British Society For Rheumatology Guidelines Research Articles

Sjögren disease, new name, new guidelines: Key messages for primary care

Sjögren’s syndrome is increasingly renamed Sjögren disease, as in the recent British Society of Rheumatology guidelines. These guidelines provide evidence-based recommendations for the management of adult and juvenile onset Sjögren disease. Sjögren disease is the second most common autoimmune rheumatic disease (after rheumatoid arthritis), affecting approximately 0.6% of adults, over 90% of whom are women. Sjögren disease can occur as a stand-alone autoimmune disease or overlap with other conditions such as rheumatoid arthritis, systemic lupus erythematosus or systemic sclerosis. This article aims to highlight the salient features of the guidelines for primary care physicians to improve the early diagnosis of Sjögren disease and inform the day-to-day management of established cases. The two clinical case scenarios featured in this article should help to highlight the importance of early diagnostic pick up whilst minimising false positive diagnosis and to highlight key messages from the new guidelines. A summary sheet of these guidelines is included in the supplementary material.

Retrospective Analysis of Specimen Quality in Temporal Artery Biopsies for Giant Cell Arteritis and Disease Association in North Midlands, England.

Background Temporal artery biopsy (TAB) is the recommended index diagnostic method for giant cell arteritis (GCA). Per the British Society for Rheumatology (BSR) guidelines, we assessed our procedural performance. Additionally, we evaluated the occurrence of GCA diagnosis in immunosuppressed patients and other comorbidities. Methods Following the audit registration, a retrospective analysis of prospectively collected data was conducted from 2017 to 2022 at a large university hospital in North Midlands, England. Data on demographics and comorbidities were gathered. The study's primary outcome was adherence to BSR guidelines and our service provisions. Secondary outcomes included examining the relationship between biopsy-confirmed GCA and other comorbidities. Statistical analysis was carried out using SPSS version 29 (IBM Corporation, Armonk, New York, United States of America). Two-sample t-test and Chi-square/Fisher exact test were used for continuous and categorical variables, respectively. Holm-Bonferroni method was incorporated to adjust for multiple comparisons. Results A total of 156 patients who underwent temporal artery biopsy (TAB) were included in the study, with a male-to-female ratio of 0.44:1. The median age was 73. Among the patients, 19% were smokers. The procedures were performed by either a vascular surgeon (119, 76%) or by an ophthalmologist (37, 24%). Two-thirds of the patients underwent TAB within seven days of referral. In 73, 47% of cases, the post-fixation biopsy sample size exceeded 10 mm. Positive biopsy results were found in 45 patients (29%). GCA was confirmed in 39% of patients with polymyalgia rheumatica (PMR), 24% with diabetics, 20% with hypothyroidism, 29% with hypertension, 32% with hyperlipidaemia,and 26% with other inflammatory diseases. However, the p-value was below the statistically significant threshold. The biopsy outcome was also not dependent on the speciality, time from referral to biopsy, nor on the length of the post-fixation specimen. Conclusions Temporal artery biopsy remains a valuable and crucial diagnostic tool in challenging equivocal cases of giant cell arteritis (GCA), although it is limited by its sensitivity, but there is also room for improvement. There is still uncertainty regarding the relationship between biopsy positivity, post-fixation sample size, and the interval between referral and procedure. Additionally, the speciality of the clinician performing the biopsy does not appear to significantly influence the likelihood of a positive result. We still do not fully understand why this is, but the association of the GCA with other comorbidities was unpredictably insignificant.

E008 Review of rheumatology care for women of childbearing age

Abstract Background/Aims Autoimmune rheumatic diseases are frequently diagnosed in women of childbearing age. Managing these conditions during pregnancy is complex because commonly used disease-modifying antirheumatic drugs (DMARDs) can pose risks. Specialized care for this patient group is crucial, necessitating adherence to established rheumatology practice standards and British Society for Rheumatology (BSR) guidelines. Our main objective is to review management of childbearing age females with rheumatic diseases attending Basildon hospital as per BSR guidelines. Methods The data for this retrospective study was collected from the electronic records of female patients attending the rheumatology outpatient clinic at Basildon Hospital between September and December 2022. We reviewed age, the specific rheumatological diagnosis, disease duration, disease activity, current medications, and whether general advice or pregnancy-specific advice was provided. Results Out of the initial cohort of 63 female patients, 48 (76%) aged between 18-55 years were selected as women of childbearing age, The median age was 46 years, with 65% in the age groups of 31-50 years, 25% in group 51-55 years and 10% 18-30 years age group. 58% of patients had inflammatory arthritis, 18.7% had connective tissue disease, 18.7% had other conditions such as hypermobility, osteoarthritis, and regional pain syndrome, 2.3% were diagnosed with vasculitis and 2.3% with polymyalgia rheumatica. Breakdown of inflammatory arthritis patients revealed rheumatoid arthritis in 64%, psoriatic arthritis 15% and ankylosing spondylitis 12%. Axial spondyloarthropathy, palindromic rheumatism, and juvenile idiopathic arthritis, each accounted for 3%. Regarding prescribed medications, 66% of the individuals were on conventional DMARDs, biologics 24%, corticosteroids 6% and 4% were on other treatments. The DMARDs prescribed were methotrexate 27%, hydroxychloroquine 19%, sulfasalazine 13%, mycophenolate 3% and leflunomide 1%. The majority of patients had disease activity in remission or mild, each accounting for 23%. Moderate and severe disease activity were reported in 21% each of the audited sample. Patients received advice specifically related to pregnancy 29%, while 71% did not have documented pregnancy-related guidance. 70% of females of reproductive age received general advice. Conclusion The study highlights a gap in pregnancy-related advice among the childbearing age patients as only 29% received guidance on pregnancy. This underpins the need for proactive counselling and education for female patients in routine practice, work in partnership with obstetric teams, and primary care to reduce potential pregnancy related complications and improve outcomes. Disclosure M. Mohareb: None. S. Ahmed: None. A. Bharadwaj: None. A. Nandagudi: None.

P089 Comprehensive comparison of current guidelines in the management of Systemic Lupus Erythematosus in children, with a focus on Lupus Nephritis

Abstract Background/Aims Lupus nephritis (LN) is a common complication of systemic lupus erythematosus (SLE); LN affects 50-60% of those with a diagnosis of childhood-SLE (cSLE). Currently one set of paediatric recommendations exists for the diagnosis and treatment of LN, published by the Single Hub and Access point for Paediatric Rheumatology in Europe (SHARE). This paper compares SHARE recommendations against two current sets of adult guidelines, published by the British Society of Rheumatology (BSR) and the European Alliance of associations for Rheumatology (EULAR). This paper aims to identify similarities and differences between the three sets of guidelines, and to evaluate the evidence base used to formulate them. Methods Paediatric SHARE recommendations were recorded within a spreadsheet. The recommendations were separated into recommendations for diagnosis and recommendations for treatment. The BSR paper was then examined for equivalent guidelines. The evidence level was recorded for each guideline. In the second phase, the EULAR 2019 guidelines were assessed for corresponding guidelines to the SHARE recommendations. EULAR levels of evidence were recorded. A Likert score of similarity (0-10) was assigned to each trio of guidelines (the trio consisting of one each from SHARE, BSR and EULAR). If a comparable guideline couldn’t be found in either the BSR or EULAR papers, this is made clear in the table. Results When comparing six diagnostic SHARE recommendations for paediatric LN with equivalent BSR and EULAR guidelines, the Likert similarity score ranged between 0-9. Only 50% of the 20 treatment SHARE recommendations had a Likert score ≥5 with their equivalent BSR and EULAR guidelines. Three SHARE treatment recommendations had no comparable guidelines, these are clearly identified in the results tables. All SHARE recommendations were based on level 3 or 4 evidence. Level 3 evidence comes from descriptive studies, whilst level 4 evidence comes from expert opinion and is considered the lowest level of evidence. Conclusion The quantity of differences noted in this paper leads to questioning whether transitional guidelines should be developed for care of young adults with LN to ensure safe transition as they move from paediatric to adult medical care. LN is a chronic condition that will impact a child’s entire life. Optimising care from as early in life as possible and continuing this into the future is essential to maximising quality of life and reducing adverse outcomes associated with renal involvement. Disclosure J.A. Day: None. M.W. Beresford: None.

E005 Immunoglobulins review prior to rituximab infusion: implications and how we can improve our service

Abstract Background/Aims Rituximab (RTX), used in the treatment of autoimmune and lymphoproliferative diseases, depletes B-cells through anti-CD20. The resulting hypogammaglobulinemia increases susceptibility to recurrent or severe infections, however the absence of a protocolised approach to measuring serum immunoglobulin levels prior to, or between, RTX infusions in our infusion unit has led to cancelled treatments, and even delivery of treatments without a timely record of immunoglobulin levels. British Society for Rheumatology guidelines recommend checking immunoglobulin levels prior to treatment, then four to six months after infusions and before any future cycles of treatment. Our aim was to optimise monitoring standards of immunoglobulin levels in patients receiving RTX infusions, thereby minimising avoidable harm and unnecessary treatment cancellations. Methods Data was collected retrospectively using electronic patient records. The analysis included sixty patients with rheumatological conditions scheduled for RTX infusions during a three-month period. Results Treatment was appropriately withheld in six patients without up-to-date immunoglobulin levels, and in one patient with active infection. However, RTX was given in 28% (17 out of 60) of patients without up-to-date immunoglobulin levels; the mean duration of time between the current cycle of RTX treatment and most up-to-date prior immunoglobulin result being 179 days (median 109 days). Of note, this exceeded 200 days for 4 of these 17 patients (24%), and an absence of pre-RTX immunoglobulin levels was observed in a further 3 of these 17 patients (18%). Although no adverse events have occurred, this represents a compromise in patient safety. Whilst there is no definitive guidance on the reasonable maximum time limit between a RTX infusion and the most up-to-date immunoglobulin levels, a departmental consensus of one month was agreed upon through discussion and literature reviews. Robust measures have been taken, using a multi-disciplinary and multi-step approach, to achieve this:1. Patient list generated one week in advance for the clinical team to review pre-screening tests, including immunoglobulins. Any missing tests can be requested in advance of the infusion date.2. Pharmacy update of their checklist to include reviewing immunoglobulins results prior to dispensing Rituximab; escalating to the clinical team if missing or abnormal result.3. If the above measures have failed, a final safety net has been agreed by the multi-disciplinary team that bloods are taken and urgently processed in the laboratory, with RTX conditionally screened by pharmacy, to reduce treatment delay from appointment cancellation. Conclusion Next steps will be to develop this into a first cycle of quality improvement. This will involve measuring changes from comparing data points prior to and after implementation of the above changes. Furthermore, rates of post-RTX infections or complications of immunodeficiency will be measured before and after the interventions to determine the impact on patient safety and minimise avoidable harm and unnecessary treatment cancellations. Disclosure U. Kalluri: None. V. Thanopoulou: None. T. Malley: None.

Treatment of polymyalgia rheumatica: British Society for Rheumatology guideline scope.

The last British Society for Rheumatology (BSR) guideline on PMR was published in 2009. The guideline needs to be updated to provide a summary of the current evidence for pharmacological and non-pharmacological management of adults with PMR. This guideline is aimed at healthcare professionals in the UK who directly care for people with PMR, including general practitioners, rheumatologists, nurses, physiotherapists, occupational therapists, pharmacists, psychologists and other health professionals. It will also be relevant to people living with PMR and organisations that support them in the public and third sector, including charities and informal patient support groups. This guideline will be developed using the methods and processes outlined in the BSR Guidelines Protocol. Here we provide a brief summary of the scope of the guideline update in development.

P017 Prescription trends and reasons for discontinuation amongst at-home biological therapies

Abstract Background/Aims Our unit currently follows the 2019 British Society of Rheumatology Guidelines in the prescribing and monitoring of bDMARDs which advocates 3-6 monthly monitoring blood tests in patients prescribed a biologic without a concomitant csDMARD. The guideline acknowledges “there is no evidence on the optimal monitoring requirements for patients receiving biologics”. In particular there is lack of evidence on the extent to which routine blood monitoring in such patients results in the discontinuation of the biologic. Given the costs associated with complying with this aspect of the guideline we devised this project to describe at-home biologic prescribing trends at our unit over the previous 5 years and to identify the rate of biologic discontinuation due to dyscrasias. Methods We retrospectively analysed all at-home biologic prescriptions issued at our unit between 2017 and 2021 to describe temporal trends in biologic prescribing habits. We used this data to identify patients that discontinued biological therapies and then performed a detailed retrospective analysis of electronic case records of patients who discontinued an at-home anti-TNF biologic (adalimumab, etanercept, golimumab, and certolizumab) between 01/01/2017 and 31/12/2018 to describe the reasons for discontinuation of anti-TNF biologics. Blood dyscrasia was defined as: white cell count <3.5 × 109/l; neutrophils <1.6 × 109/l; creatinine increase >30% over 12 months and/or calculated GFR <60 ml/min; unexplained eosinophilia >0.5 × 109/l; ALT and/or AST >100 U/l; platelet count <140 × 109/l; unexplained reduction in albumin <30 g/l. Results Between 2017 and 2021 our unit issued a total of 39,298 prescriptions for at-home biologics. During this timeframe the total number of annual prescriptions at our unit increased by 76.6% (2017: 5240, 2021: 9265) and the number of unique patients prescribed a biological therapy increased by 72.4% (2017: 1018, 2021: 1755). The total number of anti-TNF biologic prescriptions increased by 49.8%, and the number of adalimumab prescriptions increased by 89.8%. Between 1/1/2017 and 31/12/2018 295 patients discontinued an anti-TNF biologic. Reasons for discontinuation included: drug inefficacy: n = 156 (52.9%), treatment de-escalation: n = 15 (5.1%), adverse event (e.g. infection, side effect, intolerance): n = 36 (12.2%), blood dyscrasia: n = 4 (1.4%), patient lost to follow up: n = 43 (14.6%), pregnancy: n = 8 (2.7%), other (e.g. malignancy, heart failure, interstitial lung disease): n = 33 (11.2%). Conclusion Our data suggests that prescription of at-home biological therapies has increased significantly between 2017-2021. Amongst patients taking anti-TNF therapies the number of patients discontinuing therapy due to blood dyscrasia was very low. In view of the increasing number of biologic prescriptions and the associated costs of 3-6 monthly blood monitoring, further data to determine the optimal monitoring requirements for patients on biological therapies is needed. Disclosure M.D.J. Gibson: None. J. Wells: None. S. Subesinghe: None.

P016 To rescreen or not to rescreen, that is the question: an evaluation of practice of rescreening for infections when switching advanced therapies in rheumatology patients

Abstract Background/Aims The 2018 British Society for Rheumatology guidelines mandate pre-treatment screening for infections (including tuberculosis [TB], viral hepatitis and HIV) in patients prior to treatment initiation with advanced therapies. It is increasingly common for patients to switch advanced therapies due to inefficacy or intolerance. There is no established guideline stipulating the frequency of rescreening patients for infections when switching advanced therapies. Rescreening is expensive and can delay the prescribing process. This audit reviewed the current practice at a single tertiary rheumatology centre. Methods A retrospective case note analysis of 100 consecutive patients who underwent biologic switch between April 2021 to March 2022 was included. Data extraction included patient demographics, rheumatic diagnosis, drug exposures, co-morbidities including past infections and rescreening tests were undertaken (including T-SPOT.TB, chest X-ray and serological tests for hepatitis B, C and HIV). Results The median age of this cohort (64 female, 36 male) was 53 (IQR 41 - 60). The most common diagnosis was rheumatoid arthritis (n = 62), followed by psoriatic arthritis (n = 27) and ankylosing spondylitis (n = 7). Seven patients were identified as high-risk individuals: two patients with hepatitis B, one with latent TB, one with previous positive TSPOT.TB and three with underlying lung diseases. 69 patients were partially rescreened for infections and 21 patients had a complete re-screen including chest X-ray, TSPOT.TB, HIV serology, HBsAg, Anti-HbC and Anti HCV. 31 patients did not have any re-screening tests when switching to a different biological drug. The range since the previous pre-advanced therapy screening was between 6 months and 5 years. There was no significant difference in the rate of rescreening investigations between those who switched drugs within the same class, versus those switching drug classes (p = 0.874). No new infections, active or latent, were identified on rescreening. The total cost involved in rescreening this cohort of patients was estimated at £5930. Conclusion Our audit data showed that rescreening for infections at 18 months or less has a low yield for identifying new incident infections. The decision to rescreen patients was primarily driven by the clinician’s judgement. It is pertinent to standardise the practice by establishing an evidence-based guideline based on a robust risk assessment which may then lead to long-term cost-savings. Disclosure A. Masood: None. Y. Xiang: None. S. Rose-Hartwell: None. S. Subesinghe: None.

P010 Designing a fast-track pathway for the diagnosis of giant cell arteritis in a busy Ambulatory Emergency Care Unit based on British Society of Rheumatology guidelines

Abstract Background/Aims BSR states: “GCA is a medical emergency. Patients should be evaluated by a specialist ideally on the same working day if possible and in all cases within 3 working days.” Currently in this DGH there is no pathway for diagnosis and management of GCA. Patients are referred from their GP and A&E directly to the Ambulatory emergency care unit (AECU), but it is not guaranteed they will be seen by a specialist within 3 days. We were also receiving inappropriate referrals for possible GCA such as patients under the age of 50 or chronic headache. We have 7-day access to acute ultrasonography in this DGH. We aimed to utilise this service in our fast-track GCA pathway. Aims: 1. All patients with suspected GCA to be seen within 3 working days by specialist. 2. Reduce the number of inappropriate referrals. 3. Reduce irreversible sequelae (visual loss, scalp tissue necrosis and stroke) Methods We developed a fast-track pathway containing referral criteria, directions for obtaining urgent ultrasonography and management advice. This was uploaded onto the intranet and was put up as posters in the AECU (see pathway). Baseline measurement: data were collected from ambulatory care referrals over a 5-month period. 29 patients were referred as possible GCA. After introduction of the pathway, data were re-collected over a 3-month period, with nine patients referred as possible GCA. Results Outcomes measured: The percentage of inappropriate referrals decreased by 16% . The percentage of patients reviewed by rheumatology within 3 days increased from 44% to 78%. The percentage of sequelae did not change. Visual loss occurred in both groups at presentation (transient in one patient). Prior to pathway implementation, 31% of patients referred had raised CRP/ESR. ESR/CRP was not tested in 34% of referrals. Following implementation, 100% of patients had CRP and ESR tested; of these 66% had raised CRP/ESR. Conclusion We have shown that having a fast-track pathway in place results in higher likelihood of a specialist evaluation within 3 days, as per BSR guidelines. To improve we suggest implementation of dedicated same-day AECU appointments for Rheumatology Specialists. Disclosure P.M. Lakhani: None. S. Ali: None. E. Sames: None. P. Agarwal: None. R. Lisk: None.

Prospective study of patients with inflammatory back pain, clinical characteristics and treatment response in ankylosing spondylitis in two centers of rheumatology in South India

Introduction: Ankylosing spondylitis is inflammatory arthritis affecting the spine and peripheral joints more commonly in men of 15 years to 40 years of age and is a part of the spectrum of diseases called spondyloarthropathy. Psoriasis, uveitis, ulcerative colitis, and inflammatory bowel disease form part of the systemic manifestations. There exists a long delay between the onset of inflammatory back pain and being diagnosed with ankylosing spondylitis.Methodology: We set out to study the clinical profile, diagnosis, and management of patients with spondyloarthritis (SpA) prospectively and follow-up over 2 years period. All patients who had inflammatory back pain and diagnosed to have SpA were included in this prospective study in two different centers of Rheumatology. Clinical characteristics, magnetic resonance imaging (MRI)-spine and sacroiliac joints, disease activity using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), and early treatment response were assessed. Other investigations including bloods, X-rays, and screening for biologics were done as and when indicated. We used both synthetic Disease-Modifying AntiRheumatic Drugs (DMARDS) and biosimilars as per the British Society of Rheumatology guidelines and patient choice. Patients were reviewed every 3 months for 1–2 years. The response to treatment was assessed and compared with other studies.Results: Forty -two patients were studied in this 2 years period (15 patients out of 57 lost to follow up). All patients had the diagnosis of ankylosing spondylitis as per Assessment of Spondylo Arthritis international Society (ASAS Score) criteria and MRI evidence of sacroiliitis and 22 patients had peripheral synovitis. HLA-B27 was positive in 11/19 patients. Eleven patients had been on anti-Tumor Necrosis Factor (TNF) drugs and 26 patients were on DMARDs. At the end of 24 weeks, disease activity indices including BASDAI and BASFI were low in remission and statistically significant. At the end of 2 years, most of them were in remission and 81% were continuing to work and maintain productivity. Patients who underwent treatment with biosimilar TNFs showed a significant reduction in disease activity and achieved remission earlier, as evidenced by BASDAI and BASFI scores, compared to others who were on DMARDS and supportive therapy. The usage of DMARDS was more than biosimilar drugs as they are expensive.Conclusion: This study shows the real-world data on the diagnosis and management of patients with ankylosing spondylitis, achieving remission, and maintaining the work-life balance. Early diagnosis with MRI and appropriate intervention with DMARDS are the important factors in this study.

Менеджмент пацієнтів з ревматоїдним артритом у періопераційному періоді

Пацієнти з ревматоїдним артритом (РА), незважаючи на успіх консервативної терапії, мають високу потребу у проведенні ортопедичних хірургічних втручань, а також операцій за соматичними показаннями. Таким пацієнтам необхідна ретельна періопераційна оцінка та підготовка для досягнення сприятливих результатів оперативного лікування й менеджменту в післяопераційному періоді. Повинен бути зібраний детальний анамнез, проведено детальне фізикальне обстеження з відповідною лабораторною оцінкою функції органів і систем, з диференціюванням ураження органів, вторинного щодо РА або пов’язаного з коморбідними станами. Слід поінформувати пацієнтів про потенційні ризики хірургічного втручання, зокрема підвищення ризику інфікування, уповільнення загоєння ран і розвиток венозних тромбоемболій, а також про основні можливі серцево-судинні, легеневі й неврологічні порушення, що можуть бути зумовлені хірургічним втручанням. В оглядовій статті підбито підсумки останніх досягнень у цій галузі та розглянуто останні рекомендації, запропоновані Американською колегією ревматологів і Американською асоціацією хірургів, щодо періопераційного ведення й тактики антиревматичної терапії в пацієнтів перед тотальним ендопротезуванням колінних і кульшових суглобів 2017 року і керівництво з біологічної безпеки хворобомодифікуючих антиревматичних препаратів (ХМАРП) Британського товариства ревматологів при запальних артритах. Менеджмент ХМАРП у передопераційному періоді має здійснюватися згідно з рекомендаціями основних провідних ревматологічних спільнот, але підхід повинен бути індивідуалізований, із залученням мультидисциплінарної команди. На сьогодні рекомендації підтримують продовження прийому синтетичних ХМАРП упродовж усього періопераційного періоду й рекомендують короткочасне переривання біологічної терапії на один інтервал дозування перед операцією з продовженням прийому через 14 днів після операції. Більш високі дози глюкокортикоїдів роблять значно більший внесок у ризик післяопераційної інфекції, аніж біологічна терапія. Рекомендується уникати планової операції в пацієнтів, які приймають преднізолон в дозі більше за 20 мг/д. Рекомендується зниження дози глюкокортикоїдів до мінімально можливої перед операцією. Незважаючи на те, що невизначеність залишається, ці недавні дослідження та рекомендації дозволяють більш раціонально і науково обґрунтовано підходити до ведення пацієнтів з РА, яким заплановано хірургічне втручання або яким необхідно провести її терміново.

P006 The potential of colour Doppler ultrasound in reducing temporal artery biopsies in suspected giant cell arteritis

Abstract Background/Aims Giant cell arteritis (GCA) is an emergency. The initial treatment with high dose glucocorticoids (GC) is often started on clinical suspicion without waiting for temporal artery biopsy (TAB) results. Colour Doppler ultrasound (CDUS) is a simple, non-invasive test which is readily available. However, like any other ultrasound, it is operator dependent. Non-compressible ‘halo sign’ is the most specific abnormality on CDUS. British society for Rheumatology (BSR) guidelines advises to avoid TAB in patients with low clinical probability and negative CDUS as well as in high clinical probability and positive CDUS. Methods We adopted the quality improvement methodology for assessment. Retrospective data of suspected GCA patients was collected over the last two years. CDUS was introduced to investigative plan midway, after eleven months. Two rheumatology consultants were trained in CDUS. Results were compared before and after the introduction of ultrasound as a diagnostic tool. In collecting the data, our main focus for documentation was based on clinical symptoms, CDUS and TAB results. Patient were divided into high, medium and low probability groups based on clinical assessment by a rheumatologist. Final diagnosis was decided on the basis of clinical assessment at 6 months. Results It was a retrospective review from January 2018 to November 2019, 101 patients were referred with suspected GCA. Median age was 72 years (50 - 91 years) with male to female ratio of 1:3. Thirty five patients were referred in the first 11 months and 28.6% were diagnosed with GCA. CDUS and TAB was done in 20% and 49% of patients respectively. Sixty six patients were referred in the next 12 months after CDUS was introduced and 21.2% were diagnosed as GCA. CDUS and TAB were done in 82% and 38% of the patients respectively. We reviewed all TABs in the second phase of QIP (38%). As per current BSR guideline, 8 TABs could have been avoided in patients with positive CDUS and high probability of GCA or negative CDUS and low probability of GCA. Even if we deduct these 8 TABs from total of 25, 26% of our suspected GCA referrals would still require TAB for diagnostic workup. Conclusion After the routine introduction of CDUS, the percentage of patients requiring TAB has declined. Approximately one fourth patients would still require TAB as per BSR guidelines. To improve the clinical relevance of biopsies further we recommended; the routine use of GCA probability score, improve CDUS skills and arrange availability of urgent slots in clinic for CDUS. We also noticed that the number of patients referred has almost doubled. This might be due to better education and awareness at the primary and secondary care level which was done as part of the project. Disclosure A.A. Sidhu: None. A. Nandagudi: None. A. Bharadwaj: None.

P037 DMARDs & hepatitis E: the hidden culprit

Abstract Background/Aims Disease-modifying anti-rheumatic drugs (DMARDs) require blood monitoring as recommended by the British Society for Rheumatology guidelines. Deranged liver function tests are a common abnormality, and when a significant transaminitis occurs further investigations are required. We wish to present three cases where a transaminitis was caused by acute hepatitis E. Hepatitis E rarely causes illness in the general population. Transmission can occur via sewage-contaminated food and water, undercooked or raw pig and game meat, or processed pork and shellfish. Blood transfusion and solid organ transplantation is very rare. There is an estimated 60,000 cases of Hepatitis E per year in England. Those who are immunosuppressed are more likely to develop chronic liver disease. Methods . Results Case 1 is 55 year old male with a seronegative inflammatory arthritis treated with methotrexate and sulfasalazine whose ALT rose to 2043 U/l. After a negative liver screen including autoantibodies, Hepatitis E IgM was detected. Case 2 is a 71 year old male with seropositive rheumatoid arthritis prescribed Methotrexate and Sulfasalazine who developed a transaminitis following a holiday to Spain. Hepatitis E serology was positive. Case 3 is a 65 year old male with seropositive rheumatoid arthritis on Abatacept and Methotrexate who also developed deranged liver function tests following a trip to Spain. Alcohol excess was initially suspected due to the consumption of > 20 units per week. However, on cessation of all medications the ALT continued to rise to 1087 U/l. He was found to be Hepatitis E IgM positive with viral PCR also detected. In all three cases contaminated food was likely to be the source of infection and DMARDs were successfully restarted in all patients following normalisation of liver function tests. Conclusion This case series highlights an important differential for transaminitis with very little published literature. Hepatitis E is under reported and not routinely requested in practice as part of a liver screen. Failure to check Hepatitis E serology may lead to DMARDs being discontinued inappropriately. All patients should be educated about the risks of Hepatitis E from food products.We recommend that DMARDs are suspended once Hepatitis E infection has been diagnosed in order to allow the immune system combat the infection. Treatment is usually self limiting, though in severe cases Ribavirin has been used with good effect. DMARDs should be restarted once liver markers normalise, and two serum Hepatitis E RNA results and two stool samples are negative. The presence of persistent Hepatitis E RNA (viral shedding) is highly suspicious for chronic infection, which would warrant hepatology input. Disclosure G.A. Brown: None. L. Kearney: None. E. Warner: None. S. Ellis: None.

P038 Is it all in the eyes?

Abstract Background/Aims The ocular manifestations of giant cell arteritis (GCA) and ocular myasthenia gravis (OMG) have significant overlap, which can lead to clinical uncertainty in the absence of awareness and routine diagnostic testing. Methods We present the case of a 63-year-old male patient with a strong family history of autoimmune disease. He presented to the Rheumatology department in 2009 with symptoms of polymyalgia rheumatica (PMR) and was treated successfully with a reducing regime of Prednisolone. In 2013, he presented to the Ophthalmology department with blurred vision and diplopia. Giant cell arteritis was suspected and a high dose of Prednisolone was started. His temporal artery biopsy was normal and inflammatory markers were not raised, but there was a complete resolution of his symptoms since starting steroids. Under the care of the Rheumatology department, reducing regimes of Prednisolone were attempted and a steroid sparing agent, Methotrexate was introduced. Unfortunately, he continued to have recurring symptoms of blurred vision and diplopia, particularly at Prednisolone doses less than 20mg. Over the course of a few years, there was a progression of his ocular symptoms. He developed a horizontal diplopia, monocular ptosis and a 4th nerve palsy. He was referred back to the Ophthalmology department, where alternate diagnoses were investigated. Anti-acetylcholine receptor antibodies (AChR) were strongly positive at 35 mU/L (normal <0.44 mU/L). MRI head was normal, and CT chest showed no thymoma. Single fibre EMG confirmed severe OMG. Our patient was subsequently commenced on Pyridostigmine, with which symptoms improved. Results The literature on OMG mimicking GCA is sparse. The prevalence of an exclusively ophthalmic presentation in patients with GCA is 1 in 5. Ocular signs and symptoms in GCA can vary drastically due to the propensity of the disease to affect different structures within the eye. Transient and permanent visual loss, affects 10-30% of GCA patients due to anterior ischemic optic neuropathy. Diplopia affects 5% of GCA patients. In comparison, OMG can be the only presenting feature in 15% of patients with Myasthenia Gravis, and is characterised by unilateral ptosis, oculomotor paresis and binocular diplopia. Conclusion This case highlights the clinical similarities of OMG and GCA, and that OMG should be considered as a differential diagnosis when the clinical picture of GCA does not truly fit. In patients presenting with GCA with ocular symptoms, normal inflammatory markers and no systemic features, OMG should be considered and AChR antibody testing be performed. More awareness of OMG is needed. We also propose that OMG should be included as a differential diagnosis, in the British Society of Rheumatology guidelines for GCA. Disclosure A. Gharatya: None. J. Wajed: None. N. Cernovschi: None. D. Christidis: None.

Assessment of glucocorticoid tapering in large vessel and anti-neutrophil cytoplasmic antibody-associated vasculitides.

Glucocorticoids (GC) remain integral to large vessel vasculitis (LVV) and ANCA-associated vasculitis (AAV) treatment. We aimed to assess real-world GC tapering trajectories among patients referred for LVV or AAV and identify factors associated with 'delayed' tapering. Patients first assessed at a vasculitis clinic July 2017-August 2019 for LVV or AAV and taking GC were included. Delayed tapering was defined as prednisone >10 mg above target based on tapering recommendations (2010 British Society of Rheumatology Guidelines for Giant Cell Arteritis, 2015 CanVasc AAV Recommendations). We compared characteristics of patients with delayed and appropriate tapering and assessed barriers to timely tapering though chart reviews and referring physician surveys. 160 patients (65 LVV, 95 AAV) were taking GC at their first visit. Among the 42 (26%) patients with delayed tapering, mean daily prednisone dose was 39.2 mg (SD 14) compared to a target of 15.2 mg (SD 15). Pulse GC were administered to 19/42 (45%) patients with delayed tapering compared to 26/118 (22%) with appropriate tapering (p<0.05). Mean Birmingham Vasculitis Activity Score at treatment onset and GC duration were not significantly different between the two groups. Vision loss and/or stroke was more frequent in LVV referrals who experienced delayed (9/21, 43%) vs. appropriate (6/44, 14%) tapering (p<0.05). Managing risk of vasculitis flare was the most common challenge to tapering GC among surveyed referring physicians. In one quarter of patients referred for LVV or AAV taking GC, tapering was slower than recommended. Promoting timely tapering may reduce GC toxicity.

EP01 Audit of the monitoring and documentation of DAS28 score in patients prescribed high cost DMARDs for rheumatoid arthritis every 6 months according to British Society for Rheumatology guidelines

Abstract Background DAS28 is a measure of disease activity in rheumatoid arthritis (RA) which is comprised of the number of tender and swollen joints, inflammatory markers and visual analogue score. Both NICE and British Society of Rheumatology recommend DAS28 is recorded at least every 6 months in patients with RA, to monitor disease activity and ensure adequate response to treatment. CCG mandate 6 monthly DAS28 scores for patients on high cost DMARDs in order to secure funding. Absence of DAS28 scores results in CCGs refusing to fund treatment at the expense of the Trust. Methods Our aim was to review whether a DAS28 was documented in every consultation and if it meets the audit standard of a review every 6 months. If the 6 month target is not met, to understand the reason for this and to suggest ways to meet the standard. Blueteq is the software used to identify all patients with a diagnosis of RA between January 2014 and January 2019 at Royal Surrey County Hospital (RSCH). Clinic letters were reviewed to identify whether a DAS28 score was recorded, the date it was recorded and whether this was done within 6 months. Results In total, 207 patients are prescribed high cost DMARDs for RA at RSCH. 166 (80%) patients have a documented DAS28, but 41 (20%) patients did not have a documented DAS28. 14 (7%) patients have a documented DAS28 at least 6 monthly. 152 (73%) patients did not meet the audit standard. Conclusion Documentation of DAS28 in clinic letters at RSCH does not meet the audit standard. However, these scores have been recorded on Blueteq in order to satisfy CCG requirements. There needs to be consistency in where DAS28 is recorded. Factors contributing to an absence of a documented DAS28 in clinic letters include: no recent inflammatory markers, patients not receiving clinic appointments scheduled at the correct interval, patients not attending clinic, limited follow-up clinic capacity. DAS28 documentation can be improved by incorporating a table into each rheumatology clinic letter template. On initiation of a high cost therapy, the importance of regular blood monitoring and clinic attendance should be reiterated to patients as well as to the appointments booking team. An early arthritis pathway already exists, which can be extended to incorporate a high cost DMARD pathway detailing how to achieve target documentation. Disclosures: K.F.W. Tsoi: None. A. Sahni: None. B. Selvanayagam: None. M. Memon: None.

Temporal artery biopsies: a retrospective audit of compliance with british society for rheumatology guidelines

Temporal artery biopsies: a retrospective audit of compliance with british society for rheumatology guidelines

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

ObjectivesWe aimed to conduct a large audit of routine care for patients with ANCA-associated vasculitis.MethodsWe 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.ResultsWe 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.ConclusionWe 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.

The compliance of guidelines set by the British Society for Rheumatology for managing Gout

Gout is a form of arthritis that is caused by the build-up and deposition of monosodium urate crystals in the joints of the body and surrounding areas. Guidelines for the management of gout have been produced by the British Society for Rheumatology (BSR) which are based on expert opinion and evidence supported by a systematic review of literature. The aim of this audit is to establish how well these guidelines are being followed in general practice. By gaining access to the electronic patient record at the practice, compliance to the BSR guidelines can be assessed by review of patient notes. Results showed that the practice was not following the guidelines with respect to gout management and many patients were not receiving the gold standard of gout care. Changes need to be implemented which should see an improvement in the detection and monitoring of gout in primary care.

18. Hot off the Presses - Applying the 2017 British Society for Rheumatology Guidelines in a Patient with Polyarticular Tophaceous Gout and Renal Impairment

18. Hot off the Presses - Applying the 2017 British Society for Rheumatology Guidelines in a Patient with Polyarticular Tophaceous Gout and Renal Impairment