Fear of movement and competence frustration mediate the relationship between pain catastrophising and physical function in people living with axSpA: an online cross-sectional survey

The objective of this study is to examine the contribution of pain catastrophising to Axial Spondyloarthritis (axSpA) patient's physical function and to test the mediating role of fear of movement, and uniquely, the contribution of competence frustration to the fear-avoidance model. Participants (N = 98, 70% female, M age = 45.62, SD 12.16) completed an online survey (December 2020-May 2021) distributed in the United Kingdom via the National Axial Spondyloarthritis Society (n ≈ 3500; NASS, 2019). The PROCESS SPSS macro was used to test three mediation models using percentile bootstrap 95% confidence intervals (PBCI). A significant indirect effect on the relationship between pain and physical function via fear of movement (β = 0.10, 95% PBCI = 0.030-0.183) was observed (Model 1). Model 2 showed the relationship between pain catastrophising and physical function to be significantly mediated by fear of movement (β = 0.16, 95% PBCI = 0.005-0.322). Finally, Model 3 showed a significant indirect effect on the relationship between pain catastrophising and physical function via competence frustration (β = 0.15, 95% PBCI = 0.014-0.309) but not through fear of movement (β = 0.062, 95% PBCI = - 0.134 to 0.248). To our knowledge, this is the first study to examine and demonstrate the unique contribution of competence need frustration to the Fear-avoidance model in people that live with axSpA. Identifying modifiable factors that contribute to disease outcomes such as physical function can improve the care and quality of life for people living with a disease currently without a cure.

Rehabilitation interventions delivered via telehealth to support self-management of rheumatic and musculoskeletal diseases: A scoping review protocol

BACKGROUND

Telerehabilitation is a term to describe rehabilitation services delivered via information and communication technology. Such services are an increasingly important component for the management of rheumatic and musculoskeletal diseases (RMDs). Telerehabilitation has the potential to expand the long-term self-management options for individuals with RMDs, improve symptoms, and relieve pressures on health care services. Yet, little is known about the variety of interventions implemented, and how they are being evaluated. Thus, this scoping review aims to identify and describe existing rehabilitation interventions delivered via telehealth for RMDs. Specifically, we aim to identify and summarize the key components of rehabilitation, the technology used, the level of health care professional interaction, and how the effectiveness of interventions is evaluated.

METHODS

We will conduct this review following the latest JBI scoping review methodology and the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). The 'Population-Concept-Context (PCC)' framework will be used, whereby the 'Population' is RMDs (≥18 years); the 'Concept' is rehabilitation; and the 'Context' is telehealth. Developed in collaboration with a subject Librarian, refined PCC key terms will be utilized to search (from 2011-2021) three electronic databases (i.e., Embase, Scopus, Web of Science) for articles published in English. Search results will be exported to the citation management software (EndNote), duplicates removed, and eligibility criteria applied to title/abstract and full-text review. Relevant information pertaining to the PCC framework will be extracted. Data will be summarized qualitatively, and if appropriate, quantitatively via frequency counts of the components comprising the 'Concept' and 'Context' categories of the PCC framework.

DISCUSSION

Findings from the proposed scoping review will identify how telehealth is currently used in the delivery of rehabilitation interventions for RMDs. The findings will develop our understanding of such interventions and provide a platform from which to inform future research directions.

Evaluation of the current use of MRI to aid the diagnosis of axial spondyloarthritis in the UK: results from a freedom of information request

AIM

To evaluate the impact of recommendations from the 2019 consensus exercise conducted by radiologists and rheumatologists on the use of magnetic resonance imaging (MRI) to investigate axial spondyloarthritis (axSpA) in clinical practice.

MATERIALS AND METHODS

A freedom of information (FOI) request was used to assess the use of MRI in the diagnosis of axSpA and radiologists' awareness of the 2019 guidance across all NHS Trusts and Health Boards in the UK, including England, Scotland, Northern Ireland, and Wales.

RESULTS

The FOI request was sent to 150 Trusts/Health Boards, and 93 full responses were received. Of the 93 respondents (97%), 90 reported familiarity with the term axSpA and 70/93 (75%) reported familiarity with the 2019 recommendations. Awareness of recommendations regarding specific MRI features supportive of the diagnosis of axSpA was 74/93 (80%) for the sacroiliac joints (SIJs) and 66/93 (71%) for the spine. The median wait for MRI acquisition was 2-3 months. Fifty-two of the 93 (56%) reported at least some outsourcing of axSpA MRI (33%/29% for specialist/non-specialist outsourcing respectively); 32/93 (34%) reported some scans being reported in-house by non-musculoskeletal radiologists.

CONCLUSION

There have been several positive developments in the understanding and use of MRI for the diagnosis of axSpA in the UK since the 2017 survey, although substantial scope for further improvement remains. Several new challenges have also emerged, including the increase in waiting times, reliance on outsourcing, and the reporting of MRI by non-musculoskeletal radiologists.

Diagnostic delay in axial spondylarthritis: A lost battle?

Diagnostic delay in axial spondylarthritis (axSpA) remains an unacceptable worldwide problem; with evidence suggesting significant detrimental impact both clinically on the individual, and economically on society. There is therefore, a need for global action across various healthcare professions that come into contact with patients living, and suffering, with undiagnosed axSpA. Recent estimates of the median diagnostic delay suggest that globally, individuals with axSpA wait between 2 and 6 years for a diagnosis - revealing a clear benchmark for improvement. This timespan presents a window of opportunity for earlier diagnosis and intervention, which will likely improve patient outcomes. This review describes the current diagnostic delay as estimated across countries and over time, before presenting evidence from published strategies that may be implemented to improve this delay across primary and secondary care, including for specialties treating extra-musculoskeletal manifestations of axSpA (ophthalmology, gastroenterology, dermatology). Ongoing campaigns tackling delayed diagnosis in axSpA are also highlighted.

Real-world evidence for secukinumab in UK patients with psoriatic arthritis or radiographic axial spondyloarthritis: interim 2-year analysis from SERENA

Objectives

The aim was to evaluate retention rates for secukinumab in patients with active PsA or radiographic axial spondyloarthritis (r-axSpA) treated in routine UK clinical practice.

Methods

SERENA (CAIN457A3403) is an ongoing, non-interventional, international study of patients with moderate-to-severe chronic plaque psoriasis, active PsA or active r-axSpA, who had received secukinumab for ≥16 weeks before enrolment. The primary objective of this interim analysis was to assess treatment retention rates in patients with PsA or r-axSpA who were enrolled and followed for ≥2 years at centres in the UK. The safety analysis set includes all patients who received at least one dose of secukinumab. The target population set includes all patients who fulfilled the patient selection criteria.

Results

The safety set comprised 189 patients (PsA, n = 81; r-axSpA, n = 108), and the target population set comprised 183 patients (PsA, n = 78; r-axSpA, n = 105). In the safety set, 107 patients (45 of 81 with PsA and 62 of 108 with r-axSpA) had previously received a biologic agent. Retention rates were similar between patients with PsA and r-axSpA after 1 year (PsA 91.0%, 95% CI: 84.0, 98.0; r-axSpA 89.2%, 95% CI: 82.7, 95.7) and 2 years (PsA 77.6%, 95% CI: 67.6, 87.7; r-axSpA 76.2%, 95% CI: 67.4, 85.0) of observation. Overall, 17.5% of patients (33 of 189) experienced at least one treatment-related adverse event, and 12.7% of patients (24 of 189) discontinued secukinumab because of adverse events.

Conclusion

This analysis of real-world data from the UK demonstrates high retention rates for secukinumab over 2 years in patients with PsA or r-axSpA, with a favourable safety profile.

Protocol for a systematic literature review of smartphone apps to support the self-management of rheumatic and musculoskeletal diseases: development strategies, theoretical underpinnings and barriers to engagement

BACKGROUND

Rheumatic and musculoskeletal diseases (RMDs) cause significant burden to the individual and society, requiring lifelong management and specialist healthcare resource use. Costing over 200 billion euros per year in Europe, RMDs are the most expensive of all diseases for European healthcare systems. The incidence and burden of RMDs are projected to rise with the ageing global population and increase in sedentary, obesogenic lifestyles. In parallel, there is a global crisis in the rheumatology workforce, whereby capacity to deliver specialist care is being exceeded by demand. Pervasive, scalable mobile health technologies, such as apps, are being developed to support the self-management of RMDs and reduce pressure on healthcare services. However, it is unknown whether these apps are informed by theory or their use supported by an appropriate evidence base. The purpose of this review is therefore to provide a comprehensive overview of the development strategies, interventional components and theoretical underpinnings of existing smartphone apps, designed to support the self-management of RMDs.

METHODS

Searches will be conducted within PubMed, Scopus, Web of Science, Embase, MEDLINE and PsycINFO. Reference lists and citing articles of the included studies will be searched. Identified publications will be screened for eligibility by two independent reviewers. Any discrepancies between reviewers will be resolved by consensus, with input from a third reviewer if required. Data will be extracted on study designs, methods, populations, setting, utilised theoretical frameworks, intervention components, behaviour change techniques, methods to evaluate effectiveness and barriers/facilitators to intervention engagement. Exploratory outcomes include reported effectiveness, acceptability and usability. A systematic, narrative synthesis of evidence will be presented. If appropriate (depending on quality and pool of evidence identified), qualitative meta-summary techniques will be used to combine and summarise qualitative findings regarding barriers/facilitators to intervention engagement.

DISCUSSION

The results of this systematic literature review will provide insights for healthcare professionals, researchers, app designers and policy makers, to inform future development and implementation of smartphone apps to support self-management of RMDs. Evidence gaps for future research will be identified. Findings will be disseminated through a final manuscript/publication of results and via a conference abstract, patient organisations and social media.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022359704.

The natural history of chronic widespread pain in patients with axial spondyloarthritis: a cohort study with clinical and self-tracking data

OBJECTIVES

This study investigates longitudinal patterns, predictors and long-term impact of pain in axial spondyloarthritis (axSpA), using clinical and self-tracking data.

METHODS

The presence of multisite pain (MSP), affecting at least six of nine body regions using a Margolis pain drawing, and subsequent chronic widespread pain (CWP), MSP at more than one timepoint, was assessed in a cohort of axSpA patients. Incident MSP (MSP at two consecutive visits or more), intermittent MSP (MSP at two or more non-consecutive visits) and persistent MSP (MSP at each visit) were described. Demographic, clinical and self-tracking measures were compared for the CWP vs non-CWP groups using Students t test, Wilcoxon-Mann-Whitney and χ2 test for normal, non-normal and categorical data, respectively. Predictors of CWP were evaluated using logistic regression modelling.

RESULTS

A total of 136 patients, mean clinical study duration of 120 weeks (range 27-277 weeks) were included, with sufficient self-tracking data in 97 patients. Sixty-eight (50%) patients reported MSP during at least one clinical visit: eight (6%) incident MSP; 16 (12%) persistent MSP; and 44 (32%) intermittent MSP. Forty-six (34%) of the cohort had CWP. All baseline measures of disease activity, function, quality of life, sleep disturbance, fatigue and overall activity impairment were significant predictors of the development of CWP. BASDAI and BASFI scores were significantly higher in those with CWP and self-tracking data revealed significantly worse pain, fatigue, sleep quality and stress.

CONCLUSIONS

The development of CWP is predicted by higher levels of disease activity and burden at baseline. It also impacts future disease activity and wellbeing.

ASAS consensus definition of early axial spondyloarthritis

OBJECTIVES

To develop a consensual definition for the term 'early axial spondyloarthritis-axSpA'-and 'early peripheral spondyloarthritis-pSpA'.

METHODS

The ASAS (Assessment of SpondyloArthritis international Society-Spondyloarthritis EARly definition) steering committee convened an international working group (WG). Five consecutive steps were followed: (1) systematic literature review (SLR); (2) discussion of SLR results within the WG and ASAS community; (3) a three-round Delphi survey inviting all ASAS members to select the items that should be considered for the definition; (4) presentation of Delphi results to the WG and ASAS community and (5) ASAS voting and endorsement (2023 annual meeting).

RESULTS

Following the SLR, consensus was to proceed with an expert-based definition for early axSpA (81% in favour) but not for pSpA (54% against). Importantly, early axSpA should be based on symptom duration taking solely axial symptoms into account. 151-164 ASAS members participated in the Delphi surveys. Consensus was achieved for considering the following items within early axSpA definition: duration of symptoms ≤2 years; axial symptoms defined as cervical/thoracic/back/buttock pain or morning stiffness; regardless of the presence/absence of radiographic damage. The WG agreed that in patients with a diagnosis of axSpA 'early axSpA' should be defined as a duration of ≤2 years of axial symptoms. Axial symptoms should include spinal/buttock pain or morning stiffness and should be considered by a rheumatologist as related to axSpA. The ASAS community endorsed this proposal (88% in favour).

CONCLUSIONS

Early axSpA has newly been defined, based on expert consensus. This ASAS definition should be adopted in research studies addressing early axSpA.

Patient-clinician dynamics in remote consultations: a qualitative study of cardiology and rheumatology outpatient clinics in the UK

OBJECTIVE

Explore the experiences of patients and clinicians in rheumatology and cardiology outpatient clinics during the first year of the COVID-19 pandemic, focusing on the impact of remote consultations on interpersonal dynamics.

DESIGN

Qualitative study using semistructured interviews, conducted between February and June 2021.

SETTING

The rheumatology and cardiology departments of a general hospital in England, UK.

PARTICIPANTS

All clinicians and a convenience sample of 100 patients in each department who had taken part in a remote consultation in the past month were invited to take part. Twenty-five interviews were conducted (13 with patients, 12 with clinicians).

RESULTS

Three themes were developed through the analysis: adapting to the dynamics of remote consultations, impact on the patient's experience and impact on the clinician's experience. The majority of remote consultations experienced by both patients and clinicians had been via telephone. Both clinicians and patients found remote consultations to be more business-like and focused, with the absence of pauses restricting time for reflection. For patients with stable, well-managed conditions, remote consultations were felt to be appropriate and could be more convenient than in-person consultations. However, the loss of visual cues meant some patients felt they could not give a holistic view of their condition and limited clinicians' ability to gather and convey information. Clinicians adjusted their approach by asking more questions, checking understanding more frequently and expressing empathy verbally, but felt patients still shared fewer concerns remotely than in person; a perception with which patients concurred.

CONCLUSIONS

These findings highlight the importance of ensuring, for each patient, that remote care is appropriate. Future research should focus on developing ways to support both clinicians and patients to gather and provide all information necessary during remote consultations, to enhance communication and trust.

Treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs: British Society for Rheumatology guideline scope

Pharmacological management has advanced considerably since the 2015 British Society for Rheumatology axial spondyloarthritis (axSpA) guideline to incorporate new classes of biologic DMARDs (bDMARDs, including biosimilars), targeted synthetic DMARDs (tsDMARDs) and treatment strategies such as drug tapering. The aim of this guideline is to provide an evidence-based update on pharmacological management of adults with axSpA (including AS and non-radiographic axSpA) using b/tsDMARDs. This guideline is aimed at health-care professionals in the UK who care directly for people with axSpA, including rheumatologists, rheumatology specialist nurses, allied health professionals, rheumatology specialty trainees and pharmacists; people living with axSpA; and other stakeholders, such as patient organizations and charities.

POS0305 TIME TO IMPROVEMENT OF FATIGUE IN PATIENTS WITH ANKYLOSING SPONDYLITIS IN A STUDY OF TOFACITINIB

Background

Fatigue is common in patients (pts) with ankylosing spondylitis (AS) and is associated with higher levels of pain and functional disability.1 Tofacitinib is an oral JAK inhibitor approved for the treatment of AS. In pts with AS, greater improvements in fatigue were seen with tofacitinib vs placebo (PBO).2

Objectives

To estimate the time to improvement in fatigue in pts with AS treated with tofacitinib.

Methods

This post hoc analysis used data from a Phase 3 trial (NCT03502616) in pts with AS receiving tofacitinib 5 mg twice daily (BID) or PBO for 16 weeks; after Week (W)16, all pts received open-label tofacitinib until W48.2 Fatigue was assessed by Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) total score (range 0–52; higher scores indicate less fatigue3). A series of time to event analyses were performed using non-parametric Kaplan–Meier models. Median times to initial improvements in FACIT-F total score were assessed based on different thresholds. The initial improvement event was defined as time to first post-baseline week with an improvement in FACIT-F total score of at least 5%, 10%, 15% etc, up to 100%. Median times to events based on absolute changes in FACIT-F total score were also investigated.

Results

Overall, 269 pts were assessed; baseline demographics/disease characteristics have been previously reported.2 The median times to initial improvements in FACIT-F total score were significantly (p<0.05) shorter in pts receiving tofacitinib 5 mg BID vs PBO (Figure 1). For example, median time to initial improvement of 30% in FACIT-F total score was 16 weeks in pts receiving tofacitinib 5 mg BID; however, in pts receiving PBO, the median time for this event was not achieved up to W16. More pts receiving tofacitinib 5 mg BID vs PBO experienced initial improvement events up to W16 (Table 1). For example, 36.1% of pts receiving tofacitinib 5 mg BID experienced 50% improvement of fatigue up to W16, compared with 19.9% of pts receiving PBO.

Table 1.

Proportions of pts who experienced initial improvement events in FACIT-F total score up to W16

Fatigue improvement thresholdInitial improvement, n (%)p valuea25%Tofacitinib 5 mg BID82 (61.7)0.0009PBO58 (42.6)50%Tofacitinib 5 mg BID48 (36.1)0.0031PBO27 (19.9)75%Tofacitinib 5 mg BID30 (22.6)0.0626PBO19 (14.0)100%Tofacitinib 5 mg BID23 (17.3)0.1233PBO15 (11.0)

N=133 (tofacitinib 5 mg BID); N=136 (PBO)

aTest of equality over strata log-rank test, p<0.05 n, number of pts achieving an initial improvement event; N, total number of pts in each treatment group

Conclusion

In pts with AS, initial improvements in fatigue, as determined by FACIT-F total score, occurred faster and were larger in magnitude with tofacitinib vs PBO up to W16. These results may help physicians better understand the speed and magnitude for fatigue benefit in pts receiving tofacitinib.

References

[1]Turan et al. Rheumatol Int 2007; 27: 847-852.

[2]Deodhar et al. Ann Rheum Dis 2021; 80: 1004-1013.

[3]Hewlett et al. Arthritis Care Res (Hoboken) 2011; 63: S263-286.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Lauren Hogarth, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Laure Gossec Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, Roche and UCB, David Cella Consultant of: AbbVie, Alexion Pharmaceuticals, Astellas Pharma, Bayer, Bristol-Myers Squibb, Clovis Oncology, Evidera, Exelixis, Horizon Therapeutics, Janssen, Merck/Schering-Plough, National Academy of Sciences, Novartis Pharma K.K. (Japan), Pfizer Inc, PledPharma and Regeneron, Jessica A. Walsh Consultant of: AbbVie, Celgene and UCB, Raj Sengupta: None declared, Andrew G Bushmakin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Joseph C Cappelleri Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Arne Yndestad Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Oluwaseyi Dina Shareholder of: Pfizer Inc, Employee of: Pfizer Inc.

POS0936 DISEASE TRAJECTORIES OF AXIAL SPONDYLOARTHRITIS PATIENTS INITIATED ON BIOLOGIC DMARDs: PRELIMINARY ANALYSIS FROM A REAL-WORLD COHORT

Background

The number of biologic/targeted synthetic (b/ts) disease-modifying anti-rheumatic drugs (DMARDs) available for the treatment of axial spondyloarthritis (axSpA) are increasing. However, 1 in 4 axSpA patients may discontinue their first bDMARD within the first 12-months (1). A greater understanding of real-world axSpA disease/treatment trajectories pre- and post-bDMARD initiation is needed to inform optimal treatment for patients.

Objectives

To explore the use of biologic therapies in patients living with axSpA, and estimate the natural progression of disease and patient reported measures pre- and post- initiation of first bDMARD.

Methods

Data was extracted from the Bath SpA Research Biobank for all bio-naïve axSpA patients initiated on bDMARDs between 7th March 2000 and 1st February 2021. Patients were grouped based on first bDMARD. Linear regression models were used to explore changes in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI) over time; from 36-months before first bDMARD initiation, to 36-months after initiation. Changes in BASDAI/BASFI were estimated using piecewise mixed-effects linear regression. Models included fixed terms for age, sex, HLA-B27 status and disease duration. Switches to a second bDMARD and reasons for switching were captured.

Results

In total, 282 axSpA patients were included, and grouped into 3 cohorts based on first bDMARD: adalimumab (46.1%), etanercept (30.9%), other (23.1%; 6.4% certolizumab pegol, 5.0% golimumab, 5.3% infliximab, 0.7% rituximab, 5.7% secukinumab). Mean age at diagnosis was 30.7 (SD 11.3), 69.9% of patients were male, 11.0% diagnosed with non-radiographic axSpA and 85.3% HLA-B27 positive. In the 36-month period before bDMARD initiation, patients on average had a BASDAI score of 4.50 (95% CI 4.21-4.79) and BASFI of 4.02 (95% CI 3.68-4.38), with a linear and statistically significant worsening of 0.56 (95% CI 0.43-0.68) per year for the BASDAI and 0.55 (95% CI 0.41-0.69) for the BASFI (minimally clinically important difference defined as 1.1 and 0.6 for BASDAI and BASFI, respectively (2)). Following bDMARD initiation, patients indicated a statistically significant reduction in BASDAI to 3.13 (95% CI 2.82-3.45), 3.23 (95% CI 2.83-3.63) and 3.46 (95% CI 3.04-3.88) and reductions in the BASFI to 3.22 (95% CI 2.86-3.60), 3.06 (95% CI 2.61-3.53) and 3.64 (95% CI 3.16-4.12) for those treated with adalimumab, etanercept or other biologics respectively. Reduced scores were maintained over 36-months post initiation (Figure 1). Details of first and second bDMARD are outlined in Table 1. Reasons for switching were switch to biosimilar (32.4%), intolerance (25.1%), inefficacy (22.2%), malignancy (1.9%) or other (18.4%).

Table 1.

First and second bDMARD

First bDMARDSecond bDMARDAdalimumabEtanerceptOtherAdalimumab59 (57.3%)22 (21.4%)22 (21.4%)Etanercept28 (40.6%)37 (53.6%)4 (5.8%)Other15 (48.4%)8 (25.8%)8 (25.8%)Figure 1.

Predictive margins of BASDAI and BASFI 36-months pre- and post- bDMARD initiation

A-E, Predictive margins of the BASDAI score (overall – all components, A); BASDAI Q1 fatigue (B); BASDAI average of Q2-Q4 spinal pain, joint pain, enthesitis (C); BASDAI average of Q5-Q6 morning stiffness (D); and BASFI (E).

Conclusion

In our study population, there was clinically meaningful worsening of disease activity over 36-months prior to initiation of first bDMARD, despite baseline (36-months prior to first bDMARD initiation) BASDAI exceeding the current threshold for bDMARD treatment (BASDAI≥4). A clinically meaningful and maintained improvement in disease activity was reported across all cohorts in the 36-months following first bDMARD initiation.

References

[1]Lindström et al. Arthritis Research & Therapy. 2019;21(1):128-.

[2]Kviatkovsky et al. Journal of Rheumatology. 2016;43(9):1680-6.

Disclosure of Interests

Rosie Barnett Grant/research support from: UCB, Lewis Carpenter Consultant of: Statistical consultancy for Pfizer, Charlotte Cavill: None declared, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Lilly, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Lilly, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, UCB

AB0781 Malaysia Spondylarthritis Accelerated Management (SAM) Model: Expediting AxSpA patient journey from early referral, diagnosis and access to optimal care

Background

Axial spondyloarthritis (axSpA) is an important cause of inflammatory back pain (IBP). It is under-recognized, leading to significant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, significant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert.

Objectives

The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia.

Methods

The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The first local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded ‘3-R’ referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021.

Figure 1.

Summary of optimal Key performance indicators (KPIs) for Malaysia SAM

Results

At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a first Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had x-rays (sacroiliac joints or pelvis). MRI requests in x-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic.

Conclusion

The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.

References

[1]Lau, Ing Soo et al., Malaysian family physician, vol. 16,2 2-6. 27 May. 2021

Acknowledgements

Authors would like to acknowledge that this abstract is part of the Malaysia SpA Consortium Working Group. The SAM expert panel discussion and the preparation of this abstract were funded by Novartis (Malaysia). The authors acknowledge writing support from Vidya Sagar AEC (Novartis, Hyderabad)

Disclosure of Interests

Fariz Yahya Speakers bureau: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Janssen, Gilead, Abbvie, Upjohn, Paid instructor for: Novartis, ZP Therapeutics, Abbvie, Consultant of: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Gilead, Abbvie, Janssen, Grant/research support from: Gilead, Galapagos, Abbvie, Janssen, Novartis, Habibah Mohd Yusoof: None declared, Asmah Mohd: None declared, Shereen Ch’ng Suyin Speakers bureau: Pfizer, Boehringer Ingelheim, Johnson & Johnson, Novartis, Abbvie, Suk Chyn Gun: None declared, Mollyza Mohd Zain: None declared, Sargunan Sockalingam Speakers bureau: Novartis, Roche, Johnson & Johnson, Pfizer, Paid instructor for: Johnson & Johnson, Grant/research support from: Novartis, Siew Li Lai Employee of: Novartis, Chen Bao Jing Employee of: Novartis, John Tiong Employee of: Novartis, Ing Soo Lau: None declared, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Lilly, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Lilly, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, UCB

P261 Early and accurate diagnosis of patients with axial spondyloarthritis using machine learning: a predictive analysis from electronic health records in the United Kingdom

Background/Aims

On average, there is a delay of 6.7 years between symptom onset and diagnosis of axial spondyloarthritis (axSpA). Since traditional approaches to improving early axSpA identification have had limited success, predictive automated analyses using patient records may help alleviate the burden on healthcare providers. We report results from a machine learning (ML) algorithm developed with UK electronic health records (EHRs) Clinical Practice Research Datalink (CPRD) data to estimate the probability or likelihood of a patient being diagnosed with axSpA based on prior clinical indicators and patient history.

Methods

Primary care UK EHR data - CPRD GOLD was used to identify patients with axSpA and healthy controls (HC). Patients aged ≥18 years with first diagnosis date of axSpA within the identification period (01-Jan-2005 to 31-Dec-2018) and fulfilling CPRD research acceptability criteria were included. Data pertaining to clinical presentation, consultation, referral, test, and therapy history were extracted for individual patients prior to diagnosis of axSpA. A total of 5,090 patients with axSpA satisfied the acceptability criteria. HC were randomly sampled to create a subset of one unique HC matched to each patient with axSpA, resulting in 5,089 HC. ML usable features derived from the total population (patients with axSpA and HC) numbered 820. After using a further exclusion criterion for the patients with axSpA and HC who had ≥1 of 820 usable features, the final dataset included 7,813 patients (3,902 with axSpA and 3,911 HC). This combined dataset was randomly split (67:33) into a train (n = 5237) and a test (n = 2576) dataset. A random forest (RF) model was trained on the train dataset. Cross-validation was performed for hyper-parameter tuning of the RF classifier. Once the model was trained, accuracy, precision, and F-1 scores were obtained with the test dataset.

Results

The RF-based algorithm resulted in a high level of accuracy (88.12%), with precision of 0.95 for patients with axSpA and 0.83 for HC. The RF algorithm identified 89 best clinical predictors (out of 820 used as inputs) that differentiated between patient and HC such as: total number of tests, total number of referrals, first age of consultation, first symptom age, and number of low back pain symptoms. The model sensitivity was 0.75 and positive predictive value was 80.88%. The model specificity was 0.96 and negative predictive value was 82.56%.

Conclusion

The ML algorithm demonstrated a high level of accuracy and precision in the identification of possible cases of axSpA, which may be useful in reducing the delay in diagnosis. Previous studies have successfully demonstrated automated cohort identification of axSpA in large datasets, with only a few using ML-based approaches for diagnosis from patient medical history. While our model supports previous work in axSpA, it needs further validation in routine clinical practice (exploration ongoing).

Disclosure

R. Sengupta: Honoraria; AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Roche, UCB. Grants/research support; AbbVie, Celgene, Novartis, UCB. S. Narasimham: Shareholder/stock ownership; Novartis. Other; Employee of Novartis. B.S. Mato: Shareholder/stock ownership; Novartis. Other; Employee of Novartis. M. Meglic: Other; Employee of Novartis. C. Perella: Other; Employee of Novartis. P. Pamies: Other; Employee of Novartis. P. Emery: Consultancies; AbbVie, Astra-Zeneca, BMS, Boehringer Ingelheim, Celltrion, Gilead, Janssen, MSD, Lilly, Novartis, Pfizer, Roche, Samsung, UCB. Grants/research support; AbbVie, BMS, Lilly, Novartis, Pfizer, Roche, Samsung.

P288 Protocol for a scoping review to identify self-management support interventions delivered via telehealth for rheumatic and musculoskeletal diseases

Background/Aims

For some time, there has been an importance placed in rheumatology on promoting and supporting patient self-management. Self-management aims to improve patients’ independence and quality of life by empowering individuals to be proactive decision makers while managing their illness. Self-management support (SMS) as detailed in the Practical RevIews in Self-Management Support (PRISMS) taxonomy can include education, monitoring, adherence, training, and support with healthcare practitioner (HCP) interaction. In rheumatic and musculoskeletal diseases (RMDs), interventions for SMS are complex, and have been described by the European League Against Rheumatism (EULAR) as a current unmet need. In response to the COVID-19 pandemic, telerehabilitation has been successfully used at the Royal National Hospital for Rheumatic Diseases in Bath to provide continued SMS to axial spondyloarthritis (axial SpA) patients. Although some research into SMS of inflammatory arthritis has been conducted, there appears to be a scarcity of research on SMS interventions provided through telerehabilitation for axial SpA. The present scoping review aims to systematically identify and describe existing SMS interventions delivered via telehealth for RMDs, and how effectiveness is evaluated within these interventions.

Methods

The method for a scoping review protocol will be outlined using the JBI manual for evidence synthesis guidance. It is anticipated that there will be a lack of interventions for axial SpA, therefore the broader population of RMDs will be included. Three electronic databases will be searched (Embase, Scopus and Web of Science Core Collection), as well as the reference lists of included full-text studies. A study team of three researchers will apply a priori eligibility criteria, based on the Population (RMDs), Concept (rehabilitation) and Context (telehealth) components of the research focus, to the abstract screening and full-text screening.

Results

Data will be extracted into a charting table for relevant full-text articles to allow a narrative synthesis of identified SMS telerehabilitation interventions. We will explore SMS definitions used, aspects of rehabilitation targeted (e.g. education, disease management, psychological support, physical activity, physiotherapy, occupational health input, behaviour change techniques), details on the SMS intervention (e.g. autonomous/group-based, mode of telerehabilitation delivery, length of intervention, synchronous/asynchronous interaction), components of SMS included (PRISMS taxonomy), HCP interaction details, and measures of effectiveness.

Conclusion

Telehealth, and specifically telerehabilitation, have become a critical feature of healthcare over the last 18 months and may provide an effective long-term solution to broaden provision of SMS for RMDs and improve symptoms, while relieving pressure on healthcare systems. Through this scoping review, existing telehealth delivered SMS interventions for RMDs will be identified, which will help to understand how interventions are currently delivered and effectiveness evaluated in rheumatology. A greater understanding of existing interventions will be critical as we move into the new post-COVID-19 age of blended in-person/ virtual service provision.

Disclosure

N. Shakaib: Grants/research support; NS has received funding for research from the Sir Halley Stewart Trust. R. Barnett: Grants/research support; RB has received funding for research from the Sir Halley Stewart Trust. R. Sengupta: Consultancies; RS is a member of the BSR Spondyloarthritis Special Interest Group, RS is a member of BSR axSpA Biologics Guidelines Committee, Consultancy fees: AbbVie, Biogen, Celgene, Chugai, Lilly, MSD, UCB, Novartis. Honoraria; AbbVie, Biogen, Celgene, Chugai, Lilly, MSD, UCB, Novartis. Grants/research support; RS has received funding for research from Sir Halley Stewart Trust; other grants/ research support include AbbVie, Celgene, Novartis, UCB. Other; Advisory boards: AbbVie, Biogen, Chugai, Lilly, UCB, Novartis. S. Jones: Grants/research support; SJ has received funding from the Sir Halley Stewart Trust. P.C. Rouse: Grants/research support; PR has received funding for research from Sir Halley Stewart Trust.

P263 Autoantibodies in ankylosing spondylitis: a systematic literature review

Background/Aims

Ankylosing spondylitis (AS) is a chronic inflammatory arthritis leading to long term disability. It is frequently diagnosed late when irreversible damage has already occurred. Unlike most autoimmune rheumatological diseases, there are no known autoantibodies associated with AS; this can confound the diagnostic challenge as diagnosis depends not only on symptoms but on finding evidence of active inflammation at the time of assessment or damage from previously active disease. Our aim was to determine the extent to which autoantibodies may be pathognomonic of AS.

Methods

A systematic literature review was conducted to identify all articles reporting on autoantibodies in AS. The protocol was preregistered on PROSPERO. Articles were screened and reviewed independently by two reviewers. Disagreements were solved by consensus. Data were extracted and the MINORS (Methodological Index for Non-Randomised Studies) tool was used to assess and compare the quality of the studies. Data were pooled in a narrative synthesis.

Results

743 papers were identified after removal of duplicates. Following review of abstracts, 31 full text articles were assessed for eligibility and 18 were excluded, leaving 13 studies to be included in the final systematic review. 12 articles looked at 14 biomarkers; one article looked at 2 high density nucleic acid protein arrays expressing 3,498 proteins. Samples sizes were small and the papers were found to be of modest quality. AS patients showed a wide-ranging autoantibody response across studies. One study found that 60% of autoantibodies detected were found only in the AS cohort versus the rheumatoid arthritis cohort and heathy controls. Antibodies against HLA-B27, pANCA, CD74, OmpC, collagens, PPM1A, noggin, sclerostin, Klebsiella pneumoniae and Breg cells were found more commonly in AS patients than in controls (both healthy controls and those with other autoimmune diseases). Antibodies to human tTG and anti DFS70 were not found to be associated with AS and there was conflicting evidence regarding the association of antibodies to the cell-wall mannan of Saccharomyces cerevisiae (ASCA) in AS from different papers.

Conclusion

Although many autoantibodies have been found among persons with AS, there is currently no evidence that any are specifically and independently associated with the disease. We therefore conclude that as yet no autoantibodies can be considered to be pathognomonic for AS. However, some autoantibodies may be clinically significant and combined with other biomarkers, such as HLA-B27, may prove fruitful in reducing the delay to diagnosis. Further work should seek to explore other avenues, in particular autoantibodies in closely related diseases, such as inflammatory bowel disease, to try to determine autoantibodies that may aid in the earlier diagnosis of this chronic disease.

Disclosure

E.J. Davies: None. G.T. Jones: None. R. Sengupta: Honoraria; Received grants, honoraria, and expenses for attendance at advisory board meetings or conferences and for giving lectures from AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Roche and UCB. Grants/research support; Received grants, honoraria, and expenses for attendance at advisory board meetings or conferences and for giving lectures from AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Roche and UCB.

P270 ‘Act on Axial SpA': a gold standard time to diagnosis

Background/Aims

A lack of public understanding of the symptoms of axial spondyloathritis (axial SpA) is a significant factor in diagnostic delay. Research commissioned by The National Axial Spondyloarthritis Society (NASS) found that 91% of the UK population had never heard of axial SpA, despite more people living with the condition than MS and Parkinson’s combined. Additionally, 8 in 10 people could not identify the symptoms of axial SpA when prompted. As part of a 5-year programme called ‘Act on Axial SpA’, NASS created the first phase of a campaign to increase public awareness, help people recognise symptoms, and encourage them to visit their GP if concerned. Aims: 1) Ensure people have heard of axial SpA. 2) Help people understand that it’s a condition that affects young people. 3) Ensure people recognise the signs and symptoms of the condition. 4) Get people to visit actonaxialspa.com to use the symptom checker and visit their GP if concerned.

Methods

1) Raise awareness about the condition: to make an emotional connection with a cold audience, who are unlikely to have heard of axial SpA (AS) and show them why the campaign is relevant to them. We told stories about people with the condition and their families, so people can see that the condition could affect someone like ‘them’. We ensured our campaign key messages are highly visible in the places, publications and online media people in our target audiences are likely to see every day. 2) Identify a core set of symptoms using a newly developed acronym (SPINE). 3) Direct people to an online symptom checker which combines the ASAS, Berlin and Calin inflammatory back pain criteria. 4) Provide information for the patient and primary care professional on the results of the symptom checker and next steps as per the NICE guidelines 5) Provide information for the patient on preparing for their GP and rheumatologist appointments.

Results

We report results from June 23 - October 13 2021. 1) Case studies have featured in 11 national media publications with a combined reach of over 101 million. 2) Social media activity has a reach of 440,000. 3) Video content has been viewed 375,000 times. 4) 1,264 people have used the symptom checker. 5) We are reaching new audiences, in particular those aged 18-45 and a larger proportion of women.

Conclusion

The first phase of the campaign has demonstrated cut through to new audiences. People are interested, engaged and eager to learn more about axial SpA. When people are aware of the condition and its symptoms, they are more likely to act. We are confident that, with time, the ‘Act on Axial SpA’ public awareness campaign will play a huge part in reducing diagnosis times for people with axial SpA.

Disclosure

L. Marshall: None. D. Webb: None. F. MacAulay: None. K. Gaffney: Consultancies; Novartis, AbbVie, UCB, Lilly, Pfizer. Shareholder/stock ownership; SpA Academy www.spaacademy.org. Honoraria; Novartis, AbbVie, UCB, Lilly, Pfizer. Member of speakers’ bureau; Novartis, UCB, AbbVie, Lilly. Grants/research support; NASS, AbbVie, Pfizer, UCB, Novartis, Lilly, Cellgene, Celltrion, Janssen, Gilead, Biogen. Other; Expenses: Abbvie, Lilly, Roche, Novartis, Pfizer and UCB. R. Sengupta: Consultancies; Abbvie, Biogen, Celgene, Chugai, Lilly, MSD, Novartis, UCB. Honoraria; Abbvie, Biogen, Celgene, Chugai, Lilly, MSD, Novartis, UCB. Grants/research support; Abbvie, Celgene, Novartis, UCB. Other; Advisory boards:, Abbvie, Biogen, Chugai, Lilly, Novartis, UCB.

The Future of Axial Spondyloarthritis Rehabilitation: Lessons Learned From COVID-19

Supervised physical therapy and rehabilitation are vital for effective long-term management of axial spondyloarthritis (SpA). However, the unprecedented year of 2020 and the COVID-19 pandemic has prompted a drastic change in health care provision across all disease areas. In this review, we summarize changes that have been introduced to support rehabilitation in axial SpA during the pandemic and considerations for the future of axial SpA rehabilitation in the wake of COVID-19. We have witnessed the launch of online virtual physical therapy and education, in addition to an emphasis on remote monitoring. We have been propelled into a new era of digital service provision; not only providing a temporary stop-gap in treatment for some patients, but in the future, potentially allowing for a wider reach and provision of care and resilience of vital services. Unique collaboration between patients, health care professionals, and researchers will be key to fostering relationships and trust and facilitating wider evaluation and implementation of digital services at each stage in a patient's journey, which is imperative for relieving pressure from health care providers. Despite the potential of such digital interventions, it is important to highlight the maintained critical need for face-to-face services, particularly for vulnerable patients or during diagnosis or a flare of symptoms. It is also vital that we remain vigilant regarding digital exclusion to avoid further widening of existing health inequalities. Optimization of digital infrastructure, staff skills, and digital education alongside promoting accessibility and engagement and building trust among communities will be vital as we enter this new age of blended in-person and digital service provision.

Understanding flare in axial spondyloarthritis: novel insights from daily self-reported flare experience

OBJECTIVES

Our objective was to explore daily self-reported experiences of axial SpA (axSpA) flare based on data entered into the Project Nightingale smartphone app (www.projectnightingale.org), between 5 April 2018 and 1 April 2020.

METHODS

Paired t-tests were conducted for mean_flare_on and mean_flare_off scores for each recorded variable. The mean estimated difference between flare and non-flare values for each variable was calculated with 95% CIs. Mean, S.d. and range were reported for flare duration and frequency. Participants with ≥10 days of data entry were included for affinity propagation cluster analysis. Baseline characteristics and mean flare on vs mean flare off values were reported for each cluster. Welch's t-test was used to assess differences between clusters.

RESULTS

A total of 143/189 (75.7%) participants recorded at least one flare. Each flare lasted a mean of 4.30 days (S.d. 6.82, range 1-78), with a mean frequency of once every 35.32 days (S.d. 65.73, range 1-677). Significant relationships were identified between flare status and variable scores. Two clusters of participants were identified with distinct flare profiles. Group 1 experienced less severe worsening of symptoms during flare in comparison to group 2 (P < 0.01). However, they experienced significantly longer flare duration (7.2 vs 3.5 days; P < 0.01), perhaps indicating a prolonged, yet less intense flare experience. Groups were similar in terms of flare frequency and clinical characteristics.

CONCLUSIONS

Two clusters of participants were identified with distinct flare experiences but similar baseline clinical characteristics. Smartphone technologies capture subtle changes in disease experience not currently considered in clinical practice.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

POS0059-PARE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS – TIME FOR A GOLD STANDARD APPROACH

Background:

In the UK, the average time to diagnosis of axial SpA is 8.5 years (1). There is little evidence this has improved, despite the acceptance of MRI use in diagnosis (2). A recent review identified significant clinical, economic and humanistic burden from delayed diagnosis (3). Urgent action is needed to ensure delayed diagnosis is not normalized.

Objectives:

We created a proposal for a Gold Standard time to diagnosis for axial SpA and a national implementation plan (4) through consensus development with patients, healthcare professionals and professional bodies.

Methods:

A.A scoping literature review identifying where delays occur, from first symptom onset to diagnosis by a rheumatologist, and potential solutions. From this, a summary report / draft plan was produced for consultation

B.A national consultation survey to elicit views on the proposals from clinicians, healthcare professionals, professional societies and patients

C.Structured feedback to written proposals via e-consultation with clinicians and patients

D.A consensus development workshop to finalise the Gold Standard and implementation plan.

Results:

The literature review identified four delays:

1. People do not know axial SpA may be a cause of their chronic back pain

2. Primary care practitioners may not recognise features of axial SpA

3. People may be referred to non-rheumatologists who may not recognise axial SpA promptly

4. Rheumatology and radiology teams may not optimally request or interpret investigations.

202 participants responded to the summary report (74% patients, 21% healthcare professsionals, 5% professional societies). All supported the principles behind the gold standard time to diagnosis. Qualitive analysis confirmed agreement with the proposed solutions, underscoring the importance of education and visibility for axial SpA within primary care and increased public awareness. Additional proposals were suggested, including a tool in primary care to run audits on IT systems.

40 clinicians contributed to the e-consultation and 55 clinicians, policy makers, social marketing experts, health journalists and patients attended the consensus workshop. Consensus was reached on a gold standard time to diagnosis of one year, and the principles, key components and phasing of the implemention plan. This included: public awareness about axial SpA symptoms; a primary care clinical champions programme; creating a referral pathway from primary care direct to rheumatology; a secondary care service educational programme.

Conclusion:

There is consensus from UK axial SpA clinicians, patients and professional societies on the need for a Gold Standard time to diagnosis of axial SpA of one year, so that patients can live happy, healthy and productive lives.

References:

[1]Hamilton L, Gilbert A, Skerett J, et al. Services for people with ankylosing spondylitis in the UK - a survey of rheumatologists and patients. Rheumatology 2011:50:1991

[2]Sykes MP, Doll H, R Sengupta, Gaffney, K. Delay to diagnosis in axial spondyloarthritis: are we improving in the UK? Rheumatology, July 2015

[3]Yi E, Ahuja A, Rajput T, et al. Clinical, Economic, and Humanistic Burden Associated With Delayed Diagnosis of Axial Spondyloarthritis: A Systematic Review. Rheumatol Ther. 2020 Mar;7(1):65–87.

[4]Webb D, Zhao S, Whalley S, et al. Gold Standard Time to Diagnosis in axial Spondyloarthritis: Consultation Document. 2020, NASS.

Disclosure of Interests:

Dale Webb Speakers bureau: Janssen, Novartis, Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB, Karl Gaffney Speakers bureau: Abbvie, Lilly, Novartis, UCB, Consultant of: Abbvie, Celltrion, Lilly, Grant/research support from: Abbvie, Pfizer, Lilly, UCB, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, Sizheng Steven Zhao: None declared, Lisa Swingler Grant/research support from: NASS receives grants from AbbVie, Biogen, Eli Lilly, Novartis and UCB.

POS0959 DIAGNOSTIC DELAY IN AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE NATIONAL EARLY INFLAMMATORY ARTHRITIS AUDIT

Background:

Diagnostic delay is a significant problem in axial spondyloarthritis (axSpA), and there is a growing body of evidence showing that delayed axSpA diagnosis is associated with worse clinical, humanistic and economic outcomes.1 International guidelines have been published to inform referral pathways and improve standards of care for patients with axSpA.2,3

Objectives:

To describe the sociodemographic and clinical characteristics of newly-referred patients with axSpA in England and Wales in the National Early Inflammatory Arthritis Audit (NEIAA), with rheumatoid arthritis (RA) and mechanical back pain (MBP) as comparators.

Methods:

The NEIAA captures data on all new patients over the age of 16 referred with suspected inflammatory arthritis to rheumatology departments in England and Wales.4 We describe baseline sociodemographic and clinical characteristics of axSpA patients (n=784) recruited to the NEIAA between May 2018 and March 2020, compared with RA (n=9,270) and MBP (n=370) during the same period.

Results:

Symptom duration prior to initial rheumatology assessment was significantly longer in axSpA than RA patients (p<0.001), and non-significantly longer in axSpA than MBP patients (p=0.062): 79.7% of axSpA patients had symptom durations of >6 months, compared to 33.7% of RA patients and 76.0% of MBP patients; 32.6% of axSpA patients had symptom durations of >5 years, compared to 3.5% of RA patients and 24.6% of MBP patients (Figure 1A). Following referral, median time to initial rheumatology assessment was longer for axSpA than RA patients (36 vs. 24 days; p<0.001), and similar to MBP patients (39 days; p=0.30). The proportion of axSpA patients assessed within 3 weeks of referral increased from 26.7% in May 2018 to 34.7% in March 2020; compared to an increase from 38.2% to 54.5% for RA patients (Figure 1B). A large majority of axSpA referrals originated from primary care (72.4%) or musculoskeletal triage services (14.1%), with relatively few referrals from gastroenterology (1.9%), ophthalmology (1.4%) or dermatology (0.4%).

Of the subset of patients with peripheral arthritis requiring EIA pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs. 97.8%; p<0.001), and RA patients reported a better understanding of their condition (p<0.001). HAQ-DI scores were lower at baseline in axSpA EIA patients than RA EIA patients (0.8 vs 1.1, respectively; p=0.004), whereas baseline Musculoskeletal Health Questionnaire (MSK-HQ) scores were similar (25 vs. 24, respectively; p=0.49). The burden of disease was substantial across the 14 domains comprising MSK-HQ in both axSpA and RA (Figure 1C).

Conclusion:

We have shown that diagnostic delay remains a major challenge in axSpA, despite improved disease understanding and updated referral guidelines. Patient education is an unmet need in axSpA, highlighting the need for specialist clinics. MSK-HQ scores demonstrated that the functional impact of axSpA is no less than for RA, whereas HAQ-DI may underrepresent disability in axSpA.

References:

[1]Yi E, Ahuja A, Rajput T, George AT, Park Y. Clinical, economic, and humanistic burden associated with delayed diagnosis of axial spondyloarthritis: a systematic review. Rheumatol Ther. 2020;7:65-87.

[2]NICE. Spondyloarthritis in over 16s: diagnosis and management. 2017.

[3]van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-91.

[4]British Society for Rheumatology. National Early Inflammatory Arthritis Audit (NEIAA) Second Annual Report. 2021.

Acknowledgements:

The National Early Inflammatory Arthritis Audit is commissioned by the Healthcare Quality Improvement Partnership, funded by NHS England and Improvement, and the Welsh Government, and carried out by the British Society for Rheumatology, King’s College London and Net Solving.

Disclosure of Interests:

Mark Russell Grant/research support from: UCB, Pfizer, Fiona Coath: None declared, Mark Yates Grant/research support from: UCB, Abbvie, Katie Bechman: None declared, Sam Norton: None declared, James Galloway Grant/research support from: Abbvie, Celgene, Chugai, Gilead, Janssen, Lilly, Pfizer, Roche, UCB, Jo Ledingham: None declared, Raj Sengupta Grant/research support from: AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Karl Gaffney Grant/research support from: AbbVie, Biogen, Cellgene, Celltrion, Janssen, Lilly, Novartis, Pfizer, Roche, UCB.

POS0919 BIMEKIZUMAB SHOWS SUSTAINED LONG-TERM IMPROVEMENTS IN PATIENT-REPORTED OUTCOMES AND QUALITY OF LIFE IN ANKYLOSING SPONDYLITIS: 3-YEAR RESULTS FROM A PHASE 2B STUDY

Background:

Bimekizumab (BKZ), a monoclonal antibody that selectively inhibits interleukin (IL)-17A and IL-17F, has demonstrated clinical efficacy and safety in patients with ankylosing spondylitis (AS) treated over a period up to 96 weeks.1,2

Objectives:

To report 3-year interim patient-reported outcomes (PROs) in patients with active AS treated with BKZ in a phase 2b dose-ranging study (BE AGILE; NCT02963506) and its open-label extension (OLE; NCT03355573).

Methods:

BE AGILE study design has been described previously.1 Patients treated with BKZ 160 mg or 320 mg every 4 weeks (Q4W) at Week 48 in BE AGILE were eligible for OLE entry. All OLE patients received BKZ 160 mg Q4W. Outcome measures are reported for the OLE full analysis set (patients who entered the OLE and had ≥1 dose of BKZ and ≥1 valid efficacy variable measurement in the OLE), and include: BASDAI, BASDAI50 responder rate, BASFI, fatigue (BASDAI Q1), morning stiffness (mean of BASDAI Q5 + 6), total spinal pain (numeric rating scale [NRS]), SF-36 PCS and MCS, and ASQoL. Missing data were imputed using multiple imputation (MI; based on the missing at random assumption) for continuous variables and non-responder imputation (NRI) for dichotomous variables.

Results:

262/303 (86%) patients randomised at BE AGILE study baseline (BL) completed Week 48 on BKZ 160 mg or 320 mg, of whom 255/262 (97%) entered the OLE (full analysis set: 254). From baseline to Week 48 in BE AGILE, BKZ-treated patients showed clinically relevant improvements in disease activity (BASDAI, BASDAI50), physical function (BASFI), fatigue, morning stiffness, spinal pain, and quality of life (SF-36 PCS and MCS, ASQoL) (Figure 1). Group-level improvements in all reported continuous efficacy measures exceeded published minimally important difference (MID), minimum clinically important improvement (MCII), and/or minimum clinically important difference (MCID) thresholds (Figure 1).3,4 Efficacy in all reported outcome measures was maintained or continued to improve from Week 48 to Week 144 or 156 (Figure 1).

Conclusion:

BKZ treatment was associated with sustained and consistent efficacy in patients with active AS over 3 years, including patient-reported disease activity, physical function, fatigue, morning stiffness, spinal pain, and quality of life.

References:

[1]van der Heijde D. Ann Rheum Dis 2020;79:595–604.

[2]Baraliakos X. Arthritis Rheumatol 2020;72 (suppl 10).

[3]Ogdie A. Arthritis Care Res 2020;72 (S10):47–71.

[4]Maruish ME. User’s manual for the SF-36v2 Health Survey (3rd ed). 2011; Lincoln, RI: QualityMetric Incorporated.

Acknowledgements:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Xenofon Baraliakos Speakers bureau: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Paid instructor for: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, MSD, Novartis, Pfizer, UCB Pharma, Maxime Dougados Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer and UCB Pharma, Grant/research support from: AbbVie, Eli Lilly, Novartis, Pfizer and UCB Pharma, Karl Gaffney Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Eli Lilly, Novartis, UCB Pharma, Grant/research support from: AbbVie, Gilead, Eli Lilly, Novartis, UCB Pharma, Raj Sengupta Speakers bureau: AbbVie, Biogen, Celgene, MSD, Novartis, UCB Pharma, Consultant of: AbbVie, Biogen, Celgene, Eli Lilly, MSD, Novartis, UCB Pharma, Grant/research support from: AbbVie, Celgene, UCB Pharma, Marina Magrey Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Marga Oortgiesen Employee of: UCB Pharma, Thomas Vaux Employee of: UCB Pharma, Carmen Fleurinck Employee of: UCB Pharma, Valerie Ciaravino Employee of: UCB Pharma, Atul Deodhar Speakers bureau: Janssen, Novartis, Pfizer, Consultant of: AbbVie, Amgen, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Gilead, GSK, Janssen, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB Pharma

Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit

Objectives

Updated guidelines for patients with axial SpA (axSpA) have sought to reduce diagnostic delay by raising awareness among clinicians. We used the National Early Inflammatory Arthritis Audit (NEIAA) to describe baseline characteristics and time to diagnosis for newly referred patients with axSpA in England and Wales.

Methods

Analyses were performed on sociodemographic and clinical metrics, including time to referral and assessment, for axSpA patients (n = 784) recruited to the NEIAA between May 2018 and March 2020. Comparators were patients recruited to the NEIAA with RA (n = 9270) or mechanical back pain (MBP; n = 370) in the same period.

Results

Symptom duration prior to initial rheumatology assessment was longer in axSpA than RA patients (P < 0.001) and non-significantly longer in axSpA than MBP patients (P = 0.062): 79.7% of axSpA patients had symptom durations of >6 months, compared with 33.7% of RA patients and 76.0% of MBP patients. Following referral, the median time to initial rheumatology assessment was longer for axSpA than RA patients (36 vs 24 days; P < 0.001) and similar to MBP patients (39 days; P = 0.30). Of the subset of patients deemed eligible for early inflammatory arthritis pathway follow-up, fewer axSpA than RA patients had disease education provided (77.5% vs 97.8%) and RA patients reported a better understanding of their condition and treatment.

Conclusion

Diagnostic delay in axSpA remains a major challenge despite improved disease understanding and updated referral guidelines. Disease education is provided to fewer axSpA than RA patients, highlighting the need for specialist clinics and support programmes for axSpA patients.

P097 Raised inflammatory markers with unclear cause; what do they tell us? An audit of patients presenting to rheumatology service at RNHRD, Bath

Background/Aims 

Unexplained persistently raised inflammatory response in patients’ leads to concern for clinicians. Different studies have demonstrated increased risk of mortality in patients with persistently raised inflammatory response. Rheumatology input is often sought in these cases when cause of inflammatory response is unclear. We conducted this project in our department to see the progress of new patients with raised inflammatory markers presenting to the rheumatology service.

Methods 

Patients referred to the rheumatology outpatients with raised inflammatory markers (Plasma viscosity &gt;1.85 or CRP&gt;100) from April to November 2018 were included. Patient demographic information was gathered through patient’s records and imaging information was gathered through PACS system. Information about investigative modalities was included. Treatment recommendations were also included. Patients were followed up for 6 months and any change in their diagnosis was also incorporated into the data.

Results 

169 patients satisfied the inclusion criteria. Median age was 58 years. Majority were females (72%). Mean referral to seen time was 3.43 weeks. Mean elevation in CRP and PV was 10 and 1.93 respectively. A diagnosis of mechanical/non rheumatological cause was made in 36% patients of those 11% were Fibromyalgia. Inflammatory arthritis diagnosis made in 34% patients. Autoimmune testing and radiological tests were performed in 97% and 90% patients respectively. 67% patients had malignancy or infection work up. Diagnosis was changed in 25% patients on follow up with investigation. With PV &gt; 2.0 (44 patients), only 20% had non inflammatory conditions. There were 6 deaths in this cohort of patients (13% mortality). 3 new cases of malignancy were diagnosed. P097 Table 1:Investigative modalitiesInflammatory disorders N=number of scansNon-inflammatory conditionsCT100MRI1812PET CT71NM scan14

Conclusion 

Patients with persistently elevated inflammatory markers had a higher mortality rate than the other group over 6 months. Three quarters of patients with raised inflammatory markers remain under follow up of Rheumatology team for surveillance. Patients were reviewed in Rheumatology clinics in reasonable time. Appropriate investigative modalities were considered while investigating for inflammatory disorders. Further large scale studies are required to find an association between raised inflammatory response with mortality in rheumatology patients.

Disclosure 

M. Jamal: None. R. Peck: None. R. Sengupta: None.

P177 Management of patients with axSpA: an audit against the NICE diagnosis and management of adults with spondyloarthritis quality standard, QS170, and clinical practice guidelines

Background/Aims 

The Royal National Hospital for Rheumatic Diseases in Bath is a tertiary centre for axial spondyloarthritis (axSpA). Our objective was to perform an audit to establish compliance with NICE QS170: patients with no radiographic evidence of axSpA receive an MRI scan; patients with axSpA undergo a structured exercise programme from a specialist physiotherapist; and patients receive information about their axSpA and its management. The aim was to identify opportunities for improvements in the care given to people using our service.

Methods 

A retrospective case note review was performed for 300 patients with axSpA who commenced biologic disease-modifying anti-rheumatic drug (bDMARD) therapy between 2011 and 2018, selected at random from 539 patients in our database using systematic random sampling. Using NICE QS170 and clinical practice guidelines for reference, the audit explored the frequency and nature of imaging examination (X-ray or MRI) as part of the diagnostic work up; dissemination of patient information and education regarding their condition; nature and sequence of administered treatments; monitoring for adverse events; and response to treatment.

Results 

269 patients met the inclusion criteria for the audit. The majority (n = 177; 65.8%) were male, white (n = 242; 90.0%) and had a diagnosis of ankylosing spondylitis (n = 222; 82.5%). Non-radiographic axSpA was diagnosed in 42 (15.6%) patients, reactive arthritis in 4 (1.5%) and psoriatic spondyloarthritis in 1 patient (0.4%). Thirty-one patients did not have a date recorded for symptom onset and for the remaining 238 patients, median (min, max) time from symptom onset to diagnosis was 6.26 (0, 50) years. Baseline median (min, max) BASDAI score was 6.7 (0, 9.7). Of 225 patients with suspected axSpA who had imaging data recorded, 19 had X-rays showing no sacroiliitis and of these, 18 (94.7%) underwent MRI using an inflammatory back pain protocol. Of 267 patients with data regarding education on axSpA, most (n = 228; 85.4%) received education via a leaflet, the National Axial Spondyloarthritis Society website or attendance of a 2-week rehabilitation programme. Regarding exercise education, most (217/259; 83.8%) had evidence of referral to a structured exercise programme. Of 248 patients with data on medical management, 246 (99.2%) received first-line non-steroidal anti-inflammatory drugs (NSAIDs), as recommended in guidelines. Renal function was monitored 6-monthly in 80.3% of patients on NSAIDs. Twelve-week assessment of bDMARD treatment response (BASDAI scoring) occurred for 85.0% of patients (198/233), 74 patients stopped treatment before this timepoint and 3 patients had no BASDAI scores available.

Conclusion 

Performing this audit ensured that we benchmarked our service against NICE QS170 and clinical practice guidelines, to identify deficient care aspects and enable action plans to be developed to improve patient care.

Disclosure 

R. Sengupta: Honoraria; RS has received honoraria/expenses/research grants from AbbVie, Biogen, Celgene, Lilly, MSD, Novartis, Pfizer, UCB. M. Savino: Grants/research support; MS received expenses for data collection within this study from Novartis. E. Reilly: Grants/research support; ER has received research grants from Actelion and Celgene Corporation outside of this work. ER has also received expenses from Novartis, Celgene, UCB, Pfizer. C. Cavill: Grants/research support; CC has received research grants from Abbott, Celgene, Lilly, Novartis, Janssen and Pfizer.

P181 Long-term improvement in axial spondyloarthritis clinical outcomes following 2-weeks of intensive education and rehabilitation: results from the Bath residential rehabilitation programme

Background/Aims 

Axial spondyloarthritis (axSpA) is a chronic rheumatic condition, characterised by inflammatory back pain - often associated with impaired function and mobility, sleep disturbance, fatigue, and reduced quality of life. Despite the vast advances in pharmacological treatments for axSpA over the last few decades, physical activity and rehabilitation remain vital for effective disease management. At the Royal National Hospital for Rheumatic Diseases in Bath (RNHRD), the 2-week inpatient axSpA rehabilitation programme has been integral to axSpA care since the 1970’s. Prior research has demonstrated significant short-term improvements in spinal mobility (BASMI), function (BASFI) and disease activity (BASDAI) following course attendance. However, the long-term outcomes are yet to be evaluated in this unique cohort.

Methods 

Since the early 1990’s, clinical measures of spinal mobility, function and disease activity have been routinely collected at the RNHRD at all clinical appointments through administration of the BASMI, BASFI and BASDAI, respectively. Dates of attending the axSpA course and standard clinical and treatment follow-up data were also collected. Multiple linear regression models were used to investigate the impact of course attendance on final reported BASMI, BASDAI and BASFI scores (final score=most recent). Length of follow-up was defined as time between first and last recorded BASMI.

Results 

Of the 203 patients within the Bath SPARC200 cohort, 77.8% (158/203) had attended at least one rehabilitation course throughout follow-up. 70.0% (140/203) of patients were male. The mean duration of follow-up was 13.5 years (range 0-35 years); 28.1% (57/203) of individuals with 20+ years of follow-up. Course attendance (yes versus no) significantly reduced final BASMI score by 0.84 (p = 0.001, 95%CI -1.31 to -0.37) and final BASDAI score by 0.74 (p = 0.018, 95%CI -1.34 to -0.13). Although course attendance reduced final BASFI by 0.45 (95%CI -1.17 to 0.28), this relationship did not reach significance (p = 0.225). Whilst minimally clinically important difference (MCID) is, to our knowledge, yet to be defined for BASMI, MCIDs were achieved long-term for both BASDAI and BASFI - defined by van der Heijde and colleagues in 2016 as 0.7 and 0.4 for BASDAI and BASFI, respectively.

Conclusion 

These results provide novel evidence to support the integral role of education, physical activity and rehabilitation in the management of axSpA. Future work should investigate additional outcomes of critical importance to patients and clinicians, such as fatigue, quality of life and work productivity. Furthermore, a greater understanding of the factors that confound these outcomes may provide insights into those patients who may most benefit from attending a 2-week rehabilitation course. In addition to facilitating identification of those patients who may require additional clinical support.

Disclosure 

R. Barnett: None. A. McGrogan: None. M. Young: None. C. Cavill: None. M. Freeth: None. R. Sengupta: Honoraria; Biogen, Celgene, AbbVie, Novartis, MSD. Grants/research support; Novartis, UCB.

P007 Service evaluation of the nurse-led telephone advice line in the wake of COVID-19: a report of audit and staff satisfaction

Background/Aims 

The Rheumatology nurse advice line (NAL) at the Royal National Hospital for Rheumatic Diseases (RNHRD, Bath) provides a vital service for direct patient access to specialist advice via a designated voicemail system. Increasing numbers and difficulty connecting call returns have increased staff workload, reduced efficiency and impacted on staff satisfaction. An audit was therefore undertaken to evaluate service use and efficiency, paired with formal assessment of staff satisfaction in order to identify areas for improvement.

Methods 

The total number of monthly calls through the NAL during 2020 were counted. A subset of consecutive calls were audited in detail, documenting temporal parameters in relation to the call being logged, returned and concluded. The number of clinicians and attempts required to contact the patient was noted. An anonymised staff satisfaction questionnaire was completed by NAL nurses and administrators. Data was analysed using Excel.

Results 

An average 653 calls per month (range 340-894) came through the NAL between January and September 2020. 97 consecutive patient contacts were audited from August 2020. Multiple attempts were required to successfully return the call in 19.6% of cases (n = 19/97). Of those, 68.4% (n = 13/19) of calls needed ≥ 2 nurses to contact the patient. In general, the first attempt to return the call was prompt (average 7.6 hours, range 0.1-27.7). However, the time to conclude the call from the patient’s first call log ranged from 0.1 - 142.6 hours (average 12.7 hours) with increased time associated with difficulties contacting the patient or when further advice was required from a Rheumatology doctor (18.5%, n = 18/97).

Staff surveys revealed 67% of staff felt that the NAL is a good service to offer patients. However, 67% of staff did not feel the NAL in its current format was easy to manage. Specific comments included that the lack of rota'd responsibility, unpredictable workload and time inefficiencies were barriers to managing the service.

Conclusion 

From this data, we conclude that patient calls are returned promptly, but utilising a system of voicemail and unscheduled call returns is inefficient and contributes to staff dissatisfaction. This data has driven change for service improvement. To improve efficiency, calls will be answered live by an administrator during working hours and patients given a call-back time. A doctor will be named as a single point of contact for the nurses to seek additional advice and a nurse rota will designate responsibility for NAL calls to reduce work-load uncertainty. Follow up service evaluation will include staff and patient satisfaction questionnaires, and repeat audit, with consideration of ways to support frequent service users.

Disclosure 

J. Day: None. J. Ball: None. J. Down: None. R. Sengupta: None. V. Flower: None.

P178 The impact of peripheral articular manifestations on the efficacy of ixekizumab in patients with radiographic axial spondyloarthritis

Background/Aims 

Axial spondyloarthritis (axSpA) is characterised by chronic inflammation of the axial skeleton and is commonly associated with peripheral articular manifestations (PA), which further increases disease burden. Ixekizumab (IXE), a high-affinity monoclonal antibody that selectively targets IL-17A, is approved for treating both nonradiographic and radiographic (r-) forms of axSpA. We explored the efficacy of IXE in patients with raxSpA with (PA+) and without (PA−) PA at baseline.

Methods 

Week 16 data from two Phase 3, randomized, double-blind, placebo (PBO)-controlled trials, with patients who fulfilled the Assessment of Spondylo-Arthritis International Society (ASAS) criteria for r-axSpA and were either biologic-naïve (COAST-V, NCT02696785) or TNFi-experienced (COAST-W, NCT02696798), were analysed. Patients were randomly assigned 1:1:1:1 to subcutaneous PBO, 80 mg IXE every 4 (Q4W) or 2 (Q2W) weeks (80 mg or 160 mg starting dose, assigned 1:1) or 40 mg adalimumab (ADA) Q2W in COAST-V or 1:1:1 in COAST-W. We present a post-hoc analysis of data from COAST-V and -W and an integrated dataset, with patients categorized by baseline PA status. Presence of PA was defined as a 44-joint swollen joint count (SJC) ≥1 or a 46-joint tender joint count (TJC) ≥1. Efficacy and health-related quality of life (HRQoL) outcomes were analysed at week 16.

Results 

Data from 656 patients (COAST-V: N = 146 PA−/194 PA+; COAST-W: N = 93 PA−/223 PA+) were analyzed. At baseline, PA+ patients had a higher mean age, more enthesitis (higher Spondyloarthritis Research Consortium of Canada [SPARCC] scores), and higher disease activity (higher CRP levels, Ankylosing Spondylitis Disease Activity Score [ASDAS] and BASDAI). ASAS40, ASDAS &lt;2.1, and BASDAI50 responder rates (Table, section a) were all significantly higher for both IXE dose regimens versus PBO in both PA− and PA+ patients in the integrated dataset and numerically higher in the separate datasets. Furthermore, short-form-36 physical component summary (Table, section b) showed significantly greater improvements from baseline in both IXE groups vs PBO in the separate and integrated datasets, regardless of baseline PA status.

Conclusion 

IXE led to significant improvements versus PBO in all efficacy and HRQoL endpoints at Week 16 in the integrated dataset, irrespective of PA manifestations at baseline. P178 Table 1:a) Responder rates at Week 16 for the intent-to-treat population, number (%)No peripheral articular manifestations at baselinePeripheral articular manifestations at baselinePBOADAQ2WIEQ4WIXEQ2WPBOADAQ2WIXEQ4WIXEQ2WIntegrated datasetaN=71N/AN=63N=66N=119N/AN=132N=115ASAS4011.5N/A29 (46.0)‡28 (42.4)‡18 (15.1)N/A39 (29.5)†45 (39.1)‡ASDAS &lt;2.18 (11.3)N/A24 (38.1)‡23 (34.8)†8 (6.7)N/A31 (23.5)‡28 (24.3)‡BASDAI5010 (14.1)N/A21 (33.3)*26 (39.4)†15 (12.6)N/A38 (28.8)‡33 (28.7)†COAST-VbN=34N=39N=35N=38N=52N=51N=46N=45ASAS408 (23.5)17 (43.6)18 (51.4)*18 (47.4)8 (15.4)15 (29.4)21 (45.7)†25 (55.6)‡ASDAS &lt;2.17 (20.6)18 (46.2)*14 (40.0)17 (44.7)*4 (7.7)16 (31.4)†21 (45.7)†18 (40.0)‡BASDAI507 (20.6)16 (41.0)13 (37.1)16 (42.1)8 (15.4)13 (25.5)21 (45.7)†20 (44.4)†COAST-WbN=37N/AN=28N=28N=67N/AN=86N=70ASAS403 (8.1)N/A11 (39.3)†10 (35.7)*10 (35.7)*N/A18 (20.9)20 (28.6)ASDAS &lt;2.11 (2.7)N/A10 (35.7)‡6 (21.4)*4 (6.0)N/A10 (11.6)10 (14.3)BASDAI503 (8.1)N/A8 (28.6)*10 (35.7)*7 (10.4)N/A17 (19.8)13 (18.6)Non-responder imputation was used for missing responses.P-values vs. PBO (aCochran-Mantel-Haenszel test, adjusted by study;bFisher’s exact test):*P&lt;0.05,†P&lt;0.01,‡P&lt;0.001.b) Change from baseline in SF-36 PCS scores at Week 16 for the intent-to-treat population, LSM (SE)No peripheral articular manifestations at baselinePeripheral articular manifestations at baselinePBOADAQ2WIXEQ4WIXEQ2WPBOADAQ2WIXEQ4WIXEQ2WIntegrated dataseta1.6 (0.90)N/A7.2 (0.95)‡6.1 (0.92)‡3.8 (0.69)N/A7.7 (0.67)‡8.2 (0.71)‡COAST-Vb2.3 (1.15)7.0 (1.10)†6.9 (1.13)†6.4 (1.07)*4.6 (1.00)6.9 (1.01)8.3 (1.07)*9.3 (1.10)†COAST-Wc0.64 (1.57)N/A7.1 (1.75)†5.4 (1.72)*1.9 (0.96)N/A6.4 (0.85)‡6.3 (0.97)‡P-values vs. PBO (MMRM analysis with treatment,a,b,c study,a baseline value,a,b,c visit,a,b,c baseline value-by-visit,a,b,c treatment-by-visit interaction,a,b,c geographic region,b,c baseline CRP status,b,c and number of prior TNF inhibitorsc included as fixed factors):*P &lt; 0.05,†P &lt; 0.01,‡P &lt; 0.001.ADAQ2W = adalimumab every 2 weeks; ASAS = Assessment of Spondyloarthritis International Society criteria; ASDAS = ankylosing spondylitis disease activity score; BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; CRP = c reactive protein; IXEQ2W = ixekizumab every 2 weeks; IXEQ4W = ixekizumab every 4 weeks; MMRM = mixed-effects model of repeated measures; N/A = not applicable; PBO = placebo; PCS = physical component summary; SE = standard error; SF-36 = short-form-36; TNF = tumour necrosis factor.

Disclosure 

R. Sengupta: None. P. Bird: Grants/research support; Pfizer, Eli Lilly, Gilead, Abbvie, Novartis. D. Aletaha: Consultancies; Abbvie, Amgen, Celgene, Eli Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Genzyme. Grants/research support; Abbvie, Novartis, Roche. M. Magrey: Consultancies; Novartis, Pfizer, Eli Lilly, Abbvie, UCB. Other; Clinical trials with: Abbvie and UCB. Y. Kadono: Member of speakers’ bureau; Abbie, Lilly, Novartis. E. Soriano: Consultancies; Abbvie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, Sandoz. Member of speakers’ bureau; Abbvie, Amber, Bristol-Myers Squibb, Eli Lilly, Novartis, Pfizer, Roche, UCB. Grants/research support; Abbvie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, Sandoz, UCB. A.J. Bradley: Shareholder/stock ownership; Eli Lilly. Other; Employee of Eli Lilly and Company. S. Liu-Leage: Shareholder/stock ownership; Eli Lilly. Other; Employee of Eli Lilly and Company. Y. Schymura: Other; Employee of Eli Lilly and Company. M.J. Nissen: Corporate appointments; Abbvie, Celgene, Lilly, Novartis, Pfizer. Member of speakers’ bureau; Abbvie, Celgene, Novartis, Pfizer. Other; Member of EuroSpA (supported by Novartis).

Depression among Patients Presenting with Gastrointestinal Symptoms: Prevalence and Associated Factors

Gastrointestinal diseases frequently affect patients' physical and emotional wellbeing as being heavily affected by stress. This study was conducted to find out prevalence and severity of depressive symptoms among patients presenting with gastrointestinal symptoms. This cross sectional study was conducted at Outpatients Department jointly by Department of Gastroenterology and Department of Psychiatry of a tertiary care hospital in north east part of Bangladesh from November 2011 to June 2012. Consecutive patients with gastrointestinal symptoms underwent psychiatric evaluation using HDRS and analyzed. 442 patients, 38(8.6%) were found normal. Among the rest 128(28.96%), 138(31.22%), 72(16.29%) and 66(14.93%) had mild, moderate, severe and very severe depressive symptoms respectively. Female sex (95.03% vs. 89.32%), married people (93.77 vs. 86.13%), older age (98.24%), rural people (94.26% vs. 84.36%), farmers (96.36%) and house wives (96.24%) were more affected. Prevalence of depression was also higher among patients with lower socioeconomic class, less educated people and rural background. Depressive symptoms are very common in patients presenting with gastrointestinal symptoms. Awareness regarding psychiatric assessment and intervention may reduce sufferings and thus improve wellbeing of these patients.

A novel IMU-based clinical assessment protocol for Axial Spondyloarthritis: a protocol validation study

Clinical assessment of spinal impairment in Axial Spondyloarthritis is currently performed using the Bath Ankylosing Spondylitis Metrological Index (BASMI). Despite being appreciated for its simplicity, the BASMI index lacks sensitivity and specificity of spinal changes, demonstrating poor association with radiographical range of motion (ROM). Inertial measurement units (IMUs) have shown promising results as a cost-effective method to quantitatively examine movement of the human body, however errors due to sensor angular drift have limited their application to a clinical space. Therefore, this article presents a wearable sensor protocol that facilitates unrestrained orientation measurements in space while limiting sensor angular drift through a novel constraint-based approach. Eleven healthy male participants performed five BASMI-inspired functional movements where spinal ROM and continuous kinematics were calculated for five spine segments and four spinal joint levels (lumbar, lower thoracic, upper thoracic and cervical). A Bland-Altman analysis was used to assess the level of agreement on range of motion measurements, whilst intraclass correlation coefficient (ICC), standardised error measurement, and minimum detectable change (MDC) to assess relative and absolute reliability. Continuous kinematics error was investigated through root mean square error (RMSE), maximum absolute error (MAE) and Spearman correlation coefficient (ρ). The overall error in the measurement of continuous kinematic measures was low in both the sagittal (RMSE = 2.1°), and frontal plane (RMSE = 2.3°). ROM limits of agreement (LoA) and minimum detectable change were excellent for the sagittal plane (maximum value LoA 1.9° and MDC 2.4°) and fair for lateral flexion (overall value LoA 4.8° and MDC 5.7°). The reliability analysis showed excellent level of agreement (ICC > 0.9) for both segment and joint ROM across all movements. The results from this study demonstrated better or equivalent accuracy than previous studies and were considered acceptable for application in a clinical setting. The protocol has shown to be a valuable tool for the assessment of spinal ROM and kinematics, but a clinical validation study on Axial Spondyloarthritis patients is required for the development and testing of a novel mobility index.

Feasibility, acceptability and change in health following a telephone-based cognitive behaviour therapy intervention for patients with axial spondyloarthritis

Objective

The aim was to assess the feasibility and acceptability of a telephone-based cognitive behaviour therapy (tCBT) intervention for individuals with axial SpA (axSpA), with and without co-morbid FM, and to measure the change in patient-reported health outcomes.

Methods

A convenience sample of individuals recruited from British Society for Rheumatology Biologics Registry for AS (BSRBR-AS) sites were offered a course of tCBT (framed as coaching). Patient-reported outcomes were measured at baseline and on course completion. Semi-structured qualitative interviews assessed intervention acceptability. Thematic analysis was informed by the theoretical framework of acceptability.

Results

Forty-two participants attended for initial assessment. Those completing at least one tCBT session (n = 28) were younger, more likely to meet classification criteria for FM (57 vs 29%) and reported higher disease activity. Modest improvements were reported across a range of disease activity and wider health measures, with 62% of patients self-rating their health as improved (median 13 weeks post-intervention). Twenty-six participants were interviewed (including six who discontinued after initial assessment). tCBT was widely acceptable, offering a personalized approach. Despite low or unclear expectations, participants described improved sleep and psychological well-being and gained new skills to support self-management. Reasons for non-uptake of tCBT centred on lack of perceived need and fit with individual value systems. Many felt that tCBT would be most useful closer to diagnosis.

Conclusion

Higher uptake among axSpA patients with co-morbid FM suggests that these individuals have additional needs. The findings are helpful in identifying patients most likely to engage with and benefit from tCBT and to maximize participation.

Longitudinal profiling of the gut microbiome in patients with psoriatic arthritis and ankylosing spondylitis: a multicentre, prospective, observational study

BACKGROUND

Psoriasis is a chronic inflammatory disease of the skin affecting 2-3% of UK population. 30% of people affected by psoriasis will develop a distinct form of arthritis within 10 years of the skin condition onset. Although the pathogenesis of psoriatic arthritis is still unknown, there is a genetic predisposition triggered by environmental factors. Limited but convincing evidence link the gut microbiome to psoriatic arthritis. The Microbiome in Psoriatic ARThritis (Mi-PART) study propose is to characterise the microbiome-metabolic interface in patients affected by psoriatic arthritis to deepen our understanding of the pathogenesis of the disease.

METHODS

This is a multicentre, prospective, observational study. Psoriatic arthritis (n = 65) and ankylosing spondylitis (n = 30) patients will be recruited in addition to a control group of healthy volunteers (n = 30). Patients eligibility will be evaluated against the Criteria for Psoriatic Arthritis (CASPAR), the Bath Ankylosing Spondylitis Activity Index (BASDAI) and the healthy volunteers who fulfil study inclusion and exclusion criteria. Information regarding their medical and medication history, demographics, diet and lifestyle will be collected. All the participants in the study will be asked to complete a 7-day food diary, to provide stool samples and to complete quality of life questionnaires. Routine clinical laboratory tests will be performed on blood and urine samples. Patients and healthy volunteers with gastrointestinal symptoms, previous history of cancer, gastrointestinal surgery in the previous 6 months or alcohol abuse will be excluded from the study.

DISCUSSION

The aim of this trial is to characterise the microbiome of psoriatic arthritis patients and to compare it with microbiome of healthy volunteers and of patient with ankylosing spondylitis in order to define if different rheumatologic conditions are associated with characteristic microbiome profiles. Investigating the role of the microbiome in the development of psoriatic arthritis could deepen our understanding of the pathogenesis of the disease and potentially open the way to new therapies.

Secukinumab provided significant and sustained improvement in the signs and symptoms of ankylosing spondylitis: results from the 52-week, Phase III China-centric study, MEASURE 5

BACKGROUND

Secukinumab demonstrated sustained efficacy in patients with ankylosing spondylitis (AS) through 5 years in pivotal Phase III studies. Here, we present efficacy and safety results (52-week) of secukinumab in patients with AS from the MEASURE 5 study.

METHODS

MEASURE 5 was a 52-week, Phase III, China-centric study. Eligible patients were randomly assigned (2:1) to receive subcutaneous secukinumab 150 mg or placebo weekly for the first five doses and then once every 4 weeks (q4w). All placebo patients switched to secukinumab 150 mg q4w starting at Week 16. Primary endpoint was Assessments of SpondyloArthritis international Society (ASAS) 20 at Week 16. Randomization was stratified by region (China vs. non-China).

RESULTS

Of 458 patients (secukinumab 150 mg, N = 305; placebo, N = 153) randomized, 327 (71.4%) were from China and 131 (28.6%) were not from China. Of these, 97.7% and 97.4% patients completed Week 16 and 91.1% and 95.3% (placebo-secukinumab) patients completed Week 52 of treatment. The primary endpoint was met; secukinumab significantly improved ASAS20 response at Week 16 vs. placebo (58.4% vs. 36.6%; P < 0.0001); corresponding rate in the Chinese population was 56.0% vs. 38.5% (P < 0.01). All secondary efficacy endpoints significantly improved with secukinumab 150 mg in the overall population at Week 16; responses were maintained with a trend toward increased efficacy from Week 16 to 52. No new or unexpected safety signals were reported up to Week 52.

CONCLUSIONS

Secukinumab 150 mg demonstrated rapid and significant improvement in signs and symptoms of AS. Secukinumab was well tolerated and the safety profile was consistent with previous reports. Efficacy and safety results were comparable between the overall and Chinese populations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02896127; https://clinicaltrials.gov/ct2/show/NCT02896127?term=NCT02896127&draw=2&rank=1.

Axial spondyloarthritis 10 years on: still looking for the lost tribe

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

Evaluation of a patient self-stratification methodology to identify those in need of shielding during COVID-19

The logistical challenges of rapidly and accurately identifying those patients who needed to shield during the COVID-19 pandemic were unprecedented. We report our experiences of meeting this challenge for >9,000 patients with rheumatic and musculoskeletal disease at our centre, incorporating an element of guided patient self-stratification. Our results indicate that patients are able to stratify their own risk accurately using the BSR COVID-19 risk stratification guidance.

SAT0628-HPR “IT IS THE NEVER ENDING QUEST, HOW TO MOTIVATE PEOPLE” – HEALTH PROFESSIONALS’ PERSPECTIVES ON SUPPORTING PHYSICAL ACTIVITY MAINTENANCE IN THOSE LIVING WITH AXIAL SPONDYLOARTHRITIS

Background:

Physical activity (PA) has been identified as a primary treatment option for people living with axial spondyloarthritis (axSpA) [1]. Yet, people living with axSpA can find it difficult to maintain PA at levels required to gain the evidenced benefits [2]. Intensive rehabilitation programmes harness the benefits of physical activity, but little is known about how to support PA maintenance when patients return to everyday life. The perspectives’ of health professionals involved in rehabilitation programmes can provide important and rich insights into how people living with axSpA could be helped to maintain their PA.

Objectives:

To explore health professionals‘ experiences of supporting PA maintenance during and after a rehabilitation programme for those living with axial spondyloarthritis.

Methods:

A qualitative study was conducted using semi-structured interviews. Nine health professionals (i.e., 4 physiotherapists; 1 clinical nurse specialist; 1 rheumatology SpR; 1 psychologist; 1 occupational therapist; and 1 podiatrist) who contribute to a rehabilitation programme were recruited from the Royal National Hospital for Rheumatic Diseases in Bath, UK (Mtime contributing to course = 6.79 yrs, range 1-19.25 yrs; contact time over course range = 1 to 45 hrs). Interviews were audio recorded, transcribed verbatim, and a thematic analysis employed [3].

Results:

Maintaining a physically active lifestyle is a challenge for those living with axSpA and is an issue that is currently not being addressed. Health professionals’ perspectives on supporting PA maintenance was illustrated through four main themes: (1) Social environment (group dynamic, importance of others with the same condition, immersion of the disease, external peer groups); (2) Re-framing (education, ownership, exercise off the pedestal, combating fear, routine and habit); (3) PA support (enjoyment and interest, PA as flexible, encouragement and importance, balance and realistic expectations, internal and external feedback); and (4) Challenges for health professionals (training, resources, knowledge of transition process to everyday life, difficulty motivating). The reasons why people engage in PA play a key role within each of these themes.

Conclusion:

Results emphasize the current lack of support for the maintenance of PA and the complexities and challenges involved in maintaining PA for people living with axSpA. Interventions to support PA maintenance should pay particular attention to the importance of socially supportive environments, the need for enjoyment, and the use of internal and external feedback. The challenges faced by health professionals in motivating those living with axSpA to engage in PA regularly suggests a need for more training opportunities in motivation and health behaviour change.

References:

[1]Rausch Osthoff, A., Niedermann, K., Braun, J., et al., (2012) EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the Rheumatic Diseases, 77 (9), pp. 1251-60.

[2]McDonald, M. T., Siebert, S., Coulter, E. H., McDonald, D. A., and Paul, L. (2019) Level of adherence to prescribed exercise in spondyloarthritis and factors affecting this adherence: a systematic review.Rheumatology International, 39 (2), pp. 187-201.

[3]Braun, V., and Clarke, V. (2006) Using thematic analysis in psychology.Qualitative Research in Psychology, 3 (2), pp. 77-101.

Acknowledgments:

The authors would like to thank the Bath Institute for Rheumatic Diseases (BIRD) and the University of Bath for funding the PhD studentship associated with this project

Disclosure of Interests:

Thomas Ingram: None declared, Peter Rouse: None declared, Martyn Standage: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

FRI0309 DAILY SELF-REPORTED FLARE PROFILES IN AXIAL SPONDYLOARTHRITIS: ASSOCIATIONS BETWEEN FLARE, SYMPTOMS AND BEHAVIOUR

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease, characterised by fluctuating periods of flare and remission. Flare is a multidimensional change of disease state; whereby flare definitions have previously been formulated using validated composite indices, or through qualitative retrospective investigation of flare states. Smartphone technologies for tracking disease symptoms provide unique, daily insights into self-reported individual flare experience, and may present an opportunity to gain a more complete understanding of flare burden and symptom patterns.

Objectives:

To assess frequency and characteristics of axSpA flares, utilising data collected in the uMotif symptom tracking app.

Methods:

Patients with axSpA attending the Royal National Hospital for Rheumatic Diseases in Bath were invited to participate. Through the uMotif app, patients were sent daily reminders to log flare, pain, fatigue, sleep, recommended exercise, mood and stress using 5-point Likert scales, in addition to optional variables such as smoking and menstrual cycle. Self-reported periods of flare were identified. For each patient reporting flare within the study period, a mean ‘flare’ and ‘non-flare’ score was calculated for each variable. Paired t-tests were conducted for each variable, to investigate which variables correlate with flare status.

Results:

Between 5th April 2018 and 8th March 2019, 174 patients consented for research and logged a mean of 99.73 (SD 99.97, range 1 - 323 days) days of data. 136/174 (78%) patients recorded at least 1 flare, with 1330 flares recorded in total. For patients reporting at least 1 flare, each flare lasted a mean of 2.20 days (SD 2.53 days, range 1 – 33 days), with a mean frequency of once every 45.19 days (SD 53.06, range 3.2 -314 days). Significant relationships were identified between flare status and uMotif scores (Table 1).

Table 1.

Paired t-tests: flare vs. non-flare scores for each variable

Estimated difference^p-valueN95% CI (lower limit)95% CI (upper limit)Variable-0.870.266-2.630.88Red Painful Eyes-0.670.000*130-0.78-0.56Pain-0.570.004*25-0.94-0.20Chest Pain-0.510.005*15-0.83-0.18Hot Flushes-0.500.000*129-0.61-0.40Fatigue-0.440.1962-2.231.35Blood in Stool-0.380.000*128-0.47-0.29Mood-0.360.000*127-0.52-0.20Anti-Inflammatory Use-0.360.000*128-0.48-0.23Recommended Exercise-0.340.000*33-0.51-0.17Confidence in Self-Management-0.260.000*128-0.37-0.15Stress-0.250.17015-0.620.12Screen Time-0.190.000*130-0.26-0.12Sleep Quality-0.150.45812-0.590.28Menstrual Cycle-0.110.10322-0.250.02Eyesight0.090.1953-0.120.30Flare of Psoriasis0.050.65626-0.170.26Medication Adherence0.040.7973-0.530.61Smoking Today-0.030.48450-0.110.05Caffeine Intake

N= number of patients with both a flare and non-flare entry for each variable; CI=confidence interval

Higher variable scores indicate more positive outcomes (e.g. a higher pain score indicates less pain)

^Estimated difference between flare and non-flare entries (e.g. on average, the mean pain score of a flare entry is 0.67 [0.56– 0.78 CI] less than a non-flare entry)

*p<0.01

Conclusion:

These findings demonstrate significant relationships between a variety of patient-reported symptoms and flare, including variables that to our knowledge, have not yet been explored in axSpA. Small estimated differences were found between scores for ‘flare’ versus ‘no-flare’. Further work is needed to characterise fluctuating flare/no-flare patterns of individuals tracking daily symptoms in the uMotif app. In future research, it will be important to determine whether there is a chronological pattern of variables during the pre-flare period that can predict a flare. Greater understanding of such patterns may allow identification of the optimal timing of intervention to prevent a period of flare and improve quality of life for patients with axSpA.

Acknowledgments:

We thank UCB for funding use of the uMotif application.

Disclosure of Interests:

Rosie Barnett: None declared, Stanley Ng: None declared, Simon Jones: None declared, Matthew Young: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

AB0675 RED CELL DISTRIBUTION WIDTH AND FATIGUE IN AXIAL SPONDYLOARTHRITIS: A SLEEPER SIGNAL

Background:

Fatigue is a ubiquitous feature of autoimmune conditions, and axial Spondyloarthritis (axSpA) is no exception, with over 50% of patients reporting some degree of fatigue1. Erythrocyte size variability (as measured by red cell distribution width (RDW)) has been found to correlate with fatigue in a cohort of systemic lupus erythematous (SLE) patients and may reflect early iron deficiency2. We investigate whether this finding holds true in axSpA.

Objectives:

To investigate the relationships between fatigue, disease activity, and RDW (as a proxy for functional iron deficiency) in patients with axSpA.

Methods:

Cross-sectional analysis performed on patients with axSpA, as defined by the Assessment of SpondyloArthritis international Society (ASAS) criteria, enrolled in a longitudinal data collection study from October 2017 until January 2020 in a single outpatient setting. Patients required a minimum of 1 set of patient-reported outcome measures (PROMs), including the completion of a Functional Assessment of Chronic Fatigue Illness Therapy (FACIT) Fatigue Scale v4 (numerical score between 0–52 with a lower score indicating greater fatigue), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). C-reactive protein (CRP) as a biochemical marker of disease activity, as well as Haemoglobin (Hb) and RDW performed within 3 months either side of a PROMs set were extracted and matched. Only one pair of matched data was selected per patient according to the least timeframe between a set of PROMs and bloods of interest (if multiple were available). Anaemia was defined according to World Health Organisation criteria, i.e., Hb <120 g/L in females and Hb <130 g/L in males. Non-parametric analysis of variables was performed using Spearman’s rank correlation with significance defined at a p-value <0.05.

Results:

63 patients were included in the analysis (63.5% (40) male, mean time to diagnosis 11.46 (±9.04) years, 79.4% (50) HLA-B27 positive, 46% (29) current or ex-smokers). Blood parameters showed mean Hb of 139.6 (±16.03) g/L, mean RDW of 13.55 (±1.46) %, mean CRP of 5.23 (±10.82) mg/L. Mean BASDAI score of cohort was 3.69 (±2.02) and FACIT score 34.18 (±11.30). Mean absolute interval time difference between a PROMs set and bloods of interest was 16.14 (±41.11) days.

Univariate analysis showed a statistically significant, negative correlation between fatigue (FACIT) and disease activity (BASDAI), (p<0.001; r= -0.63), but failed to demonstrate an association between fatigue and Hb, RDW, or CRP. Sub-group analysis of 51 patients, following exclusion of patients with anaemia (12), engendered a significant and moderately negative correlation between fatigue and RDW (p=0.02, r=-0.32) (Figure 1), maintained a significant correlation between fatigue and BASDAI (p<0.0001, r=-0.56) and showed a non-significant association between RDW and BASDAI (p=0.07, r=0.25).

Figure 1.

Negative correlation between FACIT score and RDW

Conclusion:

These findings suggest that RDW may potentially represent a surrogate marker of disease activity in patients with axSpA. RDW may also be implicated in the multi-faceted aetiology of fatigue in axSpA patients, and may reflect functional iron deficiency. A recent cohort study of axSpA patients found anti-TNF therapy ineffective at alleviating fatigue in nearly 80% of patients1. Management of potential functional iron deficiency as reflected by RDW may offer an alternative treatment target for fatigue in these patients.

References:

[1]Bedaiwi M, Sari I, Thavaneswaran A, et al. J Rheumatol. 2015;42(12):2354.

[2]Wincup C, Parnell S, Cleanthous B, et al. Clin Exp Rheumatol. 2019 Sep-Oct;37(5):852-54.

Disclosure of Interests:

Saion Chatterjee: None declared, Chris Wincup: None declared, Anisur Rahman: None declared, Raj Sengupta Grant/research support from: Research grants from UCB, Pfizer, Abbvie and Novartis, Speakers bureau: Received honoraria for giving talks from Abbvie, Biogen, UCB, Novartis, Pfizer

Back pain, ankylosing spondylitis and social media usage; a descriptive analysis of current activity

Social media usage by back pain patients is a new and developing area. Analysing patterns of this online activity offers a new way to understand our patients’ concerns and behaviour around disease. Large volume data can be evaluated on a scale not feasible through alternative methods. A cross sectional review of specific terms relating to ‘back pain’ (BP) and ‘ankylosing spondylitis’ (AS) were tracked internationally on popular websites, blogs and boards over two 3 month periods, in 2016 and 2019. Relevant co-terms were also tracked in these discussions, such as ‘exercise’, ‘medication’ and ‘doctor’. The size of the current online BP conversation is significant; there were over 100,000 mentions/month across each study period, particularly ‘low-’ BP. Discussions about AS increased threefold between 2016 and 2019. More discussions took place online at the start of the week, and in the afternoons. Pregnancy, baby and mens’ health resources were the most popular sites for BP chats. People posting about AS were mainly female (80%) and predominantly had an established diagnosis, with health forums hosting more of these discussions than for BP. Exercise was more commonly mentioned in the context of BP, whereas medications were more common in the AS conversations. Analysing online discussions about BP and AS helps to identify themes amongst patients. Some are seeking a diagnosis, support, or treatment information. Understanding the massive scale of online conversations could help clinicians adopt targeted approaches to increase patient identification, meet patient concerns better, and optimise engagement.

Response to lower dose TNF inhibitors in axial spondyloarthritis; a real-world multicentre observational study

OBJECTIVE

Dose optimization of TNF inhibitors in axial spondyloarthritis (axSpA) is attractive, but it is unclear for which patients this approach might be appropriate.

METHODS

Seventy-one patients with axSpA, from six UK centres, were identified who had reduced their dose of TNF inhibitor after being considered to be stable responders. All completed a questionnaire concerning their approach to and experience of dose reduction. Data on patient characteristics, metrology and CRP were retrieved retrospectively from patient records.

RESULTS

Over 2 years of observation, 60 (84.5%) remained (REM) on reduced-dose medication and 11 (15.5%) reverted (REV) to the original dose. The overall mean dose reduction was 39% for REM patients and 44% for REV patients. Both groups initially responded in a similar manner to treatment, but the data showed a trend that younger women were more likely to revert. Neither BMI nor smoking was associated with continued low-dose responsiveness. Eight of the 11 REV patients reverted by 6 months. None reached criteria of secondary drug failure, and all regained control after increasing back to the original dose. Most patients in both groups reached the decision to reduce the dose jointly with clinicians. A preference for taking the reduced dose was not associated with low-dose drug survival.

CONCLUSION

Many patients with axSpA remain well symptomatically after stepping down the dose of TNF inhibitor, but young women are less likely to do well on a reduced dose. Dose reduction should be one element of the management of patients with axSpA.

The Future of Axial Spondyloathritis Treatment

Axial spondyloathritis (axSpA) treatment with biologic DMARDs was previously focused around anti-TNF agents. Significant advances in research have led to new therapeutic options, such as secukinumab, an IL-17 inhibitor, which has been approved for the treatment of axSpA. Two other biologic agents that are already licensed for rheumatoid and psoriatic arthritis, tofacitinib and ixekizumab, have demonstrated improved outcomes in axSpA. Several newer agents have been developed to inhibit IL-17, IL-23, and JAK. Early trials are promising; however, further research is needed. Rapid expansion of therapies available to treat axSpA could lead to improved disease control and decreased disease burden.

P269 Longitudinal patterns of pain distribution in axSpA patients: a retrospective cohort study

Background

Chronic pain is an important and debilitating symptom experienced by patients with axial Spondyloarthritis (axSpA). The patterns of pain and their associations in this patient group is poorly understood. The overall aim of the study is to investigate patterns of pain distribution in patients with axSpA using Margolis Pain Diagrams, and any associations with clinical and demographic measures.

Methods

We analysed data collected from individuals attending the axSpA outpatient clinic at the Royal National Hospital for Rheumatic Diseases in Bath. All participants were asked to record their pain on a pre-printed Margolis Pain diagram at each clinical visit. The number and distribution of painful areas were assessed and then categorised into regional or widespread pain, using pre-defined anatomical criteria. Descriptive analyses and any associations between pain distribution and demographic and clinical variables were assessed. Changes in pain distribution over time, using data from up to four clinic visits, were further investigated using a Sankey diagram.

Results

Of the 187 participants who had a baseline pain assessment, their mean age at diagnosis was 31.6 (11.9) years and 31.6% were female. 89.3% of patients reported pain at baseline, and of these 21.4%, 29.4 % and 38.5% reported pain in 1-2, 3-4, and 5-6 regions respectively. The most common sites of pain are in the Trunk (68.4%), followed by Head and Cervical (65.8%) and Left lower limb regions (58.8%). Univariate analyses did not reveal any significant associations between the presence of widespread pain and age at diagnosis, sex, smoking or HLA-B27 status. Disease activity, measured using Bath Ankylosing Spondylitis Disease Activity Index, was significantly higher in participants with widespread pain compared to those with regional pain OR 1.60 (1.30-1.96), and a trend towards higher sleep disturbance, was demonstrated OR 1.05 (1.00-1.10). Longitudinal analyses demonstrated considerable flux over time in the number and distribution of pain reported.

Conclusion

The Margolis Pain diagram is a practical instrument for assessing pain in axSpA patients. Several pain patterns were noted in patients with axSpA, and future research should focus on the potential impact on quality of life measures, response to treatment, and radiological findings.

Disclosures

R. Nishtala None. R. Barnett None. T. Chyou None. A. Soni None. R. Sengupta None.