Patient-reported outcomes in vasculitis

Systemic vasculitis encompasses a group of multisystem disorders; both the diseases and the treatment strategies can have a significant impact on a patient's health-related quality of life (HRQoL). Using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to evaluate the patient's view of their condition, treatments, and healthcare journey is essential to the patient-centered care approach. In this paper, we discuss the use of generic, disease-specific, and treatment-specific PROMs and PREMs in systemic vasculitis and future research goals.

AB0589 TOCILIZUMAB FOR GIANT CELL ARTERITIS: BASELINE AND TWELVE MONTH AUDIT DATA FROM THE UK BRISTOL AND BATH MULTIDISCIPLINARY MEETING

Background

Giant Cell Arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Treatment is with high dose glucocorticoids. Steroid-sparing agents and Tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. TCZ has only been permitted for a maximum of one year; this time limitation was extended during the Covid-19 pandemic (1). The monthly virtual Bristol and Bath regional MDT started in November 2018.

Objectives

We aimed to review: 1) Baseline data on all patients referred to the Bristol and Bath TCZ for GCA MDT, including demographics, clinical presentation and previous steroid-sparing agents used and 2) 12 month follow up data including number of completions, adverse effects, and flares on treatment.

Methods

The TCZ MDT referral proforma, adapted from the NHS England Blueteq approval form, was reviewed for all patients referred. 12 month follow up data was obtained from clinic letters.

Results

Baseline data

Thirty-eight cases were referred between November 2018 and September 2021. Of these, 31 were approved for TCZ usage; 100% fulfilled the criteria for either refractory (n=11) or relapsing (n=20) disease. Mean age was 74 years and 74.2% were female. Average disease duration was 161.5 days for the refractory and 827.3 days for the relapsing group.

77.4% had cranial GCA, 48.4% had large vessel involvement, 45.2% had visual symptoms and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%).

64.5% had trialled a steroid-sparing agent at time of referral (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), 35.5% had received intravenous methylprednisolone and 58% were receiving greater than 40mg prednisolone at the time of referral.

Glucocorticoid adverse effects of osteoporosis, weight gain, cataracts and hypertension were each seen in 19.4%; whilst diabetes, neuropsychiatric symptoms and sleep disturbance were each reported in 16.1%.

Those with ocular involvement tended to be referred earlier than those without (478.2 days vs 648.1 days), were referred on higher doses of glucocorticoids (71.4% vs 47.1% on ≥ 40mg) and had less steroid-sparing agents prior to referral.

Follow up data

In December 2021, a follow-up audit revealed 14/31 patients had completed at least 12 months of tocilizumab; 5 of these had had an extension under Covid-19 exceptional guidance (mean duration of 5.2 months). Of the remaining 17: 3 patients had stopped early (1 death, 1 moved away, 1 due to adverse effects of headache and gastro-intestinal side effects), 4 had not started tocilizumab and 10 had not completed 12 months of treatment at that point.

Adverse events in the 14 patients at 12 months included: liver abnormalities (2/14; 14.3%), neutropenia (2/14; 14.3%), thrombocytopaenia (1/14; 7.1%), soft tissue infections (3/14; 21.4%), urinary tract infection (1/14; 7.1%) and lipid derangement (4/14 28.6%). One case of GCA relapse occurred on TCZ (mild headache and raised inflammatory markers settled on small increase in prednisolone). After 12 months, mean prednisolone dose was 3mg (range 0-15mg).

Conclusion

All patients approved for Tocilizumab in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Follow up data suggests that TCZ was effective in allowing glucocorticoid weaning and disease control, but with some adverse effects. Future work to follow up patients after stopping Tocilizumab would be informative, as the twelve month limitation on treatment is likely to be re-instated.

References

[1]https://www.england.nhs.uk/coronavirus/publication/tocilizumab-for-giant-cell-arteritis-gca-during-the-covid-19-pandemic-rps-2007/

Disclosure of Interests

Chandrin N. R. Jayatilleke: None declared, Aishwarya Anilkumar: None declared, Shalini Janagan: None declared, Robert W Marshall: None declared, Sarah Skeoch: None declared, Catherine Guly Grant/research support from: Eli Lilly and Company - paid consultant for a research trial, Fang En Sin: None declared, Keziah Austin: None declared, Laith Al-Sweedan: None declared, Alexandra Bourn: None declared, Lynsey Clarke: None declared, Harsha Gunawardena: None declared, Baashar Boyce: None declared, Sally Knights: None declared, John D Pauling: None declared, Elizabeth Reilly: None declared, Timothy D Reynolds: None declared, Sarah Villar: None declared, Joanna C Robson: None declared

AB1581-PARE ATTITUDES TOWARDS MEDICATIONS AND COMMONLY REPORTED SIDE EFFECTS TO DMARDS IN RHEUMATOID ARTHRITIS PATIENTS ATTENDING A TERTIARY CARE HOSPITAL IN SRI LANKA

Background

Rheumatoid arthritis(RA) is a chronic multisystem disease which can be controlled with disease modifying anti-rheumatic drugs (DMARDs). Compliance to treatment can be affected by attitudes to medicines and side effects of drugs.

Objectives

To identify attitudes towards medicines in patients with rheumatoid arthritis and its relationship to disease characteristics and identify the side effect profile of commonly used DMARDs in a Sri lankan population.

Methods

A cross sectional study was carried out on patients attending a rheumatology clinic at National hospital of Sri Lanka between August to November 2018. Patients diagnosed with RA based on standard criteria and on DMARDS for more than 3 months were administered an interviewer administered questionnaire regarding sociodemographic and beliefs about medicines questionnaire (BMQ) assessing patients’ attitudes to the necessity of prescribed medication for controlling their disease and their concerns about potential adverse consequences of taking it. Further questions about commonly reported side effects were also asked. Data was analysed using SPSS software.

Results

160 patients fulfilled our inclusion criteria and the response rate was 75%. The study population consisted of 84% females with an average age of 52 years. They were predominantly Sinhalese (82 %) with a median duration of disease of 10 years (interquartile range-1.6-18.4 years). Three fourths of them were seropositive. The mean disease activity (DAS-28) was 4.03 (SD-1.29). Respondents indicated their degree of agreement with each statement in the BMQ on a five-point Likert scale, ranging from 1 = strongly disagree to 5 = strongly agree. The first ten questions specifically asked regarding arthritis medication.

Table 1.Percentage agreeing or strongly agreeingNecessity scaleMy health at present depends on my arthritis medicines77.5My life would be impossible without my arthritis medication72.5Without my arthritis medication I would be very ill68.3My health in the future will depend on my arthritis medication66.7My arthritis medication protects me from becoming worse.59.2Concern scaleHaving to take arthritis medication worries me40I sometimes worry about the long-term effects of my arthritis medication62.5My arthritis medication is a mystery to me28.3My arthritis medication disrupts my life38.3I sometimes worry about becoming too dependent on my arthritis medication57.5

The overall necessity scale score (mean 19.2, S.D. 3.21) was higher than the concerns scale score (mean 14.86, S.D. 3.89; P<0.01) but was not statistically significant. The overall necessity scale score was found to be significantly correlated with duration of disease (p<0.05) but not with age, sex, seropositivity or disease activity.

59.2 %, 13.4 %, 8.2 %, 6.1 % of the patients were on monotherapy with Methotrexate, Leflunomide, Sulphasalazine, HCQ respectively. 12.8 % were on combination methotrexate and leflunomide and remainder were on biologics. The commonest side effects noted on methotrexate were leucopenia, loss of appetite,raised liver enzymes, oral ulcers, hair loss which were 30 %, 21 %, 8 %, 7% and 11% respectively. Patients on leflunomide reported raised BP, raised liver enzymes, loss of appetite and leucopenia in 30 %, 14 %, 8 % and 6 % respectively. Patients on both reported raised liver enzymes, leucopenia, loss of appetite in 78 %, 60 %,11 % respectively. Sulphasalazine caused anaemia,leucopenia and insomnia in 23 %, 17 %, 8 % respectively.HCQ caused pigmentation and maculopathy at 17 % and 9 % respectively.

Conclusion

Though a positive attitude towards their medication was seen in most patients with rheumatoid arthritis, they had concerns regarding potential long-term effects and dependency. This was found to be significantly correlated to duration of disease. Educating patients about their medication and clarifying misconceptions will improve compliance and disease outcomes. Side effects noted were similar to western population but GI side effects were notably less.

Disclosure of Interests

None declared

AB1579-PARE THE EFFECTS OF A HEALTH EDUCATION PROGRAMME ON PATIENTS’ SYMPTOMS AND LIFESTYLE CHANGES IN PATIENTS WITH KNEE OSTEOARTHRITIS ATTENDING A TERTIARY CARE CLINIC IN SRI LANKA

Background

Osteoarthritis is the major cause of joint pain and disability among middle aged and elderly with no disease specific treatment. Management includes analgesics, lifestyle changes and physical therapy.

Objectives

We aimed to study the demographics of the patients and knowledge regarding osteoarthritis among those who attended our clinic with mechanical knee pain and the effects of a health education programme.

Methods

Patients complaining of mechanical knee pain who were found to have examination findings suggestive of knee joint osteoarthritis were enrolled in this study (N-150). Where available diagnosis was confirmed by radiography. Data was collected when they attended a health education programme which focused on lifestyle changes in osteoarthritis including diet and exercise (n-76). An interviewer administered questionnaire regarding disease, dietary changes for reduction of weight and exercise was used to obtain data before and 3 months after the health education programme. Anthropometric measurements were taken using validated instruments. Data was analyzed using SPSS software.

Results

Response rate was 50.67 %.The average age of the study population was 54.8 years and constituted of 92.1 % females. About one fifth of them had received only primary school and 50 percent were unemployed. The average BMI was 29.68 (SD-5) and average WOMAC score was 44.1 (SD -19.4).

Their knowledge of healthy dietary habits, primarily to lose weight and exercises for knees were assessed before the health education programme and 3 months later.

Table 1.Before health education3 months after health educationn7620BMI (average)29.6830.2Not aware of disease90%50%Aware of diet to reduce weight32%65%Aware of exercises5 %35%WOMAC score44.136.7

There was no statistically significant correlation between WOMAC score and age, educational level or BMI.Though the knowledge regarding disease and lifestyle measures improved significantly(p< 0.05) following the health education program, there was no significant difference in the WOMAC score.

Conclusion

Health education was seen to improve the knowledge regarding disease and lifestyle measures despite no significant improvement in the pain or disability scores.Further studies are needed to see the long term effects of health education.

References

[1]Jönsson, T., Eek, F., Dell’Isola, A., Dahlberg, L. E., & Ekvall Hansson, E. (2019). The Better Management of Patients with Osteoarthritis Program: Outcomes after evidence-based education and exercise delivered nationwide in Sweden. PloS one, 14(9), e0222657. doi:10.1371/journal.pone.0222657

[2]Espanha M, Marconcin P, Campos P, et alPARE0005 Educational program for older adults with knee osteoarthritisAnnals of the Rheumatic Diseases 2017;76:1553.

Disclosure of Interests

None declared

P293 Tocilizumab for refractory or relapsing giant cell arteritis: audit data from the Bristol and Bath regional multidisciplinary meetings 2018-2021

Background/Aims

Giant cell arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Patients can present with cranial, ocular or large vessel (LVV-GCA) involvement. Treatment is with high dose glucocorticoids. Steroid-sparing agents and tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. We reviewed the case mixture of patients referred to the Bristol and Bath regional MDT.

Methods

The Bristol and Bath regional MDT started in November 2018 and runs monthly. A referral proforma was designed, adapted from the NHS England Blueteq approval form for TCZ in GCA (definitions of refractory and relapsing disease), with tick boxes for clinical features, investigations, treatment, glucocorticoid adverse events and a free text clinical vignette. All referral proformas were reviewed.

Results

Audit data from all cases referred, between November 2018 and September 2021, were analysed. 38 cases of GCA were discussed with 31 cases approved for TCZ usage. Of the approved, 100% fulfilled the criteria for either refractory (n = 11) or relapsing (n = 20) disease. Mean age of approved cases was 74 years with three quarters being female (74.2%). Average disease duration was 161.5 days for the refractory group and 827.3 days for the relapsing group. Over three quarters of cases (77.4%) had cranial GCA, 48.4% had LVV-GCA, 45.2% had visual symptoms (reduction in visual acuity, blurring or diplopia) and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%). Almost two-thirds (64.5%) had previously had a steroid-sparing agent (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), one third (35.5%) had received intravenous methylprednisolone and more than half (58%) were receiving greater than 40mg prednisolone at the time of referral. Common glucocorticoid adverse effects (each seen in 19.4% of cases) included osteoporosis, weight gain, cataracts or hypertension, whilst diabetes, neuropsychiatric symptoms or sleep disturbance were each reported in 16.1% of cases. The majority of patients with ocular involvement had cranial symptoms (71%). Patients with ocular involvement tended to be referred earlier than those with no ocular involvement (478.2 days vs 648.1 days), were on a higher dose of glucocorticoids at time of referral (71.4% vs 47.1% on more than 40mg) and had fewer steroid-sparing agents prior to referral.

Conclusion

All patients approved for TCZ in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel vasculitis involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Patients with ocular involvement were referred slightly earlier with less use of other steroid sparing treatments prior to TCZ in our cohort.

Disclosure

C. Jayatilleke: None. S. Janagan: None. R. Marshall: Other; Has received sponsorship from UCB Pharma to attend educational conferences in the last 2 years. S. Skeoch: None. C.M. Guly: None. F. En Sin: None. L. AL Sweedan: None. A. Anilkumar: None. K. Austin: None. A. Bourn: None. L. Clarke: None. H. Gunawardena: None. A. Johnson: None. S. Knights: None. J.D. Pauling: None. E. Reilly: None. T.D. Reynolds: None. S. Villar: None. J.C. Robson: None.

P050 Rapidly worsening subcutaneous oedema in a young boy: a case of juvenile dermatomyositis

Background/Aims

Juvenile onset dermatomyositis (JDM) is a rare disease with an incidence of 2-4 per million. The presentation includes skin manifestations of heliotrope rash, Gottron's papules, nail fold changes, bilateral peri-orbital or upper eyelid edema and focal mild facial swelling with muscle weakness. Widespread and generalized subcutaneous oedema is a rare presentation in JDM.

Methods

A 4-year-old previously healthy boy presented to a tertiary care hospital in Sri Lanka with generalized rash involving the face, limbs and trunk for seven days associated with facial puffiness and hair loss. He also complained of generalized myalgia and irritability and refused to walk. He did not have dysphagia, dysphonia or shortness of breath. He had a prodromal febrile illness two weeks back that had been treated as a viral fever. He had evidence of palatal ulcers, chelitis, malar rash, erythema of eyelids, eyelid swelling and necrotic vasculitic lesions in peripheries. He had tenderness over his thighs with muscle power being MRC grade 3/5 in the proximal muscles of his lower limbs. Arm and neck flexors’ power was normal.

Results

His ESR was raised at 35 mm/hour and CRP was normal. His CPK was 2726 U/l, AST was raised at 931 U/l, ALT was 511 U/l and albumin was 33 g/l. His ANA, dsDNA and ENA panel was negative. A myositis immunoblot could not be done due to financial constraints. An EMG showed evidence of myositis in his proximal muscles. He fulfilled the criteria for juvenile dermatomyositis based on Bohan and Peter’s criteria. He was treated with high dose steroids, dexamethasone 2 mg 6 hourly. While receiving steroids he deteriorated with worsening subcutaneous oedema of face and neck with high fever spikes. The oedema progressed to involve his whole body. His muscle power deteriorated with involvement of his arms. A venogram ruled out any obstructive venous disease. A CT CAP ruled out any underlying malignancy. His 2D echo revealed normal heart function. He was converted to IV Methylprednisolone 30 mg/kg and was started on plasmapharesis. He improved after the 3rd cycle and was started on cyclophosphamide infusions. He received six cyclophosphamide pulses with a tapering course of steroids. He remains controlled in his disease with no new muscle weakness or skin manifestations. However, he remains steroid dependent and is awaiting treatment with Rituximab.

Conclusion

Subcutaneous oedema in JDM is attributed to a vasculopathy. This is associated with severe rapidly progresssive disease with high mortality and requires aggressive immunosuppression. As seen in our patient disease is resistant to conventional treatment. Early recognition leads to better outcomes in these patients.

Disclosure

S. Janagan: None. W.A.E. Udeshika: None. P.M. Samarasinghe: None. J.D. Jagoda: None.

P048 A young girl with myocardial infarction

Background/Aims

Takayasu arteritis is a chronic granulomatous inflammatory disease of the aorta and its major branches. It is commonly seen in young women but has been reported in children as young as 6 months. Acute myocardial infarction due to coronary artery involvement is a rare presentation in Takayasu’s arteritis.

Methods

A previously healthy 13-year-old girl presented with a history of five episodes of short lasting exertional tightening type chest pain with adrenergic symptoms over a week which was relieved by rest. She didn't have any history of shortness of breath, limb claudication or constitutional symptoms. However, on two of the occasions she felt faint. She denied any recreational drug use. There was no family history of cardiovascular disease, connective tissue diseases or sudden cardiac death. On examination she was of average build with no peripheral stigmata of connective tissue diseases or hypercholesterolemia. Apart from a tachycardia of 110 bpm, her cardiovascular examination was normal. There was no BP difference between the arms and no audible bruits. All her peripheral pulses were felt.

Results

Her ECG showed ST segment depressions in V1-V5. High sensitivity Troponin I was strongly positive. An urgent CT coronary angiogram revealed aortitis involving the ascending and arch of the aorta extending to the left subclavian artery with both coronary arteries showing smooth short segment narrowing at the origin. Doppler USS abdomen showed wall thickening of proximal and mid abdominal aorta. Blood investigations showed a leucocytosis of 14,100/µl and thrombocytosis of 532000/µl. Her ESR was raised at 31 mm/hr and CRP was 5 mg/l. While further awaiting investigations she was started on treatment as for non-ST elevation myocardial infarction according to standard guidelines. Screening for tuberculosis and VDRL were negative . A CT aortic angiogram showed wall thickening involving the aortic root, coronary arteries, ascending aorta and the abdominal aorta with involvement of the origins of coeliac axis and the superior mesenteric artery. Appearance were suggestive of Takayasu arteritis Type v. She was pulsed with intravenous methylprednisolone 30 mg/kg for 3 days followed by oral prednisolone 2 mg/kg. As a steroid sparing agent methotrexate was added. Despite treatment, while in hospital she developed chest pain with ECG showing new onset ST elevation in aVR. An urgent coronary angiogram done showed severe LMCA disease for which stenting was done.

At this stage Tocilizumab was initiated. A year later she remains well controlled in terms of her disease activity.

Conclusion

Though rare, Takayasu’s arteritis should be considered in any adolescent female presenting with ischemic type symptoms and positive inflammatory response. High index of suspicion can lead to early imaging and aggressive immunosuppression that will reduce the morbidity and mortality of this disease.

Disclosure

S. Janagan: None. M.P.M.L. Gunathilaka: None. L. Rajagopala: None. J.D. Jagoda: None.

ANCA Associated Vasculitis Subtypes: Recent Insights and Future Perspectives

The ANCA associated vasculitides (AAVs) affect a range of internal organs including ear nose and throat, respiratory tract, kidneys, skin and nervous system. They include granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA) and microscopic polyangiitis (MPA). The AAVs are treated with high dose glucocorticoids, immunosuppressants, and targeted biological medications. Since the 1990s classification criteria for the AAVs have been based on clinical features, laboratory tests and basic imaging; an initiative to update the classification criteria incorporating newer tests, for example, anti-neutrophil cytoplasmic antibodies (ANCA) and novel imaging techniques will be published this year. There is also evidence for classification of patients based on ANCA subtype; those with anti-proteinase 3 antibodies (PR3) or anti-myeloperoxidase antibodies (MPO) have differences in response to treatment and clinical outcomes. An update is described within this review. The pathogenesis of AAV involves necrotizing inflammation of small to medium blood vessels involving multiple immunological pathways. We present an update on emerging evidence related to auto-antibodies, complement and lymphocyte pathways. This review describes emerging treatment regimens, including evidence for plasma exchange in severe disease and the inhibitor of the complement C5a receptor (C5aR) inhibitor, Avacopan. Lastly, patient reported outcomes are key secondary outcomes in randomised controlled trials and increasingly clinical practice, we report development in disease specific and glucocorticoid-specific PROs.

Patient reported outcomes in systemic vasculitis

PURPOSE OF REVIEW

This review paper evaluates the use of patient reported outcome (PROs) in systemic vasculitis and the increasing incorporation of these measures in the evaluation of clinical outcomes and healthcare provision.

RECENT FINDINGS

Generic PROs such as the SF-12, SF-36, EQ-5D have been used to evaluate health-related quality of life (HRQOL) across the spectrum of vasculitis; including giant cell arteritis, antineutrophil cytoplasmic antibody (ANCA)-related vasculitis and immunoglobulin A vasculitis (IgA) vasculitis. More recently disease-specific PROs have been developed including the associated vasculitis (AAV)-PRO and GCA-PRO, whilst further work is ongoing including a Steroid-PRO.

SUMMARY

Generic and disease-specific PROs are complimentary in nature, but the advent of disease-specific PROs allows evaluation of the impact of specific symptoms and intervention on patient HRQOL. Following the COVID-19 pandemic, the advent of increasing virtual work has brought the potential for electronic-PRO measures to the forefront and is a current area of interest.