Early Inflammatory Arthritis Clinic Research Articles

P103 Centralised pain in early rheumatoid arthritis predicts worse bodily pain outcomes

Abstract Background/Aims Features of centralised pain, encompassing widespread pain and non-pain features such as multisensory hypersensitivity, fatigue, and sleep disturbance are common in RA. We hypothesise that centralised pain in early RA affects response to standard first-line treatment. Methods Prospective cohort study of adults with a clinical diagnosis of RA recruited from the early inflammatory arthritis clinic, Oxford University Hospitals, who completed an online assessment within two weeks of starting a DMARD. Centralised pain was assessed using three measures: the 2016 Fibromyalgia Survey Criteria (0-31), Central Sensitisation Inventory (CSI, 0-100), and PainDetect (0-38). The primary outcome, bodily pain, was assessed using the Short Form-36 Bodily Pain Scale (BPS), where lower scores indicate worse pain severity. During follow-up, participants completed three sets of follow-up questionnaires at 3-, 6- and 12-months. Linear mixed effects models were used to account for repeated measurements and patient variability. Three models were fitted, for an association between baseline values of each centralised pain measure with BPS over time. An interaction between centralised pain scores with time was fitted to assess for effect of the exposure on change over time. Age, sex, and symptom duration at baseline were included as confounding variables. Ethical approval was granted by South Central Oxford B Research Ethics Committee. Results Of 149 participants, 117 (79%) completed follow-up: median (IQR) age 59.8 (24.6) years; 36% male; 30% with symptoms >1 year at baseline. There were no significant baseline differences among those lost to follow-up, apart from a longer symptom duration (53% vs 30% symptom duration >1 year; P = 0.033). At baseline, median (IQR) Fibromyalgia Survey Criteria, CSI, and PainDetect scores were 12 (6), 36 (17), and 14 (9) respectively. The median (IQR) BPS at baseline was 32.5 (22.5). Measures of centralised pain were moderately-to-strongly correlated with each other, and with BPS. Individuals with symptoms for >1 year had higher scores on the PainDetect (P = 0.0015), but not the CSI (P = 0.0545) or Fibromyalgia Survey Criteria (P = 0.672). After adjusting for age, sex, and symptom duration, there was a significant association between centralised pain at baseline and BPS over follow-up, e.g.; for every unit increase in the fibromyalgia survey criteria at baseline, the BPS decreased by 2.40 (95%CI -3.29, -1.49; P < 0.001) points over follow-up. Similar relationships were seen with the CSI and PainDetect scores. Conclusion Centralised pain measures in early RA patients can be indicative of the severity of bodily pain experienced during the subsequent 12 months after starting a DMARD treatment. Recognising and assessing centralised pain in early RA patients may enable us to tailor more effective and individualised treatment regimens. Further studies, especially those utilising neuroimaging and QST, are essential to elucidate the neural mechanisms underlying the impact of centralised pain on treatment outcomes in RA. Disclosure E. Kelleher: None. A.J. Wall: None. M.T. Sanchez-Santos: None. V. Wanigasekera: None. A. Irani (nee Soni): None.

EP15 A self-limiting symmetrical polyarthritis following COVID-19 infection

Case report - IntroductionWe describe an acute onset self-limiting seronegative non-destructive symmetrical polyarthritis five weeks after laboratory confirmed COVID-19 infection.Case report - Case descriptionA 37-year-old male hospital doctor of presented to the Early Inflammatory Arthritis clinic with a four-week history of acute onset joint pain, swelling and early morning stiffness in excess of two hours. The symptoms began at the left ankle with Achilles’ tendonitis but progressed over the following 72 hours to a symmetrical polyarthritis affecting the wrists, proximal interphalangeal joints, shoulders, elbows, and knees. Approximately five weeks prior to the onset of his joint symptoms he had laboratory confirmed SARS-CoV-2 infection with six days of fever, non-productive cough, and fatigue. He did not require hospitalisation. His past medical history was significant for biopsy proven non-alcoholic fatty liver disease. There was no prior history of inflammatory arthritis and no personal or family history of skin psoriasis, inflammatory bowel disease or uveitis. There was no preceding genitourinary or gastrointestinal upset. His family history was significant for a sister with seronegative rheumatoid arthritis for which she was taking sulfasalazine. Examination revealed a normal BMI, synovitis at the wrists and proximal interphalangeal joints without evidence of joint effusion in the large joints. Blood tests revealed elevations in the ESR (83 mm/hour, reference range 0-10 mm/hour) and CRP (25mg/dL, reference range <5mg/dL). Serology was negative for the rheumatoid factor, anti-CCP antibodies, antinuclear antibodies, and an extractable nuclear antigen panel. Radiographs of the affected joints were unremarkable. Serological testing was positive for anti-SARS-CoV-2 IgG antibodies.He was started on oral Prednisolone 20mg daily and an NSAID with good symptomatic response and normalisation of his ESR (5mm/hour) and CRP (<1mg/dL). The course of prednisolone was tapered over a 6-week period and he is still in steroid free remission with normal inflammatory markers at follow up. The patient was given a diagnosis of a post-viral reactive arthritis which was attributed to the preceding COVID-19 illness. Case report - DiscussionPost infectious inflammatory arthritis has been described with many viral infections including: hepatitis virus, parvovirus B19, enterovirus, rubella, alphavirus (including Chikungunya), flavivirus (including Zika), herpes viruses (including Epstein-Barr virus), varicella, cytomegalovirus and human immunodeficiency virus (HIV). Interestingly, viral arthritis has not been reported in influenza and human coronaviruses (including SARS and MERS). Arthralgia was reported in 14.9% of laboratory confirmed COVID-19 cases in China during the early phases of the pandemic but inflammatory arthritis was not well described. The clinical course of the inflammatory arthritis in this case was self-limiting with enthesitis and synovitis resolving within six weeks of onset with the mainstay of treatment being symptomatic relief in the form of non-steroidal anti-inflammatory drugs and corticosteroids.Patient perspective: When I woke up that Tuesday morning with severe joint pains and stiffness, I knew something was not right. It was not like anything I have felt before in terms of my joints, having had sports injuries in the past. It was to the point where I was even struggling to go from sitting to standing. Without Prednisolone, I feel as if I would not have been able to work and may even have been house bound. I was relieved that this inflammatory arthritis did respond to Prednisolone. After six weeks of taking Prednisolone, the condition seemed to settle. Case report - Key learning pointsA self-limiting episode of inflammatory arthritis may occur following COVID-19 infection.

O37 Utility of RA classification criteria in early inflammatory arthritis referral prioritisation

Abstract Background Early arthritis clinics are increasingly utilised as a method of ensuring patients suspected of disease are assessed promptly to enable suitable treatment. Early recognition with treat to target has been demonstrated in systematic reviews to significantly improve mortality and morbidity outcomes. The United Kingdom’s National Institute for Health and Care Excellence (NICE) recommend potentially affected patients are referred from primary care within 3 days and seen in secondary care within 3 weeks. We hypothesised that utilising the ACR/EULAR 2010 rheumatoid arthritis classification criteria we could identify variables within the primary care referral which make an early arthritis more or less likely. Methods A retrospective study of all the patients seen in early inflammatory arthritis (EIA) Clinic from September 2017 to August 2018 in Aneurin Bevan University Health Board. EULAR scores of 145 patients were calculated based on the data provided in the primary care referral. These scores and their components were then compared to the eventual diagnosis. Results EULAR score of ≥ 5 had specificity of &amp;gt; 78% and sensitivity of &amp;lt; 30% in predicting EIA. EULAR score of 8 or more was 100% specific for EIA with positive likelihood ratio of infinity. Whereas EULAR score &amp;lt; 3 had a specificity of &amp;gt; 70% and sensitivity of &amp;lt; 45% for Non EIA with a positive likelihood ratio of 1.59. Considering individual EULAR components a high positive Rheumatoid Factor (RF) or Anti-citrullinated peptide antibody (ACPA) and involvement of greater than 10 joints had a positive likelihood ratio of ≥ 3.00 for EIA. A low positive RF or ACPA had a specificity of 66.67% and sensitivity of 27.59% for EIA with a positive likelihood ratio of 0.83. Surprisingly involvement of 4-10 small joints or 2-10 large joints or just 1 large joint had a specificity of ≥ 75% for EIA and a positive likelihood ratio of greater than 1.00. A positive ESR or CRP had a specificity of 36.84% and sensitivity of 67.92% with a positive likelihood ratio for EIA of 1.08. A negative ESR and CRP had a specificity of 67.92% and a sensitivity of 35.00% for Non EIA with a positive likelihood ratio of 1.09. The duration of symptoms of &amp;lt; 6 weeks had a specificity of 77.55% and sensitivity of 24.39% with positive likelihood ratio for Non EIA of 1.08, however duration of &amp;gt; 6 weeks had a positive likelihood ratio of 0.97 for EIA with a lower specificity of 22.45% . Conclusion The total EULAR score and individual components can be used to prioritize primary care referrals. A EULAR score of less than 3, duration of symptoms of &amp;lt; 6 weeks, a negative ESR and CRP, a low positive RF or ACPA makes EIA less likely. Disclosures S.M. Imaduddin None. P. O'Biern 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.

Experiences of South Asian patients in early inflammatory arthritis clinic: a qualitative interview study.

ObjectiveThe aim was to explore how UK South Asian patients living with RA interact with health care professionals and experience receiving health information in an early inflammatory arthritis clinic.MethodsA semi-structured interview schedule, designed in conjunction with a patient partner, was used for face-to-face interviews. South Asian participants with RA were recruited from Central Manchester University Hospitals National Health Service Foundation Trust. Data were recorded and transcribed by an independent company. Data were analysed using inductive thematic analysis.ResultsFifteen participants were interviewed. Three predominant themes emerged around participants’ experiences and interaction with health care professionals in early inflammatory arthritis clinic. First, ‘the personal experiences of RA and cultural link to early inflammatory arthritis clinic’, where participants described the impact of RA as individuals and their altered roles within their cultural setting. Second, ‘experiences of interacting and receiving information in the early inflammatory arthritis clinic’, where participants described their limited engagement with health care professionals and the quality of information discussed in the clinic. Third, ‘views on future content for early inflammatory arthritis clinics’, where participants highlighted new innovative ideas to build on current practice.ConclusionWe believe this to be the first study to generate insight into the experiences of South Asian patients of interacting with health care professionals while attending an early inflammatory arthritis clinic. Policy directives aimed at improving access to services and delivery of information for ethnic minority groups in early inflammatory arthritis clinics should include consideration of the different roles of cultures. Professionals should be cognizant of the factors that drive health inequalities and focus on improving service delivery.

Health-care professionals' perceptions of interacting with patients of South Asian origin attending early inflammatory arthritis clinics.

ObjectiveThe aim was to explore the perceptions of rheumatology health-care professionals (HCPs) of interacting with patients of South Asian origin attending early inflammatory arthritis clinics. MethodsWe used face-to-face semi-structured interviews, designed in partnership with a clinician partner, to interview 10 HCPs involved in the running of early inflammatory arthritis clinics across seven centres in the UK. Data were recorded, transcribed by an independent company and analysed using inductive thematic analysis.ResultsThree emerging themes were identified that characterized consulting experiences of HCPs: varied approaches were used in early inflammatory arthritis clinic; the challenges for rheumatology HCPs in managing and delivering information to patients of South Asian origin in early inflammatory arthritis clinics; and moving towards good practice, the views on managing future patients of South Asian origin in early inflammatory arthritis clinics. Overall, HCPs found that they required additional skills to support the engagement and management for patients of South Asian origin living with inflammatory arthritis. The HCPs felt that they were less effective in addressing self-management issues for this patient group, and they found it difficult to determine adherence to medication. In such consultations, HCPs perceived that their own limitation of inadequate training contributed towards poor consultations.ConclusionFor the first time, our data demonstrate that the management of patients of South Asian origin in early inflammatory arthritis clinics is under-served. To address this, HCPs have identified training needs to improve knowledge and skills in engaging with and supporting patients of South Asian origin. These findings provide a good direction for future research.

144 The perceptions and perspectives of rheumatology health care professionals on managing South Asian patients in early inflammatory arthritis clinic

144 The perceptions and perspectives of rheumatology health care professionals on managing South Asian patients in early inflammatory arthritis clinic

I167 Managing rheumatoid arthritis between two worlds: experience of South Asian patients in early inflammatory arthritis clinic

I167 Managing rheumatoid arthritis between two worlds: experience of South Asian patients in early inflammatory arthritis clinic

096 Service evaluation of one-stop provision of diagnostic ultrasound, drug education and therapy services in an early inflammatory arthritis clinic in Salford

096 Service evaluation of one-stop provision of diagnostic ultrasound, drug education and therapy services in an early inflammatory arthritis clinic in Salford

143 I’m managing rheumatoid arthritis between two worlds: experiences of South Asian patients in early inflammatory arthritis clinic

143 I’m managing rheumatoid arthritis between two worlds: experiences of South Asian patients in early inflammatory arthritis clinic

095 Development of an occupational therapy advanced practitioner role within a multidisciplinary early inflammatory arthritis clinic in Salford

095 Development of an occupational therapy advanced practitioner role within a multidisciplinary early inflammatory arthritis clinic in Salford

E37 The early inflammatory arthritis clinic: who do we see and can we predict biologic use?

e37 The early inflammatory arthritis clinic: who do we see and can we predict biologic use?

SAT0589-HPR Body Mass Index and Its Relationship to Disease Activity in Early Rheumatoid Arthritis

BackgroundObesity rates in Canada have increased 3% (to 25%) over the past 8 years. Obese patients develop more severe forms of many diseases and have more comorbidities develop over time....

OP0270-HPR Should A Successful Early Inflammatory Arthritis Clinic Also Address Cardiac Risk?

BackgroundRA patients have higher cardiovascular disease (CVD) risk. There is a 60% increase in the risk of death from cardiovascular causes compared with the general population and, survival rates for...

THU0596 Tight Control with Regular Review for Rheumatoid Arthritis in a DGH - Reduces the Use of Biologic Therapy According to Nice Guidelines even if Moderate Disease Activity was Treated

BackgroundNational Institute of Clinical Excellence Clinical Guideline 79 (NICE CG79) in the UK states that newly diagnosed RA patients should be offered combination DMARDs within 3 months of persistent symptom...

To what extent is NICE guidance on the management of rheumatoid arthritis in adults being implemented in clinical practice? A regional survey

Rheumatoid arthritis (RA) is a chronic disease associated with significant morbidity. The 2009 NICE guidance advises on the management of patients with RA. In this study, we undertook a survey to assess the implementation of the guidance into practice across the Midlands. In total, 19 rheumatology units participated, of which nine have designated early inflammatory arthritis clinics (EIAC). Data for 311 patients with RA attending clinics were collected during a two week period. The median time from symptom onset to first visit was four months. Of the patients, 95.6% were seen within 12 weeks of referral. Of those seen in EIAC, 75.9% had erosions documented on X-rays versus 49.4% of non-EIAC patients. In addition, 57.9% of patients were offered combination disease-modifying antirheumatic drugs (DMARD) therapy in EIAC, versus 30.4% in non-EIAC units. Monthly disease-activity scores were calculated more in patients attending EIAC than non-EIAC units (51.1% versus 25.4%). Based on our results, there is significant regional variation in implementation of the NICE guidance. In addition, patients with RA attending EIACs are more likely to receive a treat-to-target approach.

The relationship between the presence of anti-cyclic citrullinated peptide antibodies and clinical phenotype in very early rheumatoid arthritis

BackgroundAnti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for RA, but are not detectable in all RA patients. The aim of this study was to establish whether the clinical phenotypes of anti-CCP positive and negative disease are distinct at the earliest clinically apparent phase of disease.MethodsPatients were recruited from the Birmingham early inflammatory arthritis clinic. Participants were included in the current study if they presented within 3 months of symptom onset and fulfilled 1987 ACR criteria for RA at some point during an 18 month follow-up. Data were collected on demographic variables, joint symptoms and tender (n = 68) and swollen (n = 66) joint counts. CRP, ESR, rheumatoid factor and anti-CCP2 status were measured.Results92 patients were included (48 anti-CCP positive). The anti-CCP positive and negative groups were comparable in terms of demographic variables, inflammatory markers, joint counts and 1987 ACR classification criteria, except that more anti-CCP positive patients were rheumatoid factor positive (83.3% vs. 11.4%, p < 0.01). There was no significant difference in the pattern of joint involvement, except for an increased prevalence of knee joint swelling in anti-CCP positive patients (42.9% vs. 22.2%, p = 0.03).ConclusionsPatients with and without anti-CCP antibodies present in a similar way, even within three months of clinically apparent disease that eventually develops into RA.

Using ultrasonography to facilitate best practice in diagnosis and management of RA

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Objectives and outcome of running an early inflammatory arthritis clinic

A substantial number of people in our population will, at some stage in their lives, have one or more episodes of inflammatory arthritis (Lawrence and Bennett, 1960). The clinician's dilemma is how to decide which are those unfortunate few who are going to develop chronic destructive inflammatory arthritis, of whom the great majority will have rheumatoid arthritis (RA). However, even the diagnosis of RA does not necessarily have grave implications for the patient because it is claimed that as many as 80% may spontaneously recover (Harris, 1981). Identifying the poor prognosis patient with early inflammatory arthritis has received considerable attention over the years, as it is well recognized as being of critical importance. The most obvious means of studying this was to set up early inflammatory arthritis (EIA) clinics to scrutinize the evolution of these arthritides and their prognostic features. Two early studies were by Bywaters and Dresner (1952) and Otten and Boerma (1959), although there have been many more since then (Tables 1 and 2). The prodromal period, pattern of joint involvement and associated symptoms have all been studied in great detail and are still essential in early diagnosis. Haematological and biochemical indices (especially rheumatoid factor--Otten and Boerma, 1959), with radiological assessment for erosions, have also been carefully assessed for their prognostic significance in many studies. However, although of great diagnostic benefit, they do not accurately predict the course of inflammatory arthritis. At best these clinical and laboratory measures provide about 70-80% accuracy in predicting outcome, either of self-limiting or chronic destructive disease (Young et al, 1987). To date this has not been improved by the addition of genetic markers (M6tt6nen, 1988). This predictive power has generally been felt to be insufficiently accurate to justify early treatment with potentially toxic disease-modifying antirheumatic drugs (DMARDs). Hence the hunt for better prognostic markers is on, and has become one of the major objectives of clinical rheumatology. Another important issue to be addressed is the aetiology of inflammatory arthritides. RA in particular has been extensively investigated in terms of both genetic and environmental factors. Advances have been made in the