Background:Recently evolved from a monochromic flu-like disease to a polysyndromic “spectrum of disease”, our understanding of coronavirus disease 2019 (COVID-19) is still far from being complete [1]. Hyperinflammation involving not only the lungs but also the musculoskeletal system, skin, cardiovascular, genitourinary systems is immune-mediated resembling the flares of a full-blown rheumatic disease [2,3].Objectives:To describe the prevalence and type of rheumatic manifestations in a cohort of COVID-19 patients hospitalized in the COVID-19 rheumatology department in University Hospital St. Marina, Varna, Bulgaria.Methods:In the present single-center cohort study, а retrospective database analysis was performed among all COVID-19 patients hospitalized from 1 Dec 2020 to 22 Jan 2021. All 243 patients (age 19 - 93 years) were treated for moderate or severe SARS-CoV-2 infection confirmed by laboratory tests, including positive polymerase chain reaction (PCR) test, and imaging modality. Inpatient treatment included antibiotics, dexamethasone, anticoagulants, and antiviral drug remdesevir (optional). Detailed disease history and clinical examination were carried out by a fully certified rheumatologist and/or specialist in internal medicine.Results:Among all 243 COVID-19 patients, those with prominent self-reported myalgia and arthralgia were 26% (n = 63) and 21.3 (n = 52), respectively. We had 4 (1.6%) cases of newly developed cutaneous vasculitis and 2 (0.8%) cases of severe Raynaud’s phenomenon after SARS-CoV-2 infection onset. Two patients experienced severe muscle weakness, had elevated creatine phosphokinase, and were diagnosed with inflammatory myopathy secondary to COVID-19. Lupus-like syndrome was observed in 2 (0.8%) patients.Conclusion:Rheumatic manifestations are part of the heterogeneous spectrum of COVID-19 disease. Amidst the COVID-19 crisis, each newly onset rheumatic manifestation warrants exclusion of SARS-CoV-2 infection. Therefore, a rheumatologist should be a part of a multidisciplinary approach towards the COVID-19 treatment.References:[1]Misra DP, Agarwal V, Gasparyan AY, Zimba O. Rheumatologists’ perspective on coronavirus disease 19 (COVID-19) and potential therapeutic targets. Clin Rheumatol. 2020;39(7):2055-2062[2]Georgiev T, Angelov AK. Complexities of diagnosis and management of COVID-19 in autoimmune diseases: Potential benefits and detriments of immunosuppression. World J Clin Cases. 2020;8(17):3669-3678[3]Ciaffi J, Meliconi R, Ruscitti P, Berardicurti O, Giacomelli R, Ursini F. Rheumatic manifestations of COVID-19: a systematic review and meta-analysis. BMC rheumatology. 2020 Dec;4(1):1-5.Disclosure of Interests:None declared

Background:Sustainability, the ability of drugs to maintain remission or low disease activity (LDA) in patients with rheumatoid arthritis (RA), plays a crucial role for the prevention of structural damage to joints and thus, preserving patients’ functional capacity, health-related quality of life and general sense of well-being. Therefore, studying the sustainable effectiveness of tocilizumab (TCZ) as a monotherapy or combined with methotrexate (MTX) is important (1).Objectives:We aimed to examine to what extend TCZ, alone or combined with MTX, could achieve and further sustain LDA in patients with long-standing RA in the light of current, strictly index-based definitions of LDA and to compare the two versions of DAS28 in patients in real clinical practiceMethods:85 RA patients treated with TCZ for at least eighteen months were consecutively enrolled in the present single-center, retrospective cohort study. All participants met the 1987 ACR classification criteria and attended the rheumatology department of University Hospital “St. Marina” Varna in an outpatient setting. Patients receiving pre-filled syringe contained 162 mg TCZ once weekly subcutaneously. Real-world data were extracted and analyzed from patient’s full medical file. For each visit, disease activity score 28 with ESR and CRP (DAS28-ESR and DAS28-CRP) and simple disease activity index (SDAI) were calculated simultaneously according to generally adopted formulas. A twelve-month result was determined for sustained LDA at each of the patient’s three visits (at 6-month intervals), according to DAS28 and SDAI. Descriptive statistics, Chi square test, Cochran´s Q test, kappa statistic were used, a binary logistics model was compiled to study the impact. Significance level of p <0.05.Results:Two hundred fifty-five patient visits were analyzed. The mean durations of RA and treatment with TCZ were 12.6 (±9.6) years and 3.64 (±1.8) years, respectively. The mean age of patients was 60.3 years (37-87 years), 80% were women, 24.7% were obese, 65.9% have concomitant hypertension. 61.2% of patients are treated with combination therapy TCZ with MTX.Of all patients, these with a sustained 12-month LDA were 41.2%, 28.2% or 23.5% depending on the studied index (DAS28-CRP, SDAI, or DAS28-ESR, respectively).A 12-month SDAI LDA was found in a significantly small proportion of patients (28.2%, p = 0.001). The DAS28 ESR determined a proportion similar to SDAI (23.5%, p> 0.05), while according to the DAS28 CRP, patients with a sustained 12-month LDA were significantly more (41.2% p = 0.005). A moderate level of agreement was found between the assessments of SDAI and the two variants of DAC28 when determining 12-month results of Tocilizumab treatment (DAS28-ESR k = 0.511, p <0.001 and DAC28-CRP k = 0.618, p <0.001). No relationship was found between the combination of TCZ with MTX and the patients’ chance of a sustained 12-month LDA, regardless of which index the result was measured.Patients with hypertension were significantly less likely to have sustained 12-month LDA according to SDAI and DAS 28 ESR (OR 0.135, 95% CI 0.048-0.386; OR 0.313, 95% CI 0.111-0.882, respectively), but not according to DAS28 CRP.Conclusion:Sustained 12- month LDA with TCZ in patients with long-term RA remains uncommon in daily clinical practice. Co-administration of MTX is not associated with an increased likelihood of achieving a sustained LDA in the analysis of long-term responses. Patients with concomitant hypertension are less likely to be in a sustained 12-month LDA, according to SDAI and DAS28-ESR. The results according to DAS28 ESR, but not according to DAS28CRP are comparable to those of SDAI when measuring long-term results of treatment with TCZ.References:[1]Hamann PDH, Pauling JD, McHugh N, Shaddick G, Hyrich K; BSRBR-RA Contributors Group. Predictors, demographics and frequency of sustained remission and low disease activity in anti-tumour necrosis factor-treated rheumatoid arthritis patients. Rheumatology (Oxford). 2019 Dec 1;58(12):2162-2169.Disclosure of Interests:None declared

Background:Systemic lupus erythematosus (SLE) is autoimmune connective tissue disorder of unclear etiology. It is characterized by autoantibody production and a variety of clinical manifestations. The introduction of biological treatment over the past few years provided an opportunity for a disease control.Objectives:The aim was to assess the effectiveness and safety profile of Belimumab in the treatment programs of SLE patients during a 2 year period.Methods:We initiated a prospective observational study of SLE patients in the Rheumatology Department in University Hospital St Marina – Bulgaria. The study comprises data from 26 patients at baseline before Belimumab treatment initiation and data after 6, 12, 18 and 24 months of treatment. All patients were with moderate disease activity according to SELENA – SLEDAI index and were on treatment with immunosuppressive drug (azathioprine) and glucocorticoids (GCs). We observed the change in the dosage of glucocorticoids over the observed period, the number of flares of SLE, as well the SELENA – SLEDAI index change. Safety profile of Belimumab was also registered.Results:We included 26 patients with SLE over a period of 4 years – between 2015 and 2019. The mean age was 45.8 + 11.4 years and 94% were Caucasian females. All patients were on a stable dosage of GCs at least 3 months before the first infusion of Belimumab and azathioprine 100 mg daily. Ninety percent of patients were diagnosed with SLE for more than 6 years according to ACR – SLE criteria. All of SLE patients were with moderate disease activity. Main reasons for biological treatment decision were persistent mucocutaneous manifestations (20%), polyarthritis (15%), haematological disturbances (35%) and persistent immunological markers (30%). One patient was excluded from the study due to infusion- related flush and severe hypotension reaction while the rest 25 completed the observation. We investigated and analyzed haematological results, ANA, anti – ds DNA, anti – Sm autoantibodies and complement fractions at baseline as well on the 12th and 24th month of treatment. The mean SELENA – SLEDAI index changed from 8.9 to 4.5 after 12 months of treatment and remained unchanged until the end of the study. We observed a mean reduction of GCs daily dosage from 12 mg to 6 mg after 18 months.Conclusion:Biological treatment with Belimumab added to the standard treatment with GCs and AZA in patients with non-lupus nephritis SLE patients adds additional benefits. Our results show that there is a reduction in SLEDAI index as well as reduction in daily GCs intake. Safety profile is not different from the one reported previously.Disclosure of Interests:None declared