EULAR delegates share their standout sessions on fibroblasts, vasculitis imaging, gene sequencing for treatment targets, SLE management and more.
Rheumatology advanced trainees Dr Maxine Isbel, Dr Sadia Islam and Dr Elaine Ng have found EULAR 2022 very educational!
Dr Maxine Isbel
Fibroblasts: The next frontier
Sun Tzu said, “If you know your enemy and know yourself, you need not fear the outcome of a hundred battles”.
Centuries later these words still ring true as I listen in to a livestream presentation taking place half a world away. Sun Tzu would not recognise our modern battlefield. Our wars are waged within bodies against an anatomical landscape. Our soldiers are cells we are only now beginning to understand. But his advice will still help us will this war.
Professor Christopher D Buckley is an experienced traveller in this alien landscape and opens the Wednesday basic and translational science stream with a fascinating introduction to fibroblasts. Professor Buckley has published in Nature on this topic for more years than I have been training in rheumatology, and this oral presentation orients the listener to understanding key concepts and potential areas for future intervention.
He is followed by equally adroit speakers covering topics as diverse as macrophage/fibroblast interactions, inflammatory tissue priming and the role of T-cells in early rheumatoid disease.
If you missed it, watch it online. These are quality speakers with important information which may be a platform to the next generation of therapeutics for arthritic disease.
Taking the headache out of GCA
Imaging for large vessel vasculitis is evolving at a speed guaranteed to leave rheumatologists begging off further updates with headaches of their own. A PubMed search on this topic produces 2,900 papers between 2019 and 2022 alone. Thank goodness we can hear a sensible summary of it at EULAR from some of the most published clinician/researchers in this field.
It’s Thursday. I’m listening to the 16:15 session titled “Imaging for the diagnosis and management of vasculitis”. Professor Wolfgang Schmidt has leapt into the churning ocean of large vessel vasculitis imaging with gusto.
Then Professor Annamaria Iagnocco throws a detailed lifesaver ring of tips and technical advances in ultrasound for GCA.
The session winds up with shout from the horizon with Dr William Febry Jiemy, a postdoctoral researcher, talking about the promised land of even better options.
It’s an area that you might easily spend weeks reading up on just to catch up with the last 12 months of data. Or you might to tune in to this session and save the panadol for your patients?
Let’s hope EULAR uploads it on 6 June for another viewing.
A glimpse of the future
Technology has evolved exponentially in the last fifty years. In 1977, Fredrick Sanger sequenced the first whole genome of a virus. Today, Associate Professor Isabelle Meyts uses gene sequencing to identify treatment targets in patients. It’s Friday morning at EULAR and I am hearing about molecular mechanisms which underlie pathogenesis of autoinflammation.
Professor Meyts practices on the razor-sharp edge of translational medicine and can explain molecular pathways as if she is describing her own backyard. But genetic sequencing is a controversial topic. As pointed out by a moderator, even obtaining a timely serology can prove challenging. No one mentions co$t. Evidence of improved outcomes is not presented. As far as tests go, this falls short of several of the WHO criteria for a screening test in rheumatology.
But that is not the point of a good basic science presentation.
In 1969 Neil Armstrong landed on the moon using less computing power than I hold in my iPhone today. Perhaps fifty years from now, genome sequencing will be offered as a bedside test alongside urine dipsticks.
In the meantime, we need to try to keep up with researchers like Professor Meyts. Or get left behind.
Crystal Arthritis
My eight-year-old is obsessed with crystals. When he found out that humans could manufacture birefringent ones from our blood, he was beside himself with enthusiasm for gout. That enthusiasm barely waned when I explained (in probably too much detail) what these crystals did to joints and kidneys.
But we are not here to talk about my dubious parenting philosophies, we’re here to discuss the Saturday 9:10 am session on Crystal Arthritis at EULAR 2022.
Perhaps the most exciting slide was presented by Professor Thomas Bardin as he discussed refractory gout. Professor Bardin had already outlined standard treatments and went on to summarise adjunct therapies in one slide. SGLT2 inhibitors get a mention, reflecting emerging evidence that this drug could potentially cure everything but a rainy day.
Other presenters cover imaging updates and treat to target skilfully, while the final presentation offers some data that rounds it all off with an ice-cold splash of reality. It seems up to 50% of patients will cease their urate lowering therapy within a year of initiation.
Appropriate education to achieve adherence remains our greatest challenge. And, for the record, we are still not discussing my parenting.
- Origin and role of fibroblasts subsets during synovial inflammation (in The role of the synovial microenvironment during onset and progression of arthritis – Basic and Translational Science, 2 June)
- Imaging for the diagnosis and management of vasculitis (2 June)
- Autoinflammatory genes (in Autoinflammation – Basic and Translational Science, 3 June)
- Crystal Arthritis – Clinical Science (4 June)
Dr Maxine Isbel is a Perth-based final year rheumatology trainee and is currently doing a master’s in clinical research.
Dr Sadia Islam
As the EULAR 2022 congress comes to a close, I reflect on some of my highlights including these presentations, which took us through the most challenging aspects of SLE management.
Professor Thomas Dörner provided a whirlwind tour of advances in our understanding of pathogenesis and new therapies in SLE. He highlighted the role of belimumab in achieving low disease activity, reducing glucocorticoid burden and delaying damage, particularly in patients with SLEDAI>10, positive dsDNA, hypocomplementaemia and glucocorticoids>10mg.
He also reviewed anifrolumab, recently approved for moderate-severe SLE, particularly in patients with high IFN signatures aged 18-65 years. The responder profile for patients with low IFN signatures, as well as distinct profiles for belimumab versus anifrolumab responders, remains an exciting area for further research.
Nephrology Professor Gabriella Moroni provided valuable insight into management of lupus nephritis, discussing multitargeted therapy with mycophenolate and calcineurin inhibitors for patients with significant proteinuria, though the eGFR cut-off for voclosporin remains unknown. She also highlighted the importance of repeat renal biopsy at 6-12 months to evaluate response and guide ongoing therapy.
Professor Guillermo Ruiz-Irastorza emphasised the importance of reducing glucocorticoid burden for our SLE patients, stressing the role of pulsed methylprednisone to rapidly achieve disease control and tapering quickly to minimise toxicity.
I can’t wait dig my teeth and mind into the on-demand content and catch up on all the sessions I’ve missed and re-visit my favourites.
- From pathogenesis to new therapies: what is new in SLE? (in Systemic lupus erythematosus – What is New (WIN) 2 June
- How to Manage (HOT) Lupus Nephritis (in Lupus nephritis How to Treat (HOT) 2 June)
- Glucocorticoids in SLE: how much is too much? (in Clinical challenges in SLE – Challenges in Clinical Practice 4 June)
Dr Sadia Islam is a final year rheumatology advanced trainee at Royal Prince Alfred Hospital in Sydney.
Dr Elaine Ng
This article was illustrated by Dr Elaine Ng, a rheumatology advanced trainee based in NSW who enjoys drawing.
