P.185 Impact of immunosuppressive therapy on burden of recurrent digital ulcers in scleroderma vasculopathy

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Introduction Digital ulcers (DUs) are a painful and disabling ischemic complication of systemic sclerosis (SSc), affecting up to 30% of patients and reflecting underlying vasculopathy. Complex interactions between endothelial cells, vascular smooth muscle cells and circulating immune mediators contribute to the vascular manifestations in SSc. Bosentan, a dual oral endothelin receptor antagonist treatment was associated with a 30% reduction in the number of new DUs compared with placebo. While vasodilators remain the cornerstone of treatment for SSc-related DUs, it remains unclear whether immunosuppressive therapy may ameliorate digital vasculopathy and reduce recurrence balanced against the potential risk of infection in cohort with severe DU burden despite maximal vasomodulatory approaches. Material and Methods We retrospectively analysed the records of 80 SSc patients who are receiving bosentan therapy for DUs. Recurrent digital ulcer was defined as the development of a new digital ulcer despite at least 24 weeks of bosentan therapy. We included patients who were receiving concurrent treatment with immunosuppressants (both conventional synthetic DMARDs and biologic DMARDs) for other SSc-related indications. Results Demographic and clinical characteristics of the cohort, stratified by the presence or absence of recurrent DUs, are summarized in table 1. Immunosuppressive therapy was not associated with reduced odds of developing recurrent DUs (table 2). The only variable significantly associated with increased odds of recurrence was the presence of anti–Scl-70 antibodies (OR 2.85, p= 0.025). Moreover, among patients with recurrent digital ulcers, immunosuppressive therapy was not associated with a higher number of ulcers in the year following initiation of bosentan. Interestingly, the number of DU post bosentan treatment was negatively associated with diffuse cutaneous phenotype, R =-0.58 (p=0.017). Immunosuppressive therapy was not associated with increased odds of soft tissue infection in digital ulcers requiring antibiotic treatment. Among the 67 patients receiving immunosuppressive therapy, none developed osteomyelitis, gangrene, or required hospital admission. Conclusions In this retrospective single-centre study with severe digital vasculopathy, the concurrent use of immunosuppressive therapy was not associated with reduced ulcer recurrence. Importantly, there was no increased risk of infection observed in the immunosuppressive cohort. Larger, multicentre prospective studies are warranted to confirm these observations and better inform clinical decision-making.

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