Objective. To explore the relationship between changes in the severity of skin disease and morbidity and mortality in patients with diffuse cutaneous systemic sclerosis (dcSSc).Methods. From a large single-center cohort, we identified 225 patients with dcSSc for whom serial clinical information was available from within 24 months of the onset of the first non-Raynaud's phenomenon manifestation of SSc. The end points analyzed included death and heart, lung, kidney, and gastrointestinal tract involvement. Latent linear trajectory modeling (LTM) was applied to identify patients with a similar trajectory of modified Rodnan skin thickness score (MRSS) changes over the first 3 years of followup. Clinical outcomes were compared between 3 different LTM subgroups.Results. LTM permitted classification of 131 patients (58%) into 1 of 3 subgroups with different skin score trajectories. Survival was lowest in the subgroup of patients who had a high baseline skin score and experienced little improvement during followup (P ‫؍‬ 0.003). However, the frequency of clinical end points was similar in the subgroup with the most favorable trajectory (i.e., a low initial MRSS and subsequent improvement) and the subgroup with a high baseline MRSS and no improvement. Interestingly, the end point frequency was greatest in the subgroup with a high initial MRSS and subsequent improvement, suggesting that sustained severe skin disease does not necessarily predict the number of visceral complications, and that the relationship between the skin score and internal organ involvement in dcSSc is more complex than previously thought.Conclusion. Although mortality was highest among patients with the worst skin-related outcomes, no simple relationship between burden of disease and change in skin score was observed.

Backgrounds and aims: To evaluate the prognosis of primary biliary cirrhosis (PBC) together with systemic sclerosis (SSc), as this is unknown. Methods and results: A PBC database of 580 patients identified 43 with PBC and SSc: two patients with PBC alone were matched to each PBC-SSc patient for serum bilirubin concentration at the initial visit. Forty (93%) patients had limited cutaneous SSc. At diagnosis of PBC, median values were: 49.7 years, bilirubin 17 mmol/l, and albumin 40.5 g/l. Liver diagnosis occurred a median 4.9 years after SSc in 24 (56%) patients. In matched patients, median values at diagnosis were: 53.2 years, bilirubin 12 mmol/l, and albumin 41 g/l. Median follow up was similar: 3.16 years (PBC-SSc) and 4.8 years (PBC alone). The risk of transplantation or death from diagnosis, adjusting for sex, age, log bilirubin, and alkaline phosphatase was significantly lower in PBC-SSc (hazard ratio 0.116, p = 0.01) due to less transplantation (hazard ratio 0.068, p = 0.006). The rate of bilirubin increase was less in PBC-SSc (p = 0.04). Overall survival was similar (hazard ratio 1.11, p = 0.948); there were nine deaths (21%) in PBC-SSc (six SSc related and two liver related) and nine (11%) in PBC alone (six liver related). Conclusions: Liver disease has a slower progression in PBC-SSc compared with matched patients with PBC alone.

ObjectiveTo investigate whether antidrug antibodies and/or drug non‐trough levels predict the long‐term treatment response in a large cohort of patients with rheumatoid arthritis (RA) treated with adalimumab or etanercept and to identify factors influencing antidrug antibody and drug levels to optimize future treatment decisions.MethodsA total of 331 patients from an observational prospective cohort were selected (160 patients treated with adalimumab and 171 treated with etanercept). Antidrug antibody levels were measured by radioimmunoassay, and drug levels were measured by enzyme‐linked immunosorbent assay in 835 serial serum samples obtained 3, 6, and 12 months after initiation of therapy. The association between antidrug antibodies and drug non‐trough levels and the treatment response (change in the Disease Activity Score in 28 joints) was evaluated.ResultsAmong patients who completed 12 months of followup, antidrug antibodies were detected in 24.8% of those receiving adalimumab (31 of 125) and in none of those receiving etanercept. At 3 months, antidrug antibody formation and low adalimumab levels were significant predictors of no response according to the European League Against Rheumatism (EULAR) criteria at 12 months (area under the receiver operating characteristic curve 0.71 [95% confidence interval (95% CI) 0.57, 0.85]). Antidrug antibody–positive patients received lower median dosages of methotrexate compared with antidrug antibody–negative patients (15 mg/week versus 20 mg/week; P = 0.01) and had a longer disease duration (14.0 versus 7.7 years; P = 0.03). The adalimumab level was the best predictor of change in the DAS28 at 12 months, after adjustment for confounders (regression coefficient 0.060 [95% CI 0.015, 0.10], P = 0.009). Etanercept levels were associated with the EULAR response at 12 months (regression coefficient 0.088 [95% CI 0.019, 0.16], P = 0.012); however, this difference was not significant after adjustment. A body mass index of ≥30 kg/m2 and poor adherence were associated with lower drug levels.ConclusionPharmacologic testing in anti–tumor necrosis factor–treated patients is clinically useful even in the absence of trough levels. At 3 months, antidrug antibodies and low adalimumab levels are significant predictors of no response according to the EULAR criteria at 12 months.

LON occurs infrequently after RTX, but can present with infection.

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Background Late onset neutropaenia (LON) is a recognised complication of rituximab (RTX) treatment in patients with haematological malignancies. There is increasing evidence that LON can also complicate B-cell depletion in patients with rheumatological conditions including rheumatoid arthritis (RA).1 Objectives To identify the frequency of LON occurring after RTX therapy in rheumatoid arthritis patients. Methods Retrospective review of patients with RA treated with RTX between October 2007 and July 2011. Patients were identified from the day unit records, case notes and haematology results were reviewed. LON was defined as absolute neutrophil count <1.5×109/l occurring at least 4 weeks after RTX.For each patient we recorded demographics, serology, concurrent DMARDs, number of cycles of RTX, neutrophil count pre treatment and up to one year after the last cycle. RTX regime was 1g IV given 2 weeks apart. Repeated as clinically needed but not less than 6 monthly. FBC was monitored according to DMARD guidelines or 3 monthly, or at the time of clinical review. Results Over this period 108 patients with RA were treated with RTX (72% women). Median age 64 years (25-86). 96 patients were sero-positive for RF or ACPA (9 negative, 3 unrecorded). 66.6% were on a concurrent DMARD. The total number of RTX cycles received was 237. Patients received up to 8 cycles of RTX, median 2. 5 patients (4.6%) developed LON after a mean of 142 days. 3 were were taking DMARDS.Doses were stable prior to starting RTX. 2 were not on DMARDS. LON occurred after 2.1% of all cycles. LON was complicated by neutropaenic sepsis with pneumonia in 2 patients. 2 patients were treated with Granulocyte colony stimulating factor (G-CSF):1 chest infection, 1 recent joint replacement. Neutropaenia was transient with a maximum duration of 15 days.LON did not recur in 2 patients who were retreated with RTX (follow up >6 months). Table 1 NoAge at first RTX (y)SexDisease duration when RTX started (y)DMARDsTotal No of RTX cyclesNo of RTX cycles before neutropaeniaANC nadir (×109/l)Interval between RTX and neutropaenia (d)Duration of neutropaenia (d)G-CSFComplications 163F18None1101689noSepsis (chest) 225F10None77071,10614,4†yesno 362F14MMF5301517yesSepsis (chest) 451M24MTX210.418415nono 555F19MTX21¶1.313514nono †A spontaneous recovery from an initial period of asymptomatic neutropaenia, which recurred 21 days later. ¶Follow up 3 month after retreatment. Conclusions In our patients, RTX treatment was complicated by LON in 4.6%, this compares to 3% incidence reported by Tesfa et al.1 LON followed 2.1% of treatment cycles and was associated with infections in 40% of the patients. We may have underestimated the frequency of LON as we did not routinely check FBC after RTX except in patients on DMARDs.LON may occur after only one treatment cycle of rituximab, several months after therapy and can be profound.It is therefore imperative that we are aware of LON and monitor FBC; the frequency of monitoring is uncertain as LON is transient. References Tesfa D, Aje...

k d t h Cardiovascular events PAPPA c0.01 mlU/ml PAPPA >or = 0.01 (n42) mlU/ml (N=62) 9 (21%) 17 (27%) 10 (24%) I I (18%) 4(10%) Stroke 2 (5%) 0th 4 (10%)