Arthritis Rheumatol. 2016;68(10):2527–39. Lescoat A et al. Arthritis Care Res. 2016;Epub ahead of print. Newman JS et al. Radiology. 1996,198:582–584. Disclosure of Interest None declared

Background MRP8/14 (also known as calprotectin) has been widely studied as potential predictor of disease activity and response to treatment in inflammatory diseases. In Juvenile Idiopathic Arthritis (JIA), MRP8/14 levels are highly predictive of disease flares in systemic JIA. In a more heterogeneous group of JIA patients (pts), MRP8/14 levels have been shown to predict response to MTX. High levels of baseline MRP8/14 are associated with good response to anti-TNF treatment, whereas elevated MRP8/14 levels at time of discontinuation are associated with higher chance to flare. In clinical practice, ultrasound could be usefull to define the state of disease activity. Indeed, PD-US assessment of synovial vascularization has been shown to be more sensitive than serum markers of inflammation in the identification of active disease in JIA. Objectives To explore the association between calprotectin, clinical and US assessment in JIA pts. Methods A total of 30 consecutive pts (aged under 18 years) with oligo or poly JIA were assessed by US, clinical examination and MRP8/14 serum levels. Serum MRP8/14 was measured by ELISA in all pts and in 20 age matched healthy controls. Ultrasonographic B-mode and power Doppler assessment of 44 joints each pts were performed. Patients were evaluated using Wallace criteria. Results 30 consecutive non systemic JIA pts (F 18) were evaluated: 13 persistent and 8 extended oligoarticular, 6 polyarticular (1 RF positive), 2 ERA, 1 psoriatic JIA. Median age at disease onset was 10.6 yrs (mean 10.8, range 2–16). Mean disease duration was 5.4 yrs (range 0.1–15.9). Mean active joints was 2 (range 0–26). 14 pts were active according to Wallace criteria and 16 pts were active according to US evaluation. Ultrasonographic B-mode and power Doppler assessment was significantly correlated with clinical examination (Mcnemar test p=0.683, Cohen9s K 0.602). The majority of our enrolled pts were in phase of oligoarticular involvement with minimal disease activity (median active joints=0). No statistically significant difference in serum MRP8/14 was found between all JIA pts and healthy controls (p=0.33). No statistically significant difference in serum MRP8/14 was found between active (according to clinical examination) JIA pts and healthy controls (p=0.69) and between inactive JIA pts and healthy control (p=0.23). Concentrations of MRP8/14 in active and inactive pts according to Wallace were not significantly different (p=0.75). No statistically significant difference in serum MRP8/14 was found between active and inactive pts according to US assessment (0.85). Only 6 pts (4 out of 6 with polyarticular course) showed calprotectin levels higher than normal. We found a correlation between calprotectin and CRP (Spearman r 0.4380, p=0.01) and between calprotectin and ESR (Spearman r 0.3800, p=0.05). Conclusions To our knowledge this is the first study to examine the correlation between MRP8/14 levels, clinical and US assessment in JIA. Serum levels of MRP8/14 (a biomarker of activation of the innate immune system) are not significatively different in oligoarticular JIA from healthy controls. Calprotectin high levels, could be related with a poliarticular disease either in clinical activity or in subclinical remission. However our study need to be extended to a larger number of pts followed prospectively. Disclosure of Interest None declared

Background and aims To investigate effectiveness, damage accrual and predictors of response to belimumab in active SLE patients in clinical practice setting. Methods 188 active SLE patients with anti-dsDNA antibodies and low C3 and/or C4, from 11 Italian centres, were treated with belimumab as add-on-therapy. Gender, age, disease duration, polyarthritis, skin rashes, glomerulonephritis, haematological involvement, SLEDAI-2K≥10, prednisone ≥7,5 mg/day and concomitant immunosuppressants were used to determine baseline predictors of 12- and 24 month response according to SRI-4. Data were analysed by SPSS (version 22.0). Results Prominent clinical manifestations are summarised in Table 1. Clinical and serological variables at baseline, 12 and 24 months are reported in Table 2. SRI-4 was achieved by 71.3% and 68.7% of patients at 12 and 24 months, respectively. 92% of 12 month responders maintained SRI-4 response at 24 months; conversely, 87.5% of non-responders at 12 months were non-responders even at 24 months. Drug discontinuation for any cause was observed in 36.2% of patients; median treatment duration was 12 months. Damage accrual variation was significant between 5 years before drug initiation and baseline (p Conclusions Belimumab seems to be effective and to reduce damage accrual in SLE patients in clinical practice setting. Patients with arthritis and high disease activity were the best responders to belimumab.

Background TNF-α neutralizing molecules represent one of the most efficient therapeutic approaches to control inflammation in rheumatoid arthritis (RA). The widespread distribution in the body induces the inhibition of TNF-α in all the tissues, requesting the use of high dose of this expensive drug. Another problem that has not yet been solved in the management of RA patients is how to reduce and possibly avoid the side effects, particularly the increased risk of common and opportunistic infections, which may be associated with long-term administration of these therapeutic drugs. Objectives The aim of the present investigation was to show that a recombinant protein obtained by fusing a synovial targeting peptide to an anti-TNF-α neutralizing antibody has a distinctive homing property for inflamed synovium and is effective in controlling joint inflammation in experimental models of arthritis. Methods The modified anti-TNF-α antibody specific for the synovial tissue (MC13) was generated by cloning the sequence for a synovial homing peptide (CKSTHDRLC) downstream of the cDNA for the variable regions of anti- TNF-α antibody adalimumab in the context of a miniantibody (scFv-Hinge-CH2-CH3 domains). Immunofluorescence technique was used to initially assess the ability of fluorescent-MC13 to target only inflamed synovial tissue. The biodistribution and the efficacy of the treatment with MC13 were evaluated in a rat model of antigen-induced arthritis (AIA). Results In vitro studies have shown that adalimumab and MC13 maintain the ability to neutralize human TNF-α and bind to rat and mouse TNF-α. Based on these findings, we used a rat model of arthritis to evaluate their in vivo therapeutic effect. The ability of MC13 to selectively target inflamed synovial tissues was evaluated by immunofluorescence analysis. A rat model of antigen-induced mono-arthritis was used to analyse the in vivo distribution of MC13 labelled with the near-infrared probe cyanine 5.5 using time-domain near infrared optical imaging. The results showed that the labeled-MC13 preferentially localized in the inflamed synovium with a peak at 4 days and persisted for more than 3 weeks, while failing to bind to healthy synovial tissue. MC13 was able to prevent inflammation in the rat model of antigen-induced arthritis, as evaluated by the measurement of joint swelling, the count of PMN number and the level of IL6 in synovial tissue and the histologic assessment of tissue damage. Intravenous injection of MC13 prevents acute inflammation in all the animals while the same dose of adalimumab was almost ineffective. MC13, administred i.v. 4 days after arthritis induction, was also able to cure joints analysed 7 days after the induction of inflammation. Conclusions Our results demonstrated that MC13 can selectively target inflamed and abrogate the inflammation in a model of antigen-induced arthritis with no sign of toxicity. Disclosure of Interest None declared

Background Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease affecting joints due to the persistent synovial tissue inflammation. RA treatment has dramatically evolved in the last 20 years due to the production of biological Disease Modifying Antirheumatic Drugs (bDMARDs). However, side effects and the high costs of biological drugs are holding back their widespread usage. Moreover, some patients fail to respond to bDMARDs, for all of these reasons, DMARDs remains the main desired strategy for the treatment of RA, and Methotrexate (MTX) is still the “anchor” drug to treat RA. A successful treatment depends also on the early diagnosis, treating patients as soon as possible to prevent the late stages of the pathology. Objectives The aim of this work is to develop targeted biodegradable nanoparticles (tBNPs) that could be used as a platform suitable to delivery drugs or diagnostic tracers specifically into the inflamed synovial tissue. This approach usually allows to enhance the efficacy and to reduce the side effects. Methods We used polymeric biodegradable nanoparticles, made of polylactic acid, polycaprolactone and polyethylene glycol and coated with a peptide characterized for its ability to target only inflamed synovial tissue. The tBNPs diameter was 170 nm with a low negative charge. Toxicity was studied in-vitro assay and in-vivo. Immunofluorescence technique was used to initially assess the ability of fluorescent-tBNPs to preferentially target inflamed synovial tissue. The biodistribution of the nanoparticles and the efficacy of the treatment with tBNPs loaded with MTX were studied in a rat model of antigen-induced arthritis (AIA). Finally, tBNPs efficacy was also studied in a mouse model of collagen-induced arthritis (CIA). Results Targeted BNPs evidenced the ability to specifically bind inflamed synovial tissue both in vitro and in vivo. The targeting is dependent on the inflammation degree and this highlights the potentiality of the tBNPs as an early diagnostics tools. A single injection of targeted BNPs loaded with MTX completely abrogated the inflammatory process in acute AIA rat model while the same dose of free-MTX was ineffective. Equivalent therapeutic effects were obtained comparing MTX-loaded tBNPs and the same dose of free-MTX in the mouse model of chronic CIA and no toxic effect was documented when MTX was loaded in nanoparticles in these animals. Conclusions Our results demonstrated that tBNPs can efficiently and selectively delivery drugs and diagnostic probes to inflamed synovial tissue, providing a new platform for an early detection and efficient chronic treatment of inflammatory arthritis, with minimal side effects. Disclosure of Interest F. Colombo: None declared, L. Nunez Employee of: Biotarget, P. Durigutto: None declared, S. Biffi: None declared, E. Rampazzo: None declared, B. Belmonte: None declared, D. Sblattero: None declared, A. Gulino: None declared, P. L. Meroni: None declared, F. Tedesco: None declared, P. Macor: None declared

International standards for anti-beta2 glycoprotein I (anti-β2GPI) testing are needed. We evaluated the suitability of polyclonal/monoclonal candidate reference materials (RM) for the assay. IgG/IgM anti-β2GPI were affinity-purified (AP) from high-positive antiphospholipid syndrome sera and IgG from HCAL clone supernatant. Igs were tested for purity by SDS-PAGE, pooled, concentrated, sterile-filtered and the protein concentration determined. One unit was defined as the binding activity of 1 µg/ml of AP anti-β2GPI Ig. IgG/IgM RM were each assigned a unit value using the respective AP material as a calibrator. Polyclonal/monoclonal RM and 30 samples were evaluated for linearity, unit equivalency and commutability. Polyclonal AP material was assigned a value of 100 U IgG and 15 U IgM anti-β2GPI, respectively. IgG-RM had a value of 270 IgG and the IgM-RM of 220.3 IgM anti-β2GPI U. The linearity ( R2) of each RM curve for the various assays ranged from 0.96 to 0.99. Commutability samples fit very well within 95% prediction intervals and had excellent correlation when comparing assays. IgG and IgM polyclonal and IgG monoclonal RM displayed excellent linearity and commutability, being good candidates for better standardization of anti-β2GPI immunoassays.

Introduction L’evolution a long terme du syndrome des antiphospholipides primaire a ete peu decrite. Notre objectif etait d’evaluer les recidives thrombotiques, la survenue d’atteintes d’organes, de comorbidites, et le risque d’evolution vers une connectivite associee. Patients et methodes Etude retrospective des patients suivis au moins annuellement, pendant une duree d’au moins 15 ans dans l’un des 6 centres participants (hopitaux Pitie-Salpetriere et Cochin, Paris, France ; Brescia, Milan, Padua et Rome, Italie), pour un syndrome des antiphospholipides (defini selon les criteres de Sydney), sans connectivite definie associee au diagnostic. Resultats Cent quinze patients (88 % femmes) suivis entre 1983 et 2014, d’âge moyen (± SD) 33 ± 10 ans au diagnostic de syndrome des antiphospholipides primaire, et avec un suivi moyen de 19 ± 3,5 ans ont ete inclus. Cinquante et un patients (44 %) ont presente au moins un episode thrombotique au cours du suivi avec un total de 75 evenements et une incidence annuelle de 3,5 %. La survenue de thromboses etait plus frequente chez les patients avec antecedents de thrombose ( odds ratio [OR] : 4,8, IC95 % : 1,6–14,7 ; p = 0,002). Six des 31 patientes (19 %) ayant initialement un syndrome des antiphospholipides purement obstetrical ont ete atteinte d’une thrombose au cours du suivi. Six patients (5 %) sans antecedent de syndrome catastrophique des antiphospholipides, tous triples positifs pour la biologie antiphospholipides, ont presente un episode de syndrome catastrophique des antiphospholipides au cours du suivi. Cinquante-deux femmes ont eu 87 grossesses qui ont abouti a la naissance d’un enfant vivant dans 78 % des cas. Trente-quatre patients (29 %) avaient une sequelle fonctionnelle (principalement neurologique centrale, cardiaque, visuelle, renale, surrenalienne). La survenue de sequelles etait statistiquement associee aux antecedents de thromboses (OR : 13,9, IC95 % : 1,8–288,4 ; p = 0,004) et aux evenements arteriels (OR : 7,9, IC95 % : 2,7–24,3 ; p Conclusion Un nombre significatif de patients developpe de nouvelles thromboses et/ou des sequelles au cours du suivi prolonge.

Two-hundred ninety five patients with the antiphospholipid syndrome (APS) were studied for the presence of antibodies against six anti-beta2GPI-related peptides Abs. The prevalence of a wide spectrum of clinical and laboratory parameters of APS was evaluated in all patients, and correlated with the presence of each anti-beta2GPI peptide antibody. The rates of the various antipeptides Abs ranged from 18.0 to 63.7%. Altogether, 87.1% of the patients had antibody reactivity against at least one of the six beta2GPI-related peptides. A high degree of simultaneous reactivity against several beta2GPI-peptides was found. Positive and negative correlations were found between several antipeptides Abs and the rates of thrombosis and fetal loss. Our results point to a heterogeneous activity of antiphospholipid Abs in APS patients, directed, often concurrently, against various epitopes of the beta2GPI molecule. Evaluation of APS patients for the presence of specific antipeptides Abs may be of a value in predicting the risk for future thrombotic and obstetrical complication, as well as for specific therapeutic purposes.

Beta2-glycoprotein I (beta2GPI) is a cofactor for anti-phospholipid (aPL) binding to cardiolipin (CL)-coated plates. Beta2GPI is also able to bind to endothelial cell (EC) membranes as supported by in-vivo as well as by in-vitro studies. The PL-binding site in the fifth domain of the molecule is involved in the adhesion to endothelium. Actually, specific mutations in this molecular portion abolish endothelium binding and a synthetic peptide spanning the sequence Glu274-Cys288 of the CL-binding site displays comparable adhesion to EC monolayers. Heparan sulphate appears to be one of the anionic EC membrane structures with which cationic beta2GPI interacts, as supported by studies with heparitinase-treated EC. Beta2GPI binding to EC might be related to its activity as endothelial growth factor or as a lipid-carrying glycoprotein. Adhesion of beta2GPI to endothelial membranes offers suitable epitopes for circulating aPL that, once bound, can induce cell activation

Background Fibrosis and vasculopathy are the major concerns in systemic sclerosis (SSc), the pathogenesis of which is not clear. Lysyl oxidase (LOX) is an extracellular copper enzyme that cross-links collagen and elastin, thus stabilizing collagen fibrils [1]. In a preliminary study, LOX was found to be overexpressed in SSc patients and was suggested to be related to diffuse disease [2]. We evaluated skin and lung biopsies from 11 SSc patients and were able to show LOX located in the epidermis in the skin and in the endothelium of blood vessels within the dermis and in lung tissue. It is not clear whether the source of elevated LOX levels in SSc is damaged vascular endothelium or fibrotic tissues. Objectives To evaluate LOX serum level of patients with SSc compared to patients with very early diagnosis of SSc (VEDOSS), patients with primary Raynaud9s phenomena (PRP) and healthy controls in order to validate the elevated levels in SSc and to delineate its source. Methods We prospectively evaluated patients for demographics, clinical manifestations and laboratory results including blood count, chemistry, urine examination, autoantibodies and serum LOX concentration determined by ELISA. We further evaluated lung function tests, echocardiography, lung high resolution CT scans, as needed, and determined lung involvement, modified Rodnan skin score (mRSS), Medsger disease severity scale and Valentini activity index [3]. Results 86 SSC patients (76 women and 10 men) at a mean age of 49±12.4 were evaluated and compared with 110 patients with VEDOSS, 86 patients with PRP, and 80 age and gender matched healthy controls. Of the SSc patients, 42 had diffuse disease- 23 of them with lung fibrosis, and 44 had limited disease. LOX concentration in SSc was higher than VEDOSS, PRP and healthy controls, 12.8±7.5 ng/ml vs. 9.7±7.4 ng/ml vs. 8.1±5.4 vs. 8.9±5.1 ng/ml, respectively (p Conclusions LOX level was found to be high in the serum of patients with SSc correlating with disease severity and inversely correlated with lung diffusion, suggesting a vascular source of LOX excretion in SSc. LOX was not elevated in patients with VEDOSS or PRP. Our study confirms our former observation of elevated LOX level in SSc and suggests LOX to be a possible biomarker of disease severity and vasculopathy in SSC. References Csiszar K, et al. Lysyl oxidases: a novel multifunctional amine oxidase family. Prog. Nucleic Acid Res. Mol. Biol. 2001;70: 1–322. Rimar D et al. Brief report: lysyl oxidase is a potential biomarker of fibrosis in systemic sclerosis. Arthritis Rheumatol. 2014;66(3):726–30 Hudson M, et al. Update on indices of disease activity in systemic sclerosis. Semin Arthritis Rheum 2007;37(2):93–8. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by vascular changes and progressive fibrosis of skin and various internal organs. A variety of circulating autoantibodies have been detected in SSc. Some of them are well-established tools strongly associated with SSc and useful for diagnosis and management of the disease (e.g. ANA, anti-centromere, anti-topoisomerase I, anti-RNA polymerase III – RNAP III). Other autoantibodies are less frequent and non-specific for SSc even if potentially useful to better assess clinical subsets and prognosis (e.g. anti-Th/To, anti-Ku, anti-PM/Scl). Objectives To investigate the prevalence of anti-Th/To, anti-Ku, anti-RNAP III and anti-PM/Scl antibodies as well as to study the associations between these antibodies and clinical features in Italian SSc patients. Methods Sera from 176 consecutive patients with SSc collected at two Italian sites were tested for anti-Th/To (anti-Rpp25 and anti-Rpp38), anti-Ku, anti-RNAP III, anti-PM/Scl, and anti-centromere antibodies (anti-CENP-A and B) using QUANTA Flash chemiluminescence immunoassays (CIAs) on the BIO-FLASH instrument (Inova Diagnostics, San Diego, USA). Additionally, ANA screening was performed using QUANTA Flash CTD Screen Plus which includes the most relevant nuclear/cytoplasmic antigens. The Italian cohort included: women 162 (92%), limited cutaneous (lc-SSc) subtype 137 (78%), patients with present or past history of digital ulcers 56 (32%), calcinosis 25 (14%), lung fibrosis 69 (39%), heart involvement 22 (12.5%), pulmonary arterial hypertension 11 (6%) and esophageal involvement 84 (48%). Results 152 (86.4%) patients were CTD Screen Plus positive, 8 (4.5%) anti-Th/To positive, 8 (4.5%) anti-Ku positive, 20 (11.4%) anti-RNAP III positive, 0 (0%) anti-PM/Scl positive, 70 (39.8%) anti-CENP-A positive, and 87 (49.3%) anti-CENP-B positive. Anti-CENP-A, anti-CENP-B and anti-Ku antibodies were significantly associated with the lc-SSc subtype ( p p p =0.0469, respectively). None of patients positive for anti-Ku antibodies displayed digital ulcers ( p =0.0075). Anti-Th/To (Rpp25) antibodies were associated with the presence of calcinosis ( p =0.0399) while anti-RNAP III antibodies with its absence ( p =0.0353). All patients positive for anti-Th/To were positive for the Rpp25 component while only one of them was also positive for the Rpp38 component. Conclusions The present study points out the low prevalence of anti-RNAP III and highlights a lower prevalence of anti-Th/To in Italian SSc patients. Several known associations between autoantibodies as SSc subsets have been confirmed while others could not be verified in the study. This supports the potential utiliy of autoantibodies to stratify SSc into clinical subsets. Large international multi-center studies are required to define and validate rare autoantibodies such as anti-Th/To, anti-Ku and anti-PM/Scl antibodies. Disclosure of Interest None declared

Background A potential role of hydroxychloroquine (HCQ) use in patients with antiphospholipid antibodies (aPL) has been suggested by some retrospective cohorts and in animal models based on its potential beneficial effects on autoantibody effect and titer, endothelial function and glucose or lipid metabolism [1–3]. Objectives To evaluate the impact of HCQ on aPL titers, on glucose and cholesterol levels and its role in the prevention of thrombotic recurrences in Primary Antiphospholipid Syndrome (PAPS). Methods Patients with PAPS, diagnosed according to 2006 Classification Criteria without any Connective Tissue Disease, that received HCQ (HCQ+) but no immunosuppressive drugs, were matched with similar patients that did not received HCQ (HCQ-) according to the following characteristics: same gender, follow-up duration, disease onset, age at the beginning of the follow-up ±10 years and initial date of the follow-up ± 5 years. Results Seventy-two patients (36 HCQ+ and 36 HCQ-) with a mean follow-up of 77 (±SD 49) months between 1992 and 2015 were studied. No significant variations in demographical, clinical, serological features were observed between the two groups except for of anti-extractable nuclear antigen antibodies (19% in HCQ+ versus 0% in HCQ-,p:0.014). Anti-β2Glycoprotein I IgG titers were significantly lower in HCQ+ than in HCQ- patients at the end of the follow-up (Student t,p:0.018). The variations of all the aPL titers in the two groups are shown in Figure 1. No differences in glucose and cholesterol levels were detected. Eight percent of HCQ+ and 17% of HCQ- patients experienced a thrombosis during the follow-up. Among patients with a history of thrombosis the annual incidence of recurrences was lower (0,87%) in HCQ+ patients than in HCQ- (2,17%). Conclusions This study showed a strong reduction of aPL titers and of the incidence of recurrences in patients treated with HCQ, supporting a possible role of this drug in the treatment of patients with PAPS. References Rand JH, Wu XX, Quinn AS, et al. Hydroxychloroquine directly reduces the binding of antiphospholipid antibody-beta2-glycoprotein I complexes to phospholipid bilayers. Blood 2008, 112:1687–1695. Broder A, Putterman C. Hydroxychloroquine use is associated with lower odds of persisently positive antiphospholipid antibodies and/or lupus anticoagulant in systemic lupus erythematosus. J Rheumatol 2013, 40:30–33. Schmidt-Tanguy A, Voswinkel J, Henrion D, et al. Antithrombotic effects of hydroxychloroquine in primary antiphospholipid syndrome patients. Journal of Thrombosis and Haemostasis. 2013;11(10):1927–1929. Disclosure of Interest None declared

Background Thrombosis of arteries in the central nervous system (CNS) represents the most frequent CNS manifestation and the most frequent arterial event in antiphospholipid syndrome (APS). Previous in vivo studies demonstrated that beta2 glycoprotein I (β2GPI) - the main antigenic target for anti-phospholipid antibodies (aPL) - does not localize in brain in resting conditions. However, β2GPI is detectable on the brain vascular endothelium in association with IgG and complement elements in immunized mice treated with lipopolysaccharide. These data suggest that after an appropriate second hit, β2GPI can play a critical role of in APS CNS damage, likely interacting with the complement system. To date, the pathophysiological functions of β2GPI in brain ischemic injury have not been investigated. Objectives To investigate the presence and the distribution of the activated form of β2GPI in the ischemic brain at different time points. Methods Eleven-week old male mice underwent focal cerebral ischemia induced by 609 transient middlecerebral artery occlusion (tMCAo), or sham-operation. Mice were sacrified at 909, 6h, 24h, 48h, 4d or 7d after tMCAo to obtain brains and plasma. The presence and time course of β2GPI deposition within the ischemic territory and its spatial distribution relative to blood vessels and brain cells were defined the by post mortem immunofluorescence and confocal microscopy. The activated β2GPI was detected by anti-beta2 glycoprotein I minibody (MBB2) – a human monoclonal IgG antibody targeting β2GPI domain I. Results β2GPI was present in the ischemic brain tissue starting from 909 after ischemic onset and was still detectable at 7d. β2GPI localized within blood vessels and in brain parenchyma at all times. Notably, at 24h β2GPI was mainly extravascular and colocalized with neurons (NeuN positive cells). Sham-operated mice showed only a faint signal for β2GPI. Conclusions β2GPI is present in its activated conformation in the brain vessels and tissue after experimental cerebral ischemia. It localizes on neurons in brain ischemic areas. These data suggest that an ischemic/inflammatory hit may up-regulate β2GPI tissue presence and may expose the N-terminal domain I of the molecule which is thougth to be the main target for pathogenic aPL. Disclosure of Interest None declared

Background During the last sixteen years, biologics have been used in our centre in an open prospective study for the treatment of refractory JIA not only in paediatric age but also in young adults. Objectives To underline the capability to become pregnant, not negatively influenced by biologics and to describe the pregnancy outcome of our young patients who got pregnant during the biologics treatment, since this event seems to be facilitated from a low disease activity under biologics. Methods Seventeen women affected by refractory JIA became pregnant during biologic therapy. Two males affected by JIA, both treated with Adalimumab have been achieved as indirect pregnancies. All patients had a long lasting refractory polyarticular disease not responsive to DMARDs. Patients were treated with biological agents like Etanercept (9 patients), Adalimumab (4 patients), Golimumab (3 patients), Infliximab (1 patient) and Rituximab (2 patients) as monotherapy and most of the cases after multiple switches. Results 3 patients decided for an elective termination; 16 patients had a normal pregnancy resulted in live born infants, full term, with no structural abnormalities and still in good health. The median time of exposure to biologics was 48 months (min 10- max 72 months). No abnormalities were achieved neither in the live born infants nor in the fetuses of the pregnancies which ended with an elective termination. The paternal exposure did not influence conception and was not associated with negative outcome of pregnancy. Conclusions The availability of therapies like antiTNFa and other biologics has raised important questions about pregnancy outcome in female and male patients affected by JIA exposed to biologics. Other data regarding limited populations affected by Crohn9s disease or Rheumatoid Arthritis treated with antiTNFa have been published. It doesn9t seem to be an increased risk to pregnancy loss. Even if there is no increase in miscarriage or malformation or birth defect, as reported in letterature, TNFa inhibitors are raccomended to be discontinued after pregnancy detection. In our experience no complications or unexpected side effects on the course of pregnancy were observed. Disclosure of Interest None declared

Background Based on more recent recommendations, remission or low-disease activity are pivotal targets to be achieved in the treatment of rheumatoid arthritis (RA). However, despite a clinical remission, subclinical joint and tendon inflammation potentially leading to structural and functional worsening can be detected in a large number of patients. Objectives To determine the prevalence of joint and tendon inflammation by ultrasound (US) gray scale (GS) and power Doppler (PD) in RA patients treated with biological (bDMARDs) or synthetic disease modified anti-rheumatic drugs (sDMARDs) achieving a sustained clinical remission. Methods RA patients treated with sDMARDs or bDMARDs achieving a sustained clinical remission (defined as DAS28 Results Forty-eight RA patients were enrolled (20 on bDMARDs and 28 on sDMARDs). A total of 1056 joints and 1248 tendons/tendon compartments with synovial sheath were examined. Twenty-seven (56.2%) patients presented at least one joint with GS synovial effusion or hypertrophy (9/20 in bDMARD and 16/28 in sDMARD group, respectively; p=0.559). In 15 (31.2%) patients we found at least one joint with active PD signal (7/20 in bDMARD and 8/28 in sDMARDs group, p=0.755). In 8 (16.7%) patients at least one tendon sheath with GS synovial effusion or hypertrophy (2/20 treated with bDMARDs and 6/28 with sDMARDs, respectively; p=0.440) was reported. No patients presented at least one tendon sheath with active PD signal in bDMARD group and 3/28 in sDMARD group (p=0.255). Finally, GS alterations were significantly more frequent in the dominant hand compared to the contralateral (22 [45.8%] vs 10 [20.8%], p=0.017). Conclusions Our data confirmed the high prevalence of US-detected subclinical active synovitis/tenosynovitis in RA patients achieving a sustained DAS28 remission. Joints resulted more frequently involved than tendons in subclinical detected inflammatory process. No differences were found according with bDMARD or sDMARD treatment. GS synovitis was more frequently demonstrated in the dominant hand. Disclosure of Interest None declared

Background Data on the long-term outcome in primary antiphospholipid syndrome (PAPS) patients are still very limited. Objectives To assess the long-term frequency of recurrences, organ damage, severe comorbidities, mortality and evolution in connective tissue disease (CTD) in PAPS patients. Methods Medical records of PAPS patients followed in 6 centers for ≥15 years were retrospectively reviewed. Chi square for categorical and Student t test for continuous variables were used. P Results One hundred and fifteen patients (88% females) followed between 1983 and 2014 with a mean age at diagnosis of 33 (±10) years and mean follow-up of 19 (±3.5) years were studied. Fifty-one patients (44%) had at least a thrombotic event during follow-up for a total of 75 events and an annual incidence of 3.5%. Thromboses were more frequent in patients with previous thrombotic history (p:0.002,OR:4.8, 95%CI:1.6–14.7). There was a tendency towards anticoagulant treatment being not protective against recurrences (p:0.063). Six patients (5%) had a catastrophic event. Fifty-two women had 87 pregnancies, successful in 78% of cases. Twenty-nine percent of patients had functional damage. Damage was significantly associated with a thrombotic history (p:0.004,OR:13.9,95%CI:1.8–288.4) and to arterial events (p Conclusions Despite therapy, a high proportion of patients experienced new thrombotic events,while pregnancy outcome was significantly improved. Organ damage developed in a significant proportion of patients and was associated with arterial events. The risk of evolution in CTD has to be considered. Disclosure of Interest None declared

Background Long-term data on drug survival of TNF inhibitors (TNFi) in the treatment of spondyloarthropathies are still lacking. Objectives The aim of the study is to analyze in a setting of real-life the 8-year retention rate of the first TNFi for the treatment of psoriatic arthritis (PsA) and axial spondyloarthritis (ax-SpA) and to compare the between-group discontinuation rates for each TNFi (infliximab [IFX], etanercept [ETN], and adalimumab [ADA]). Methods Data were retrospectively extracted from four local registries including all patients affected by PsA and ax-SpA treated with a biologic drug between January 2005 and May 2015. The analysis was limited to patients treated with IFX, ETN, or ADA as first-line biologic agent, with at least 1-year follow-up period. The 8-year drug survival was evaluated by Kaplan-Meier method and the risk for discontinuation among the 3 treatment groups was compared by a stratified log-rank test. Results The study population (614 patients) included 316 ax-SpA (69.9% male, mean age [±SD] 42.8 [±12.1] years, mean disease duration 7.2 [±7.9] years), treated with ADA (n=95), ETN (n=42), or IFX (n=179); and 298 PsA (51.7% male, mean age 47.8 [±12.1] years, mean disease duration 8.8 [±7.7] years), treated with ADA (n=108), ETN (n=89), or IFX (n=101). The overall median survival on treatment of the whole study population was 117.17 months (102.84 and >117.17 months for axSpA and PsA, respectively; p=NS). The overall retention rate was 66.2% (69.5% versus 62.8% in axSpA and PsA, respectively) at 5 years and 55.5% (57.2% versus 53.4% in axSpA and PsA, respectively) at 8 years. No significant differences emerged in the comparison among ADA, ETN, and IFX in both ax-SpA group (p=0.1065) and PsA group (p=0.06). IFX and ETN showed similar survival rates in PsA and axSpA (HR 1.252, 95% CI 0.600–2.608, and HR 1.224, 95% CI 0.8441–1.774, respectively), whereas ADA showed a significantly higher survival in axSpA compared to PsA (HR 1.775, 95% CI 1.045–3.013). Overall, 265 (43.1%) patients (129 [43.2%] PsA and 133 [42.1%] axSpA), stopped the first course TNFi. Inefficacy led to discontinuation in 115 (18.7%) patients (65 [21.8%] PsA and 50 [15.8%] axSpA), without significant differences between the two disease groups (p=0.1076). Adverse events led to discontinuation in 88 (14.3%) patients, (43 [14.4%] PsA and 45 [14.2%] axSpA), without significant differences between PsA and axSpA (p=0.9049). Conclusions In a real-life setting, the 8-year retention rate of the first TNFi in the treatment of spondyloarthropathies was about 50%, with no significant difference between ax-SpA and PsA. The risk of stopping IFX and ETN treatment was similar in both ax-SpA and PsA group, whereas ADA showed a higher survival in axSpA group. Disclosure of Interest None declared

Background Early identification of patients (pts) unlikely to achieve good long-term disease control with anti-TNF therapy in rheumatoid arthritis (RA) is important for physicians following treat-to-target recommendations. Predictability of response has previously been demonstrated in RA pts treated with certolizumab pegol (CZP), with previous work focusing on the predictability of long-term (1-year) response based on response at Week (Wk) 12. 1 In addition to clinical and patient-reported outcomes, musculoskeletal ultrasonography (US) is an increasingly important tool for assessing pt disease activity. Objectives To assess the impact of CZP treatment on clinical, patient-reported and US outcomes, and to assess the ability of early treatment response to predict long-term outcomes in Italian pts with RA. Methods CZP-SPEED (NCT01443364) was a 52-wk, open-label, prospective, interventional, multicenter study. Pts were biologic-naive, had active RA (≥6 swollen and ≥6 tender joints), and had failed treatment with ≥1 DMARD. All pts received CZP (400mg at Wks 0, 2 and 4, followed by 200mg every 2 wks). Positive predictive value was defined as the percentage of pts with clinical response (reduction from baseline in DAS28(ESR)≥1.2) at an early time point who also had clinical response at Wk52. Early time points were Wks 1, 2, 4, 6, 8 and 12. Clinical and patient-reported outcomes were DAS28(ESR), ACR20/50/70, HAQ-DI, Pain (VAS) and PtGADA. US was assessed using the composite power Doppler/US (PDUS) score, defined as the sum of synovial fluid and proliferation, Doppler signal/blood flow, cartilage damage and bone erosion scores. US operation parameters were harmonized across all study sites. Data are reported descriptively with NRI imputation for dichotomous data and LOCF for continuous data. Results 132 pts were enrolled and received CZP (safety set; SS), of whom 131 (99%) provided ≥1 baseline and ≥1 post-baseline DAS28(ESR) assessment (full analysis set; FAS), and 91 (69%) completed to Wk52. Pts had a mean age of 54.8, 82% were female, and disease duration was relatively short (median 1.8 years). Between 64–70% of pts who responded at Wk 2, 4, 6, 8, or 12 maintained response at Wk52 (Figure). Rapid improvements in clinical and US outcomes were observed at Wk8 and were maintained to Wk52 (Table). There were 301 adverse events (AEs) in 94 pts (71.2%) and 25 serious AEs in 16 pts (12.1%). No deaths or cases of tuberculosis were observed. No new safety signals were observed for CZP. Conclusions In Italian RA pts treated with CZP, clinical response up to Wk12 was predictive of long-term response at Wk52. In addition to the rapid and sustained clinical improvements observed in this cohort, this is the first report of the maintenance of US improvements over 52 wks in CZP-treated pts. Coupled with the clinical predictability data, US evaluation may allow rheumatologists to make decisions earlier in the treatment journey. References Curtis J. Arthritis Care Res 2012;64:658–67 Acknowledgement The authors acknowledge Costello Medical Consulting, funded by UCB Pharma, for writing and editorial assistance. Disclosure of Interest P. Sarzi-Puttini: None declared, E. Filippucci Consultant for: UCB Pharma S.A., Bristol Myers Squibb, Merck Sharp & Dohme, AbbVie S.R.L. Italy, Roche, Pfizer, S. Adami: None declared, P. L. Meroni: None declared, P. Talavera Employee of: UCB Pharma, T. Kumke Employee of: UCB Pharma, W. Grassi Consultant for: UCB Pharma S.A., Bristol Myers Squibb, Merck Sharp & Dohme, AbbVie S.R.L, Pfizer

Background The serum anti-phospholipid antibody (aPLs) prevalence in the general population and the association with cardiovascular disease and risk factors remain unclear. Objectives To test serum samples from a population study for aPLs and determine the presence of cardiovascular and metabolic comorbidities in a Northern Italian city. Methods We performed a cross-sectional study on 1712 adult subjects (median age 47 year-old, interquartile range 37–61, 49.8% women), randomly enrolled in 2010 from the voting lists of a 32.000-population city in the Lombardia region. All subjects completed a questionnaire for medical history and ongoing/past medications and underwent physical examination and abdomen and carotid ultrasound. Anti-cardiolipin (aCL), anti-beta2 glycoprotein I (aGPI), anti-phosphatidylserine-prothrombin (aSP) IgG, IgM, and IgA antibodies were tested in all subjects by ELISA. Results At least one aPL was positive in 258 (15.1%), at high titer in 56 (3.3%) subjects; 35 (2%) were positive for two or more aPL, 15 (0.9%) at high titer. Serum aCL were positive in 26 (1.5%) subjects, at high titer in 17 (1%), without additional aPL in 2; IgG in 15 (0.9%; at high titer in 11), IgM in 18 (1.1%, at high titer in 10), IgA at high titer in 4 (0.2%). Serum aGPI were positive in 73 (4.3%) subjects, at high titer in 48 (2.8%), without additional aPL in 4; IgG in 20 (1.2%; at high titer in 3), IgM in 28 (1.6%, at high titer in 6), IgA in 35 (2%, at high titer in 12). Serum aSP were positive in 201 (11.7%) subjects, at high titer in 29 (1.7%), without additional aPL in 167; IgG in 157 (9.2%, at high titer in 19), IgM in 65 (3.8%, at high titer in 12). Women represented 53.1% of aPL positive subjects, with higher incidence for aGPI, especially IgA, and aSP. Among aPL positive subjects, there were 10 cases of acute myocardial infarction, 7 strokes, 17 peripheral arteriopathy and 22 increased intimal-medial-thickness. Positivity for aPL was associated with older age, particularly for aGPI and aSP, while high-titer aCL IgG and aSP IgG were associated with tobacco smoking. Hypertension and hypercholesterolemia were significantly associated to aGPI IgG and IgM positivity, respectively. Hyperhomocystinemia was significantly associated with high titer multiple aPLs. Hyperuricemia was associated with aSP IgG positivity. Subjects with positive aPL had significantly higher frequency of thyroid disease (p=0.02 for high titer), peripheral arteriopathy (crude odds ratio –OR- 2; 95% confidence interval –CI- 1.2–3.6; isolated aCL crude OR 25.1; 95% CI 1.6–405.4), myocardial infarction (isolated aCL crude OR 28.5; 95%CI 1.8–460.5). Importantly, adjusted ORs for cardiovascular risk factors were not statistically significant. Conclusions We confirm that serum aPL are common in the general population, particularly at older age and possibly in association with smoking. Serum aPL is associated with common cardiovascular risk factors and specific events, however this latter effect needs to be clarified in the follow-up study to determine the real impact of aPL on the risk of cardiovascular events. Disclosure of Interest None declared

Background PTX3, an important component of the innate immune system,has been proposed as a useful biomarker of inflammation and cardiovascular (CV) risk, but its role in inflammatory rheumatic diseases (IRDs) is still uncertain [1,2]. Objectives The aim of this study was to examine if methotrexate (MTX) and/or anti-tumor necrosis factor treatment (anti-TNF) treatment reduced serum PTX3 (s-PTX3) levels in IRDs (RA, PsA and AS), and if s-PTX3 levels were related to other markers of inflammation and to endothelial function (EF). Methods From the biobank of PSARA, an observational study, we examined samples from 114 IRD patients starting with either MTX or anti-TNF with or without MTX (anti-TNF±MTX) due to active disease, who completed a 6 months follow up. s-PTX3 (enzyme-linked immunosorbent assay), EF (finger plethysmography) and established inflammatory biomarkers were evaluated at baseline and after 6 weeks and 6 months of therapy. Results The s-PTX3 levels in IRD and all the diagnostic subgroups were above the upper limit of the reference range. In contrast to established inflammatory markers, in particular C- reactive protein (CRP) and erythrocyte sedimentation rate (ESR) (all p-values 0.2). The effect of MTX monotherapy and anti-TNF±MTX on s-PTX3 levels was similar. Changes in CRP, ESR and EF were not related to changes in s-PTX3 levels neither in univariate analyses nor in analyses adjusted for potential confounders. Conclusions IRD patients have increased s-PTX3 levels, which, in contrast to other inflammatory markers, do not seem to improve within 6 months of therapy with MTX and/or anti-TNF. Thus, in theory, s-PTX3 might reflect a persisting immune process, even a causal factor of the inflammation, not inhibited by the standard anti-rheumatic treatment. Furthermore, even though PTX3 is thought to be a strong predictor of CV prognosis, it was not related to EF. References Bottazzi, B., et al., An integrated view of humoral innate immunity: pentraxins as a paradigm. Annu.Rev.Immunol., 2010. 28: p. 157–183. Jylhava, J., et al., Pentraxin 3 (PTX3) is associated with cardiovascular risk factors: the Health 2000 Survey. Clinical and Experimental Immunology, 2011. 164(2): p. 211–217. Disclosure of Interest None declared

Background The role of methotrexate (MTX) in association with TNF inhibitors (TNFi) for the treatment of rheumatoid arthritis (RA) is well defined, although the optimal MTX dose is still unclear. Recently the CONCERTO randomized controlled trial demonstrated efficacy and safety of ascending MTX doses in combination with adalimumab (ADA) for the treatment of MTX-naive RA [1], but observational data from real-life registries are still lacking. Objectives The aim of our study is to retrospectively evaluate the effect of different MTX regimen as combination therapy with 1st line ADA and etanercept (ETN) on 6- and 12-month clinical response and safety profile in RA patients. Methods We selected all RA patients treated with ADA or ETN as 1st line biotherapy in our Rheumatology Department from January 2000 to October 2015. The analysis was performed only on subjects with at least 1-year follow-up and the study population was stratified according to concomitant MTX regimen in 3 subgroups: TNFi as monotherapy (group 1), TNFi in association with low MTX dose (≤10 mg/week, group 2), and TNFi combined with high MTX dose (≥12.5 mg/week, group 3). Six- and 12-month clinical response was evaluated as mean change from baseline of disease activity score 28 (DAS28) and as DAS28 remission/low disease activity (LDA) rates, comparing the 3 subgroups by Kruskal-Wallis and Dunn tests. Results The study population included 322 RA patients (265 [82.3%] female, mean age [± standard deviation] 55.4 [±12.8] years, disease duration 11.4 [±9.4] years, positive rheumatoid factor 248 [77%], mean baseline DAS28 5.39 [±1.18]) treated with ADA (n=166) or ETN (n=156). According to concomitant MTX regimen, 108 patients were assigned to subgroup 1, 110 to subgroup 2, and 104 to subgroup 3. No significant differences were found in baseline characteristics among the 3 subgroups. The mean change from baseline of DAS28 was significantly higher in subgroup 3 compared with subgroup 1 and 2 at both 6 (2.14, 1.2, and 1.44, respectively; p Conclusions Our retrospective analysis demonstrated that in a real life setting the 6- and 12-month clinical response of ADA and ETN was significantly improved by combination strategy only when MTX has been used at high doses (≥12.5 mg/week). Interestingly, increasing MTX dose was also associated with a more favorable safety profile. References Burmester GR, Kivitz AJ, Kupper H, et al. Efficacy and safety of ascending methotrexate dose in combination with adalimumab: the randomized CONCERTO trial. Ann Rheum Dis 2015;74(6):1037–44. Disclosure of Interest None declared