AB1420-HPR THE USE OF SUBCUTANEOUS METHOTREXATE IN INFLAMMATORY ARTHRITIS: TRANSLATING RESEARCH INTO PRACTICE USING QUALITY IMPROVEMENT METHODOLOGY.
Authors: Aicha Bouraoui
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Methotrexate (Mtx) is considered as the drug of choice in the management of inflammatory arthritis (IA). There is growing evidence of the benefit of sub-cutanous (s/c) methotrexate compared to the oral route. At the same dose, pharmacokinetic studies showed that s/c Mtx has better bioavailability. RCT studies showed that patients respond better to s/c mtx. Finally s./c Mtx has better tolerability with less risks of GI side effects. Translating research into practice can be sometimes challenging due to a number of barriers including individual choices and variations as well as systems or organizational factors. Over the recent years there has been great focus on quality improvement in healthcare to make health care "safe, effective, patient centered timely efficient and equitable". <h3>Objectives</h3> We aimed that within 6 months period, 100% of our patients with inflammatory arthritis should have trial of s/c methotrexate before starting biologics unless there is contraindication. <h3>Methods</h3> We reviewed the data of 50 patients to assess management of patients with IA using our biologic register. We used the 5 why strategy to have better understanding of the lack of prescribing of s/c mtx and vairiations in clinical practice. By applying improvement science we standardized our pathway, included methotrxate s/c trial prior to biologics. We also conducted a number of interventions including multidisciplinary educational events and one to one meetings, we mobilised and organised our resources in better way to meet our patients needs. We monitored our data over time and reviewed our practice accordingly. <h3>Results</h3> Baseline data showed that the majority of our patients had rheumatoid arthritis (RA) (74%) followed by Psoriatic arthritis in 24% of cases. Most patients had initial trial of methotrexate but only 32% were kept on oral methotrexate and 26% of patients had trial of s/c mtx before starting biologics. The main indication of starting s/c Mtx was oral methotrexate induced gastrointestinal side effects. Methotrexate was stopped all together in 34% of patients due to suspected major side effects(SE). SE mainly encountered with oral route with 10% suspected ILD, 14% had deranged LFTs. In order to have better understanding with issues related to the poor use of subcut Mtx the author conducted staff unstructured interviews to explore their experience with s/c Mtx. We also noticed variations between clinicians in their clinical practices. Our theory of change included a number of interventions and results showed significant improvement in prescribing of s/c Mtx among IA patients. 3 months after starting the projects 1st cycle: 42 patients were switched to sub-cut Mtx with only 6 patients required subsequent biologics use. There was reduction in the number of patients referred for biologics and among those started on biologics 50% of patients had trial of S/C methotrexate. <h3>Conclusion</h3> In summary, our baseline data showed poor use of s/c Mtx in patients with IA despite the growing evidence of its benefit. In order to translate research findings into practice we used 5 whys methodology to have better understanding of the barriers within our systems, we applied QI methodology and standardized our practice for better use of resources at lower cost. <h3>References</h3> [1] Braun J, Kastner P, Flaxenberg P, et al. Comparison of the clinical efficacy and safety of subcutaneous versus oral administration of methotrexate in patients with active rheumatoid arthritis: results of a six-month, multicenter, randomized, double-blind, controlled, phase IV trial. Arthritis Rheum2008;58:7381. [2] Stamp LK, Barclay ML, ODonnell JL, et al. Effects of changing from oral to subcutaneous methotrexate on red blood cell methotrexate polyglutamate concentrations and disease activity in patients with rheumatoid arthritis. J Rheumatol2011;38:25407. <h3>Acknowledgement</h3> Dr Bharadwaj and the Rheumatology team at Basildon Hospital. <h3>Disclosure of Interests</h3> None declared