Rapporteurs ReportTravancore Hall

Saturday, November 26

8:00-8:30 am: Meet the professor

Prof Ingrid Lundberg

• Inflammatory myositis – presentation can be varied, including arthritis and ILD

• MSAs are important in characterizing phenotype

• Muscle biopsy essential in diagnostic work up

• Treatment resistant PM – consider IBM

8:30-8:50 am: Meet the professor

Prof Lahitha

3 case based discussion (SLE)• CH50 useful as a functional assay• Refractive chronic pericarditis – IL6 inhibitor/TNFi• Klinefelter’s with AIH• African american lady with uremia – post Tx

Concurrent symposium (SLE)8:50-9:10 am: Defining treatment targets

• T2T EULAR recommendations 2012 target – remission• SACQ – unnecessary treatment with steroid – damage accrual• Steroid – as low as possible; HCQ benefits• Addressing APS, comorbidities• Challenges – composite index; target of lupus activity –

corticosteroid free clinical remission; definition of remission – individual organ based targets; lack of effective therapy

Dr Vaidehi Govindarajan

Concurrent symposium (SLE)9:10-9:40 am: Newer therapies in SLE

• Summarized trials of RTX and Belimumab in lupus• Rationale for anti IFN therapy in lupus • Promising results from phase II trial of Anifrolumab-

IFNr antagonist • Anti cytokine therapies in lupus – IFX, ETA, TCZ

Prof Robert Lahitha

Concurrent symposium (SLE)9:40-10:00 am: APS: beyond thrombosis and miscarriages

• Role of Eculizumab and Sirolimus in APS nephropathy?• Descriptions of varied systemic manifestations • AVN- 20% on MRI of asymptomatic individuals • RITAPS trial- RTX in Non Thrombotic manifestations of APS

Prof Alakendu Ghosh

Clinical science symposium (RA)10:10-10:40 am – Gum joints and lungs: Where RA begins

Prof Lars Klareskog

• Possibility of preventing disease by identifying environmental risk factors?

• ACPAs Osteoclastogenesis• PADI inhibition (mice) ACPA induced Osteoclastogenesis• Role of ACPA in development of arthralgia before Rheumatoid

arthritis begins • Textile dust: additional risk factor in the Asian population

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Primary and secondary preventionby modification of environmental factors should be included in routine care

Clinical science symposium (RA)10:40-11:00 am: Can we predict response to biologics

Prof Maya Buch

• Baseline HAQ, MTX response, Male gender• MRP8/14 • Type 1 IFN signature- poor response to RTX

Primary and secondary drug non responses have different causes

Clinical science symposium (RA)11:00-11:20 am: Biosimilars the current status

Dr Inderjeet Agarwal

• Definition and development • Switching from biologics to biosimilars- huge budget implications

Indian dataIntacept: 81 vs. 25 ACR 20 and 50 responses same Exemptia: equal efficacy Need for registry to maintain pharmacovigilance

What is new: 11:30—11:45 amInflammasomes

Dr Shrilekha

• Nomenclature of inflammasomes and activation pathway • Regulatory role• Drugs with anti inflammasome activity

What is new: 11:45 am -12:15 pmMacrophage activation syndrome in AIRD

Dr A V Ramanan• Genotype phenotype correlations in primary HLH, role of

apoptosis genes• Secondary HLH- Most often SOJIA, Lupus; viral trigger • Prognostic factors of early death in adult HLH (n=162)

Low platelets, HIV, LDH, Increasing age 12% mortality – more in anemia, high ferritin

• Human IL-1 r antagonist in MAS decreases mortality in sepsis patients with features of MAS

Ferritin in MAS • Ferritin lower in SLE vs. AOSD• Ferritin >10,000 (HLH vs. sepsis) 90% sensitivity 96 % specificity• Dengue related HLH 2016 criteria for MAS in development

What is new: 12:15-12:30 pmNewer autoinflammatory syndrome

Dr Satish Kumar

Comprehensive descriptions of newer auto-inflammatory syndromesNewer AI syndromes- monogenic disorders

DADA2- juvenile PAN phenotypeNLRC MAS – GI inflammation, fever, MAS

IL10 RA/RB mutation: early onset IBD

SAVI: Interferonopathy- vasculopathy and ILD CANDLE and PRAAS- lipodystrophyHaplo-insufficiency of A20- Early onset behcet’s

12:40-1:10 pm Zydus oration Dr Ruchika Goel

• Association between SNPs in IL-17 and TA phenotypes • CRP gene polymorphisms (rs 1205) – protective

• Tuberculosis -8.3% cases Exposure to mycobacterial antigen causative?

• mRNA of TLR4 ligands (MRP8/14) overexpressed, but serum levels do not differ; Due to high baseline levels in our country?

Zydus oration contd

ITAS-A CRP- best for new areas if involvement in angiographyITAS 2010 best for in stent re stenosis

• Soluble HLA E levels could be a biomarker of treatment • Serum amyloid A (n=99): marker of disease activity and

response to therapy

Outcome in TA (n=251)Predictors of Sustained disease inactivityLow ERS, CRP, Dei.Tak scores, type 4 diseasePrediction module- sensitivity 70%, specificity 61%

Panel discussion: 2:00-2:45 pmOsteoarthritis • NSAIDs better than PCM for pain relief : meta-analysis • Glucosamine and NSAIDs equal efficacy: meta-analysis ,

Diacerin GI and hepatic ADRS: suspended for use • Duloxetine approved for knee pain

ESCEO – symptomatic knee OA 2016 guidelines:Step 1 : Slow acting drugs: GC/CS + PCM/topical NSAIDS Step 2 : Intermittent or continuous NSAIDs.

What may come up in the future?• Tanezumab : phase III trial resumed • Anti-inflammatory therapies and PRP remain investigational

Role of non pharmacologic management- weight reduction and physiotherapy; pre-surgery strengthening

Myositis2:45-3:10 pm- Pathogenesis of myositis

Dr K Nagaraju

• Conditional upregulation of MHC1 in mouse model of myositis• Upregulation of the unfolded protein response • Non immune mechanisms of muscle weakness: AMP deaminase

definciency• Decreased expression of mitochondria in the inflamed muscle

Myositis3:10-3:30 pm- Diagnosis: Do autoantibodies help?

Dr Ruchika Goel

Predictive of phenotypes • Anti MDA5- different phenotypes

• Anti SAE Ab- amyopathic initially- late myositis• Anti FHL-1- severe subset • Vellore data- (n=307) all malignancy cases negative for Ab (NXP2/TIF-1 γ/MDA-5)

East Asians- CADM and RPILDCaucasian- mild and responsive to therapy

• Ab help in increase diagnostic yield compared to clinical criteria • Prognosis: MSAs correlate with biopsy scores in jDM • RIM Trial- Anti Mi-2 and antisynthetase Ab –better response to RTX

Myositis3:30-4:00 pm- Current and evolving therapies

Prof Ingrid Lundberg

Glucocorticoids followed by steroid sparing agent 50% unresponsive to glucocorticoids Poor response- Reevaluate the diagnosis IBM

Muscle dystrophyCAM

Peristent activity: • Combine IS drugs • High dose IVIG• Biologics • ILD: No RCTs A third each remain stable, deteriorate or improve on conventional drugs

Statin associated: IVIG at 8-12 w

ARTEMIS: Abatacept in myositis- active treatment vs. delayed 3 months treatment started Responder by IMACS CORE SET- 50% responders vs. 14%

Debate: 4:10-5:00 pm Low dose steroids in RA in the era of biologics

For steroids:– 61% response rates with

csDMARDs = Biologics – ADRs of low dose steroids

uncommon, not serious

Against biologics:– Higher infection rates – TB endemic country– Cost

• Cochrane review:Established RA– lesser role of GC • Higher radiographic progression at 2 y

with csDMARDs • BeSt study: Rx switches most in csDMARD

groupCost saving:• Discontinuation often possible• Biosimilars now availableSafety concerns • VFs common with GC , mortality @ >5

mg/d

Dr Kaushik Bhojani Dr Ramesh Jois

CPC: 5:00-5:45 PM Prof Rohini Handa

Thank you