ACR23 – Day 1 Report Save

ACR 2023 is back in San Diego for its annual convergence of thousands of rheumatologists to partake, discover and learn from thousands of abstracts and hundreds of sessions and presentations.  The inaugural day began with a big bang with the Year in Review that featured the sage insights of Drs. Philip Seo (Johns Hopkins University) and Tomas Mustelin (University of Washington, Seattle) about the scientific and clinical rheumatology highlights from the past year.

Also big was the first public presentation of the American College of Rheumatology Guidelines for the screening, monitoring, and treatment of systemic autoimmune rheumatic disease (SARD) associated interstitial lung disease (ILD). These were previously published and discussed by many on RheumNow.  

It was a big return for the Poster Hall with rows and rows of research, friends, fellows and poster tours.  Below are a few of my favorite presentations from the posters, Plenary and oral sessions on day one.

Vagotomy Increases the Risk of Rheumatoid Arthritis (RA) (Abstract 0836)   Baker et al provided reciprocal proof that vagal nerve stimulation may help patients with RA – thus far small pilot studies have been yielded inconclusive or conflicting results. To further examine this possibility, Baker et al presented the outcomes of total truncal vagal nerve surgery.  The hypothesis was that if vagal nerve stimulation helps RA inflammation by eliciting an anti-TNF reflex response, then the converse; vagotomy should augment TNF production and increase the risk of RA.  The data was drawn from the Danish National Patient Registry from 1977 to 2018. The aim of this study was to see if full truncal vagotomy (done for peptic ulcer disease) would increase the risk of developing RA, without affecting the risk of developing osteoarthritis (OA). Patients undergoing vagotomy (n 2260) were compared 1:10 to normal population controls (22,610). Among the vagotomy patients they found a clear convincing increased risk of RA (HR 2.62; 1.47-4.67), but no OA (HR 1.26; 0.88 – 1.81). These data were similar to that seen in a prior Swedish study showing a modestly increased risk of future RA in vagotomy patients (OR 1.17). These results support the hypothesis that disruption of vagal nerve stimulation may impact the inflammatory reflex and augment the risk of RA.  Further study of vagal nerve stimulation is needed to support this finding.

PEXIVAS Study Shows the Danger of Low Dose Steroids in Patients with Granulomatosis with Polyangiitis. (Abstract 0725)  Nagle et al utilized the PEXIVAS study construct to retrospectively assess the efficacy and safety of a reduced-dose glucocorticoid (GC) regimen in a real-world setting. Patients with severe GPA or microscopic polyangiitis flare were either treated with a reduced dose vs. standard dose GC between January 2018 and April 2022. The primary composite endpoint included the occurrence of death, ESKD, progression before remission requiring treatment modification or relapse, whichever occurred first.  A total of 234 patients were enrolled (93 MPA and 148 GPA), 54% received a reduced GC regimen and 46% received a standard regimen. Significantly more hazardous outcomes were seen in the reduced GC group, with the primary endpoint occurred in 62/234 (26.5%) of patients during the first year of follow-up: 33.3% of patients on the reduced dose versus 18.5% on the standard dose (p=0.016).  Thus, a reduced-dose GC regimen was associated with an increased risk of death, ESKD, progression; especially if serum creatinine levels >300 umol/L, or with rituximab induction therapy.

Abatacept in Preclinical RA; The APIPPRA Study (Abstract 0835)  This study was presented at EULAR  2023 and again at ACR 2023 by lead investigator, Dr. Andrew Cope. This 2-year intervention trial studied the effects of 1 year of blinded placebo or abatacept (SC) weekly in preclinical RA (defined as adults, seropositive with inflammatory arthralgia). They enrolled 206 patients without synovitis and with modest activity (e.g., TJC 2-3, low ESR/CRP, 72% with US power doppler = 0) and at week 52, RA had developed in only 6% of ABA vs. 29% of PBO patients (p=0.0002).  During this active treatment phase (up to week 52) those on ABA had reduced anxiety, fatigue, sleep problems and work instability.  When followed off ABA, out to week 104 (1 year off ABA), RA developed in n only 25% of ABA vs. 37% of PBO patients (p=0.003). These results clearly showed a delay in developing RA (mean=99 mos.) for those treated with 1 year of ABA. These results were even more pronounced in the subset of patients who had very high titers of ACPA or those positive for multiple RA autoantibodies (RA, IgG ACPA, IgA ACPA, ACarbP, APAA). These findings suggest that aggressive use of abatacept in patients with mild to moderate inflammatory arthralgia can significantly delay the onset of chronic RA.  The long-term implications of such a delay on disease trajectory, severity and other critical outcomes remains to be seen.