American College Of Rheumatology Guidelines Research Articles

Fitwalking: A New Frontier for Kidney Patients. A Center' s Experience.

Physical inactivity is common in patients with chronic kidney disease (CKD) and is an important modifiable risk factor for mortality, morbidity, and reduced quality of life. The present single-centre pilot study evaluated the possibility of performing structured physical exercise using a specific walking model, Fitwalking, in a population of patients with CKD and, according to the American College of Rheumatology guidelines, also in a population with immuno-rheumatological disease. Patients were recruited from the nephrology, haemodialysis, peritoneal dialysis, transplantation, and immuno-rheumatology outpatient clinics. After general and functional clinical evaluation and exercise prescription at the Department of Sports Medicine, we performed scientifically proven tests on CKD (Six-minute walk test and Sit to stand test), before and after the Fitwalking technique training course, and again after 6 and 12 months, to evaluate its effectiveness and identify any critical issues. We enrolled 80 patients, (41 males, 51.2%), mean age 53±12 years; the clinical data showed statistically significant improvements in systolic, average, and differential blood pressure, average speed, and physical strength. Participants also adapted to muscle fatigue, experienced a reduction in BMI with stable lean mass and reduced fat mass, and reported improved perceptions of physical and mental health, and quality of life. All enrolled patients successfully completed the process. A specific prescription was used that provided health education and allowed for the implementation of structured physical activity that could be performed safely and independently even after the training period. The activity was sustainable thanks to the training of in-house medical and nursing staff, demonstrating that it is possible to overcome this type of barrier to physical activity in CKD and in immuno-rheumatological patients.

Knowledge of and stated adherence to the 2020 ACR Guideline for Gout Management: Results of a survey of US rheumatologists.

This report evaluates rheumatologists' stated adherence to and agreement with the 2020 American College of Rheumatology (ACR) Guideline for the Management of Gout. A 57-item questionnaire was administered to US rheumatologists. Stated adherence scores were based on several guideline recommendations reported to be followed by rheumatologists in practice, whereas stated agreement scores were based on whether respondents always followed the recommendations. All 201 rheumatologists completed the questionnaire. The mean overall stated adherence score was 11.5 (maximum: 15), whereas the mean overall stated agreement score was 7.7 (maximum: 14). Less experienced rheumatologists (≤8 years; n=49) were likely to claim adherence to more individual ACR recommendations than those with more experience (>8 years; n=152; mean stated adherence score: 12.3 vs 11.3; P ≤ 0.05). Rheumatologists who claimed to see ≤75 patients with gout in 6 months (n=66) had a mean stated adherence score of 12.1 versus 11.2 for those who claimed to have seen >75 patients (P ≤ 0.05). Approximately 78% of rheumatologists claimed to follow the guideline for initiating urate-lowering therapy (ULT), and 89% were likely to prescribe allopurinol as a first-line ULT. Claimed adherence to recommendations for dosing was lower (febuxostat, 43%; allopurinol, 39%). Rheumatologists from academic settings were more likely to prescribe an interleukin-1 inhibitor for gout flares. The self-reported practice of the surveyed US rheumatologists was generally concordant with the 2020 ACR Guideline for the Management of Gout. However, there were gaps in guideline knowledge and stated adherence among rheumatologists, mainly concerning the dosing of treatment regimens.

Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study.

Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up. A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable. The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroidwas 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively.Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative andpositive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05. Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

Glucocorticoid-Induced Osteoporosis: Increased Awareness as a Management Strategy for Prevention of this Complication in Patients with Systemic Autoimmune Rheumatic Disease.

It has been estimated that about 1% of the US population is treated with long-term glucocorticoids. High doses of glucocorticoids particularly those used by rheumatologists and oth- ers for systemic autoimmune rheumatic disease result in bone loss, causing glucocorticoid-induced osteoporosis and an increase in the risk of fractures. The increased risk is related to both the daily dose and the cumulative dose of the glucocorticoids. Despite the availability of effective preventative and treatment options, glucocorticoid-induced osteoporosis is often not mitigated with the use of these preventive therapies. The risk of glucocorticoid-induced osteoporosis often also goes under- recognized, because it occurs in a different group of patients compared to age-related osteoporosis. As a result, glucocorticoid-induced osteoporosis is not always treated until after fractures may have occurred. Our objective is to determine if a structured health-care provider's educational interven- tion with intermittent educational updates would lead to improvement in the identification, evalu- ation, and prevention of glucocorticoid-induced osteoporosisin those patients at the highest risk of glucocorticoid-induced osteoporosis. In this single-center, prospective study, patients over 40 years of age, receiving a total cumu- lative dose of glucocorticoids of >5 g or a single dose of >30 mg of prednisone or its equivalent was enrolled. All providers attended an academic Journal Club, where the current American College of Rheumatology guidelines regarding glucocorticoid-induced osteoporosiswas reviewed. All providers received monthly reminders during academic meetings within the department. There was a statistically significant improvement between pre- and post-educational data, with increasing use of glucocorticoid-induced osteoporosis preventive measures, which was sus- tained over the 12-month duration of the study. This research shows the importance of provider education as a means of disseminating information and improving the quality of patient care.

Part II: Interactive case: Drug‐induced endocrine disorders

Part <scp>II</scp>: Interactive case: <scp>Drug‐induced</scp> endocrine disorders

2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis.

To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n=20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

Vaccination for rheumatic diseases: Current issues (based on ACR guidelines)

In modern rheumatology, comorbid infections have a significant impact on morbidity and mortality, especially in immuno-inflammatory rheumatic diseases (IIRD). One of the ways to solve this problem is the study and active use of various vaccines. This article analyzes the recommendations for vaccination of patients with acute respiratory infections, proposed in 2022 by experts of the American College of Rheumatology (ACR). The safety and immunogenicity of vaccination associated with the prevention of various infections in patients with IVR are discussed. It is emphasized that the decision to suspend taking the drug before or after vaccination should be made taking into account the existing IIRD, its activity and the risk of vaccine-controlled infection. A key component of any vaccination strategy (especially for conditional recommendations) is decision-making together with the patient. The main directions of future research on the problem under consideration are outlined.

Real-world treatment of gout and asymptomatic hyperuricaemia in Japan.

Recently a retrospective cohort study in Japan conducted by Koto et al. disclosed that the risk of the first gout flare would decrease 55% if serum uric acid was reduced to 5–6 mg/dl among people with asymptomatic hyperuricaemia receiving uric acid–lowering drugs as compared with untreated people (serum uric acid ≥ 8.0 mg/dl) [1]. Another study by Koto et al. published in Modern Rheumatology using the same database disclosed that the prevalence of gout was about 1.1% in Japan [2], which was lower than Taiwan (3.1%) [3].The authors commented that the low prevalence of gout in Japan could be attributed to the early drug treatment of asymptomatic hyperuricaemia based on the Japanese guideline [2, 4]. Both studies by Koto et al. provide the evidence that the natural course of asymptomatic hyperuricaemia can be changed by the intervention of uric acid–lowering drugs. Some points are discussed. First, hyperuricaemia and gout are closely related but are not the same disease. Most of the people with hyperuricaemia do not develop a gout flare during their lives [5]. Whether people with asymptomatic hyperuricaemia should take uric acid–lowering drugs to prevent the first gout flare, the academic community has not yet established a consensus. The American College of Rheumatology guideline suggests against the use of uric acid–lowering drugs to treat asymptomatic hyperuricaemia [6]. The Japanese guideline suggests that the treatment goal of hyperuricaemia is to prevent monosodium urate deposition in joints and viscera, not only leading to the risk reduction of gout flares but also leading to the risk reduction of organ damage and then leading to prolonged disease-free survival, especially cardiovascular diseases [4]. After lifestyle modification, if serum uric acid is still ≥ 9.0 mg/dl, clinicians may talk to people with asymptomatic hyperuricaemia about the current evidence of managing hyperuricaemia and possible adverse events of uric acid–lowering drugs, such as hepatotoxicity, urinary stones, and cutaneous adverse reactions. Only after informed consent is obtained, clinicians are able to consider prescribing uric acid–lowering drugs to those suitable patients [4]. Although serum uric acid ≥ 9.0 mg/dl is an independent risk factor for gout flares, there have been no randomized control studies focusing on the management of asymptomatic hyperuricaemia where the primary endpoint was set as the development of the first gout flare. Therefore, in the current situation, urate-lowering drugs are not strongly recommended for asymptomatic hyperuricaemia in order to prevent the first gout flare. Moreover, in the present guidelines, how to treat hyperuricaemia should be decided after assessing the patients’ concomitant diseases. Second, benzbromarone is a uricosuric drug to lower serum uric acid. Because of its potential hepatotoxicity, benzbromarone had been withdrawn from some markets since 2003, but it still can be prescribed in many countries including Taiwan and Japan [7]. Three case reports in Japan showed that benzbromarone could be related to fulminant hepatotoxicity, but none was confirmed by rechallenge tests [8–10]. However, no hepatotoxicity was reported in Taiwan and South Korea. Allopurinol is the first drug of choice to lower serum uric acid in western countries [6]. Allopurinol use has a potential risk to cause severe cutaneous adverse reactions. Among the three Asian countries, the incidence rate of allopurinol-related severe cutaneous adverse reactions was the highest in Taiwan (2.57/1000 person-years), followed by South Korea (2.31/1000 person-years), and the lowest in Japan (2.00/1000 person-years) [11]. In ethnic groups with a high frequency of HLA-B*5801, benzbromarone will be safer than allopurinol for the management of hyperuricaemia. The standard doses of benzbromarone (100 mg/day) are more effective in lowering serum uric acid than the standard doses of allopurinol (300 mg/day) [12]. Only higher doses of allopurinol (450 mg/day) are as equally effective in lowering serum uric acid as the standard doses of benzbromarone (100 mg/day) [12]. Third, current guidelines do not present which drug should be the first-line drug for asymptomatic hyperuricaemia. If we want to set up a new clinical guideline, it is necessary to determine which drug is more effective and safer to prevent the first gout flare in people with asymptomatic hyperuricaemia. It indicates a future research direction.

Trends in Total Joint Arthroplasty Among Patients With Rheumatoid Arthritis: The Effect of Recent Disease Modifying Antirheumatic Drug Utilization Guidelines.

The 2015 change in the American College of Rheumatology (ACR) guidelines narrowed indications for initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). This study sought to evaluate trends in total joint arthroplasty (TJA) in patients with RA and to characterize the effect of bDMARDs on arthroplasty risk in this population after the change in ACR treatment guidelines. A retrospective review was conducted using the PearlDiver database. TJA procedures included total shoulder arthroplasty, total elbow arthroplasty, total hip arthroplasty, and total knee arthroplasty. The Cochran-Armitage Trend Test was used to evaluate trends in the volume of TJA procedures conducted in patients with RA between 2010 and 2019. Logistic regression was used to compare 2-year arthroplasty risk after an initial joint-specific RA International Classification of Diseases 10th Revision diagnosis for RA patients with versus without bDMARD exposure. A total of 2,942,360 patients with RA were identified, and 80,744 (2.74%) underwent TJA between 2010 and 2019. Rates of TJA procedures trended significantly upward over the decade (2.6% versus 5.1%, P < 0.001) with a sharp increase between 2015 and 2016 (2.1% versus 4.9%, P < 0.001). Among the 16,736 identified patients with an initial International Classification of Diseases 10th Revision joint-specific RA diagnosis, 3362 patients (20.09%) were treated with bDMARDs and 13,374 (79.91%) were not. Untreated patients exhibited significantly lower risk of any TJA (5.92% versus 7.73%; odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.64 to 0.82), total hip arthroplasty (OR: 0.69, 95% CI: 0.50 to 0.95), and total knee arthroplasty (OR: 0.63, 95% CI: 0.52 to 0.75) compared with treated patients. The volume of TJA procedures conducted in patients with RA has trended markedly upward over the past decade, with a sharp increase after 2015. bDMARD treatment was associated with markedly increased risk of TJA, likely because of initiation of bDMARDs in only those patients with advanced disease per ACR guidelines.

Recommendations for the treatment of rheumatoid arthritis in Saudi Arabia: adolopment of the 2021 American College of Rheumatology guidelines

BackgroundThe 2021 American College of Rheumatology (ACR) rheumatoid arthritis (RA) guideline considers the specific context of the United States which differs from that of Saudi Arabia in many aspects that may impact recommendations. The objective of this project was to adapt a set of prioritized recommendations from the 2021 ACR guideline for the treatment of rheumatoid arthritis RA for the context of Saudi Arabia, by the Saudi Society for Rheumatology (SSR).MethodsThe process followed the GRADE-ADOLOPMENT methodology, and the reporting adhered to the RIGHT-Ad@pt checklist. Working groups included a coordination group and a 19-member panel representing different stakeholder groups. The Evidence to Decision (EtD) tables included evidence on health effects from the source guideline and contextual information from the Saudi setting.ResultsThe panel prioritized and adapted five recommendations from the source guideline. The process led to modifying two out of the five prioritized recommendations, all listed here. In naive patients with low disease activity, methotrexate (MTX) is conditionally recommended over sulfasalazine (SSZ) (modified direction); hydroxychloroquine (HCQ) is conditionally recommended over SSZ (unmodified). Initiation of csDMARDs with short-term glucocorticoids is conditionally recommended over csDMARDs alone in naive patients with moderate to high disease activity (modified direction). Switch to subcutaneous MTX is conditionally recommended over addition/switch to alternative DMARD(s) in patients taking oral MTX who are not at target (unmodified). Discontinuation of MTX is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD for patients taking MTX plus a bDMARD or tsDMARD who wish to discontinue a DMARD (unmodified).ConclusionRheumatologists practicing in Saudi Arabia can use the adoloped recommendations generated by this project while adopting the rest of the recommendations from the 2021 ACR guidelines.

Impact of specialty pharmacy collaboration with rheumatology clinics to improve the achievement of treat-to-target goals in patients with rheumatoid arthritis: a pilot study

In rheumatoid arthritis, the use of Routine Assessment of Patient Index Data 3 (RAPID3) assessments to meet treat-to-target goals is endorsed by the 2021 American College of Rheumatology guidelines. In November 2020, the Baylor Scott & White specialty pharmacy implemented a new service that included more frequent collection of RAPID3 scores and standardized provider communication for patients co-managed by a Baylor Scott & White rheumatology clinic. The objective was to evaluate the impact of this new service on rheumatoid arthritis disease activity. Before the new service started, patients followed a protocol of RAPID3 assessments that occurred every 6 months; once the service began, patients were followed using an algorithm in which patients with higher disease activity were contacted more frequently. Eighty-six percent of patients in the pre-intervention group (n = 7) compared with 100% of patients in the post-intervention group (n = 10) had high to moderate disease activity at baseline. Within a 6-month follow-up period in both groups, the percentage of high to moderate disease activity patients decreased by 30% in the post-intervention group and remained the same in the pre-intervention group. These results support the positive impact increased specialty pharmacy services may have on clinical outcomes; therefore, the continued expansion of these services should be considered.

Baricitinib in COVID-19: a coming-of-age from artificial intelligence to reducing mortality

Baricitinib in COVID-19: a coming-of-age from artificial intelligence to reducing mortality

Evaluation of Access Disparities to Biologic Disease-Modifying Antirheumatic Drugs in Rural and Urban Communities.

The American College of Rheumatology guidelines provides a strong recommendation for the use of biologic disease-modifying antirheumatic drugs (bDMARDs) when conventional rheumatoid arthritis treatments fail to meet treatment targets. Although bDMARDs are an effective and important treatment component, access inequalities remain a challenge in many communities worldwide. The purpose of this analysis is to assess nationwide trends in bDMARD access in the United States, with a specific focus on rural and urban access gaps. This study combined multiple county-level databases to assess bDMARD prescriptions from 2015 to 2019. Using geospatial analysis and the Moran’s I statistic, counties were classified according to prescription levels to assess for hotspots and coldspots. Analysis of variance (ANOVA) was used to compare significant counties across 49 socioeconomic variables of interest. The analysis identified statistically significant hotspot and coldspot prescription clusters within the United States. Coldspot (Low-Low) clusters with low access to bDMARDs are located predominantly in the rural west North Central region, extending down to Oklahoma and Arkansas. Hotspot (High-High) clusters are seen in urban and metro areas of Wisconsin, Minnesota, Pennsylvania, North Carolina, Georgia, Oregon, and the southern tip of Texas. Comparing coldspot to hotspot areas of bDMARD access revealed that the Medicare populations were older, more rural, less educated, less impoverished, and less likely to get their bDMARDs from a rheumatologist.

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype. We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well-balanced, age-appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision-making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging.

To provide recommendations for the management of juvenile idiopathic arthritis (JIA) with a focus on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, irrespective of JIA phenotype. We developed clinically relevant Patient/Population, Intervention, Comparison, and Outcomes questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of evidence (high, moderate, low, or very low). A Voting Panel including clinicians and patients/caregivers achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. Recommendations in this guideline include the use of physical therapy and occupational therapy interventions; a healthy, well-balanced, age-appropriate diet; specific laboratory monitoring for medications; widespread use of immunizations; and shared decision-making with patients/caregivers. Disease management for all patients with JIA is addressed with respect to nonpharmacologic therapies, medication monitoring, immunizations, and imaging. Evidence for all recommendations was graded as low or very low in quality. For that reason, more than half of the recommendations are conditional. This clinical practice guideline complements the 2019 American College of Rheumatology JIA and uveitis guidelines, which addressed polyarthritis, sacroiliitis, enthesitis, and uveitis, and a concurrent 2021 guideline on oligoarthritis, temporomandibular arthritis, and systemic JIA. It serves as a tool to support clinicians, patients, and caregivers in decision-making. The recommendations take into consideration the severity of both articular and nonarticular manifestations as well as patient quality of life. Although evidence is generally low quality and many recommendations are conditional, the inclusion of caregivers and patients in the decision-making process strengthens the relevance and applicability of the guideline. It is important to remember that these are recommendations. Clinical decisions, as always, should be made by the treating clinician and patient/caregiver.

Provider Specialty and the Use of Disease‐Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Older Adults in the 2005‐2016 National Ambulatory Medical Care Survey

ObjectiveWe compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).MethodsIn this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.ResultsWe identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).ConclusionDMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.

Use of protocol-driven medication refills by pharmacists decreases rheumatologist in-basket work and improves rheumatologist satisfaction

Burn-out among US physicians has been on the rise in the past few decades. Similarly, rheumatologists in the Geisinger Health System have experienced professional dissatisfaction through significant administrative burden and...

Stachys schtschegleevii tea, matrix metalloproteinase, and disease severity in female rheumatoid arthritis patients: a randomized controlled clinical trial.

Stachys schtschegleevii (SSC) is a herbal medicine used to treat infections. To date, this is the first study aimed to investigate the effects of SSC tea on disease activity score (DAS), serum inflammatory biomarkers and matrix metalloproteinases (MMP-1 and MMP-3) among women with rheumatoid arthritis (RA). This pilot, triple-blind, randomized controlled clinical trial was conducted among forty-four women (age: 30-65 years) diagnosed with moderately active RA. Subjects were randomly assigned (1:1 ratio) into either SSC group (2.4 g/day SSC + 2.4 g/day black tea, n=22) or placebo (2.4 g/day black tea, n=22) for 8 weeks. Serum high-sensitivity C-reactive protein (hs-CRP), interleukin-1 beta (IL-1β), and MMPs were measured using ELISA. According to the American College of Rheumatology guideline considering hs-CRP, DAS28 was assessed. Both study groups had respondent rates above 94.9%. The SSC intervention caused significant reductions in the number and the percent changes of the tender joints (SSC: -74.39%vs.placebo: -57.15%, mean differences= -0.77; P<0.05) and DAS28 [SSC: -32.44% vs.placebo: -22.32%, mean differences= -0.41, P<0.05). Unlike the intervention within SSC group that showed significant reductions in the mean serum levels of hs-CRP, IL-1β, and MMP-3, SSC caused significant MMP-3 reductions (SSC: -20.59%vs.placebo: 1.29%, P<0.05). The SSC intervention showed an appropriate clinical efficacy for female RA patients, accompanying remarkable reductions in the number of tender and swollen joints, DAS28, and serum levels of MMP-3. This can provide additional insights to the interventional studies controlling RA-related pathological and inflammatory outcomes. Trial registration Prospectively registered at the Iranian Registry of Clinical Trials (IRCT), linked to the WHO Registry Network ( https://en.irct.ir/trial/11602 , IRCT registration number: IRCT2015032011335N5, Registration date:2015-05-12). Key Points • Stachys schtschegleevii improved clinical outcomes and attenuated disease severity in RA patients. • Stachys schtschegleevii ameliorated serum level of MMP-3 in RA patients.

Fibromyalgia in social media: content and quality of the information analysis of videos on the YouTube platform

ABSTRACT To evaluate the fibromyalgia (FM) content in YouTube videos and verify if American College of Rheumatology (ACR) guidelines are being met. The videos were searched with the keyword “Fibromyalgia.” Two independent researchers evaluated and coded specific characteristics of the videos. The popularity of the videos, the presentation properties, and content related to FM according to the ACR criteria were analyzed. Of the 200 videos included, the majority were presented by health professionals, 61.5%. Most videos covered more than one subject, 38.5%. The videos presented by health professionals were the most viewed. Following the ACR guidelines, 38% defined FM, 24% described the etiology, 19.5% described the diagnostic criteria and 52% presented recommended management strategies. The results indicate that users mainly watch videos published by health professionals. Most of the published videos do not follow the information recommended by the ACR guidelines. Therefore, videos should be interpreted with caution, not being the most appropriate resource for health education for patients with FM. Most of the videos published on YouTube about FM do not meet the ACR guidelines for FM.

Screening of Corticosteroid-Induced Osteoporosis in Patients with Immune Thrombocytopenia or Warm Autoimmune Hemolytic Anemia in the Outpatient Setting

Introduction:Corticosteroids (CS) are the standard first line treatment for immune thrombocytopenia (ITP) and warm autoimmune hemolytic anemia (WAIHA). Current guidelines advise against long-term CS (LTCS) use to minimize associated toxicities. Despite these guidelines, a number of patients remain on LTCS. For example, in a retrospective study of 53 patients with WAIHA, the mean duration of CS therapy was 15 months (mo) with 20% of patients with CS-induced diabetes, 10% with worsening of pre-existing diabetes, 10% with osteoporosis (OP) with fracture, and 4% with osteonecrosis of the femoral head (Roumier 2014).It is our observation that our hematology clinic patients may benefit from the application of guidelines for the prevention of CS-induced OP. The 2017 American College of Rheumatology (ACR) guidelines for prevention and treatment of CS-induced OP include a baseline clinical fracture risk assessment within 6 mo of the start of LTCS therapy (≥3 mo) followed by age and risk-adapted OP screening (Buckley 2017). Adults <40 years old (yo) with OP risk factors or prior OP fracture should undergo baseline bone mineral density (BMD) testing within 6 months of the start of CS therapy. For patients ≥40 yo, the Fracture Risk Assessment Tool (FRAX) with CS dose correction and BMD testing should be done within 6 mo of the start of CS therapy. With no similar national hematology guidelines, we applied 2017 American College of Rheumatology (ACR) guidelines for the prevention of CS-induced OP to our hematology clinic patients. The aim of the study was to improve screening for CS-induced OP in patients with ITP or WAIHA.Methods:We retrospectively identified patients with ITP or WAIHA by ICD-10 codes who were seen in the hematology clinic at LAC+USC Medical Center, Los Angeles, CA, from October 1, 2020 to March 31, 2021. The electronic medical record (EMR) was reviewed for demographic data and to confirm diagnosis. The relevant clinical history including CS dose/duration, common adverse events (AEs) from LTCS use, and BMD screening with a dual-energy X-ray absorptiometry (DEXA) scan. The patients were assessed for whether they underwent appropriate screening for CS-induced OP based on ACR guidelines.Results:Of the 2256 patient encounters in the hematology clinic during the 6-mo study period, 54 patients were identified with either ITP and/or WAIHA. The median age was 49 yo (range: 21-87), 74% were female (40/54) and 85.2% (46/54) were Hispanic. Of these 54 patients, 46 patients had prior or current CS therapy with either prednisone or dexamethasone. The most common AEs associated with CS included: weight gain (34.8%, 16/54), hypertriglyceridemia (34.8%, 16/54), worsening of diabetes (7.4%, 4/54), and worsening hypertension (3.7%, 2/54). Of the 15 patients <40 yo, 7 received LTCS therapy for ≥3 months and 42.9% (3/7) underwent screening with a DEXA scan. 1 had a normal BMD, 1 had osteopenia and 1 had OP. Of the 39 patients ≥40 years, 14 had received LTCS therapy for ≥3 months and 14.3% (2/14) had a screening DEXA scan; both demonstrated osteopenia. 2 patients with <3 months of CS therapy underwent screening - 1 for CS use, which showed osteopenia and one for age-appropriate screening of OP, which also showed osteopenia. Of the 6 patients with osteopenia or OP, 83.3% (5/6) were on vitamin D and calcium supplementation prior to screening. After diagnosis of osteopenia, one patient was not started on vitamin D and calcium supplementation. Bisphosphate therapy was initiated after diagnosis of OP in 1 patient.Conclusions:The majority of patients with ITP or WAIHA seen in our hematology clinic who were treated with LTCS ≥3 months did not receive a screening DEXA scan for OP as recommended by ACR guidelines. With this baseline data, we propose a quality improvement initiative in our clinic to ensure that all patients on LTCS are assessed for OP risk. Planned interventions include resident/fellow education, creation of a handout of the ACR guidelines posted in clinic, implementation of clinical fracture risk reassessment at baseline and every 12 months with BMD as indicated, and implementation of an EMR template to ensure uniform documentation. More broadly, our findings serve as a reminder of the importance for monitoring CS duration and suggest a need for a structured approach to monitoring for short and long-term toxicities of CS for the field of hematology. The creation of hematology-specific guidelines may be beneficial in this effort. DisclosuresPiatek: Apellis: Research Funding; Alexion: Consultancy, Research Funding; Rigel: Consultancy, Research Funding; Dova: Consultancy, Speakers Bureau.