Plenary I presents five of the top abstracts submitted for this year’s Annual Meeting. From the latest in B cell biology and targets to a reliable shortcut to identify fibromyalgia in routine care, five of the top ACR abstracts for 2018 will be presented on Sunday from 11:00 am – 12:30 pm in Room W375c.
Identifying Individuals with High Risk for Imminent Onset of Rheumatoid Arthritis
One of rheumatoid arthritis’ longstanding conundrums has been identifying patients who are at highest risk for progression from autoantibodies and arthralgias without clinically evident synovial inflammation to active RA. New research from the Netherlands found that patients with five or more dominant-B cell receptor (BCR) clones in peripheral blood are more likely to progress to active disease.
Niek de Vries, MD, PhD, Professor of Rheumatology at the Academisch Medisch Centrum Universiteit van Amsterdam, the Netherlands will discuss findings showing that a higher number of BCR clones is associated with a higher risk of progressing to active disease. Having nine or more BCR clones yields a positive predictive value of 90 percent for developing active RA within three years. Dr. de Vries said the data support therapeutic intervention in this high-risk group.
Genetic Risk Score Prediction in Ankylosing Spondylitis
Ankylosing spondylitis (AS) poses a similar conundrum. There is a significant delay between the onset of AS symptoms and diagnosis. And there is increasing evidence that early intervention can lead to improved long-term management.
“We need to develop a discriminatory tool for the early diagnosis of AS,” said Zhixiu Li, PhD, Research Fellow in Bioinformatics at the Queensland University of Technology in Brisbane, Australia. “The average lag between first symptoms and diagnosis is eight to ten years. A tool that can accurately tell who actually has AS is an opportunity for early intervention to provide better outcomes for patients.”
Existing genetic risk scores based on genome-wide significant single nucleotide polymorphisms (SNPs) have limited discriminatory potential, Dr. Li said. Polygenic risk scores based on hundreds to thousands of SNPs could provide better discrimination and accuracy in AS risk prediction.
Researchers developed two polygenic genetic risk scores (GRS) for AS, one based on samples from European descent and a second based on East Asian samples. The European GRS used nearly 4,000 SNPs, and the East Asian GRS used about 8,700 SNPs.
In the European cohort, the area under the curve (AUC) was 0.92 with 83 percent sensitivity and 92 percent specificity. In the East Asian cohort, AUC was 0.95 with 91 percent sensitivity and 95 percent specificity. The AUC performance is at least as good as the current gold standard MRI screen.
“Given that the cost of a SNP microarray is less than $50 U.S.,” Dr. Li said, “this test is potentially far cheaper than MRI and at similar cost as traditional HLA-B27 testing. This test can tell you that even if you don’t have AS at the moment, you have a very strong potential to develop it later, and we can think about early treatment.”
Efficacy of High-Dose Versus Standard-Dose Influenza in Seropositive Rheumatoid Arthritis Patients
In the first study directly comparing standard influenza vaccine to high-dose vaccine in RA patients, the high-dose trivalent inactivated influenza vaccine (HD-TIV) substantially improves the immune response to vaccination compared to standard dose. The abstract will be presented by Ines Colmegna, MD, Associate Professor of Rheumatology at McGill University, Montreal, Canada.
RA patients have a 2.75-fold increased risk for influenza and related diseases compared to age-matched healthy controls, Dr. Colmegna noted, making RA patients a priority group for annual vaccination. The problem is that vaccine antibody response and protection are low in RA. Her group found that RA patients who received HD-TIV were more than twice as likely to seroconvert compared to patients who received standard dose influenza vaccine.
Efficacy and Safety of Combined Immunosuppressive Therapy with High-Dose Glucocorticoid, Tacrolimus, and Cyclophosphamide in Interstitial Lung Disease Accompanied By Anti-MDA5-Positive Dermatomyositis — a Multicenter Prospective Study
Patients with idiopathic inflammatory myopathy who have interstitial lung disease (ILD) and anti-melanoma differentiation-associated gene 5 (MDA5) positive dermatomyositis can benefit from an intensive immunosuppressive regimen of high-dose glucocorticoids, tacrolimus, and cyclophosphamide. These patients have a poor prognosis on conventional therapy because of rapidly progressive ILD.
Case reports have suggested possible efficacy from combined immunosuppression, said Hideaki Tsuji, MD, Department of Rheumatology and Clinical Immunology, Kyoto University Graduate school of Medicine, Kyoto, Japan. Those reports prompted the first-ever prospective clinical trial using this triple therapy. Patients receiving the intensive treatment were significantly more likely to survive compared to historical controls.
“It is important to screen for anti-MDA5 when clinicians encounter dermatomyositis and interstitial lung disease,” Dr. Tsuji said. “For anti-MDA5 positive patients, it is vital to start with combined immunosuppressive treatment of high-dose glucocorticoids, tacrolimus and cyclophosphamide as soon as possible even if the interstitial lung disease seems to be only a minor lesion.”
Fibromyalgia Is Identified in Routine Care on Indices Derived from an MDHAQ (MultiDimensional Health Assessment Questionnaire) with Robust Agreement with 2011 Revised Fibromyalgia Criteria Questionnaire
Fibromyalgia is common in rheumatology, but identifying it can be difficult when patients have concomitant rheumatic diseases. New research suggests the familiar MDHAQ (multi-dimensional health assessment questionnaire) used in multiple rheumatologic conditions can also be adapted to identify fibromyalgia, even in the presence of other rheumatic diseases.
Five MDHAQ scales showed high correlation with the 2011 fibromyalgia questionnaire, said Juan Schmukler, MD, now staff rheumatologist at Mount Sinai Hospital in Chicago.
The MDHAQ symptom checklist, self-report painful joint count, fatigue, RAPID3, and pain scale all demonstrated high agreement with the fibromyalgia questionnaire. The five scales were combined into five different indices. All of the indices showed greater than 84.3 percent correlation with the fibromyalgia criteria questionnaire.
“We don’t always know if our RA or lupus patients are having a flare or have developed fibromyalgia,” Dr. Schmukler said. “What we found is that you can use the MDHAQ to identify fibromyalgia just as well as the 2011 fibromyalgia criteria questionnaire. Using the MDHAQ for fibromyalgia is going to help you give better care for your patients.”