OP0183 IDENTIFICATION OF A SUBGROUP OF PEOPLE WITH RHEUMATOID ARTHRITIS CHARACTERISED BY HIGH DISABILITY OVER 10 YEARS, DESPITE LOW INFLAMMATION: RESULTS FROM TWO EUROPEAN PROSPECTIVE COHORT STUDIES

Background:

Long-term studies in rheumatoid arthritis (RA) have reported low inflammation yet high disability over time. It is important to determine which factors are driving this disparity, so appropriate interventions can be used to reduce this gap.

Objectives:

To identify a subgroup of people with RA with low inflammation yet high disability over 10 years, and describe their characteristics.

Methods:

Data came from two cohorts of inflammatory arthritis with regular assessments over 10 years: the Norfolk Arthritis Register (NOAR, inclusion: ≥2 swollen joints for ≥4 weeks) from the UK and the Etude et Suivi des Polyarthrites Indifférenciées Récentes study (ESPOIR, inclusion: early RA) from France. Participants provided demographic data and completed patient reported outcomes (PROs, including the Health Assessment Questionnaire [HAQ]). The 2-component Disease Activity Score (DAS28-2C)1, a measure of inflammation, was calculated from swollen joint counts and C-reactive protein level. Inclusion criteria for this analyis: <2 years baseline symptom duration; HAQ and DAS28-2C at baseline and one other follow-up; recruited after 1/1/2000. HAQ and DAS28-2C were modelled simultaneously using a multivariate group-based trajectory model, to identify groups of participants with similar trajectories of HAQ and DAS28-2C over 10 years. Baseline demographics and PROs were compared between the trajectory groups using logistic regression. Analyses performed separately in NOAR and ESPOIR.

Results:

1001 NOAR and 767 ESPOIR participants were included. In both cohorts, a four group trajectory model had the best fit (Figure). Two subgroups were identified in each cohort that demonstrated the hypothesised relationship: similar DAS28-2C but differing HAQ scores (red trajectories in Figure), titled “High HAQ” and “Low HAQ” (mean difference in HAQ over follow-up [95% confidence interval (CI)]: NOAR 0.76 [0.73, 0.80]; ESPOIR 0.89 [0.82, 0.96]). At baseline, the High HAQ groups in both NOAR and ESPOIR were older, had a higher proportion of women, and had higher levels of fatigue (NOAR: odds ratio [OR] 1.16 [95% CI 1.06, 1.28]; ESPOIR: OR 1.20 [95% CI 1.05, 1.36] [Table]) and pain (NOAR only).

Table 1.

Baseline characteristics / logistic regression analysis

NOARESPOIRVariableLow HAQ trajectory, mean (SD)High HAQ trajectory, mean (SD)OR (95% CI)Low HAQ trajectory, mean (SD)High HAQ trajectory, mean (SD)OR (95% CI)N (%)343 (59%)239 (41%)-131 (55%)108 (45%)-Age, years54.9 (14.2)62.1 (13.8)1.07 (1.05, 1.08)47.8 (13.3)51.8 (11.2)1.04 (1.01, 1.06)Women, N (%)224 (65.3%)176 (73.6%)1.82 (1.12, 2.78)100 (76.3%)95 (88.0%)2.73 (1.20, 6.23)Symptom duration, months7.8 (5.1)8 (5.4)1.10 (0.98, 1.05)3.4 (1.8)3.6 (1.8)1.16 (0.98, 1.37)Current smoker, N (%)77 (22.4%)50 (20.9%)1.19 (0.71, 2.00)61 (46.6%)52 (48.1%)1.52 (0.82, 2.83)DAS28-2C3.14 (1.46)3.21 (1.56)-4.65 (1.31)4.41 (1.35)-HAQ0.8 (0.6)1.4 (0.5)-1.1 (0.6)1.6 (0.6)-Pain (0-10)3.7 (2.4)4.6 (2.5)1.16 (1.07, 1.26)4.1 (2.8)5.1 (2.6)1.07 (0.95, 1.20)Fatigue (0-10)4.3 (2.8)5.3 (2.5)1.16 (1.06, 1.28)5.0 (2.6)6.5 (2.5)1.20 (1.05, 1.36)AIMS anxiety3.99 (1.96)4.42 (1.99)1.06 (0.88, 1.29)4.9 (2.26)5.98 (2.25)1.10 (0.94, 1.29)AIMS depression2.85 (1.87)3.38 (1.87)1.10 (0.94, 1.29)3.96 (1.99)5.08 (2.32)1.12 (0.94, 1.33)RF+, N (%)142 (41.4%)106 (44.4%)0.94 (0.60, 1.46)79 (60.3%)50 (46.3%)0.77 (0.34, 1.75)Anti-CCP+, N (%)113 (32.9%)86 (36.0%)1.35 (0.84, 2.17)76 (58.0%)45 (41.7%)0.89 (0.39, 2.05)

Conclusion:

There is a group of people with RA with high levels of disability, despite low inflammation. These results underline the potential need for pain and fatigue management in people with RA, even when inflammation is low.

References:

[1]Hensor et al (2019). Rheumatology (Oxford) 58(8)

Acknowledgements:

Thanks to the participants of NOAR and ESPOIR and those working in the recruiting centres

ESPOIR Funding:

An unrestricted grant from Merck Sharp and Dohme (MSD) was allocated for the first 5 years of the cohort study. Two additional grants from INSERM supported part of the biological database. The French Society of Rheumatology, Abbvie, Pfizer, Lilly and more recently Fresenius and Biogen supported the ESPOIR cohort study.

Disclosure of Interests:

James Gwinnutt Grant/research support from: Research grant from Bristol Myers Squibb unrelated to this project, Sam Norton Consultant of: Pfizer and AstraZeneca, Kimme Hyrich Consultant of: Abbvie, Grant/research support from: Pfizer and BMS, Mark Lunt: None declared, Bernard Combe: None declared, Nathalie Rincheval: None declared, Adeline Ruyssen-Witrand: None declared, Bruno Fautrel: None declared, Jacqueline Chipping: None declared, Alex MacGregor: None declared, Suzanne Verstappen: None declared

POS0018 INVESTIGATING VIRTUAL IMMERSIVE EXPERIENCES IN THE MANAGEMENT OF CHRONIC PAIN – THE VIPA STUDY (PRELIMINARY RESULTS)

Background:

Chronic pain is debilitating and prevalent. Current non-pharmacological management of pain conditions such as Fibromyalgia Syndrome (FMS) are labour intensive to implement and poorly available, especially during the pandemic. There is an urgent need to develop widely adoptable, innovative treatment options for pain cohorts.

Virtual reality (VR) provides an innovative therapeutic tool, immersing users within a three-dimensional, interactive virtual environment with use of a head-mounted display (HMD). Beneficial effects of VR have been demonstrated in acute pain1, with limited studies in chronic pain. Given the variation of available VR technologies, it is vital to investigate the impact of different VR characteristics on acceptability in specific chronic pain cohorts.

Objectives:

This feasibility study aims to establish the acceptability of four different VR technologies in patients with FMS whilst undertaking a single interactive VR experience.

Methods:

Patients with FMS were recruited through outpatient clinics at the Norfolk and Norwich University Hospital. Baseline questionnaires were used including the McGill pain questionnaire (MPQ-SF), pain visual analogue scale (VAS) and Revised Fibromyalgia Impact Questionnaire (FIQR). Subjective experience questionnaires collected acceptability data with 7-point Likert scale rating questions (strongly disagree to strongly agree). The simulation sickness questionnaire (SSQ) gained side-effect data (total severity score: 0-235). Categorical data were described using frequencies; and continuous data using mean and standard deviation. Likert-scale data were dichotomised (rating ≤3: disagree, rating ≥5: agree).

Four VR systems representing the spectrum of commercially available technologies were used (seen in Figure 1). These possess different characteristics including screen resolution, processor speed, weight, strap and controller type. The VR experience used with each headset was co-developed alongside industry partners (Orbital Global). Participants are immersed within a naturalistic environment, situated on a wooden boat travelling slowly along a calm river surrounded by trees and hills. The interactive element involves the user shooting targets that appear using handheld controllers.

Results:

13 patients with FMS were included (mean age 41.8±15.6, 92.3% female). Most had severe disease (mean FIQR 67.8±14.1) with moderate self-reported pain at baseline (mean MPQ 25.5±8.8, VAS 6.0±1.7). Most had no previous VR exposure (69.2%). 100% of participants agreed that they would be open to using VR for future pain management (mean rating 6.5±0.7) and that they would use VR regularly at home (mean rating 6.5±0.7). VR HMD comfort and enjoyment data are presented in Table 1. Mean ratings of comfort were high across the four HMDs (Gear VR: 4.9±1.7, Oculus Go: 4.5±1.8, Oculus Quest 5.3±1.9, Oculus Rift 6.6±0.5). Mean ratings of enjoyment with each HMD were also high (Gear VR: 5.4±1.6, Oculus Go: 5.4±1.8, Oculus Quest: 5.6±1.9, Oculus Rift S: 6.6±0.5). Low levels of side effects were described with mean SSQ total scores ranging from 20.1±16.8 (Oculus Rift S) to 38.0±23.9 (Gear VR).

Conclusion:

Preliminary results indicate that FMS patients find VR acceptable, describing high ratings of comfort and enjoyment across the VR HMD spectrum. Side-effect frequency was low, with most settling after HMD removal. All participants were open to future use of VR for home-based pain management.

References:

[1]Dascal J, Reid M, Ishak WW, Spiegel B, Recacho J, Rosen B, Danovitch I. Virtual reality and medical inpatients: A systematic review of randomized, controlled trials. Innov Clin Neurosci 2017;14(1-2):14-21

Table 1.

Subjective experience results across VR HMDs

Mean Likert scale ratings (% agreement: rating ≥5)VR HMDOverall, I found the VR experience using this equipment comfortableOverall, I enjoyed using this VR headsetGear VR4.9±1.7 (62%)5.4±1.6 (77%)Oculus Go4.5±1.8 (54%)5.4±1.8 (75%)Oculus Quest5.3±1.9 (77%)5.6±1.9 (100%)Oculus Rift S6.6±0.5 (100%)6.6±0.5 (100%)

Acknowledgements:

I would like to acknowledge the contributions of the staff working within the Rheumatology department at the Norfolk and Norwich University Hospital. I would also like to thank and acknowledge our participants for being involved in the study.

Disclosure of Interests:

Jordan Tsigarides Grant/research support from: Our digital health industry partners (Orbital Global) provided a small financial contribution to support this study., Vanessa Grove: None declared, Dheeraj Sethi: None declared, Jacqueline Chipping: None declared, Susan Miles: None declared, Nicholas Shenker: None declared, Saber Sami: None declared, Alex MacGregor: None declared.

THU0130 PATTERNS OF COGNITIVE DECLINE IN RHEUMATOID ARTHRITIS: RESULTS OF CASE CONTROL STUDY NESTED IN A POPULATION-BASED COHORT

Background:

The risk of cognitive decline and dementia is of particular interest for patients exposed to prolonged inflammation. In rheumatoid arthritis (RA), the inflammatory mechanisms that are central to the disease’s pathology share many features with those seen in Alzheimer’s disease (AD). However, published reports on the strength and direction of the putative associations with cognitive decline and dementia in RA are conflicting and the potential impact of immunomodulation has not been fully established. This study reports on a case control analysis comparing the results of a cognitive test conducted in RA cases from a longitudinal population register with healthy controls. The relationship between test outcomes, disease characteristics, and treatment is examined.

Objectives:

To characterise differences in cognitive function as assessed by a validated test battery between a group of patients with RA and a matched sample of healthy controls.

To investigate disease and treatment related factors that might have an impact on the cognitive function of patients with RA.

Methods:

A total of 38 people with RA were selected at random from subjects who had enrolled on the Norfolk Arthritis Register as part of the ICORA (Investigation of Cognition in RA) Study. The register is a large longitudinal inception cohort of patients recruited from both primary and secondary care. The study subjects were over 55 years old with a diagnosis of RA defined by the ACR criteria. Cognitive function was assessed using the Addenbrooke’s Cognitive Examination III (ACE-III) battery. The ACE-III is a validated screening test for dementia that evaluates five cognitive domains (attention, memory, verbal fluency, language and visuospatial skills). A cut off value of 82 is indicative of cognitive impairment. The ACE-III scores in the cases were compared with scores from 29 healthy population-based controls matched for age and sex.

Results:

The mean age of the patient and control groups was 69 years. The RA patients had a mean disease duration of 9.8 years and had been taking DMARDs for 7.1 years. Among the patient group with RA, 14 (37%) scored below 82 compared with none in the group of healthy controls. The mean ACE-III scores of both groups are shown in the table below:

Controls N=29RA N=38ACE-III Total95.2 (3.7)85.2 (7.4)•Attention17.7 (0.5)16.5 (1.9)•Memory24.6 (1.9)19.8 (4.0)•Fluency12 (1.4)9.9 (2.6)•Language25.5 (0.8)24.6 (1.7)•Visuospatial15.8 (0.5)14.4 (1.5)

After adjusting for age, sex, BMI and smoking status, significant differences were seen in the ACE-III total (adjusted mean difference(SE)=8.67(1.77); p<0.001), memory (adjusted mean difference(SE)=4.16(1.03); p<0.001), fluency (adjusted mean difference(SE)=2.29(0.67); p=0.001) and visuospatial (adjusted mean difference(SE)=1.36(0.38); p<0.001). There was no difference in attention (p=0.19) or language (p=0.10).

Among the patients with RA there was no clear association between disease duration and ACE-III Total scores; however, there was a trend for increasing cognitive scores in those who had been taking DMARDs for longer (<5 years: mean ACE-III Total=84.1; 5-10 years: 85.0: 11-14 years: 85.4; >14 years: 89.6).

Conclusion:

This study provides evidence to suggest that patients with established RA are at increased risk of cognitive decline when compared with healthy controls. The pattern of cognitive deficit, predominantly involving visuospatial and memory function, is consistent with an Alzheimer’s disease profile. Our data suggest a potential role for DMARDs in reducing the rate of cognitive decline in patients with RA.

Disclosure of Interests:

Tasuku Toyoda: None declared, Jacqueline Chipping: None declared, Jack Dainty: None declared, Stephen Jeffs: None declared, Michael Hornberger: None declared, Eneida Mioshi: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Max Yates: None declared, Alex MacGregor: None declared

Mortality trends in patients with early rheumatoid arthritis over 20 years: results from the Norfolk Arthritis Register

OBJECTIVE

To examine mortality rates in UK patients with early rheumatoid arthritis (RA) from 1990-2011 and compare with population trends.

METHODS

The Norfolk Arthritis Register (NOAR) recruited adults with ≥2 swollen joints for ≥4 weeks: cohort 1 (1990-1994), cohort 2 (1995-1999), and cohort 3 (2000-2004). At baseline, serum rheumatoid factor and anti-citrullinated protein antibody were measured and the 2010 American College of Rheumatology/European League Against Rheumatism RA classification criteria were applied. Patients were followed for 7 years, until emigration or death. The UK Office for National Statistics notified the NOAR of the date and cause of deaths, and provided mortality rates for the Norfolk population. All-cause and cardiovascular-specific standardized mortality ratios (SMRs) were calculated. Poisson regression was used to compare mortality rate ratios (MRRs) between cohorts and then, with cubic splines, to model rates by calendar year. Analyses were performed in patients 1) with early inflammatory arthritis, 2) classified as having RA, and 3) autoantibody positive.

RESULTS

A total of 2,517 patients were included, with 1,639 women (65%) and median age 55 years, and 1,419 (56%) fulfilled the 2010 RA criteria. All-cause and cardiovascular-specific SMRs were significantly elevated in the antibody-positive groups. There was no change in mortality rates over time after accounting for changes in the population rates. In RA patients, all-cause MRRs, compared to cohort 1, were 1.13 (95% confidence interval [95% CI] 0.84-1.52) and 1.00 (95% CI 0.70-1.43) in cohorts 2 and 3, respectively.

CONCLUSION

Mortality rates were increased in patients with RA and SMRs were particularly elevated in those who were autoantibody positive. Compared to the general population, mortality rates have not improved over the past 20 years.