Initiation Of Disease-modifying Antirheumatic Drugs Research Articles

Intermetatarsal Bursitis, a Novel Feature of Juxtaarticular Inflammation in Early Rheumatoid Arthritis Related to Clinical Signs: Results of a Longitudinal Magnetic Resonance Imaging Study.

Intermetatarsal bursae in the forefeet possess a synovial lining similar to joints and tendon sheaths. Inflammation of these bursae (intermetatarsal bursitis [IMB]) was recently identified as specific for early rheumatoid arthritis (RA). The present study was undertaken to determine if IMB is indeed an RA feature by assessing the following: 1) the association with other local inflammatory measures (synovitis, tenosynovitis, and osteitis), 2) the association with clinical signs, and 3) whether it responds to disease-modifying antirheumatic drug (DMARD) therapy similarly to other local inflammatory measures. One hundred fifty-seven consecutive early RA patients underwent unilateral contrast-enhanced 1.5T forefoot magnetic resonance imaging (MRI) at diagnosis. MRIs were evaluated for IMB presence and for synovitis, tenosynovitis, and osteitis in line with the RA MRI Scoring (RAMRIS) system (summed as RAMRIS inflammation). MRIs at 4, 12, and 24 months were evaluated for IMB presence and size in patients who had IMB at baseline and received early DMARD therapy. Logistic regression and generalized estimating equations were used. Anti-citrullinated protein antibody (ACPA) stratification was performed. Sixty-nine percent of RA patients had ≥1 IMB. In multivariable analysis on bursa level, presence of IMB was independently associated with local presence of synovitis and tenosynovitis, with odds ratios (OR) of 1.69 (95% confidence interval [95% CI] 1.12, 2.57) and 2.83 (95% CI 1.80, 4.44), respectively, but not osteitis. On the patient level, IMB presence was most strongly associated with tenosynovitis (OR 2.92 [95% CI 1.62, 5.24]). IMB presence was associated with local joint swelling (OR 2.7 [95% CI 1.3, 5.3]) and tenderness (OR 1.7 [95% CI 1.04, 2.9]) independent of RAMRIS inflammation. During treatment, IMB size decreased between 0 and 12 months. This decrease associated with decrease in RAMRIS inflammation, which was driven by synovitis decrease. Within ACPA-positive and ACPA-negative RA, similar results were obtained. IMB particularly accompanies inflammation of the synovial lining of joints and tendon sheaths, showed a similar treatment response after DMARD initiation, and associates with typical clinical signs. These findings suggest that IMB represents a frequently present novel RA feature of juxtaarticular synovial inflammation.

Prévention des infections et vaccination dans les rhumatismes inflammatoires chroniques

Patients with chronic inflammatory rheumatisms (CIR) have a higher risk of infections compared to healthy subjects. Viral and bacterial pneumonia are the most frequent infections observed in CIR under targeted DMARDs. Moreover, drugs used to treat CIR and especially biologic and synthetic targeted disease modifying anti-rheumatic drugs (DMARDs) increase this risk of infection and expose CIR patients to opportunistic infections such as tuberculosis reactivation. In order, to limit the risk of infection, the benefit and risk ratio has to be evaluated for each patient according to characteristics and comorbidities. To prevent infections, an initial pretreatment work up has to be performed especially before initiation of conventional synthetic DMARDs or biological and synthetic targeted DMARDs. This pre-therapeutic assessment is based on questioning, biological and morphological explorations as well. Vaccination's update has to be checked and recommended vaccines for patients with auto-immune diseases and treated with conventional synthetic DMARDs, bDMARDs, tsDMARDs and/or steroids should be done. Information and education of patients are very important. During specific workshop, they learn how to manage drugs in situations at risk and they learn symptoms that require drug discontinuation.

Impact of multimorbidity on disease modifying antirheumatic drug therapy in early rheumatoid arthritis: Data from the ESPOIR cohort.

Multimorbidity is frequent in rheumatoid arthritis (RA) and could interfere with the therapeutic response. The aim of this study was to evaluate multimorbidity in the French cohort of early arthritis, the ESPOIR cohort, and its possible impact on the therapeutic response. We included patients fulfilling 2010 ACR/EULAR criteria for RA. An adapted MultiMorbidity Index (aMMI) was developed. Each patient was assigned scores of binary aMMI (0=no comorbidity, 1=at least 1 comorbidity) and counted and weighted aMMI. The primary endpoint was achievement of Clinical Disease Activity Index (CDAI) low disease activity after initiation of a first disease-modifying antirheumatic drug (DMARD) according to the aMMI. We collected data from the visit preceding the first DMARD initiation and the visit after at least 3 months of treatment. The impact of aMMI on therapeutic maintenance at 1, 3, 5 and 10 years was evaluated. Analyses involved 472 patients: 302 (64%) had at least 1 comorbidity. Overall, 45.3% and 44.7% with binary aMMI=0 or 1, respectively (non-significant), achieved CDAI low disease activity. Similar results were found with counted and weighted aMMI. Therapeutic maintenance was significantly better with binary aMMI=1 than binary aMMI=0 (OR at 10 years=14.0 [CI 95% 3.3-59.4]). Increased counted aMMI was associated with increased probability of still being on the first initiated DMARD at each time point. In the ESPOIR cohort, therapeutic response to a first DMARD was not affected by multimorbidity but therapeutic maintenance was better in multimorbid patients.

P030 Quality improvement project on awareness in patients to stop teratogenic disease-modifying anti-rheumatic drugs (DMARDs) while planning pregnancy and need for highly effective contraception

Abstract Background/Aims The MHRA (Medicines and Healthcare Products Regulatory Agency) published guidelines in February 2018 on highly effective contraception (injectable/IUCD/partner vasectomy) for women of childbearing age consuming potentially teratogenic DMARDs (disease-modifying anti-rheumatic drugs) which might result in increased risk of birth defects. Objective: A quality improvement project was carried out in the rheumatology department at James Cook University Hospital, Middlesbrough to assess patient awareness of the potential teratogenicity of the DMARDS like methotrexate, leflunomide and mycophenolate mofetil and need for highly effective contraception to avoid foetal complications. Methods A spot audit was carried out from June to September 2019, through patient questionnaires to assess awareness in women of childbearing age (15- 45 years) about the potential teratogenic effects of these DMARDs and the need for highly effective contraception. Following this audit more tailored consent forms were introduced in February 2020 to increase awareness of potential teratogenicity at initiation of DMARDs with robust counselling. Subsequent to this we carried out quality improvement project to accumulate similar data between June and September 2021. Results Data were collected from 43 patients during the spot and 27 patients during the second cycle. 88% patients were on methotrexate, 9% on MMF, 2% on leflunomide and 2% on multiple DMARDS during the first audit compared to 66.6% on methotrexate, 16.6% on leflunomide and 6% on MMF during the second cycle. It was very positive to see 74% of patients reporting increased awareness about potential teratogenicity of the DMARDS gained through counselling compared to the 37% previously. 90% of the patients were aware to stop these DMARDs when planning pregnancy compared to the 88% previously. We achieved 100% awareness that the medication should be stopped in pregnancy compared to 90% previously. Rates of contraception use were comparable across cycles - 54% during the first cycle and 56.7% during the second. Of patients using contraception, 33.3% were using highly effective contraception the first cycle which improved to 37% during the second cycle. Nearly 44.4% patients were not on any contraception. Reasons why contraception was not used was not explored which was beyond remit of this project. Since this is a significant proportion there is certainly a need for further assessment and analysis. Conclusion Overall this quality improvement project has highlighted the need for robust counselling as well as structured and informative consent forms to improve the awareness of teratogenicity with certain DMARDs therapy in woman of childbearing age. In spite of increased awareness of the teratogenicity of these DMARD 44.4% patients were not on any form of contraception. There is definitely room for improvement in effectively disseminating information regarding highly effective form of contraception to prevent inadvertent exposure during pregnancy which may result in foetal birth defects. Disclosure F.A. Khan: None.

P122 Early inflammatory arthritis referrals should be seen face-to-face for their initial consultation: an analysis of rheumatology new patient teleconsultations

Background/AimsThe COVID-19 pandemic has hugely impacted on the structure of rheumatology services across the country and remote consultations have become a familiarity. It is important to understand the effectiveness of new patient consultations conducted over the telephone, whether there is a role to continue using teleconsultations to triage referrals and whether there is a difference in outcomes based on the type of initial consultation [telephone or face-to-face (F2F)].MethodsAll new referrals to our department that received an initial telephone consultation over a 2-month period (October-November 2020) were identified. The conversion rate to a F2F consultation and discharge rates were calculated. Referrals were also separated into two groups based on the referral details [early inflammatory arthritis (EIA) and non-early inflammatory arthritis (non-EIA)]. Patients ultimately diagnosed with inflammatory arthritis (IA) were identified and separated into two groups according to their initial consultation; initial telephone consultation (October-November 2020) and initial F2F consultation (March-April 2021). The time from first encounter to disease-modifying antirheumatic drug (DMARD) initiation was calculated and compared between the two groups.ResultsOctober-November 2020: 154 new patient referrals had teleconsultation for their first appointment (44% were EIA referrals). 56% of the 154 patients were given a F2F appointment following the telephone consultation. The conversion rate was higher in the EIA group in comparison to the non-EIA group (69% vs 41%). 10 patients were diagnosed with IA (8 were EIA referrals) and the average time to initiation of DMARD was 55 days. 19% of the 154 patients were discharged following the initial telephone consultation, of which 72% were non-EIA referrals, with the most common diagnoses being mechanical/degenerative problems and fibromyalgia. These results were presented at a departmental meeting and it was agreed that all future new EIA referrals should have an initial F2F consultation to minimise the number of consultations and potential delays in treatment. March-April 2021: 319 patients had a F2F consultation for their first consultation. There were 39 patients with confirmed IA in this group (36 were EIA referrals). The average time to initiation of DMARD was 22 days, with 40% starting a DMARD on initial consultation.ConclusionThere seems to be a role for teleconsultation for new patient referrals, as evidenced by a 19% discharge rate. However, high conversion rates to F2F appointment in the EIA group suggests that initial teleconsultations were not only ineffective but also led to slower DMARD initiation. One limitation of this project was that EIA patient sample sizes were small. As our specialty continues to utilise other modes of consultation beyond traditional F2F reviews, we must adapt and better identify which patients are most suitable for each particular mode of consultation.Disclosure Y. Man: None. S. Patel: None. N. Ng: None.

Review of publications evaluating opioid use in patients with inflammatory rheumatic disease.

This article discusses publications assessing the prevalence, efficacy, and safety of opioid analgesics in patients with rheumatic diseases, including rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, and systemic sclerosis. Recent studies show long-term opioid use is common in patients with inflammatory rheumatic disease. We did not find any studies demonstrating improved function or pain control with long-term opioid use in people with rheumatic diseases. Some data shows potential adverse effects including increased risk for fractures and opioid poisoning hospitalizations. There is evidence demonstrating an association of opioid use with mental health disorders, fibromyalgia, obesity, and disability, although causative links have not been established. Only minimal reductions in opioid use were observed after initiation of biologic disease modifying antirheumatic drugs (DMARDs). Studies have shown delayed DMARD initiation and reduced DMARD use in patients on opioids, raising concerns that these analgesics may delay care or initially mask symptoms of active disease. Available literature highlights high levels of opioid use in people with rheumatic disease, without scientific evidence to support efficacy for chronic pain control and increasing evidence of adverse events. These findings strongly suggest that opioids do not have a routine role in the chronic management of inflammatory rheumatic diseases.

The Incidence, Prevalence, and Associated Costs of Anemia, Malignancy, Venous Thromboembolism, Major Adverse Cardiovascular Events, and Infections in Rheumatoid Arthritis Patients by Treatment History in the United States.

ObjectiveComorbidities in rheumatoid arthritis (RA) can influence treatment selection, impact treatment persistency, and increase health care costs. This study assessed the magnitude of comorbidity burden via epidemiology (incidence and prevalence) and associated costs of select comorbidities in RA patients: anemia, malignancy, venous thromboembolism (VTE), major adverse cardiovascular events (MACE), and infections, stratified by history of disease‐modifying antirheumatic drug (DMARD) exposure.MethodsFrom the IQVIA PharMetrics® Plus database, we selected adult patients with RA (2 or more RA diagnostic codes at least 30 days apart) at initiation of a new DMARD (DMARD‐naïve), after the first conventional synthetic DMARD (csDMARD) or after the first biologic DMARD (bDMARD). We assessed pre‐index prevalence (percentage) and on‐treatment incidence (per 100 patient‐years [P100PY]) of the aforementioned comorbidities. For patients with versus without incident conditions, we compared total all‐cause health care costs as unadjusted and adjusted for baseline characteristics and health care costs.ResultsPrior to initiating a new treatment, among DMARD‐naïve patients (N = 28,201), csDMARD switchers (N = 7,816), or bDMARD switchers (N = 4,656), the overall prevalence ranged from 14.1% to 16.2% (anemia), from 1.3% to 5.2% (malignancy, evaluated in csDMARD and bDMARD switchers), from 1.5% to 2.1% (VTE), from 1.8% to 2.9% (MACE), and from 66.6% to 76.1% (infections). Once on index treatment, overall incidence (P100PY) among the cohorts ranged from 6.9 to 8.9 (anemia), from 2.0 to 2.3 (malignancy), from 0.7 to 0.9 (VTE), from 1.6 to 2.0 (MACE), and from 77.4 to 87.7 (infections). The incident comorbidities (except herpes zoster) were associated with increased adjusted health care costs.ConclusionAnemia, malignancy, VTE, MACE, and infections affect patients with RA at all stages of their treatment journey and are associated with increased health care costs.

Exploring the Role of Antinuclear Antibody Positivity in the Diagnosis, Treatment, and Health Outcomes of Patients With Rheumatoid Arthritis.

ObjectiveThe objective of this study was to describe differences in the clinical course of patients with rheumatoid arthritis (RA) who are antinuclear antibody (ANA)–positive compared with those who are ANA‐negative.MethodsThis was a retrospective population‐based cohort study of residents in Olmsted County, Minnesota, who first fulfilled 1987 American College of Rheumatology criteria for RA in 2009‐2014. Data were collected on first documentation of joint swelling. Data on rheumatoid factor or anti‐cyclic citrullinated peptide antibody testing and the ANA level were also collected. Comparisons between groups were performed by using χ2 and rank sum tests.ResultsIn this cohort, 64% of patients were tested for ANA within ±90 days of RA criteria fulfillment. In the161 patients with ANA testing, 25% were ANA‐positive. Patients who were ANA‐positive were younger, female, and less likely to be current smokers. ANA positivity did not differ between patients with RA who were seropositive and seronegative. In seropositive patients who were ANA‐positive, there was an increased time to fulfillment of RA criteria, increased time to treatment with disease‐modifying antirheumatic drugs (DMARDs), and increased likelihood of being treated with hydroxychloroquine as opposed to methotrexate. Other outcomes, including disease activity and mortality, did not differ significantly between groups.ConclusionIn patients with RA, important differences exist between those who are ANA‐positive and ANA‐negative in terms of time to fulfillment of RA criteria and time to DMARD initiation as well as choice of initial pharmacotherapy. These findings could indicate a difference in clinical presentation or perception of patients with RA who are ANA‐positive. Further research is needed to study the long‐term outcomes of patients with RA who are ANA‐positive.

OP0098 POLYPHARMACY IS ASSOCIATED WITH A POORER TREATMENT RESPONSE AND INCREASED RISK OF ADVERSE EVENTS IN EARLY RHEUMATOID ARTHRITIS

OP0098 POLYPHARMACY IS ASSOCIATED WITH A POORER TREATMENT RESPONSE AND INCREASED RISK OF ADVERSE EVENTS IN EARLY RHEUMATOID ARTHRITIS

A practical approach for vaccinations including COVID-19 in autoimmune/autoinflammatory rheumatic diseases: a non-systematic review.

The COVID-19 pandemic has occupied the world agenda since December 2019. With no effective treatment yet, vaccination seems to be the most effective method of prevention. Recently developed vaccines have been approved for emergency use only and are currently applied to large populations. Considering both the underlying pathogenic mechanisms of autoimmune/autoinflammatory rheumatological diseases (AIIRDs) and the immunosuppressive drugs used in treatment, vaccination for COVID-19 deserves special attention in such patients. In this article, we aimed to give simple messages to the clinicians for COVID-19 vaccination in patients with AIIRDs based upon the current evidence regarding the use of other vaccines in this patient group. For this purpose, we conducted a “Pubmed search” using the following keywords: Influenza, Hepatitis B, Pneumococcal, and Shingles vaccines and the frequently used conventional and biologic disease-modifying antirheumatic drugs (DMARDs). Likewise, an additional search was performed for the COVID-19 immunization in patients with AIIRDs and considering such drugs. In summary, patients with AIIRDs should also be vaccinated against COVID-19, preferably when disease activity is under control and when there is no concurrent infection. Low-degree immunosuppression does not appear to decrease antibody responses to vaccines. Ideally, vaccinations should be done before the initiation of any biological DMARDs. Patients receiving rituximab should be vaccinated at least 4 weeks before or 6 months after treatment. Since tofacitinib may also reduce antibody responses, especially in combination with methotrexate, it may be appropriate to discontinue this drug before vaccination and to restart after 14 days of immunization. Key points• COVID-19 vaccinations should preferably be made during remission in patients with autoimmune/autoinflammatory rheumatological diseases.• Low-degree immunosuppression may not interfere with antibody response to vaccines.• Ideally, vaccinations should be made before the initiation of any biological DMARDs.• Timing of vaccination is especially important in the case of rituximab.

Managing rheumatoid arthritis during COVID-19.

The outbreak of coronavirus in the world has led to an uncertainty about treatment of patients with autoimmune disorders because of their weakened immune system coupled with immunosuppressive agents they take which predisposes them to a host of infections. Data on COVID-19 patients with underlying rheumatological diseases has been emerging mostly in the form of small case series and one global registry. From these data, it seems like our patients, although immunosuppressed, are not particularly susceptible to the coronavirus infection and if infected, do not have significantly worse outcomes than other patients. In fact, drugs like hydroxychloroquine, dexamethasone, and tocilizumab have been studied for treatment of COVID-19. However, this is only preliminary data, and since a few parts of the world are still grappling with the pandemic at its peak, we need to be equipped on how to protect and manage our immunosuppressed patients. Published evidence to guide treatment decisions are lacking and doubts regarding continuation and initiation of immunosuppressants remain. Rheumatoid arthritis (RA) is the most common immune-mediated disorder in COVID-19 patients, and in this review, we discuss how the commonly used drugs in RA alter the patients’ susceptibility to this infection. The review also summarizes the recommendations from the major bodies on how to manage this disease in these times.Key Points• Patients on immunosuppressive medications are not found to be at a greatly increased risk of acquiring COVID-19 infection.• Patients doing well on a stable dose of steroid and/or Disease-Modifying Antirheumatic Drugs (DMARDs) should be allowed to continue the same unless they get infected in which case, temporary stoppage of methotrexate and leflunomide may be considered.• Initiation of high-dose steroids, DMARDs, and biologics, if the clinical situation demands so, can be done.• Maintenance biologic therapy for stable patients should be individualized by the treating physician.

Initiating disease-modifying anti-rheumatic drugs rapidly reduces purchases of analgesic drugs in juvenile idiopathic arthritis

Objective: To describe the use of analgesics 12 months before and after initiation of the first disease-modifying anti-rheumatic drug (DMARD) in children with juvenile idiopathic arthritis (JIA). Method: A register-based study linked three nationwide registers in Finland: the Register on Reimbursement for Prescription Medicines, the Drug Purchase Register (both maintained by the Finnish Social Insurance Institution), and the Finnish Population Register. The study ran from 1 January 2010 to 31 December 2014. It included 1481 patients aged < 16 years with diagnosed JIA and 4511 matched controls. Index day was the date when reimbursement for JIA medication was approved and treatment was initiated. The study period included 12 months pre- and post-index date, and purchases of prescription drugs were assessed for 3 month periods. Results: Non-steroidal anti-inflammatory drugs (NSAIDs) were purchased for 60% of the patients. Compared to controls, NSAID purchases for JIA patients were at their highest during the last 3 months before the index day [relative rate (RR) 21.2, 95% confidence interval (CI) 17.1–26.2], and they decreased steeply over the 10–12 months post-index (RR 4.0, 95% CI 3.1–5.0). Similar trends were seen with paracetamol and opioid purchases, but only 2% of patients purchased opioids during the 12 months pre-index and 1% during the 12 months post-index. Methotrexate was the most commonly used DMARD (91.9%), biologic DMARDs were used by 2.8% and glucocorticoids by 24.8% in the 3 months after the index day. Conclusion: Initiation of DMARDs rapidly reduces the need for analgesics in patients with JIA.

Risk factors for cervical spine instability in patients with rheumatoid arthritis.

Cervical spine (C-spine) instability is a unique and significant characteristic of rheumatoid arthritis (RA) because its occurrence is not rare and it can cause compressive cervical myelopathy, which may lead to serious neurologic sequelae. This study evaluated the prevalence and risk factors of C-spine instabilities in RA patients with a focus on anti-citrullinated protein antibody (ACPA) and biologic disease-modifying antirheumatic drug (DMARD) therapies. The presence of C-spine instabilities in 1114 patients with RA was evaluated using C-spine radiographies according to the defined metrics. Multivariable logistic regression analyses were performed to identify independent predictors of C-spine instability. The initiation of biologic DMARDs was assessed via a Kaplan-Meier analysis and compared using log-rank tests. In total, 306 (27.5%) patients presented with C-spine instabilities. The most common type was atlantoaxial subluxation (AAS; n = 199 [17.9%]). Male sex, positivity for rheumatoid factor and ACPA, erosive change in the peripheral joints, and presence of osteoporosis were independently associated with C-spine instabilities (all P < 0.05). In particular, positivity for ACPA was the most powerful risk factor (odds ratio: 2.33 [95% confidence interval: 1.37, 3.96], P = 0.002), and it was closely associated with AAS. Patients with AAS were at a higher risk for early initiation of biologic DMARDs. Positivity for ACPA was a significant risk factor for C-spine instability, and AAS was remarkably correlated to the early initiation of biologic DMARDs, a surrogate index of poor long-term outcomes. Key Points • The presence of antibodies against citrullinated proteins was a strong risk factor for C-spine instability in patients with rheumatoid arthritis. • Atlantoaxial subluxation was significantly associated with early initiation of biologic DMARDs, a surrogate index of poor long-term outcome.

SAT0654-HPR AN OUTCOME EVALUATION FOR THE NURSE-LED EARLY ARTHRITIS CLINIC ON THE DIAGNOSIS AND MANAGEMENT OF RHEUMATOID ARTHRITIS AT CARITAS MEDICAL CENTRE IN HONG KONG

Background:Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory disease that may cause progressive joint damage and deformity, leading to functional disability and reduced quality of life. However, there is often a long waiting time for the first assessment in Rheumatology Clinic by doctor. Development of rheumatology nurse-led clinic allows early assessment by qualified rheumatology nurse for patients with suspected RA. It may potentially facilitate the decision and treatment plan in the first doctor clinic. A nurse-led Early Arthritis Clinic (EAC) for RA patients had been established in Caritas Medical Centre (CMC) since January 2018.Objectives:To determine the effectiveness of the EAC by early identification of new cases of RA and to facilitate decision in early initiation of disease-modifying anti-rheumatic drugs (DMARDs) during the first doctor clinic assessment.Methods:New cases were screened and recruited by Rheumatology nurse from January to December 2018 to nurse-led EAC. The recruited new cases were seen in EAC around 1 to 4 weeks before the first doctor clinic. Rheumatology nurse performed nursing assessment in EAC according to the 2010 ACR-EULAR Classification of RA. These cases will be reviewed by Rheumatologist during the first doctor clinic for confirmation of diagnosis and formulation of treatment plan. If urgent problems were identified during assessment in EAC, patients would be prioritized to have an earlier doctor clinic appointment or hospitalization may be arranged.Results:A total of 128 patients with articular symptoms were seen in nurse-led EAC during the study period. Nursing assessment revealed that 71 patients were required further evaluation for the diagnosis of RA (26 males and 45 females, mean age for males: 51, mean age for females: 56) and they were recruited into the study. 36 of these 71 patients were confirmed with the diagnosis RA by rheumatologist during the first consultation of doctor clinic. 13 of 36 patients were prescribed with DMARDs on the same day of consultation. Before the establishment of EAC, the mean time of confirmation of RA by rheumatologist was 8 weeks (range from 4 to 12 weeks). Therefore, EAC facilitates both the early diagnosis of RA and the prompt initiation of treatment after confirmation of diagnosis. Reduction in disease activity was also noted after treatment. The mean Disease Activity Score of 28 joints (DAS 28) during the assessment in EAC was 4.66 (range 3.22 to 6.54) while post treatment after EAC and the first doctor clinic was 3.30 (range 2.08 to 5.16) with mean difference of -1.36 (p&lt;0.01). Other diagnoses were also made among the 71 patients. 8 patients were diagnosed of Spondyloarthropathy, 2 patients were diagnosed of psoriatic arthritis and 2 patients were diagnosed of systemic lupus erythematosus. 3 of these 71 patients were identified urgent medical problems required early intervention. Among these 3 cases, two patients with liver function derangement and one of them needed hospital admission for assessment of acute hepatitis. Another patient was arranged hospitalization to rule out sepsis due to raised total white cell count and erythrocyte sedimentation rate.Conclusion:Rheumatology nurse assessment in EAC is effective in assessing patients with suspected diagnosis of RA. It shortened the time to confirm the diagnosis of RA, and facilitated the decision on treatment plan. It effectively improved the disease activity of patients due to the prompt initiation of DMARDs by Rheumatologist.

Role of DMARD Naïve Period in the Development of Severe Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a symmetric poly-arthritis predominantly affecting the small synovial joints, although any synovial joint can be involved. The underlying cause is not known; however, predilection for the disease is impacted by genetic and environmental factors. Several factors predict disease severity in RA including development of erosions, female sex and duration of disease. This study evaluates the role of disease duration, early initiation of disease modifying anti-rheumatic drugs (DMARDs) and auto-antibodies like rheumatoid factor in predicting erosive disease in Indian patients with rheumatoid arthritis. A 2-year hospital-based cross-sectional observational study was conducted in the Department of Medicine in a tertiary care centre in Kumaon region of Uttarakhand in northern India. 260 patients diagnosed with RA on the basis of 2010 ACR/EULAR criteria were included. A total of 135 patients had erosive disease, with DMARD naive median period of 3years compared to 125 patients with non-erosive disease, with DMARD naive median period of 2years. On the basis of this data and after evaluation for radiographic erosions, it was found that a longer DMARD naive period predicts higher odds of developing erosive disease. Early diagnosis of rheumatoid arthritis and initiation of DMARDs is crucial in increasing quality of life and preventing severe disease with deformities, erosive changes and extra-articular manifestations.

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.

Evidence of Diagnostic and Treatment Delay in Seronegative Rheumatoid Arthritis: Missing the Window of Opportunity

ObjectivesTo compare the time from first joint swelling to fulfillment of the American College of Rheumatology/European League Against Rheumatism classification criteria between patients with seropositive and seronegative rheumatoid arthritis (RA) and to assess the impact of seronegative status on the time from first joint swelling to initiation of disease-modifying antirheumatic drug (DMARD) therapy and achievement of remission. Patients and MethodsTimes from first provider-documented joint swelling to fulfillment of the 1987 and 2010 American College of Rheumatology/European League Against Rheumatism criteria and to the clinical diagnosis of RA were measured in a population-based cohort of adults with incident RA between January 1, 2009, and December 31, 2014. Disease characteristics and achievement of remission were compared between seropositive (rheumatoid factor positive and/or anti–citrullinated peptide antibody positive) and seronegative (rheumatoid factor negative/anti–citrullinated peptide antibody negative) patients. ResultsThe median time from first joint swelling to fulfillment of the 1987 (48 [interquartile range (IQR), 0-300] days vs 2 [IQR, 0-45] days; P=.001) and 2010 (14 [IQR, 0-196] days vs 0 [IQR, 0-29] days; P=.004) classification criteria and the median time from first joint swelling to the clinical diagnosis of RA (187 [IQR, 13-503] days vs 11 [IQR, 0-76] days; P<.001) were significantly longer in seronegative patients than in seropositive patients. The median time from first joint swelling to first prescribed DMARD therapy was significantly longer in seronegative patients (40 [IQR, 5-199] days vs 14 [IQR, 0-73] days; P=.01). Patients with seronegative RA were less likely to achieve remission (28% vs 50% at 5 years after fulfillment of the 2010 criteria; P=.007), but there was no difference when the patient global score was removed from the remission definition. ConclusionPatients with seronegative RA experienced a delay in diagnosis, according to both the 1987 and 2010 classification criteria, as well as a delay in the initiation of DMARD therapy. Patients with seronegative RA were also less likely to attain remission, suggesting that the window of opportunity for intervention may be more frequently missed in this group.

Responsiveness of Patient-Reported Outcomes Measurement Information System Measures in Rheumatoid Arthritis Patients Starting or Switching a Disease-Modifying Antirheumatic Drug.

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a calibrated item bank used to assess patient-reported outcomes across multiple domains. The purpose of this study was to describe the performance of selected PROMIS measures in patients with rheumatoid arthritis (RA) with active disease who were initiating a disease-modifying antirheumatic drug (DMARD). Participants in an ongoing prospective observational study completed 8 PROMIS measures before and after DMARD initiation. Linear regression models were performed to identify cross-sectional associations between baseline PROMIS measures and disease activity, measured using the Clinical Disease Activity Index (CDAI). Paired t-tests were performed to evaluate responsiveness after 12 weeks of DMARD treatment. Associations between changes in PROMIS measures and changes in the CDAI score were assessed using linear regression. Among the 156 participants who completed the first study visit, the mean ± SD baseline CDAI score was 25.5 ± 14.0. Baseline scores for PROMIS measures of physical health, pain, and sleep were associated with the baseline CDAI score (P ≤ 0.05). Among the 106 participants with 12-week data, all PROMIS scores improved after DMARD initiation (P ≤ 0.05). With the exception of depression, changes in all assessed PROMIS measures were correlated with changes in the CDAI score (standardized βs from |0.23| to |0.38|). These data provide support for the utility of PROMIS measures for the assessment of physical and mental health in individuals with active RA. All PROMIS measures improved significantly after DMARD initiation, with the magnitudes of association between changes in PROMIS measures and changes in the CDAI score in the low-to-moderate range.

What is the additional value of MRI of the foot to the hand in undifferentiated arthritis to predict rheumatoid arthritis development?

BackgroundMRI-detected subclinical joint inflammation in the hand joints of patients with undifferentiated arthritis (UA) predicts progression to rheumatoid arthritis (RA). It is unknown if adding MRI of the foot increases predictive accuracy compared to the hand alone.Methods1.5-T contrast-enhanced MRI of the unilateral foot (MTP-1-5) and hand (MCP-2-5 and wrist) was performed in 123 patients presenting with UA (not fulfilling the 2010 RA criteria) and scored for bone marrow edema (BME), synovitis and tenosynovitis. Symptom-free controls (n = 193) served as a reference for defining an abnormal MRI. Patients were followed for RA development ≤ 1 year, defined as fulfilling the classification criteria or initiation of disease-modifying antirheumatic drugs because of the expert opinion of RA. The added predictive value of foot MRI to hand MRI was evaluated.ResultsFifty-two percent developed RA. Foot tenosynovitis was predictive (OR 2.55, 95% CI 1.01–6.43), independent of BME and synovitis (OR 3.29, 95% CI 1.03–10.53), but not independent of CRP and number of swollen joints (OR 2.14, 95% CI 0.77–5.95). Hand tenosynovitis was also predictive independent of BME and synovitis (OR 3.99, 95% CI 1.64–9.69) and independent of CRP and swollen joints (OR 2.36, 95% CI 1.04–5.38). Adding foot tenosynovitis to hand tenosynovitis changed the sensitivity from 72 to 73%, specificity from 59 to 54% and AUC from 0.66 to 0.64; the net reclassification index was − 3.5.ConclusionMRI-detected tenosynovitis of the foot predicts progression to RA. However, adding MRI of the foot does not improve the predictive accuracy compared to MRI of the hand alone. In view of cost reduction, the performance of foot MRI for prognostic purposes in UA can be omitted.

Prescription patterns of anti-rheumatic drugs in patients with rheumatoid arthritis at a community pharmacy near a secondary-care hospital in South Korea

Rheumatoid arthritis (RA), one of the most common forms of inflammatory disease, induces chronic inflammation of the joints and various organs. Therapy with disease-modifying anti-rheumatic drugs (DMARDs) should be initiated immediately after a diagnosis of RA because the early initiation of DMARDs can prevent joint damage in a large proportion of RA patients. The aims of this study were to analyze the prescription patterns of RA medication in Korean patients visiting a community pharmacy and to examine drug-drug interactions (DDIs) between DMARDs and concomitant medications. A retrospective study was conducted with RA patients visiting the community pharmacy, located at the southern region of South Korea, between January and February 2015. Data were collected through the review of patients’ prescriptions. During the study period, 931 were diagnosed with RA. Methotrexate (MTX), hydroxychloroquine (HCQ), leflunomide (LEF), tacrolimus (TAC), and sulfasalazine (SUL) were prescribed to 703 (75.51%), 387 (41.57%), 303 (32.55%), 131 (14.07%), and 83 (8.92%) patients, respectively. The most commonly prescribed combination was DMARDs+glucocorticoids (GCs) (40.79%). MTX and TAC showed drug interactions with non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs), but significant DDIs between HCQ or LEF and co-administered drugs were not found. MTX was the most commonly prescribed DMARD for both monotherapy and in combination with other DMARDs. The commonly prescribed DMARDs (i.e., MTX and TAC) were demonstrated to have DDIs with NSAIDs and PPIs. Therefore, the co-administration should be carefully monitored, especially in elderly patients with polypharmacy.