bluuebunny/crossref_metadata_2025_split huggingface dataset:
OA05 Potential impact of European Medicines Agency measures to minimise risk of serious side effects on those using JAK inhibitors in the UK
Authors: Tian Zixing , Kearsley-fleet Lianne , Galloway James , Watson Kath , Lunt Mark ,   BSRBR-RA Contributors Group, Hyrich Kimme L 
Published: April 2024

Abstract

Background/Aims
Janus kinase inhibitors (JAKi) are effective therapies for rheumatoid arthritis (RA). However, concerns about their safety in certain 'at-risk' populations have resulted in risk minimisation measures introduced by European Medicines Agency (EMA) in January 2023, which limits JAKi prescription to certain patient subgroups unless no suitable alternative is available. The potential impact on current and future JAKi use in the UK is unknown. Using a national cohort study of patients who have already started their first JAKi, this analysis aimed to describe the proportion meeting ≥1 of these criteria and therefore may be impacted by these changes.

Methods
RA patients starting their first-ever JAK inhibitor (tofacitinib, baricitinib, upadacitinib, or filgotinib) therapy in the British Society for Rheumatology RA Biologics Register (BSRBR-RA) before 31st May 2022 (pre-EMA warning) were included. Patients with missing data in any EMA criteria related variables were excluded. Descriptive statistics were used to present patients' characteristics at the start of JAKi. This analysis defined four at-risk criteria assessed at the treatment start: 1) aged ≥65; 2) increased risk of major cardiovascular issues (history of hypertension, hyperlipidaemia, diabetes, ischaemic heart disease, or stroke); 3) current or past smokers; 4) increased risk of cancer (defined as prior cancer). The previous number of distinct biological disease-modifying antirheumatic drugs (bDMARDs) classes was described among those who met the criteria.

Results
A total of 1,362 patients starting their first JAKi were included, most commonly baricitinib (76%), followed by tofacitinib (16%; see Table). The cohort was 78% female, with an average age of 60. Among them, 28% of patients had received ≥3 prior bDMARDs classes. 80% percent of patients (1,090) met ≥1 EMA risk criterion, with the most common individual criterion current/past smoker (54%). Of those who met ≥1 risk criteria, 645 (59%) met ≥1 EMA risk criterion and 29% had already received ≥3 prior bDMARDs classes.

Conclusion
A very high proportion of patients, four-in-five, initiating JAKi in UK before the EMA advisory would have fallen into the ‘high-risk' category for whom prescribing would only be advised if no suitable alternatives were available. Whilst almost a third of them had previously received ≥3 different bDMARDs classes, it’s likely that many of them would have suitable alternatives. These data highlight the enormous impact of the recent licensing updates for JAKi class.

Disclosure
Z. Tian: None. L. Kearsley-fleet: None. J. Galloway: Honoraria; Abbvie, Galapagos, Janssen, Lilly, Novartis, Pfizer, UCB, Vifor. Grants/research support; Abbvie, Galapagos, GSK, Janssen, Pfizer. K. Watson: None. M. Lunt: None. K.L. Hyrich: Honoraria; Abbvie. Grants/research support; Pfizer, BMS.
OA18 Takayasu arteritis mimicking pulmonary embolism: a case series
Authors: Kostich Sophia , Lee Sangoh , Babar Syed , Youngstein Taryn A , Mason Justin , Porter Andrew 
Published: April 2024

Abstract

Background/Aims
Takayasu arteritis (TA) is a rare autoimmune large vessel vasculitis with estimated incidence of 0.7-1.5 per million per annum in Europe. Conversely, pulmonary embolism (PE) is common with incidence estimates of 115 per 100,000 per year. Whilst TA is rare, it can have serious sequelae, including pulmonary vasculitis (PV), resulting in stenoses, aneurysm formation and pulmonary hypertension (PAH). Those with PV may have higher rates of PAH, with estimates around 42%. Early diagnosis ensures early treatment/immunosuppression to minimise arterial injury. Given the rarity of TA with PV, it can be misinterpreted on imaging as a PE. This study aimed to review initial imaging features of TA patients with confirmed PV to identify those who had been incorrectly diagnosed as having a PE. Subsequently, features to differentiate PE and PV were assessed.

Methods
We performed a retrospective analysis of all 158 patients in the Imperial College TA Cohort to identify those with PV. Records and imaging from these patients were reviewed including initial pulmonary vascular imaging.

Results
9 patients with PV were identified, of which 3 had initially been misdiagnosed as having a PE, thereby delaying TA treatment and possibly resulting in accelerated disease course. Table 1 summarises initial presenting features. All patients received anticoagulation for PE; however, their symptoms did not improve. Details of subsequent imaging are included in the table. They each experienced a delay in diagnosis of 7 years, 3 years, and 6 months respectively.

Conclusion
Whilst TA is rare, it is an important diagnosis and not to be missed. Where clinical features are not fitting with a diagnosis of PE, or symptoms are persisting despite management, consider further investigation. Early diagnosis of TA can aid management to try and prevent long term sequelae. Important criteria that should raise suspicion and may suggest TA, some of which were seen in our patient cohort, could include: more insidious onset of symptoms and persistent symptoms despite treatment; normal saturations on observations; normal D-dimer results and a raised ESR/CRP. In the event of clinical doubt for PE, further investigations (ESR) and imaging (MR pulmonary angiogram) should be considered.

Disclosure
S. Kostich: None. S. Lee: None. S. Babar: None. T.A. Youngstein: None. J. Mason: None. A. Porter: None.
OA37 Regional variations in adiposity is a strong predictor of fragility fractures in a large cohort: a cross sectional study
Authors: Amin Hamzah , Khan Aqib , Sultan Zain , Bukhari Marwan 
Published: April 2024

Abstract

Background/Aims
BMI is a core component of fracture risk estimation tools; however, it does not consider the body composition of patients. Emerging research is highlighting that total body fat percentage (TBF%) may be a superior predictor of fracture. Increases in TBF% is thought to be protective of hip fracture while associated with major fragility fractures. However, we have yet to see whether regional variations (abdominal vs hip) in fat deposition is even still a better predictor of fracture.

Methods
Patients were referred to a DEXA scanner in the northwest of England from 2004-2019. A multivariate logistic regression analysis reporting odds ratios was conducted looking at the fat percentage at the left and right hip (FPLH% and FPRH%), as well as abdominally (FPA%), as predictors of fracture. Results were adjusted for smoking, gender, BMI, steroid use and left femoral t-score. Statistical significance was set at p &lt; 0.05 with STATA V12 used as the statistical package.

Results
31,547 patients (5,390 males and 26,156 females) were included in our analysis. The mean age was 64.9 (95% CI 64.8-65.1), BMI 27.1 (95% CI 27.0-27.2), weight 71.1kg (95% CI 70.9-71.3) and height 162cm (95% CI 162.0 cm-162.1cm). 11,875 fractures were reported with 1,375 (11.6%) hip fractures. Table 1 demonstrates the results of our analysis.

Conclusion
The FPLH% was associated with both hip and all major fragility fractures, while FPA% and FPRH% was only associated with major fragility fractures. We would have expected to see a protective effect for hip fractures, considering our patients were clinically overweight; however, this was not observed. Hence, we report in the literature for the first time that FPLH% is predictive for both hip and major fragility fractures even in patients who are clinically overweight. Our approach of considering regional variations in body fat seems to be superior to methods currently used. Hence, we make the recommendation to conduct further research to validate our findings, as well as investigating ways to incorporate such methods into future iterations of fracture risk calculators.

Disclosure
H. Amin: None. A. Khan: None. Z. Sultan: None. M. Bukhari: None.
P005 Early inflammatory arthritis combined nurse and therapist clinic
Authors: Harrison Heather , Allan Rachel 
Published: April 2024

Abstract

Background/Aims
NICE guidelines recommend patients have ongoing access to a multidisciplinary team (MDT). However, ensuring all patients are seen by physiotherapy, podiatry, and occupational therapy (OT), when needed, can be challenging. The aim of the project was for patients to be seen by a therapist, in the first six months of their disease. The plan was to provide treatment and encourage long-term self-management, by providing knowledge of when self-referring to the different therapy services would be beneficial.

Methods
A Nurse and therapist pilot clinic was implemented at the first Disease Modifying Anti-Rheumatic Drugs review appointment. The clinic allowed 15-minutes with a specialist nurse to discuss medication issues and drug counselling. This was followed by 30-minutes with a therapist, to discuss any functional needs and objectively assess any joint issues and to provide treatment. Patients were educated about their condition and signposted to information. Patients were also provided with self-management advice and informed about the role of MDT members. Written or emailed advice was provided. Patients were invited to complete an anonymous questionnaire evaluating their experience.

Results
60 patients were seen in the first three months. Personalised therapy input was given to each patient; however, hand exercises and joint protection advice was given to over 60% of patients. Other therapy input included exercises for other specific joints that were problematic, the provision of wrist splints and relaxation advice. Results of the patient questionnaire showed 98% of patients felt they ‘definitely’ had more information to help manage their arthritis and 100% felt they knew where to go to get more information, if needed. Patients also had a greater understanding of the role of physiotherapy and OT. 88% of patients were confident they would ‘definitely’ know when to ask to be referred to these specialities in the future. Less than 15% of patients required further therapy input following the appointment.

Conclusion
The pilot clinic received excellent patient feedback and fulfilled the aims of providing therapy input, early in patient’s journey. Patients liked the convenience of seeing both the professionals in one visit, felt they had gained more information on their condition and were able to help themselves. Patient’s comments included ‘feeling more supported’ and ‘being able to help myself’. One experienced therapist seeing the patients was more cost effective than separate physiotherapy and OT appointments. The next stage will be to invite all newly diagnosed patients into this clinic as part of an early inflammatory arthritis pathway. We will then audit the impact on therapy referral rates and assess if early intervention reduces the number of therapy referrals long-term, encourages patient self-management and improves patient outcomes.

Disclosure
H. Harrison: None. R. Allan: None.
P006 A new digital front door for existing rheumatology patient queries
Authors: Nadesalingam Kavitha , Short Catherine , Christian Kurt , Helliwell Philip 
Published: April 2024

Abstract

Background/Aims
NICE guidelines recommend people with rheumatological conditions need rapid access to specialist care to manage flares and to advise on medication. With growing demand for NHS services, rheumatology advice lines are coming under pressure. We carried out an audit on our advice line queries over four clinics in summer 2021 with a view to developing a triaging system to improve response time. Over four advice line clinics, there were 44 calls averaging 13 minutes per call. The response time was two to three weeks. 34% of calls were deemed to be inappropriate. Inappropriate calls were considered ones that could be better directed elsewhere.

Methods
In 2022 we started working with DrDoctor, a digital health company to design a digital nurse advice line form to redirect inappropriate calls away from the nurse advice line call backs. This involved designing a digital pathway addressing common inappropriate themes from our audit including redirection of calls to secretaries, patient booking team, prescription management and a digital booking form for phlebotomy appointments. The new digital tool enabled us to expand the service and we used the opportunity to adopt patient assessment tools and educational videos as part of the service. We promoted the digital pathway through patient information leaflets, department website and sent a text with the link to all rheumatology patients. We continued to offer the traditional contact telephone number into the service as well.

Results
The digital nurse advice line went live at the end of July 2023 and after two months the response time has reduced to 1.5- 2 weeks. Since then there have been 529 form submissions from 417 unique patients. 47% of submissions were inappropriate and redirected. 97 patients called to book a blood test and 76 patients opted for the online self-service clinic. 151 patients had a query about their condition. 50% of patient had RA or inflammatory arthritis. 5% AS. 5% SLE. 17% PsA. 23% selected ‘other’ and a free text box captured conditions such as fibromyalgia, osteoporosis, PMR and OA. 26% of patients with rheumatoid arthritis opted to see the educational video on self-examination and 17% watched the educational video on rheumatoid arthritis. Based on 251 submissions that were inappropriate for the advice line, assuming each inappropriate call takes an average of nine minutes based from our previous audit, 39 hours of phone time was saved from avoiding booking inappropriate nurse advice line appointments in two months.

Conclusion
The digital rheumatology advice service is an efficient and effective method of responding to patient queries and can be a source of patient education and self assessment. Informal patient and staff feedback has been positive and we will be collecting formal feedback as the service becomes more established.

Disclosure
K. Nadesalingam: None. C. Short: None. K. Christian: None. P. Helliwell: None.
P023 A case of ANCA-associated vasculitis with possible IgG4-related disease
Authors: Eltahir Hala , Lloyd Mark 
Published: April 2024

Abstract

Background/Aims
IgG4-related disease (IgG4-RD) and granulomatous polyangiitis (GPA) have apparent different pathology. There are infrequent reports of the two conditions occurring simultaneously. We add to the literature by describing a patient who appears to have both conditions.

Methods
A 65-year-old male presented with low back pain radiating to the perineum. His past history included T2DM, CABG and ablation for AF. Initial investigations showed a CRP of 102mg/ml and an eGFR of &gt; 90ml/hr. A CT urogram revealed possible aortitis. A dedicated aortogram showed a cuff of added tissue around the infrarenal aorta and iliac arteries. A whole aortogram showed an increase in the abnormal tissue and detected a left upper lobe cavitating lesion. A PET-CT scan showed activity in the infrarenal aortic tissue, with focal uptake in the aortic arch and right superficial femoral artery. Several pleural based and parenchymal lesions showing moderate increased FDG activity were seen. A CT scan of the sinuses showed multifocal sinonasal mucosal thickening without bony erosions. C-ANCA was positive at 1/40, with raised PR3 of 32U/ml and IgG4 of 2.2g/L. Other immunoglobulin levels were normal and IGRA was negative. A biopsy of the lung lesion showed necrotising granulomatous inflammation and surrounding palisading histocytes, withno vasculitic element. Treatment with prednisolone 40mg daily and methotrexate 15mg weekly was started. A quick symptomatic improvement followed. CRP fell to 14mg/ml within two months. It was discussed in the national IgG4-RD MDT, and the consensus was that he had features of both GPA and IgG4-RD. A follow-up CT scan showed reduction in the volume of para-aortic tissue, with regression of some lesions in the chest, while others increased. However, he remains well with a normal CRP, stable renal function and normal urinalysis. His latest IgG4 level dropped to 0.67 g/L.

Results
The ANCA positivity and lung biopsy findings satisfy classification criteria of GPA. While aortic involvement is not commonly seen in GPA; it is typical of IgG4-RD; however, its diagnostic criteria require a confirmatory biopsy. This is challenging due to the risk of sampling around the aorta and ureters. Our case fulfils criteria for ‘possible’ IgG4-RD. In retrospect, an earlier PET CT scan may have spared the patient several CT scans.

Conclusion
The co-existence of IgG4-RD and ANCA-associated vasculitis may be more common than might be expected. Our case highlights the usefulness of early PET-CT scanning in rheumatic conditions. It is important to check ANCA in suspected IgG4-RD cases. It is possible that future AI programmes may help clinicians better judge the timing of investigations that may be more expensive, invasive or have increased radiation exposure in such complex cases. Finally, the usefulness of a national MDT for IgG4-RD is highlighted. Fortunately, treatment modalities are similar for both conditions.

Disclosure
H. Eltahir: None. M. Lloyd: None.
P044 Janus Kinase Inhibitors-a retrospective study on side effects and discontinuation reasons
Authors: Klein Justus , Alexander Jason , Robertson Lindsay , Hollick Rosemary 
Published: April 2024

Abstract

Background/Aims
In light of drug safety warnings for Janus kinase inhibitors (JAKi), we aimed to evaluate the occurrence of adverse events and identify reasons for discontinuation of JAKi in clinical practice.

Methods
Medical records of all patients prescribed JAKi in NHS Grampian from January 2021 to January 2023 for rheumatic diseases were retrospectively reviewed. Patient demographics, co-morbidities, reasons for treatment discontinuation and occurrence of adverse events (including cardiovascular events) were recorded.

Results
160 patients were prescribed JAKi. 131 (81.8%) patients had rheumatoid arthritis, 16 (10%) psoriatic arthritis, five (3%) axial spondyloarthritis, three (2%) juvenile idiopathic arthritis (in adulthood), 3 (2%) undifferentiated inflammatory arthritis, one (0.6%) granulomatous polyangiitis (GPA), one (0.6%) enteropathic arthritis. Mean duration of treatment was 9.9±12 months with 34.4% on treatment for &gt;12 months. 47.5% discontinued JAKi after an average of 7.0 ± 5.1 months. Patients discontinuing treatment were significantly older than patients who continued treatment 60.1yrs ± 11.0 vs 55.9yrs ± 12.5 respectively, p = 0.03. There were no differences between discontinuing and continuing treatment groups with respect to BMI, smoking, diabetes, cardiovascular disease, hypertension or statin use. Discontinuation rates were 66.7 % tofacitinib, 44.4 % filgotinib and 34.4 % upadacitinib. Discontinuation reasons were inefficacy (37.9 %), headache (9.2 %), infections (9.2 %) and gastrointestinal adverse effects (8.0 %). One patient discontinued JAKi due to an arterial embolism (DVT in the context of undiagnosed patent foramen ovale), three developed new onset hypertension. Common infections leading to discontinuation were urinary tract (37.5 %) and chest (25.0 %), with one case of tuberculosis. No herpes zoster infections led to JAKi discontinuation. In patients who continued treatment infections occurred in 27.1% (30% chest, 21.7%, Covid-19, 13% UTIs, 8.7% herpes zoster 8.7% otitis media). Other adverse events such as fatigue and nausea were reported in &lt; 4 % of all patients. No malignancies were recorded.

Conclusion
Older patients are more likely to discontinue JAKi due to infections. Upadacitinib patients were least likely to discontinue. Treatment inefficacy, urine and chest infections were the commonest reasons for discontinuation.

Disclosure
J. Klein: None. J. Alexander: None. L. Robertson: Other; LR has received funding for conference attendance from UCB. R. Hollick: None.
P058 A service evaluation of rheumatologist-led ultrasound clinics at a tertiary care centre
Authors: Zmuda Alexandra , Manson Jessica , Castelino Madhura 
Published: April 2024

Abstract

Background/Aims
Rheumatologist-led ultrasound (USG) clinics were established at UCLH over 10 years ago with an intention to improve speed of diagnosis and/or execution of treatment plan with the benefit of clinical assessment and diagnostic imaging in one appointment. The benefits for patients may include reduced time taken from work and reduced anxiety. This project aimed to evaluate reasons for referral to this clinic, the outcome of a patient review and the impact of this service.

Methods
Retrospective Health-record data were collected from EPIC using Google forms for patients who had USG of their hands in the specialist clinics for 3 months (Jan - March 2022). Data included patient demographics, clinical data, USG findings, intended change or initiation of treatment, and outcome of the review.

Results
54 patients had been reviewed in the three months. More than half (61%) were referred to help answer a treatment-related question and the remaining were to confirm diagnosis (39%). Most patients referred for diagnosis had their diagnosis confirmed (86%). Majority (62%) also had appropriate follow up and two were discharged; a further six had potential to be discharged at this time. Out of the 33 referred for treatment questions, there were 23(70%) patients who needed no change to their treatment; 15(65%) of these would have potentially been initiated on biologics otherwise. This resulted in potential savings of between £76,497-£107,601 per 6-month (trial of DMARD) period due to drug cost. Table 1 lists potential indirect savings.

Conclusion
This service evaluation found considerable direct and indirect savings that emphasises the need for such specialist service in the cost-strapped NHS. The direct cost savings relate to the drugs that were not required to be initiated, with the majority attributed to the avoidance of biologics. In addition to the indirect cost savings to the NHS , the reduction of risk to the patient of unnecessary immunosuppression remains undefined. As a result of this service evaluation, to enhance potential discharges from this clinic, referring clinicians manage patient expectations at referral and communicatepotential for discharge at referral to the scanning clinician.

Disclosure
A. Zmuda: None. J. Manson: None. M. Castelino: None.