Perceived Need for Mental Health Care in a Cohort of Persons With Inflammatory Bowel Disease

BACKGROUND

Psychiatric comorbidity is common in inflammatory bowel disease (IBD) and can negatively affect disease outcomes. We explored the perceived need for mental health care among persons with IBD.

STUDY

Persons with IBD completed self-report questionnaires, including the Hospital Anxiety and Depression Scale (HADS), and reported whether they wanted help with their mood. Each was also assessed using the Structured Clinical Interview for DSM-IV-TR Axis-I Disorders (SCIDs). We used logistic regression analyses to determine factors associated with the perceived need for mental health care.

RESULTS

Of 245 participants, 28% met the criteria for a past diagnosis of depression or anxiety disorder by SCID, and nearly 23% met the criteria for a current diagnosis of depression or anxiety disorder. One-third (n = 74) reported a perceived need for mental health care. Among those meeting criteria for a current SCID diagnosis of depression or anxiety, only 58% reported needing mental health care. Need for mental health care was reported by 79% of persons currently treated for either depression or 71% treated for anxiety. Persons with a perceived need for mental health care had higher mean HADS for depression and HADS for anxiety scores and also higher IBD symptom activity scores. Of those reporting no perceived need for mental health care, 13% had a current diagnosis of depression or anxiety disorder by SCID; even fewer had symptoms of depression or anxiety.

CONCLUSIONS

Symptoms of depression or anxiety are more important than a formal diagnosis of depression or anxiety in predicting which persons with IBD will perceive a need for mental health care.

Kawasaki disease in Kenya and review of the African literature

BACKGROUND

Kawasaki disease has been described across the globe, although publications from Africa are limited. To our knowledge, there are no publications on Kawasaki disease from Kenya, which triggered this report.

METHODS

A retrospective cross-sectional study was undertaken to identify in-patients with a discharge diagnosis of Kawasaki disease, over 2 different 5-year periods, at two pediatric hospitals in Nairobi, Kenya. We reviewed the medical records of all patients and report their clinical findings, diagnostic workup and treatment. In addition, we undertook a detailed review of the literature.

RESULTS

Twenty-three patients with Kawasaki disease were identified, of those 12 (52.2%) had incomplete disease. The mean age was 2.3 years (SD+/-2.2) (range 0.3-10.3) with a male to female ratio of 1:1. The mean duration of fever at diagnosis was 8.3 days (SD+/-4.7) (range 2-20). Oral changes were the most common clinical feature and conjunctivitis the least common. Thrombocytosis at diagnosis was seen in 52% (12/23). Twenty-one patients (91.3%) were treated with intravenous immunoglobulin and all except 1 received aspirin. Baseline echocardiograms were performed in 95.7% (22/23) and found to be abnormal in 3 (13.6%). Follow-up data was limited. Our literature review identified 79 publications with documented cases of Kawasaki disease in children from 22 countries across the African continent with a total of 1115 patients including those from this report. Only 153 reported cases, or 13.7%, are from sub-Saharan Africa.

CONCLUSIONS

This is the first publication on Kawasaki disease from Kenya and one of the largest reports from sub-Saharan Africa. It is the first to have a complete review of the number of published cases from the African continent. Challenges in the diagnosis and management of Kawasaki disease in many African countries include disease awareness, infectious confounders, access and cost of intravenous immunoglobulin, access to pediatric echocardiography and follow-up. Increasing awareness and health care resources are important for improving outcomes of Kawasaki disease in Africa.

Having More Tender Than Swollen Joints is Associated With Worse Function and Work Impairment in Patients With Early Rheumatoid Arthritis

OBJECTIVE

Patients with early rheumatoid arthritis (RA) may present with more tender than swollen joints, which can persist. Elevated tender-swollen joint difference (TSJD) is often challenging, because there may be multiple causes and it may contribute to overestimating disease activity. Little is known about the phenotype and impact of TSJDs on patient function. Our objective was to evaluate the impact of TSJD on functional outcomes in early RA and to see whether associations vary by joint size.

METHODS

Data were from patients with active, early RA (≤12 months) enrolled in the Canadian Early Arthritis Cohort, who completed assessments of general function (Multidimensional Health Assessment Questionnaire [MDHAQ]), upper extremity (UE) function (Quality of Life in Neurological Disorders [Neuro-QoL] UE scale), and work/activity impairment (Work Productivity and Activity Impairment RA) over their first year of follow-up. A total of 28 joint counts were performed. TSJDs were calculated. Adjusted associations between TSJDs and functional outcomes were estimated in separate multivariable linear mixed effects models. Separate analyses were performed for large- versus small-joint TSJD.

RESULTS

Patients (N = 547) were 70% female, mean age 56 (SD 15) years, mean disease duration 5.3 (SD 2.9) months. At baseline, 287 (52%) had TSJD >0 (43% involved large joints and 34% small joints), decreasing to 32% at 12 months. A one-point increase in TSJD was significantly associated with worse function (MDHAQ: adjusted mean change 0.10, 95% confidence interval [CI] 0.08-0.13; Neuro-QoL UE function T score: adjusted mean change -0.59, 95% CI -0.76 to -0.43; and greater work impairment: adjusted mean change 1.95%, 95% CI 0.85%-3.05%). Higher large-joint TSJDs were associated with the worst functional outcomes.

CONCLUSION

Having more tender than swollen joints is common in early RA and is associated with worse function, most notably when involving large joints. Early identification and targeted intervention strategies may be needed.

Pain and participation in social activities in people with relapsing remitting and progressive multiple sclerosis

Background

Differences in pain between subtypes of multiple sclerosis are understudied.

Objective

To compare the prevalence of pain, and the association between pain and: (a) pain interference and (b) social participation in people with relapsing-remitting multiple sclerosis and progressive multiple sclerosis.

Methods

Participants completed the McGill Pain Questionnaire Short-Form-2, Pain Effects Scale and Ability to Participate in Social Roles and Activities-V2.0 questionnaires. We tested the association between multiple sclerosis subtype, pain severity, and pain interference/social participation using quantile regression.

Results

Of 231 participants (relapsing-remitting multiple sclerosis: 161, progressive multiple sclerosis: 70), 82.3% were women. The prevalence of pain was 95.2%, of more than mild pain was 38.1%, and of pain-related limitations was 87%; there were no differences between multiple sclerosis subtypes. Compared to participants with relapsing-remitting multiple sclerosis, those with progressive multiple sclerosis reported higher pain interference (mean (standard deviation) Pain Effects Scale; progressive multiple sclerosis: 15[6.0] vs relapsing-remitting multiple sclerosis: 13[5], p = 0.039) and lower social participation (Ability to Participate in Social Roles and Activities T-scores 45[9.0] vs 48.3[8.9], p = 0.011). However, on multivariable analysis accounting for age, physical disability, mood/anxiety and fatigue, multiple sclerosis subtype was not associated with differences in pain interference or social participation.

Conclusions

Pain was nearly ubiquitous. Over one-third of individuals with relapsing-remitting multiple sclerosis and progressive multiple sclerosis reported pronounced pain, although this did not differ by multiple sclerosis subtype.

Preferences for COVID-19 Vaccination in People With Chronic Immune-Mediated Inflammatory Diseases

OBJECTIVE

To understand how people with chronic immune-mediated inflammatory diseases (IMIDs) trade off the benefits and risks of coronavirus disease 2019 (COVID-19) vaccine options.

METHODS

We conducted an online discrete-choice experiment in people with IMIDs to quantify the relative importance (RI) of attributes relevant to COVID-19 vaccination. Participants were recruited between May and August 2021 through patient groups and clinics in Canada, and completed 10 choices where they selected 1 of 2 hypothetical vaccine options or no vaccine. The RI of each attribute was estimated and heterogeneity was explored through latent class analysis.

RESULTS

The survey was completed by 551 people (89% female, mean age 46 yrs) with a range of IMIDs (inflammatory bowel disease [48%], rheumatoid arthritis [38%], systemic lupus erythematosus [16%]). Most had received 1 (94%) or 2 (64%) COVID-19 vaccinations. Across the ranges of levels considered, vaccine effectiveness was most important (RI = 66%), followed by disease flare (21%), rare but serious risks (9%), and number/timing of injections (4%). Patients would accept a risk of disease flare requiring a treatment change of ≤ 8.8% for a vaccine with a small absolute increase in effectiveness (10%). Of the 3 latent classes, the group with the greatest aversion to disease flare were more likely to be male and have lower incomes, but this group still valued effectiveness higher than other attributes.

CONCLUSION

Patients perceived the benefits of COVID-19 vaccination to outweigh rare serious risks and disease flare. This supports COVID-19 vaccine strategies that maximize effectiveness, while recognizing the heterogeneity in preferences that exists.

"From Where I Stand": using multiple anchors yields different benchmarks for meaningful improvement and worsening in the rheumatoid arthritis flare questionnaire (RA-FQ)

PURPOSE

The Rheumatoid Arthritis Flare Questionnaire (RA-FQ) is a patient-reported measure of disease activity in RA. We estimated minimal and meaningful change from the perspective of RA patients, physicians, and using a disease activity index.

METHODS

Data were from 3- to 6-month visits of adults with early RA enrolled in the Canadian Early Arthritis Cohort. Participants completed the RA-FQ, the Patient Global Assessment of RA, and the Patient Global Change Impression at consecutive visits. Rheumatologists recorded joint counts and MD Global. Clinical Disease Activity Index (CDAI) scores were computed. We compared mean RA-FQ change across categories using patients, physicians, and CDAI anchors.

RESULTS

The 808 adults were mostly white (84%) women (71%) with a mean age of 55 and moderate-high disease activity (85%) at enrollment. At V2, 79% of patients classified their RA as changed; 59% were better and 20% were worse. Patients reporting they were a lot worse had a mean RA-FQ increase of 8.9 points, whereas those who were a lot better had a -6.0 decrease. Minimal worsening and improvement were associated with a mean 4.7 and - 1.8 change in RA-FQ, respectively, while patients rating their RA unchanged had stable scores. Physician and CDAI classified more patients as worse than patients, and minimal and meaningful RA-FQ thresholds differed by group.

CONCLUSION

Thresholds to identify meaningful change vary by anchor used. These data offer new evidence demonstrating robust psychometric properties of the RA-FQ and offer guidance about improvement or worsening, supporting its use in RA care, research, and decision-making.

AB1180 COVID-19 HAD DISPROPORTIONATE IMPACTS ON RA SYMPTOMS AND FUNCTION BY SEX AND AGE: RESULTS FROM THE CANADIAN EARLY ARTHRITIS COHORT (CATCH)

Background

During the COVID-19 pandemic, Canadians with RA faced considerable uncertainty due to greater risk of infection, hospitalization, changing access to RA medications, and very limited access to in-person RA care. Further, to reduce transmission of the virus and COVID-related hospitalizations, stringent mitigation measures were implemented across the country to greatly reduce social contacts including curfews, limits on private gatherings and business closures. Little is known about the impact of the COVID-19 pandemic and associated mitigation efforts in RA. We hypothesized that women and younger adults with RA would report greater impairments in HRQL.

Objectives

To compare changes in HRQL prior-to and during the COVID-19 pandemic by sex and age groups in real-world RA patients seen in routine practice settings.

Methods

Data were from patients in the Canadian Early Arthritis Cohort (CATCH) who completed a study visit in the year prior to the COVID-19 pandemic (Mar 2019 through Feb 2020) and a repeat assessment during the pandemic period (Mar 2020 – Jan 2022). RA disease activity was assessed using the RA Flare Questionnaire, a validated patient-reported measure of current RA disease symptoms (pain, stiffness, fatigue) and function (physical, participation). An RA-FQ score ≥ 20 was used to classify RA symptoms consistent with an RA inflammatory flare. HRQL was assessed using PROMIS-29 Adult Profiles. We compared changes in mean Physical (PHS) and Mental Health (MHS) scores, and the proportion of patients with impairments in each domain (i.e., scores ≥ 55 for pain interference, fatigue, anxiety, depression, and sleep and ≤45 for physical function and participation) before and during the COVID-19 pandemic across sex and age groups (<40, 40-64, ≥65 years).

Results

The 938 CATCH participants in the analytic sample with data available at both time periods had a mean (SD) age of 60 (13) and RA symptom duration of 5.8 (3.7) years; 72% were women, 88% were white, and 64% reported >high school education. Most (80%) were in CDAI REM/LDA at the most recent visit prior to start of pandemic. The proportion of patients with RA-FQ ≥20 were similar at both time periods. While physical and emotional RA symptom impacts remained stable in men prior to and during the COVID-19 pandemic, women reported significant increases in anxiety and depression during the pandemic period. Younger RA patients <40 reported increases in depression, and older RA patients (65+) reported increases in anxiety and greater impacts on participation.

Conclusion

Our results illustrate that while the proportions of patients with high inflammatory disease activity were similar prior to and during the COVID-19 pandemic, we observed disproportionate impacts on HRQL by sex and age with a higher proportion of women, adults <40, and those ≥65 years of age experiencing greater impairments in several HRQL domains.

Table 1.DomainWomen (N = 673)Men (N=265)Age <40 (N=84)Age 45-64 (N=492)Age 65+ (N= 362)BeforeDuringBeforeDuringBeforeDuringBeforeDuringBeforeDuringRA Flare >20%17%21%19%18%13%7%18%21%18%21%Anxiety34%*42%*23%23%42%55%32%35%28%*35%*Depression28%*34%*22%20%25%*42%*28%28%24%30%Fatigue36%38%24%23%43%43%36%33%26%32%Pain47%52%48%45%39%48%46%49%49%54%Physical function54%57%46%46%40%40%49%50%59%62%Participation42%47%34%36%37%38%40%41%40%*49%*Sleep30%34%18%22%26%29%29%33%23%28%

*p <0.05

Acknowledgements

CATCH is supported through unrestricted research grants from: Amgen and Pfizer Canada since 2007; AbbVie since 2011; Medexus since 2013; Sandoz Canada since 2019; Fresenius Kabi Canada since 2021 and; Organon Canada since 2021. Previous funding from Janssen Canada (2011-16); UCB Canada and Bristol-Myers Squibb Canada (2011-18); Hoffman La Roche (2011-21); Sanofi Genzyme (2016-17); Eli Lilly Canada (2016-20); Merck Canada (2017-21) and Gilead Sciences Canada (2020-21)

Disclosure of Interests

None declared

POS1210 SAFETY AND IMMUNOGENICITY OF COVID-19 VACCINES IN PATIENTS WITH IMMUNE MEDIATED INFLAMMATORY DISEASE

Background

COVID-19 vaccination strategies have evolved with increasing vaccine availability and emerging vaccine safety data. While data on immunogenicity and safety of COVID vaccination strategies exists, there is limited data for people with immune mediated inflammatory diseases (IMIDs) such as inflammatory arthritis (IA), systemic autoimmune rheumatic disease (SARD), inflammatory bowel disease (IBD) and multiple sclerosis (MS).

Objectives

In IMID patients treated with homologous or heterogeneous COVID vaccines, to compare post vaccine IMID disease activity and COVID antibody responses.

Methods

Between March 2021 and Dec 2021, patients with IA (n= 70; 77% rheumatoid arthritis), SARD (n=82; 70% lupus), IBD (n= 92; 40% crohn’s), and MS (n= 71; 77% RRMS) self-reported COVID illness and exposure risks, and disease activity prior to and 1 month post both COVID-19 vaccinations (V1 and V2). Disease activity was assessed by the Systemic Lupus Activity Questionnaire (SLAQ) for SARDs, the RAPID-3 and RA flate index for IA, the IBD Symptoms Inventory-short form (IBDSI) and IBD flare index for IBD and the 25 meter walk and 9 hole peg test and Expanded Disability Status Scale (EDSS) for MS. Patient reported flare state was assessed using the relevant questions these indices (SLAQ “Have you had a flare?”; RA Flare index “Are you in a flare?”; IBD flare “My IBD is sometimes to continously active“). Disease activity and serum anti-spike, anti-receptor binding domain (RBD) and anti-nucleocapsid (NC) IgG antibody titers at 30 days post V2 were compared across vaccine courses and to age-sex matched vaccinated blood donor controls (CNTS).

Results

Patients were predominantly female (79.7%), with a mean (standard deviation-sd) age of 56 (15) years; 8% had suspected or diagnosed COVID-19 illness; 1.2% positive anti-NC (Table 1). For all IMIDS, the majority received mRNA vaccines-BNT162b2 (BNT) or mRNA1273 (V1 74%; V2 97%;) the rest received ChAdOx1 viral vector vaccines; 71% received homologogous vaccines (ChAdOx1-ChAdOx n=6; BNT-BNT n=174; mRNA1271-mRNA1273 n=21; ChAdOx1-BNT n=36; ChAdOx1- mRNA1273 n=30; BNT-mRNA1273 n=15; mRNA1273-BNT n=3; other n=4). For most IMIDs, disease activity was similar before and after each vaccination. Post V2 disease activity did not differ between homologous versus heterologous vaccines nor by vaccine type (RAPID3; SLAQ, 25 meter walk and 9 hole peg test and EDSS overall and subscales, IBDSI overall and subscales all p=NS). In 254 IMIDs, most seroconverted (anti-spike 86%; anti-RBD 96%). Seroconversion rates for CNTS were 98.1% for anti-Spike and 3.5% for anti-NC. Antibody titers were higher following homologous mRNA (BNT or mRNA12723) than homologous vector vaccine (Figure 1). For IMIDs primed with ChAdOx vector vaccine, boosting with BNT or mRNA1273 generated similarly increased anti-Spike and anti-RBD titers.

Table 1.All IMIDsIASARDIBDMSAge (mean (sd) years)56(15)63(12)56(14)54(16)51(17)Female (%)8084906483COVID risk exposure (%) Any4439465044 Contact1412141221 Travel66666 HCW/hospitalized151516209 Other risk9610128V1 mRNA (%)7480688264V2 mRNA (%)9798969699Homologous V1 V2 (%)7179677464Flare status post V2 (%)101560-Seroconversion (%) Anti-Spike8990869384 Anti-RBD9192869688Figure 1.

Post vaccine antibody titers

Conclusion

Heterologous COVID vaccination improves seroconversion rates following a viral vector vaccine and does not lead to disease flare in most IMID patients. While data is needed to assess vaccine effectiveness, duration of immunogenicity and effects of subsequent vaccination, this work supports mixing COVID vaccines for IMID patients.

Acknowledgements

Study funded by Research Manitoba

Disclosure of Interests

None declared

AB1089 PSYCHOSOCIAL IMPACTS OF THE COVID-19 PANDEMIC ON ETHIOPIAN AND CANADIAN RHEUMATOLOGY PATIENTS

Background

The Coronavirus-2019 (COVID-19) pandemic increased psychosocial distress in the general population and in patients with rheumatic disease. Limited data exists on the impact of COVID-19 in rheumatology patients living in Africa.

Objectives

To describe COVID-19 related illness and psychosocial impact in Ethiopian (ET) rheumatology patients attending the only public rheumatology clinic in Ethiopia (Tikur Anbessa Specialized Hospital (TAH) in Addis Ababa). To compare findings in ET with findings in Canadian (CA) rheumatology patients.

Methods

Between May 1 and Oct 31 2021, 130 patients attending the TAH rheumatology clinic answered questions related to COVID-19 infection, symptoms and testing, and psychosocial impacts of the COVID-19 pandemic. We assessed depression (Patient Health Questionnaire- 9), anxiety (General Anxiety Disorder-7; GAD7), COVID-19 stress factors and coping measures, Resilience (Brief Resilience Scale-BRS) and medication compliance (Morisky medication adherence scale – 4 item; MAS4). Rheumatic disease severity was assessed with the Routine Assessment of Patient Index Data-3 (RAPID-3). Questionnaires were translated to Amharic. Descriptive statistics are reported [mean (standard deviation), median (25%, 75%) number and percent.)] and compared to data of 97 CA patients with rheumatoid arthritis (RA) and lupus patients from Quebec1.

Results

ET patients were mainly female (71%) with a mean (SD) age of 47 (16), and resided in the capital city (Addis Ababa) (72%). Half had RA or lupus. A quarter of patients had moderate to severe rheumatic disease severity desite good medication adherence [MAS4 score of 3(2,4)]. Most (89%) reported no COVID-19 symptoms since the beginning of the pandemic, were not tested for COVID-19 and reported few risk factors for COVID-19 exposure. Eight (6%) ETs were diagnosed with COVID-19; 2 required hospitalization. Diagnosed patients reported a median of 2 COVID-19 symptoms (range 0-8; mainly cough, fever and malaise). Within the entire cohort, depression (PHQ9= 10 or above) and anxiety (GAD7=10 or above) were more frequent in ETs than CAs (depression 30% vs 3%; anxiety 16% vs 1%) yet nearly half (47%) of ETs had normal or high resilience levels. The most common COVID-19 stressors were risk of contracting COVID illness personally [ETs vs CAs risk ratio(95% confidence limits- CL); 0.67 (0.5, 0.99)] or of loved one [0.56 (0.36, 0.86)]. More ETs reported COVID-19 related stress related to difficulty obtaining food, medicine or other essentials [1.74, (1.00-3.0)], and getting needed supports [1.97 (1.03, 3.77)] (Table 1). CAs and ETs used similar levels of problem solving [median (25%,75%) CA 3.3 (2.8, 3.3), ET 3.5 (3.0, 3.7)] and emotion-focus [CA 2.5 (2.2, 3.1); ET 3.3 (2.8, 3.7)] coping strategies.

Table 1.

COVID-19 related stressors reported by Ethiopian and Canadian rheumatology patients

Common stressors from the coronavirus pandemic reported as severe †ET % reportedCA % reportedRR (95% CI) ET vs CAGetting sick28410.67 (0.5, 0.99)Having a loved one who becomes ill23410.56 (0.36, 0.86)Difficulty getting food, medicine and other essentials29161.74 (1.0-3.0)Difficulty getting support or help24121.97 (1.03-3.77)Postponement or cancellation of tests8200.42 (0.18, 0.95)Losing a job or experiencing a drop in income19100.185 (0.90, 3.81)Having more responsibilities at home21201.06 (0.59, 1.87)Having to work in a place likely to expose you to the coronavirus20270.73 (0.42, 1.24)Postponement or cancellation of medical visits19151.2 (0.63, 2.28)Changes in treatments7150.43 (0.17, 1.06)

†Severe stress = score 2 (moderately) to 5 (extremely)

Conclusion

During the COVID-19 pandemic, depression was more common in ETs compared to CAs with rheumatic disease. COVID-19-related stressors due to insecurity in obtaining the basic essentials and support were more pronounced in ETs. Differences between ETs and CA in these stressors may reflect local public health and economic supports. There were no differences in coping strategies.

References

[1]DaCosta et al presented at 21stCentury Lupus Conference, Sept. 2021

Acknowledgements

Study supported by the Global Rheumatology Alliance-International League of Associations for Rheumatology “ COVID-19 illness in Ethiopian rheumatology patients” and the Arthritis Society: “The impact of antimalarial drugs in arthritis patients exposed to SARS-CoV-2-the CoVIRAL project. The Arthritis Society. COVID-20-001.”

Disclosure of Interests

None declared

OP0308-HPR MORE THAN HALF OF RA PATIENTS WITH A LIFETIME HISTORY OF MOOD DISORDERS WERE ANXIOUS AND DEPRESSED DURING THE COVID-19 PANDEMIC: RESULTS FROM THE CANADIAN EARLY COHORT (CATCH) STUDY

Background

A growing number of studies indicate the considerable mental health impacts of the prolonged COVID-19 pandemic in the general population as chronic stress is a risk factor for the development of depression and anxiety. Mood disorders are more prevalent in RA and a history of anxiety or depressive disorders increases the risk of recurrence in the future.

Objectives

To compare trends in prevalence of anxiety and depressive symptoms, prior to and during the COVID-19 pandemic in RA patients with and without a lifetime history of mood disorders.

Methods

Data were from RA patients diagnosed and treated for RA in rheumatology clinics across Canada enrolled in the Canadian Early Arthritis Cohort (CATCH) Study. We estimated monthly trends in prevalence of clinically significant levels of anxiety and depression (PROMIS Depression and Anxiety 4a score 55+) from all visits between Mar 2019 and Jan 2022 and compared monthly trends in anxiety and depression in the year prior to (Mar 2019- Feb 2020) and during the pandemic (Mar 2020 to Jan 2022) stratified by lifetime history of mood disorders.

Results

4,148 visits were completed from Mar 2019 to Jan 2022 in 1,644 RA patients with a mean (SD) age of 60 (14) and disease duration of 6 (4) years. 73% were women, 84% white, 60% had completed some post-secondary education, and 77% were in CDAI REM/LDA at the visit closest to the start of pandemic. 253 (15%) reported a lifetime history of depression and 217 (13%) a lifetime history of anxiety; 8% reported prior treatment for either.

Patients with a history of mood disorders had higher levels of depression and anxiety prior-to and during the pandemic compared with patients without a history of mood disorders (Table 1). Proportions were highest during COVID waves in all and were substantially higher and more variable in people with a previous history of mood disorders as compared to those without a history (Figure 1). While depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021).

Table 1.

Prevalence of depression and anxiety symptoms prior to and during the COVID-19 pandemic in RA patients with and without a history of mood disorders.

Period Prevalence (monthly range)DepressionAnxietyNo historyPrior HistoryNo HistoryPrior HistoryN observations35276213610538Prepandemic (3/19 - 2/20)21%(14%-30%)51%(29%-64%)27%(20%-35%)58%(31%-89%)Pandemic (3/20 - 1/22)22%(15%-29%)53%(33%-78%)28%(20%-43%)59%(33%-80%)Figure 1.

During the first 22 months of the COVID-19 pandemic, the proportion of patients with depression and anxiety increased in all groups. More than half of those with a history of emotional distress had clinically significant levels of depression and anxiety; proportions were highest during COVID waves in all and were substantially higher in people with previous history as compared to those without a history (see Figure 1). Whereas depressive symptoms peaked early in the pandemic, anxiety increased with each wave, peaking in Wave 3 (May-Jun 2021).

Conclusion

Symptoms of anxiety and depression were common in Canadian adults with RA prior to and after the onset of the COVID-19 pandemic. Whereas others have found that high levels of depression and anxiety occurred early in the pandemic but declined fairly rapidly in the general population1, emotional distress was not attenuated over time in this large cohort of RA patients. Individuals reporting lifetime history of mood disorders were more than twice as likely to report anxiety and depression, with depression peaking early in the pandemic and anxiety growing with each successive wave in the first year. The results demonstrate the importance of applying a lifetime perspective as previous episodes of anxiety and depression may be an important marker of increased vulnerability and recurrence in RA patients, particularly during the pandemic.

References

[1]Fancourt D et al. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England. Lancet Psychiatry. 2021;8:141-9.

Acknowledgements

CATCH is supported through unrestricted research grants from: Amgen and Pfizer Canada since 2007; AbbVie Corporation since 2011; Medexus since 2013; Sandoz Canada since 2019; Fresenius Kabi Canada since 2021 and; Organon Canada since 2021. Previous funding from Janssen Canada (2011-16); UCB Canada and Bristol-Myers Squibb Canada (2011-18); Hoffman La Roche Limited (2011-21); Sanofi Genzyme (2016-17); Eli Lilly Canada (2016-20); Merck Canada (2017-21) and; Gilead Sciences Canada (2020-21)

Disclosure of Interests

None declared

Vaccine effectiveness against SARS-CoV-2 infection and severe outcomes among individuals with immune-mediated inflammatory diseases tested between March 1 and Nov 22, 2021, in Ontario, Canada: a population-based analysis

Background

We estimated COVID-19 vaccine effectiveness against SARS-CoV-2 infection and severe COVID-19 outcomes among individuals with immune-mediated inflammatory diseases in Ontario, Canada.

Methods

In this population-based analysis, we used a test-negative design across four immune-mediated inflammatory disease population-based cohorts, comprising individuals with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease. We identified all SARS-CoV-2 tests done in these populations between March 1 and Nov 22, 2021 (a period in which there was rapid uptake of vaccines, and the alpha [B.1.1.7] and delta [B.1.617.2] SARS-CoV-2 variants were predominantly circulating in Canada) and separately assessed outcomes of SARS-CoV-2 infection and severe COVID-19 outcomes (hospitalisation due to COVID-19 and death due to COVID-19) for each disease group. We used multivariable logistic regression to estimate the effectiveness of one, two, and three doses of mRNA-based COVID-19 vaccine (BNT162b2 [Pfizer–BioNTech], or mRNA-1273 [Moderna]) among individuals at the time of SARS-CoV-2 testing.

Findings

Between March 1 and Nov 22, 2021, we identified 2127 (5·9%) test-positive cases among 36 145 individuals (26 476 [73·2%] were female and 9669 [26·8%] were male) with rheumatoid arthritis tested, 476 (6·1%) test-positive cases among 7863 individuals (4130 [52·5%] were female and 3733 [47·5%] were male) with ankylosing spondylitis tested, 3089 (6·5%) test-positive cases among 47 199 individuals (26 062 [55·2%] were female and 21 137 [44·8%] were male) with psoriasis tested, and 1702 (5·4%) test-positive cases among 31 311 individuals (17 716 [56·6%] were female and 13 595 [43·4%] were male) with inflammatory bowel disease tested. Adjusted vaccine effectiveness of two doses against infection was 83% (95% CI 80–86) in those with rheumatoid arthritis, 89% (83–93) among those with ankylosing spondylitis, 84% (81–86) among those with psoriasis, and 79% (74–82) among those with inflammatory bowel disease. After two vaccine doses, effectiveness against infection generally peaked 31–60 days after vaccination and waned gradually with each additional month. Vaccine effectiveness against severe outcomes after two doses was 92% (95% CI 88–95) in those with rheumatoid arthritis, 97% (83–99) among those with ankylosing spondylitis, 92% (86–95) among those with psoriasis, and 94% (88–97) among those with inflammatory bowel disease. Vaccine effectiveness after a third dose against infection was similar to or higher than after the second dose (ranging from 76% [47–89] to 96% [72–99]), although due to a paucity of events, estimates could not be calculated for some subgroups for severe outcomes.

Interpretation

Two vaccine doses were found to be highly effective against both SARS-CoV-2 infection and severe COVID-19 outcomes in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease during the study period. Research is needed to determine the durability of effectiveness of three doses over time, particularly against emerging variants.

Funding

Public Health Agency of Canada

Utility of Baseline Transcriptomic Analysis of Rheumatoid Arthritis Synovium as an Indicator for Long-Term Clinical Outcomes

Objective:

Rheumatoid arthritis is a chronic inflammatory autoimmune disease that can lead to synovial damage, persistent joint pain, and functional disability. Our objective was to evaluate baseline synovial transcriptome from early inflammatory arthritis patients (EIA) and identify pretreatment biomarkers that could potentially provide insights into long-term functional outcomes of rheumatoid arthritis (RA).

Methods

Synovial biopsies from clinically inflamed knee joints were procured from either 17 EIA patients before initiation of disease modifying anti-rheumatic drug (DMARD) therapy (DMARD-naïve EIA) using the minimally invasive closed needle biopsy technique or advanced RA patients undergoing arthroplasty. Affymetrix Human Genome U133 Plus 2 microarray platform was used to profile the synovial transcriptome. The cohort was followed clinically for a median of 12.3 years, and patient data was collected at each visit. Short-term and long-term clinical outcomes were determined by assessing RA-associated clinical parameters Statistical adjustments were made to account for asynchronous clinical visits and duration of follow up.

Results

Based on the transcriptomic analysis, we identified 5 differentially expressed genes (DEGs), including matrix metalloproteinase (MMP)-1 (fibroblast collagenase) and MMP-3 (stromelysin-1) in DMARD-naïve EIA patients, relative to advanced RA patients (q < 0.05). Dichotomous expression of MMP-1 and MMP-3 mRNA and protein was confirmed by qPCR and immunohistochemistry respectively, based on which DMARD-naïve EIA subjects were classified as MMP-high or MMP-low. Hierarchical clustering of transcriptomic data identified 947 DEGs between MMP-high and MMP-low cohorts. Co-expression and IPA analysis of DEGs in the MMP-high cohort showed an enrichment of genes that participated in metabolic or biochemical functions and intracellular immune signaling were regulated through NF-κB and β-catenin complexes and correlated with markers of systemic inflammation. Analysis of short-term clinical outcomes in MMP-high cohort showed a significant reduction in the DAS-CRP scores relative to baseline (P <0.001), whereas area under the curve analyses of modified HAQ (mHAQ) scores correlated negatively with baseline MMP-1 (R = −0.59, P = 0.03). Further, longitudinal mHAQ scores, number of swollen joints, number of DMARDs and median follow-up duration appeared to be higher in MMP-low cohort.

Conclusion

Overall, our results indicate that the gene expression profiling of synovial biopsies obtained at the DMARD-naive stage in patients with EIA categorizes them into subsets with varying degrees of inflammation and can predict the future of long-term clinical outcome.

Predictors of Influenza Vaccination in Early Rheumatoid Arthritis 2017-2021: Results From the Canadian Early Arthritis Cohort

Objective

Adults with rheumatoid arthritis (RA) are at a higher risk for infections, including influenza and related complications. We identified influenza vaccination coverage in adults newly diagnosed with RA and examined sociodemographic RA characteristics and attitudes associated with vaccination.

Methods

We used data from patients enrolled in the Canadian Early Arthritis Cohort between September 2017 and February 2021. At enrollment, participants reported their vaccination status in the previous year and completed the Beliefs About Medicines Questionnaire (BMQ). Clinical data were obtained from medical records. Logistic regression was used to identify predictors of vaccination in the year after RA diagnosis.

Results

The baseline analytic sample of 431 patients were mostly White (80%) women (67%) with a mean age of 56 (SD 14) years. Prediagnosis, influenza vaccine coverage was 38%, increasing to 46% post diagnosis in the longitudinal sample (n = 229). Participants with previous influenza vaccination (odds ratio [OR] 15.33; 95% confidence interval [CI] 6.37‐36.90), on biologics or JAKs (OR 5.42; 95% CI 1.72‐17.03), and with a higher change in BMQ Necessity‐Concerns Differential scores (OR 1.08; 95% CI 1.02‐1.15) had greater odds, whereas women (OR 0.32; 95% CI 0.14‐0.71), participants with a non‐White racial background (OR 0.13; 95% CI 0.04‐0.51), and participants currently smoking (OR 0.09; 95% CI 0.02‐0.37) had lower odds of influenza vaccine coverage.

Conclusion

Influenza vaccination coverage in patients with early RA remains below national targets in adults living with a chronic condition. Discussing vaccine history and medication attitudes at initial clinic visits with new patients with RA may enhance vaccine acceptance and uptake.

COVID-19 Vaccination Uptake among individuals with Immune-Mediated Inflammatory Diseases in Ontario, Canada between December 2020 and October 2021: A population-based analysis

OBJECTIVE

We assessed COVID-19 vaccine uptake among individuals with immune-mediated inflammatory diseases (IMID) and the Ontario general population.

METHODS

We studied all residents 16 years and older who were alive and enrolled in Ontario's universal health insurance plan as of December 14, 2020 when vaccination commenced (n=12,435,914). Individuals with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), psoriasis (PsO), and inflammatory bowel disease (IBD) were identified using established disease-specific case definitions applied to health administrative data. Vaccination status was extracted from the provincial COVaxON registry. Weekly cumulative proportions of first and second doses up until October 3, 2021 were expressed as the vaccinated percentage of each disease group, and compared to the general Ontario population, and stratified by age.

RESULTS

By October 3, 2021, the cumulative percentage with at least one dose was 82.1% for the general population, 88.9% for RA, 87.4% for AS, 90.6% for PsA, 87.3% for PsO, and 87.0% for IBD. There was also a higher total cumulative percentage with two doses among IMIDs (83.8-88.2%) vs the general population (78.0%). The difference was also evident when stratifying by age. Individuals with IMIDs in the youngest age group initially had earlier uptake than the general population but remain the lowest age group with two doses (70.6% in the general population vs. 73.7-79.2% across IMID groups).

CONCLUSION

While implementation of COVID-19 vaccination programs has differed globally, these Canadian estimates are the first to reassuringly show higher COVID-19 vaccine uptake among individuals with IMIDs.

Characterization and use of the ECV304 autoantigenic citrullinome to understand anti-citrullinated protein/peptide autoantibodies in rheumatoid arthritis

Background

Anti-citrullinated protein antibodies (ACPAs) are highly specific for rheumatoid arthritis (RA). In vivo, ACPAs target peptidyl-citrulline epitopes (cit-) in a variety of proteins (cit-prot-ACPAs) and derived peptides (cit-pept-ACPAs) generated via the peptidylarginine deiminase (PAD) isoenzymes. We aimed to identify a cell line with self-citrullination capacity, to describe its autoantigenic citrullinome, and to test it as a source of autocitrullinated proteins and peptides.

Methods

Human cell lines were screened for cit-proteins by Western blot. PAD isoenzymes were identified by RT-PCR. Autocitrullination of ECV304 was optimized, and the ECV304 autocitrullinomes immunoprecipitated by sera from three RA patients were characterized by mass spectrometry. Cit-pept-ACPAs were detected using anti-CCP2 ELISA and cit-prot-ACPAs, by an auto-cit-prot-ECV304 ELISA. Sera from 177 RA patients, 59 non-RA rheumatic disease patients and 25 non-disease controls were tested.

Results

Of the seven cell lines studied, only ECV304 simultaneously overexpressed PAD2 and PAD3 and its extracts reproducibly autocitrullinated self and non-self-proteins. Proteomic analysis of the cit-ECV304 products immunoprecipitated by RA sera, identified novel cit-targets: calreticulin, profilin 1, vinculin, new 14–3-3 protein family members, chaperones, and mitochondrial enzymes. The auto-cit-prot-ECV304 ELISA had a sensitivity of 50% and a specificity of 95% for RA diagnosis.

Conclusions

ECV304 cells overexpress two of the PAD isoenzymes capable of citrullinating self-proteins. These autocitrullinated cells constitute a basic and clinical research tool that enable the detection of cit-prot-ACPAs with high diagnostic specificity and allow the identification of the specific cit-proteins targeted by individual RA sera.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02698-2.

Depressive symptom trajectories and polygenic risk scores in individuals with an immune-mediated inflammatory disease

OBJECTIVE

To develop group-based trajectories of depressive symptoms in immune-mediated inflammatory disease (IMID) to understand their evolution and identify any associated factors, with the overall goal of identifying those at highest risk of higher depressive symptom burden.

METHOD

922 participants had an IMID or anxiety/depression. The PHQ-9 was administered at four visits, and polygenic risk scores (PRS) for major depressive disorder, depressive symptoms, and body mass index (BMI) were generated. Group-based trajectory modelling of PHQ-9 scores estimated distinct trajectories. Regression tested whether specific factors were associated with the trajectories. Mediation analyses assessed whether IMID mediated the association between BMI PRS and trajectories.

RESULTS

Three trajectories were identified. Regression demonstrated those in Group 3 ('high symptoms') had significantly higher PRS for the three traits, compared to Group 1 ('minimal symptoms') (OR: 1.34-1.66, P < 0.01). Stratified analyses in the IMID subgroup revealed an increased effect for BMI PRS in Group 3 (OR: 2.31, P < 0.001), in contrast, BMI PRS was no longer associated in the non-IMID sample. No significant indirect effect of BMI PRS on depressive symptoms trajectories was identified via IMID.

CONCLUSIONS

A significant association between polygenicity and PHQ-9 trajectories supports a role for genetic inheritance in the variability in depressive symptoms in IMID.

Childhood Maltreatment and Psychiatric Comorbidity in Immune-Mediated Inflammatory Disorders

OBJECTIVE

To determine whether childhood maltreatment is associated with immune-mediated inflammatory disorders (IMIDs; multiple sclerosis [MS], inflammatory bowel disease [IBD], and rheumatoid arthritis [RA]). We further aimed to determine the relationship between maltreatment and psychiatric comorbidity in IMIDs and whether these relationships differed across IMID.

METHODS

Six hundred eighty-one participants (MS, 232; IBD, 216; RA, 130; healthy controls, 103) completed a structured psychiatric interview to identify psychiatric disorders, and the Childhood Trauma Questionnaire to evaluate five types of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. We evaluated associations between maltreatment, IMID, and psychiatric comorbidity using multivariable logistic regression models.

RESULTS

The prevalence of having ≥1 maltreatment was similar across IMID but higher than in controls (MS, 63.8%; IBD, 61.6%; RA, 62.3%; healthy controls, 45.6%). Emotional abuse was associated with having an IMID (adjusted odds ratio [aOR] = 2.37; 1.15-4.89). In the sex-specific analysis, this association was only present in women. History of childhood maltreatment was associated with a lifetime diagnosis of a psychiatric disorder in the IMID cohort (OR = 2.24; 1.58-3.16), but this association did not differ across diseases. In those with IMID, total types of maltreatments (aOR = 1.36; 1.17-1.59) and emotional abuse (aOR = 2.64; 1.66-4.21) were associated with psychiatric comorbidity.

CONCLUSIONS

Childhood maltreatment is more common in IMID than in a healthy population and is associated with psychiatric comorbidity. Given the high burden of psychiatric disorders in the IMID population, clinicians should be aware of the contribution of maltreatment and the potential need for trauma-informed care strategies.

A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort

OBJECTIVE

To describe patterns of glucocorticoid use in a large real-world cohort with early rheumatoid arthritis (RA) and assess the impact on disease activity and treatment.

METHODS

Data are from adults with new RA (≤1 year) recruited to the Canadian Early Arthritis Cohort (CATCH) and are stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry. Disease activity was compared over 24 months. Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months, with random effects terms to account for prescribing patterns clustering by study site.

RESULTS

Among 1891 persons, 30% received oral steroids. Users were older, were less often employed, and had shorter disease duration and higher disease activity. Disease activity improved over time, with early glucocorticoid users starting at higher levels of disease activity. Participants with early oral glucocorticoids were more likely to be on a biologic at 12 months (aOR = 2.4; 95% confidence interval [CI], 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0). Despite Canadian clinical practice guidelines to limit corticosteroid use to short-term or 'bridge' therapy, 30% of patients who used oral glucocorticoids still used them 2 years later.

CONCLUSION

Early steroids were prescribed sparingly in CATCH and were often indicative of more active baseline disease as well as the need for progression to biologics.

Prevalence and Risk Factors of Substance Use Disorder in Rheumatoid Arthritis

Objective

In this study, we aimed to determine the lifetime prevalence of substance use disorder (SUD) in a Canadian rheumatoid arthritis (RA) cohort and factors associated with SUD in RA.

Methods

Participants with RA (N = 154) were recruited via rheumatology clinics as part of a larger cohort study of psychiatric comorbidity in immune‐mediated inflammatory diseases. SUD is defined as the uncontrolled use of a substance despite the harmful consequences of its use. To identify lifetime SUD, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was administered to participants. Participants’ sociodemographic and RA clinical characteristics were also assessed. We examined factors associated with lifetime SUD using unadjusted and adjusted logistic regression modeling.

Results

Twenty‐three (14.9%) of 154 participants with RA met the criteria for a lifetime diagnosis of SUD. The majority of the participants were women, were White, had postsecondary education, and were on a disease‐modifying antirheumatic drug. Factors associated with increased odds of SUD were male sex (adjusted odds ratio [aOR]: 3.63, 95% confidence interval [CI]: 1.03‐12.73), younger age (aOR: 0.94, 95% CI: 0.90‐0.98), and ever smoking (aOR: 6.44, 95% CI: 1.53‐27.07).

Conclusion

We found that approximately 1 in 7 individuals with RA had a lifetime diagnosis of SUD, highlighting the importance of identifying and treating SUD in those with RA. In particular, the following factors were associated with higher odds of SUD: male sex, younger age, and smoking behaviors.

Diabetes mellitus and cardiovascular risk management in patients with rheumatoid arthritis: an international audit

Aim

The objective was to examine the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its risk factors among patients with RA with diabetes mellitus (RA-DM) and patients with RA without diabetes mellitus (RAwoDM), and to evaluate lipid and blood pressure (BP) goal attainment in RA-DM and RAwoDM in primary and secondary prevention.

Methods

The cohort was derived from the Survey of Cardiovascular Disease Risk Factors in Patients with Rheumatoid Arthritis from 53 centres/19 countries/3 continents during 2014–2019. We evaluated the prevalence of cardiovascular disease (CVD) among RA-DM and RAwoDM. The study population was divided into those with and without ASCVD, and within these groups we compared risk factors and CVD preventive treatment between RA-DM and RAwoDM.

Results

The study population comprised of 10 543 patients with RA, of whom 1381 (13%) had DM. ASCVD was present in 26.7% in RA-DM compared with 11.6% RAwoDM (p<0.001). The proportion of patients with a diagnosis of hypertension, hyperlipidaemia and use of lipid-lowering or antihypertensive agents was higher among RA-DM than RAwoDM (p<0.001 for all). The majority of patients with ASCVD did not reach the lipid goal of low-density lipoprotein cholesterol <1.8 mmol/L. The lipid goal attainment was statistically and clinically significantly higher in RA-DM compared with RAwoDM both for patients with and without ASCVD. The systolic BP target of <140 mm Hg was reached by the majority of patients, and there were no statistically nor clinically significant differences in attainment of BP targets between RA-DM and RAwoDM.

Conclusion

CVD preventive medication use and prevalence of ASCVD were higher in RA-DM than in RAwoDM, and lipid goals were also more frequently obtained in RA-DM. Lessons may be learnt from CVD prevention programmes in DM to clinically benefit patients with RA.

Validity of the Health Assessment Questionnaire Predicting All-Cause Mortality in Early Rheumatoid Arthritis: Reply to three letters to the editor

We appreciate the interest in our manuscript concerning the Health Assessment Questionnaire disability index (HAQ) in an early rheumatoid arthritis incident cohort (the CATCH cohort) which predicted all-cause mortality (1). We will clarify queries raised in letters to the editor (2-4).

OP0262-HPR THE NEURO-QOL UPPER EXTREMITY FUNCTION SCALE: NEW OPPORTUNITIES TO MORE RELIABLY AND PRECISELY MEASURE SELF-REPORTED HAND FUNCTION AND SELF-CARE ACTIVITIES IN PEOPLE WITH RA

Background:

RA is an inflammatory disease that results in pain and loss of function, especially in the hands and wrists. Brief self-assessment tools that can reliably and precisely quantify hand/wrist function are needed to assess inflammatory activity when a physical exam is not feasible and to capture day-to-day experience of living with RA. Neuro-QoL is part of the PROMIS family of self-report measures created using a patient-centred approach and IRT methodology. The Neuro-Qol Upper Extremity Function (UEF) scale measures ability across fine motor and ADLs involving digital, manual and reach-related function and self-care. Little is known about its performance in RA.

Objectives:

To evaluate the validity and responsiveness of the 8-item Neuro-QoL UEF in RA. We hypothesized scores would be strongly (r>.70) associated with MHAQ, MD-HAQ, and PROMIS PF, moderately (r=.4 to .7) to symptoms, disease activity, and QoL indicators, and be responsive to change in disease activity and PF.

Methods:

Data were from the 0 and 6-month visits of adults with early RA (sx <1 yr) enrolled in the Canadian Early Arthritis Cohort, a prospective real-world study at 16 sites across Canada. Participants completed the Neuro-QoL UEF, MHAQ, MDHAQ, PROMIS-29, and PT Global at each visit. Rheumatologists recorded joint counts and MD Global. To evaluate content validity, we examined descriptive statistics across CDAI disease activity levels, and Pearson correlations between the Neuro-QOL UEF, legacy measures, CRP & ESR. Responsiveness was assessed by correlating change scores from visits 0-6 between Neuro-QoL UEF, disease activity and legacy PF scores.

Results:

The 262 participants were mostly white (83%) women (71%) with a mean (SD) age of 55 (13). Summary statistics at 6-months are shown in Table 1. Neuro-QOL UEF was moderately-strongly correlated with MHAQ, MDHAQ, PROMIS-PF (|r|=.63-.75) and moderately correlated with pain and stiffness, (|r|=.59, -.64), and CDAI, SDAI, PT&MD Global, TJ & SJ (|r|=.39-.58). Neuro-QOL UEF was moderately correlated with PROMIS QoL domains Pain, Fatigue, Anxiety, Depression, Sleep & Participation (|r|=.39-.60).

Table 1.

Summary statistics of physical function and RA disease activity indices at 6 months.

MeanSDMdn25%75%(Min, Max)Physical FunctionNeuro-Qol UEF46.59.753.837.553.8(21.8, 53.8)MHAQ (0-3)0.290.430.130.000.38(0.00, 2.25)MD-HAQ (0-10)1.391.640.700.002.00(0.00, 8.00)PROMIS-PF46.48.546.239.556.0(23.3, 56.0)RA Disease ActivityCDAI9.39.96.03.013.0(0.0, 56.0)SDAI10.710.96.83.115.2(0.0, 57.0)Patient Global3.02.5315(0, 10)MD Global1.82.2103(0, 9)Swollen Joints (28)2.13.7002(0, 20)Tender Joints (28)2.43.9103(0, 24)

Neuro-QOL scores decreased in a dose-response manner across worsening CDAI DA states reflecting increasing impairment (Table 2). Persons with HDA reported the highest disability, scoring nearly 0.5 SD lower on the Neuro-QoL UEF than PROMIS PF. Change from baseline to 6 months in Neuro-QoL UEF was moderately correlated with changes in PROMIS PF, MHAQ, PT Global, and CDAI (|r|=.44-.65). The mean change and range from 0-6 months in Neuro-QoL was significantly larger than in PROMIS (8.9 [95% CI 7.5, 10.4] vs. 5.4 [95% CI 4.4, 6.4])(see Figure).

Table 2.

Mean scores (95% CI) at 6 months by CDAI level.

REMLDAMDAHADNeuroQol UEF52.8 (51.8, 53.7)48.1 (46.6, 49.7)42.0 (39.4, 44.6)33.8 (30.5, 37.1)MHAQ (0-3)0.05 (0.02, 0.09)0.19 (0.14, 0.24)0.45 (0.34, 0.57)0.90 (0.63, 1.17)MD-HAQ (0-10)0.31 (0.17, 0.46)1.11 (0.90, 1.32)2.15 (1.71, 2.59)3.56 (2.56, 4.56)PROMIS-PF52.8 (51.4, 54.2)46.8 (45.3, 48.2)42.3 (40.4, 44.2)38.0 (34.4, 41.6)

Conclusion:

Clinicians, researchers, and patients benefit from practical self-report tools that reliably and precisely monitor hand function in RA. Results offer initial evidence of validity and responsiveness and support use of Neuro-QoL UEF to self-assess inflammatory activity in the hands and day-to-day experiences of living with RA.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

None declared

POS1459-HPR IDENTIFYING MEANINGFUL CHANGE IN THE RA FLARE QUESTIONNAIRE SCORES IN RHEUMATOID ARTHRITIS

Background:

The RA-FQ is a patient-reported measure of current disease activity in RA that can be used to identify disease flares. The RA-FQ queries pain, physical function, fatigue, stiffness, and participation and yields a score from 0-50. We previously reported on reliability, validity, and responsiveness.

Objectives:

To identify changes in RA-FQ that represent minimal and meaningful improvement or worsening from the perspective of people with RA, treating rheumatologists, and in relation to disease activity indices. We hypothesized that

Methods:

Data were from adults with early RA (sx <1 year) enrolled in the Canadian Early Arthritis Cohort, a prospective study of real-world patients treated across Canada. Participants completed the RA-FQ, Patient Global, and RA transition item since last visit (a little vs. a lot better or worse or same) between consecutive 3- and 6-month visits. Rheumatologists recorded joint counts, MD Global, and change in RA. We compared mean change across improvement and worsening using patient anchors and disease activity indicators.

Results:

The 808 adults were mostly white (84%) women (71%) with a mean (SD) age of 55 (15) and moderate-high CDAI level (85%) at enrollment. Most (79%) reported their RA had changed; 59% were better and 20% worse. Patients who were a lot worse had a mean increase of 8.9 points whereas those who rated themselves as a lot better had a -6.0 decrease on the RA-FQ (Figure 1). Minimal worsening and improvement were associated with 4.7 and -1.8 change in RA-FQ scores, respectively, while patients who rated their RA unchanged had stable RA-FQ scores (Table 1).

Similar changes were evident in CDAI, SDAI, and DAS indices (Table 1). Larger differences were observed with patient vs. physician global scores and tender vs. swollen joints. Across measures, the change associated with worsening was greater than for improvement. Results supported all prespecified hypotheses ab.

Table 1.

Spearman’s correlation coefficients of PsAQoL with the other parameters for construct validity

DomainA Lot Better(N=346; 43%)A Little Better(N=132; 16%)The Same(N=174; 21%)A Little Worse(N=94; 12%)A Lot Worse(N=62; 8%)Δ95% CISDΔ95% CISDΔ95% CISDΔ95% CISDΔ95% CISDRA-FQ Total (0-50)-6.0(-7.1, -4.9)10.3-1.8(-3.2, -0.3)8.4-0.1(-1.3, 1.1)8.14.7(2.9, 6.6)9.18.9(5.1, 12.7)15.0 Pain-1.2(-1.4, -0.9)2.4-0.4(-0.8, 0.0)2.30.0(-0.2, 0.3)1.81.3(0.8, 1.7)2.22.0(1.2, 2.9)3.3 Physical Function-1.3(-1.6, -1.1)2.4-0.3(-0.6, 0.1)2.10.0(-0.3, 0.3)2.10.9(0.4, 1.4)2.41.8(0.8, 2.7)3.7 Fatigue-1.1(-1.4, -0.8)2.6-0.4(-0.7, 0.0)1.90.0(-0.3, 0.3)2.10.7(0.3, 1.1)2.11.3(0.5, 2.1)3.2 Stiffness-1.1(-1.4, -0.9)2.4-0.4(-0.7, 0.0)2.0-0.1(-0.4, 0.2)2.01.1(0.6, 1.5)2.21.8(1.0, 2.7)3.3 Participation-1.2(-1.5, -1.0)2.5-0.1(-0.5, 0.3)2.1-0.1(-0.4, 0.2)2.20.8(0.4, 1.3)2.22.0(1.1, 2.8)3.4Disease ActivityCDAI*-5.3(-6.3, -4.3)9.1-3.3(-5.4, -1.3)11.5-0.8(-2.0, 0.5)8.11.7(-0.1, 3.5)8.86.8(3.7, 9.8)12.0SDAI-5.6(-6.8, -4.4)9.2-3.5(-6.1, -0.9)12.2-1.9(-3.6, -0.2)8.91.5(-0.7, 3.7)9.24.7(1.0, 8.4)12.2DAS28-CRP-0.7(-0.8, -0.6)1.01-0.5(-0.7, -0.2)1.2-0.2(-0.4, 0.0)1.00.3(0.1, 0.5)1.00.5(0.2, 0.9)1.2Patient Global (0-10)-1.3(-1.5, -1.0)2.7-0.5(-0.9, -0.1)2.1-0.1(-0.4, 0.2)2.11.3(0.8, 1.8)2.42.9(2.1, 3.6)3.1MD Global (0-10)-1.2(-1.4, -1.0)1.9-0.7(-1.1, -0.3)-0.1-0.1(-0.4, 0.2)1.90.1(-0.3, 0.5)2.80.7(0.0, 1.5)2.8Swollen Joints (28)-1.4(-1.7, 1.0)3.2-1.0(-1.8, -0.2)4.6-0.4(-0.9, 0.0)3.00.0(-0.7, 0.7)3.41.3(0.2, 2.5)4.6Tender Joints (28)-1.5(-1.9, -1.1)3.9-1.3(-2.2, -0.3)5.50.0(-0.7, 0.6)4.30.3(-0.7, 1.2)4.52.2(0.8, 3.5)5.4

Conclusion:

In this large cohort of adults with ERA, the RA-FQ was responsive to change and generally distinguish between minimal and meaningful improvement and worsening. These data add to a growing evidence demonstrating robust psychometric properties of the RA-FQ and offer initial guidance about the amount of change associated with improvement or worsening, supporting its use in RA care, research and decision-making.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

None declared

POS0531 FACTORS ASSOCIATED WITH BASELINE HYPERTENSION IN EARLY RHEUMATOID ARTHRITIS: DATA FROM A REAL-WORLD LARGE INCIDENT COHORT

Background:

It is not well understood why hypertension (HTN) is so common in rheumatoid arthritis (RA) patients. Reported prevalence of HTN in RA patients ranges from 4-73%.(1)

Objectives:

This study explored the prevalence of HTN at time of RA diagnosis and which demographic, behavioural and clinical factors were associated with HTN.

Methods:

Data from the Canadian Early Arthritis Cohort (CATCH), a prospective inception cohort of patients with RA <1 year duration, were used to analyze baseline demographic, behavioural and clinical characteristics associated with HTN, which was reported by physicians. Univariate logistic regression models were created to explore associations with baseline HTN. A multivariate logistic regression model was built based on goodness of fit indicated by likelihood ratio tests. Variables included in the model were age, sex, race, body mass index (BMI), education, smoking, alcohol servings, seropositivity, disease activity and comorbidities.

Results:

In total, 2052 subjects were included with mean (±SD) age of 55 (±14) years and symptom duration 5.60(5.47, 5.73) months, 71% of subjects were female and 85% were Caucasian. HTN was reported in 26% of subjects at baseline. Hypertensive subjects were older and more likely to be male. Other factors significantly associated with HTN at baseline were lower education, ever smoking, high BMI, diabetes, hyperlipidemia, worse RA disease activity, longer duration of RA symptoms, being seropositive, as well as the use of NSAIDs and/or corticosteroids (Table 1). In multivariable analysis HTN was associated with older age, overweight and obese BMI, diabetes, and hyperlipidemia. Expression of anti-citrullinated protein antibodies was inversely associated with HTN (Table 1). Other RA disease factors and treatments were not significantly associated with HTN on multivariable analysis.

Table 1.

Results of univariate and multivariate logistic regression analyses exploring the association between baseline characteristics and HTN in early RA.

Univariate Logistic RegressionMultivariable Logistic RegressionVariableCrude OR (95% CI)Adjusted OR (95% CI)Socio-Demographic20-39 years old0.15 (0.07, 0.26)0.14(0.05, 0.34)40-59 years oldReference60-79 years old2.81 (2.26, 3.50)2.26(1.65, 3.11)80-99 years old5.87 (3.36,10.25)3.80(1.53, 9.41)Female0.55 (0.45, 0.68)1.10(0.78, 1.54)Lifestyle/BehaviouralNormal weight (18.5- 24.9kg/m2)ReferenceOverweight (25-29.9 kg/m2)2.33(1.74, 3.11)1.63(1.10, 2.43)Obese (30+ kg/m2)3.19(2.38, 4.27)2.84(1.91, 4.23Ever-smoking1.41(1.15, 1.73)1.02(0.75, 1.40)Post-secondary education0.58(0.47, 0.71)0.88(0.65, 1.20)Clinical CharacteristicsSymptom duration0.99(0.99, 0.99)1.00(1.00, 1.00)DAS-281.09(1.09, 1.17)1.02(0.92, 1.13)ACPA+0.68(0.56, 0.85)0.64(0.44, 0.92)Corticosteroid use pre-baseline1.37(1.04, 1.81)OmittedNSAID use at baseline0.68(0.55, 0.84)OmittedDiabetes5.62(4.09, 7.73)3.20(1.99, 5.15)Hyperlipidemia4.75(3.74, 6.03)2.80(1.94, 4.02),CVD15.59(3.35, 72.64)Omitted

DAS-28; Disease activity score 28, ACPA; Anti-citrullinated protein antibody, CVD; Cardiovascular disease. Pre-baseline is 29 to 365 days before entering the cohort. Baseline is within 28 days before entering the cohort. Omitted variables either failed likelihood ratio test or were colinear. Additional variables tested but found insignificant: race, alcohol servings, depression, RF+, and use of DMARDs.

Conclusion:

Approximately 1 in 4 diagnosed with RA had HTN reported by their rheumatologists, which is similar to that of the general population. This suggests that increased risk of HTN in RA patients may develop as RA disease or treatment time progresses. Factors that may be predictive of this excess risk will be explored in further analysis.

References:

[1]Panoulas VF, Metsios GS, Pace AV, et al. Hypertension in rheumatoid arthritis. Rheumatology (Oxford) 2008;47:1286-98.

Acknowledgements:

The CATCH study was designed and implemented by the investigators and financially supported through unrestricted research grants from: Amgen and Pfizer Canada - Founding sponsors since January 2007; AbbVie Corporation and Hoffmann-LaRoche since 2011; Medexus Inc. since 2013;, Merck Canada since 2017, Sandoz Canada, Biopharmaceuticals since 2019,Gilead Sciences Canada since 2020 and Fresenius Kabi Canada Ltd. since 2021. Previously funded by Janssen Biotech from 2011-2016, UCB Canada and Bristol-Myers Squibb Canada from 2011-2018, Sanofi Genzyme from 2016-2017, and Eli Lilly Canada from 2016-2020.

Disclosure of Interests:

Brook Hadwen: None declared, Saverio Stranges: None declared, Neil Klar: None declared, Kuriya Bindee: None declared, Janet Pope Speakers bureau: UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, BMS, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB;, Grant/research support from: Abbvie, BMS, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Gilles Boire Speakers bureau: Merck, BMS, Pfizer, Janssen, Grant/research support from: Amgen, Abbvie, BMS, Eli Lilly, Merck, Novartis, Pfizer, Sandoz, Louis Bessette Speakers bureau: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis, Consultant of: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis., Grant/research support from: Amgen, BMS, Janssen, Roche, UCB, AbbVie, Pfizer, Merck, Celgene, Sanofi, Lilly, Novartis., Carol Hitchon Grant/research support from: Pfizer and UCB Canada, Glen Hazlewood: None declared, Edward Keystone Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Consultant of:: AbbVie, Amgen, AstraZeneca Pharma, Bristol-Myers Squibb Company, Celltrion, Myriad Autoimmune, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, Sanofi-Genzyme, Samsung Bioepsis, Grant/research support from: AbbVie, Amgen, Gilead Sciences, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, PuraPharm, Sanofi, Orit Schieir: None declared, Carter Thorne Speakers bureau: Medexus/Medac, Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Grant/research support from: Amgen, Pfizer, Abbvie, Celgene, CaREBiodam, Novartis, Diane Tin: None declared, Marie-France Valois: None declared, Vivian Bykerk Consultant of: Amgen, BMS, Gilead, Sanofi-Genzyme/Regeneron, Scipher, Pfizer Pharmaceuticals, UCB, NIH, Lillian Barra: None declared

Canadian Rheumatology Association Recommendation for the Use of COVID-19 Vaccination for Patients With Autoimmune Rheumatic Diseases

OBJECTIVE

To develop guidance on the use of coronavirus disease 2019 (COVID-19) vaccines in patients with autoimmune rheumatic diseases (ARD).

METHODS

The Canadian Rheumatology Association (CRA) formed a multidisciplinary panel including rheumatologists, researchers, methodologists, vaccine experts, and patients. The panel used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Outcomes were prioritized according to their importance for patients and clinicians. Evidence from the COVID-19 clinical trials was summarized. Indirect evidence for non-COVID-19 vaccines in ARD was also considered. The GRADE evidence-to-decision (EtD) framework was used to develop a recommendation for the use of the 4 COVID-19 vaccines approved in Canada as of March 25, 2021 (BNT162b2, mRNA-1273, ChAdOx1, and Ad26.COV2.S), over 4 virtual panel meetings.

RESULTS

The CRA guideline panel suggests using COVID-19 vaccination in persons with ARD. The panel unanimously agreed that for the majority of patients, the potential health benefits of vaccination outweigh the potential harms in people with ARDs. The recommendation was graded as conditional because of low or very low certainty of the evidence on the effects in the population of interest, primarily due to indirectness and imprecise effect estimates. The panel felt strongly that persons with autoimmune rheumatic diseases who meet local eligibility should not be required to take additional steps compared to people without ARDs to obtain their vaccination. Guidance on medications, implementation, monitoring of vaccine uptake, and research priorities are also provided.

CONCLUSION

This recommendation will be updated over time as new evidence emerges, with the latest recommendation, evidence summaries, and EtD available on the CRA website.

Health Assessment Questionnaire at One Year Predicts All-Cause Mortality in Patients With Early Rheumatoid Arthritis

OBJECTIVE

Higher self-reported disability (high Health Assessment Questionnaire [HAQ] score) has been associated with hospitalizations and mortality in established rheumatoid arthritis (RA), but associations in early RA are unknown.

METHODS

Patients with early RA (symptom duration <1 year) enrolled in the Canadian Early Arthritis Cohort who initiated disease-modifying antirheumatic drugs and had completed HAQ data at baseline and 1 year were included in the study. Discrete-time proportional hazards models were used to estimate crude and multi-adjusted associations of baseline HAQ and HAQ at 1 year with all-cause mortality in each year of follow-up.

RESULTS

A total of 1,724 patients with early RA were included. The mean age was 55 years, and 72% were women. Over 10 years, 62 deaths (3.6%) were recorded. Deceased patients had higher HAQ scores at baseline (mean ± SD 1.2 ± 0.7) and at 1 year (0.9 ± 0.7) than living patients (1.0 ± 0.7 and 0.5 ± 0.6, respectively; P < 0.001). Disease Activity Score in 28 joints (DAS28) was higher in deceased versus living patients at baseline (mean ± SD 5.4 ± 1.3 versus 4.9 ± 1.4) and at 1 year (mean ± SD 3.6 ± 1.4 versus 2.8 ± 1.4) (P < 0.001). Older age, male sex, lower education level, smoking, more comorbidities, higher baseline DAS28, and glucocorticoid use were associated with mortality. Contrary to HAQ score at baseline, the association between all-cause mortality and HAQ score at 1 year remained significant even after adjustment for confounders. For baseline HAQ score, the unadjusted hazard ratio (HR) was 1.46 (95% confidence interval [95% CI] 1.02-2.09), and the adjusted HR was 1.25 (95% CI 0.81-1.94). For HAQ score at 1 year, the unadjusted HR was 2.58 (95% CI 1.78-3.72), and the adjusted HR was 1.75 (95% CI 1.10-2.77).

CONCLUSION

Our findings indicate that higher HAQ score and DAS28 at 1 year are significantly associated with all-cause mortality in a large early RA cohort.

SAT0127 REAL-WORLD PREDICTORS OF STARTING DIFFERENT ADVANCED DMARD TREATMENTS IN RHEUMATOID ARTHRITIS: A PROSPECTIVE INVESTIGATION FROM THE CANADIAN EARLY ARTHRITIS COHORT (CATCH) GROUP

Background:

RA patients with inadequate DMARD response may be treated with a TNF inhibitor (TNFi), non-TNFi or janus kinase inhibitor (JAKi) [1].

Objectives:

Compare characteristics of real-world early RA (ERA) patients starting TNFi, non-TNFi, and JAKi post DMARD failure.

Methods:

Data were analyzed from early RA patients (symptoms < 1 year) enrolled in CATCH who started TNFi, non-TNFi or JAKi as first line advanced therapy from 2014 to 2019. Descriptive statistics, t-tests and chi-square tests summarized and compared secular trends and patient characteristics initiating each class of therapy. Multinomial logistic regression analyses were done.

Results:

246 participants started advanced therapy during the study period; (75%) female, mean(SD) age 50(14) years. First line prescriptions for JAKi increased and TNFi decreased (Fig. 1). Those receiving JAKi had longer disease duration, fewer tender joints, and lower DAS28, CDAI, ESR, MD global (all p <0.05) (Table 1). The strongest predictor of starting JAKi was province (Ontario where access is preferential for JAKi and biosimilar TNFi) (Table 2). Those prescribed TNFi had shorter disease duration, younger age, fewer comorbidities, and treatment location outside Ontario (Table 1,2). Those starting non-TNFi had higher DAS28; predictors included older age, higher education, and more comorbidities (Table 1,2).

Table 1.

Characteristics prior to starting advanced therapy

VariableTotal Sample(N = 246)JAKi(N = 61)TNFi(N = 153)Non-TNFi(N = 32)p-value£Disease duration (months) mean (SD)39 (34.1)50.8 (39.3)32.5 (29.1)48 (38.6)0.0006DAS28 (ESR - CRP if ESR was missing) mean (SD)4.2 (1.4)3.6 (1.4)4.3 (1.4)4.8 (1.5)0.0012CDAI mean (SD)21.5 (14.8)16.5 (13.7)22.9 (14.8)24.8 (14.9)0.0089Tender joint count (0-28), median (IQR)§4 (7)2 (6)5 (8)6 (9)0.0224ESR median (IQR)§13 (20)12 (13)13 (20)28.0 (23.5)0.0448MD Global (0-10) mean (SD)4.2 (2.7)3.2 (2.7)4.4 (2.6)4.8 (2.8)0.0030

§IQR: 75 – 25 percentile

£p-value: ANOVA for continuous variable, chi-square for categorical

Table 2.

Multinomial regression for initiating advanced DMARD therapy

Disease stage & Clinical Disease ActivityAdvanced DMARDAdjusted for Age, sex, education, comorbidityFullyAdjustedφNon-TNF vs TNFJAK vsTNFNon-TNF vs TNFJAK vsTNFAge1.01 (0.98, 1.05)1.01 (0.99, 1.04)1.01 (0.97, 1.05)1.02 (0.99, 1.05)Women vs Men1.98 (0.71, 5.58)1.33 (0.63, 2.80)2.35 (0.76, 7.27)1.72 (0.73, 4.02)Education(< HS vs ≥ HS)2.92 (1.28, 6.63)1.49 (0.78, 2.86)2.83 (1.12, 7.15)2.08 (0.97, 4.47)RDCI baseline1.35 (1.01, 1.81)1.21 (0.95, 1.53)1.30 (0.95, 1.78)1.23 (0.94, 1.60)Private Insurance(No vs Yes)NINI1.26 (0.47, 3.40)0.99 (0.44, 2.25)RF PositiveNINI1.47 (0.56, 3.85)1.84 (0.82, 4.12)CDAININI1.01 (0.98, 1.04)0.97 (0.94, 1.00)RegionQuebec vs Ontario (ON)NINI0.59 (0.20, 1.72)0.44 (0.20, 0.94)West vs ONNINI1.32 (0.29, 5.98)0.11 (0.01, 0.99)

φAdjusted for; baseline age, sex, education, RDCI; province; RF positive in first year; private insurance; CDAI at visit prior to initiation

Conclusion:

Patient and physician related factors (location of practice) determined which advanced therapeutic was prescribed. JAKi use is increasing in ERA.

Reference:

[1]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the Rheumatic Diseases Published Online First: 22 January 2020

Disclosure of Interests:

Madina Weiler: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Glen Hazlewood: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer

, Speakers bureau: Medexus/Medac, Vivian Bykerk: None declared, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB

FRI0030 MORE THAN HALF OF NEWLY DIAGNOSED RA PATIENTS ARE NOT CONVINCED OF THE NECESSITY OF RA MEDICINES: ASSOCIATIONS WITH RA CHARACTERISTICS, SYMPTOMS, AND FUNCTION IN THE CANADIAN EARLY ARTHRITIS COHORT (CATCH)

Background:

Although DMARDs are essential for early aggressive control of RA to reduce symptoms and disability, medication adherence is variable. Beliefs about the necessity of medications and safety concerns predict adherence and are modifiable.

Objectives:

To examine associations among RA medication necessity beliefs and concerns, sociodemographics, RA characteristics, symptom level and function in newly diagnosed RA patients.

Methods:

Baseline data were analyzed from participants in the Canadian Early Arthritis Cohort (CATCH) who enrolled between 2017-2020 and completed the Beliefs about Medicine Questionnaire (BMQ) and PROMIS-29. All met ACR1987 or 2010 ACR/EULAR criteria and had active RA at enrollment. BMQ Necessity (N) and Concerns (C) scores were classified ashigh(≥20) orlow(<20) and categorized into: Accepting (↑N ↓C); Ambivalent (↑N↑C); Sceptical (↓N↑C); and 4) Indifferent (↓N↓C). Groups were compared using ANOVA and chi-square tests.

Results:

The 362 patients were mostly white (83%) women (66%) with a mean (SD) age of 56 (15), symptom duration of 6 (3) months, and 32% were obese (BMI≥30). More than half (56%) were DMARD-naive or minimally exposed. Mean N and C scores were similar between men and women; 54% were classified asIndifferent, 31%Accepting, 9%Ambivalent,and 6%Sceptical.

As compared to those classified asAccepting, moreIndifferent participantssmoked, had a healthy weight, lower TJCs, and trend for lower CDAI (Table). Groups were similar by sociodemographics, symptom duration, and DMARD/steroid use, except fewerIndifferentpatients received MTX.Indifferentpatients had statistically and meaningfully lower patient global, depression, anxiety, fatigue and pain interference, and higher function and participation scores (Table).

Conclusion:

Many new RA patients had low medication necessity beliefs and concerns, and only 31% had high necessity beliefs and low concerns around diagnosis. Lifestyle and lower CDAI, TJCs, symptoms and functional impacts were associated with RA medication indifference. Identifying medication indifference can prompt discussions about medication beliefs/concerns to facilitate shared decision-making and adherence.

Disclosure of Interests:

Viviane Ta: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Glen Hazlewood: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion, Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Vivian Bykerk: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie

FRI0064 SAFETY OF LOW DOSE METHOTREXATE (MTX) AND TUBERCULOSIS (TB)

Background:

Increased awareness of the importance of MTX in rheumatic disease is leading to more MTX use in patients from TB-endemic areas. Current management guidelines for rheumatic disease address TB in the context of biologics but not MTX use.

Objectives:

To systematically review the published literature on TB rates with MTX ≤30 mg per week.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘tuberculosis’. We also searched citations from review articles. Titles, abstracts or full manuscripts of the 4707 reports identified were screened independently by 2 reviewers to identify studies reporting TB in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on TB incidence (new TB diagnosis vs reactivation of latent TB), and outcomes (pulmonary, dissemination, death) and safety of isoniazid, INH. Descriptive summaries are presented on studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or providing sufficient information, 31 studies were included (8 cohort, 7 case-control, 1 clinical trial, 15 case reports/case series). Only 27% of articles reported data from low to moderate human development index countries. Studies were of moderate quality. Seven case control studies were heterogeneous but most demonstrated a modest increased risk of TB with MTX (Table). Five cohort studies reported TB incidence rates in rheumatic disease (treated with MTX +/- biologics) ranging from 102-367.9/100,000 patient-years. These rates were generally higher than comparator general population rates. Two cohort studies of MTX in RA (without biologic) reported cumulative TB incidence in Maldova (12 TB cases in 44 RA patients, 27%) and in China (9/114, 7.9%). Other cohort studies generated rates of overt infection (143/100,000 patient years in Spain, higher if co-prescribed with corticosteroids and other immunosuppressants in South Africa), and latent TB rates detection (16/922 RA screened, 1.7%, in Canada). When reported, rates of extra-pulmonary TB were higher than comparator general population rates. One clinical trial (China), 2 cohorts (Japan, USA) and 2 case-series (Belgium, USA) evaluated safety of INH and MTX. Isoniazid-related hepatotoxicity and neutropenia were generally more common when taken with MTX, but were usually reversible.

Conclusion:

Despite a paucity of high-quality data, this review confirms that TB screening and clinical surveillance are needed in patients from TB-endemic areas who are prescribed MTX, particularly with co-administration of corticosteroids or other immunosuppressants. Isoniazid, if monitored, appears safe and prevents TB reactivation.

References:

Table .

Case control studies

Region (Year)DiagnosisTB with MTXTB without MTXOdds RatioMexico(1999)Mixed (4 RA)1/65/752.76Japan(2004)RA3/4717/1540.56Canada(2009)RA29/48321/10463.12Brazil(2010)Lupus2/31/57112Taiwan(2012)Psoriasis33/144464/23411.2Taiwan(2015)JIA4/3574/10262.90South Africa (2017)RA0/1340/18NA

JIA=juvenile idiopathic arthritis

Acknowledgments:

Funded by the International League Against Rheumatism and McGill University Global Health Scholar Awards

Disclosure of Interests:

Anna Davidson: None declared, Alize Gunay: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Rosie Scuccimarri: None declared, Yewondwossen Mengistu: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

PARE0023 ORAL HEALTH IN RHEUMATOID ARTHRITIS: LISTENING TO PATIENTS

Background:

Rates of periodontal disease and tooth loss are increased in rheumatoid arthritis (RA). Periodontal disease may exacerbate RA inflammation and complicate RA care. Understanding factors that contribute to the increased burden of periodontal disease in RA is critical to improving oral health and possibly arthritis outcomes. People with RA may have unique needs and/or barriers to maintain oral health.

Objectives:

To determine from people with RA what are their experiences and perceptions about their oral health, their most important questions relating to oral health, and how they wish to receive oral health information.

Methods:

Semi-structured interviews were conducted with RA patients. Recorded interview transcripts underwent iterative content analysis. Transcripts were initially reviewed to develop a coding guide. Latent content, or larger themes, were then applied to the transcripts. Constructs were considered saturated when no new themes were identified with subsequent interviews. We report identified themes with representative quotes.

Results:

Interviews with 11 RA (10[91%] female; all on RA medication) averaged 19 minutes (range 8-31 minutes) and were mostly conducted face-to-face. Many believed RA medication contributed to dry mouth. Most participants had not previously considered other links between oral health and RA. Themes identified included the need for complicated oral health routines, barriers of cost and access to dental care, and shame relating to oral health (Table 1). Participants preferred to receive oral health education from their rheumatologists or dentists over printed or online resources.

Conclusion:

RA patients have unique needs relating to oral health and report poor oral quality of life. Strategies to optimize oral health in RA may include educational tools for optimizing oral self-care appropriate for RA, and improved access to oral care professionals who are aware of the needs of arthritis patients.

Disclosure of Interests:

Jennifer Protudjer: None declared, Corrie Billedeau: None declared, Chrysi Stavropoulou: None declared, Anastasia Cholakis: None declared, Robert Schroth: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

OP0263-HPR MAJOR STRESSORS IN THE YEAR PRIOR TO RA DIAGNOSIS: IMPACT ON PATIENT-REPORTED OUTCOMES ONE YEAR LATER

Background:

Stress is implicated in RA onset and poorer prognoses through changes in neuro-endocrine and autoimmune function. Although many people with RA link disease onset to recent stressful life events, results from retrospective studies are unclear.

Objectives:

To describe the incidence of major stressors(+STRESS) in year prior to diagnosis and compare characteristics and patient-reported outcomes (PROs) of newly diagnosed RA patients with and without+STRESSat 0 and 12 months.

Methods:

Data were from early RA patients (symptoms <1 yr) enrolled in the Canadian Early Arthritis Cohort (CATCH) from 2007-17 who met 1987/2010 ACR/EULAR criteria and had ≥12 months of follow-up. Patients reported major psychological (death, divorce/separation, family, financial, other) and physical (motor vehicle accident, surgery, major illness/infection, other) stressors in previous year. We used independent t-tests and chi square to compare characteristics by stressors at baseline, and multivariable regression to examine the impact of+STRESSon disease activity and PROs at 1 year, adjusting for age, sex, education, fibromyalgia, and SJC.

Results:

The 1933 adults were mostly female (72%), with a mean (SD) age of 55 (15) years. 52% reported 1+ stressors in previous year; family (48%), financial stress (36%), death (35%), surgery (28%), and major illness (26%) were the most common stressors. Patients with +STRESS were more likely to be women, younger, have more comorbidities including fibromyalgia, and higher mean DAS28. Patients with +STRESS also had significantly higher mean pain, fatigue, depression, sleep disturbance, patient global, and HAQ scores at baseline.

At 1 year, SJC and the proportion in DAS28 REM was similar between groups. However, PROs (pain, HAQ, Fatigue, Pt Global, Depression, Poor Sleep) remained higher in+STRESS, with evidence of an additive effect for number of stressors and having both physical and psychological stressors (Table). The greatest impacts were on mood, sleep disturbance, and fatigue.

Conclusion:

In this pan-Canadian early RA cohort, more than half reported 1+ stressful life events in the year prior to diagnosis. Individuals reporting major stressors had significantly worse pain, patient global, disability, depression, fatigue, and sleep disturbance at diagnosis; 1 year later, though disease activity was similar between groups, the effects of +STRESS on PROs persisted. Early RA patients with recent major stressors may benefit from emotional support and stress reduction to optimize how they feel and function.

Mean (SD) or N (%)No Stress(N=928; 48%)Physical(N=131; 7%)Psychological(N=658; 34%)Both(N=216; 11%)Age56 (15)56 (15)53 (14)52 (15)Women622 (67%)82 (63%)512 (78%)174 (81%)College Education464 (50%)76 (58%)345 (52%)126 (58%)Rheum Dis Comorbid Index1.1 (1.2)1.4 (1.4)1.1 (1.3)1.4 (1.3)OA or Spinal pain168 (18%)35 (27%)117 (18%)55 (25%)Fibromyalgia diagnosis15 (2%)2 (2%)13 (2%)11 (5%)Symptom duration (months)5.6 (3.0)5.7 (3.0)5.9 (3.0)5.9 (3.0)DAS28 – mean5.0 (1.4)5.1 (1.5)5.0 (1.5)5.2 (1.4)MTX ±csDMARDs679 (73%)100 (76%)489 (74%)166 (77%)Oral Steroids295 (32%)40 (31%)215 (33%)55 (25%)Pain (0-10)5.3 (2.8)5.5 (2.9)5.7 (2.8)6.2 (2.8)HAQ-DI1.0 (0.7)1.2 (0.7)1.1 (0.7)1.3 (0.7)Fatigue (0-10)4.7 (3.1)5.0 (3.0)5.7 (2.9)5.9 (2.9)Patient Global (0-10)5.6 (2.9)6.0 (2.9)6.0 (2.9)6.4 (3.0)Depression (SF12 MCS < 45.6)329 (35%)54 (41%)356 (54%)123 (57%)Poor sleep (0-10)4.5 (3.4)4.8 (3.3)5.3 (3.2)6.0 (3.1)

Disclosure of Interests:

Nicole Andersen: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Glen Hazlewood: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer

Speakers bureau: Medexus/Medac, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Vivian Bykerk: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie

FRI0024 HOW OFTEN DOES REACHING TARGET MISS THE MARK? LONGITUDINAL PATTERNS OF REMISSION IN REAL-WORLD EARLY RHEUMATOID ARTHRITIS PATIENTS

Background:

Early diagnosis and rapid initiation of DMARDs following a treat-to-target approach have made remission a realizable goal for many with RA. Yet, some patients are unable to sustain remission over time.

Objectives:

To describe longitudinal patterns of remission and identify predictors of sustained vs transient remission in real-world early RA patients.

Methods:

Data were from the Canadian Early Arthritis Cohort (CATCH), a prospective study of early RA patients (symptoms < 1 year) treated in rheumatology clinics across Canada from 2007- 2019. The sample was limited to patients with active disease at enrolment who later reached remission (SDAI<=3.3) and were followed for 12-24 months thereafter. Patients were classified as in sustained remission (Pattern 1) or transient remission with transient remission patients divided into those who transitioned from REM to LDA only (Pattern 2) and those who transitioned from REM to MDA or HDA (Pattern 3), over FU. Multi-adjusted multinomial regression was used to identify predictors of transient remission patterns.

Results:

The study included 1,419 (46%) CATCH participants that reached remission. At enrolment, most (70%) were female, mean(sd) SDAI was high (27(15)) and 92% were treated with csDMARDs. Only 47% remained in sustained remission by 12-months and, only 40% by 24 months (Pattern 1) (Figure). Among patients with transient remission patterns, transitions to LDA only (Pattern 2) were more common than to MDA/HDA over FU (Pattern 3) (Fig 1). Older age, female sex, smoking, higher comorbidity index and positive serology, were significantly associated with transient remission patterns (Table). There were also borderline significant associations between transient remission patterns and longer time to remission, lack of early MTX treatment and reducing treatment after remission (Table).

Table .

Adjusted Multinomial Regression Results of Predictors of Transient Remission Patterns over 24-Month Follow Up

Pattern 2 vs, Pattern 1OR (95% CI)Pattern 3 vs. Pattern 1OR (95% CI)Age1.01 (1.00, 1.02)1.01 (0.99, 1.02)Women vs Men1.78 (1.33, 2.39)1.63 (1.09, 2.44)Current smoker1.57 (1.09, 2.28)1.53 (0.95, 2.47)RDCI at baseline1.11 (0.99, 1.25)1.30 (1.13, 1.50)Seropositive1.38 (1.03, 1.85)1.21 (0.81, 1.80)MTX first 3 months1.18 (0.85, 1.63)0.76 (0.51, 1.12)Time to remission (months)1.01 (1.00, 1.01)1.01 (1.00, 1.02)Treatment reduction after REM vs. No Change1.33 (0.96, 1.86)1.01 (0.99, 1.02)

  Pattern 1: Sustained REM

  Pattern 2: Transient REM: Transitions to LDA only

  Pattern 3: Transient REM: Transitions to MDA/HDA

   RDCI: Rheumatic Disease Comorbidity Index (range 0-9)

  Treatment reduction: Change from biologic or JAK to csDMARD(s) OR reduction in number of csDMARDs OR change from MTX +/- csDMARDs to non-MTX csDMARD

Figure.

Distribution of Disease Activity States over 12-24 After First Achieving SDAI REM

Conclusion:

Results of this large longitudinal analysis of real-world data suggests that < 50% of patients that reach remission sustain remission for 12-24months. Closer monitoring of patients with prognostic indicators for transient remission and additional research focusing on why remission is lost may help improve the rates of sustained remission.

References:

[1]Ajeganova S, Huizinga T. Sustained remission in rheumatoid arthritis: latest evidence and clinical considerations. Ther Adv Musculoskelet Dis. 2017;9(10):249-62.

Disclosure of Interests:

Orit Schieir: None declared, Glen Hazlewood: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Marie-France Valois: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion, Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Diane Tin: None declared, Vivian Bykerk: None declared

FRI0032 REGIONAL AND WIDESPREAD PATTERNS OF NON-ARTICULAR PAIN ARE COMMON AT RA DIAGNOSIS AND CONTRIBUTE TO POOR OUTCOMES AT 12 MONTHS: A PROSPECTIVE STUDY OF PAIN PATTERNS IN CANADIANS WITH RA

Background:

Persistent pain can occur in early RA patients, despite improvement in synovitis and may be due to coexisting non-articular pain (NAP). Though NAP is often attributed to fibromyalgia and widespread NAP, regional NAP syndromes may be more common and under-recognized.

Objectives:

To describe patterns of NAP, predictors of persistent NAP and impact on outcomes in the first year following early RA diagnosis.

Methods:

Data were from participants enrolled in the Canadian Early Arthritis Cohort (CATCH) between2017-2019who completed 0,6,12-month evaluations with patient-reported outcomes [PROs] and clinical data available. We used the McGill Body Pain Diagram (BPD) to classify patients as experiencing no NAP, regional (RP:1-2 regions) or widespread NAP (WP:3-5 regions). Multinomial regression was used to identify baseline predictors of persistent RP and WP at 12-months. Multi-adjusted GEE with linear and logit links were used to estimate time-varying associations of NAP patterns with outcomes updated at each time point.

Results:

Study included 421 participants: 66% were female, with a mean(sd) age 56 (14); 72% were seropositive and 90% were treated with MTX ± csDMARDs as initial therapy. NAP at baseline was common (55%), with majority (62%) reporting regional NAP. NAP prevalence was 33% at 12 months (Figure). Female sex and baseline depressive symptoms were independent predictors of widespread NAP at 12 months while poorer function and lack of early MTX treatment independently predicted regional NAP, at 12 mos. Regional and widespread NAP were associated with lower likelihood of remission in adjusted models that accounted for changes in NAP and remission over time (Table).

Figure.

Point prevalence of regional and widespread NAP at baseline, 6 and 12 months.

Table .

Results of Multi-Adjusted GEE Logistic Regression showing Regional and Widespread NAP is associated with a reduced likelihood of achieving Stringent Remission Targets

Conclusion:

NAP is commonly reported in early RA pts seen in real world settings. Regional NAP was more common than WSP at all time-points, but both NAP patterns were associated lower odds of achieving remission targets by 12 months. These data support considering the role of NAP when assessing RA treatment efficacy during clinical visits and warrant different treatment approaches to reduce symptoms in RA patients receiving target-based care.

Disclosure of Interests:

Vivian Bykerk: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Glen Hazlewood: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie

SAT0053 ESTIMATING REAL-WORLD UNMET NEEDS FOR REACHING REMISSION IN THE FIRST YEAR FOLLOWING EARLY RA DIAGNOSIS: RESULTS FROM THE CANADIAN EARLY ARTHRITIS COHORT (CATCH)

Background:

Several composite RA disease activity indices are commonly used in clinical practice and research. Different disease activity indices however can be inconsistent in classifying remission (REM).

Objectives:

1) Compare remission prevalence across 4 common RA indices; 2) compare changes in remission across indices; and, 3) Identify predictors of persistent active disease across all indices, in real-world early RA patients over 1 year follow up.

Methods:

Data were from patients with early RA (symptoms < 1 year) enrolled in the Canadian Early Arthritis Cohort (CATCH) between 2007 and 2018. Participants had active disease at enrolment, were treated with csDMARDs and completed standardized clinical assessments every 3-months. Remission status was assessed using 4 indices: 1) DAS28< 2.6 OR DAS28CRP < 2.5, 2) CDAI ≤ 2.8, 3) SDAI≤ 3.3, and 4) ACR/EULAR Boolean remission – SJC28, TJC28, CRP, PGA all ≦1. T-tests/ chi-squared tests were used to compare differences in remission prevalence by 1 year, and changes in remission before and after a QI program. Logistic regression was used to identify predictors of persistent active disease on all 4 indices.

Results:

1202 adults were eligible for this analysis. At enrolment, 877 (73%) were women, mean (sd) age was 55 (14), average disease activity was high (DAS28 5.1 (1.4); CDAI 27 (14); SDAI 29 (15)). Prevalence of remission by 12-months follow up was 14-21% higher when estimated with the DAS28 compared with CDAI, SDAI and Boolean criteria, and 378 (31%) did not achieve remission according to any of the 4 indices (Fig 1). Improvement in remission after a QI program however was similar across all 4 indices(~+15-17%). In adjusted logistic regression, Persistent active disease across all measures was most strongly associated with positive serostatus and smoking in men, and with obesity and more tender joints in women. Pain and lower education were predictors in BOTH men and women (Table 2)

Table 1.

Multivariable Logistic Regression Predicting Persistent Active Disease by 12-months across ALL RA indices

Conclusion:

In the absence of a single “best measure” that also takes in to account the patient’s perspective, we estimate unmet needs for achieving remission in the first year of follow up in 1 in 3 ERA patients who did not achieve remission by ANY of the 4 indices.

References:

[1] Kuriya B, Sun Y, Boire G, Haraoui B, etal. Remission in Early Rheumatoid Arthritis – A Comparison of New ACR/EULAR Remission Criteria to Established Criteria.J Rheumatol2012;39:1155-1158.

Disclosure of Interests:

Orit Schieir: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Marie-France Valois: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Glen Hazlewood: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer

, Speakers bureau: Medexus/Medac, Diane Tin: None declared, Vivian Bykerk: None declared

FRI0037 ALL-CAUSE MORTALITY IN EARLY RHEUMATOID ARTHRITIS PREDICTED BY HEALTH ASSESSMENT QUESTIONNAIRE AT ONE YEAR

Background:

Patients with RA are at greater risk of mortality than the general population. Higher HAQ disability has been associated with hospitalizations and mortality in established RA; whether HAQ disability predicts mortality in early RA (ERA) is unknown.

Objectives:

The objective of this study is to analyze how well the HAQ can predict future mortality in patients with early RA.

Methods:

Data were from adult early RA patients (symptoms <1 year) enrolled in the Canadian Early Arthritis Cohort (CATCH) between 2007 and 2017; who initiated treatment with 1 or more DMARDs and had completed HAQ data at baseline and 1 year. Descriptive statistics, t-tests and chi-square tests were used to summarize and compare baseline patient characteristics including sociodemographic variables, RA characteristics and comorbidities amongst deceased and non-deceased patients. Discrete-time proportional hazards models were used to estimate crude and multi-adjusted associations between HAQ at baseline and 1 year, respectively, with all-cause mortality in each year of follow up.

Results:

This study included 1724 patients with early RA; mean age was 55 years and 72% were female. In 10 years of follow up, 62 deaths (2.4%) occurred. Deceased patients had higher HAQ scores and DAS28 scores at baseline and at 1 year versus the non-deceased group. Age, male sex, lower education, smoking, more comorbidities, higher baseline disease activity and steroid use were associated with mortality in unadjusted survival models (Table 1). Contrary to HAQ at baseline, the association between all-cause mortality and HAQ at 1 year remained significant even after adjusting for age, gender, comorbidities, disease activity, smoking, education, seropositivity, symptom duration and steroid use in adjusted survival models (Table 2).

Table 1.

Unadjusted survival model: Association of each variable with all-cause mortality

Baseline VariableUnadjustedHazard OR95% CISocio-DemographicAge (years)1.101.07 – 1.13Female0.370.22 – 0.62Caucasian (white or European)1.010.46 – 2.24Aboriginal1.710.61 – 4.76Education > high school degree0.480.28 – 0.82Current Smoker1.811.01 – 3.24Rheumatic Disease Comorbidity Index (0-9)1.601.36 – 1.87RA CharacteristicsSymptom duration (months)0.990.91 – 1.08Seropositivity in first year1.110.55 – 2.23DAS28 ESR or CRP if ESR is missing1.261.06 – 1.51Oral Steroid use1.751.03 – 2.98Table 2.

Multivariable discrete-time survival models: HAQ baseline vs 1 year

ModelModel 1:Crude(Time + HAQ-DI)Model 2:Adjusted for age + sexModel 3:Adjusted for Model 2 + DAS28 + RDCIModel 4:Adjusted for Model 3 + education, smoking, seropositivity, symptom duration and oral steroids useModel 5:Adjusted for Model 3 + smoking, symptom duration onlyHAQ-DI (0-3) (at baseline)1.461.02 – 2.091.370.96 – 1.951.250.81 – 1.941.320.85 – 2.041.300.84 – 2.00HAQ-DI (0-3) (at 1 year)2.581.78 – 3.722.401.63 – 3.521.751.10 – 2.771.871.16 – 3.021.731.09 – 2.74

*Hazard OR, 95% CI

~HAQ-DI: (Health Assessment Questionnaire Disability Index); RDCI: Rheumatic Disease Comorbidity Index; DAS28: Disease Activity Score

Conclusion:

Higher HAQ at 1 year was significantly associated with all-cause mortality in a large early RA cohort suggesting that poorer disease control and function in the first year of RA contributes to higher mortality.

Disclosure of Interests:

Safoora Fatima: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Glen Hazlewood: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer, Speakers bureau: Medexus/Medac, Vivian Bykerk: None declared, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB

SAT0078 SAFETY OF LOW DOSE METHOTREXATE (MTX) IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

Background:

Increased awareness of the efficacy of MTX in rheumatic disease is leading to more MTX use in patients from HIV endemic areas. While HIV related immunosuppression may contribute to improvement of some rheumatic diseases, immune reconstitution from highly active antiretroviral therapy (HAART) may lead to exacerbation or presentation of autoimmune disorders for which MTX therapy may be warranted. Most management guidelines for rheumatic disease do not address MTX use in the context of HIV.

Objectives:

To systematically review the published literature on the safety of using MTX ≤30 mg per week in HIV.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘human immunodeficiency virus’. We also searched citations from review articles. Titles, abstracts or full manuscripts were screened independently by 2 reviewers to identify studies reporting HIV in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on MTX and HIV adverse events (MTX toxicity, HIV viral load, CD4 count). Descriptive summaries are presented for studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or not providing sufficient information, 42 of the 2714 identified reports were included (1 clinical trial, 2 cohort, 1 cross-sectional study, 38 case reports/case series). Most reports (81%) originated from USA or Europe. Study quality was generally good with most studies fulfilling 50-100% of MMAT criteria. The randomized controlled trial (USA) assessing MTX on atherosclerotic disease in HIV showed that adverse events were more common in MTX versus placebo (12.8% vs 5.6%, p non-inferiority <0.05) and included infection, transient CD4 and CD8 drop, pulmonary toxicity, and death (1 attributed to MTX/HIV, 1 unrelated). One cohort study (South Africa) reported 43 RA patients on MTX who acquired HIV. In this cohort, RA generally improved despite only 5 individuals continuing MTX. No data on MTX adverse event rates was reported. One cohort study (USA) reported 13 HIV patients with myositis. One received MTX (with other immunosuppression) without MTX adverse effects but died due to AIDS. A cross-sectional study (France) of 43 HIV pts with autoimmune disease reported one patient on MTX (and other immunosuppression) developed an adverse event (cytopenia) compared to 5/33 patients not on MTX (cytopenia). The 38 case reports/series described 54 individuals with HIV receiving MTX. Of these studies, 27 (describing 42 subjects) reported on MTX adverse events and 35 (describing 46 subjects) reported on HIV adverse events. MTX adverse events developed in 29 subjects (hematologic 13, renal/hepatic 1, opportunistic infections 10, other events 2). HIV adverse events were noted in 23 subjects (Kaposi’s sarcoma 4, CD4 decrease 16, HIV viral titer increase 4). Five deaths were reported (2 infection, 1 infection and wasting, 2 HIV related deaths). Most subjects also received corticosteroids or other immunosuppressants including biologics.

Conclusion:

There remains limited data on the safety of low dose MTX in HIV. Surveillance for HIV is warranted for individuals on MTX who are at risk for acquiring HIV. Caution and careful monitoring for MTX toxicity, opportunistic infections and HIV state is suggested if MTX is used in the setting of HIV particularly if combined with other immunosuppression.

References:

[1] Clin Infectious Disease 2019:68

[2] J Rheumatology 2014:41

[3] Arthritis and Rheumatism 2003:49

[4] Medicine 2017:96

Acknowledgments :

Funding from International League Against Rheumatism

McGill University Global Health Scholar Awards

Disclosure of Interests:

Alize Gunay: None declared, Anna Davidson: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Yewondwossen Mengistu: None declared, Rosie Scuccimarri: None declared, Zenebe Yirsaw: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

A quarter of patients time their early rheumatoid arthritis onset differently than physicians

Objective

Early rheumatoid arthritis (RA) treatment requires timely recognition. This large, multicentre study compared patient-reported vs physician-reported onset of early RA.

Methods

Patients from the Canadian Early ArThritis CoHort with early/suspected RA (persistent synovitis <1 year) completed questionnaires asking about the date of symptom onset; and rheumatologists date of onset for persistent synovitis. Groups with similar reported timing (patient and physician) versus differing timing of 30 days or more were compared.

Results

In 2683 patients, the median patient symptom duration (IQR) was 178 days (163) and physician-reported duration was 166 (138). 1940 (72%) patients had similar patient-reported and physician-reported onset (<30 days), whereas 497 (18%) reported onset 30 or more days preceding physicians, and 246 (9%) 30 or more days after physicians. Patients reporting onset preceding physicians had lower baseline Disease Activity Score based on 28 joint count, swollen joint counts and erythrocyte sedimentation rate (p<0.05). Patients reporting onset after physicians were more likely to be rheumatoid factor positive (p<0.001) and had higher anticitrullinated protein antibody titres (p<0.009). Regression showed low income, smoking, fibromyalgia, osteoarthritis and baseline non-methotrexate non-biological disease-modifying antirheumatic drug use were predictors for longer patient-reported symptoms. At 12 months, patients reporting longer symptom duration than physicians had lower rates of Simplified Disease Activity Index remission and higher physician global assessments.

Conclusion

Over one-fourth of patients reported differences of >1 month in symptom onset from their rheumatologist. Patients with longer symptom durations had less improvement at 1 year, which may be reflective of comorbid musculoskeletal conditions.

Palindromic Rheumatism Frequently Precedes Early Rheumatoid Arthritis: Results From an Incident Cohort

Background

This multicenter incident cohort aimed to characterize how often early rheumatoid arthritis (ERA) patients self‐report episodic joint inflammation (palindromic rheumatism) preceding ERA diagnosis and which characteristics differentiate these patients from those without prior episodic symptoms.

Methods

Data were from patients with early confirmed or suspected RA (more than 6 weeks and less than 12 months) enrolled in the Canadian Early ArThritis CoHort (CATCH) between April 2017 to March 2018 who completed study case report forms assessing joint pain and swelling prior to ERA diagnosis. Chi‐square and t tests were used to compare characteristics of patients with and without self‐reported episodic joint inflammation prior to ERA diagnosis. Multivariable logistic regression was used to identify sociodemographic and clinical measures associated with past episodic joint inflammation around the time of ERA diagnosis.

Results

A total of 154 ERA patients were included; 66% were female, and mean (SD) age and RA symptom duration were 54 (15) years and 141 (118) days. Sixty‐five (42%) ERA patients reported a history of episodic joint pain and swelling, half of whom reported that these symptoms preceded ERA diagnosis by over 6 months. ERA patients with past episodic joint inflammation were more often female, had higher income, were seropositive, had more comorbidities, fewer swollen joints, and lower Clinical Disease Activity Index (CDAI) around the time of ERA diagnosis (P < 0.05). These associations remained significant in multivariable regression adjusting for other sociodemographic and RA clinical measures.

Conclusion

Almost half of ERA patients experienced episodic joint inflammation prior to ERA diagnosis. These patients were more often female, had higher income, and presented with milder disease activity at ERA diagnosis.

A Prospective Study of the Development of Inflammatory Arthritis in the Family Members of Indigenous North American People With Rheumatoid Arthritis

OBJECTIVE

To determine the incidence of inflammatory arthritis and autoantibody prevalence in Indigenous North American people.

METHODS

Unaffected relatives of Indigenous North Americans with rheumatoid arthritis (RA) from central Canada and Alaska were systematically monitored from 2005 to 2017. Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs) were tested at every visit, and a subset was tested for ACPA fine specificity using a custom multiplex assay. Multistate models based on all available study visits were developed to determine the likelihood of transitioning between autoantibody states, or to inflammatory arthritis.

RESULTS

Eighteen of 374 relatives (4.8%) developed inflammatory arthritis during follow-up (after a mean ± SD of 4.7 ± 2.4 years), yielding a transition rate of 9.2 cases/1,000 person-years. Thirty percent of those who developed inflammatory arthritis were seronegative at baseline, but all were seropositive at inflammatory arthritis onset. Although 30% of ACPA/RF double-seropositive individuals developed inflammatory arthritis (after 3.2 ± 2.2 years), the majority of these individuals did not develop inflammatory arthritis. Multistate modeling indicated a 71% and 68% likelihood of ACPA and RF seropositive states, respectively, reverting to a seronegative state after 5 years, and a 39% likelihood of an ACPA/RF double-seropositive state becoming seronegative. Fine specificity testing demonstrated an expansion of the ACPA repertoire prior to the development of inflammatory arthritis.

CONCLUSION

Despite a high incidence of inflammatory arthritis in this cohort of at-risk relatives of Indigenous North Americans with RA, a large proportion of autoantibody-positive individuals do not develop inflammatory arthritis and revert back to an autoantibody-negative state.

Gender differences in information needs and preferences regarding depression among individuals with multiple sclerosis, inflammatory bowel disease and rheumatoid arthritis

OBJECTIVE

We assessed the information needs of persons with any of three immune-mediated inflammatory diseases (multiple sclerosis [MS], inflammatory bowel disease [IBD] and rheumatoid arthritis [RA]) regarding depression, as a first step toward developing patient-relevant information resources, ultimately to facilitate self-management and appropriate care. We also compared information needs across genders.

METHODS

We surveyed participants with MS, IBD and RA regarding depression-related information needs including types of treatments, effectiveness, risks, benefits, and perceived helpfulness of treatments. We compared responses between groups using multivariate regression.

RESULTS

328 participants provided complete responses (MS: 141, IBD: 114, RA: 73). Most of the topics queried were perceived as very important, and similarly important for all groups. Women placed higher importance than men on most topics. The most popular formats for receiving information were discussion with a counselor (very preferred: 67.4%) and written information (very preferred: 65.5%); this did not differ between groups.

CONCLUSIONS

Persons affected by MS, IBD and RA are interested in receiving information about multiple topics related to depression treatment, from multiple sources. Women desire more information than men.

PRACTICE IMPLICATIONS

These findings can be used to design information resources to meet information needs regarding depression in MS, IBD and RA.

Prevalence and Characteristics of Metabolic Syndrome Differ in Men and Women with Early Rheumatoid Arthritis

Objective

Metabolic syndrome (MetS) prevalence in early rheumatoid arthritis (ERA) is conflicting. The impact of sex, including menopause, has not been described. We estimated the prevalence and factors associated with MetS in men and women with ERA.

Methods

A cross‐sectional study of the Canadian Early Arthritis Cohort (CATCH) was performed. Participants with baseline data to estimate key MetS components were included. Sex‐stratified logistic regression identified baseline variables associated with MetS.

Results

The sample included 1543 participants; 71% were female and the mean age was 54 (SD 15) years. MetS prevalence was higher in men 188 (42%) than women 288 (26%, P < 0.0001) and increased with age. Frequent MetS components in men were hypertension (62%), impaired glucose tolerance (IGT, 40%), obesity (36%), and low high‐density lipoprotein cholesterol (36%). Postmenopausal women had greater frequency of hypertension (65%), IGT (32%), and high triglycerides (21%) compared with premenopausal women (P < 0.001). In multivariate analysis, MetS was negatively associated with seropositivity and pulmonary disease in men. Increasing age was associated with MetS in women. In postmenopausal women, corticosteroid use was associated with MetS. Psychiatric comorbidity was associated with MetS in premenopausal women. MetS status was not explained by disease activity or core RA measures.

Conclusion

The characteristics and associations of MetS differed in men and women with ERA. Sex differences, including postmenopausal status, should be considered in comorbidity screening. With this knowledge, the interplay of MetS, sex, and RA therapeutic response on cardiovascular outcomes should be investigated.

Early Rheumatoid Arthritis Presentation, Treatment, and Outcomes in Aboriginal Patients in Canada: A Canadian Early Arthritis Cohort Study Analysis

OBJECTIVE

Health inequities exist in chronic diseases for Aboriginal people. This study compared early rheumatoid arthritis (RA) presentation, treatment, and outcomes between Aboriginal and white patients in a large Canadian cohort study.

METHODS

Longitudinal data from the Canadian Early Arthritis Cohort, a prospective multicenter early RA study, were analyzed for participants who self-identified as Aboriginal or white ethnicity. Disease characteristics at presentation, prognostic factors, frequency of remission, and disease-modifying therapy strategies were contrasted between population groups. Linear mixed models were used to estimate rates of change for disease activity measures over a 5-year period.

RESULTS

At baseline, 2,173 participants (100 Aboriginal and 2,073 white) had similar mean ± SD symptom duration (179 ± 91 days), 28-joint Disease Activity Scores (DAS28; 4.87 ± 1.48), and Health Assessment Questionnaire (0.88 ± 0.68) scores. Factors associated with poor prognosis were more frequently present in Aboriginal participants, but disease-modifying therapy selection and frequency of therapy escalation was similar between the 2 groups. DAS28 remission was achieved less frequently in Aboriginal than in white participants (adjusted odds ratio 0.39 [95% confidence interval 0.25-0.62]). Results were primarily driven by slower improvement in swollen joint counts and nonsignificant improvement in patient global scores in Aboriginal participants. Pain levels remained higher in Aboriginal patients.

CONCLUSION

Aboriginal early RA patients experienced worse disease outcomes than their white counterparts. This may reflect unmeasured biologic differences and/or disparities in prognostic factors informed by inequities in determinants of health. The appropriateness of current treatment strategies applied in different contexts should be considered.

A comparison between childhood and adult onset systemic lupus erythematosus adjusted for ethnicity from the 1000 Canadian Faces of Lupus Cohort

OBJECTIVE

Childhood-onset SLE (cSLE) manifests differently than adult-onset SLE (aSLE). This study determined whether ethnic differences contribute to the differences in clinical presentation between the two groups.

METHODS

This cross-sectional study used data from a multi-centred registry from eight adult and four paediatric Canadian centres gathered at study entry. We compared the frequency of clinical manifestations and autoantibodies between aSLE and cSLE. For those with a significant difference, a multivariable logistic regression was performed, adjusting for ethnicity, SLE onset (cSLE vs aSLE), disease duration and centre. Disease activity and damage between aSLE and cSLE were compared after stratifying by disease duration.

RESULTS

Of 552 aSLE subjects, 502 (90.9%) were female and 381 (69.0%) were Caucasian. Mean age at diagnosis was 37.0 ± 13.6 years and disease duration 10.9 ± 9.6 years. Of 276 cSLE subjects, 231 (83.7%) were female and 101 (36.6%) were Caucasian. Mean age at diagnosis was 12.7 ± 3.3 years and disease duration 5.6 ± 8.2 years. In multivariable regression analysis, aSLE was associated with decreased odds of having a neurologic disorder (odds ratio = 0.49) and increased odds of having aCL antibodies (odds ratio = 1.85). Disease activity and damage accrual scores were higher in aSLE than cSLE within the same disease duration strata, although the differences were not clinically significant. Ethnicity was not associated with any differences in clinical manifestations or autoantibody frequency between aSLE and cSLE.

CONCLUSIONS

Although a crude comparison of aSLE and cSLE yielded several differences in clinical symptoms and autoantibodies, this difference was not attributable to ethnic differences between aSLE and cSLE.

Frequency and spectrum of outpatient musculoskeletal diagnoses at a pediatric hospital in Kenya

Chronic pediatric musculoskeletal (MSK) conditions are a major cause of morbidity. The burden of pediatric rheumatic diseases in East Africa is largely unknown. The purposes of this study were to estimate frequencies and assess the spectrum of MSK-related diagnoses using ICD-10 diagnostic codes among outpatients at a pediatric hospital in Kenya and to evaluate the accuracy of the assigned codes used for the 'arthropathies' category. All pediatric outpatient diagnoses classified under the ICD-10 codes for 'diseases of the MSK system and connective tissue' (M00-M99) recorded between January and December 2011 were extracted from the electronic medical record system at Gertrude's Children's Hospital (GCH). For each of the ten MSK disease categories, frequencies were calculated. The assigned ICD10 code for cases in the 'arthropathies' (M00-M25) category was assessed by two rheumatologists. MSK diagnoses (n = 1078) accounted for 0.5% of all GCH outpatient consults available for analysis. 'Soft tissue disorders' were the most frequent MSK diagnoses (n = 614, 57%), followed by 'arthropathies' (n = 332, 30.8%), 'dorsopathies' (n = 81, 7.5%), 'osteopathies and chondropathies' (n = 39, 3.6%), and 'other' disorders (n = 12, 1.1%). No patients were classified in the category of 'systemic connective tissue disorders'. In cases classified as 'arthropathies', there was poor agreement (Kappa 0.136) between the ICD10 code assigned by the treating physicians and that assigned by the rheumatologists. However, when the rheumatologists' classification was loosened, agreement was moderate (Kappa 0.533). This study provides estimates of the frequency of outpatient MSK diagnoses at a pediatric hospital in Kenya in 2011. MSK diagnoses were not rare. Despite limitations of administrative databases to estimate frequencies of specific diagnoses, they provide a snapshot of the overall burden and spectrum of MSK conditions.

Overweight, Obesity, and the Likelihood of Achieving Sustained Remission in Early Rheumatoid Arthritis: Results From a Multicenter Prospective Cohort Study

OBJECTIVE

Obesity is implicated in rheumatoid arthritis (RA) development, severity, outcomes, and treatment response. We estimated the independent effects of overweight and obesity on ability to achieve sustained remission (sREM) in the 3 years following RA diagnosis.

METHODS

Data were from the Canadian Early Arthritis Cohort, a multicenter observational trial of early RA patients treated by rheumatologists using guideline-based care. sREM was defined as Disease Activity Score in 28 joints (DAS28) <2.6 for 2 consecutive visits. Patients were stratified by body mass index (BMI) as healthy (18.5-24.9 kg/m² ), overweight (25-29.9 kg/m² ), and obese (≥30 kg/m² ). Cox regression was used to estimate the effect of the BMI category on the probability of achieving sREM over the first 3 years, controlling for age, sex, race, education, RA duration, smoking status, comorbidities, baseline DAS28, Health Assessment Questionnaire disability index, C-reactive protein level, and initial treatment.

RESULTS

Of 982 patients, 315 (32%) had a healthy BMI, 343 (35%) were overweight, and 324 (33%) were obese; 355 (36%) achieved sREM within 3 years. Initial treatment did not differ by BMI category. Compared to healthy BMI, overweight patients (hazard ratio [HR] 0.75 [95% confidence interval (95% CI) 0.58-0.98]) and obese patients (HR 0.53 [95% CI 0.39-0.71]) were significantly less likely to achieve sREM.

CONCLUSION

Rates of overweight and obesity were high (69%) in this early RA cohort. Overweight patients were 25% less likely, and obese patients were 47% less likely, to achieve sREM in the first 3 years, despite similar initial disease-modifying antirheumatic drug treatment and subsequent biologic use. This is the largest study demonstrating the negative impact of excess weight on RA disease activity and supports a call to action to better identify and address this risk in RA patients.

High Adherence to System-Level Performance Measures for Rheumatoid Arthritis in a National Early Arthritis Cohort Over Eight Years

OBJECTIVE

To assess adherence to 3 system-level performance measures in a national early rheumatoid arthritis (RA) cohort.

METHODS

Patients enrolled in the Canadian Early Arthritis Cohort (2007-2015) who met 1987 or 2010 American College of Rheumatology/European League Against Rheumatism criteria with <1 year of symptom duration and ≥1 year of followup after enrollment were included. Performance measures assessed were the percentage of RA patients seen in yearly followup, and the number of gaps between visits of >12 or >14 months, the percentage of RA patients treated with a disease-modifying antirheumatic drug (DMARD), and days from RA diagnosis to initiation of a DMARD. Results are shown stratified by enrollment year to assess for temporal changes in performance.

RESULTS

A total of 1,763 early RA patients were included (mean age 54 years, 73% female, and 82% white). At enrollment, mean ± SD disease duration was 6 ± 3 months, and Disease Activity Score in 28 joints was 5.1 ± 1.5. Over 8 years, the proportion of patients seen in annual followup declined from 100% to 91%. Over followup, 42% of patients had 0 gaps in care of >12 months, and 64% had 0 gaps >14 months. The percentage of DMARD-treated early RA patients was and remained high (95-87%), and the percentage receiving DMARDs within 14 days of diagnosis was 75%. Median time-to-DMARD therapy was 1 day, indicating DMARDs were initiated at diagnosis (90th percentile 93 days).

CONCLUSION

There was evidence of high adherence to system-level performance measures in this early RA cohort following a protocol. Small declines in performance were noted with increasing length of patient followup. Our findings are useful for performance measure benchmarking.

Rheumatoid arthritis-specific cardiovascular risk scores are not superior to general risk scores: a validation analysis of patients from seven countries

Objectives

Cardiovascular disease (CVD) risk calculators developed for the general population do not accurately predict CVD events in patients with RA. We sought to externally validate risk calculators recommended for use in patients with RA including the EULAR 1.5 multiplier, the Expanded Cardiovascular Risk Prediction Score for RA (ERS-RA) and QRISK2.

Methods

Seven RA cohorts from UK, Norway, Netherlands, USA, South Africa, Canada and Mexico were combined. Data on baseline CVD risk factors, RA characteristics and CVD outcomes (including myocardial infarction, ischaemic stroke and cardiovascular death) were collected using standardized definitions. Performance of QRISK2, EULAR multiplier and ERS-RA was compared with other risk calculators [American College of Cardiology/American Heart Association (ACC/AHA), Framingham Adult Treatment Panel III Framingham risk score-Adult Treatment Panel (FRS-ATP) and Reynolds Risk Score] using c-statistics and net reclassification index.

Results

Among 1796 RA patients without prior CVD [mean ( s . d .) age: 54.0 (14.0) years, 74% female], 100 developed CVD events during a mean follow-up of 6.9 years (12430 person-years). Estimated CVD risk by ERS-RA [mean ( s . d .) 8.8% (9.8%)] was comparable to FRS-ATP [mean ( s . d .) 9.1% (8.3%)] and Reynolds [mean ( s . d .) 9.2% (12.2%)], but lower than ACC/AHA [mean ( s . d .) 9.8% (12.1%)]. QRISK2 substantially overestimated risk [mean ( s . d .) 15.5% (13.9%)]. Discrimination was not improved for ERS-RA (c-statistic = 0.69), QRISK2 or EULAR multiplier applied to ACC/AHA compared with ACC/AHA (c-statistic = 0.72 for all) or for FRS-ATP (c-statistic = 0.75). The net reclassification index for ERS-RA was low (-0.8% vs ACC/AHA and 2.3% vs FRS-ATP).

Conclusion

The QRISK2, EULAR multiplier and ERS-RA algorithms did not predict CVD risk more accurately in patients with RA than CVD risk calculators developed for the general population.

Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis

OBJECTIVES

Patients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD). We aimed to assess the impact of CVD risk factors, including potential sex differences, and RA-specific variables on CVD outcome in a large, international cohort of patients with RA.

METHODS

In 13 rheumatology centres, data on CVD risk factors and RA characteristics were collected at baseline. CVD outcomes (myocardial infarction, angina, revascularisation, stroke, peripheral vascular disease and CVD death) were collected using standardised definitions.

RESULTS

5638 patients with RA and no prior CVD were included (mean age: 55.3 (SD: 14.0) years, 76% women). During mean follow-up of 5.8 (SD: 4.4) years, 148 men and 241 women developed a CVD event (10-year cumulative incidence 20.9% and 11.1%, respectively). Men had a higher burden of CVD risk factors, including increased blood pressure, higher total cholesterol and smoking prevalence than women (all p<0.001). Among the traditional CVD risk factors, smoking and hypertension had the highest population attributable risk (PAR) overall and among both sexes, followed by total cholesterol. The PAR for Disease Activity Score and for seropositivity were comparable in magnitude to the PAR for lipids. A total of 70% of CVD events were attributable to all CVD risk factors and RA characteristics combined (separately 49% CVD risk factors and 30% RA characteristics).

CONCLUSIONS

In a large, international cohort of patients with RA, 30% of CVD events were attributable to RA characteristics. This finding indicates that RA characteristics play an important role in efforts to reduce CVD risk among patients with RA.

Thresholds for the 28-joint disease activity score (DAS28) using C-reactive protein are lower compared to DAS28 using erythrocyte sedimentation rate in early rheumatoid arthritis

OBJECTIVES

The 28-Joint Disease Activity Score (DAS28) using C-reactive protein (CRP) and DAS28 using erythrocyte sedimentation rate (DAS28-ESR) may not be interchangeable. We sought to compare and estimate optimal thresholds for the DA28-CRP for use in early rheumatoid arthritis (ERA).

METHODS

Patients from the Canadian Early Arthritis Cohort with baseline and 12 months' data for both DAS28-ESR and DAS28-CRP were examined for correlations and differences between DAS28-CRP and DAS28-ESR across their range of values. Receiver operating characteristic analysis identified thresholds for DAS28-CRP that best corresponded to established thresholds for the DAS28-ESR using the total sample, then stratified by age and sex. Agreement between DAS28-CRP and DAS28-ESR thresholds was assessed with the kappa statistic.

RESULTS

The sample included 995 patients with mean (SD) age of 53.7 (14.5) years, 5.8 (2.9) months of symptom duration and 74% were female. DAS28-CRP and DAS28-ESR scores were highly correlated (r= 0.92, p<0.0001), however DAS28-CRP values were consistently lower than DAS28-ESR values. Calculated thresholds for DAS28-CRP were lower with 2.5 for remission, 2.9 for low disease activity, and 4.6 for high disease activity but showed moderate agreement with the DAS28-ESR thresholds (kappa=0.70).

CONCLUSIONS

In this large sample of ERA patients, newly estimated thresholds for DAS28-CRP were consistently lower than DAS28-ESR thresholds across the spectrum of disease activity. This may have important clinical implications if inflammatory markers are used interchangeably. Additional external validation of our findings is needed.