Author: Christakis Christodoulou1,2
1. University of Nicosia Medical School, Egkomi, Cyprus
2. Synesio Medical Centre, Larnaca, Cyprus
Citation: EMJ Rheumatol. 2023;10[1]:28-32. DOI/10.33590/emjrheumatol/10302209. https://doi.org/10.33590/emjrheumatol/10302209.
This excellent congress took place between 31st May–3rd June 2023 in the beautiful city of Milan, Italy, featuring the stunning church of Duomo di Milano in the centre of the city. The congress covered all topics of Rheumatology. During the opening plenary session, Annamaria Iagnocco, European Alliance of Associations for Rheumatology (EULAR) President, presented EULAR’s new strategy and its key priorities.
RHEUMATOID ARTHRITIS
Daniel Aletaha, University of Vienna, Austria, presented research on the prevention of rheumatoid arthritis (RA), explaining that abatacept may have a role if used early. Drug safety is very important and rheumatologists need to carry out risk/benefit assessments before choosing therapeutic agents. Aletaha mentioned a few new treatments with interesting modes of action/delivery systems, and discussed treatment targets. Comorbidities are relevant in the management of RA and can influence our choice of therapy and its response.
LUNG INVOLVEMENT IN AUTOIMMUNE RHEUMATIC DISEASES
Oliver Distler, University of Zürich, Switzerland, presented evidence supporting the use and clinical benefit of the following agents in the management of systemic sclerosis-associated interstitial lung disease: cyclophosphamide, nintedanib, mycophenolate mofetil, tocilizumab, and rituximab. Distler also presented evidence supporting the use and clinical benefit of nintedanib and pirfenidone in the management of RA interstitial lung disease.
OSTEOARTHRITIS THERAPIES
Ruth Wittoek, Ghent University, Belgium, presented data on the successful structure modification in erosive hand osteoarthritis (OA) by denosumab, a RANKL inhibitor. Michelle Heijman, Sint Maartenskliniek, Nijmegen, the Netherlands, presented data suggesting that colchicine 0.5 mg daily was associated with a lower incidence of total hip and knee replacements as compared with placebo. Timothy McAlindon, Tufts Medical Center, Boston, Massachusetts, USA, presented evidence that lorecivivint 0.07 mg, a CLK/DYRK inhibitor, appears safe and well-tolerated in patients with severe knee OA. There is potential benefit on joint space narrowing at 24 and 36 months, and there are potential benefits on patient reported outcomes. Tuva Moseng, Diakonhjemmet Hospital, Oslo, Norway, presented an update on the EULAR recommendations for the non-pharmacological management of hip and knee OA.
BIOLOGICS FOR RHEUMATOID ARTHRITIS
Andrew Cope, King’s College London, UK, presented the results of the APIPPRA study, which demonstrated that abatacept reduces the rate of progression to clinical arthritis or RA during the treatment phase. The study also demonstrated that there are consistent effects on symptoms and patient-reported outcomes during the first 12 months.
Noortje van Herwaarden, Sint Maartenskliniek, Nijmegen, the Netherlands, presented the results of the DRESS study, which revealed that long term disease activity guided dose optimisation of TNF inhibitors in RA results in stable low disease activity, and a 40–50% reduction in TNF inhibitors and other biological disease-modifying antirheumatic drug (DMARD) use.
Discontinuation does not seem to cause long-term disease deterioration, and biologic and targeted synthetic DMARD-free remission for a relevant period of time is possible in a non-negligible number of patients.
AXIAL AND PERIPHERAL SPONDYLOARTHRITIS
Désirée van der Heijde, Leiden University, the Netherlands, presented on the management of spondyloarthritis, highlighting the importance for correct diagnosis and types of manifestations in order to choose the correct treatment strategy. The Assessment of SpondyloArthritis International Society (ASAS)-EULAR recommendations provide guidance to therapy.
SJÖGREN’S SYNDROME
Hendrika Bootsma, University Medical Center Groningen, the Netherlands, presented the clinical phenotype of the disease, the 2016 EULAR/American College of Rheumatology (ACR) classification criteria, and mucosa-associated lymphoid tissue lymphoma in Sjögren’s. syndrome They presented clinical trials on iscalimab (anti-CD40), ianalumab (anti-BAFF receptor), belimumab/rituximab combination, remibrutinib (BTK inhibitor), and stem cell therapy rescue for hyposalivation with positive results.
SYSTEMIC LUPUS ERYTHEMATOSUS
Dimitrios Boumpas, University of Athens, Greece, presented the important features in renal biopsy, i.e., the activity and chronicity features. They stressed the importance of not underestimating haematuria and of having a low threshold for renal biopsy. Haematuria and active urine sediment are reliable indicators for activity and flare. Proteinuria is a good prognostic factor if below 0.7 mg/dL. Boumpas discussed remission and lupus low disease activity state. They presented evidence on the treatment of lupus nephritis, i.e., the similar efficacy of mycophenolate mofetil and cyclophosphamide, and the efficacy of belimumab, voclosporin, and obituzumab. Boumpas also described tapering of therapy in patients with quiescent disease and that steroids should be tapered first. They highlighted that there is no safe dose of steroids for long-term use. Following renal response their team continues treatment of lupus nephritis for at least 3 years.
ANTIPHOSPHOLIPID SYNDROME
Savino Sciascia, University of Turin, Italy, discussed the complex pathogenesis of antiphospholipid syndrome (APS), explaining that different mechanisms might justify the heterogeneity of the clinical presentation and the importance of individualised treatment. Maria Tektonidou, National and Kapodistrian University of Athens, Greece, presented the anticoagulant therapy of antiphospholipid syndrome. They discussed the EULAR and ACR guidelines, and presented evidence that direct oral anticoagulants are less effective than warfarin in the treatment of thrombotic APS. Tektonidou also presented evidence that hydroxychloroquine and statins may be considered as adjunctive to antithrombotic treatment for anticoagulant refractory thrombotic APS. Hydroxychloroquine can be considered in patients with recurrent pregnancy complications, despite low dose aspirin and prophylactic low-dose heparin. Doruk Erkan, Hospital for Special Surgery, New York, USA, discussed the presentation and treatment of microvascular and catastrophic APS.
LARGE VESSEL VASCULITIS
Carlo Salvarani, University of Modena and Reggio Emilia, Italy, discussed the impact of age on giant cell arthritis (GCA), immunosenescence and GCA, imaging in large vessel vasculitis, and what is new in GCA therapy. They concluded that tocilizumab can be used in all patients with newly-diagnosed or relapsing GCA due to its efficacy and steroid-sparing effect. However, 1 year of tocilizumab induces prolonged drug-free remission in only half of the patients. Dose reduction or increase of the treatment interval in patients in remission after 12 months of tocilizumab maintained most patients in remission. Secukinumab and mavrilumab seem to be effective therapies in GCA. JAK inhibitors could be effective in GCA, but their use in GCA will be limited by the European Medicines Agency (EMA) recommendations regarding their safety.
PSORIATIC ARTHRITIS
Laure Gossec, Pitié-Salpêtrière Hospital, Paris, France, presented the treatment of psoriatic arthritis. They presented the limited role of non-steroidal anti-inflammatory drugs, the role of conventional synthetic DMARDS, the role of biologic DMARDs, and targeted synthetic DMARDs. Gossec presented the different risks of specific infections with different biologic and targeted synthetic DMARDs. They stressed the importance of different features of psoriatic arthritis, and safety considerations in the selection of the most appropriate therapy.
BEHÇET’S DISEASE
Gulen Hatemi, Istanbul University, Türkiye, discussed the clinical domains, the classification criteria, imaging for the diagnosis of eye involvement, and the effectiveness of different therapeutic agents for different clinical manifestations of the disease. They reported the following changes in the treatment of Behçet’s syndrome: apremilast may be used in patients with oral and genital ulcers, with inadequate response to colchicine; first-line use of TNF inhibitors is increasingly used in patients with uveitis; TNF inhibitors may be used for induction treatment in patients with arterial aneurysms and major venous thrombosis; and TNF inhibitors may be a better option than azathioprine for maintenance treatment of vascular involvement, nervous system, and gastrointestinal involvement.
OSTEOPOROSIS
Natasha Appelman-Dijkstra, Leiden University Medical Centre, the Netherlands, suggested to also do a vertebral fracture assessment during a dual-energy X-ray absorptiometry scan. They advised, if possible, to start anabolic therapy in severe osteoporosis with vertebral fractures. Treating a hip fracture with zoledronic acid reduced morbidity, and decreased the treatment gap after a hip fracture. Appelman-Dijkstra advised to always prescribe follow-up therapy after romosozumab, teriparatide, and denosumab. They recommended to start patients on preventive therapy when starting glucocorticoids.
GOUT
Abhishek Abhishek, University of Nottingham, UK, reported that gout has a strong genetic risk. Lifestyle changes could improve the inherited risk of gout. Some patients may be less responsive to allopurinol due to genetic factors. They suggested to screen for the HLAB5801 allele in Han Chinese, Thai, Korean, and African American populations (7–8% prevalence) before allopurinol is prescribed, since they are at higher risk of hypersensitivity reaction.
Fernando Perez-Ruiz, Cruces University Hospital, Barakaldo, Spain, presented the challenge in managing gout in patients with kidney disease. Patients with advanced chronic kidney disease are difficult to treat, and high-risk medicines and pharmacokinetic interactions should be avoided. Most urate lowering therapies are safe in renal transplant patients and haemodialysis is effective. Pascal Richette, Hôpital Lariboisière, Paris, France, gave a presentation comparing guidelines on gout management.
They referred to the EULAR, ACR, British Society for Rheumatology (BSR), National Institute for Health and Care Excellence (NICE), and other guidelines. Richette mentioned the significance of lifestyle modification, cessation of hyperuricaemia-inducing drugs, and the role of diet and exercise. They discussed the importance of treat-to-target, the use of urate lowering therapies, the treatment of flares, the use of prophylaxis, and the treatment of comorbidities.
Robert Keenan, Duke University School of Medicine, Durham, North Carolina, USA, presented a 12-week Phase IIb study of AR882 in patients with gout. The majority of patients achieved serum urate levels below 5 or 4 mg/dL, 75 mg AR882 reduced tophi faster than standard oral therapy, and the medication was well-tolerated and easy to use.
WHAT IS NEW ON ULTRASOUND IN RHEUMATIC AND MUSCULOSKELETAL DISEASES?
Peter Mandl, Medical University of Vienna, Austria, gave an overview on the use of ultrasound in rheumatic and musculoskeletal diseases (RMD). They concluded that ultrasound scan is a tool that can provide information in virtually every RMD; it can be utilised in predicting the development of persistent arthritis in patients at risk of developing RA; it is sensitive to change, and may help identify sub-phenotypes in psoriatic arthritis; it is reliable in assessing inflammation in hand OA; it is the imaging method of choice in patients with suspected GCA; and ultrasound scan signs of crystal deposits have high specificity and sensitivity in diagnosing gout.
THE CONUNDRUM OF DIAGNOSING AXIAL SPONDYLOARTHRITIS RESOLVED
Robert Landewe, Amsterdam University Medical Centers, the Netherlands, presented the ASAS Axial Spondyloarthritis Criteria in a historic perspective. Walter Maksymowych, University of Alberta, Edmonton, Canada, presented the CLASSIC study. The rationale was to re-evaluate the 2009 ASAS classification criteria for axial spondyloarthritis.
The primary outcome was to validate the existing criteria with a pre-specified specificity of more than 90% and sensitivity of more than 75%. The CLASSIC study revealed that the sensitivity was 73.8% and the specificity 84.3%; therefore, the primary outcome was not met. They proposed the following steps: discussion and definitions of spondyloarthritis variables, discussions of pros and cons of modifications to ASAS 2009 criteria, and voting of members on preference for modifications to the ASAS criteria.
EULAR RECOMMENDATIONS
Bruno Fautrel, Sorbonne University, Paris, France, and Fabrizio De Benedetti, Banbino Gesù Children’s Hospital, Rome, Italy, presented the EULAR/Paediatric Rheumatology European Society (PRES) recommendation for the diagnosis and management of systemic juvenile idiopathic arthritis and adult-onset Still’s disease. Gossec presented the 2023 update of the EULAR recommendations for the management of psoriatic arthritis. Boumpas presented the 2023 EULAR recommendations for the management of systemic lupus erythematosus.
CLINICAL/BASIC/ TRANSLATIONAL HIGHLIGHTS
Christian Dejaco, Medical University of Graz, Austria, presented the clinical highlights of the congress. Leonie Taams, King’s College London, UK, presented the basic and translational science highlights. These presentations provided an overview of the most important research presented in this year’s congress. EULAR 2023 was a successful and enjoyable meeting, and we look forward to the EULAR 2024 congress in Vienna, Austria.
