The population of elderly individuals with rheumatoid arthritis is rapidly expanding, mainly due to the increased life expectancy. While targeted biological therapies are well established for the treatment of this disease, their use may be lower in elderly (> of 65 years old) and very elderly patients (> 75 years old) due to perceived higher risks for adverse events in this population taking into account comorbidity, polypharmacy and frailty. In this review we discuss available evidence for the use of biological therapies in this growing patient group with specific attention towards eventual reasons for biological treatment failure or withdrawal. The majority of data is found in secondary analyses of clinical trials and in retrospective cohorts. Most information is available about tumor necrosis factor (TNF) blockers. Older patients seem to have a less robust response to anti-TNF agents than a younger population, but drug survival that may considered a proxy for efficacy does not seem to be influenced by age. Despite an overall rate of adverse effects comparable to that in younger patients, elderly RA patients are at higher risk of serious infections. Other biologics appear to have an efficacy similar to anti-TNF agents, also in the elderly RA patients. Again, the drug survival rates for tocilizumab, rituximab and abatacept resemble those in young RA patients with good general tolerability and safety profiles. The cardiovascular risk and the risk of cancer, increased in RA patents and in the elderly patients, do not appear to be strongly influenced by biologicals. Key points-Biological drugs targeting specific cytokines or immune cell populations are an important part of the management strategy for rheumatoid arthritis patients, including the elderly. 3-Overall safety and tolerability in the elderly patients is very good and age should not be a critical factor to decide against biological drug use.-The drug survival rate of biologicals in the elderly RA patients is comparable to that in the young RA population.-Co-morbidities and risk of infection are important variables to assess when considering a biological drug in the elderly.-More data and specific studies are required to better position biological drug use in this particular population as current studies provide a low level of evidence. Data in patients above 75 years are still largely missing. Moreover, the group of elderly patients that were included in clinical trials may be influenced by selection bias at inclusion and not be fully representative for infections risks and other comorbidities.4

In the XX century rheumatology has seen an exponential growth. Discoveries in the pathophysiology of rheumatic diseases, progress in research methodology and novel treatments cardinally changed the natural course of rheumatic diseases and revolutionized patient management. Although underrepresented in this field, women have made considerable input in advancing our specialty towards the new era. In this article we acknowledge key scientific discoveries and major contributions made by 20 brilliant women scientists that shaped the field of rheumatology in the XX century. We hope that achievements of these remarkable women will inspire young rheumatologists and researchers.

We describe the case of a 67-year-old Asian female patient suffering from severe systemic lupus erythematosus (SLE), including biopsy-proven glomerulonephritis, since the age of 40 who was admitted for tetraparesis. Neurological examination confirmed proximal muscular weakness, hypoesthesia and diminished tendon reflexes. The patient suffered from extremely severe Jaccoud's arthropathy. Magnetic resonance imaging (MRI) demonstrated severe narrowing of the upper spinal canal due to a soft tissue mass surrounding the odontoid process, assumed to be a synovial pannus, causing myelopathy. The patient was treated with three intravenous pulses of methylprednisolone with prompt and full clinical recovery. Follow-up MRI confirmed considerable regression of the pannus. Inflammatory transverse myelopathy is the most common explanation for para/tetraparesis in SLE. However, in this case, the symptoms were caused by atlantoaxial synovitis, which is more typical for rheumatoid arthritis.

BackgroundMusculoskeletal ultrasound (US) was developed more than four decades ago and gradually made its way to daily rheumatological practice. This dynamic, non-irradiating and relatively inexpensive technique allows detection of synovitis/tenosynovitis as well as quantification of joint inflammation. However, several external factors, such as, joint position, machine settings, sonographer expertise and certain medications can influence the results of the US examination.ObjectivesThe aim of this study was to investigate whether the pharmacokinetics of intravenous (i.v.) infliximab (IFX) influences the grade of US detected synovitis, measured by gray-scale (GS) and colour Doppler (CD) in rheumatoid arthritis (RA) patients.MethodsInclusion criteria were RA patients with at least one swollen joint, being treated with i.v. IFX, who had neither, changes in DMARD therapy nor local corticosteroid injections in the previous 3 months. Patients underwent clinical, laboratory and US assessment at three time points: at trough, peak plasma drug concentration and at mid-cycle. US assessments were performed blindly to the clinical and laboratory data. Twenty-four joints were assessed for the presence and grade (0–3) of GS synovitis and synovial CD signal: elbows, wrists, 2nd-5th metacarpophalangeal (MCP) joints, knees, ankles, 2nd-5th metatarsophalangeal (MTP) joints. A global OMERACT-EULAR synovitis score (GLOESS) as well as the sum of GS and CD scores were calculated for the 24-joint set, for the 12-joint set (Naredo score) and for wrists-MCP-ankles-MTP joints. Several disease activity scores (DAS) [28-joint DAS (DAS28-CRP), Simplified Disease Activity Index (SDAI)] and health assessment questionnaire (HAQ) were assessed in all patients. Trough plasma IFX concentrations were available in 20 patients.ResultsTwenty-two RA patients were prospectively recruited from the biologic therapy unit of our hospital. Two thirds of patients were female and mean age was 61 years. The majority of them had long-standing seropositive RA and over 90% had radiographic damage. The median of IFX treatment duration was 9 years. There were no significant differences between the GS, CD and GLOESS scores at IFX peak time and trough time. US-joint count, GS, CD and GLOESS scores did not significantly differ between peak time and trough time. Patients with long-lasting RA treated with IFX had relatively stable US-detected synovitis and slightly lower clinical scores at 4 weeks after IFX administration as compared to baseline. The DAS28CRP, 28 and 44 swollen joint counts did not correlate with trough serum IFX concentrations. US scores (GS and GLOESS) significantly correlate with trough serum IFX concentrations (Spearman correlation coefficient, r=−0.55, p=0.01, n=20). Patients with low trough IFX levels, especially ≤1 µg/ml, had higher US joint count as well as US scores (p<0.01).Reference[1] US-scored synovitis is not significantly influenced by pharmacokinetics of IFX in RA patients. US examination can be conducted independently of time of IFX admini...

Background:Psoriatic arthritis (PsA) is an inflammatory joint disease that is traditionally included in the Spondyloarthritis (SpA) spectrum. Prevalence and impact of axial involvement in PsA remains understudied but increasingly affects treatment decisions.Objectives:The first step, in this multi-purpose radiographic study, is to report on baseline radiographic damage of the sacroiliac joints (SIJ) in PsA patients from a prospective multicentre cohort study in private and academic rheumatology practices.Methods:Data from the Belgian Epidemiological Psoriatic Arthritis Study (BEPAS), a prospective multicentre cohort involving 17 Belgian rheumatology practices. Recruitment was from December 2012 until July 2014. Patients were included in the study when the local rheumatologist could diagnose an existing or new PsA and when patients fulfilled the Classification criteria for Psoriatic Arthritis (CASPAR). Radiographs of the SIJ were obtained at baseline and after 2 years. Two calibrated readers assessed radiographic damage by grading the SIJ according to the modified New York (mNY) criteria. When assessing the images, readers were blinded for clinical data and information from other obtained images (radiographs of the hands, feet and spine). Individual scores as well as consensus scores are described.Results:In total 461 patients where included in BEPAS. Mean age was 52.79±12.29 years and 43.0% (n=198) were female; average disease duration was 8.5 ± 9.3 yrs and approximately 34% of the patients report inflammatory axial pain. From 338 patients SIJ radiographs were obtained. At baseline, the vast majority of patients did not fulfil the mNY criteria (n=325, 96.2%), according to both readers. In 8 cases (2.4%) there was concordance on fulfilment of the mNY criteria. Discordant cases (n=5, 1.4%) were equally distributed. Agreement between the 2 readers was good with 98.5% overall agreement and kappa=0.75. Therefore, with a more sensitive approach (any of the 2 readers scores mNY positive) we see slight differences; 13 patients (3.8%) fulfil the mNY criteria. Table 1 shows radiographic damage by individual readersTable.Baseline data on radiographic damage of the sacroiliac joints in Belgian patients with newly diagnosed or existing PsA included in the BEPAS.N=338Right sacroiliac jointLeft sacroiliac jointGradesType of lesionReader 1Reader 2Reader 1Reader 20No abnormalities298 (88.2%)301 (89.1%)298 (88.2%)296 (87.6%)1Indefinite abnormalities32 (9.5%)23 (6.8%)27 (8.0%)23 (6.8%)2-3Abnormalities5 (1.5%)12 (3.6%)9 (2.7%)19 (5.6%)Erosion3 (0.9%)11 (3.3%)4 (1.2%)18 (5.3%)Sclerosis4 (1.2%)12 (3.6%)5 (1.5%)13 (3.9%)Joint space alteration (narrowing or widening)1 (0.3%)1 (0.3%)4 (1.2%)2 (0.6%)Partial ankylosis2 (0.6%)3 (0.9%)5 (1.5%)8 (2.4%)4Total ankylosis3 (0.9%)2 (0.6%)4 (1.2%)-In 128 patients (37.9%) a follow-up x-ray after 2 years was available. In 124 patients (96.9%) there was reader agreement on mNY negative status. There was disagreement between readers on a positive mNY in 2 patients (equally distributed) and agreement on 2 patients (1.6%). There were no patients with consensus between readers on the change in mNY over 2 years, but 1 reader reported 1 patient becoming mNY positive after 2 years.Conclusion:Despite the patient self-identified presence of axial disease in up to 34% in this cohort of PsA patients, there was minimal radiographic damage on SIJ, suggesting that SIJ disease is not a major manifestation of PsA.Disclosure of Interests:Manouk de Hooge: None declared, Alla Ishchenko: None declared, Serge Steinfeld: None declared, Adrien Nzeusseu Toukap Grant/research support from: AbbVie, Celgene Corporation, Janssen, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Eli Lilly, Janssen, Novartis, UCB – consultant, Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, UCB – advisory board member, Dirk Elewaut: None declared, Hermine Leroi Employee of: MSD Belgium, Rik Lories Grant/research support from: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – grant/research support (on behalf of Leuven Research and Development), Consultant of: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – consultant (on behalf of Leuven Research and Development), Speakers bureau: AbbVie, Boehringer Ingelheim, Celgene Corporation, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Samumed and UCB – speaker (on behalf of Leuven Research and Development), Kurt de Vlam Grant/research support from: Celgene, Eli Lilly, Pfizer Inc, Consultant of: AbbVie, Eli Lilly, Galapagos, Johnson & Johnson, Novartis, Pfizer Inc, UCB, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB