PLUS: four covid shots boosts immunogenicity in rituximab patients; upadacitinib success for nrAxSpA; ARDS risk calculator for RMD patients.
LLDAS is a useful tool in a real world treat to target setting, suggest authors reporting on the initial findings in a longitudinal study of SLE patients.
PLUS:
- Rituximab patients: if at first you don’t succeed, vaccinate, vaccinate again
- Early signs of success for upadacitinib in nrAxSpA
- Model helps predict ARDS in rheumatic disease patients with covid
LLDAS shows good agreement with physicians’ assessments
Spanish researchers have compared the definition of lupus low activity state (LLDAS) with physicians’ subjective evaluation of lupus activity and found “a fair correlation” between the two.
The prospective, longitudinal multicentre study included over 500 patients, with just over 300 in LLDAS and 430 classified as in remission or low activity by physicians at baseline. Overall agreement between the two was 71% (Cohen’s kappa 0.3). For patients in LLDAS, 96% were classified as remission or low activity by the physician, whereas for patients that did not fulfill LLDAS, 70% were classified by the physician as in remission or low disease activity.
The LLDAS definition has been associated with reduced flare rate and damage accrual, reduced mortality, better health-related quality of life, better pregnancy outcomes and reduced hospital costs, making it a useful tool in a real world treat-to-target setting, write the authors.
The study will continue over three years, with researchers investigating the impact of maintaining remission and low disease activity on different long-term outcomes including damage, hospitalisation and quality of life.
Rheumatology 2022, online 12 August
Rituximab patients: if at first you don’t succeed, vaccinate, vaccinate again
Giving rituximab patients a fourth covid vaccine helped improve immunogenicity in some of them, according to Austrian research published in the Annals of the Rheumatic Diseases. An open-label study examined 37 patients who had been on rituximab and had had three covid vaccine doses, and looked at the humoral and cellular immunogenicity from a fourth dose (booster with Pfizer or Moderna).
The number of patients with an antibody response went from 33% to 58%, and antibody titres increased across the cohort as well. Although most patients had a decline in T cell response 12 weeks after the third vaccination, many received a small boost in cellular immunity after the fourth vaccine.
Patients who had a rituximab dose between the third and fourth vaccination, however, mounted a less immunogenic response, further supporting considerations around timing booster doses before rituximab retreatment.
These findings further support the latest ACR covid vaccination guidelines which suggest clinicians should “discuss the optimal timing of dosing and vaccination with the rheumatology provider before proceeding”.
Patients receiving rituximab in Australia are eligible for five covid vaccine doses, and most local guidance allows them tixagevimab/cilgavimab (Evusheld, AstraZeneca) for pre-exposure prophylaxis to help compensate for poor vaccine response.
Ann Rheum Dis 2022, online 17 August
Early signs of success for upadacitinib in nrAxSpA
A phase 3 multicentre trial of JAK inhibitor upadacitinib found it significantly improved signs and symptoms of non-radiologic axial spondyloarthropathy, according to research published in the Lancet.
Upadacitinib has demonstrated efficacy in patients with ankylosing spondylitis and is listed on the PBS for that indication.
The study was part of the SELECT-AXIS 2 axial spondyloarthritis programme, and had sites in 23 countries, including Australia. Patients included 314 adults with active nrAxSpA who were randomised 1:1 to 15mg upadacitinib daily or matched placebo for 14 weeks. Primary endpoint was the proportion of patients with as ASAS40 response at week 14.
Significantly more patients in the upadacitinib group had an ASAS40 response at 14 weeks than the placebo group (45% vs 23%, p<0.0001). Patients in the upadacitinib group experienced clinically relevant and significant improvements in disease activity, pain, objective signs of inflammation and quality of life compared with placebo.
The rate of adverse events reported was similar in both groups, affecting almost half of the participants. Serious treatment-emergent adverse events affected four patients (of 156) in the upadacitinib group and two (of 157) in the placebo group.
There is an ongoing extension study to investigate long-term outcomes.
“The results from this phase 3 trial show that upadacitinib could be a safe and effective treatment option for patients with non-radiographic axial spondyloarthritis, who might prefer to use an oral therapy,” concluded the authors.
Model helps predict ARDS in rheumatic disease patients with covid
Researchers have used machine learning algorithms to develop a prediction model for acute respiratory distress syndrome (ARDS) in rheumatic disease patients with covid. The model was presented at ACR 2021 and published in ACR Open Rheumatology.
Using data from the COVID-19 Global Rheumatology Alliance (GRA) registry, 83 predictor variables related to demographics, disease diagnosis and activity, medications and comorbidities were crunched to identify the 10 most influential predictors. These factors predicted ARDS with over 70% sensitivity.
The predictors were higher average glucocorticoid dose, pulmonary hypertension, interstitial lung disease, chronic renal insufficiency or end-stage renal disease, using anti-CD20 antibodies, diabetes, hypertension, moderate-high disease activity and morbid obesity.
A points system was then assigned to the 10 variables to create a risk calculator that can be used in clinical settings.
A risk calculator to predict the risk of ARDS related to #COVID19 in patients with #rheumatic diseases
— Nelly ZIADE 🍀 (@Nellziade) November 4, 2021
🔴Age
🔴Comorbidities (PHT, ILD, CKD, obesity, DB, HTN)
🔴Medications (Rituximab, Prednisone)
🔴Rheumatic disease activity@rheum_covid @JYazdanyMD#ACR21 #ACRambassador pic.twitter.com/N2x0p7AEho
“Our study findings help identify patients with underlying rheumatic diseases who may be at a higher risk for ARDS from COVID-19. Use of baseline information at COVID-19 symptom onset or at COVID-19 exposure or diagnosis in asymptomatic patients facilitates early triage of high-risk patients for monitoring, prophylaxis, or treatment interventions,” wrote the authors.
