Flares Of Disease Activity Research Articles

Association between depression and anxiety with the risk and flare of inflammatory bowel disease: a systematic review and meta-analysis.

Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation in the gastrointestinal tract. Previous studies have suggested a potential association between mental disorders, such as depression and anxiety, and the risk and flare of IBD. However, the findings have been inconsistent. This study aimed to conduct a systematic review and meta-analysis to assess the relationship between mental disorders and IBD. A comprehensive literature search was performed to identify relevant studies. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to determine the association between mental disorders and the risk and flare of IBD. Heterogeneity between studies was assessed using the I2 statistic. Sensitivity analysis was conducted to evaluate the stability of the results. A total of seven studies met the inclusion criteria and were included in the meta-analysis. The pooled results demonstrated a significant association between symptoms of depression at baseline and an increased risk of disease activity flare during longitudinal follow-up, with an OR of 1.69 (95% CI 1.34, 2.13). However, there was high heterogeneity between studies (I2 = 82%). Furthermore, patients who underwent surgery had a higher risk of disease activity flare (OR: 1.49, 95% CI 1.13, 1.95), and hospitalization was also identified as a contributing factor (OR: 1.22, 95% CI 1.10, 1.36). This meta-analysis provides evidence for a significant association between symptoms of depression and the risk of disease activity flare in IBD. However, the high heterogeneity observed between studies suggests the need for further research to explore potential moderators and underlying mechanisms. These findings highlight the importance of addressing mental health in the management and treatment of patients with IBD.

Low-Dose Glucocorticoids in Older Patients with Rheumatoid Arthritis: What Does the Evidence Say?

The short-term use of glucocorticoids (GCs) in combination with methotrexate was recommended for the initial treatment of rheumatoid arthritis by the European League Against Rheumatism. A randomized controlled trial (GLORIA) showed that treatment of older patients with low-dose GCs in combination with disease-modifying anti-rheumatic drugs was more efficacious than disease-modifying anti-rheumatic drugs plus placebo in terms of disease activity control and prevention of joint destruction. Glucocorticoid-related adverse events were likely to increase relative to placebo, with no increase in serious adverse events and fractures over 2 years. Observational studies showed an increased risk of serious infections, cardiovascular events, and fractures associated with long-term continuation of GCs in older patients, but the adverse events may be associated not only with GC toxicity but also with poor disease control of rheumatoid arthritis. In the GLORIA study, low-dose GCs during 2 years could be tapered off safely, but many patients had a flare of disease activity after discontinuation of GCs. In the two representative large Japanese registries (IORRA and NinJa), the proportion of patients using GCs and non-tumor necrosis factor inhibitors increased with increasing age at disease onset, with a decreasing trend in methotrexate use. The proportion of patients in remission with GC treatment also increased with increasing age at onset. These suggested that it is not easy to discontinue GCs in older patients. If GCs cannot be terminated in the short term, it may be acceptable to use GCs to control disease activity for up to 2 years.

Performance of the Rheumatoid Arthritis Impact of Disease (RAID) score in relation to flares in disease activity

ObjectivesTo explore the performance of the EULAR-initiated patient-reported Rheumatoid Arthritis Impact of Disease (RAID) questionnaire in relation to flares in disease activity, including comparison with other disease activity outcomes.MethodsPatients with...

Effect of tapered versus stable treatment with tumour necrosis factor inhibitors on disease flares in patients with rheumatoid arthritis in remission: a randomised, open label, non-inferiority trial

ObjectivesMany patients with rheumatoid arthritis (RA) require treatment with tumour necrosis factor inhibitor (TNFi) to reach remission. It is debated whether tapering of TNFi to discontinuation should be considered in...

Discontinuation of Conventional Synthetic Disease-Modifying Antirheumatic Drugs in Patients With Rheumatoid Arthritis and Excellent Disease Control

This open-label randomized clinical trial assessed the 12-month risk of disease activity flares after discontinuation of conventional synthetic DMARDs (csDMARDs) compared with continuing half-dose csDMARDs in adult Norwegian patients with rheumatoid arthritis and excellent disease control.

COVID-19 vaccination in adults with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are not at increased risk of SARS-CoV-2 infection compared to the general population, and most are not at increased risk for severe disease. COVID-19 is nonetheless common, and vaccination is critical. Four safe and efficacious vaccines are now available for the prevention of COVID-19, with most data available for mRNA vaccines. Patients with IBD have a robust humoral response to vaccination with rates of seroconversion exceeding 95% following a two-dose mRNA vaccine series and 99% following a three-dose mRNA series, although those on certain therapies including anti-tumor necrosis factor α agents may have lower antibody concentrations and waning of antibodies over time. Additionally, rates of cell-mediated immune response, even in those patients with IBD who did not have evidence of humoral immunity, are high. Vaccines are safe and have not been associated with flares in disease activity. Gastroenterology providers should take an active role in ensuring patients with IBD are appropriately vaccinated against COVID-19.

Scrub Typhus-Induced Macrophage Activation Syndrome with Flare of Systemic Lupus Erythematosus: A Rare Case Report

Aims: Infection is a major trigger for both Lupus flare and Macrophage activation syndrome. Scrub typhus infection associated with lupus flare or MAS has been very rarely reported. We report a case of scrub typhus-induced MAS along with a flare of disease activity in a neuropsychiatric lupus patient presenting after discontinuation of medications.
 Presentation of Case: 13-year-old girl, a known case of neuropsychiatric lupus with lupus nephritis, on immunosuppressant for the last 1 year had stopped all medications for 3 months. She had presented with a fever and altered sensorium. Based on clinical and laboratory investigations, a diagnosis of scrub typhus-induced macrophage activation syndrome with a flare of lupus disease activity was made and the patient was treated with injection doxycycline and glucocorticoids. There was rapid clinical improvement with treatment.
 Discussion: The case emphasizes the importance of identifying the exact trigger behind the deterioration of a patient with lupus and its therapeutic implications. An infection alone requires antibiotics only, flare without infection requires up titrating immunosuppressants but the presence of life-threatening complications like MAS along with infection requires prompt treatment of both facets simultaneously.
 Conclusion: Scrub typhus infection should be ruled out apart from other common infections in any patient with lupus flare or MAS.

Predictors of flare in rheumatoid arthritis patients with persistent clinical remission/low disease activity: Data from the TARAC cohort.

To identify predictors of rheumatoid arthritis (RA) disease activity flare in RA patients who achieved low disease activity (LDA) or persistent remission from the observational Thai Army Rheumatoid Arthritis Cohort study.RA patients with persistent clinical remission, defined by disease activity score 28 (DAS28) < 2.6 and LDA defined by DAS28 ≤ 3.2 for 3 consecutive months, were recruited and followed-up for at least 2 years. The flare was defined by an escalation of DAS28 ≥ 1.2 plus their physicians’ decision to enhance RA treatment. Differences between sustained remission/LDA and flare groups were analyzed, by Chi-square test and unpaired Student t test. Multivariate Cox proportional hazard regression analysis was conducted to determine flare predictors.From 199 RA patients, female were 82.9%. Anticitrullinated peptide antibodies (ACPA) or Rheumatoid factor (RF) were found in 69.8% of patients. Flares occurred in 69 patients (34.9%). Multivariate analysis found that the timescale from symptoms emergence to DMARD commencement, the timescale from DMARD commencement to when RA patients showed remission/LDA, the occurrence of RF or ACPA, LDA (in contrast to remission) and the increased DAS28 score when remission/LDA was achieved and tapering DMARDs promptly when persistent remission/LDA was achieved were predictors of RA flares with hazard ratios of (95% confidence interval [CI]) of 1.017 (1.003–1.030), 1.037 (1.015–1.059), 1.949 (1.035–3.676), 1.926 (0.811–4.566), 2.589 (1.355–4.947), and 2.497 (1.458–4.276), respectively.These data demonstrated that early and aggressive DMARDs treatment approach could maintain remission espcially in seropositive patients. Tapering should be applied minimally 6 months after reaching remission.

The Non-medical Switch from Reference Adalimumab to Biosimilar Adalimumab is Highly Successful in a Large Cohort of Patients with Stable Inflammatory Rheumatic Joint Diseases: A Real-Life Observational Study

IntroductionThe adalimumab biosimilar (ADAbio) Amgevita® has a similar efficacy and safety profile as the adalimumab reference (ADA) Humira®. We studied the clinical consequences of a non-medical switch from ADA to ADAbio in adult patients with mainly established rheumatoid arthritis (RA), psoriatic arthritis (PsA), and spondyloarthritis (SpA).MethodsPatients that received treatment with ADA for at least three months were switched to ADAbio. Data was collected retrospectively from 1 year before the switch up to 6 months after.ResultsA total of 603 patients were switched from ADA to ADAbio (switch group). During a 1-year follow-up, over 93% of all patients underwent a successful transition in terms of disease activity and safety from ADA to biosimilar, supporting the bioequivalence of both drugs in patients with stable inflammatory rheumatic joint diseases. Forty patients (6.6%) switched back to ADA (re-switch group). There were no objective changes in disease activity score in 28 joints using C-reactive protein (DAS28-CRP), or adverse effects before and after the switch between both groups.ConclusionsIn line with earlier reports, the transition to ADAbio went successful in the majority of patients with stable inflammatory rheumatic joint diseases. Patient-reported symptoms without objective signs that indicate a flare of disease activity after the switch to ADAbio are probably explained by nocebo effects. A pre-emptive approach to counteract nocebo effects and stimulate placebo response may have a positive impact on health outcomes for patients and preserve the economic benefits of cost savings that can be achieved by prescribing a biosimilar instead of the reference drug.

P194 Flares of rheumatoid arthritis following coronavirus vaccination

Background/AimsWith the emergence of the coronavirus vaccine and the clear and important role it provides in maintaining the health of individuals and the population, it is important that our patients receive or are recommended the vaccine. We here document a case series of patients who have long-term quiescent rheumatoid arthritis who then experienced a flare of disease activity after receiving a vaccine. This information is important to understand as it allows informed discussions regarding the side effect profile of the vaccine and also the influence this may have on the patient’s disease control and future management options.MethodsPatients were reviewed in clinic as part of standard care. Individuals with rheumatoid arthritis who had experienced a flare defined as a self-reported disease activity score of > 5.1 in otherwise stable disease were noted and their response to treatment reviewed. This was a review of usual clinical practice and did not alter the treatment undertaken or monitoring of the patent. Information obtained was through the consultation with a rheumatologist and the data was collected retrospectively through review of clinical notes and clinic letters.Results Table 1 outlines the patient details and treatment responses.All flares occurred within two weeks of receiving the vaccine. Of the patients who flared, two required short-term steroid treatment; three an increase in the usual medications and one who had been in disease remission to re-start previous therapy. More patients in the Pfizer vaccine group required an escalation of usual care compared to the AstraZeneca vaccine group.ConclusionWe report six cases of rheumatoid arthritis flare soon after receipt of the coronavirus vaccine. In all, disease control was returned with minimal changes to treatment, 33% of those requiring either no treatment or an intramuscular steroid injection alone. Therefore, we recommend that clinicians should counsel patients of this potential effect, but continue to advocate the vaccine, as the risk of complications to their underlying arthritis is very low and seemingly easily treatable. P194 Table 1Antibody statusVaccine brandTime since diagnosisTime since last flareFlare after 1st or 2nd doseUsual treatmentFlare managementSeropositive, anti-CCP positiveAstraZeneca13 years3 years1stEtanercept, MethotrexateIntramuscular MethylprednisoloneSeropositive, anti-CCP positiveAstraZeneca11 years4 years1stEtanercept, SulfasalazineIntramuscular Methylprednisolone, local joint injectionSeronegative, anti-CCP negativeAstraZeneca13 years2 years1stMethotrexateIncrease methotrexate doseSeronegative, anti-CCP positivePfizer23 years11 years1stInfliximabLocal joint injection, reduce interval of infusionsSeronegative, anti-CCP positivePfizer7 years3 years2ndSulfasalazine, hydroxychloroquineIncrease Sulfasalazine doseSeropositive, anti-CCP positivePfizer7 years4 years2ndnilRe-start methotrexate, hydroxychloroquineDisclosure R.J. Hayward: None. Z. Farah: None.

Hematopoietic Stem Cells Undergo Immune Training and Constitute a Long-Term Reservoir for Hyper-Inflammatory Macrophages in a Mouse Model of Chronic Autoimmunity

Auto-immune diseases (AD) are characterized by repeated flares of disease activity separated by periods of remission. Cycles of AD remission and relapse can occur even with therapeutic intervention and contribute to AD morbidity. Paradoxically, during remission myeloid cells retain increased expression of genes related to interferon signaling and antigen presentation. Given the relatively short lifespan of myeloid cells, these observations imply the existence of a clonal reservoir fueling AD relapse. Recent literature describes hematopoietic stem cells (HSC) as a cellular source for trained myeloid cells in response to immune stimuli. Thus, we hypothesize that HSC may also retain a long-term memory of chronic autoimmune inflammation, thereby providing a continuous supply of myeloid cells that promote AD pathogenesis.To test this hypothesis, we have combined high-throughput molecular and cytokine profiling approaches with functional assays to address heritable changes in immune function using the pristane-induced mouse model of systemic lupus erythematosus (SLE). Eight weeks after pristane injection, we observe significant myeloid lineage expansion in the bone marrow (BM), including mature myeloid cells, granulocyte/monocyte progenitors (GMP) and multipotent progenitor (MPP) populations. To understand the impact of SLE-like disease on the molecular programming of the hematopoietic system, we performed RNA-seq analyses of BM Mon and HSC. As anticipated, BM Mon activated inflammatory programs and antigen presentation genes, which overlapped with gene signatures of human monocytes from SLE patients. HSC also activated innate defense gene programs resembling signatures of trained immunity, thus establishing the potential for autoimmune inflammation to induce immune training in HSC.To establish whether these molecular programs potentiate myeloid cell function, we generated BM-derived macrophages (BMDM) from control and pristane-induced mice. BMDMs from pristane-induced mice exhibited significantly increased capacity to kill Mycobacterium avium. Further, co-culture of T cells with BMDMs from pristane-induced mice significantly boosted T cell proliferation, indicative of enhanced antigen presentation. To establish whether HSC from pristane-induced mice propagate molecular memory of SLE-like disease to myeloid progeny, we transplanted stringently enriched (LSK/SLAM/CD34 -/EPCR +) long-term (LT)-HSC into lethally irradiated recipient mice. 18 weeks post transplant, mice transplanted with LT-HSC from pristane-induced donors had a small but significant reduction in donor BM HSC chimerism but did not exhibit overt changes in lineage output. Strikingly, BMDMs from pristane-induced donors showed increased bacterial killing and inflammatory cytokine generation following M. avium challenge, as well as increased capacity to induce antigen-specific T cell proliferation. Thus, LT-HSC retain and pass on altered functional properties to myeloid cells, even in the absence of AD activity.To characterize the molecular mechanisms underlying HSC-propagated alterations in myeloid cell function, we ran RNA-seq on donor-derived GMP and BMDMs. Notably, GMP derived from pristane-induced donor LT-HSC had increased expression of Fos and Jun/b/d, key molecular drivers of immune training in stem cells. Likewise, pristane-induced donor BMDMs maintained increased expression of IFN-regulated genes including MHC-I, a gene also overexpressed in PBMCs from human SLE patients. Consistent with these findings, re-stimulation of recipient mice with pristane led to a significant increase in cytokine-producing lymph node T cells versus recipient mice transplanted with control HSC, further supporting a model of immune training.Overall, these data show that chronic autoimmune inflammation can induce in HSC a heritable trained immunity phenotype that is transmitted to myeloid progeny, enhancing their functional activity. Ongoing studies are establishing the capacity for this phenotype to exacerbate AD. We are also testing the importance of molecular players identified above in establishing AD-related immune training and assessing the potential for therapeutic interventions to disrupt HSC memory in this setting. Our data thus stand to establish a new paradigm for trained immunity in HSC as a key contributor to AD pathology and relapse. DisclosuresNo relevant conflicts of interest to declare.

Prevalence and impact of Rome IV versus Rome III irritable bowel syndrome in patients with inflammatory bowel disease.

Irritable bowel syndrome (IBS)-type symptoms are common in inflammatory bowel disease (IBD), but few studies have examined the prevalence and impact of IBS-type symptoms in IBD according to Rome IV criteria. We collected demographic, symptom (Rome III, Rome IV, and clinical disease activity indices), psychological (anxiety, depression, and somatization), and quality of life data from 973 IBD patients. Medical records were reviewed to document disease type, extent/location, behavior, medical therapy, and antidepressant or opioid use. We compared characteristics of individuals with no IBS-type symptoms, Rome III IBS-type symptoms, and Rome IV IBS-type symptoms. In total, 302 (31.0%) patients met the Rome III criteria for IBS, and 172 (17.7%) met Rome IV criteria. Those with IBS-type symptoms were younger, more likely to be female, and had higher rates of antidepressant (p=0.006) or opioid use (p=0.001). Rome IV IBS-type symptoms were associated with symptoms of mood disorders, flare of disease activity, and lower quality of life scores (p<0.001 for all analyses). Compared with Rome III criteria, those with Rome IV IBS-type symptoms had significantly higher rates of anxiety (p<0.001), depression (p=0.002), and somatization (p<0.001), lower quality of life scores (p<0.001) and were more likely to have CD (p=0.011), with ileal distribution (p=0.006). Rome IV IBS-type symptoms are associated with increased psychological co-morbidity, lower quality of life scores, and higher rates of antidepressant or opioid use. This is a cohort potentially at risk of adverse clinical outcomes and should be a focus for future research.

Preliminary definition of flare in cutaneous lupus erythematosus using the Cutaneous Lupus Erythematosus Disease Area and Severity Index

To the Editor: “Flare” in cutaneous lupus erythematosus (CLE) is a clinically significant increase in disease activity from baseline. While quantitatively defined for systemic lupus erythematosus and used as a clinical research end point, flare has not been defined for CLE. The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) has been used to define improvement in CLE, but not worsening.1 To determine the change in CLASI activity (CLASI-A) score that corresponds to a meaningful flare in disease activity, we conducted a retrospective review of our institutional review board–approved prospective CLE database at the University of Pennsylvania.

Longitudinal follow-up study: effect of psychological co-morbidity on the prognosis of inflammatory bowel disease.

Psychological co-morbidity is more common in patients with inflammatory bowel disease (IBD), compared with the general population, but little is known about the cumulative effect of increasing psychological burden on disease behaviour. To examine the effect of psychological co-morbidity on inflammatory bowel disease in a longitudinal follow-up study. We collected complete demographic, symptom and psychological co-morbidity data (anxiety, depression and somatisation scores) at baseline from adults with IBD in biochemical remission (faecal calprotectin <250µg/g). Objective markers of disease activity, including glucocorticosteroid prescription or flare of disease activity, escalation of therapy, hospitalisation or intestinal resection, were reviewed ≥2years of follow-up. We performed multivariate Cox regression, controlling for patient characteristics and follow-up duration, to examine cumulative effect of psychological co-morbidities on subsequent IBD behaviour. Among 218 participants, 48 (22.0%) had one, 13 (6.0%) two and nine (4.1%) three psychological co-morbidities at baseline. Following multivariate Cox regression analysis, glucocorticosteroid prescription or flare, and escalation of medical therapy were significantly higher among those with two (hazard ratio [HR]=3.18; 95% confidence interval [CI] 1.44-7.02, and HR=2.48; 95% CI 1.03-5.93, respectively) or three (HR=3.53; 95% CI 1.26-9.92, and HR=8.19; 95% CI 2.88-23.23, respectively) psychological co-morbidities. Occurrence of at least one endpoint of interest was significantly higher with increasing psychological co-morbidity (HR=1.74; 95% CI 1.07-2.82 for one, HR=2.47; 95% CI 1.12-5.46 for two and HR=4.93; 95% CI 1.84-13.17 for three psychological co-morbidities). Individuals with IBD in biochemical remission experienced a worse disease course with increasing psychological co-morbidity at baseline.

P180 Endoscopic scoring systems for Crohn’s Disease and Ulcerative Colitis and their correlation with histological and clinical outcomes

Abstract Background Endoscopy and histopathology are vital for evaluating disease activity and treatment response in inflammatory bowel disease. Correlation between endoscopic and histological indices has not been fully examined. The primary aim of this study was to examine the correlation of endoscopic scores with histological assessment and association with flare/hospitalisation in the ensuing 12 months. Methods We selected 100 random colonoscopies performed for IBD surveillance/assessment in 2019. Adult patients with a complete colonoscopy were included. All reports were blindly scored by 2 expert endoscopists using SES CD or Mayo score as appropriate. Histology was retrieved from HistoLab database and classified as normal, mild, moderate and severe. Clinical demographics, CRP, fecal calprotectin levels, flare episodes and hospitalisations were recorded. Correlation between endoscopic and histologic activity was tested. Comparisons were made between patients in histologic and endoscopic remission v those with endoscopic and histologic activity regarding association with flare/hospitalisation. Results 100 IBD patients (median age 49 IQR 22; 54% female; 50% Crohn’s disease) were included. A wide range of SES-CD scores were noted (median score 2 and IQR 6). 48% were in remission (0–2), 34% mild with score 3–6, 18% moderate with score 7–15 and 4% severe disease activity scoring &amp;gt; 16. Of those in endoscopic remission, 87.5% had normal histology. Of the 9 with moderate endoscopic disease all ranges of histological status were described. All levels of the Mayo scale (median score 1) were represented. Similar to the Crohn’s group, 87.5% of those in endoscopic remission also had normal histology. In total 42 patients were in both endoscopic and histological remission, and only 7% experienced a flare of disease activity in the following 12 months, with no hospitalisations. In total 40 patients had both endoscopically and histologically active disease, and 45% of these had a flare in the ensuing 12 months with two hospitalisations.The ROC curve for SES-CD score and histological remission is 0.73 +/- 0.07 95%CI 0.59 -0.87 and for the Mayo score and histological remission 0.87 +/- 0.05 95%CI 0.78- 0.97. Conclusion Accurate assessment of disease activity guides therapy choices and helps assess response to treatment in our IBD cohort. In this study the SES-CD and Mayo endoscopic scores showed good correlation with histological assessment. Those with active endoscopic and histologic disease experienced more flares and had higher rates of hospitalisation than those in remission. Further investigation with higher study numbers and incorporation of a standardised histological grading system are required.

POS1472-HPR CLINICIANS’ PERSPECTIVES ON PSYCHOLOGICAL DISTRESS AND MEETING PATIENTS’ SUPPORT NEEDS IN RHEUMATOLOGY CARE SETTINGS

Background:People with inflammatory rheumatic diseases (IRDs) face challenges that include fluctuations in pain, fatigue and flares of disease activity, complex medical regimens, and decisions about when to seek clinical help with symptoms [1,2]. Evidence suggests levels of anxiety and depression are higher in people with IRDs compared to the general population [3]. Rheumatology teams report that psychologically distressed patients can have additional support needs and require more time. Patients’ concerns include health-related anxiety and difficulty accepting the diagnosis. This group can have poor outcomes and poor adherence to treatments. However, little is currently known about optimal ways to meet these patients’ support needs.Objectives:To understand rheumatology clinicians’ perspectives on psychological distress in care settings with the long-term aim to develop a proposed model/pathway of support.Methods:Telephone interviews were conducted with members of UK rheumatology teams who have clinical experience with patients experiencing distress. The semi-structured interviews explored both ‘what happens now’ (current clinical practice) and ‘what should happen’ (acceptable models of future psychological support provision). The semi-structured format provided flexibility to probe more deeply and develop new lines of enquiry based on participants’ responses.Results:Fourteen interviews were conducted with rheumatology clinicians including 2 consultants, 4 nurses, 1 physiotherapist, 4 occupational therapists, 2 clinical psychologists and 1 podiatrist. Inductive thematic analysis was used to analyse the data. Two main themes represent the data (Table 1).Table 1.Main ThemeSub-themes1. ‘No one shoe fits all’ – the many manifestations of distress in patients.‘I pick up on distress as increased emotion…tearfulness and sadness I suppose, but also frustration, anger...A lot of helplessness comments’1. ‘Distress can be quite emotive and quite obvious, but then it can also hide away’2. ‘They’re [patients] trying to manage their own conditions, but they’re also trying to manage life’2. ‘If Rheumatology could be interwoven with psychological principles’ – the need to attend to the psychological impact of IRDs, alongside the physical impact.‘The physical and mental health side of things are so closely linked because one affects the other…after a while they [patients] don’t really know what’s affecting what’1. ‘Prioritising physical health…sometimes the stress gets not thought about’2. ‘Make best use of everyone in the team to work with patients who are struggling’3. ‘For the psychological side of things we don’t measure anything about that at all’Conclusion:Distress can be obvious or hidden and cause issues for both patient and clinician. It can lead to poor engagement with care provision. Clinicians differ in their perceptions of distress and in their thresholds for dealing with distress and have described the inconsistency of support offered for distressed patients. They described the powerful link between physical and mental distress, the vicious cycle that can develop, and the benefits of incorporating a psychological approach to treatment. This study suggests psychological support should be embedded within the team as it is felt there is a need for speciality understanding and for patients’ emotional wellbeing to consistently be given equal priority to their physical wellbeing.

Travelling with children and adolescents with rheumatic diseases

Für Kinder und Jugendliche mit rheumatischen Erkrankungen bestehen durch ihre Grunderkrankung und immunsuppressive Therapie auf (Fern‑)Reisen zusätzliche Risiken. Eine frühzeitige und umfassende Reiseberatung ist daher unbedingt zu empfehlen. Die Reisefähigkeit hängt im Wesentlichen von der Aktivität der Grunderkrankung, dem Alter des Kindes und der Art der Reise ab. Spezielle Risiken sind – in Abhängigkeit vom Grad der Immunsuppression – insbesondere ein erhöhtes Risiko für (reiseassoziierte) Infektionen und eine Aktivitätszunahme der Grunderkrankung. Größter Wert kommt der Durchführung einer adäquaten Expositionsprophylaxe zu: Grundimmunisierungen sollten aktualisiert sowie indizierte Reiseimpfungen durchgeführt werden. Allerdings müssen ggf. Einschränkungen durch die Immunsuppression beachtet werden. Bei Reisen in Malariaendemiegebiete muss die Notwendigkeit einer Chemoprophylaxe bzw. Stand-by-Medikation evaluiert werden. Dabei sind potenzielle Medikamentenwechselwirkungen zu bedenken. Gründlich aufgeklärt werden sollten die Familien über Regeln einer guten Nahrungsmittel‑, Hände- und Kontakthygiene. Aufgrund der Photosensibilität bei bestimmten rheumatischen Erkrankungen und Medikamenten ist unbedingt auf einen geeigneten Sonnenschutz zu achten. Zur Prophylaxe von Insektenstichen steht neben Barrieremaßnahmen eine Reihe auch für Kinder zugelassener Insektenrepellents zur Verfügung. Die Möglichkeiten adäquater medizinischer Versorgung vor Ort sollten vor Abreise geklärt sein und in die Beurteilung der Reisefähigkeit mit einfließen. Die übliche Reiseapotheke sollte um die antirheumatische Medikation erweitert werden. Hier müssen Lagerungsbestimmungen für einige Medikamente beachtet werden. Letztlich hängt der Erfolg einer Reise von der Planung aus Sicht des Kindes mit seinen spezifischen Bedürfnissen ab.

P80 Value of the clinical nurse specialist role in the care of patients with systemic lupus erythematosus: the patient experience

Abstract Background Systemic lupus erythematosus (SLE) is a complex, multi-system, chronic disease that is predominantly managed by rheumatologists in a clinical setting. Clinical Nurse Specialist (CNS) access and support for patients can be variable and mostly lacking. The value of the CNS role in supporting patients with SLE has not previously been explored in depth from the patient’s perspective. This service evaluation investigates the role of the SLE CNS in supporting patients with SLE, with the aim to further develop the CNS role in SLE care to support patients locally in North Wales. Methods Seven SLE participants, who had access to a dedicated SLE CNS, were selected from connective tissue disease clinics at a district general hospital. The age range was 33-69 years with a disease duration from 4-20 years. Participants took part in a one to one semi-structured interview using open ended questions. Interviews were digitally recorded, transcribed verbatim, and analysed using thematic analysis. Results The analysis of the interviews highlighted the value of a specific SLE CNS role to SLE patients. Overall, responses were positive with participants feeling reassured knowing they could contact the CNS for support via the telephone nurse advice line during flares of disease activity: “It’s like a lifeline”. Owing to the complex nature of SLE, participants valued having a nurse to monitor their condition, enabling them to feel supported between routine appointments: “I think of the nurse as my safety blanket”. Validation of symptoms led participants to feel in control, as they appreciated having a nurse to discuss their concerns with, who took the time to listen: “It’s about not putting it all down to lupus”. All respondents valued receiving information about SLE from the CNS, who was perceived as having specialist knowledge of SLE: “The specialist nurse knows the ins and outs”. This expert knowledge of SLE was fundamental to participants at diagnosis and throughout their disease trajectory, as those without support from a CNS soon after diagnosis felt isolated and ill informed: “I didn't even know what I had”. The majority of participants reported a lack of empathy and understanding of SLE among primary care specialists, and experiences of misdiagnosis were not uncommon: ‘“They said I had scarlet fever, psoriasis and various other things”. Conclusion Though the number of participants was small, the study has revealed that the SLE CNS provides an important and unique role in the care of patients with SLE. Continued support from SLE CNS roles, and improved knowledge of SLE within primary care, is fundamental so that SLE patients have enhanced support soon after diagnosis and throughout their journey with SLE. Disclosures A.N. Culshaw None. D. Roychowdhury None.

P232 Effectiveness of adalimumab biosimilar switching: real world data from a London rheumatology centre

Abstract Background Biologic drugs have revolutionised the management of many rheumatological diseases with remission or low disease activity now the realistic targets for treatment. However, given the chronic nature of most rheumatological disease and the need for long term treatment, there has been a significant increase in the cost associated with disease treatment. The advent of biosimilars offers an attractive target in reducing drug costs for payers. Biosimilar medications are thought to be equally efficacious as originator drugs. Real world data in adalimumab biosimilar switching is limited. In this audit we aim to examine the real-world outcomes from switching from originator Humira to biosimilar Amgevita in a London teaching hospital. Methods A list of all adult rheumatology patients on Amgevita was obtained through pharmacy records. All patients had been switched from Humira to Amgevita from February 2019. Using clinic letters and an in-house biologics database, data was collected on the underlying disease and the date of switch. Outcomes reviewed were disease activity scores pre and post switch, documented side effects and flare of disease activity following switch including decision to revert to originator Humira or change treatment. Results There was a total of 289 adult patients on Humira who switched to Amgevita. Of these patients, 28 in total discontinued treatment - 13 with rheumatoid arthritis, 10 with psoriatic arthritis and 5 with ankylosing spondylitis. 22 had to be switched back to Humira, with a further 4 patients approved to switchback and awaiting to restart. Two additional patients were switched to alternative biologic therapy due to inefficacy. A further 3 patients refused to switch onto Amgevita. Sixteen patients had documented flares, with one requiring admission and ten requiring local or systemic corticosteroid therapy to control activity. Seven patients had documented side effects which included chest pain, headache, rash and site reactions and one patient developed shingles post switch. Conclusion A total of 9.6% of patients switched to Amgevita had disease flare or side effects resulting in a switchback to Humira or alternative biologic therapy. For a biosimilar to be approved, efficacy and safety profiles needs to be comparable to the originator biological therapy and usually looks at two treatment naïve groups, rather than direct switch. Thereby, data on switches in therapy is limited. One systematic review looking at 11,053 patients with inflammatory arthritis treated with Etanercept and switched to Benepali, found 768 reverting to original therapy giving a lower total of 6.9%. We find that although no previous data of Amgevita, our figure of 9.6% appears high in the context of previously controlled inflammatory disease with Humira. Disclosures S. Vigneswaran None. M. Galloway None. S. Hanlon None. A. Tynan None. A. Singh None.

Disease activity flares and pain flares in an early rheumatoid arthritis inception cohort; characteristics, antecedents and sequelae

BackgroundRA flares are common and disabling. They are described in terms of worsening inflammation but pain and inflammation are often discordant. To inform treatment decisions, we investigated whether inflammatory and pain flares are discrete entities.MethodsPeople from the Early RA Network (ERAN) cohort were assessed annually up to 11 years after presentation (n = 719, 3703 person-years of follow up). Flare events were defined in 2 different ways that were analysed in parallel; DAS28 or Pain Flares. DAS28 Flares satisfied OMERACT flare criteria of increases in DAS28 since the previous assessment (≥1.2 points if active RA or ≥ 0.6 points if inactive RA). A ≥ 4.8-point worsening of SF36-Bodily Pain score defined Pain Flares. The first documented episode of each of DAS28 and Pain Flare in each person was analysed. Subgroups within DAS28 and Pain Flares were determined using Latent Class Analysis. Clinical course was compared between flare subgroups.ResultsDAS28 (45%) and Pain Flares (52%) were each common but usually discordant, with 60% of participants in DAS28 Flare not concurrently in Pain Flare, and 64% of those in Pain Flare not concurrently in DAS28 Flare. Three discrete DAS28 Flare subgroups were identified. One was characterised by increases in tender/swollen joint counts (14.4%), a second by increases in symptoms (13.1%), and a third displayed lower flare severity (72.5%). Two discrete Pain Flare subgroups were identified. One occurred following low disease activity and symptoms (88.6%), and the other occurred on the background of ongoing active disease and pain (11.4%). Despite the observed differences between DAS28 and Pain Flares, each was associated with increased disability which persisted beyond the flare episode.ConclusionFlares are both common and heterogeneous in people with RA. Furthermore our findings indicate that for some patients there is a discordance between inflammation and pain in flare events. This discrete flare subgroups might reflect different underlying inflammation and pain mechanisms. Treatments addressing different mechanisms might be required to reduce persistent disability after DAS28 and Pain Flares.