Japan College of Rheumatology guidance for the use of methotrexate in patients with rheumatoid arthritis: Secondary publication

Methotrexate (MTX), the anchor drug in the current treatment strategy for rheumatoid arthritis (RA), was first approved for the treatment of RA in Japan in 1999 at a recommended dose of 6-8 mg/week. The approved maximum dose of MTX has been 16 mg/week since February 2011 when MTX was approved as a first-line drug in the treatment of RA. Recent evidence of MTX-polyglutamate concentration in the red blood cells of Japanese patients with RA justifies the current daily use of MTX in Japan. Additionally, after a nationwide clinical trial, a subcutaneous MTX injection formula (7.5-15 mg/week) was approved for RA treatment in September 2022. Therefore, in March 2023, a subcommittee of the Japan College of Rheumatology updated the guidance (formerly 'guidelines') for the use of MTX in Japanese patients with RA. This article, an abridged English translation summarizing the 2023 update of the Japan College of Rheumatology guidance for the use of MTX and management of patients with RA, will be helpful to both Japanese and global rheumatology communities.

Psychological support and patient-centered care for patients with rheumatoid arthritis: Nurses' opinions and practice in Japan

AIM

To investigate nurses' opinions and practices regarding psychological support and patient-centered care (PCC) for patients with rheumatoid arthritis.

METHOD

Registered nurses engaged in rheumatic care in Japan were asked to complete the questionnaire regarding nurses' perceived necessity, understanding, and implementation of psychological support, and six patient supports related to PCC, using a seven-point Likert scale. Correlation on practice between psychological support and PCC was evaluated.

RESULTS

A total of 53 nurses participated. Nurses indicated high necessity of providing psychological support, whereas implementation was statistically significantly lower than necessity and motivation. Nurses' answers showed significantly lower implementation compared with understanding regarding basic concepts of psychological support: listening, empathy, acceptance, open questions, and closed questions. Most nurses (54.7%) sometimes provided psychological support, followed by often (34.0%), always (5.7%), and not at all (5.6%). Perceived necessity of PCC was rated high. However, its implementation was significantly lower than necessity for all evaluated cares, such as patients' need-based support and support to patients' families, related to PCC. Positive correlations were observed between the implementation of psychological support and PCC. Nurses stressed the importance of psychological support for patient education and shared decision-making.

CONCLUSION

This preliminary study indicated that most nurses considered psychological support and PCC necessary, but their implementation was relatively low. As psychological support is also crucial to shared decision-making, in addition to PCC, barriers to its implementation should be addressed to improve patients' outcomes and quality of life.

Challenges faced by nurses engaged in rheumatology care in Japan

OBJECTIVES

This study aimed to identify the challenges faced by nurses engaged in rheumatology care in Japan.

METHODS

We conducted a questionnaire survey of nurses in Japan in 2020 on challenges experienced in rheumatology care. The participants were nurses certified by the Japan Rheumatism Foundation. Participants' answers were coded and categorized based on relevant phrases and words. Content analysis was performed on the findings.

RESULTS

Responses were collected from 162 participants, and a total of 228 issues were identified. Eighteen categories with 56 subcategories emerged from the data analysis, which were grouped into five types of challenges: (1) communication, (2) understanding, (3) expertise, (4) system, and (5) collaboration. In particular, the results highlighted deficiencies in needs-based multidisciplinary team care.

CONCLUSION

This study elucidated issues experienced by rheumatology nurses in clinical settings in Japan. Furthermore, this investigation revealed the necessity of patient-centered multidisciplinary team care, including health professionals, patients, and other relevant individuals. This study provided practical directions to facilitate the implementation of effective care focused on improving patients' quality of life.

Assessing acceptability and identifying barriers and facilitators to implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with rheumatology professionals in 23 European and Asian countries

OBJECTIVES

To disseminate and assess the level of acceptability and applicability of the European Alliance of Associations for Rheumatology (EULAR) recommendations for patient education among professionals in rheumatology across Europe and three Asian countries and identify potential barriers and facilitators to their application.

METHODS

A parallel convergent mixed-methods design with an inductive approach was used. A web-based survey, available in 20 different languages, was distributed to health professionals by non-probability sampling. The level of agreement and applicability of each recommendation was assessed by (0-10) rating scales. Barriers and facilitators to implementation were assessed using free-text responses. Quantitative data were analysed descriptively and qualitative data by content analysis and presented in 16 categories supported by quotes.

RESULTS

A total of 1159 completed the survey; 852 (73.5%) were women. Most of the professionals were nurses (n=487), rheumatologists (n=320), physiotherapists (n=158). For all recommendations, the level of agreement was high but applicability was lower. The four most common barriers to application were lack of time, lack of training in how to provide patient education, not having enough staff to perform this task and lack of evaluation tools. The most common facilitators were tailoring patient education to individual patients, using group education, linking patient education with diagnosis and treatment and inviting patients to provide feedback on patient education delivery.

CONCLUSIONS

This project has disseminated the EULAR recommendations for patient education to health professionals across 23 countries. Potential barriers to their application were identified and some are amenable to change, namely training patient education providers and developing evaluation tools.

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients' perspectives

Objectives

To explore patients’ agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA).

Methods

This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants’ demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories.

Results

The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9–10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE.

Conclusion

The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients’ preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals.

AB0894-HPR THE JOURNEY OF PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The course of rheumatoid arthritis (RA) differs from patient to patient, and each patient has a unique story. The disease condition affects psychological and social aspects, greatly affecting the quality of life. The disease course is unpredictable, and each patient’s story can be seen as a lifelong journey, full of ups and downs. Therefore, it is crucial to know what kind of support is required during the course of their life.

Objectives:

The aim of this study is to examine the life story of patients with RA and clarify a common situation in their stories in order to consider what kind of support is needed.

Methods:

This is a qualitative study using life story interview for patients with RA in Japan. Interview included disease history, patients’ behaviors, effects on daily life, the patients’ perspectives regarding psychological considerations and useful support. Data were analyzed using content analysis. This study was approved by the ethics committee and informed consent was obtained.

Results:

Eight patients participated in this study. They were all females and the average age was 57 years old. As a result of the categorization, we extracted the following eight situations: (1) Emergence of symptom; patients thought joint pain would go away, however, the symptom did not improve and began to affect their daily life and work, (2) Choose a hospital to visit; pain and anxiety have continued and decided to visit a hospital, (3) Encounter with their doctors; patients expected their doctor to relieve their pain, while they were afraid of being told that they were suffering from a serious disease. (4) Diagnosis of RA; patients were shocked when diagnosed and anxious about what would happen and wondered why they had such a disease, (5) Choice of treatment; patients were afraid of the side effects. They wanted to make a decision discussing with their doctor, but they could not understand the explanation about drugs well and, therefore, followed the doctor’s opinion. (6) Change of treatment; a biological agent was often recommended. Patients were also worried about side effects and the financial burden. (7) Remission or stable phase; they felt better mentally too, however, they often felt anxiety about disease flare, side effect of drugs and financial burden, and (8) Flare and remission; patients felt shocked and disappointed when RA flared, and then, they noticed that patients with RA had alternating periods of relapse and remission and they had to live with RA.

These interviews revealed repeated worsening and improvement of symptoms and many similar repeated psychological reactions such as anxiety, shock, denial, conflict, acceptance, giving up and relief. To cope with these fluctuating disease and mental conditions, patients were supported by educational and psychological assistance, timely consultations, social life help from nurses and support from their family. The patients considered a trusting relationship with their doctors is necessary. The patients had also realized through their experience the importance of enhancing their own abilities, such as decision-making, prevention of infections and self-management skills. Moreover, they noticed that it is important to have their own goals including hobbies and work.

Conclusion:

This study elucidated the common behaviors of patients with RA, the impact of RA on their psychological state and daily and social life, and the required support. The psychological condition and daily and social life also had a great influence on medical behavior. Therefore, psychosocial support and establishment of trust between healthcare professionals and patients are crucial. In addition, improving patients’ self-management skills including self-efficacy and empowerment is also necessary. As patients with RA often feel anxious in various situations and expect nurses’ support, nurses should listen to patients, pay attention to their concerns and anxieties, and show a solution-oriented attitude. In order for patients to feel at ease in their Patient Journey, nurses should sail with them while maintaining a patient-centered perspective.

Disclosure of Interests:

None declared

THU0646-HPR EXPLORING THE ROLE OF NURSE IN RHEUMATIC CARE AND FEASIBILITY OF ENHANCING TREAT TO TARGET STRATEGIES IN JAPAN

Background:

The role of rheumatology nurses is considered important for the implementation of T2T [1]. For nurses’ contribution to implementation of the T2T strategy, it is necessary to explore the nurses’ opinion on their roles in real clinical practice.

Objectives:

The aim of this study is to evaluate what is required for nurses to implement T2T in real clinical practice in Japan.

Methods:

Registered nurses engaged in rheumatic care in clinical practice in Japan were enrolled. Focus group interviews were conducted exploring ‘What is necessary for RA nurses to implement T2T’using semi-structured interviews. Data analysis was used with Krippendorff’s content analysis method.

Results:

24 nurses (all females) from 10 hospitals were enrolled in this study. The results of the qualitative analysis were categorized in 10 main categories, derived from 37 subcategories based on 64 different codes: (1) provide basic knowledge of RA, (2) provide knowledge of RA drugs, (3) provide knowledge and skills of self-monitoring, (4) enhance self-efficacy and support self-management, (5) support decision-making, (6) psychological and social support, (7) understand the diversity and feelings of patients and their families, (8) support based on individual needs, (9) ensure continuing educational opportunities for nurses to enable the provision of high quality care, (10) collaborate with multidisciplinary teams.

These categories are mostly covered in the contents of the 2018 updated EULAR recommendations for the role of nurses except “evidence-based rheumatic care”, “telehealth” and “comprehensive participation in disease management”.

Conclusion:

These findings indicate the areas of exploration including further educational and training needs, attitudes and the professional scope for nurses to extend their roles to provide greater value to patient care.

In Japan, evidence-based RA nursing and telehealth systems have not yet been established. In addition, therapeutic intervention by nurses and nurse-led clinic are not permitted. Our results might reflect this situation and possibly elucidates the gap between EULAR’s evidence-based recommendations and opinions of Japanese nurses working in daily clinical practice. As evidence-based nursing is considered to be crucial from both cost-effectiveness and improvement of patients QOL, this result also might shed light on what we need for future better rheumatic nursing in Japan.

References:

[1]van Eijk- Hustings Y, et al. Ann Rheum Dis 2012;71: 13–19.

Disclosure of Interests:

MIE FUSAMA: None declared, Miyabi Uda: None declared, Harumi Matsumura: None declared, Yvonne van Eijk-Hustings Grant/research support from: grand from sanofi and UCB, Consultant of: fee from amgen, Susan Oliver: None declared, Hideko Nakahara: None declared

Improvement of health status evaluated by Arthritis Impact Measurement Scale 2 (AIMS-2) and Short Form-36 (SF-36) in patients with rheumatoid arthritis treated with tocilizumab

OBJECTIVE

To evaluate the improvement of health status in patients with rheumatoid arthritis (RA) treated with tocilizumab.

METHODS

Thirty-nine patients were treated with 8 mg/kg tocilizumab every 4 weeks for 24 weeks. Disease activity was assessed by Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI). Improvement of health status was assessed by Arthritis Impact Measurement Scale 2 (AIMS-2) and Short Form-36 (SF-36).

RESULTS

Tocilizumab improved CDAI and SDAI significantly at week 4 compared with at baseline. In the components of AIMS-2, "physical score", "symptom" and "affect" improved significantly at week 4 compared with at baseline, while "social interaction" did not improve significantly during 24 weeks of tocilizumab therapy. Similarly in SF-36, "bodily pain", "general health", "vitality" and "mental health" improved significantly at week 4. The most correlative component of AIMS-2 with CDAI was "symptom", while "social interaction" did not correlate with CDAI during tocilizumab treatment.

CONCLUSION

The time-course diversity in improvement of health status should be considered to provide proper healthcare when treated with tocilizumab.

Changes in electrophoretic mobility pattern of erythrocytes in patients with paroxysmal nocturnal hemoglobinuria

The electric surface charge of erythrocytes in patients with paroxysmal nocturnal hemoglobinuria (PNH) was analyzed by means of a fully automated cell electrophoretic instrument (Parmoquant-L). The electrophoretic mobility of PNH erythrocytes decreased significantly and showed a broader pattern. After a blood transfusion, erythrocytes of PNH patients showed a bimodal pattern because of the emergence of the higher mobility peak corresponding to normal erythrocytes. However, the next day after transfusion, this new peak disappeared. Furthermore, the next day after administration of Prednisolone, the main peak of the mobility pattern shifted to the higher side, and after treatment for 7 days, the pattern showed several peaks and tended to disperse. Reticulocytes had higher complement lysis sensitivity, lower cholinesterase activity and lower electric surface charge, and it was shown that PNH erythrocytes consisted of 2 populations. Studies on the electrophoretic mobility patterns of PNH erythrocytes under various conditions can be useful in understanding the properties of erythrocyte membrane surfaces.