Rapporteurs report

Malabar Hall

26th November 2016

Meet the professorProf Lars Klareskog

• Current smoking – most important determinant for bad response – more so for TNFi

• Increased physical activity – less severe disease

• Obese – 50% less response

• Always include occupational and leisure activity to estimate true disability

Roadmap for vasculitis

Prof P Bacon

• Descriptions of vasculitis• Diagnostic criteria• Definition of disease – standard nomenclature

• Future – focus on pathogenesis and biomarkers• Management recommendations – EULAR • DCVAS 2017 criteria for AA, SV and PAN – weighted

criteria

Immunosuppression in TA – when and how?

Prof D Danda

• Early diagnosis; treat-to-target – better outcome• Challenges - biomarkers, imaging, assessment• Steroid – 0.5mg/kg/day; slow tapering• AZA better than MTX• MMF – comparable to AZA; better safety profile• TCZ, TNFi, UST, RTX• High dose steroid – TCZ – slow tapering – MMF

maintenance• Steroid + MMF – good option; ITAS monitoring helps

Management of AAV

Prof S Rajeswari

• Importance of testing ANCAs, biopsies• Induction: CYC, RTX• Severe renal – plasma exchange + MP; DAH – IPX + GC• Limited disease – MTX• Maintenance – AZA, MTX, MMF (refractory – higher

relapse)• Prophylaxis; Comorbidities; Vaccinations• Future targets – B cell survival factors, Eculizumab (C5a),

Mepolizumab (IL-5)

When to stop immunosuppression in lupus?

Prof D Karp

• Remission – 1.8 yrs median (3% high dis act)• HCQ – reduced flares, increased survival• Prednisone – major cause of organ damage • ALMS – induction with MMF vs CYC equal;

Maintenance – MMF better than AZA • Reducing MMF – significant risk for flare if

tapered before 18 months

Treatment of NPSLE

Dr D Chellapandian

• Primary prevention – anti-malarials, statins• Non-pharmacological intervention• Pharmacological – AED, dopamine agonists, NSAIDs• Inflammatory - CS, CYC, AZA, MMF (not effective as first line

agent), MTX – intra-thecal (rare), RTX, IVIG, IPX, HSCT• Ischemic – low dose Aspirin, anticoagulation• Future – Belimumab, Tabalumab, Sifalimumab,

Rontalizumab, newer OAC - DTIs• Targets - disruption of BBB, targeting cytokines involved,

TWEAK, Eculizumab

Refractory cutaneous lupus

Prof R Saigal

• Definition – acute, subacute, chronic• CLASI • Therapeutics – Tacrolimus (0.1% & 0.03%), Pimecrolimus

(1%), R-salbutamol• Photoprotection• Steroid topical therapies• Refractory CLE – intra-lesional triamcinolone, HCQ, MTX,

Dapsone, Thalidomide, AZA, Lenalidomide, RTX, BEL

Abstract presentations

• Low dose vs high dose CYC in LN– Short term outcome equal in both

• NMR based metabolomics - distinct signature in LN– Improvement of aerobic oxidation as evidenced by

decrease in glucose levels and normalisation of dyslipidemia

• Monocyte, macrophage related biomarkers in LN – uMCP-1 and sCD163 levels higher in renal disease;

correlate with SLEDAI

• Pro-inflammatory cytokines in SLE– IL6, TNF-α good reliable markers of disease activity– Good correlation with major organ involvement in

SLE

• Comparison of PRP vs steroids in OA knee– PRP - sustained improvement up to 24 weeks– Safe and cost effective

WIN – Sjogren’s

Dr P Sandhya

• ACR/EULAR classification criteria for pSS – 5 criteria; weighted score; score ≥ 4; OSS – 5

• Minor salivary gland biopsy in pSS – NPP of FS<3 – 98%• Anti-TRIM38, antibodies against carbamylated

proteins, anti-muscuarinic 3 receptor• Pathogenesis – EBV, IFN expression correlates with key

phenotypic features, Baminercept trial, RBMS3 gene, epigenetics – hypomethylation of IFN regulated genes,

• Salivary microbiome

Disease modification in SS – is it possible?

Dr S Upadhyaya

• Fatigue – exercise and self care; HCQ• MSK – HCQ followed by MTX, CS• Sicca sympoms – RTX• TNFi not to be used to treat sicca

Abstract presentations

• Serum angiogenic markers of inflammation in early RA by PDUS

• MHA HLA DQ6.1 increases RA risk in Indians irrespective of shared epitope

• Cytokine levels may assist in identifying RA patients achieving remission

• Direct LPS recognition and activation of CD8+ T cells via TLR4 in patients with RA

• Assessment of hand arterial flow patterns from proximal to distal arterial segments in RA

• PET CT in assessing treatment response in DMARDs in RA

Mechanism of action of csDMARDs

Dr S Kumar

• SSZ, MTX, LEF, HCQ, Gold• Mode and scope of action still being determined• Pleotropic modes of action• HCQ and LEF – synergestic action with MTX• MTX – immunomodulatory effect by adenosine• LEF – antiproliferative

HCQ and eye: a blind spot

Dr SJ Gupta

• SAE – thrombocytopenia, agranulocytosis, mental disorders, myopathy

• Mechanism of retinal toxicity – increase pH of RPE lysozomes – impairs RPE cell function

• Bull’s eye maculopathy• SD OCT, mfERG, FAF, 10-2 automated visual field• AAO recommendation for screening of HCQ

retinopathy – actual body weight ≤5mg/kg

Cs& biologic DMARDs in perioperative setting

Brg Narayanan

• CS – Hydrocortisone• MTX – stop one week prior to surgery• TNFi – ACR - withhold ≥1 wk before surgery; BSR –

withhold 3-5 half times of drug • RTX – no association between complication and

length of time of infusion• Withhold drugs for 1.5 times the dosing interval

and restart after wound healing

Evaluation of bone health in AIRDDr Nisha N

• Risk of vertebral fractures in AS – high• Hip fractures not high in AS• DEXA limitations in AS – hip BMD, cannot assess bone

microarchitecture and strength• HRpQCT • Treatment with biologic drugs associated with decrease in

bone loss in RA• TNFi agents show preservation or increase in spine and hip

BMD

Osteoporosis : Therapeutic advances

Dr Pande I

• How to choose between various bone agents – 1st line oral BP, HRT, severe OP – teriparatide, CKD - Denosumab

• How to assess and monitor response – 3 mth follow-up - bone markers

• How long to treat – drug holiday – ON jaw; atypical fractures

• Treatment failure – fracture after Rx for 1 yr

WIN – detection of autoantibodies

Prof Stoecker W

• Automated washing of IIF slides• Euroimmun microchip ANA • Euro-pattern microscope – automated ANA

pattern reader• Autoimmune myositis, systemic sclerosis, DM,

PBC

Lupus anticoagulant - Lab

Dr Kamath V

• Common errors occurring in labs with LAC test• Phospholipid platform – tenase complex +

prothrombinase complex• Two APTTs needed – screening &

confirmation; mixing studies• International sensitivity index = 1 / sensitivity• International normalized ratio

Thank you