bluuebunny/crossref_metadata_2025 huggingface dataset:
Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy
Authors: Norvell Miranda R , Porter Melissa , Ricco Madison H , Koonce Ryan C , Hogan Craig A , Basler Eric , Wong Megan , Jeffres Meghan N
Published: April 2023

Background

Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin.

Methods

This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin.

Results

A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06).

Conclusions

The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.
Sustained release of brimonidine from polydimethylsiloxane-coating silicone rubber implant to reduce intraocular pressure in glaucoma
Authors: Huang Chang , Shen Yuening , Zhao Yujin , Zhang Zhutian , Gao Shunxiang , Hong Jiaxu , Xu Jianjiang , Meng Qingtao , Sun Xinghuai , Sun Jianguo
Published: April 2023

Glaucoma is the leading cause of irreversible blindness, affecting 111 million people by 2040 worldwide. Intraocular pressure (IOP) is the only controllable risk factor for the disease and current treatment options seek to reduce IOP via daily taking eye drops. However, shortcomings of eye drops, such as poor bioavailability and unsatisfied therapeutic effects, may lead to inadequate patient compliance. In this study, an effective brimonidine (BRI)-loaded silicone rubber (SR) implant coated with polydimethylsiloxane (BRI@SR@PDMS) is designed and fully investigated for IOP reduction treatment. The in vitro BRI release from BRI@SR@PDMS implant reveals a more sustainable trend lasting over 1 month, with a gradually declined immediate drug concentration. The carrier materials show no cytotoxicity on human corneal epithelial cells and mice corneal epithelial cells in vitro. After administrated into rabbit’s conjunctival sac, the BRI@SR@PDMS implant releases BRI in a sustained fashion and effectively reduces IOP for 18 days with great biosafety. In contrast, BRI eye drops only maintain IOP-lowering effect for 6 h. Therefore, as a substitute of eye drops, the BRI@SR@PDMS implant can be applied as a promising non-invasive platform to achieve long-term IOP-lowering in patients suffering from ocular hypertension or glaucoma.
Metformin promotes angiogenesis by enhancing VEGFa secretion by adipose-derived stem cells via the autophagy pathway
Authors: Tao Zihan , Liu Lei , Wu Minliang , Wang Qianqian , Wang Yuchong , Xiong Jiachao , Xue Chunyu
Published: April 2023

Human adipose tissue-derived stem cell (ADSC) derivatives are cell-free, with low immunogenicity and no potential tumourigenicity, making them ideal for aiding wound healing. However, variable quality has impeded their clinical application. Metformin (MET) is a 5′ adenosine monophosphate-activated protein kinase activator associated with autophagic activation. In this study, we assessed the potential applicability and underlying mechanisms of MET-treated ADSC derivatives in enhancing angiogenesis. We employed various scientific techniques to evaluate the influence of MET on ADSC, assess angiogenesis and autophagy in MET-treated ADSC in vitro, and examine whether MET-treated ADSC increase angiogenesis. We found that low MET concentrations exerted no appreciable effect on ADSC proliferation. However, MET was observed to enhance the angiogenic capacity and autophagy of ADSC. MET-induced autophagy was associated with increased vascular endothelial growth factor A production and release, which contributed to promoting the therapeutic efficacy of ADSC. In vivo experiments confirmed that in contrast to untreated ADSC, MET-treated ADSC promoted angiogenesis. Our findings thus indicate that the application of MET-treated ADSC would be an effective approach to accelerate wound healing by promoting angiogenesis at wound sites.
OA15 IL-13 inhibition used for atopic diseases is associated with risk of psoriatic arthritis
Authors: Zhao Sizheng Steven , Hyrich Kimme L , Yiu Zenas Z N , Barton Anne , Bowes John
Published: April 2023

Background/Aims

Inhibitors of the IL-13 pathway, such as dupilumab and tralokinumab, are licensed to treat atopic diseases such as eczema and asthma. Musculoskeletal adverse events that resemble enthesitis and psoriatic arthritis (PsA) after dupilumab initiation have been reported, but evidence is limited to case reports and spontaneous pharmacovigilance with uncertain causal inference. Naturally occurring genetic variation in drug targets can provide insight into their potential adverse effects. We used population-level data to investigate whether genetically proxied IL-13 inhibition (IL-13i) increases risk of PsA and other spondyloarthritis-related diseases.

Methods

Dupilumab is recognised to reduce eosinophil count in clinical studies; we therefore used it as the biomarker of IL-13i. We instrumented IL-13i using missense (protein coding) variants within the IL13 gene that are associated with circulating eosinophil count at genome-wide significance (p < 5x10-8) in a study of 563,946 individuals. Outcome genetic associations were taken from studies of PsA, psoriasis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis and iritis. To examine instrument validity, we used atopic eczema and asthma as positive control outcomes, and rheumatoid arthritis as a negative control. We used the ratio method, with estimates scaled to per standard deviation (SD ∼0.14x109/L) reduction in eosinophil count.

Results

One missense variant, rs20541, was selected to proxy IL-13i. Genetically proxied IL-13i was associated with increased risk of PsA (OR 37.39; 95%CI 11.52, 121.34), psoriasis (OR 20.08; 4.38, 92.01), Crohn’s disease (OR 3.49; 1.38, 8.81), but not ulcerative colitis, ankylosing spondylitis or iritis. IL-13i was associated with reduced risk of positive control outcomes, but not with the negative control (Table 1).

Conclusion

Genetically proxied IL-13 inhibition is associated with increased risk of PsA, psoriasis and Crohn’s disease, which may be a class effect relevant to other IL-13i that are not yet reported to have Th17-type adverse events. These findings are compatible with the hypothesis that Th2 cytokines IL-4/-13 may act as a restraint toward Th17-type disease activation in some organs. Clinicians assessing adverse events after dupilumab initiation should be aware of incident PsA and related features. This study demonstrates the value of MR in evaluating rare adverse events in the study of drug safety.

Disclosure

S. Zhao: None. K.L. Hyrich: None. Z.Z.N. Yiu: None. A. Barton: None. J. Bowes: None.
OA20 Differences in management approaches for lupus nephritis within the UK
Authors: Ibrahim Sara T , Rhodes Benjamin , Griffiths Bridget , Gordon Caroline , Edwards Christopher J , Jayne David , Vital Edward M , Lightstone Liz , Ehrenstein Michael R , Hewins Peter , Mclaren Zoe , Reynolds John A
Published: April 2023

Background/Aims

Outcomes of current therapy for lupus nephritis (LN) are suboptimal. Guidelines offer varied options for treatment of LN at onset, for refractory disease or relapse. Recent randomised trials have demonstrated the efficacy of newer agents and combination therapies, although these are not all permitted within NICE or NHS England funding. Therefore, treatment strategy may vary between clinicians or regions. We aimed to describe variations in usual practice of UK physicians who treat LN.

Methods

We conducted an online survey of simulated LN case scenarios for rheumatologists and nephrologists within the UK to identify treatment preferences for proliferative (class IV) and membranous (class V) LN.

Results

Of 77 respondents who completed the survey 48 (62.3%) were rheumatologists and 29 (37.7%) were nephrologists. 69% of the nephrologists but only 27% of rheumatologists reported having a formal departmental protocol for treating patients with LN (p < 0.001). The first-choice treatment of class IV LN in pre-menopausal female patients differed significantly between nephrologists and rheumatologists (p = 0.026) (see Table 1). For patients who failed to improve on first-line therapy there was no significant difference between nephrologists' and rheumatologists' second-choice therapy (p = 0.50) (see Table 1). However, 55% of nephrologists chose to change to second-choice treatment 3-6 months from the start of first treatment and 34.5% would change after 6-12 months but 81.3% of rheumatologists chose to change after 3-6 months and 10.4% would change in less than 3 months (p = 0.016). For class V LN, MMF was the preferred initial treatment irrespective of whether proteinuria was in nephrotic range or not. For nephrotic range class V LN not responding to first-choice treatment there were significant differences between nephrologists' and rheumatologists' choices for second-line therapy (p = 0.041) (see Table 1).

Conclusion

There is variation in treatment choices for LN between physicians with different choices reported by nephrologists and rheumatologists. These results suggest that: (i) care may not be well coordinated between rheumatologists and nephrologists; (ii) clearer guidelines are required to ensure use of the best therapies; (iii) access to the most effective therapies needs to be improved.

Disclosure

S.T. Ibrahim: None. B. Rhodes: None. B. Griffiths: None. C. Gordon: None. C.J. Edwards: None. D. Jayne: None. E.M. Vital: None. L. Lightstone: None. M.R. Ehrenstein: None. P. Hewins: None. Z. Mclaren: None. J.A. Reynolds: None.
OA26 Characterisation of a basket trial population for arthritis associated with ANA-positive RMDs
Authors: Arnold Jack , Carter Lucy Marie , Hassan Sabih , Dutton Katherine , Wigston Zoe , Dass Shouvik , Md Yusof Yuzaiful Md , Vital Ed
Published: April 2023

Background/Aims

Musculoskeletal inflammation is the most common reason for the inclusion of patients in SLE trials or biologic use. It is also common across other ANA-associated diseases, but these patients do not have access to the same therapies as SLE patients despite a seemingly similar problem. Our aims were to test whether (i) patient-reported impact and (ii) immunological profile of MSK inflammation are equivalent across ANA-associated diseases; (iii) identify features that stratify ANA-associated arthritis; (iv) explore the criterion validity of BILAG-MSK in other ANA-associated arthritis.

Methods

We used cross-sectional analysis of patient-reported outcome measures, antibody, gene expression and flow cytometric data from a study of mixed ANA-associated diseases (DEFINITION). The clinical and immunological implications of legacy diagnosis membership were analysed by comparing QoL measures (SF36, EQ5D-5L, Patient VAS, ICECAP-A, FACIT-F, WPAI and ICECAP-A), gene expression scores (2 IFN Scores, neutrophil, plasmablasts, myeloid and inflammation scores) and flow cytometry using Kruskal Wallis tests. The association between the BILAG MSK domain and physician arthritis VAS was tested for SLE and non-SLE patients.

Results

Of 300 patients, 215 had current or prior joint or tendon inflammation. Only FACIT-F and EQ5DL-5L showed trends to difference between diseases, being worst in the MCTD group. No other clinical or immunological variable differed between groups (Table 1). However, significant associations were found for non-disease-specific variables; worse EQ5D-5l index scores were associated with chromatin antibody positivity (T-Test, p < 0.001) and non-European ancestry (T-Test, p < 0.05). There was a significant association between BILAG-MSK and physician arthritis VAS in both SLE (Kruskal Wallis Chi-Sq=56.8, p < 0.0001), and non-SLE (Kruskal Wallis Chi-Sq=17.468, p < 0.001) patients.

Conclusion

Patients with ANA-associated arthritis appear clinically homogenous across legacy diagnoses so performing trials in a basket population appears appropriate and may be more clinically homogenous than populations currently included in SLE trials who have mixed organ involvement. Furthermore, such a basket trial could benefit from an organ-specific outcome measure, which our preliminary analysis of BILAG-MSK suggests would be valid. Predictors of worse symptoms are not specific to individual diseases, including autoantibody profile and ancestry.

Disclosure

J. Arnold: None. L. Carter: Consultancies; UCB. S. Hassan: None. K. Dutton: None. Z. Wigston: None. S. Dass: Consultancies; Roche, Abbvie, UCB and Chugai. Honoraria; Roche, Abbvie, UCB and Chugai. M. Md Yusof: Consultancies; Aurinia and, UCB. E. Vital: Consultancies; Roche, GSK, AstraZeneca, Aurinia, Lilly, UCB and Novartis. Grants/research support; Roche, AstraZeneca and Sandoz.
OA27 Mortality in patients with moderate-to-severe SLE: results from the British Isles Lupus Assessment Group Biologics Registry (BILAG-BR)
Authors: Dyball Sarah , Rodziewicz Mia , Sutton Emily , Aksoy Aysun , McDonald Stephen , Parker Benjamin ,   BILAG-BR, Bruce Ian N
Published: April 2023

Background/Aims

Individuals with systemic lupus erythematosus (SLE) have an increased rate of mortality compared to the general population. We aimed to assess the cause of death and characteristics of these patients in a large national biologics register.

Methods

Patients receiving biological or standard of care (SoC) treatment recruited to the UK national SLE biologics registry (2010-21) were included. Demographic, clinical and laboratory data were recorded at recruitment. Information relating to date and cause of death were collected from study centres and the UK Office for National Statistics. The relationship between mortality and patient variables was analysed using a Cox proportional hazards model.

Results

There were 54 deaths in 1,477 patients over 6,162 patient years of follow up. The mortality rate was 5.97 (6.92-11.80) per 1000 person years (py). The cause of death was identifiable in 52 (96.2%) patients and included infection (21, 38.9%), active SLE (10, 18.5%), malignancy (6, 11.1%), cardiovascular disease (6, 11%), thrombosis (3, 5.6%), opiate toxicity (1, 1.9%) and cerebral haemorrhage (1, 1.9%). The characteristics of patients who died are described in Table 1. The median time between BILAG-BR registration and death was 679 (251-1,227) days. The mortality rate was 11.34 (8.54-15.04) per 1,000 py in patients on rituximab, 2.52 (0.36-17.90) per 1,000 py in belimumab and 3.32 (1.25-8.86) per 1,000 py in patients on SOC medicines. Factors independently associated with mortality included age at recruitment (HR 1.07 [1.05-1.09]), previous myocardial infarction (HR 5.35 [2.27-12.59]), diabetes mellitus (HR 3.87 [1.81-8.29]), previous cancer (HR 3.30 [1.59-6.86]) and hypertension (HR 1.81 [1.00-3.27]). In multivariate models adjusted for age, gender and presence of co-morbidities at baseline, risk of death was not significantly different between rituximab and belimumab (HR 0.36 [0.05-2.65) or SOC (HR 0.40 [0.12-1.32]) groups.

Conclusion

Risk of mortality was not different between treatment groups after accounting for differences in baseline demographics and co-morbidities. Co-morbidities were independently associated with high risk of death for patients with moderate-to-severe SLE; these should be actively assessed and managed to improve mortality outcomes.

Disclosure

S. Dyball: Grants/research support; MRC. Other; GSK, UCB. M. Rodziewicz: Grants/research support; MRC. Other; UCB. E. Sutton: None. A. Aksoy: None. S. McDonald: None. B. Parker: Honoraria; Fresenius-Kabi, AbbVie. Grants/research support; Genzyme/Sanofi, GSK. Other; Eli Lilly, Roche. I. Bruce: Consultancies; AstraZeneca, Eli Lilly, UCB, ILTOO, Merck Serono, GSK. Grants/research support; UCB, Roche, GSK, Genzyme/Sanofi. Other; AstraZeneca, GSK, UCB.
OA36 Treatment of Takayasu’s arteritis with anti-tumour necrosis factor: real world data from a UK tertiary referral centre
Authors: Colquhoun Matthew , Maughan Robert , Porter Andrew , Satara Japna , Hanlon Samuel , Nouza Jan , Youngstein Taryn A , Mason Justin
Published: April 2023

Background/Aims

Takayasu’s arteritis (TAK) is a rare granulomatous vasculitis affecting the aorta and its major branches. It is associated with significant morbidity. Initial treatment typically consists of corticosteroids and one or more conventional synthetic steroid sparing agents e.g. methotrexate/mycophenolate. In the case of disease progression or inability to wean corticosteroids, additional therapy in the form of biologic medications may be necessary. Tocilizumab is approved for the treatment of Takayasu’s arteritis in the UK, while anti-TNF therapies are not commissioned for this indication. This stands in contrast to guidelines from the USA, which prefer anti-TNF as a first line biologic agent. We describe the characteristics and outcomes of patients treated with anti-TNF at a single UK centre.

Methods

We retrospectively evaluated 14 Takayasu’s arteritis patients treated with anti-TNF agents out of a total cohort of 158 patients at a tertiary Takayasu’s arteritis clinic at a single UK academic centre.

Results

14/158 patients (8.8%) received anti-TNF therapy for treatment of active TAK. The average age at diagnosis was 27 years. 93% (13/14) patients were female. 71% (10/14) were Caucasian and 3/14 (21%) were Asian. Prior treatment with prednisolone was ubiquitous. 5/14 (35.7%), 1/14 (7.1%), 4/14 (28.5%) and 3/14 (21%) received treatment with 1, 2, 3 or 4 csDMARDs respectively. 78.5% received methotrexate and 64.5% of patients received azathioprine with cyclophosphamide (35%) and mycophenolate mofetil (28.5%) less commonly used. 6/14 (42.8%) of the cohort had a co-existent justification for anti-TNF treatment e.g. ankylosing spondylitis, uveitis or Crohn’s disease. 100% of the cohort had stenotic/occlusive disease prior to anti-TNF treatment with 6/14 (42.8%) also having abnormal vascular dilatation. 4/14 (28.5%) experienced treatment failure defined as active inflammation or disease progression. 3 patients experienced radiographic progression (stenosis or dilatation) and 1 early treatment failure. Total time on anti TNF treatment for these four patients were 2 (early treatment failure), 13, 15 and 93 months. 71.5% of patients had stable radiographic appearances during an average total treatment time of 70 months (range 24-120).

Conclusion

This retrospective examination of patients with severe Takayasu’s arteritis treated with anti-TNF at a specialist centre demonstrates that 71.5% of patients had stable angiographic disease over a long duration of follow up, suggesting anti-TNF therapy may be an option for those patients for whom tocilizumab is ineffective or not tolerated.

Disclosure

M. Colquhoun: Honoraria; Support to attend a conference from Pfizer. R. Maughan: None. A. Porter: None. J. Satara: None. S. Hanlon: None. J. Nouza: None. T.A. Youngstein: None. J. Mason: None.
OA41 Online MDT patient education for early inflammatory arthritis
Authors: Gwynne Catherine , Gilbard Shaun , Weller Zoe , Clemence Mark , Parsons Claire , Penford Rian
Published: April 2023

Background/Aims

Patient education in early inflammatory arthritis (EIA) promotes understanding and engagement with treatment, empowering patients to use self-management in their long-term health condition. It is embedded in national guidance and audit. Individual appointments are time consuming, and groups sessions became impossible during the COVID-19 pandemic. Our education sessions have evolved to a monthly online meeting which aims to be engaging, effective and time efficient.

Methods

Face-to-face group education afternoons were previously embedded into our early arthritis pathway. Presentations and opportunities for questions were given by a rheumatology consultant, nurse, physiotherapist, podiatrist and occupational therapist. Sessions lasted 2 hours and local charity representatives attended. Group education sessions completely stopped with the COVID-19 pandemic restrictions. This successful MDT model was moved to a monthly Microsoft Teams meeting and condensed to 1 hour. Sessions continue to consist of five short presentations, introduction to charity representatives and opportunity for questions. Following the session, all patients received links to videos of the talks for future reference, contact details for the MDT and local charities, and a link to download our local rheumatology self management app. Patients who are unable to attend also receive this content by email. Patient feedback was gathered through an online questionnaire.

Results

Attendance has increased over time with 75% of our new EIA patients now attending each month. Feedback from 16 patients rated 75% of all talks as extremely useful or useful. 89% are interested in attending future meetings. 93% had already used or plan to use our rheumatology self management app. Positive patient feedback included: “the whole team were brilliant giving advice and answering questions”, “nice to see the specialists' faces, and to get the feeling they really cared”, and “a perfectly sensible and productive way to introduce all the options for help and support”.

Some patients did not feel confident to ask questions in the meeting. Email and telephone advice lines were signposted. Attendance was increased by 40% by a short telephone reminder of the appointment.

Conclusion

An online meeting has proven to be a time efficient and effective way of providing multidisciplinary education and introducing self management. A short time investment from each MDT member gives breadth to the education. Inviting all newly diagnosed early arthritis patients and encouraging attendance by a short telephone call has maximised reach. Ensuring all patients are sent presentation videos to re-watch and the self referral details further facilitates self management. The format could easily be adapted to other patient education events.

Disclosure

C. Gwynne: None. S. Gilbard: None. Z. Weller: None. M. Clemence: None. C. Parsons: None. R. Penford: None.
P006 A national patient-reported experience survey (PREM) of advanced nurse practitioners in rheumatology, Ireland
Authors: Martin Una E
Published: April 2023

Background/Aims

Data collection to assess the impact of rheumatology advanced nurse practitioners (RANPs) on service quality tends to prioritise the quantitative impact on waiting lists and hospital admissions. However, patients’ views on the quality of service experienced is fundamental and essential to achieve high quality of care. Recording patients experience of care has the potential to improve quality of care. The Irish Rheumatology Nursing Forum (IRNF) wanted to measure patients' experience of care by an RANP and highlight triggers for change to enhance the quality of care delivery nationally.

Methods

The IRNF conducted a service evaluation postal survey using patient reported experience measure (RA PREM), previously designed, and validated for use with rheumatology patients. This tool examines eight domains of care specific to patients with inflammatory arthritis (need and preferences; care coordination; information about care; daily living; emotional support; family and friends; access to care) and is proven to be effective in measuring and monitoring patient experience. Minor adjustments were made to the questionnaire specific to the role of the advanced nurse practitioner. Patients seen by an advanced nurse practitioner within the previous 12-months were supplied with a questionnaire and a stamped address envelope during a 6-week period, in early 2022. Patient participation was voluntary, postal return of a complete survey implied consent.

Results

Eleven eligible rheumatology centres with twenty advanced nurse practitioners participated nationally. A total 350 questionnaires were disseminated, 188 completed questionnaires were returned, (54% response rate). In the previous 12-month period 38% of respondents had at least 2 appointments. Appointments with the advance nurse practitioner were predominantly face-to-face (73%), and a further 26% were telephone consultations. Most patients reported involvement in their care decisions, being emotionally supported, and that communication and service access were timely. Patients endorsed a good experience of care for their inflammatory arthritis (67% strongly agreed, 25% agreed). Most patients (71%) reported good control of their arthritis which allowed them to get on with usually daily life activities. Results from the self-care domain demonstrated low levels of knowledge about patient organisations and self-management programmes.

Conclusion

Optimising the quality of care delivered by advance nurse practitioners is contingent on measuring patient experience. The self-management organisations/programme knowledge deficit among patients will be addressed by the IRNF in partnership with the patient organisation Arthritis Ireland. It is incumbent on advanced practice nurses to undertake service evaluations for quality improvement and further service development. Periodic use of PREMS is a feasible way to inform service evaluation for quality improvement.

Disclosure

U.E. Martin: None.
P008 Hydroxychloroquine-related adverse events, attrition and reasons for cessation over 5 years at a district general hospital: estimating future ophthalmology screening service use
Authors: Barahman Dalal , Saleh Christopher , Paul Anindita
Published: April 2023

Background/Aims

Hydroxychloroquine (HCQ) is used widely in the management of rheumatic diseases and is considered to be generally well tolerated. HCQ ocular toxicity is a dose- and time-related reaction. The Royal College of Ophthalmologists (RCOphth) noted a low rate of drug discontinuation as a result of baseline testing (< 4%) and that prevalence data for HCQ ocular toxicity was based on treatment duration >5 years. The RCOphth updated their ocular toxicity screening guideline in 2020. A major change was removal of requirement for baseline screening, with screening commenced at 5 years of treatment unless risk factors are present. Though the number of patients starting HCQ treatment and the UK prescribing data could be estimated, the proportion of patients remaining on treatment for >5 years was stated to be unknown. We reviewed departmental HCQ prescribing, adverse event and attrition data over 5 years from Bolton NHS Foundation Trust, a district general hospital which serves a population of nearly 300,000.

Methods

Patients were identified as newly commencing HCQ if they had a shared care agreement in the calendar year 2016. Adverse events, attrition rates and reasons for cessation were obtained through review of hospital records over 5 years.

Results

In the 2016 calendar year, 100 patients commenced HCQ. The mean age was 58, and 70% patients were female. The most common indication was rheumatoid arthritis (75%). At 1 year, 30% of patients had stopped taking HCQ. At 5 years 57% of patients had stopped taking HCQ. The most common reason for cessation at 1 year was gastrointestinal symptoms (30%), and remained the most common reason at 5 years (19%). Eye symptoms were documented as reason for cessation in 7% of patients at 1 year, and 5% of patients at 5 years. On review of records, none of these were thought to be attributable to HCQ, though it was not recommenced. There were no patient deaths directly attributable to HCQ use.

Conclusion

A significant proportion of patients (57%) stopped taking HCQ after 5 years. The rate of attrition was highest within 12 months, which then almost doubled by 5 years. Centres wishing to estimate the workload related to HCQ retinopathy screening can capture their prescribing for patients newly starting HCQ and/or their catchment population numbers to estimate the Ophthalmology activity related to this 5 years' hence. This may help to fund and staff adequately to successfully carry out this drug safety activity.

Disclosure

D. Barahman: None. C. Saleh: None. A. Paul: None.
P013 A three-year audit of dose tapering biologic medications in a rheumatology service
Authors: Light Helen , Firth Jill , Bluett James , Kinsey Katharine
Published: April 2023

Background/Aims

Dose tapering of biologic therapies is supported by both ACR and EULAR guidelines. Identification of appropriate patients may deliver cost savings whilst minimising the risk of disease flare. To audit dose tapering activity for patients treated with bDMARD for rheumatoid (RA), psoriatic arthritis (PsA) and ankylosing spondylosis (AS) meeting locally agreed criteria over three years.

Methods

All patients treated with a bDMARD for RA, PsA or AS fulfilling criteria for dose tapering between 1st October 2019 - 1st October 2021 were identified from electronic health records (EHR). Rituximab patients were excluded due to reactive treatment responding to flare. Patients were required to have been on their bDMARD for = > one year, not prescribed oral steroids / treated with parenteral steroids in the past six months, no swollen joints in the past six months, and not failed dose tapering in the previous year. RA patients were ineligible if DAS ≥3.2 in the previous year; PsA if their biologic was prescribed by dermatology /active psoriasis; AS patients if BASDAI score of > 4 in past year. Records were flagged to prompt a shared decision-making discussion between the treating clinician and patient during routine appointments; additional patients were identified through clinical assessment. Failing dose tapering was defined as a post tapering flare requiring dose increase within one year. Patients were tapered by increasing the interval of a bDMARD.

Results

The number of patients that dose tapered increased from 24 in 2019 to 51 in 2021, making a total estimated NHS list saving of up to £170,000 per annum. (Table 1). Tapering was unsuccessful for 7/116 (6%) due to post tapering flares. Patients flaring after tapering were reassessed urgently and had their bDMARD dose reviewed. More patients were eligible than identified from EHR search due to missing data in coding; 787 (61%) across all years.

Conclusion

Dose tapering was well tolerated in eligible patients making this a safe and acceptable initiative. Use of EHR data and behavioural prompts for clinicians supported this in practice. Cost savings were reinvested to increase pharmacy support for homecare prescription management.

Disclosure

H. Light: None. J. Firth: None. J. Bluett: Grants/research support; JB has received a research grant from Pfizer. Other; JB has received travel/conference fees from UCB, Pfizer and Eli Lilly. K. Kinsey: None.
P014 Experience of baricitinib in a real-world population with efficacy and side effects: a South London regional analysis
Authors: Buckeldee Olivia , Biddle Kathryn , Latheef Afzal , Al-Shakarchi Israa , Sofat Nidhi
Published: April 2023

Background/Aims

Baricitinib is the most common Janus Kinase inhibitor (JAKi) used in the treatment of rheumatological conditions. Whilst randomised controlled trials have demonstrated the efficacy and safety profile of baricitinib, real-world data on the experience of JAKi use in clinical practice is lacking. The aim of this analysis was to evaluate baricitinib use in a real-world patient population in South London.

Methods

We looked at two rheumatology departments in South London (St George’s Hospital; a tertiary teaching centre and Kingston Hospital; a district general hospital). All patients prescribed baricitinib between January 2017 to June 2022 were included. A retrospective assessment of electronic patient notes was performed to evaluate disease activity (determined by DAS-28 scores at baseline, 3-6 months and presently); adverse effects including side effects, rates of and reasons for discontinuation; and prescribing practice, including previous use of other biological disease modifying anti-rheumatic drugs (bDMARDs). Baseline data including age, gender, co-morbidities and rheumatological diagnoses were also included.

Results

233 patients were included in this evaluation, with seropositive rheumatoid arthritis being the most common diagnosis (58%) and with a significant female population (87%). Baricitinib improved average DAS-28 scores from 5.75 (range 3.57-8.3) at baseline to 3.23 (range 0.28-7.49) at 3-6 months post-baricitinib, with the most recent DAS-28 score of 2.90 (range 0.56-6.77). Rates of adverse effects were low as shown in Table 1. Baricitinib was discontinued in 60/233 patients, with average duration to discontinuation of 9.5 months. The most common reasons for discontinuation were: ineffective disease control (28/60), recurrent bacterial infection (5/60), deranged liver function (3/60) and venous thromboembolism (2/60). Eight patients died whilst taking baricitinib. Where documented, the causes of death were Covid-19 (4/8) and malignancy (1/8). 110 out of 233 patients had received other bDMARDs before starting baricitinib. Documented reasons for baricitinib choice over tumour necrosis factor inhibitors (TNFi) included: previous lack of response to TNFi (89/233), contra-indication to TNFi (11/233) and preference of oral route (10/233).

Conclusion

Our real-world study of JAKi use shows that baricitinib is efficacious in the treatment of rheumatological conditions. Moreover, baricitinib is well tolerated, with low rates of adverse effects and subsequent discontinuation.

Disclosure

O. Buckeldee: None. K. Biddle: None. A. Latheef: None. I. Al-Shakarchi: None. N. Sofat: None.
P023 National care of patients with Polymyalgia Rheumatica: Audit of steroid usage from UK GP data - a cause for concern?
Authors: Saha Pratayasha , Brown Julian , MacGregor Alexander , Aldus Clare , Yates Max
Published: April 2023

Background/Aims

Polymyalgia rheumatica (PMR) is the most common autoimmune musculoskeletal condition in the developed world. Current BSR guidelines recommend glucocorticoid treatment for one to two years and give suggested taper regimens. The project examines national primary care data to assess the level of adherence to current guidelines, and the proportion of patients at risk from the deleterious effects of prolonged steroid exposure.

Methods

The ECLIPSE databased covers over 25m patients across 2400 general practices in England and provides insights for enhanced clinical pathway management and to support patient safety in primary care. Routinely recorded diagnoses from primary care data are updated daily, along with administrative prescribing data. Using standardised nationally agreed disease coding frameworks, all diagnoses of PMR were retrieved from the live patient population of 25.4m individuals registered with general practices across England. Primary care diagnosis data for patients with a new diagnosis of PMR recorded in primary care on or after 01/01/2016 were linked with prescribing data from the same time period and followed to 10/10/2022. From the current BSR guidelines the following thresholds were taken to represent above recommended cumulative glucocorticoid exposure: 0-6 months >2100mg, 7 to 12 months >1400mg, 13 to 18 months >910mg and 19 to 24 months >910mg. Finally total numbers of those still prescribed glucocorticoids past 60 months was taken as to represent those who had become steroid-dependent.

Results

Over the observation period of 6.8 years there were 95,862 people diagnosed with PMR from the UK national data, of whom 22,677 were diagnosed in the East of England and 5,315 from the Norfolk and Waveney Integrated Care System. The prevalence was 0.99%, 1.00% and 1.5% for those aged older than 50 years across the three areas respectively consistent with published disease estimates. There was considerable number of individuals with PMR prescribed glucocorticoids above the recommend levels (see Table 1).

Conclusion

There is significant departure from the suggested PMR tapering regimens which may be due to frequency of relapse, inadequate treatment response or inadequate guideline implementation. Strategies to reduce glucocorticoid exposure in this older co-morbid population are required urgently.

Disclosure

P. Saha: None. J. Brown: None. A. MacGregor: None. C. Aldus: None. M. Yates: None.
P026 Chronic chilblain like lesions associated with the COVID-19 pandemic
Authors: Nathan Joseph A , Kiely Patrick
Published: April 2023

Background/Aims

We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon.

Methods

The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George’s University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively.

Results

Chilblain-like lesions first occurred between September and March; 2019/2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud’s in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years.

Conclusion

This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.

Disclosure

J.A. Nathan: None. P. Kiely: None.
P034 Results of first survey of NRAS SMILE-RA e-learning programme users
Authors: Bosworth Ailsa , Jacklin Clare
Published: April 2023

Background/Aims

An important but insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. The ability to self-manage in inflammatory arthritis (IA), with the right support (including from patient organisations), represents an essential component of care that goes beyond drug therapy and supports the patient in managing these impacts. In July 2021, EULAR Taskforce published Recommendations for Self-Management strategies in patients with Inflammatory Arthritis. Co-Convenors of the Taskforce were Ailsa Bosworth, NRAS and Elena Nikiphorou, King’s College Hospital. NICE quality standards also relate to provision of education and self-management resources. In September 2021, NRAS launched their unique e-learning programme SMILE-RA (self-management individualised learning environment). After launch, the first goal was to get a sufficient body of people using the programme in order to determine whether our key aims for each of the modules were being met. The first survey of participants took place in late summer 2022.

Methods

A survey with 21 questions was developed using Sogolytics on subjects including: navigation and ease of use, what people had learnt/gained from each module. The survey was emailed on 11 Jul, 2022 to 913 people who had registered for SMILE-RA. A follow up reminder was sent on 18th of July 2022. The survey closed on 15th of August 2022. 132 responses were received representing a response rate of 14%

Results

• Majority of respondents heard about SMILE through NRAS, only 10% through their rheumatology team. • Nearly 80% think length of the modules is just right • 86% think that the links to other resources, whether NRAS or external, are extremely (majority) or quite clear and helpful • 68% had increased their knowledge of their disease • 72% had increased their understanding of the importance of self-management • 62% had increased their knowledge of medicines used in the treatment of RA • 84% would recommend SMILE to another person.

Conclusion

These initial results from the first survey of users indicate a very high proportion of people are achieving the learning objectives of each module and are improving their understanding of their disease and how to self-manage their condition better. NRAS will build on this feedback and these results to target resources where they are most needed. These results are particularly interesting and important in the light of the move to put stable patients onto patient-initiated follow up pathways where consultations with their team are set for an interval of up to 2 years. Building patients’ knowledge of their disease, how to manage symptoms and their confidence to self-manage between appointments will improve health outcomes.

Disclosure

A. Bosworth: None. C. Jacklin: None.
P036 Gout and work participation in British adults: findings from the Health and Employment After Fifty study
Authors: D'Angelo Stefania , Walker-Bone Karen , Goodson Nicola
Published: April 2023

Background/Aims

The prevalence of gout is increasing in the UK and gout is the most common inflammatory arthritis among men aged 40 and older. As well as acute and chronic musculoskeletal manifestations, it is also associated with cardiometabolic disease and renal impairment. Given its risk factors and associated morbidities, it has potential to significantly impact work ability, but this has received little attention to date.

Methods

Data came from the Health and Employment After Fifty (HEAF) study, a cohort of 8134 men and women recruited in 2013-14 when aged 50-64. Consenting participants also agreed to data linkage to their Clinical Practice Research Datalink (CPRD) primary care records. Participants were coded as having gout if they had at least 2 CPRD records diagnosing/treating gout at any time before the baseline questionnaire. Annual follow-up questionnaires enquired about jobs altered mainly or partly because of health reasons which was coded as health-related job loss (HRJL). Other outcomes assessed were: any sickness absence in past 12 months (vs no sickness absence); prolonged sickness absence (defined as > 20 days of sickness absence in past 12 months vs less than 20 days); and any sickness absence because of musculoskeletal pain (vs no sickness absence because of musculoskeletal pain). Participants with gout who were in paid work at baseline were individually matched by sex and age (within 1 year) with 3 participants also working but without a diagnosis of gout. Associations between having gout and a subsequent work outcome were explored with multilevel logistic regression with random intercept, to account for the repeated measures for each participant, and results expressed as ORs with 95%CIs.

Results

Of the 7673 HEAF participants who consented to CPRD data linkage, 149 (1.9%) were classified with gout. The proportion of participants in work at baseline was similar among those with gout (73.8%) and without gout (67.9%). Participants with gout were mostly men, average age 58 years. Gout participants were more likely than controls to be: obese, previous smokers, heavy drinkers, to report fair/poor self-rated health (SRH) and to have prevalent hypertension as compared with those without gout. After adjustment for age, sex, time of follow-up, BMI, alcohol, and SRH, having gout was significantly associated with any sickness absence (OR = 2.68 95%CI 1.58,4.54) and musculoskeletal sickness absence (OR = 2.50 95%CI 1.15,5.43) but no association was seen with HRJL or prolonged sickness absence.

Conclusion

Gout was an independent risk factor for sickness absence but not health related job loss. As the impact of sickness absence associated with gout is likely to increase with rising disease prevalence and an older workforce, there is need to explore whether improved management of hyperuricaemia and gout can improve work outcomes.

Disclosure

S. D'Angelo: None. K. Walker-Bone: None. N. Goodson: None.