Background: Although Inflectra, biosimilar infliximab, has been approved by the EMA since September 2013 for all licensed indications of Remicade (innovator infliximab) but there is a paucity of real-world data and guidelines regarding switching from innovator Remicade to Inflectra.

Background Biological disease-modifying antirheumatic drugs (bDMARDs) have made significant positive outcomes in the lives of patients with rheumatic disease. This treatment has proven efficacy in delaying joint destruction and inducing disease remission.1 Studies have shown that pneumococcal vaccination is cost effective while the influenza vaccination significantly prevents morbidity and mortality in the elderly and in patients with chronic disease.1 Objectives To evaluate the pneumococcal and influenza vaccination status in patients receiving biological disease-modifying antirheumatic drugs (bDMARDs). Methods Patients on bDMARDs attending the rheumatology infusion unit were asked about their vaccination status on pneumococcal and influenza using a questionnaire. The patients’ diagnosis, current bDMARD and reasons for not having had vaccination were recorded. Results 92 patients were recruited. Mean age of 53.2 years with 63 (68.5%) female and 29 (31.5%) male. A total of 30 (32.6%) patients received both pneumococcal and influenza vaccination, 1 (1.1%) received pneumococcal vaccination alone, 22 (23.9%) received influenza vaccination alone and 39 (42.4%) had neither. Of the 18 (19.6%) patients age >65 years, 5 (27.8%) received influenza vaccination alone and 8 (44.4%) received both. Patients who did not receive vaccinations were given an educational booklet. The most common diagnosis from our cohort was rheumatoid arthritis(37%), followed by spondyloarthritis(13%), Behçet’s disease(9.8%), myositis(7.6%), vasculitis(5.4%), systemic lupus erythematosus(5.4%), psoriatic arthritis(4.4%) and others(17.4%). 48 (52.2%) were on rituximab, 37 (40.2%) on infliximab, 6 (6.5%) were on tocilizumab and 1 (1.1%) was on abatacept. Of the 61 (66.3%) patients who did not receive the pneumococcal vaccine, 44 (72.1%) were unaware of its availability, 6 (9.8%) were not interested in receiving it, 4 (6.6%) were afraid of the side effects, 4 (6.6%) declined vaccination and 3 (4.9%) were unaware it was recommended. 40 (43.5%) who did not receive the influenza vaccine stated that they were either unaware(45%), not interested(25%), declined vaccination(10%), forgotten(5%), unaware it was recommended(5%) and afraid of the side effects(2.5%). 3 (7.5%) had previous bad experiences from influenza vaccination. Conclusions This is the first study in Ireland looking at vaccination uptake in patients on bDMARDS. The vaccination rate in our cohort was less than satisfactory. Patients on immunosuppressants are recommended to have these vaccinations and preferably to receive them before commencing on the immunosuppressants.2 The lack of awareness is the main reason for failure to be vaccinated. Hence, primary care physicians and the rheumatology team should take active roles in increasing awareness amongst patients about the recommendation for pneumococcal and influenza vaccination. References [1] Doe S, Pathare S, Kelly CA, et al. Uptake of influenza vaccination in patients on immunosuppressant agents for rheumatological diseases: a follow-up audit of the influence of secondary care. Rheumatology. 2007;46:715–6 [] 2Assen S V, Agmon-Levin N, Elkayam O, et al. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2011;70:414–22 Disclosure of Interest None declared

Background The menstrual cycle is regulated by the rise and fall of sex hormones in the body. Literature has demonstrated anti-inflammatory properties in both progesterone and oestrogen hormones.1 There has been recent interest to determine the association between Behçet’s Disease (BD), a poorly understood autoinflammatory disorder and menstruation. Objectives The objective of this study was to evaluate the effect of menstruation in triggering exacerbations of Behçet’s disease in a Northern European cohort. Methods 18 female patients from our rheumatology department satisfying the International Study Group for Behçet’s Disease (ISGBD) criteria were recruited. A questionnaire was conducted via telephone to determine whether their exacerbations of BD were correlated to their menstrual cycle. Results All 18 patients responded to the questionnaire, with the mean age of 38.8 years and mean age of menarche of 13 years. Four (22.22%) patients were in menopausal state. Half (nine) of the patients reported that their BD flare ups were correlated to their menstrual cycle. Exacerbations experienced include oral aphthosis (88.9%), arthralgia (55.6%), genital ulcerations (44.4%), lethargy (44.4%), skin lesions (11.1%) and headaches (11.1%). Six of the seven patients (86%) who were on contraception were on a progesterone containing contraception. Four out of nine (44%) who did not notice any exacerbations during menstruation stated that they were on progesterone containing contraceptives. It is noteworthy that 10 patients (55.56%) had previous pregnancies while three patients experienced an episode of miscarriage and 1 had a stillbirth. Conclusions Our results demonstrated that the disease activity in BD is related to the menstrual cycle, which is contributed by the female sex hormones. The study supports previous hypothesis that the abrupt decline in progesterone during onset of menstruation is associated to disease flare in BD.2 Studies comprising larger cohorts should be conducted to further support and strengthen this evidence. References [1] Szekeres-Bartho J, Barakonyi A, Par G, et al. Progesterone as an immunomodulatory molecule. Int J Immunopharmacol. 2001; 1: 1037–48. [2] Bang D, Chun YS, Haam IB, et al. The influence of pregnancy on Behçet’s disease. Yonsei Med J. 1997; 38: 437–43 Disclosure of Interest None declared

Background Deep Variant Morphea (DMV), previously known as morphea profunda, is an exceptionally rare form of sclerosis that is confined to the skin, and unlike scleroderma, has no systemic or internal organ involvement. The inflammation and sclerosis involves layers of the deep dermis, panniculus, fascia or even the underlying superficial muscle. An initial inflammatory phase, which can be extremely painful, is followed by skin sclerosis, which may cause joint contractures. It is a progressive and highly destructive disease, with apparently no effective treatment, leaving patients with hard, rock-like skin, and ultimately in the worst cases, early death. Objectives To evaluate the treatment impact and efficacy of Abatacept (Orencia) in patients presented with Deep Variant Morphea. Methods Three patients with established deep variant morphea and no contraindications to Abatacept were included in this prospective, open label study. Skin biopsies were performed to confirm deposition of dense fibrous tissue in the appropriate layer of the skin. Baseline Modified Rodnan Score were performed independently by 3 clinicians. VAS scores (10cm) were measured at baseline for Patient Global Disease Activity (PGDA), Patient Global Pain (PGP), Patient Day Pain (PDP), Patient Night Pain (PNP), Physician Global Disease Activity (PhGDA). Further investigations include High Resolution Ultrasound (HRUS) at 10 sites as well as whole body MRI.Patients were commenced on Abatacept (Orencia) as per body weight (10mg/kg), intravenously with tapering dose of oral prednisolone. All outcome measures including imaging were repeated 6-months after commencement of therapy to monitor disease progression. Results All patients tolerated the Abatacept well and showed dramatic improvement including their Baseline Rodnan Score, VAS outcome measures and imaging. All of them continued to be in complete clinical remission. Conclusions Deep variant morphea are difficult to treat. Therefore, timely diagnosis of the condition is crucial, as treatment should be aimed during the early inflammatory phase. The three cases further offer support for the use of Abatacept in cases of acute deep variant morphea, a dreadful, disfiguring and life-threatening disease with apparently no effective treatment until now. References Zwischenberger BA, Jacobe HT. A systematic review of morphea treatments and therapeutic algorithm. J Am Acad Dermatol 2011: 65: 925–941. Fett N, Werth VP. Update on morphea: part II. Outcome measures and treatment. J Am Acad Dermatol 2011: 64: 231–242; quiz 43–44. B. Stausbol-Gron et al. Abatacept is a Promising Treatment for Patients with Disseminated Morphea Profunda: Presentation of Two Cases. Acta Derm Venereol 2011; 91: 686-688. Disclosure of Interest None declared