B cell pathway dual inhibition for systemic lupus erythematosus: a prospective single-arm cohort study of telitacicept.

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease associated with B-cell hyperactivity. Telitacicept is a transmembrane activator, calcium modulator, and cyclophilin ligand interactor-Fc fusion protein, which can neutralize both B-cell lymphocyte stimulator and a proliferation-inducing ligand. Patients with active SLE who received telitacicept were prospectively followed at month 1, 3, 6, 9, and 12 after telitacicept initiation. Thirty-seven participants were involved and followed for 6.00 [3.00, 6.00] months. SRI-4 rate at month 6 was 44.7%. The median dosage of prednisone was decreased by 43.8% (from 10 to 5.62 mg/d) at month 6. The anti-dsDNA level was significantly decreased, while complement levels were significantly increased at month 6 from baseline. Continuously significant reductions in serum immunoglobin (Ig)G IgA, and IgM levels were also observed. Patients experienced significant decreases in the numbers of total and naive B cells, whereas memory B cells and T cell populations did not change. The number of NK cells was significantly increased during the follow-up. At month 6, 58.3% (14 out of 24) patients experienced improved fatigue accessed by FACIT-Fatigue score exceeding the minimum clinically important difference of 4. Most adverse events were mild, but one each case of severe hypogammaglobulinemia, psychosis with suicidal behavior, and B-cell lymphoma were occurred. In our first prospective real-world study, telitacicept treatment led to a significant clinical and laboratory improvement of disease activity, as well as fatigue amelioration in patients with SLE. Safety profile was favorable overall, but more studies are greatly needed.

Real-World Clinical Equivalence of Generic and Branded Tofacitinib: A Prospective Longitudinal Cohort Study in Patients With Rheumatoid Arthritis.

OBJECTIVES: To explore the clinical efficacy and safety of generic tofacitinib vs brand name tofacitinib in patients with rheumatoid arthritis (RA) in a single-center comparative study based on a prospective real-world cohort. METHODS: Patients with RA receiving tofacitinib, either generic (Kelejia) or branded (Xeljanz), from March 2017, to December 31, 2022, were enrolled. The primary outcome was the simplified disease activity index (SDAI)-defined remission rate at month 6. Secondary outcomes included the rates of remission and low disease activity defined by other composite scores; European Alliance of Associations for Rheumatology response rate, and ultrasonic synovitis scores at months 1, 3, 6, and 12. Cost-effectiveness was investigated. Propensity score-based inverse probability of treatment weighting was adopted to reduce selection bias. RESULTS: A total of 204 patients were enrolled: 59 in the generic group and 145 in the branded group. An SDAI-defined remission was achieved in 41.1% and 39.2% of patients in the generic and branded groups, respectively, at month 6 (P=.85). Rates of remission and low disease activity achievement, changes in clinical disease activity scores, and power Doppler and gray scale synovitis scores at months 1, 3, 6, and 12 were comparable between the 2 groups. Similar proportions of patients in the groups achieved moderate/good response at months 1, 3, 6, and 12. Rates of drug retention and adverse effects were also similar in the 2 groups. Both Kelejia and Xeljanz were cost-effective, but Kelejia had a lower average cost-effectiveness ratio. CONCLUSION: Generic tofacitinib (Keljia) had equivalent clinical efficacy and safety and better cost-effectiveness compared with its originator (Xeljanz).

The Recent Outbreak of COVID-19 in China During the Omicron Variant Predominance: Clinical Features and Outcomes in Patients with Autoimmune Inflammatory Rheumatic Diseases.

INTRODUCTION: The impact of coronavirus disease 2019 (COVID-19) on vulnerable populations with autoimmune inflammatory rheumatic diseases (AIIRDs) has been variable with variants and of great concern. Here we report the clinical features, outcomes, and risk factors for infection and hospitalization in patients with AIIRDs in the first wave of infection in China in December 2022. METHODS: A real-world survey was conducted in Chinese patients with AIIRDs from 8 December 2022 to 13 January 2023. The survey was distributed via internet nationwide, clinic consultation, and to inpatients at a tertiary hospital in Beijing. Clinical features, outcomes, and vaccination status were collected. RESULTS: A total of 2005 patients with AIIRDs completed the survey. There were 1690 (84.3%) patients infected and only 48.2% of patients received COVID-19 vaccination. Most of the fully vaccinated patients received inactivated COVID-19 vaccines, including Sinovac (55.6%) and Sinopharm (27.2%), followed by recombinant subunit vaccine from Zhifei Longcom (2.0%). The independent protecting factors for infection were a time interval of less than 3 months from last vaccination (OR 0.53, p = 0.037) and rheumatoid arthritis (RA) as the underlying AIIRD (OR 0.62, p = 0.041). A total of 57 out of 1690 patients (3.4%) were hospitalized for COVID, with 46 (2.7%) experiencing severe/critical course and 6 deaths (0.4%). In multivariable logistic regression analysis, independent risk factors for hospitalization were age over 60 years (OR 11.52, p < 0.001), with comorbidity (OR 1.83, p = 0.045) and systemic lupus erythematosus (SLE) as the AIIRDs (OR 2.59, p = 0.036). Receiving booster vaccine was an independent protective factor for hospitalization (OR 0.53, 95% CI 0.30-0.98; p = 0.018). CONCLUSION: Hesitation for vaccination is common among Chinese patients with AIIRDs. The time from last vaccination of less than 3 months and having RA decreased the risk of COVID infection. Older age and having comorbidity or SLE increased the risk of hospitalization, while booster vaccination reduced the risk.

Presence of tophi and carotid plaque were risk factors of MACE in subclinical artherosclerosis patients with gout: a longitudinal cohort study.

Background: Patients with gout carry an excess risk for cardiovascular disease (CVD), but the contribution of subclinical atherosclerosis to the CVD risk has never been reported. In this study, we aimed to explore the predictive factors for incident major adverse cardiovascular events (MACE) in gout patients without a previous history of CVD or cerebral vascular disease. Methods: A single-center, long-term follow-up cohort analysis was performed to assess subclinical atherosclerosis at baseline since 2008. Patients with a previous history of CVD or cerebrovascular disease were excluded. The outcome of the study was the first MACE. The presence of subclinical atherosclerosis was assessed by carotid plaque (CP), and carotid intima-media thickness (CMIT) was determined by ultrasound. An ultrasound scan of bilateral feet and ankles was performed at baseline. The association between tophi, carotid atherosclerosis, and the risk of developing incident MACE was evaluated using Cox proportional hazards models with adjustment for the CVD risk scores. Results: A total of 240 consecutive patients with primary gout were recruited. Their mean age was 44.0 years, with male predominance (238, 99.2%). During a median follow-up of 10.3 years, incident MACE was ascertained in 28 (11.7%) patients. In a Cox hazards model, controlling for the CV risk scores, the presence of at least two tophi (HR, 2.12-5.25, p < 0.05) and carotid plaque (HR, 3.72-4.01, p < 0.05) were identified as independent predictors of incident MACE in gout patients. Conclusions: The presence of at least two tophi and carotid plaque on an ultrasound could independently predict MACE in addition to conventional cardiovascular risk factors in gout patients.

Association between triglyceride-glucose index and carotid atherosclerosis in patients with psoriatic arthritis.

OBJECTIVE: To investigate the association of the triglyceride-glucose (TyG) index with atherosclerotic risk among patients with PsA. METHODS: This cross-sectional study included 165 consecutive PsA patients receiving carotid ultrasonography with integrated TyG index, calculated as ln [fasting triglycerides (mg/dl) × fasting glucose (mg/dl)/2]. Logistic regression models were applied to analyse the association of TyG index as continuous variables and tertiles with carotid atherosclerosis and carotid artery plaque. Fully adjusted model included sex, age, smoking, BMI, comorbidities and psoriatic-related variables. RESULTS: Overall, PsA patients with carotid atherosclerosis had substantially higher TyG index than those without [8.82 (0.50) vs 8.54 (0.55), P = 0.002]. The frequency of carotid atherosclerosis was increased with increases in TyG index tertiles, showing 14.8%, 34.5%, 44.6% for tertile 1, 2 and 3, respectively (P = 0.003). Multivariate logistic analyses showed that each 1-unit increase in TyG index was significantly associated with prevalent carotid atherosclerosis [unadjusted odds ratio (OR) 2.65 (1.39-5.05); fully adjusted OR 2.69 (1.02-7.11)]. Compared with patients in tertile 1 of TyG index, the unadjusted and fully adjusted OR for occurrence of carotid atherosclerosis were 4.64 (1.85-11.60) and 5.10 (1.54-16.93) in patients in tertile 3. Similarly, higher prevalent carotid artery plaque was observed with increasing TyG index [unadjusted OR 3.11 (1.54-6.26); fully adjusted OR 3.61 (1.15-11.38)] or in tertile 3 vs tertile 1 [unadjusted OR 10.20 (2.83-36.82); fully adjusted OR 17.89 (2.88-111.11)]. Additionally, TyG index provided incremental predictive capacity beyond established risk factors, shown by an increase in discrimination ability (all P < 0.001). CONCLUSIONS: TyG index was positively correlated with the burden of atherosclerosis in PsA patients, independent of traditional cardiovascular risk factors and psoriatic-related factors. These findings suggest that TyG index may be a promising atherosclerotic marker for the PsA population.

Flare and change in disease activity among patients with stable rheumatoid arthritis following coronavirus disease 2019 vaccination: A prospective Chinese cohort study.

BACKGROUND: Vaccination has been shown effective in controlling the global coronavirus disease 2019 (COVID-19) pandemic and reducing severe cases. This study was to assess the flare and change in disease activity after COVID-19 vaccination in patients with stable rheumatoid arthritis (RA). METHODS: A prospective cohort of RA patients in remission or with low disease activity was divided into a vaccination group and a non-vaccination group based on their COVID-19 vaccination status. Each of them was examined every 3 to 6 months. In the vaccination group, disease activity was compared before and after vaccination. The rates of flare defined as disease activity scores based on 28-joint count (DAS28) >3.2 with ΔDAS28 ≥0.6 were compared between vaccination and non-vaccination groups. RESULTS: A total of 202 eligible RA patients were enrolled. Of these, 98 patients received no vaccine shot (non-vaccination group), and 104 patients received two doses of vaccine (vaccination group). The median time interval from pre-vaccination visit to the first immunization and from the second dose of vaccine to post-vaccination visit was 67 days and 83 days, respectively. The disease activity scores at pre-vaccination and post-vaccination visits in the vaccination group patients were similar. At enrollment, gender, RA disease course, seropositivity, and disease activity were comparable across the two groups. Flare was observed in five (4.8%) of the vaccination group patients and nine (9.2%) of the non-vaccination group patients at post-vaccination assessment ( P  = 0.221). In terms of safety, 29 (27.9%) patients experienced adverse events (AEs) after vaccination. No serious AEs occurred. CONCLUSIONS: COVID-19 vaccinations had no significant effect on disease activity or risk of flare in RA patients in remission or with low disease activity. Patients with stable RA should be encouraged to receive the COVID-19 vaccination.

Discrepancy in Metabolic Syndrome between Psoriatic Arthritis and Rheumatoid Arthritis: a Direct Comparison of Two Cohorts in One Center.

OBJECTIVE: We aimed to investigate the discrepancy in metabolic syndrome (MS) and cardiovascular disease (CVD) between patients with psoriatic arthritis (PsA) and those with rheumatoid arthritis (RA). METHODS: Patients with PsA and RA were enrolled between 1 December 2018 and 31 December 2021. Data on their demographics, height, weight, waist circumference, clinical and laboratory data, and comorbidities were collected. Disease activities of patients with RA and PsA were assessed. Prevalence was estimated by dividing cases (such as MS and CVD) of PsA and RA individually. Propensity score matching and inverse probability of treatment weighting were used for further validation. RESULTS: Consecutively, 197 patients with PsA and 279 patients with RA were enrolled in this study. Both MS [36.0% versus 23.3%, p = 0.002, OR 1.54 (1.16, 2.05)] and CVD [6.6% versus 1.1%, p = 0.001, OR 6.13 (1.77, 21.25)] were more frequently observed in patients with PsA compared with patients with RA. The frequency of abdominal obesity was also higher in patients with PsA [61.9% versus 33.0%, OR 1.87 (1.53, 2.29), p < 0.001]. After 1:1 propensity score matching for age, sex, smoking history, serum lipids, and disease activity, MS remained more common in 117 patients with PsA than in 117 patients with RA (37.6% versus 23.1%, p = 0.016) These findings remained after the inverse probability of treatment weighting in 196 patients with PsA and 288 patients with RA. A positive linear relationship between MS with disease activity was found in patients with PsA, but not in patients with RA. CONCLUSION: Considerable discrepancies in MS and CVD were observed between patients with PsA and those with RA. The greater odds of MS and CVD emphasize the need to pay more attention to metabolic and cardiovascular conditions in patients with PsA.

Improved diagnostic performance of CASPAR criteria with integration of ultrasound.

Background: The difficulty in determining synovitis, tenosynovitis, or enthesitis by physical examination (PE) has limited the diagnostic capability of CASPAR for psoriatic arthritis (PsA). Therefore, we aimed to evaluate the diagnostic utility of CASPAR with the integration of ultrasound (US). Methods: Patients with a hint of PsA were enrolled. Besides routine PE for tender or swollen joints, enthesitis, and dactylitis, US was performed to evaluate peripheral joints, entheses, and tendons. The additional value of the US to the CASPAR criteria was analyzed. Results: A total of 326 consecutive patients with 164 PsA and 162 non-PsA were enrolled. A total of 162 non-PsA patients consisted of 58 cases of psoriasis (PsO), 27 osteoarthritis with PsO/family history of PsO, five fibromyalgia with PsO, 69 sero-negative rheumatoid arthritis, and three undifferentiated arthritis. Significantly higher frequencies of tenosynovitis and enthesitis on US and new bone formation on X-rays were found in PsA vs. non-PsA patients (59.1% vs. 13.0%; 63.4% vs. 14.2%; 62.2% vs. 8.0%, p <0.01 for all). Logistic regression analysis showed that dactylitis (OR = 12.0, p <0.01), family history of PsO/PsA (OR = 3.1, p <0.05), nail involvement (OR = 3.5, p = 0.01), new bone formation on X-ray (OR = 14.8, p <0.01), tenosynovitis on US (OR = 21.3, p <0.01), and enthesitis on US (OR = 21.7, p <0.01) were independent risk factors for PsA. By combining US tenosynovitis and/or enthesitis, the diagnostic utility of CASPAR criteria was improved, with superior specificity (91.4% vs. 84.0%) and similar sensitivity (95.7% vs. 94.5%). Replacing X-ray by US or adding US, the CASPAR criteria showed comparable sensitivity and specificity for PsA diagnosis. The diagnostic accuracy was 89.3% for CASPAR criteria based on PE, 93.6% for CASPAR added with US, and 93.3% for CASPAR with US replacing X-ray. Conclusion: The diagnostic utility of the CASPAR was improved by integrating tenosynovitis and/or enthesitis when using US. US provides additional value for PsA recognition.

The correlation of ultrasound-detected synovitis in an individual small joint with overall clinical disease activity in patients with rheumatoid arthritis.

OBJECTIVES: To explore the correlation between the ultrasound-detected synovitis in each individual joint at metacarpophalangeal (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) regions and the clinical disease activity in patients with rheumatoid arthritis (RA). METHODS: Clinical disease activity was assessed by disease activity score (DAS) based on 28-joint count and erythrocyte sedimentation rate (DAS28-ESR), C-reactive protein (DAS28-CRP), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI). Gray scale (GS) and power Doppler (PD) synovitis was assessed by ultrasound semi-quantitatively. The correlation between clinical disease activity indices and synovitis score in each joint was assessed using Spearman's rank correlation test. RESULTS: 211 RA patients were included in this study. The whole GS scores of all MCP joints showed the highest correlation with each Clinical Disease Activity Index (r = 0.403-0.452, p < 0.01). Likewise, the whole PD scores of all MCP joints also showed the highest correlation with clinical disease activity (r = 0.332-0.396, p < 0.01). At individual joint level, the highest correlation of GS score with DAS28-ESR (r = 0.411, p < 0.01), DAS28-CRP (r = 0.459, p < 0.01), and SDAI (r = 0.444, p < 0.01) was observed in MCP3 joint while with CDAI (r = 0.421, p < 0.01) in MCP2 joint. The highest correlation of PD score with DAS28-ESR (r = 0.353, p < 0.01), DAS28-CRP (r = 0.399, p < 0.01), CDAI (r = 0.368, p < 0.01), and SDAI (r = 0.377, p < 0.01) was observed in MCP5 joint. CONCLUSIONS: The ultrasound-detected synovitis at MCP joints, especially MCP2, MCP3, and MCP5 joints, was best correlated with clinical disease activity in most RA cases, in contrast to PIP and MTP joints. Key Points • The correlation of ultrasound-detected synovitis in each individual joint with the clinical disease activity in RA patients is diverse among joint regions. MCP joints showed the best, in contrast to PIP and MTP joints.

Low-dose glucocorticoids withdrawn in systemic lupus erythematosus: a desirable and attainable goal.

OBJECTIVES: To assess the risk of flare in systemic lupus erythematosus (SLE) patients after low-dose glucocorticoid (GC) discontinuation and to evaluate the risk factors of flare. METHODS: SLE patients who ever discontinued GCs were identified from the Peking University First Hospital SLE cohort. The disease flare profile after GC discontinuation was analysed. The flare rate was analysed using Kaplan-Meier analysis. Cox regression was used to determine the effects of variables on SLE flare. A prognostic nomogram using Cox proportional hazards regression modelling was developed. RESULTS: A total of 132 SLE patients were eligible for the final analysis. They were followed up for a median of 21.8 months (interquartile range 9.01-36.7). The cumulative probability of flare after GC discontinuation was 8.3% at 6 months, 16.8% at 1 years and 27.5% at 2 years. In multivariate Cox analysis, hypocomplementemia and serologically active clinically quiescent (SACQ) were independent risk factors of flare [hazard ratio (HR0 2.53 (95% CI 1.32, 4.88); HR 3.17 (95% CI 1.44, 6.97), respectively]. Age ≥40 years at GC withdrawal and hydroxychloroquine (HCQ) usage were independent protective factors of flare [HR 0.53 (95% CI 0.29, 0.99); HR 0.32 (95% CI 0.17, 0.62), respectively]. The protective effect of HCQ was dosage related. From the perspective of different tapering strategies embodied as the duration from prednisone 5 mg/day to complete discontinuation, a slower tapering strategy (12-24 months) significantly reduced the risk of flare compared with a faster tapering strategy (<3 months) [HR 0.30 (95% CI 0.11, 0.82), P = 0.019]. The prognostic nomogram including the aforementioned factors effectively predicted the 1 and 2 year probability of being flare-free. CONCLUSION: Low-dose GC is feasibly discontinued in real-life settings. SACQ and younger age are potential risk factors of SLE flare, while HCQ use and slow GC tapering to withdrawal can reduce relapse. The visualized model we developed may help to predict the risk of flare among SLE patients who discontinued GC.

The performance of the diagnostic scoring system or criteria for macrophage activation syndrome in systemic juvenile idiopathic arthritis for adult-onset Still's disease. A multicentre case-control study in China.

OBJECTIVES: To evaluate the performance of the diagnostic scoring system/criteria for macrophage activation syndrome (MAS) used in systemic juvenile idiopathic arthritis (sJIA) for adult-onset Still's disease (AOSD). METHODS: This retrospective case-control study included AOSD patients with and without MAS from six hospitals in China. The cut-off values that best discriminated MAS from active AOSD were determined by receiver operating characteristic (ROC) curve analysis. The performance of the present diagnostic scoring system/criteria for sJIA-MAS was evaluated in AOSD-associated MAS. The optimal critical value of the ROC curve replaces the relevant indicators of the existing scoring system and different models were tested for sensitivity/specificity. RESULTS: A total of 56 AOSD-associated MAS patients (AOSD-MAS) and 112 AOSD patients without MAS matched with age and sex treated at six centres between 2007 and 2017 were enrolled. The 2016 MAS in sJIA classification criteria had an overall sensitivity of 100.0% and specificity of 80.4% for classifying AOSD-MAS. Excluding hypertriglyceridemia and substituting some other criteria with newly obtained cut-off values could increase specificity. An MS score ≥-2.1 yielded a sensitivity of 95.2% and a specificity of 76.6% in classifying AOSD-MAS. ROC curve analysis revealed that a score of -1.74 could best discriminate AOSD-MAS from AOSD without MAS. An MS score ≥-1.74 yielded a sensitivity of 93.5% and a specificity of 92.6% in diagnosing AOSD-MAS (AUC=0.96, 95%CI: 0.93-0.99, p<0.0001). CONCLUSIONS: The diagnostic tool for MAS in sJIA with modification appears to apply to AOSD-MAS.

Risk factors associated with osteoporosis and fracture in psoriatic arthritis.

BACKGROUND: Although there are few studies mentioned there may be some relationship between psoriatic arthritis (PsA) and osteoporosis, clinical data in real world still need to be clarified in China. The aim of this study was to assess the areal and volumetric bone mineral density (BMD), frequency of fracture, and risk factors in patients with PsA. METHODS: A total of one hundred PsA patients who visited Peking University First Hospital and one hundred age- and sex-matched healthy controls with DXA data were enrolled in the study. Patients with clinical fractures confirmed by X-ray during follow-up were also recorded. Clinical characteristics of the patients were recorded and compared between the abnormal BMD group and the normal BMD group, as well as between the fracture and non-fracture groups. Risk factors for fracture and low BMD were analyzed. RESULTS: Mean BMD at the total hip and femoral neck was significantly lower in PsA patients than that in healthy controls (0.809 ±â€Š0.193 vs. 0.901 ±â€Š0.152 g/cm2, P  = 0.041; 0.780 ±â€Š0.146 vs. 0.865 ±â€Š0.166 g/cm2, P  = 0.037, respectively). Moreover, lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count and DAS28-CRP (r = -0.503, -0.580, -0.438; P < 0.05). Total hip BMD and femoral neck BMD were negatively correlated with HAQ (r = -0.521, -0.335; P < 0.05). Fractures occurred in 29 patients during the follow-up period. Logistic regression analysis showed that older age (OR 1.132 [95%CI: 1.026-1.248), P < 0.05], higher HAQ score (OR 1.493, 95%CI: 1.214-1.836, P < 0.01), higher disease activity index for psoriatic arthritis (OR 1.033, 95% CI: 1.002-1.679, P < 0.05) and hip joint involvement (OR 6.401, 95% CI: 4.012-44.180, P < 0.05) were risk factors for fracture in the multivariate model. CONCLUSIONS: Increased risks of osteoporosis and fracture were found in PsA patients compared to healthy controls. Besides age, high disease activity and hip joint involvement were risk factors for decreased BMD and fracture.

Clinical Characteristics of Psoriatic Arthritis in Chinese Patients: A Cross-Sectional Study.

INTRODUCTION: The clinical features of psoriatic arthritis (PsA) varied in different studies from different countries, nevertheless rarely reported from China. We aimed to show the portraits of Chinese PsA patients. METHODS: Demographics as well as clinical and laboratory data at the first visit of a PsA cohort were collected. Joints and entheses were further assessed by imaging techniques. The correlation between psoriasis severity index (PASI) and disease activity in PsA (DAPSA) was analyzed. The metabolic comorbidities were also explored among patients with different disease activity. RESULTS: Three hundred patients with definite PsA were enrolled in this study; 159 (53.0%) of them were male. Their median age was 39 (31, 51) years with disease duration of 3 (0.6, 7) years; 15.6% patients were HLA-B27-positive, and 37.8% patients reported a family history of psoriasis or PsA. Among 300 patients, psoriasis presented earlier than arthritis in most of them (214, 74.0%), while 48 (16.6%) patients presented with arthritis before psoriasis. Articular involvement was found in 293 (97.7%) patients. Polyarticular type was most common, with proximal interphalangeal as most frequently involved joints. Axial joint involvement was found in 45 (15.4%) patients. Dactylitis was observed in 94 (31.3%) patients, most often at the second, third, and fourth toes. Enthesitis was found in 18 (6.0%) patients by physical examination, however in 129/227 (56.8%) patients by ultrasound. The DAPSA score was correlated with PASI (r = 0.22, p = 0.021). A variety of comorbidities were more often observed in patients with moderate/high disease activity comparing with those in remission/low-disease activity, especially type 2 diabetes with statistically significant difference (19.1 vs. 4.1%, p = 0.023). However, further logistic regression analysis showed diabetes was not independently associated with moderate/high disease activity. The most frequently prescribed medication was methotrexate (101, 66.4%). Biological agents were applied in 25 (16.4%) patients. CONCLUSIONS: Polyarticular involvement was most common in Chinese PsA patients. Ultrasound dramatically increased the identification of peripheral enthesitis. Active PsA patients were more likely to have comorbidities.

Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020.

OBJECTIVE: To unravel the dynamical trajectory and features of glucocorticoids (GC) tapering and discontinuation in patients with rheumatoid arthritis (RA) commencing GC with concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). METHODS: We used data from longitudinal real-world Treat-to-TARget in RA cohort. Patients with RA who started GC and contaminant csDMARDs therapy were included. The changes in GC dose and disease activity were evaluated. GC discontinuation rate was analysed using Kaplan-Meier analysis. The relapse profile within 6 months after GC discontinuation was also analysed. RESULTS: A total of 207 patients with RA were included. During a median follow-up of 38.6 months, 124 patients discontinued GC. The median prednisolone dose of 10 (5-10) mg/day at initiation was reduced by 50% in the first 6 months and then more slowly, to zero by 48 months eventually. The cumulative probabilities of GC discontinuation were 9.7%, 26.6%, 48.0% and 58.6% at month 6, years 1, 2 and 3, with calculated median time to GC cessation of 27 months. In 110 DMARD-naïve patients, the corresponding cumulative probabilities of GC discontinuation were, respectively, 12.7%, 30.0%, 50.9% and 60.6%, with calculated median time to GC cessation of 24 months. Of the 124 patients who discontinued GC, adding other csDMARDs or concomitant csDMARDs increment was documented in 28.2% of them. Approximately half of 124 patients were in clinical remission at GC discontinuation. Within 6 months after GC withdrawal, 79.1% (91/115) of patients maintained relapse free. CONCLUSIONS: In patients with RA commencing GC besides csDMARDs, GC is feasibly discontinued with favourable control of disease activity in real-life setting, mostly without short-term flare. But the withdrawal time is far from reaching the recommended time frame, indicating the gap between real-world practice and current guidelines.

Treat-to-target strategies aiming at additional ultrasound remission is associated with better control of disease activity and less flare in rheumatoid arthritis.

INTRODUCTION: Treat-to-target (T2T) strategy has greatly improved the prognosis of rheumatoid arthritis (RA). However, the additional benefit of targeting ultrasound (US) remission in addition to clinical remission has been debated. METHODS: RA patients in clinical remission or low disease activity were enrolled. They were assorted into two groups according to the principle of T2T strategy adopted. In clinical group, treatment decision was made with the aim of maintaining DAS28(ESR) ≤ 3.2 only, while in clinical US group, the aim was to attain total power Doppler (PD) US score = 0 in addition to DAS28(ESR) ≤ 3.2. The time-averaged DAS28, flare, and changes of treatment strategy were compared. RESULTS: One hundred ninety-four patients completed 1-year follow-up, with 100 in clinical US and 94 in clinical group. Compared to clinical group, time-averaged DAS28 in clinical US group was significantly lower (1.89 ± 0.51 vs. 2.33 ± 0.71, P < 0.01) with less flare (20.0% vs. 36.2%, P < 0.05). Furthermore, at the end of 1 year, significantly more patients successfully achieved step-down therapy (66.0% vs. 44.7%, P < 0.01) and dramatically fewer patients with step-up therapy in the clinical US group (13.0% vs. 25.5%, P < 0.05) compared to clinical group. In clinical US group, baseline DAS28(ESR) > 2.29, presence of subclinical synovitis, and step-down strategy were independent risk factors for relapse after clinical remission or low disease activity was achieved. CONCLUSIONS: An US-driven T2T in addition to current clinical remission strategy is associated with better control of the disease activity, reduction of relapse, as well as long-term step-down therapy. Step-down strategy should be carefully applied to the patients with baseline DAS28(ESR) over 2.29 and presence of subclinical synovitis even after they have achieved clinical remission or low disease activity. Key Points • Targeting ultrasound remission in addition to current T2T strategy is associated with a better control of RA. • Step-down strategy should be cautiously considered in those with DAS28(ESR) > 2.29 and baseline subclinical synovitis after they have achieved clinical remission or low disease activity.

Modifiable lifestyle and environmental factors associated with onset of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational studies.

BACKGROUND: Psoriatic arthritis (PsA) is a progressive joint disease associated with psoriasis. OBJECTIVES: To investigate the association of modifiable lifestyle and environmental factors with PsA risk among people with psoriasis. METHODS: We conducted a systematic search of PubMed, Embase, and Cochrane Library through May 2, 2020, for observational studies reporting lifestyle or environmental factors for PsA onset in patients with psoriasis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were combined using a random-effects model. RESULTS: We included 16 studies comprising 322,967 individuals. Obesity and being overweight were associated with an increased PsA risk in patients with psoriasis (OR, 1.75 [95% CI, 1.42-2.16] and OR, 1.50 [95% CI, 1.08-2.09], respectively), with an increase of approximately 6% for each kg/m2 rise in body mass index (OR, 1.06; 95% CI, 1.03-1.10). The presence of PsA was associated with a history of physical trauma (OR, 1.33; 95% CI, 1.16-1.54) or fracture (OR, 1.46; 95% CI, 1.22-1.74). No significant associations were observed regarding alcohol consumption (OR, 0.99; 95% CI, 0.88-1.13), smoking (OR, 0.89; 95% CI, 0.75-1.06), female hormonal exposure (OR, 1.45; 95% CI, 0.95-2.20), and psychologically traumatic events. LIMITATIONS: Inherent limitations in the included observational studies. CONCLUSIONS: Several lifestyle and environmental factors are associated with PsA onset among patients with psoriasis. These findings indicate that such risk may be modified with lifestyle changes or avoidance of physical trauma in people with psoriasis.

Immune checkpoint inhibitors therapies in patients with cancer and preexisting autoimmune diseases: A meta-analysis of observational studies.

INTRODUCTION: Immune checkpoints inhibitors (ICIs) are associated with frequent immune-related adverse events (irAEs), but patients with preexisting autoimmune disease (PAD) have been excluded from clinical trials, leaving serious gaps in knowledge. OBJECTIVE: To evaluate the safety and efficacy of ICIs in PAD patients and cancer and explore the impact of different PAD types and baseline receiving immunosuppressive therapy. METHODS: Systematic searches were performed of PubMed, EMBASE, and the Cochrane library from inception through August 2019 for observational studies reporting safety and efficacy data among ICI-treated patients with cancer and PAD. RESULTS: 619 ICI-treated patients with PAD in 14 publications were finally identified. In the random-effects meta-analysis, pooled incidence of PAD flares, de novo immune-related adverse events (irAEs) or both of any grade was 60% (95%CI = 52%-68%). Separately, there were 219 and 206 patients experiencing PAD exacerbation and de novo irAEs of any grade, yielding a pooled incidence of 35% (95%CI = 29%-41%) and 33% (95%CI = 24%-42%) respectively. Rheumatoid arthritis was associated with a trend toward higher flare occurrence compared with another individual PADs (RR = 1.25-1.88). A total of 136 patients showed complete or partial response, corresponding to a pooled response rates of 30% (95%CI = 22%-39%). There were no statistical differences between patients with and without immunosuppressive therapy at ICI start regarding flare (RR = 1.08, 95%CI = 0.72-1.62), but a trend toward lower response rates was observed in patients with baseline immunosuppressants (RR = 0.58, 95%CI = 0.26-1.33). CONCLUSIONS: Immune toxicities are frequent in ICI-treated patients with PAD but often mild and manageable without discontinuing therapy. ICI treatment are also effective in PAD patients, but close monitoring and multidisciplinary collaboration should be contemplated, especially for those concomitantly receiving immunosuppressant or having rheumatoid arthritis.

Intensive therapy alleviates subclinical synovitis on ultrasound and disease activity and reduces flare in rheumatoid arthritis patients who have achieved clinical target - a randomized controlled trial.

OBJECTIVE: Whether intensive therapy can alleviate subclinical synovitis and reduce flare in rheumatoid arthritis (RA) patients in clinical remission remains unclear. We designed a 1-year open-labelled, randomized controlled clinical trial to elucidate this question. METHODS: RA patients in clinical remission/low disease activity (defined by DAS28-CRP≤ 3.2), however with subclinical synovitis on ultrasound [power Doppler (PD)≥1 and/or gray scale (GS)≥2] were randomized to receive maintenance or intensive treatment at a ratio of 1:1. The primary outcome was the rate of RA relapse (defined by DAS28-CRP>3.2 and an increase≥0.6). The secondary outcomes were changes of PD and GS scores, and clinical disease activity at each visit from baseline. RESULTS: 108 patients with 54 in each group were enrolled. During 1-year follow-up, the relapse rate was significantly higher in maintenance group than in intensive group, regardless of all enrolled patients or those in remission [24.1% (13/54) vs. 9.1% (5/54), p=0.039; 26.2% (11/42) vs. 5.3% (2/38), p=0.026, respectively]. Although GS and PD scores were decreased at 12 months in both groups, the decline was more remarkable in intensive group than in maintenance group. The improvement of clinical disease activity score was only observed in intensive group, not maintenance group. Adverse events were comparable between two groups. Abnormal liver function tests were observed in 24 (22%) patients with 16 from intensive group. CONCLUSION: Intensive therapy can alleviate subclinical synovitis on ultrasound and clinical disease activity, and prevent relapse in RA patients who have achieved clinical remission or low disease activity, with comparable safety profiles to maintenance therapy. REGISTRATION NUMBER: ChiCTR2000029279.

Salivary gland ultrasound integrated with 2016 ACR/EULAR classification criteria improves the diagnosis of primary Sjögren's syndrome.

OBJECTIVES: To evaluate the utility of salivary gland ultrasound (SGUS) in the diagnosis of primary Sjögren's syndrome (pSS) singly or integrated with 2016 ACR/EULAR classification criteria. METHODS: Patients with suspected pSS were enrolled in the study. SGUS semi-quantitative scoring was used to assess salivary gland. Clinical characteristics were recorded, including autoantibodies, ophthalmic tests, salivary glands scintigraphy (SGS) and labial biopsy. The diagnostic accuracy of SGUS score and complementary value of SGUS to 2016 ACR/EULAR criteria were analysed. RESULTS: 282 patients were included for analysis. 161 were diagnosed as pSS and 121 as non-SS. SGUS score≥5 showed 64.7% sensitivity and 81.4% specificity for the diagnosis of pSS. Positive anti-SSA, abnormal SGS and SGUS score were significantly higher in pSS than non-SS group (80.1% vs. 14.0%, p<0.01; 91.3% vs. 57.0%, p<0.01; 8.4±6.6 vs. 2.6±3.2, p<0.01 respectively). A weighted score [(anti-SSA×16.5) + (SGS×14.5) + (SGUS×4.5)] was constructed. The score ≥17.5 could improve the sensitivity, and almost keep the specificity comparing to 2016 ACR/EULAR criteria (89.9% vs. 85.6% and 79.5% vs. 82.2%). When replacing labial biopsy by SGUS in 2016 ACR/EULAR criteria, both sensitivity and specificity were a bit decreased (85.0% vs. 85.6% and 79.8% vs. 82.2%). When adding SGUS to 2016 ACR/EULAR criteria, it showed better performance by improving the sensitivity (90.8% vs. 85.6%), while not losing the specificity (83.7% vs. 82.2%). CONCLUSIONS: Adding SGUS score to the 2016 ACR/EULAR criteria can improve the diagnosis utility of pSS. SGUS may be a feasible and prospective tool in the diagnosis of pSS.