Diagnosis Of Inflammatory Arthritis Research Articles

Non-pharmacological interventions and corticosteroid injections for the management of the Achilles tendon in inflammatory arthritis: a systematic review

BackgroundAchilles tendon (AT) pathologies, particularly Achilles enthesitis, are common in inflammatory arthritis (IA). Although there are various non-pharmacological interventions and injection therapies available, it is unknown if these interventions are effective for people with IA, as this population is often excluded from studies investigating the management of AT pathologies. This study aimed to identify and critically appraise the evidence for non-pharmacological interventions and corticosteroid injections in the management of AT pathology in those with IA.MethodsAll studies which met the inclusion criteria (AT interventions in adults with a working clinical diagnosis of IA, English language) were identified from the following databases: Medline, Embase, CINAHL and the Cochrane Library. The search strategies used the search terms ‘spondyloarthropathies’, ‘inflammatory arthritis’, ‘achilles tendon’, ‘physical therapy’, ‘conservative management’, ‘injections’, and related synonyms. Studies included were quantitative longitudinal design, such as randomised controlled trials, pseudo randomised and non-randomised experimental studies, observational studies, cohort studies, and case control studies. All outcome measures were investigated, quality assessment to determine internal and external validity of included studies was undertaken, and qualitative data synthesis was conducted.ResultsOf the 10,911 articles identified in the search strategy, only two studies that investigated the efficacy of corticosteroid injections for the management of the AT in IA met the inclusion criteria, and no studies were identified for non-pharmacological interventions. Both injection studies had low quality rating for internal and external validity, and thus overall validity. The included studies only investigated two outcome domains: pain and ultrasound (US) (B Mode and Doppler) identified abnormalities and vascularity in the AT. There is weak evidence suggesting a short-term improvement (6–12 weeks) in pain and for the reduction in some abnormal US (B-Mode and Doppler) detectable features (entheseal thickness, bursitis, and entheseal vascularity) at the AT and surrounding structures post-corticosteroid injection.ConclusionWeak evidence is available regarding the efficacy of corticosteroid injections in reducing pain and inconclusive evidence for the improvement of abnormal US detectable features. No studies were identified for non-pharmacological interventions. It is evident from the lack of relevant literature that there is an urgent need for more studies assessing non-pharmacological interventions for the AT in people with IA.

Accuracy of diagnoses of inflammatory arthritis in administrative hospitalization databases.

Studies using administrative hospitalization data often classify patients as having inflammatory arthritis based on diagnoses recorded at the hospitalization. We examined the agreement of these diagnoses with patients' prior medical histories. We identified Medicare beneficiaries hospitalized in 2011 to 2015 for total hip arthroplasty (THA), total knee arthroplasty (TKA), acute myocardial infarction (AMI), or sepsis. We compared diagnoses of rheumatoid arthritis (RA) or ankylosing spondylitis (AS) at the index hospitalization to diagnoses over prior inpatient and outpatient claims. To assess the impact of potential misclassification, we compared hospital outcomes using the alternative methods of detecting beneficiaries with arthritis. Analyses were repeated using Medicaid data. Among 506 781 Medicare beneficiaries with THA, 18282 had RA and 571 had AS at the arthroplasty hospitalization, while 13 212 had RA and 1519 had AS based on claims history. Diagnoses at the hospitalization were highly specific (0.98-0.99), but sensitivities (0.65 for RA; 0.31 for AS) and positive predictive values (PPV) (0.47 for RA; 0.83 for AS) were lower. For TKA, AMI, and sepsis, specificities were 0.97 to 0.99, sensitivities 0.60 to 0.66 for RA and 0.18 to 0.22 for AS, and PPVs 0.43 to 0.47 for RA and 0.73 to 0.77 for AS. In Medicaid, sensitivities were 0.21 to 0.67 for RA and 0.07 to 0.49 for AS. Frequencies of some hospital outcomes differed when arthritis was classified by the index hospitalization or claims history. Diagnoses of RA and AS in hospitalization databases are highly specific but fail to identify large proportions of patients with these diagnoses.

Bone changes in early inflammatory arthritis assessed with High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT): A 12-month cohort study.

Erosion development is of crucial significance as it impacts prognosis and therapy decisions in patients with inflammatory joint diseases. Our study aimed to determine the sensitivity of high-resolution peripheral quantitative computed tomography (HR-pQCT) to detect change of bone surface over time and to identify erosion development in early inflammatory arthritis (EIA) patients. Moreover, the contribution of prognostic factors on periarticular bone damage in the first year of diagnosis assessed by HR-pQCT was explored. 46 patients with arthritic symptoms for less than one year, and a clinical diagnosis of inflammatory arthritis were prospectively imaged at baseline and 12-months. HR-pQCT scans of the 2nd and 3rd MCP joints and CR of the hands and feet were performed. Joint space width (JSW), total bone mineral density (Tt.BMD), erosion presence and volume were assessed with HR-pQCT. Scan-rescan precision was assessed to define an individual-level least significant change (LSC) criterion. Regression analyses explored prognostic factors for bone damage progression. We observed no significant group-level changes in JSW, Tt.BMD or erosion volume. 20% or fewer joints demonstrated individual-level changes greater than the LSC criterion for mean JSW, Tt.BMD and erosion volume. HR-pQCT detected more erosions than CR in the 2nd and 3rd MCP. Increased symptom duration at diagnosis was weakly associated (P<0.10) with lower JSW minimum and higher JSW standard deviation. Gradual degradation of JSW, proportional to symptom duration, was detected by HR-pQCT. EIA patients need to be closely monitored for exacerbation of arthritis and progression of periarticular bone damage.

Social isolation due to the COVID-19 pandemic has led to worse outcomes in females with inflammatory arthritis.

BackgroundProlonged social isolation as a result of the COVID-19 global pandemic has been a source of considerable psychological distress for many people. This can manifest in many ways and if left undetected can impact negatively on general health. It is essential to understand the impact of these conditions on inflammatory arthritis (IA) patients, especially axial spondyloarthropathy (axSpA).AimTo capture the level of psychological distress for patients with IA following prolonged social isolation.MethodsA survey was sent out to patients with a confirmed diagnosis of IA. This captured changes in sleep, mood, disease activity, employment and general health since the beginning of the social isolation period. A PHQ-4 (Patient Health Questionnaire) was included to determine level of psychological distress.ResultsFemales with IA reported significantly higher rates of decline in general health (40% vs 16%, p = 0.01), mood disturbance (43.4% vs 26%, p = 0.03) and increased disease activity (50% vs 16%, p = 0.01) compared to males. Evaluating the mean PHQ-4 scores, no significant difference was noted between genders (4.80 vs 3.44, p = 0.10). However, females demonstrated a non-significant trend toward increased rates of moderate to severe psychological distress (40% vs 30%, p = 0.13). Subanalysis of patients with axSpA found high rates of moderate to severe distress in both genders.ConclusionsFemales with IA reported significantly higher rates of decline in general health, mood disturbance and increased disease activity during the period of social isolation. This was reflected in a trend towards greater levels of psychological distress.

Performance of Ultrasonography Compared to Conventional Radiography for the Diagnosis of Osteoarthritis in Patients With Knee Pain.

Purpose: To investigate the performance of ultrasonography (US) for the detection of knee osteoarthritis (OA) in patients suffering from knee pain, compared to conventional radiographs.Methods: Cross-sectional study performed at a university teaching hospital. Consecutive patients complaining of unilateral or bilateral mechanical knee pain who signed an informed consent were included. All patients underwent simultaneously an ultrasonographic and a radiographic evaluation of the knee. Exclusion criteria were age under 18 years, prior diagnosis of knee OA, diagnosis of inflammatory arthritis, history of knee surgery or trauma, severe knee deformities, and corticosteroid injection within the last 2 months. The diagnostic properties of US for the detection of knee OA were evaluated using radiological data as the reference method. Evaluated test properties were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the positive and negative likelihood ratio (LR+ and LR–).Results: Three-hundred twenty-two knees (281 patients) were included. Radiographic degenerative changes were present in 56.8% (183) of the evaluated knees. Regarding the diagnostic properties of the US, the presence of either osteophytes or the compromise of the femoral hyaline cartilage had the best sensitivity to detect OA (95%), with a NPV of 92% and a LR– of 0,07, while the combined identification of osteophytes and compromise of the femoral hyaline cartilage had the best specificity (94%), with 94% PPV and a LR+ of 13.Conclusion: US demonstrated an excellent sensitivity with an adequate specificity for the detection of radiographic knee OA.

Increased primary care use for musculoskeletal symptoms, infections and comorbidities in the years before the diagnosis of inflammatory arthritis

ObjectivesLittle is known about relevant events in the at-risk phase of rheumatoid arthritis before the development of clinically apparent inflammatory arthritis (IA). The present study assessed musculoskeletal symptoms, infections and...

OP0010 EFFECTIVENESS OF THE MAKING IT WORK™ PROGRAM AT IMPROVING PRESENTEEISM AND WORK CESSATION IN WORKERS WITH INFLAMMATORY ARTHRITIS – RESULTS OF A RANDOMIZED CONTROLLED TRIAL

Background:Arthritis often leads to presenteeism (decreased at-work productivity), missed days from work and permanent work disability, leading to reduced quality of life and high costs to individuals and society. Yet, health services addressing the employment needs of people with arthritis are lacking.Objectives:We evaluated the effectiveness of the Making-it-WorkTM(MiW) program, an online self-management program developed to help people with inflammatory arthritis (IA) deal with employment issues.Methods:A multi-center RCT evaluated the effectiveness of MiW at improving presenteeism and preventing work cessation (WC) over two years. Participants were recruited from rheumatologist practices, consumer organizations and arthritis programs, in three Canadian provinces. Eligibility criteria: diagnosis of IA, employed, age 18-59, and concerned about ability to work. Participants were randomized 1:1 to MiW or usual care plus printed material on workplace tips. MiW consists of five online self-learning modules and group meetings, and individual vocational counselling and ergonomic consultations. Questionnaires were administered every 6 months. Outcomes were presenteeism [Rheumatoid Arthritis Work Instability Scale (RA-WIS)], time to WC ≥ 6 months, and time to WC ≥ 2 months (secondary outcome). Baseline characteristics (age, gender, ethnicity, occupation, education, disease duration and self-employment) were collected. Intention-to-treat (ITT) longitudinal analysis of RA-WIS using linear mixed effect regression models with 2-year comparison as primary endpoint and survival analysis for time to WC using Kaplan-Meier and Cox Proportional Hazard models were performed. Robustness analyses were conducted by using various missing values imputation methods like last observation carried forward, imputation using worse possible outcomes and model-based multiple imputations; using square root transformation of RA-WIS outcome; and adjusting for baseline covariates. SAS version 9.4 was used.Results:A total of 564 participants were recruited, with 478 (84.75%) completing 2-year follow-up. Baseline characteristics were similar between groups. Mean RA-WIS scores were significantly lower in the intervention group from 6 months onwards, with the greatest difference observed at 2 years (-1.78, 95%CI: -2.7, -0.9, p &lt; .0001), yielding a standardized effect size of 32%. Satisfactory robustness was observed. Work cessation occurred less often in intervention than control groups, but only reached statistical significance for WC ≥ 2 months (WC ≥ 6 months: 31 versus 44 events, aHR 0.70, 95%CI: 0.44, 1.11, p = 0.13; WC ≥ 2 months: 39 versus 61 events, aHR: 0.65, 95%CI: 0.43, 0.98, p = 0.04).Conclusion:Results of the RCT reveal the program was effective at improving presenteeism and preventing short-term WC. Effectiveness at preventing long-term work disability will be assessed at 5 years. This program fills one of the most important and costly unmet needs for people with inflammatory arthritis.

Immune checkpoint inhibitor-induced inflammatory arthritis: a novel clinical entity with striking similarities to seronegative rheumatoid arthritis.

To determine the clinical and serologic similarities and differences between inflammatory arthritis induced by immune checkpoint inhibitors (IA-irAE) and rheumatoid arthritis (RA). In this retrospective cross-sectional comparative study, 20 patients with IA-irAE were age and sex matched to 40 seropositive and 40 seronegative RA patients. Electronic medical records were reviewed from diagnosis of inflammatory arthritis through May 2019. Arthritis characteristics, treatment, and relevant laboratory and serologic studies were captured. Clinically, IA-irAE differed from seropositive and seronegative RA with respect to disease duration (4.18 versus 11.59 and 13.3months, respectively, p = 0.005 (IA-irAE vs seropositive RA), p = 0.002 (IA-irAE vs seronegative RA)), polyarticular joint involvement at presentation (75% versus 97.5% and 100%, p = 0.013, p = 0.003), absence of erosive changes (5.9% vs 43.6% and 53.8%, p = 0.005, p = 0.001), mean prednisone dose (24.7mg versus 16.53mg and 15.68mg, p = 0.008, p = 0.005), and use of methotrexate (5.0% versus 85.0% and 70.0%, p < 0.0001, p < 0.0001). Serologically, IA-irAE closely resembled seronegative RA. ANA positivity was seen in a minority of patients and did not differ significantly between all groups; however, the ANA staining pattern (speckled) was similar between IA-irAE and seronegative RA (100% versus 75%, respectively) and was not commonly observed in seropositive RA (18.2%). IA-irAE is a new subset of IA that resembles seronegative RA immunologically. Our findings suggest that further study of IA-irAE might provide a window into underlying pathogenic mechanisms of early-stage seronegative RA. Key Points • Comprehensive comparison of clinical features between inflammatory arthritis irAE (IA-irAE) and regular rheumatoid arthritis indicates IA-irAE as a new subset of inflammatory arthritis. • IA-irAE resembles seronegative RA immunologically, suggesting that study of IA-irAE may provide a window into underlying pathogenic mechanisms of early-stage seronegative RA.

P104 Longitudinal patient reported outcome data collected from a smartphone app can map group level trajectories of disease activity over time

Abstract Background Patient-reported outcome measures are a cornerstone of the current early inflammatory arthritis audit and part of the best practice tariff. However, outcome data are collected infrequently meaning longitudinal changes in disease activity cannot be accurately examined. We report results of a twelve-month clinical pilot of a cloud-enabled commercial smartphone app to record patient self-reported disease activity outcome measures to evaluate trends of disease activity in a routine rheumatology setting. Methods Patients with a clinical diagnosis of inflammatory arthritis attending routine rheumatology clinic were offered the opportunity to use a smartphone app to record their disease activity between hospital appointments using the RAPID3. Data from the first twelve months (July 2018 - July 2019) was extracted and latent class modelling using aggregate data was undertaken to explore the trends of disease activity experienced by our patients at a group level. Standard analysis recommendations were followed. Results Over the course of twelve-months, 58 patients used the app to record their disease activity using the RAPID3. These patients had a mean age of 53 and were 76% female. 35 patients had rheumatoid arthritis, 15 patients had psoriatic arthritis and 8 had another inflammatory arthritis. The median number of RAPID3 scores completed per patient was 8 (interquartile range 14), and a total of 706 RAPID3 scores were submitted over the 12 months. Three different trajectories of disease activity were identified among our cohort of patients. The first trajectory showed a low stable plateau of disease activity for six months before further improvement (27 patients:47%) over six months. The second trajectory (23 patients; 40%) showed an initial moderate disease activity which gradually declined over six months before improving markedly in the last three months, returning to moderate disease activity. The final trajectory (8 patients; 14%) identified patients with the highest disease activity which showed a gradual but slow improvement of disease activity over twelve months. These different trajectories show the changing burden of inflammatory arthritis over time. Conclusion Regular longitudinal data collection of patient-reported outcomes via a smartphone app can be used to show distinct group level trajectories of disease activity and could be used to examine changes in outcomes of patients over time. Data such as these could be used at a departmental level to examine the burden of inflammatory arthritis experienced by patients, assist planning future service requirements, and help anticipate the timings of future appointments more accurately for patients. Disclosures P.D.H. Hamann Consultancies; Living With Ltd. Royalties; PH has provided consultancy for and has an options and limited royalty agreement with, Living With Ltd. software company for the development of the smartphone application described in this abstract. N. Minaur None. J.H. Tobias None. E.M. Clark None.

P48 A case of myasthenia gravis presenting to the rheumatology clinic

Abstract Background A 32-year-old Lithuanian lady, with a 6-year history of undifferentiated inflammatory arthritis and autoimmune neutropenia, contacted her rheumatologist reporting a constellation of new symptoms. This began with a month’s history of facial weakness and slurred speech. She progressively experienced nasal regurgitation on drinking fluids, reduced exercise tolerance, as well as difficulty chewing, swallowing, and coughing. Her symptoms initially came on in the evening but subsequently appeared earlier in the day. There were no symptoms suggestive of infection. Her arthritis had been well-controlled on hydroxychloroquine and sulfasalazine. She was previously on methotrexate, but this was discontinued due to plans to conceive. Methods Clinical examination during an urgent outpatient review yielded dysphonic, mildly dysarthric speech. Extraocular movements were normal with no ophthalmoplegia. There was mild lower motor neurone facial weakness and an absent gag reflex. She demonstrated fatiguability on repetitive tongue movements and arm abduction. There were no upper motor neurone or cerebellar signs. Blood tests showed normal inflammatory markers, full blood count, creatine kinase, immunoglobulins, liver, and renal profile. Her anti-nuclear antibody titre, previously weakly positive at time of diagnosis of inflammatory arthritis, was 1:1280 (homogenous). Anti-cyclic citrullinated peptide, rheumatoid factor, and extractable nuclear antigens were negative. Virology screen was unremarkable. Neurology input was sought. Anti-acetylcholine receptor antibody was positive at 5.2nmol/L (normal range 0-0.45nmol/L), anti-muscle specific receptor tyrosine kinase antibody was negative. Nerve conduction studies showed decremental response on repetitive stimulation of her left nasalis, consistent with a post-synaptic neuromuscular junction transmission disorder. There was no evidence of myopathy. Results The clinical symptoms and the investigations led to the diagnosis of myasthenia gravis with predominant bulbar features. Computed tomography showed no evidence of thymoma or thymic hyperplasia. Magnetic resonance imaging of the brain showed no evidence of space-occupying lesion or brainstem abnormality. She initially received pyridostigmine 30mg three times daily with propantheline cover to which she reported a good response. A viral illness led to deterioration of her symptoms of breathlessness and worsening dysphagia resulting in a hospital admission. She received intravenous immunoglobulins 20g daily for three days. Hydroxychloroquine and sulfasalazine were replaced with methotrexate 15mg weekly. She now remains on pyridostigmine 90mg five times daily and 10mg prednisolone daily with good effect. Conclusion Myasthenia gravis is a rare condition (prevalence of 10-20 per 100,000 in the United Kingdom). However, this occurs at a higher prevalence in autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. This case illustrates the importance of remaining vigilant about symptoms which patients may disclose in the rheumatology clinic which may not fit with their known diagnosis. Her previous use of methotrexate for her arthritis could have masked her myasthenic symptoms which became apparent after the drug was stopped for a prolonged period. Disclosures S. Yeoh None. S. Salam None. G. Christofi None. V. Morris None.

P90 Streamlining primary care referrals to an early inflammatory arthritis (EIA) clinic: distinguishing between patients with osteoarthritis and inflammatory arthritis

Abstract Background To use biochemical markers and ultrasound to differentiate between inflammatory and noninflammatory diagnoses in the early inflammatory arthritis (EIA) referral setting. Careful patient selection is crucial to ensure timely and efficient use of secondary care resources. Methods A retrospective audit of the EIA pathway was conducted over six months at two partnered district general hospitals in London in 2018. For each of the 75 patients studied, data collected included demographics, biomarkers of disease and inflammation, appointments dates, details of scans requested, and the clinical diagnosis made at the EIA appointment. Statistical tests included pairwise comparisons using Welch’s 2-sample t-test for continuous variables and two-sample chi squared tests for equality of proportions with continuity correction for categorical variables. Logistic regression models were used, incorporating age, inflammatory markers and serostatus. Goodness of fit was evaluated using the log likelihood method and McFadden’s pseudo-R2. Predictive modelling was carried out using the Caret package. Analysis was conducted in R (R v3.5). Results Over half of participants (59%) were diagnosed with non-inflammatory disorders; the most common diagnosis was osteoarthritis (31%). Rheumatoid Arthritis (15%) was most common amongst the 41% of Inflammatory arthritides (IA). Ultrasound confirmed the clinical diagnosis of IA vs non-IA with 70% accuracy. There were no significant differences between those with and without ultrasound evidence of synovitis in terms of age (p 0.25), CRP (p 0.22), ESR (p 0.59), RF (p 0.43) or CCP (p 1) positivity. This null is likely due to a small sample size and lack of statistical power. Comparison of patients with a clinical diagnosis of IA vs non-IA revealed significantly increased CRP (9.5 vs 4.2 p 0.01) and CCP positivity rates (22.5% vs 0%, p 0.003) in the inflammatory group, with no significant differences in age (p 0.45), ESR (p 0.24), or RF positivity rate (p 0.18). In those with a clinical diagnosis of osteoarthritis, there were a significantly higher age (55.0 vs 43.5, p 0.0009), lower CRP (3.2 vs 7.8, p 0.005), and lower ESR (9.2 vs 19.7, p 0.006). Neither RF (p 0.73) nor CCP (p 0.16) positivity rates differed significantly between osteoarthritis or other diagnoses. Conclusion It was demonstrated that even in small cohorts, simple predictive variables can be used to risk-stratify and assess the likelihood that a patient will have osteoarthritis rather than IA. It is shown that older age, lower ESR and lower CRP are indicators at differentiating IA from non-IA. Given the national high prevalence of osteoarthritis and the clinical uncertainty in distinguishing osteoarthritis from IA, ultrasound has significant value in the diagnostic work-up. Further research should attempt to predict eventual diagnosis from clinical characteristics alone to help general practitioners distinguish patients with IA from those with non-IA. Disclosures B.M. Jacobs None. N. Sarathchandra None. M. Karela None. L.E. Daniels None. N. Purkayastha None.

Early Diagnosis Of Inflammatory Arthritis By Primary Care Physicians Following Training By A Rheumatologist.

BackgroundEarly diagnosis and therapeutic management of inflammatory arthritis (IA) is crucial for minimizing disease progression and improving outcomes. We recently developed the New Early Arthritis Referral Criteria to help improve the detection of suspected early IA via musculoskeletal (MSK) examination. The present study aimed to evaluate the agreement between rheumatologists and primary care physicians (PCPs) trained by rheumatologists in detecting IA when applying the standardized MSK examination techniques used to develop this criteria in a real-world setting in Jeddah, Saudi Arabia.MethodsThis quasi-experimental study was conducted in 4 primary health centers and involved 30 PCPs and 3 rheumatologists. All PCPs were trained by rheumatologists to apply the standardized MSK examination techniques used to develop the New Early Arthritis Referral Criteria. Patients were eligible if they were >18 years of age and presented with small-joint pain that persisted for >6 weeks. Patients were excluded if they had prior diagnosis of osteoarthritis, hand fractures, or rheumatic disease associated with IA. All patients were examined separately by a PCP and a rheumatologist, with the findings compared via kappa statistics and the rheumatologist’s findings considered the “gold standard”.ResultsData from 202 of the 203 enrolled patients were analyzed. There was fair-to-moderate agreement between PCPs and rheumatologists when assessing swelling of the small joints and wrist of the right side (range of kappa: 0.14–0.41) and low-to-moderate agreement in similar examinations of the left side (range of kappa: 0.04–0.42). Assessments of joint tenderness showed fair-to-moderate agreement for both the right side (range of kappa: 0.22–0.47) and left side (range of kappa: 0.24–0.45). P-values were significant for virtually all comparisons.ConclusionMSK examinations by PCPs showed a promising extent of agreement in detecting IA with those by rheumatologists following training. Refinement of the standardized training process could further improve accuracy and help PCPs to confidently identify cases of early IA, thus allowing earlier intervention than is typical in this setting.

Treatment Patterns with Disease-Modifying Antirheumatic Drugs in U.S. Veterans with Newly Diagnosed Rheumatoid Arthritis, Psoriatic Arthritis, or Ankylosing Spondylitis.

Delays in treatment for inflammatory arthritis (IA) are associated with unfavorable outcomes, including impaired quality of life, irreversible joint damage, and disability. To characterize treatment initiation patterns in veterans with newly diagnosed rheumatoid arthritis (RA), psoriatic arthritis (PsA), or ankylosing spondylitis (AS). ICD-9/10-CM codes and natural language processing were used to identify incident cases of RA, PsA, or AS between January 1, 2007, and December 31, 2015, in patients enrolled in the Veterans Health Administration. Patterns of treatment initiation and nontreatment with disease-modifying antirheumatic drugs (DMARDs) were assessed in the 12-month follow-up period after the incident diagnosis. Outcomes included the percentage of veterans treated with a DMARD, the mean time to the initial DMARD after diagnosis, and the percentage of veterans who accessed rheumatology care before DMARD initiation. To assess outcomes over time, veterans were grouped by year of initial IA diagnosis. Additionally, outcomes were compared between nonbiologic and biologic DMARDs and among IA subtypes (RA, PsA, and AS). Groups were statistically compared with 95% confidence intervals. The population consisted of 12,118 IA veterans (9,711 RA, 1,472 PsA, and 935 AS), with 91.3% males and a mean age of 63.7 years. The percentage of veterans treated with ≥ 1 DMARD (nonbiologic or biologic) during the 12-month follow-up period increased from 48.8% in 2007 to 66.4% in 2015. In veterans diagnosed with IA in 2015, DMARD treatment was more common for PsA patients (72.9%) and RA patients (68.6%) than for AS patients (28.9%). In the subset treated with a DMARD within 12 months after diagnosis, the mean time to the initial DMARD after diagnosis did not change throughout the observation period (35.5 days for RA, 43.9 days for PsA, and 59.5 days for AS). Rheumatology specialty care was accessed by 87.4% of veterans treated with a nonbiologic DMARD and 92.2% of veterans treated with a biologic DMARD, in patients diagnosed in 2015. DMARD treatment rates during the initial 12 months after diagnosis increased between 2007 and 2015, but nontreatment remained common, particularly in veterans with AS. The time to treatment after diagnosis was stable over time; it was shortest for RA, intermediate for PsA, and longest for AS. DMARD treatment was uncommon in veterans who did not access rheumatology specialty care. AbbVie Pharmaceuticals and Marriott Daughters Foundation funded this study via investigator-initiated grants. Data analyses were completed by investigators independent of AbbVie and Marriott Daughters Foundation. Walker, Clewell, and Douglas are employed by, and stockholders in, Abbvie. Halwani reports grants from BMS, Kyowa Hakko Kirin, Seattle Genetics, Roche-Genentech, Miragen, Immunedesign, Takeda, Amgen, Pharmacyclics, and Abbvie. The other authors have nothing to disclose.

Opioid Use among Patients with Early Inflammatory Arthritides Compared to the General Population.

To assess to what extent the worldwide opioid epidemic affects Finnish patients with early inflammatory arthritis (IA). From the nationwide register maintained by the Social Insurance Institution of Finland, we collected all incident adult patients with newly onset seropositive and seronegative rheumatoid arthritis (RA+ and RA-) and undifferentiated arthritis (UA) between 2010 and 2014. For each case, 3 general population (GP) controls were matched according to age, sex, and place of residence. Drug purchases between 2009 and 2015 were evaluated 1 year before and after the index date (date of IA diagnosis), further dividing this time into 3-month periods. A total of 12,115 patients (66% women) were identified. At least 1 opioid purchase was done by 23-27% of the patients 1 year before and 15-20% one year after the index date. Relative risk (RR) of opioid purchases compared to GP was highest during the last 3-month time period before the index date [RR 2.81 (95% CI 2.55-3.09), 3.06 (2.68-3.49), and 4.04 (3.51-4.65) for RA+, RA-, and UA, respectively] but decreased after the index date [RR 1.38 (1.23-1.58), 1.91 (1.63-2.24), and 2.51 (2.15-2.93)]. Up to 4% of the patients were longterm users both before and after the diagnosis. During 2009-15 in Finland, opioid use peaked just before the diagnosis of IA but decreased rapidly after that, suggesting effective disease control, especially in seropositive RA. Further, opioids were used to treat arthritis pain of patients with incident RA and UA less often than previously reported from other countries.

36 Use of Biologics in Older Patients with Inflammatory Arthritis

Abstract Background Biologics are a key component of the treatment armamentarium for inflammatory arthritis (IA). Questions remain surrounding the prescription, efficacy and safety of biologics in the older population. This study aims to describe the use of biologics in older patients with IA and compare it to younger patients. Methods This was a retrospective cohort study of patients with a diagnosis of IA who were receiving a biologic. Data was collected from medical charts at rheumatology outpatient clinics. Patients were divided into two groups: younger group (age 45 – 65) and older group (age &gt;70). Results Each group had 30 patients (total n=60). 58% were female and the mean age overall was 65 years. Rheumatoid arthritis was the most common diagnosis (57%). 8 patients had active disease, and these were mainly older patients (n=6). 8 different biologics featured; the majority of patients received the standard dose of biologic (87% of younger, 80% of older). The incidence of biologic discontinuation due to drug ineffectiveness was the same for both groups (16%). 1 older patient had a biologic discontinued due to a serious adverse event. Infections requiring hospitalisation were not common (total n=5) but were more frequent amongst older patients (n=4). 47% of younger and 60% of older patients received concomitant therapy; most received a disease-modifying antirheumatic drug (DMARD) (72%), and those who received a steroid (n=6) were more likely to be older (n=5). Conclusion Biologic prescribing was similar between both groups with regard to the dosage administered, but there were differences in the types of biologics prescribed to each group. Rates of significant infection were low overall, however they were more prevalent amongst the older population. More older patients had active disease, and more were prescribed concomitant steroid therapy, which may represent under-dosing of biologic therapy in this older cohort.

Centre effects and case-mix in early rheumatoid arthritis observational cohorts: a narrative review.

Observational cohort studies in early RA are a key source of evidence, despite inconsistencies in methodological approaches. This narrative review assesses the spectrum of methodologies used in addressing centre-level effect and case-mix adjustment in early RA observational cohort studies. An electronic search was undertaken to identify observational prospective cohorts of >100 patients recruited from two or more centres, within 2 years of an RA or early inflammatory arthritis diagnosis. References and author publication lists of all studies from eligible cohorts were assessed for additional cohorts. Thirty-four unique cohorts were identified from 204 studies. Seven percent of studies considered centre in their analyses, most commonly as a fixed effect in regression modelling. Reporting of case-mix variables in analyses varied widely. The number of variables considered in case-mix adjustment was higher following publication of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement in 2007. Centre effect is unreported or inadequately accounted for in the majority of RA observational cohorts, potentially leading to spurious inferences and obstructing comparisons between studies. Inadequate case-mix adjustment precludes meaningful comparisons between centres. Appropriate methodology to account for centre and case-mix adjustment should be considered at the outset of analyses.

Development of a methotrexate educational guide/information/monitoring booklet for inflammatory arthritis.

There are over 40,000 people living in Ireland with inflammatory arthritis (IA), a condition that is potentially destructive in nature and can have personal, social and economic consequences. Although we have witnessed dramatic changes in the treatment of IA in the last two decades, methotrexate (MTX) remains the first-line treatment for patients with a diagnosis of IA. Despite the fact that MTX is so commonly prescribed, there is a lack of educational materials both for healthcare professionals (HCPs) and patients. The aim of the present study was to develop a suite of MTX material for patients. A comprehensive literature review of MTX (evidence, educational materials and practice guidelines) in the treatment of IA was undertaken. The content of the documents was developed, and the format and structure of the documents were agreed. A tailored patient educational guide, information/monitoring booklet and alert card were designed to address the lack of educational materials for this condition. A national pilot study of the documents was conducted (a postal questionnaire for patients and electronic survey for clinical nurse specialists). Results and recommendations were incorporated into the final documents. These documents were also incorporated into the National Clinical Care Programme-rheumatology-methotrexate pathway. A 26-page evidence-based educational guide was produced to support the HCP in educating patients taking MTX, in conjunction with a patient information/monitoring booklet and alert card to support the patient. These documents are now widely available and used in clinical practice in Ireland, providing patients with standardized, evidence-based information about MTX.

Inflammatory Arthritis Is a Risk Factor for Multiple Complications After Total Hip Arthroplasty: A Population-Based Comparative Study of 68,348 Patients

BackgroundPatients with inflammatory arthritis (IA) are likely at higher risk of postoperative complications following total hip arthroplasty (THA), from the underlying disease, the degree of articular deformity, and immunosuppressive medications. The purpose of this study was to perform a comparative study of the risk of complications after THA between IA and osteoarthritis. MethodsA national private insurance database was used to select patients undergoing unilateral primary THA. Patients were categorized to the inflammatory cohort if they had a diagnosis of IA and treatment with an IA-specific medication within the year before surgery. Patients with no diagnosis of IA were considered osteoarthritis. Risk of Centers for Medicare and Medicaid Services–reportable complications and 90-day readmission was compared between cohorts using multivariate logistic regression controlling for age, gender, length of stay, comorbidities, and corticosteroid use. ResultsA total of 68,348 patients were included; 2.12% met criteria for IA. Patients with IA were found to have higher risk of transfusion (odds ratio [OR], 1.29; P < .01), mechanical complications (OR, 1.35; P = .01), infection (OR, 1.96; P < .01), and 90-day readmission (OR, 1.35; P < .01). There were no differences in risk of venous thromboembolism or medical complications. ConclusionPatients with IA have significantly higher risk of transfusion, mechanical complications, infection, and readmission following THA. Efforts should be made to optimize their health and medications before THA to minimize their complication risk. Additionally, hospitals should receive commensurate resources to maintain access to THA for patients with IA who are prone to higher resource utilization. Level of EvidenceIII.

Nightmare disorder and REM sleep behavior disorder in inflammatory arthritis: Possibility beyond neurodegeneration.

ObjectivesTo investigate the prevalence of REM sleep behavior disorder (RBD) in patients with inflammatory arthritis (IA) to ascertain if RBD could be an internal red flag signaling a fluctuating state of inflammation based on the theory of “protoconsciousness”.Materials & MethodsOne hundred and three patients with a confirmed diagnosis of IA were consecutively recruited. The patients underwent general (IA activity, functional status, laboratory tests) and neurological evaluations. A neurologist investigated RBD and REM sleep parasomnias in a semi‐structured interview. Sleep quality was assessed with the Pittsburgh Sleep Quality Index, while the risk of obstructive sleep apnea syndrome (OSAS) was evaluated with the Berlin questionnaire. Beck Depression Inventory II and State‐Trait Anxiety Inventory investigated depression and anxiety.ResultsPatients had a mean age of 53.7 ± 14.6 years, 65% were women; 57.3% were in a clinically active phase of IA. Two women fulfilled ICSD‐3 criteria for RBD appearing 11 years after and 20 years before IA onset respectively. 31 patients scored positive for nightmare disorder (ND), 8 for recurrent isolated sleep paralysis. 65 (63.1%) patients reported poor sleep quality and 25 (24.3%) resulted at high risk for OSAS. 32 (31.0%) patients scored positively for depression or anxiety.ConclusionsThe prevalence of RBD in patients with IA did not differ from that in the general population, whereas ND presented a 2‐fold increased prevalence. Whether RBD can be considered a red flag signaling an internal danger remains an open question, while ND may be a new player in this intriguing relation.

Wrist ultrasound - the model method for grey-scale and power Doppler scoring

The use of ultrasound (US) has been at the forefront of aiding diagnosis of inflammatory arthritis since its introduction. More recently, US imaging in patients with clinical remission appears to...