FRI0743-HPR Nurse-led outpatient management for improved treatment of giant cell arteritis (GCA) and polymyalgia rheumatic (PMR) in a rheumatology outpatient clinic
Authors: M.T. Poder, B.A. Esbensen, M.B.T. Pedersen, N.G. Andersen, J.J. Lykkegaard, A.M. Johansen, T. Lundbak, B. Bech
Journal: Annals of the Rheumatic Diseases (2018)

<h3>Background:</h3> GCA and PMR are challenges with regard to diagnosis and effective treatment because of varied and vague symptom presentations and overlapping pathologies that often require specialist for diagnostic investigations and specific treatment. Long-term glucocorticoids (GC) dependency is common, and GC side effects occur in approximately 50% of patients emphasizing the need for continued monitoring and symptom control (1). <h3>Objectives:</h3> To present the development and the implementation of a nurse-led, rheumatologist-supported model of care in the outpatient management of adults diagnosed with GCA or PMR. <h3>Methods:</h3> Initially, available evidence about symptom regulated GC tapering in the treatment of GCA and PMR was identified. Subsequent, a fixed phase-out schedule for high dose GC therapy following either of three pathways (GCA with/without eye symptoms and PMR) was agreed on in a multidisciplinary working group. Furthermore, the group developed a nurse-managed protocol for nurse-led outpatient consultations to ensure systematic treatment and proper response to relapse. Prior to the implementation rheumatology nurses were taught and trained by rheumatologists in pertinent regulation of medication and identification of adverse signs and symptoms essential for providing appropriate support and patient education. Overall patient satisfaction was assessed on-site by an anonymous iPad questionnaire. <h3>Results:</h3> An individual, initial GC dose are set by the rheumatologist based on clinician diagnosis, supported by currently available diagnostic and classification criteria. Subsequently, a nurse-led protocol reassures patient education and support during approximately one year of steroid therapy. The protocol includes close and continues observation and assessment by planned rheumatology nursing consultations followed by reassuring telephone calls. A rheumatologist can be consulted if doubt arises. Further, the rheumatology nurse is responsible for allocating final tapering (approximately 24 weeks) in the individualized PMR-management-plan for general practitioner. Patient overall self-reported satisfaction first nine month was high indicated by patients' experience of confidence, being heard and having questions resolved. Within the first 18 months, n=190 patients (GCA, n=82/PMR, n=108) with a mean aged of 73.2 (SD 8.4) years have been enrolled into nurse-led managed protocols for GC tapering. <h3>Conclusions:</h3> A nurse-managed protocol for systematic and individualized GC tapering and patient support was developed as well as implemented successfully for individualized treatment of GCA and PMR. The extensive supportive patient education and involvement in symptom management secured by the rheumatology nurse provided high satisfaction. Also, the protocol executes rapid and direct access to advice for patients as recommended by EULAR for the management of PMR (2). <h3>References</h3> 1. Buttgereit F, Dejaco C, Matteson EL, et al. Polymyalgia Rheumatica and Giant Cell Arteritis. A Systematic Review. JAMA2016;315(22):2442–2458. 2. Dejaco C, Singh YP, Perel P, Hutchings A, Camellino D, Mackie S, et al. Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015;74:1799–1807. <h3>Disclosure of Interest:</h3> None declared