SHOULD COMPLETE B-CELL DEPLETION BE SUSTAINED IN RITUXIMAB LONG-TERM TREATED PATIENTS FOR RHEUMATOID ARTHRITIS?

BackgroundComplete peripheral B cell depletion has been considered as a relevant indicator of short-term response to rituximab (RTX) in rheumatoid arthritis (RA) [1,2]. However, no information is available to validate this observation in RA patients long-term treated with RTX.ObjectivesTo determine whether sustained complete B cell (BC) depletion is associated with a better clinical response in RA patients long-term treated with RTX.MethodsRetrospective routine care study conducted in the Rheumatology department of Cochin hospital. We included consecutive patients fulfilling the ACR/EULAR 2010 classification criteria for RA hospitalized in 2021 for a new RTX infusion. All recruited patients had received at least 3 prior RTX infusions and had disease activity assessment (DAS28 and DAS28-CRP) and CD19 counts (Aquios, Beckman Coulter) available during each of the 4 last infusion visits. The primary endpoint was the course of DAS28 and DAS28-CRP, calculated the day of the last 4 infusion visits according to sustained complete (mean CD19 counts <18/µL) or incomplete (mean CD19 counts ≥18/µL) BC depletion. Secondary endpoints were the frequency of end-of-dose effect and patient self-reported RA flares at each infusion visit, as well as the course of pain/fatigue VAS, CRP and gammaglobulin levels according to complete or incomplete B cell depletion.ResultsWe included 126 patients (105 women, 83%) with a mean age of 64±12 years and a mean disease duration of 22± 5 years. Only 43 patients (34%) had maintained complete BC depletion during the last 4 infusions (mean CD19 counts 13±4/µL) (Figure 1A-B). Patients with incomplete BC depletion (n=83, mean CD19 counts: 77±73/µL, p<0.001) did not differ from those who maintained complete BC depletion in terms of age, gender, disease duration, structural damages and concomitant treatment.Patients with incomplete BC depletion had a higher frequency of rheumatoid factor (92% vs. 77%, p=0.018) and ACPA (84% vs. 72%, p=0.11);these patients had received RTX for a longer period (99±57 months vs. 69±47 months, p=0.003), with significantly higher number of infusions (14±7 vs. 12±6 infusions, p=0.037) and increased cumulative dose (10±6 g vs. 8±5 g, p=0.10) compared to patients with sustained complete BC depletion. On the other hand, their interval between 2 infusions was significantly longer (8±3 months vs. 6±1 months, p<0.001).The course of DAS28 and DAS28-CRP during the last 4 infusions was not different between the 2 groups (Figures 1C-D). The mean DAS28 and DAS28-CRP calculated at the time of last 4 infusion visits did not differ between patients with incomplete or sustained complete BC depletion (DAS28: 2.71±1.06 vs. 3.01±1.10, p=0.33 and DAS28-CRP: 2.53±0.88 vs. 2.88±0.84, p=0.095). The frequency of an end-of-dose effect and self-reported flares was similar between the 2 groups, as well as the evaluation of pain VAS, asthenia VAS, CRP and gammaglobulin levels (Figures 1E-H).ConclusionMaintaining complete BC depletion is not a therapeutic target to achieve in RA patients in long-term maintenance therapy with RTX. These results show that it is possible to space out RTX infusions to 8 months without loss of clinical benefit, which remains identical to that of patients treated every 6 months with sustained BC depletion. This result may have clinical implications during the COVID-19 pandemic since the antibody response to SARS-CoV-2 vaccination is preferentially obtained in patients with detectable B cells [3].References[1]Vital EM et al. Arthritis Rheum 2011;63:603–8.[2]Dass S et al. Arthritis Rheum 2008;58(10):2993–2999.[3]Avouac et al, Rheumatology 2022Figure 1.Course of mean (±SD) CD19, DAS28, DAS28-CRP, pain and fatigue VAS, CRP and gammaglobulins at the last 4 RTX infusion visits according to sustained complete or incomplete B cell depletion (CBCD and IBCD respectively).[Figure omitted. See PDF]Acknowledgements:NIL.Disclosure of InterestsNone Declared.

La prophylaxie pré-exposition par tixagévimab/cilgavimab est efficace pour limiter le risque de contamination et la sévérité de la COVID-19 des patients atteints de maladies auto-immunes ou inflammatoires insuffisamment répondeurs à la vaccination

Introduction La combinaison d'anticorps monoclonaux tixagévimab/cilgavimab (EVUSHELD©) a reçu une autorisation d'accès précoce afin de réduire la fréquence d'infection COVID-19 symptomatique chez les patients immunodéprimés à très haut risque de forme sévère de COVID-19 non ou insuffisamment répondeurs à la vaccination. Notre objectif a été d'évaluer l'efficacité clinique de cette combinaison d'anticorps monoclonaux en prophylaxie pré-exposition chez les patients atteints de maladies auto-immunes ou inflammatoires pendant la vague Omicron en France. Patients et méthodes Étude observationnelle multicentrique réalisée entre 12/2021 et 07/2022. Inclusion de l'ensemble des patients atteints de maladies auto-immunes ou inflammatoires ayant reçu au moins une injection intramusculaire d'EVUSHELD© 150/150 mg ou 300/300 mg en prophylaxie-pré-exposition, avec comme indication une réponse déficiente à la vaccination et un très haut risque de forme sévère de COVID-19. Tous les patients ont été revus à 3 et/ou à 6 mois en consultation ou ont été contactés par téléphone pour connaître leur devenir. Le critère de jugement était l'incidence du COVID-19 pendant la période de suivi et sa sévérité, définie par la nécessité d'une hospitalisation (conventionnelle ou en réanimation) et/ou d'une oxygénothérapie, ainsi que la survenue d'un décès. Résultats L'EVUSHELD© a été administré à 124 patients, avec un âge médian de 60 ans (IC95 % 58–63 ans), principalement atteints de RIC (n = 57) de connectivite (n = 42) ou de vascularite (n = 13). Les principaux traitements reçus étaient le rituximab (RTX, n = 104), le méthotrexate (MTX, n = 48), le mycophénolate mofétil (MMF, n = 19), le cyclophosphamide (n = 15), l'azathioprine (n = 12) et les corticoïdes (n = 62, dose médiane 5 mg, IC95 % 5–12 mg). Quarante-trois patients ont reçu une injection IM d'EVUSHELD© 150/150 mg, 40 une de 300/300 mg et 41 deux injections : une première injection de 150/150 mg suivie d'une seconde à 150/150 mg (n = 13) ou à 300/300 mg (n = 28). Au cours d'un suivi médian de 117 jours (IC95 % 105–128 jours), une infection COVID-19 a été confirmée chez 23/124 patients (18,5 %). Le variant identifié était bien l'Omicron pour les 9 patients génotypés. Au cours de la période d'étude, l'incidence moyenne hebdomadaire était de 1073 pour 100 000 habitants en Île-de-France vs 618 pour 100 000 habitants pour les patients de notre série ayant reçu l'EVUSHELD©. Les patients ayant reçu un schéma à 2 injections avaient un risque plus faible d'infection que les patients ayant reçu un une seule injection (1/32, 3 % vs 22/92, 24 %, p = 0,009). Les 23 patients COVID-19+ ne différaient pas des 101 patients non infectés en termes d'âge, de type de maladie auto-immune ou inflammatoire, de durée d'évolution de la maladie, d'atteintes d'organe, de comorbidités et de traitements reçus. L'ensemble des infections COVID-19 ont été non sévères, aucun patient ayant eu recours à une hospitalisation ou à une oxygénothérapie. Aucun décès n'a été constaté. La tolérance des injections a été excellente. Conclusion Au sein d'une population à très haut risque de forme sévère de COVID-19 et présentant une réponse déficiente à la vaccination, l'Evusheld© utilisé en prophylaxie pré-exposition a permis de limiter la sévérité de l'infection. Ces résultats soutiennent l'efficacité de cette combinaison d'anticorps monoclonaux sur le variant Omicron et la pertinence de cette stratégie préventive. Il paraît important d'identifier les patients insuffisamment ou non répondeurs à la vaccination contre la COVID-19 afin de leur proposer ce traitement.

Proton pump inhibitors in systemic sclerosis: a reappraisal to optimise treatment of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is associated with substantial morbidity in patients with systemic sclerosis. Although the introduction of proton pump inhibitors (PPIs) into clinical care represents a major achievement in the management of gastro-oesophageal problems in systemic sclerosis, PPIs are seldom fully effective in patients with systemic sclerosis, and the use of maximum PPI doses is a very frequent clinical practice. However, there is little evidence to support the empirical use of PPIs in systemic sclerosis. This scarcity of evidence is especially relevant with regards to the safety concerns of long-term exposure, which have been raised in the general population. The purpose of this Viewpoint is to highlight the substantial beneficial impact of PPIs on GERD in patients with systemic sclerosis, while considering the potential adverse effects in this patient population. Furthermore, we highlight the unmet needs of people with systemic sclerosis and GERD and propose an agenda for future research to optimise the safe and effective use of PPIs in systemic sclerosis. Copyright © 2022 Elsevier Ltd

EVALUATION of PATIENTS with RHEUMATOID ARTHRITIS in TELECONSULTATION during the FIRST WAVE of the COVID-19 PANDEMIC

Background: The sudden emergence of SARS-CoV-2 onto the world stage has accelerated a major change in the management of patients with chronic rheumatic diseases and has catalyzed the rapid emergence of telemedicine. Objectives: Our aim was to describe which parameters were used by rheumatol-ogists to monitor patients with rheumatoid arthritis (RA) in teleconsultation during the frst wave of the pandemic and identify the most relevant for decision making. Methods: Retrospective monocentric routine care cross-sectional study including RA patients seen in teleconsultation between March and September 2020. Available parameters assessing disease status were collected in teleconsultation files. Clinician intervention was defned by treatment escalation and/or the need for a rapid face-to-face consultation or day hospitalization. Results: 143 RA patients were included (117 females, mean age of 58±16 years, mean disease duration of 14±11 years). The presence or absence of patient self-reported RA fares was mentioned in all medical files, followed by the presence and/or the number of tender joints (76%), the duration of morning stiffness (66%), the number of pain-related nocturnal awakenings (66%) and the CRP value (54%). Patient self-reported RA fares concerned 43/143 patients (30%). The presence of self-reported RA fares was associated with a more detailed evaluation of patient in teleconsultation: The presence (or number) of tender joints and swollen joints were more signifcantly reported in patients who presented a fare (39/43, 91% vs. 70/100, 70%, p=0.008 and 25/43, 58% vs. 23/100, 23%, p<0.001, respectively). Teleconsultation led to a clinician intervention in 22/143 patients (14%), representing 51% of patients with self-reported fares (22/43 patients). Therapeutic escalation was necessary in 13 patients: introduction or dose increase of cor-ticosteroids in 8 patients, introduction or dose increase of methotrexate in 4 patients and introduction of hydroxychloroquine in 1 patient. Face-to-face consultation or day hospitalization were organized for 10 patients. Active disease was confrmed during this next face-to-face visit in 9 patients, with DAS28 ranging from 3.35 to 5.62, leading to therapeutic modifcation. The 133 other patients were seen in face-to-face consultation 6±2 months after the teleconsultation. No DMARD modifcation was recorded during this next face-to-face consultation. The following variables were associated with clinician intervention during the tel-econsultation in univariate analysis: patient self-reported RA fares since the last visit (p<0.001), CRP >10 mg/mL (p=0.012) and a morning stiffness > 30 minutes (p<0.001). Multivariate analysis confrmed RA fares (Odds Ratio, OR: 15.6 95% CI 3.37-68.28) and CRP values >10 mg/L (OR: 3.32, 95% CI % 1.12-13.27) as the variables independently associated with clinician intervention. Conclusion: Our study identifed patient reported RA fares and increased CRP values as 2 red fags in teleconsultation, independently associated with therapeutic modifcation and/or the need for a rapid face-to-face consultation. These indicators may help clinician's decision making in teleconsultation.

INCREASED ANTIBODY RESPONSE after SARS-COV-2 MRNA-BASED VACCINATION in RITUXIMAB-TREATED PATIENTS with PREVIOUS COVID-19 INFECTION

Background: Rituximab (RTX) is associated with reduced humoral response to SARS-CoV-2 mRNA-based vaccine (1, 2). A recent study has shown that, despite their immunosuppression burden, kidney transplant recipients with previous exposure to SARS-CoV-2 showed a marked increase in antibody titer, even after a single dose of vaccine (3). Objectives: To describe the results of immunization after 1 to 3 doses of mRNA SARS-CoV-2 vaccine in RTX-treated patients with previous symptomatic COVID-19 infection. Methods: Observational prospective usual care study including consecutive patients with infammatory rheumatic diseases in maintenance therapy with RTX. All patients received a 1 to 3-dose regimen of mRNA-based COVID-19 vaccination (BNT162b2 Pfzer/BioNTech or mRNA-1273, Moderna). Serum IgG antibody levels against SARS-CoV-2 spike proteins were measured at the time of the new RTX infusion. The SARS-CoV-2 S1/S2 IgG immunoassay (DiaSorin) was used for the quantitative determination of antibodies to the receptor-binding domain of the viral spike (S) protein. Seropositivity was defned by anti-S antibodies >15 UA/mL. Results: We included 69 patients (60 females, mean age 60±13 years) on maintenance therapy with RTX including 13 with previous symptomatic COVID-19, all proven by RT-PCR (10 females, mean age 58±12 years) (Table 1). Sympto-maticCOVID-19 occurred between March 2020 and May 2021. The mean interval between the infection and vaccination was 8±3 months and the serological response was assessed after a mean of 74±58 days from the last dose of vaccination (3rd dose for 3 patients, 2nd dose for 6 patients and 1st dose for 4 patients). The 56 patients with no history of symptomatic COVID-19 infection all received 3 doses of vaccine and the serological response was assessed after a mean of 63±27 days from the 3rd dose of vaccination. The seropositivity rate was signifcantly higher in RTX-treated patients with previous symptomatic COVID-19 infection (11/13, 85% vs.15/56, 27%, p<0.001). Anti-S antibody titles were also markedly increased in patients with previous symptomatic COVID-19 infection (median 119 AU/mL, 95% CI 16-400 AU/mL vs. 3.80 AU/mL, 95% CI 3.80-4.81 AU/mL p<0.0001) (Figure 1). Antibody titles were not different according to the severity of previous COVID-19, the number of doses of vaccine, the underlying disease, and B-cell counts. Conclusion: RTX-treated patients with previous proven COVID-19 showed increased seropositivity and antibody titers after SARS-CoV-2 vaccination, even after a single-dose of vaccine. This response is strikingly different from that observed for SARS-CoV-2-naïve RTX treated patients who received 3 doses of SARS-CoV-2 mRNA-based vaccination. An 'antigen dose phenomenon' may account for these discrepancies. A potential clinical implication might be to increase antibody response with an additional dose of vaccine following an exposure to SARS-CoV-2 in RTX-treated patients with absent or insufficient postvaccination antibody response.

Évaluation des patients atteints de polyarthrite rhumatoïde en téléconsultation pendant la première vague de Covid-19

Introduction La pandémie de COVID-19 a catalysé l’émergence rapide de la télémédecine. Cet outil a été l’unique moyen de poursuivre l’activité de consultation pendant la première vague de la pandémie. Notre objectif a été de décrire sur quels paramètres les malades atteints de polyarthrite rhumatoïde (PR) vus en téléconsultation ont été évalués, et d’identifier les éléments sur lesquels les rhumatologues se sont appuyés pour prendre leur décision. Patients et méthodes Il s’agit d’une étude rétrospective monocentrique observationnelle. Nous avons inclus l’ensemble des patients atteints de PR, définie par le rhumatologue dans le « catalogue rhumatologique » du logiciel ORBIS, vus pour leur suivi entre mars et septembre 2020 en consultation téléphonique ou en téléconsultation réalisée à partir du système ORTIF. Les paramètres ayant permis l’évaluation du patient ont été recueillis dans le dossier médical. L’intervention du rhumatologue a été définie par une intensification thérapeutique et/ou une convocation pour une visite présentielle en consultation ou hospitalisation (de jour ou conventionnelle). Résultats 143 patients atteints de PR ont été inclus (117 femmes, 82 %) avec un âge moyen de 58±16 ans et une durée de la maladie de 14±11 ans. Les anti-CCP étaient positifs chez 104 patients (73 %), les facteurs rhumatoïdes chez 100 patients (70 %) et 75 patients présentaient des érosions (52 %). Sur le plan thérapeutique, 96 recevaient du méthotrexate (67 %), 67 une corticothérapie (47 %) et 69 un traitement biologique ou synthétique ciblé (48 %). La téléconsultation a eu lieu par téléphone pour 106 patients (74 %) et par visioconsultation pour 37 patients (26 %). La survenue de poussées de la maladie a été recherchée pour l’ensemble des patients et a été détectée chez 43 d’entre eux (30 %). Un seul patient avec poussée avait arrêté ses traitements par crainte de la pandémie. Les indices utilisés pour évaluer la PR ont été, par ordre décroissant : la présence et/ou le nombre d’articulations douloureuses (n=109, 76 %), la durée de la raideur matinale (n=95, 66 %), le nombre de réveils nocturnes (n=95, 66 %), la valeur de la CRP (n=77, 54 %), l’EVA globale évaluée par le patient (n=68, 48 %), la valeur de la vitesse de sédimentation (n=51, 36 %), la présence et/ou le nombre d’articulations gonflées (n=48, 33,5 %), le score DAS28 (VS ou CRP) (n=37, 26 %), l’EVA douleur (n=33, 23 %) et l’EVA Asthénie (n=24, 17 %). La téléconsultation a conduit à une intensification thérapeutique chez 13 patients (introduction ou augmentation de la corticothérapie chez 8 patients, introduction ou majoration du méthotrexate chez 4 patients et introduction de l’hydroxychloroquine chez 1 patient) et à une demande de visite présentielle pour 7 patients. Après analyse multivariée par régression logistique, la survenue d’une ou plusieurs poussées (Odds Ratio, OR : 15,6 ;IC95 % : 3,37–68,28) et une CRP>5mg/L (OR : 3,32, IC95 % : 1,12–13,27) étaient les seules variables indépendamment associées à une intervention du médecin. Conclusion La survenue de poussées, le nombre d’articulations douloureuses, la durée de la raideur matinale, le nombre de réveils nocturnes et la valeur de la CRP étaient les paramètres les plus fréquemment collectés au cours de la téléconsultation. La survenue d’une ou plusieurs poussées de PR et une valeur de CRP élevée ont été les éléments principaux ayant motivé une intervention du rhumatologue en téléconsultation. La validation de ces paramètres pour une utilisation en pratique courante de télémédecine est en cours dans une étude prospective.

Facteurs de risque de réponse insuffisante à la vaccination contre la COVID-19 chez les patients traités par rituximab

Introduction L’efficacité vaccinale anti-SARS-CoV-2 est réduite chez les patients traités par rituximab (RTX) [1]. L’objectif de ce travail a été d’identifier quels facteurs influencent la réponse humorale aux vaccins contre la COVID-19 chez les patients traités par RTX. Patients et méthodes Étude observationnelle prospective de soin courant incluant consécutivement des patients atteints de rhumatismes inflammatoires chroniques et de maladies systémiques hospitalisés pour réalisation d’une nouvelle perfusion de RTX entre avril 2021 et juin 2021. L’ensemble des patients avaient reçu deux doses de vaccins anti-COVID-19. Une sérologie COVID-19 était systématiquement réalisée le jour de l’hospitalisation, permettant la détection et la quantification des anticorps dirigés contre les protéines virales Spike (anti-S, seuil>15UA/mL, LIAISON® SARS-CoV-2 S1/S2 IgG immunoassay, DiaSorin). Un dosage systématique des CD19 était également effectué le jour de la perfusion (Aquios, Beckman Coulter). Résultats Quarante-cinq patients (39 femmes) ont été inclus, avec un âge moyen de 63±11 ans et une durée moyenne d’évolution de la maladie de 19±9 ans. La majorité des patients avaient une polyarthrite rhumatoïde (PR, 34 patients, 76 %) ;5 avaient une sclérodermie systémique, 2 un lupus systémique, 2 une connectivite mixte et 2 un syndrome de Sjögren. La dose cumulée moyenne reçue de RTX était de 7±5,5g et 25/45 patients (56 %) avaient des CD19 indétectables (<18/mL) le jour de la nouvelle perfusion. Quarante-deux patients ont reçu 2 doses du vaccin BNT162b2 Pfizer/BioNTech et 3 patients 2 doses du vaccin AZD1222 AstraZeneca. La durée moyenne entre la dernière perfusion de RTX et la première dose de vaccin était de 141±119 jours. Parmi les 45 patients recrutés, seulement 16 avaient une sérologie positive (36 %). Une sérologie négative était associée à une absence de détection des CD19 (24/25 vs 5/20, p<0,001) et le taux d’anticorps anti-S était significativement diminué chez les patients avec des CD19 indétectables (7,61±15,10AU/mL vs 196,30±167,80UA/mL, p<0,001). Parmi les 20 patients avec des CD19 détectables, les taux de CD19 étaient significativement plus bas chez les 5 patients avec une sérologie négative comparé aux 15 patients avec une sérologie positive (48,80±21,32UA/mL vs 259,30±145,60UA/mL, p=0,005). Le taux de CD19 était corrélé au taux d’anticorps anti-S (r=0,86, p<0,001). Le temps entre la dernière perfusion de RTX et la première dose de vaccin influençait également la réponse vaccinale : 23 % de sérologie positive chez les patients vaccinés dans les 6 mois suivant la dernière perfusion de RTX versus 60 % chez les patients vaccinés au-delà du 6e mois (p=0,017). Une analyse multivariée incluant comme covariables l’âge, le sexe, un IMC>30, la maladie de fond, la dose cumulée de RTX, les CD19>18/mL, une durée entre la dernière perfusion de RTX et la vaccination>6 mois, le taux de gammaglobulines, un traitement associé par méthotrexate et corticoïdes a identifié les CD19>18/mL comme l’unique variable associée à une sérologie positive (odds ratio : 35,2, IC95 % : 3,59–344,20). Conclusion La déplétion lymphocytaire B est le principal facteur de réponse humorale à la vaccination anti-SARS-CoV-2 chez les patients traités par RTX. La surveillance des CD19 pourrait être intéressante afin d’identifier la meilleure période pour effectuer la vaccination.

The impact and outcome of COVID-19 on systemic sclerosis patients from the european scleroderma trial and research group (EUSTAR)

Background: Coronavirus disease-19 (COVID-19) has been a major clinical challenge worldwide. Sex, age and comorbidities have been associated with worse outcome in the general population. Systemic sclerosis (SSc) is a severe, autoimmune disease with frequent multi-organ involvement. Objectives: To assess the impact of COVID-19 and to determine factors associated with worse outcome in SSc patients from the European Scleroderma Trial and Research (EUSTAR) database. Methods: SSc patients from the EUSTAR database with COVID-19 were prospectively collected between 15.03.-31.12.2020. Two outcomes were chosen: (1) hospitalization;and (2) severe outcome defined as either non-invasive ventilation, mechanical ventilation/extracorporeal membrane oxygenation (ECMO) or death. General risk factors assessed were sex, age and number of comorbidities. SSc related risk factors were SSc subtype, autoantibodies, disease duration, SSc associated organ manifestations including interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), cardiac, gastrointestinal (GI), and musculoskeletal involvement;digital ulcers (DU), CRP at last visit, renal disease (scleroderma renal crisis and SSc associated renal insufficiency), modified Rodnan skin score (mRSS) and immunosuppressive treatment. Descriptive statistics and logistic regression models were applied. Results: In total, 178 European SSc patients with COVID-19 were registered with a median observation time of 5.5 weeks (Table 1). 95 patients (53%) could recall SAR-Cov-2 contact, while 47 (26%) had no contact. 156 (88%) were symptomatic at COVID-19 onset with fever, cough, malaise and dyspnea being most prevalent. Over the disease course, 63 (36%) developed pneumonia. In total, 67/176 (38%) were hospitalized which were in 84% due to COVID-19. 41/170 (24%) had a severe outcome including 21 (12%) deaths. 128 (72%) recovered completely, while 14 (8%) complained of sequela, with 7 (50%) stating respiratory complications. Age, non-SSc comorbidities, presence of ILD, PAH and SSc associated renal or cardiac disease were numerically associated with hospitalization and severe outcome (Table 1). Univariable logistic analyses for hospitalization and severe outcome are shown in Figure 1. In multivariable logistic regression, age (OR 1.03, 95%CI 1.01-1.07, p=0.019), presence of non-SSc comorbidities (OR 2.52, 95%CI 1.16-5.47, p=0.019) and SSc-related renal disease (predicting success perfectly) were associated with hospitalization and for severe outcome age (OR 1.05, 95%CI 1.01-1.08). Conclusion: SSc patients at older age, with non-SSc comorbidities, SSc related renal disease or ILD are at risk of a more severe outcome and should follow precautions to avoid COVID-19 infections and need careful monitoring in case of COVID-19.

The role of chest ct in understanding interstitial lung disease (ILD): Systemic sclerosis (SSC). versus COVID-19

Background: COVID-19 pandemic is a global emergency which may overlap on the clinical and radiological scenario of ILD in SSc. In clinical practice, the striking similarities observed at computed tomography (CT) between the diseases make it difficult to distinguish a COVID-19 superinfection from a progression of SSc-ILD. Objectives: The aim of our study was to identify the main CT features that may help distinguishing SSc-ILD from COVID-19 pneumonia. Methods: 22 international readers were included and divided in the radiologist group (RAD) and non-radiologist group (nRAD). The RAD group included nonchest RAD and chest-RAD. A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study. Results: Fibrosis inside focal ground glass opacities (GGO) in the upper lobes;fibrosis in the lower lobe GGO;reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT parameters most frequently associated with SSc-ILD. The CT parameters most frequently associated with COVID-19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p <0.0001) and signs of fibrosis in GGO in the lower lobes (p <0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. These two variables were combined in a predictive score which resulted positively associated with the COVID-19 diagnosis, with 96.1% sensitivity and 83.3% specificity: 3 different risk class for COVID-19 pneumonia may be identified: high risk for COVID-19 pneumonia (5-9 points);probable overlap COVID-19 pneumonia in SSc-ILD (4 points);low risk for COVID-19 pneumonia (0-3 points). Conclusion: The CT differential diagnosis between COVID-19 Pneumonia and SSc-ILD is possible and may be fostered in practice by the use of a radiological score. In the case where an overlap of both diseases is suspected, the presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

Switching intravenous abatacept and tocilizumab to subcutaneous injections during the COVID-19 pandemic: A French experience

Background: The COVID-19 pandemic requires measures to reduce patient exposure to the risk of contamination, in particular by limiting hospital admissions and promoting lockdown. In order to respond to these healthcare measures, patients were offered to replace intravenous infusions (IV) of abatacept (ABT) and tocilizumab (TCZ) to subcutaneous injections (SC). Objectives: To assess the outcome of patients who switched from IV ABT or TCZ to SC during the COVID-19 pandemic. Methods: A survey was conducted in December 2020 in partnership with the national AFP-RIC patient association to assess the outcome and satisfaction of patients who switched from ABT or TCZ IV to SC during the first wave of COVID-19 pandemic. We also analysed the outcome of patients who switched from IV ABT or TCZ to SC in the rheumatology department of Cochin Hospital during the lockdown in April/may 2020. Articular activity parameters (swollen joint count, pain joint count, visual analogic pain scale, CRP, DAS-28 activity score) were assessed at medical visits before and 6 months after switching from IV to SC. The data collected from the AFP-RIC patient association and the rheumatology department of Cochin Hospital were then aggregated and analyzed by Chisquare and Wilcoxon tests. Results: 81 patients responded to the survey carried out by AFP-RIC patient association, including 29 treated with IV ABT (n=15, 52%) or TCZ (n=14, 48%). 17/29 (59%) were offered to switch from IV to SC, 14/17 patients (82%) accepted and 7 patients were still receiving ABT or TCZ SC injections in December 2020. In the rheumatology department of Cochin hospital, 71 patients were scheduled in April/May 2020 to receive IV ABT or TCZ, and 27 (38%) switched to SC. After 6 months, 19 patients (70%) had maintained SC injections, were satisfied with this injection route of administration and their articular activity parameters were unchanged (Table 1). The combined analysis of these two populations included 41 patients (33 rheumatoid arthritis, RA, 7 juvenile idiopathic arthritis, JIA and 1 polymyalgia rheumatica) who switched to SC ABT or TCZ. 26/41 (63.5%) patients maintained SC injections and IV was re-established in 15/41 (36.5%). Reasons for returning to IV were poor tolerance of SC injections (n=6, 40%), worsening symptoms (n=11, 73%), patient preference to see a rheumatologist in hospital (n=10, 67%) and the high number of SC injections (n=2, 13%). The proportion of patients returning to IV was higher in RA patients compared to patients with JIA (42% vs. 14%, p = 0.08). Age and disease duration were not significantly different between patients who maintained SC injections and those who returned to IV (respectively p=0.97 and p=0.63). Conclusion: Our study suggests that switching from IV ABT or TCZ to SC is an acceptable procedure during the COVID-19 pandemic, especially for patients with JIA.