Barriers and facilitators in diagnosing axial spondyloarthritis: a qualitative study

INTRODUCTION

Diagnosis of axial spondyloarthritis (axSpA) is frequently delayed for years after symptom onset. However, little is known about patient and healthcare professional (HCP) perspectives on barriers and facilitators in axSpA diagnosis. This study explored the experiences and perceptions of both groups regarding the factors affecting the timely diagnosis of axSpA.

METHOD

Semi-structured interviews with patients with axSpA and axSpA-interested HCPs from the United Kingdom (UK) were performed by telephone or Microsoft Teams and focussed on the individuals' perspective of the diagnostic journey for axSpA. Interview transcripts were thematically analysed.

RESULTS

Fourteen patients with axSpA (10 female, 4 male) and 14 UK based HCPs were recruited, the latter comprising of 5 physiotherapists, 4 General Practitioners, 3 rheumatologists, a nurse, and an occupational therapist. Barriers to diagnosis identified by patients and HCPs were: difficult to diagnose, a lack of awareness, unclear referral pathways, patient behaviour and patient/HCP communication. Patient-identified facilitators of diagnosis were patient advocacy, clear referral processes and pathways, increased awareness, and serendipity. HCPs identified promoting awareness as a facilitator of diagnosis, along with symptom recognition, improvements to healthcare practice and patient/HCP communications.

CONCLUSION

Poor communication and a lack of understanding of axSpA in the professional and public spheres undermine progress towards timely diagnosis of axSpA. Improving communication and awareness for patients and HCPs, along with systemic changes in healthcare (such as improved referral pathways) could reduce diagnostic delay.

How do patient reported outcome measures affect treatment intensification and patient satisfaction in the management of psoriatic arthritis? A cross sectional study of 503 patients

OBJECTIVES

The ASSIST study investigated prescribing in routine psoriatic arthritis (PsA) care and whether the patient reported outcome: PsA Impact of Disease questionnaire (PsAID-12), impacted treatment. This study also assessed a range of patient and clinician factors and their relationship to PsAID-12 scoring and treatment modification.

METHODS

Patients with PsA were selected across the UK and Europe between July 2021-March 2022. Patients completed the PsAID questionnaire, with the results shared with their physician. Patient characteristics, disease activity, current treatment methods, treatment strategies, medication changes and patient satisfaction scores were recorded.

RESULTS

503 patients recruited. 36.2% had changes made to treatment, 88.8% of this had treatment escalation. Overall, the mean PsAID-12 score was higher for patients with treatment escalation; the PsAID-12 score was associated with odds of treatment escalation (OR: 1.58; p< 0.0001). However, most clinicians reported PsAID-12 did not impact their decision to escalate treatment, instead supporting treatment reduction decisions. Physician's assessment of disease activity had the most statistically significant effect on likelihood of treatment escalation, (OR = 2.68, per 1-point score increase). Escalation was more likely in patients not treated with biologic therapies. Additional factors associated with treatment escalation included: patient characteristics, physician characteristics, disease activity and disease impact.

CONCLUSION

This study highlights multiple factors impacting treatment decision making for individuals with PsA. PsAID-12 scoring correlates with multiple measures of disease severity and odds of treatment escalation. However, most clinicians reported the PsAID-12 did not influence treatment escalation decisions. PsAID scoring could be used to increase confidence in treatment de-escalation.

An international multi-centre analysis of current prescribing practices and shared decision-making in psoriatic arthritis

OBJECTIVES

Shared decision-making (SDM) is advocated to improve patient outcomes in Psoriatic arthritis (PsA). We analysed current prescribing practices and the extent of SDM in PsA across Europe.

METHODS

The ASSIST study was a cross-sectional observational study of PsA patients aged ≥18 years attending face-to-face appointments between July 2021-March 2022. Patient demographics, current treatment and treatment decisions were recorded. SDM was measured by the clinician's effort to collaborate (CollaboRATE questionnaire) and patient communication confidence (PEPPI-5 tool).

RESULTS

503 patients were included from 24 centres across the UK, France, Germany, Italy and Spain. Physician- and patient-reported measures of disease activity were highest in the UK. Conventional synthetic DMARDs constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), which differed from biologic DMARDs (36.4% vs 64.4%). Implementing treatment escalation was most common in the UK. CollaboRATE and PEPPI-5 scores were high across centres. Of 31 patients with low CollaboRATE scores (<4.5), no patients with low PsAID-12 scores (<5) had treatment escalation. However, of 465 patients with CollaboRATE scores ≥4.5, 59 patients with low PsAID-12 scores received treatment escalation.

CONCLUSIONS

Higher rates of treatment escalation seen in the UK may be explained by higher disease activity and a younger cohort. High levels of collaboration in face-to-face PsA consultations suggests effective implementation of the SDM approach. Our data indicate that, in patients with mild disease activity, only those with higher perceived collaboration underwent treatment escalation. Prospective studies should examine the impact of SDM on PsA patient outcomes.

TRIAL REGISTRATION

clinicaltrials.gov, NCT05171270.

The top 10 research priorities in psoriatic arthritis: a James Lind Alliance Priority Setting Partnership

OBJECTIVES

To identify and prioritize the top 10 research questions for PsA.

METHODS

The British Psoriatic Arthritis Consortium (BritPACT) formed a Priority Setting Partnership (PSP) comprising of people living with PsA, carers and clinicians, supported by the James Lind Alliance (JLA). This PSP followed the established three-stage JLA process: first, an online survey of people living with PsA, carers and clinicians to identify PsA questions, asking, 'What do you think are the most important unanswered questions in psoriatic arthritis research?' The questions were checked against existing evidence to establish 'true uncertainties' and grouped as 'indicative questions' reflecting the overarching themes. Then a second online survey ranked the 'true uncertainties' by importance. Finally, a workshop including people living with PsA and clinician stakeholders finalized the top 10 research priorities.

RESULTS

The initial survey attracted 317 respondents (69% people living with PsA, 15% carers), with 988 questions. This generated 46 indicative questions. In the second survey, 422 respondents (78% people living with PsA, 4% carers) prioritized these. Eighteen questions were taken forward to the final online workshop. The top unanswered PsA research question was 'What is the best strategy for managing patients with psoriatic arthritis including non-drug and drug treatments?' Other top 10 priorities covered diagnosis, prognosis, outcome assessment, flares, comorbidities and other aspects of treatment (https://www.jla.nihr.ac.uk).

CONCLUSION

The top 10 priorities will guide PsA research and enable PsA researchers and those who fund research to know the most important questions for people living with PsA.

Remotely delivered cognitive-behavioural and personalized exercise interventions to lessen the impact of fatigue: a qualitative evaluation

Objectives

Fatigue can be a disabling symptom of inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) is a randomized trial of remotely delivered cognitive-behavioural approach or personalized exercise programme interventions, compared with usual care. The aim of this nested qualitative study was to evaluate participants’ experiences of taking part in the intervention, including their ideas about future service delivery.

Methods

Semi-structured telephone interviews were conducted with a subgroup of LIFT participants to discuss their views and experiences of the interventions.

Results

Forty-three participants (30 women) from six sites who had participated in the cognitive-behavioural approach (n = 22) or personalized exercise programme (n = 21) interventions took part. Five themes were identified in the thematic analysis. In the theme ‘not a miracle cure, but a way to better manage fatigue’, LIFT could not cure fatigue; however, most felt better able to manage after participating. Participants valued ‘building a therapeutic relationship’ with the same therapist throughout the intervention. In ‘structure, self-monitoring and being accountable’, participants liked the inclusion of goal-setting techniques and were motivated by reporting back to the therapist.

After taking part in the interventions, participants felt ‘better equipped to cope with fatigue’; more confident and empowered. Lastly, participants shared ideas for ‘a tailored programme delivered remotely’, including follow-up sessions, video calling, and group-based sessions for social support.

Conclusion

Many participants engaged with the LIFT interventions and reported benefits of taking part. This suggests an important future role for the remote delivery of fatigue self-management.

OA33 The top 10 research priorities in psoriatic arthritis: a James Lind Alliance Priority Setting Partnership

Background/Aims

This process aimed to identify and prioritise the top 10 research questions or evidence uncertainties for psoriatic arthritis (PsA) in adults. The British Psoriatic Arthritis Consortium (BritPACT) formed a Priority Setting Partnership (PSP) comprising people with PsA, carers and healthcare professionals, in association with the James Lind Alliance (JLA) to identify the key questions and priorities.

Methods

The JLA methodology involved a three-stage process: 1. A steering group composed of stakeholders conducted an initial online survey of people with PsA, families, carers and healthcare professionals to identify PsA questions. Participants were asked, “What do you think are the most important unanswered questions in psoriatic arthritis research?”. Duplicate questions and those which were out of scope were removed. Questions were checked against existing evidence to establish “true uncertainties”, which were then grouped as “indicative questions” reflecting the overarching themes of the original submissions (diagnosis, effects of disease and treatment, flares, psychological, financial and social factors, gender-associated issues, Covid-19 and treatment) to facilitate prioritisation in stage two. 2. In a second online survey, people with PsA, carers and healthcare professionals ranked the “true uncertainties” by importance. 3. During the final workshop, including people with PsA and clinicians, participants worked together to rank the questions to generate a top 10 list of research priorities.

Results

The initial survey recruited 317 respondents, submitting a total of 988 questions. The individual submissions generated 46 indicative questions. 69% of the respondents were people with PsA, and 15% were friends, relatives, or carers of someone affected by PsA. In the second survey, 422 respondents, of whom 82% were people with PsA, their carers, relatives or friends, prioritised these uncertainties; 18 of these questions were shortlisted and taken forward to the final online workshop. In the last stage, people with PsA, carers, and healthcare professionals met and reached a consensus on the final top 10 research priorities (Table 1).

Conclusion

The top 10 priorities identified will guide PsA research, ensuring that PsA researchers and those who fund research know the most urgent needs of people living with PsA, their families and carers, and those treating people with PsA.

Disclosure

L. Hailey: None. S. Kinsella: None. C. Bundy: None. H. Burstow: None. D. Chandler: None. R. Cowper: None. P. Helliwell: None. L. Joannes: None. A. Kelly: None. B. Kennedy: None. H. McAteer: None. S. Mukherjee: None. J. Packham: None. E. Wise: None. H. Young: None. L. Coates: None.

Diagnostic delay in axial spondyloarthritis: a systematic review

Identification of axial spondyloarthritis (axSpA) remains challenging, frequently resulting in a diagnostic delay for patients. Current benchmarks of delay are usually reported as mean data, which are typically skewed and therefore may be overestimating delay. Our aim was to determine the extent of median delay patients’ experience in receiving a diagnosis of axSpA and examine whether specific factors are associated with the presence of such delay. We conducted a systematic review across five literature databases (from inception to November 2021), with studies reporting the average time period of diagnostic delay in patients with axSpA being included. Any additional information examining associations between specific factors and delay were also extracted. A narrative synthesis was used to report the median range of diagnostic delay experienced by patients with axSpA and summarise which factors have a role in the delay. From an initial 11,995 articles, 69 reported an average time period of diagnostic delay, with 25 of these providing a median delay from symptom onset to diagnosis. Across these studies, delay ranged from 0.67 to 8 years, with over three-quarters reporting a median of between 2 years and 6 years. A third of all studies reported median delay data ranging from just 2 to 2.3 years. Of seven variables reported with sufficient frequency to evaluate, only ‘gender’ and ‘family history of axSpA’ had sufficient concordant data to draw any conclusion on their role, neither influenced the extent of the delay. Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay and this remains an extensive worldwide problem. This is further compounded by a mixed picture of the disease, patient and healthcare-related factors influencing delay.

Key points • Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay. • Median diagnostic delay typically ranges from 2 to 6 years globally. • Neither ‘gender’ nor ‘family history of axSpA’ influenced the extent of diagnostic delay experienced. • Diagnostic delay based on mean, rather than median, data influences the interpretation of the delay time period and consistently reports a longer delay period.

P16 Using virtual reality to help manage needle phobia in juvenile idiopathic arthritis

Case report - Introduction

Needle phobia is a common issue amongst children, particularly with long-term illnesses requiring repeated interventions. Psychological interventions such as coping strategies and distraction techniques can be effective in many of these children, but is not universally successful. Recent research has reportedthat the use of virtual reality (VR) headsets as a distraction technique can be effective at alleviating both pain and fear in children receiving intravenous (IV) injections, cannulation and venepuncture. Although use of VR distraction is becoming more widespread in some disciplines (such as paediatric oncology/A&E), it is yet to be widely adopted in paediatric rheumatology.

Case report - Case description

We report the case of a 9-year-old boy (ME) who in early 2019 developed psoriatic juvenile idiopathic arthritis (JIA) and an associated severe, widespread plaque psoriasis causing him substantial discomfort and distress. He has been treated with subcutaneous adalimumab biosimilar 40 mg fortnightly and oral methotrexate 20 mg weekly, alongside Keppra 1000 mg twice daily for epilepsy. Although he is just tolerating the subcutaneous adalimumab, he is requiring intermittent steroid joint injections under general anaesthetic for recurrent flares of his polyarticular arthritis and regular monitoring phlebotomy. He has been developing progressive needle phobia over the past 8 months, with superimposed anxiety about general anaesthetics with particular fear of the anaesthetic provoking an epileptic seizure.

Despite psychological intervention to teach coping strategies and standard play therapy distraction techniques, both phlebotomy and cannulation for general anaesthetics have become more distressing and challenging for him. During two recent day case admissions for joint injections, despite premedication with sedatives, distraction techniques and psychology interventions, he became so distressed that attempts to anaesthetise him had to be abandoned. This has resulted in prolonged periods of continuing joint inflammation and pain.

Discussion with local paediatric oncology colleagues resulted in a suggestion of using recently acquired VR headsets as an effective distraction technique. He has had a previous positive experience of using VR headsets in a play environment. He is receiving VR training intervention from the oncology team and is now fully engaged with the idea of using VR to distract him from negatively focussing on his next planned general anaesthetic intervention.

Case report - Discussion

Unmanaged needle-related procedural pain in children is associated with increasing pain and stress in subsequent procedures and fear/avoidance of medical care which can affect compliance in chronic disease management. The psychological distress for children with needle phobia can add to existing psychological impact from JIA and increase family stress of caring for an ill child. The cost of poor management of needle-phobic children can be considerable, with cancelled or increased time for procedural interventions and restricted therapeutic interventions. Needle phobias in childhood may persist into adulthood.

Employing distraction techniques when children undergo medical procedures can help them reduce anxiety. VR is a method of captivating an individual’s interest in a virtual environment and can help divert attention from potentially distressing situations in the real world. Recent studies have reported VR as an effective distraction technique in children. Chan (2019) reports that VR significantly decreased the pain and post procedural anxiety experienced by children aged 4—11 years old during venepuncture/IV cannulation compared to controls. The majority of children in the VR group expressed interest in utilising VR again in the future, to improve their experience of IV injections. Chen (2020) subsequently reported a randomised controlled trial which significantly reduced pain and fear experienced from IV injections by the children in the VR group.

There are cost implications to both buying VR headsets/software and training play specialists/specialist nurses to use the equipment effectively. Furthermore, the acceptability of using VR with regards to the child’s age, engagement with age-appropriate software packages and whether a passive VR or a more interactive ‘gaming’ experience is preferred should be considered. The use of VR is not a panacea, but is potentially effective as an additional new tool in clinicians’ efforts to reduce the impact of needle phobia.

Case report - Key learning points

Addressing needle phobia in children can require novel strategies.

VR has shown success as a distraction technique to alleviate pain and fear in children undergoing needle related procedures.

The implementation of VR in paediatric rheumatology has cost and staff training implications.

The use of age-appropriate software and an individual child’s preference for passive/active interaction with VR should be considered.

BSR guideline on the management of adults with systemic lupus erythematosus (SLE) 2018: baseline multi-centre audit in the UK

OBJECTIVES

To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published BSR guideline for the management of adults with SLE, the NICE technology appraisal for belimumab, and NHS England's clinical commissioning policy for rituximab.

METHODS

SLE cases attending outpatient clinics during any 4-week period between February and June 2018 were retrospectively audited to assess care at the preceding visit. The effect of clinical environment (general vs dedicated CTD/vasculitis clinic and specialized vs non-specialized centre) were tested. Bonferroni's correction was applied to the significance level.

RESULTS

Fifty-one units participated. We audited 1021 episodes of care in 1003 patients (median age 48 years, 74% diagnosed >5 years ago). Despite this disease duration, 286 (28.5%) patients had active disease. Overall in 497 (49%) clinic visits, it was recorded that the patient was receiving prednisolone, including in 28.5% of visits where disease was assessed as inactive. Low documented compliance (<60% clinic visits) was identified for audit standards relating to formal disease-activity assessment, reduction of drug-related toxicity and protection against comorbidities and damage. Compared with general clinics, dedicated clinics had higher compliance with standards for appropriate urine protein quantification (85.1% vs 78.1%, P ≤ 0.001). Specialized centres had higher compliance with BILAG Biologics Register recruitment (89.4% vs 44.4%, P ≤ 0.001) and blood pressure recording (95.3% vs 84.1%).

CONCLUSIONS

This audit highlights significant unmet need for better disease control and reduction in corticosteroid toxicity and is an opportunity to improve compliance with national guidelines. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery model.

Estimation of the burden of shielding among a cross-section of patients attending rheumatology clinics with SLE-data from the BSR audit of systemic lupus erythematosus

Objectives

We aimed to estimate what proportion of people with SLE attending UK rheumatology clinics would be categorized as being at high risk from coronavirus disease 2019 (COVID-19) and therefore asked to shield, and explore what implications this has for rheumatology clinical practice.

Methods

We used data from the British Society for Rheumatology multicentre audit of SLE, which included a large, representative cross-sectional sample of patients attending UK Rheumatology clinics with SLE. We calculated who would receive shielding advice using the British Society for Rheumatology’s risk stratification guidance and accompanying scoring grid, and assessed whether ethnicity and history of nephritis were over-represented in the shielding group.

Results

The audit included 1003 patients from 51 centres across all 4 nations of the UK. Overall 344 (34.3%) patients had a shielding score ≥3 and would have been advised to shield. People with previous or current LN were 2.6 (1.9–3.4) times more likely to be in the shielding group than people with no previous LN (P < 0.001). Ethnicity was not evenly distributed between the groups (chi-squared P < 0.001). Compared with White people, people of Black ethnicity were 1.9 (1.3–2.8) and Asian 1.9 (1.3–2.7) times more likely to be in the shielding group. Increased risk persisted after controlling for LN.

Conclusion

Our study demonstrates the large number of people with SLE who are likely to be shielding. Implications for clinical practice include considering communication across language and cultural differences, and ways to conduct renal assessment including urinalysis, during telephone and video consultations for patients who are shielding.

Composite Measures for Clinical Trials in Psoriatic Arthritis: Testing Pain and Fatigue Modifications in a UK Multicenter Study

OBJECTIVE

To test the addition of pain and fatigue to the Composite Psoriatic Arthritis Disease Activity (CPDAI) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) Composite Exercise (GRACE) composite measures of psoriatic arthritis (PsA).

METHODS

Clinical and patient-reported outcome measures were assessed in patients with PsA at 3 consecutive follow-up visits over 6 months in a UK multicenter observational study. A pain visual analog scale and Functional Assessment of Chronic Illness Therapy Fatigue scale were added as modifications to the CPDAI and GRACE composite measures. Original and modified versions were tested against the PsA Disease Activity Score (PASDAS) and the Disease Activity Index for PsA (DAPSA). Discrimination between disease states and responsiveness were tested with t-scores, standardized response means (SRMs), and effect sizes. Data were presented to members at the 2020 annual meeting who then voted on the GRAPPArecommended composite and treatment targets for clinical trials.

RESULTS

One hundred forty-one patients were recruited with a mean PsA disease duration of 6.1 years (range 0-41 yrs). The SRMs for the GRACE and modified GRACE (mGRACE) were 0.67 and 0.64, respectively, and 0.54 and 0.46, respectively, for the CPDAI and modified CPDAI (mCPDAI). The t-scores for the GRACE and mGRACE were unchanged at 7.8 for both, and 6.8 and 7.0 for the CPDAI and mCPDAI, respectively. The PASDAS demonstrated the best responsiveness (SRM 0.84) and discrimination (t-scores 8.3). Most members (82%) agreed the composites should not be modified and 77% voted for the PASDAS as the GRAPPA-recommended composite for clinical trials, with 90% minimal disease activity (MDA) as the target.

CONCLUSION

Modifying the CPDAI and GRACE with the addition of pain and fatigue does not enhance responsiveness nor the measures' ability to detect disease status in terms of requiring treatment escalation. GRAPPA members voted for the PASDAS as the composite measure in clinical trials and MDA as the target.

Composite Measures for Routine Clinical Practice in Psoriatic Arthritis: Testing of Shortened Versions in a UK Multicenter Study

OBJECTIVE

To test shortened versions of the psoriatic arthritis (PsA) composite measures for use in routine clinical practice.

METHODS

Clinical and patient-reported outcome measures (PROMs) were assessed in patients with PsA at 3 consecutive follow-up visits in a UK multicenter observational study. Shortened versions of the Composite Psoriatic Arthritis Disease Activity Index (CPDAI) and Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) Composite Exercise (GRACE) measures were developed using PROMs and tested against the Disease Activity Score in 28 joints (DAS28), composite Disease Activity in Psoriatic Arthritis, and Routine Assessment of Patient Index Data (RAPID3). Discrimination between disease states and responsiveness were tested with the t-score, standardized response mean (SRM), and effect size (ES). Data were presented to members at the GRAPPA 2020 annual meeting and members voted on the recommended composite routine practice.

RESULTS

The SRM for the GRACE, 3 visual analog scale (VAS), and 4VAS were 0.67, 0.77, and 0.63, respectively, and for CPDAI and shortened CPDAI (sCPDAI) were 0.54 and 0.55, respectively. Shortened versions of the GRACE increased the t-score from 7.8 to 8.7 (3VAS) and 9.0 (4VAS), but reduced the t-score in the CPDAI/sCPDAI from 6.8 and 6.1. The 3VAS and 4VAS had superior performance characteristics to the sCPDAI, DAS28, Disease Activity in Psoriatic Arthritis, and RAPID3 in all tests. Of the members, 60% agreed that the VAS scales contained enough information to assess disease and response to treatment, 53% recommended the 4VAS for use in routine care, and 26% the 3VAS, while leaving 21% undecided.

CONCLUSION

Shortening the GRACE to VAS scores alone enhances the ability to detect status and responsiveness and has the best performance characteristics of the tested composite measures. GRAPPA members recommend further testing of the 3VAS and 4VAS in observational and trial datasets.

Outcomes of the 2019 GRAPPA Workshop on Continuous Composite Indices for the Assessment of Psoriatic Arthritis and Membership-recommended Next Steps

OBJECTIVE

Improving the assessment of psoriatic arthritis (PsA) is a key purpose of the Group for Research and Assessment of Psoriasis and PsA (GRAPPA). Herein, we report the proceedings of the GRAPPA composites workshop at the 2019 GRAPPA annual meeting and the membership's recommended next steps.

METHODS

A review of continuous composite measures was conducted in an introductory workshop, followed by 10 breakout group sessions and a final plenary session for feedback and voting.

RESULTS

Participants included 154 members: 87 rheumatologists, 18 dermatologists, 2 rheumatologist/dermatologists, 12 patient research partners, 14 academics, 1 methodologist, and 20 industry members. Of voting members, 88.8% agreed a need exists for a continuous composite measure for routine practice, but only 62% were currently using a composite measure. Of these, 27% were using the 28-joint count Disease Activity Score (DAS), which is not a PsA-specific measure; 20% were using a PsA-specific measure such as PsA DAS (PASDAS), Composite Psoriatic Disease Activity Index (CPDAI), or Disease Activity Index for PsA (DAPSA). Members agreed that the existing measures were not feasible in their current forms (CPDAI 83%, PASDAS 82%, and DAPSA 47%) and that modification should be tested. The majority (76%) agreed that disease effect should be measured separately from disease activity.

CONCLUSION

The GRAPPA membership supports the need for a continuous composite measure of disease activity for use in routine clinical care, the separate measurement of disease effect and activity, and the testing of modifications to candidate instruments rather than the development of new measures.

AB1241 EVALUATION OF A PATIENT COMPLETED DISEASE FLARE QUESTIONNAIRE IN PSORIATIC DISEASE

Background:

Psoriatic Disease (PsD) is a chronic inflammatory disease of the skin, nails, joints, and entheses. A number of composite disease activity measures have been developed though there is yet consensus as to which to use in the clinic and in clinical trials. A patient completed disease flare questionnaire, covering multiple domains of disease impact, has been developed but has yet to be fully validated.

Objectives:

To validate the FLARE questionnaire in PsD.

Methods:

The 10 question FLARE instrument1was administered to 141 patients in an observational study of treatment change in PsD over 6 months follow up. Disease activity was measured by the PASDAS and the gold standard of flare was based on patient opinion. ROC curve was constructed to examine the optimum cut-off for disease flare. Agreement between the FLARE instrument and patient opinion was assessed by Cohen’s kappa. Test-retest was assessed in 28 patients with stable disease who underwent repeat assessment within 2 weeks and evaluated by intra-class correlation coefficient (ICC).

Results:

The FLARE questionnaire was administered at 367 patient encounters. ROC analysis indicated that the optimum cut-off for a flare of disease was 4 (sensitivity 82%, specificity 76%; area under curve 0.85: figure). Mean PASDAS scores were 2.7 and 6.3 for no-flare (4) and flare (≥4) respectively (p = < 0.0001). For those patients who were having a flare the frequency of response to each question is given in the table. Agreement between patient opinion and questionnaire was 0.57, and between patient opinion and physician (based on treatment escalation) 0.43. ICC for the questionnaire was 0.87 (95% CI 0.72 – 0.94).

Conclusion:

In PsD a flare represents escalation of symptoms and signs across multiple domains, as measured by the FLARE instrument; a score of 4 or more has external validity both in terms of composite disease activity and overall patient opinion of the state of their condition.

References:

[1]Moverley A, Waxman R, de Wit M, Parkinson A, Campbell W, Brooke M, et al J Rheum May 2016, 43 (5) 974-978

Table

FLARE item response for those in flare vs not in flare

ItemFLARE instrument score <4FLARE instrument score ≥4N (%)N (%)Worsening Itch35 (19)108 (58)Worsening skin area27 (15)91 (49)Increasing joint pain34 (19)161 (86)Increasing number of tender joints20 (11)142 (76)Decrease in ability to perform activities3 (2)81 (43)Worsening in ability to move easily8 (4)126 (67)Increase in frustration14 (8)142 (76)Worsening in depression8 (4)90 (48)Worsening in feeling of tiredness all the time37 (21)148 (79)Worsening in the number or combination of symptoms from your disease7 (4)134 (72)Figure.

ROC analysis of FLARE questionnaire

Acknowledgments:

This report is independent research funded by the National Institute for Health Research, Programme Grants for Applied Research [Early detection to improve outcome in patients with undiagnosed PsA (‘PROMPT’), RP-PG-1212-20007]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care

Disclosure of Interests:

Philip Helliwell: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Robin Waxman: None declared, Laura C Coates: None declared, Oliver FitzGerald: None declared, Jon Packham: None declared, Neil McHugh: None declared

AB0839 RELIABILITY OF COMPOSITE MEASURES FOR THE ASSESSMENT OF PSORIATIC ARTHRITIS

Background:

Composite measures of disease activity have been developed for use in Psoriatic Arthritis (PsA) to capture the wide spectrum of disease but there is a lack of consensus regarding which to adopt for routine practice. It is recognised that more data is required to understand the measurement properties of existing instruments and consider the impact of modifications that may improve face validity, responsiveness or feasibility. It is important to have an estimate of a measurement instrument’s reliability in the setting of stable disease in order to understand measurement error and responsiveness. To our knowledge no data exists on the stability of composite measures in PsA.

Objectives:

To measure test re-test reliability of composite measures of disease activity in PsA.

Methods:

Clinical and patient reported outcomes to enable the calculation of composite measures were administered to 141 patients with PsA at five time points in a UK multicentre observational study. All patients fulfilled the CASPAR criteria. Twenty-nine patients with clinically stable disease and receiving no treatment intervention underwent repeat assessment by the same examiner within 2 weeks. Patients in high and low disease were included. Reliability was evaluated by intra-class correlation coefficient (ICC) and Bland Altman plots.

Results:

Of the 29 patients included 15 were male, the mean age was 52.4 years (SD 13.39), mean disease duration at T0was 9.2yrs (SD 8.11). The mean swollen joint count was 3.4 (SD 5.1), tender joint count 11.3 (SD 15.03) and PASI 1.0 (SD1.04). The ICC (95% CI) for tender and swollen joint counts were 0.94 (0.87-0.97) and 0.91 (0.80-0.96) respectively. The ICC for PASI was 0.95 (0.90-0.98). All composite measures demonstrated high levels of test-retest reliability with ICC >0.85, table. The most reliable measure was the PADAS ICC 0.98 (95% CI 0.954-0.991). The individual ICC for each composite measures are reported in the table and Bland Altman plots, figure.

Conclusion:

All composite measures show high levels of test-retest reliability in this cohort. The PASDAS was the most stable measure. Modifications to these instruments can now be tested and the impact compared to the original versions.

Table.

Funding:

This report is independent research funded by the National Institute for Health Research, Programme Grants for Applied Research [Early detection to improve outcome in patients with undiagnosed PsA (‘PROMPT’), RP-PG-1212-20007]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests:

William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB, Philip Helliwell: None declared, Oliver FitzGerald: None declared, Robin Waxman: None declared, Anna Antony: None declared, Laura C Coates: None declared, Deepak Jadon: None declared, Paul Creamer: None declared, Suzanne Lane: None declared, Marco Massarotti: None declared, Charlotte Cavill: None declared, Mel Brooke: None declared, Jonathan Packham: None declared, Eleanor Korendowych: None declared, Anya Lissina: None declared, Neil McHugh: None declared

P275 The extent and characteristics of diagnostic delay in axSpA: a systematic review

Background

Axial spondyloarthritis (axSpA) is an inflammatory arthritis predominantly affecting the spine. It is characterised by chronic back pain, stiffness and fatigue. As axSpA progresses it can cause disability, reduction in quality-of-life, depression and impacts on work. Prompt diagnosis is important, but symptoms associated with axSpA are common in the general population resulting in diagnostic delay. The reported diagnostic delay for axSpA varies in the literature, ranging from five to fifteen years. The aim of this review was to ascertain the extent of axSpA diagnostic delay and report on axSpA characteristics associated with diagnostic delay.

Methods

A systematic review was conducted to identify articles reporting diagnostic delay in axSpA. Inclusion criteria were studies including adult axSpA populations, cohort, cross-sectional or case-control design and reporting a median time-period of delay from axSpA symptom onset to final axSpA diagnosis (studies reporting mean delay were excluded due to skewness of data). Data was also extracted which related to delay as a result of specific axSpA characteristics. Narrative synthesis was used to report our findings.

Results

9,848 articles were initially identified. After title, abstract and full-text review, 15 articles reported median diagnostic delay. Of these, 2 were from the UK, 2 from Germany, and 1 each from India, Norway, France, USA, Iran, Turkey, China and Italy. Combined, the total number of participants across eligible papers was 10,661. Though median delay ranged from ≤1 to 8 years, the majority (60%) of articles reported a median delay of between 2-5 years. Regarding the role of specific axSpA characteristics on delay, the most noted causes for delay were lack of extra-articular axSpA symptoms (5.9 vs. 8.7 years of delay for patients with and without extra-articular symptoms respectively) and misdiagnosis. Common misdiagnoses were lumbar disc herniation, rheumatoid arthritis and mechanical back pain (MBP), with the latter being significantly associated with delayed diagnosis (OR 2.83(95% CI 1.16-6.87)). Finally, delay is far from uniform, with a UK study reporting that 30.3% of patients are diagnosed within 2 years, 21% in 3-5 years, 19.9% in 6-10 years, 19.2% after 11-20 years and 9.6% after 20 years.

Conclusion

Though diagnostic delay of axSpA is considerable, affecting long term outcomes in a large number of patients, it is not as long as previously reported by using mean delay, which is more affected by bias (long term delays in small numbers of individuals) than median delay. Further research into the specific barriers and facilitators of delay is required to help reduce this delay in the future.

Disclosures

C.A. Hay None. S. Ryan None. J. Packham None. C.D. Mallen None. J.A. Prior None.

Malignancy and mortality rates in patients with severe psoriatic arthritis requiring tumour-necrosis factor alpha inhibition: results from the British Society for Rheumatology Biologics Register

Objective

The aim of this study was to compare the incidence of cancer and all-cause and cause-specific mortality rates among a cohort of patients with severe PsA receiving TNF inhibitor (TNFi) with those of the general UK population.

Methods

Cancers and deaths were identified from the national cancer and the national death registers in patients with PsA included in the British Society for Rheumatology Biologics Register from start of TNFi until 31 December 2012. Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) were calculated using published cancer and death rates for the general population. SIRs were calculated for both overall cancer risk and non-melanoma skin cancer. SMRs were calculated for (1) all-cause mortality, (2) death from malignancy and (3) death from circulatory disease. Gender-specific analyses were also performed.

Results

Thirty-four cancers and 41 deaths among 709 patients were observed. The risk of malignancy overall was not increased (SIR 0.94; 95% CI: 0.65, 1.34). However, there was a significantly increased incidence of non-melanoma skin cancer (SIR 2.12; 95% CI: 1.19, 3.50). The all-cause mortality rate in our cohort was increased (SMR 1.56; CI: 1.12, 2.11). Death from malignancy was not increased, but death from coronary heart disease was increased (SMR 2.42; 95% CI: 1.11, 4.59).

Conclusion

In our cohort of patients with severe PsA, the overall incidence of malignancy was similar to that of the general population, although the incidence of non-melanoma skin cancer was increased. All-cause mortality was significantly increased, in part due to excess of deaths attributed to coronary heart disease.

Long-term effectiveness of tumour necrosis factor-α inhibitor treatment for psoriatic arthritis in the UK: a multicentre retrospective study

Objective

Real-world evidence of the long-term effectiveness of TNF-α inhibitor (TNFi) therapy in patients with PsA is limited. This study was conducted to describe patterns of TNFi therapy and treatment responses in patients with PsA treated in UK clinical practice.

Methods

A multicentre, retrospective, observational cohort study of consenting patients treated with TNFi for PsA with ≥3 years follow-up from first TNFi initiation (observation period) was carried out in 11 UK National Health Service hospitals. Data were collected concerning baseline patient characteristics, PsA-related treatment pathways and TNFi treatment responses (PsA response criteria components: swollen/tender joint counts, physician and patient global assessments).

Results

The mean age of patients (n = 141) was 50.3 (s.d.: 12.1) years (50% male). During a median observation period of 4.5 (range: 3.4–5.5) years, patients received a median of one (range: one to five) TNFi. Twelve-week response rates for first TNFi (where available) were as follows: 80% (n = 64/80) for swollen joint counts, 79% (n = 63/79) for tender joint counts, 79% (n = 37/47) for physician global assessments, 69% (n = 41/59) for patient global assessments and 79% (n = 37/47) for PsA response criteria. At the end of the observation period, the proportions of patients remaining on first, second, third and fourth/fifth TNFi were 56, 15, 5 and 3%, respectively; 21% of patients permanently discontinued TNFi therapy.

Conclusion

Long-term TNFi therapy is generally well tolerated and may be effective; however, after initial TNFi failure, there appears to be progressively less benefit and more adverse effects with successive TNFi switches. Strategies are needed for effective therapy for PsA beyond the first TNFi failure.

Influence of co-morbid fibromyalgia on disease activity measures and response to tumour necrosis factor inhibitors in axial spondyloarthritis: results from a UK national register

Objective

To quantify the extent to which co-morbid FM is associated with higher disease activity, worse quality of life (QoL) and poorer response to TNF inhibitors (TNFis) in patients with axial SpA.

Methods

A prospective study recruiting across 83 centres in the UK. Clinical information and patient-reported measures were available, including 2011 criteria for FM. Multivariable linear regression was used to model the effect of meeting the FM criteria on disease activity, QoL and response to TNFis.

Results

A total of 1757 participants were eligible for analyses, of whom 22.1% met criteria for FM. Those with co-morbid FM criteria had higher disease activity [BASDAI average difference FM⁺ − FM⁻ 1.04 (95% CI 0.75, 1.33)] and worse QoL [Ankylosing Spondylitis Quality of Life score difference 1.42 (95% CI 0.88, 1.96)] after adjusting for demographic, clinical and lifestyle factors. Among 291 participants who commenced biologic therapy, BASDAI scores in those with co-morbid FM were 2.0 higher at baseline but decreased to 1.1 higher at 12 months. There was no significant difference in the likelihood of meeting Assessment of SpondyloArthritis international Society 20 criteria at 12 months. Less improvement in disease activity and QoL over 3 months of TNFi therapy was most strongly related to high scores on the FM criteria symptom severity scale component.

Conclusion

Fulfilling criteria for FM has a modest impact on the assessment of axial SpA disease activity and QoL and does not significantly influence response to biologic therapy. Those with a high symptom severity scale on FM assessment may benefit from additional specific management for FM.

Outcomes and compliance with standards of care in anti-neutrophil cytoplasmic antibody-associated vasculitis-insights from a large multiregion audit

Objectives

We aimed to conduct a large audit of routine care for patients with ANCA-associated vasculitis.

Methods

We invited all 34 hospitals within one health region in England to undertake a retrospective case note audit of all patients newly diagnosed or treated with CYC or rituximab (RTX) for ANCA-associated vasculitis from April 2013 to December 2014. We compared clinical practice to the British Society for Rheumatology guidelines for the management of adults with ANCA-associated vasculitis and the use of RTX with the National Health Service (NHS) England commissioning policy and National Institute for Health and Care Excellence (NICE) technology appraisal.

Results

We received data from 213 patients. Among 130 newly diagnosed patients, delay from admission to diagnosis ranged from 0 to 53 days (median 6, interquartile range 3–10.5) for those diagnosed as inpatients. BVAS was recorded in 8% of patients at diagnosis. Remission at 6 months was achieved in 83% of patients. The 1-year survival was 91.5%. A total of 130 patients received CYC for new diagnosis or relapse. The correct dose of i.v. CYC (within 100 mg of the target dose calculated for age, weight and creatinine) was administered in 58% of patients. A total of 25% of patients had an infection requiring hospital admission during or within 6 months of completing their CYC therapy. Seventy-six patients received RTX for new diagnosis or relapse. A total of 97% of patients met the NHS England or NICE eligibility criteria. Pneumocystis jiroveci pneumonia prophylaxis (recommended in the summary of product characteristics) was given in only 65% of patients.

Conclusion

We identified opportunities to improve care, including compliance with safety standards for delivery of CYC. Development of a national treatment protocol/checklist to reduce this heterogeneity in care should be considered as a priority.

Risk of fragility fracture among patients with late-onset psoriasis: a UK population-based study

This study aimed to examine fracture risk in patients with late-onset psoriasis. A cohort study was conducted using primary care records from the Clinical Practice Research Datalink. Psoriasis patients had a 10% increased risk of fracture compared to matched controls (hazard ratio (HR) = 1.10; 95% confidence interval (CI) 1.04, 1.16).

INTRODUCTION

This study aimed to examine fracture risk in patients with late-onset psoriasis and investigate the effect of methotrexate on fracture risk.

METHODS

A cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident (new onset) diagnoses of psoriasis, were identified from 1990 to 2004 and followed up until 2015. For each exposed individual, up to four age-, gender-, and practice-matched controls were randomly selected. Incidence rates of fragility fracture (hip, vertebral, spine, radius or unspecified site) per 10,000 person-years were calculated and hazard rates were compared to the unexposed using Cox regression models. The risk of fracture was also estimated, within the exposed group for patients receiving/not receiving methotrexate.

RESULTS

Twenty-four thousand two hundred nineteen patients with psoriasis and 94,820 controls were identified. The absolute rate of fracture in psoriasis patients was 58 per 10,000 person-years (95% CI 55, 61) and 53 per 10,000 person-years in the matched controls (CI 52, 54). Psoriasis patients had a 10% increased risk of fracture compared to their matched controls (HR = 1.10; 95% CI 1.04, 1.16). Methotrexate use was not associated with increased risk (HR = 0.91; 95% CI 0.72, 1.15).

CONCLUSIONS

Identifying additional clinical factors associated with increased fracture risk is important in improving fracture risk stratification. Further work is needed to determine the relationship between age of onset of psoriasis and fracture risk, explore causative explanations, and identify if existing fracture risk stratification tools underestimate fracture risk in patients with psoriasis.

Management of gout by UK rheumatologists: a British Society for Rheumatology national audit

Objectives

To assess the concordance of gout management by UK rheumatologists with evidence-based best-practice recommendations.

Methods

Data were collected on patients newly referred to UK rheumatology out-patient departments over an 8-week period. Baseline data included demographics, method of diagnosis, clinical features, comorbidities, urate-lowering therapy (ULT), prophylaxis and blood tests. Twelve months later, the most recent serum uric acid level was collected. Management was compared with audit standards derived from the 2006 EULAR recommendations, 2007 British Society for Rheumatology/British Health Professionals in Rheumatology guideline and the National Institute for Health and Care Excellence febuxostat technology appraisal.

Results

Data were collected for 434 patients from 91 rheumatology departments (mean age 59.8 years, 82% male). Diagnosis was crystal-proven in 13%. Of 106 taking a diuretic, this was reduced/stopped in 29%. ULT was continued/initiated in 76% of those with one or more indication for ULT. One hundred and fifty-eight patients started allopurinol: the starting dose was most commonly 100 mg daily (82%); in those with estimated glomerular filtration rate <60 ml/min the highest starting dose was 100 mg daily. Of 199 who started ULT, prophylaxis was co-prescribed for 94%. Fifty patients started a uricosuric or febuxostat: 84% had taken allopurinol previously. Of 44 commenced on febuxostat, 18% had a history of heart disease. By 12 months, serum uric acid levels ⩽360 and <300 μmol/l were achieved by 45 and 25%, respectively.

Conclusion

Gout management by UK rheumatologists concords well with guidelines for most audit standards. However, fewer than half of patients achieved a target serum uric level over 12 months. Rheumatologists should help ensure that ULT is optimized to achieve target serum uric acid levels to benefit patients.

Long-term persistence of TNF-inhibitor treatment in patients with psoriatic arthritis. Data from the British Society for Rheumatology Biologics Register

Background

Long-term effectiveness of tumour necrosis factor alpha inhibitors (TNFi) has mainly been explored in patients with rheumatoid arthritis (RA) and the data available on patients with psoriatic arthritis (PsA) includes limited follow-up.

Objective

Investigate long-term effectiveness of first TNFi in a PsA population by describing treatment persistence, identify factors associated with 5-year persistence and further investigate comparative long-term effectiveness of subsequent TNFi treatments through persistence to treatment.

Methods

Patients with a rheumatologist diagnosis of PsA receiving their first TNFi registered in the British Society for Rheumatology Biologics Register (BSRBR) (2002-2006) were included. Treatment at different time points was described and factors associated with 5-year treatment persistence were identified by logistic regression. Kaplan-Meier analysis was used to assess factors associated with persistence to first TNFi and subsequent TNFi treatments.

Results

At 5 years, 46.7% of patients were still on their initial TNFi treatment. Better 5 -year persistence was associated with male gender, use of etanercept or adalimumab rather than infliximab and absence of baseline comorbidity. Five-year persistence estimates (95% CI) of first, second and third TNFi were 53% (49% to 57%), 60% (43% to 57%) and 48% (36% to 59%), respectively.

Conclusion

We found good long-term persistence of TNFi in this PsA population both for the first and subsequent TNFi treatments. The relationship between persistence and relevant clinical factors was not strong and demonstrates the difficulties in predicting outcome of TNFi treatment in PsA.

Patient experiences, attitudes and expectations towards receiving information about anti-TNF medication: a quantitative study

The objective of the study was to measure patient attitudes and experience of information received during drug counselling for rheumatoid arthritis (RA) medications. This is a cross-sectional UK postal questionnaire study. Three RA patient groups-disease-modifying antirheumatic drugs (DMARDs) only, first anti-tumour necrosis factor (anti-TNF) and failed anti-TNF-were sent postal questionnaires. Data on patient history/demographics, drug counselling experience, knowledge of drug side effects, attitudes to vaccinations, cancer screening and blood borne virus testing was collected; 264/679 (39%) patients responded (median age 65 years, 66% female, median disease duration 15 years). Drug information from rheumatology nurses, rheumatology doctors and information leaflets was most useful. Thirty-eight percent of respondents felt reassured by information received, but 37% felt more worried. Forty percent of participants were aware of important drug side effects. Although 42-65% of patients understood they should temporarily halt anti-TNF therapy with concurrent infection, 75% of patients recalled continuing therapy despite infection. Thirteen percent believed that all vaccinations (including travel vaccinations) were safe while taking anti-TNF. Uptake of UK cancer screening programmes was between 87 and 94%, except prostate screening (47%). Most participants were not aware that they may need to discontinue their anti-TNF if they developed cancer. The majority of participants felt neutral/reassured by the prospect of viral hepatitis (95%) and HIV (91%) testing. Although drug counselling is a well-established part of clinical care, there is potential for further improvement to ensure that patients' knowledge empowers them to act safely. Particular areas for improvement included the following: patients halting DMARDs/anti-TNF therapy during infections, knowledge regarding vaccinations and prostate cancer screening uptake.

Reconsultation, self-reported health status and costs following treatment at a musculoskeletal Clinical Assessment and Treatment Service (CATS): a 12-month prospective cohort study

OBJECTIVES

To determine (1) reconsultation frequency, (2) change in self-reported health status, (3) baseline factors associated with reconsultation and change in health status and (4) associated healthcare costs and quality-adjusted life-years (QALYs), following assessment at a musculoskeletal Clinical and Assessment Treatment Service (CATS).

DESIGN

Prospective cohort study.

SETTING

Single musculoskeletal CATS at the primary-secondary care interface.

PARTICIPANTS

2166 CATS attenders followed-up by postal questionnaires at 6 and 12 months and review of medical records.

OUTCOME MEASURES

Primary outcome was consultation in primary care with the same musculoskeletal problem within 12 months. Secondary outcome measures were consultation at the CATS with the same musculoskeletal problem within 12 months, physical function and pain (Short Form-36), anxiety and depression (Hospital Anxiety and Depression Scale), time off work, healthcare costs and QALYs.

RESULTS

Over 12 months, 507 (38%) reconsulted for the same problem in primary care and 345 (26%) at the CATS. Primary care reconsultation in the first 3 months was associated with baseline pain interference (relative risk ratio 5.33; 95% CI 3.23 to 8.80) and spinal pain (1.75; 1.09 to 2.82), and after 3-6 months with baseline assessment by a hospital specialist (2.06; 1.13 to 3.75). Small mean improvements were seen in physical function (1.88; 95% CI 1.44 to 2.32) and body pain (3.86; 3.38 to 4.34) at 6 months. Poor physical function at 6 months was associated with obesity, chronic pain and poor baseline physical function. Mean (SD) 6-month cost and QALYs per patient were £422.40 (660.11) and 0.257 (0.144), respectively.

CONCLUSIONS

While most patients are appropriate for a 'one-stop shop' model, those with troublesome, disabling pain and spinal pain commonly reconsult and have ongoing problems. Services should be configured to identify and address such clinical complexity.

Tumour necrosis factor inhibition versus rituximab for patients with rheumatoid arthritis who require biological treatment (ORBIT): an open-label, randomised controlled, non-inferiority, trial

BACKGROUND

Tumour necrosis factor (TNF) inhibition and B-cell depletion are highly effective treatments for active rheumatoid arthritis, but so far no randomised controlled trials have directly compared their safety, efficacy, and cost-effectiveness. This study was done to test the hypothesis that using rituximab would be clinically non-inferior and cheaper compared with TNF inhibitor treatment in biological-treatment naive patients with rheumatoid arthritis.

METHODS

This open-label, randomised controlled, non-inferiority trial enrolled patients with active, seropositive rheumatoid arthritis and an inadequate response to synthetic disease modifying anti-rheumatic drugs (DMARDs) from 35 rheumatology departments in the UK. Patients were randomly assigned 1:1 to the rituximab or TNF inhibitor groups with minimisation to account for methotrexate intolerance using a web-based randomisation system. Patients were given intravenous rituximab 1 g on days 1 and 15, and after 26 weeks if they responded to treatment but had persistent disease activity (28 joint count disease activity score [DAS28-ESR] >3.2; rituximab group) or a TNF inhibitor-adalimumab (40 mg subcutaneously every other week) or etanercept (50 mg per week subcutaneously) according to the patient's and rheumatologist's choice (TNF inhibitor group). Patients could switch treatment in the case of drug-related toxic effects or absence or loss of response. The primary outcome measure was the change in DAS28-ESR between 0 and 12 months in the per-protocol population of patients who were assigned to treatment and remained in follow-up to 1 year. We assessed safety in all patients who received at least one dose of study drug. We also assessed the cost-effectiveness of each strategy. The non-inferiority margin was specified as 0.6 DAS28-ESR units. This study is registered with ClinicalTrials.gov, number NCT01021735.

FINDINGS

Between April 6, 2009, and Nov 11, 2013, 295 patients were randomly assigned and given either rituximab (n=144) or TNF inhibitor (n=151) treatment. After 12 months, the change in DAS28-ESR for patients assigned to rituximab was -2.6 (SD 1.4) and TNF inhibitor was -2.4 (SD 1.5), with a difference within the prespecified non-inferiority margin of -0.19 (95% CI -0.51 to 0.13; p=0.24). The health-related costs associated with the rituximab strategy were lower than the TNF inhibitor strategy (£9,405 vs £11,523 per patient, p<0.0001). 137 (95%) of 144 patients in the rituximab group and 143 (95%) of 151 patients in the TNF inhibitor group had adverse events. 37 serious adverse events occurred in patients receiving rituximab compared with 26 in patients receiving TNF inhibitors, of which 27 were deemed to be possibly, probably, or definitely related to the treatment (15 vs 12, p=0.5462). One patient in each group died during the study.

INTERPRETATION

Initial treatment with rituximab is non-inferior to initial TNF inhibitor treatment in patients seropositive for rheumatoid arthritis and naive to treatment with biologicals, and is cost saving over 12 months.

FUNDING

Arthritis Research UK, Roche.

The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice

BACKGROUND

Biologic drugs are expensive treatments used in rheumatoid arthritis (RA). Switching among them is common practice in patients who have had an inadequate response or intolerable adverse events. The National Institute of Health and Clinical Excellence (NICE) UK, which aims to curtail postcode prescribing, has provided guidance on the sequential prescription of these drugs. This study sought to evaluate the extent to which rheumatology centres across the Midlands were complying with NICE guidance on the switching of biologic drugs in RA, as well as analyse the various prescribing patterns of these drugs.

METHODS

Data was collected via a web-based tool on RA patients who had undergone at least one switch of a biologic drug during 2011. The standards specified in NICE technology appraisals (TA130, TA186, TA195, TA198, and TA225) were used to assess compliance with NICE guidance. Descriptive statistical analysis was performed.

RESULTS

There were 335 biologic drug switches in 317 patients. The most common reason given for switching to a drug was NICE guidelines (242, 72.2%), followed by Physician's choice (122, 33.4%). Lack of effect was the most common reason for discontinuing a drug (224, 67%). For patients on Rituximab, Methotrexate was used in 133 switches (76.9% of the time). Overall NICE compliance for all units was 65% (range 50 to 100%), with anti-TNFα to anti-TNFα switches for inefficacy making up the majority of non-compliant switches.

CONCLUSION

This study draws attention to the enigma and disparity of commissioning and prescribing of biologic drugs in RA. Currently the evidence would not support switching of a biologic drug for non-clinical purposes such as economic pressures. Flexibility in prescribing should be encouraged: biologic therapy should be individualised based on the mode of action and likely tolerability of these drugs. Further work should focus on the evidence for using particular sequences of biologic drugs.

Patient experiences, attitudes and expectations towards receiving information about anti-TNF medication--"It could give me two heads and I'd still try it!"

Background

Anti-tumour necrosis factor (anti-TNF) therapies are an important recent development in the treatment of autoimmune disease. Despite important side effects relating to immune suppression, there is lack of research into patient experiences, attitudes and expectations about the information they receive prior to starting anti-TNF therapy.

Methods

In May 2011 participants were purposively sampled to form two focus groups varying in age, anti-TNF agent and pre-therapy disease activity. A semi-structured topic guide was used to explore patients’ experiences regarding the information they received prior to commencing anti-TNF therapy. The focus groups were audio-taped and transcribed verbatim. Data were analysed using content analysis.

Results

Four key themes were identified.

Firstly, weighing the risks and benefits of anti-TNF therapy. However, most participants attached limited importance to side effects, saying their strong desire for RA symptom control was overriding. Two reported deliberately concealing illness in order to continue their medication.

Secondly, the desire for information. They suggested that counselling should occur at an early stage and not during a severe RA flare-up.

Thirdly, the process of starting anti-TNF. Many identified that their biggest worry was whether they would be eligible for the new medication. They remembered little about the investigations they underwent, and none said they would have objected to being tested for blood borne viruses.

Finally, the experience of being on anti-TNF. Most were positive, describing effects on quality of life as well as symptoms.

Conclusions

The use of qualitative methodology in this study has enabled an understanding of patients’ attitudes towards receiving information about anti-TNF therapy. The results may be useful to health professionals in terms of the timing and content of the information given to patients prior to commencing anti-TNF therapy.

Autoinflammatory gene polymorphisms and susceptibility to UK juvenile idiopathic arthritis

BACKGROUND

To investigate the autoinflammatory hereditary periodic fever syndrome genes MVK and TNFRSF1A, and the NLRP1 and IL1 genes, for association with juvenile idiopathic arthritis (JIA).

METHODS

For MVK, TNFRSF1A and NLRP1 pair-wise tagging SNPs across each gene were selected and for IL1A SNPs from a prior meta-analysis were included. 1054 UK Caucasian JIA patients were genotyped by Sequenom iPlex MassARRAY and allele and genotype frequencies compared with 5380 unrelated healthy UK Caucasian controls.

RESULTS

Four SNPs were significantly associated with UK JIA: rs2071374 within intron 4 of IL1A (ptrend=0.006), rs2228576 3' of TNFRSF1A (ptrend=0.009) and 2 SNPs, rs11836136 and rs7957619, within MVK (ptrend=0.006, ptrend=0.005 respectively). In all cases the association appeared to be driven by the systemic-onset JIA (SoJIA) subtype. Genotype data for the two MVK SNPs was available in a validation cohort of 814 JIA (oligoarticular and RF negative polyarticular) cases and 3058 controls from the US. Replication was not confirmed, however, further suggesting that this association is specific to SoJIA.

CONCLUSIONS

These findings extend the observations of the relevance of studying monogenic loci as candidates for complex diseases. We provide novel evidence of association of MVK and TNFRSF1A with UK JIA, specifically driven by association with SoJIA and further confirm that the IL1A SNP association with SoJIA is subtype specific. Replication is required in independent cohorts.

Musculoskeletal clinical assessment and treatment services at the primary-secondary care interface: an observational study

BACKGROUND

Management of musculoskeletal conditions in the UK is increasingly delivered in multidisciplinary clinical assessment and treatment services (CATS) at the primary-secondary care interface. However, there is little evidence concerning the characteristics and management of patients attending CATS.

AIM

To describe the characteristics, investigation, and treatment of adults attending a musculoskeletal CATS.

DESIGN AND SETTING

Cross-sectional analysis of cohort study baseline data from a musculoskeletal CATS in Stoke-on-Trent Primary Care Trust, UK.

METHOD

All patients referred from primary care between February 2008 and June 2009 were mailed a pre-consultation questionnaire concerning pain duration, general health status, anxiety, depression, employment status, and work absence due to musculoskeletal problems. At the consultation, clinical diagnoses, body region(s) affected, investigations, and treatment were recorded.

RESULT

A total of 2166 (73%) completed questionnaires were received. Chronic pain duration >1 year (55%), major physical limitation (76%), anxiety (49%), and depression (37%) were common. Of those currently employed, 516 (45%) had taken time off work in the last 6 months because of their musculoskeletal problem; 325 (29%) were unable to do their usual job. The most frequent investigations were X-rays (23%), magnetic resonance imaging (18%), and blood tests (14%): 1012 (48%) received no investigations. Injections were performed in 282 (13%) and 492 (23%) were referred to physiotherapy.

CONCLUSION

Although most patients presented with musculoskeletal problems suitable for CATS, chronic pain, physical limitation, anxiety, depression, and work disability were commonplace, highlighting the need for a biopsychosocial model of care that addresses psychological, social, and work-related needs, as well as pain and physical disability.

Polyarticular sonographic assessment of gout: a hospital-based cross-sectional study

OBJECTIVE

To assess the sonographic frequency of synovial effusion, synovial hypertrophy, synovitis, and double contour sign at joints commonly affected by gout and whether these features differ according to serum urate levels, disease duration, and use of urate-lowering therapy.

METHODS

Participants with gout were recruited from rheumatology clinics. A detailed clinical assessment was undertaken of gout history, co-morbidities, medication, alcohol consumption, height, weight, clinical synovitis, tophi, and serum urate. Sonographic examination of the metatarsophalangeal joints, ankles, knees, metacarpophalangeal joints, wrists and elbows for synovial effusion, synovial hypertrophy, synovitis and double contour sign was undertaken. The mean number of joints affected were compared according to serum urate (<360 μmol/L versus ≥360 μmol/L), urate-lowering therapy (yes/no), and disease duration (≤5 years versus>5 years).

RESULTS

Forty patients participated in the study. Synovial effusion, synovial hypertrophy, synovitis, and double contour sign were identified in 36 (90%), 38 (95%), 24 (62%) and 37 (93%) participants respectively. Synovial effusion was seen most frequently at the knee (right 70%, left 68%) followed by the first metatarsophalangeal (right 48%, left 40%) and lesser metatarsophalangeal joints (right 45%, left 35%). Synovial hypertrophy, synovitis, and double contour sign were seen most frequently at the first metatarsophalangeal joint (hypertrophy: right 65%, left 60%; synovitis: right 18%, left 18%; double contour: right 60%, left 68%). These findings did not differ according to serum urate, disease duration, or use of urate-lowering therapy.

CONCLUSION

Polyarticular sonography frequently identifies synovial effusion, synovial hypertrophy, synovitis and double contour sign in patients with gout, particularly at the metatarsophalangeal joints and knees.