AB0120 IDENTIFYING CORE VARIABLES TO DEVELOP A SEVERITY INDEX IN RHEUMATOID ARTHRITIS: A NATIONWIDE DELPHI CONSENSUS
Authors: S. C. Rodriguez-García, E. Toledano Martinez, M. J. García de Yébenes, L. Carmona, I. González-Álvaro
Journal: Annals of the Rheumatic Diseases (2021)

Background: Early interventions during the “window of opportunity” have been shown to improve clinical outcomes in rheumatoid arthritis (RA). However, intensive treatment can induce toxicity so identifying patients most likely to benefit from it is of great importance. Hence, tools for guiding therapeutic decisions in early disease stages are needed. Objectives: To identify core variables to develop a RA severity index according to an expert panel. Methods: An expert panel was prompted to analyze relevant variables to define a “severity” construct, specified as “early severe disease”, able to classify patients with data collected on the first 2 years of the disease. They were also asked to identify potential modifying factors and external criteria to evaluate criterion validity. An anonymous nationwide 2-round Delphi survey was applied to look for consensus about: (1) the priority of inclusion of each variable, (2) the feasibility to obtain them from usual sources (e.g., medical records) and (3) their definition. Each item was rated on a 10-point (priority) or 5-point (feasibility and definition) Likert scales were 0=complete disagreement and 5-10=complete agreement. After the 1 st round, any item rated from 5 to 10 in priority and 3 to 5 for feasibility by at least 70% of responders was included in the final variable list. Items not reaching at least 20% consensus were discarded. The remaining ones would be voted again in the 2 nd round and adopted if they reached at least 50% consensus or else discarded. Results: The task force identified 17 variables to define the “severity” construct (Table 1). Socio-economic status, knowledge of their own disease, type or work adherence to treatment, among others were proposed modifying factors. Rheumatoid factor or anti-citrullinated peptide antibody seropositivity as predictive factors The physician global assessment and the “burden of treatment” (lines of treatment, number and dose of DMARDs and cumulative steroid dose received) were proposed for evaluating criterion validity. A total of 61 stakeholders from across Spain took the survey, 56% were female and had 19.8 years of average experience after training. All variables were included after 1 st round. Nonetheless, definitions were submitted for a 2 nd round after rephrasing, including comments received on the survey. The final list was reduced to 15 items after merging 3 of the initial variables into a new one called “refractoriness”(Table 1). Conclusion: The consensus process resulted in a list of variables and modifying factors deemed of relevance for the severity construct as we defined it. These items will be used to develop a severity index to guide treatment decisions in early disease stages. Table 1. Variables proposed for the severity construct. N Initially proposed variables N Final variables after Delphi 1 Polyarthritis 1 Polyarthritis 2 Big joint involvement 2 Big joint involvement 3 High disease activity at 2 years of follow-up 3 High disease activity at 2 years of follow-up 4 Maintained disease activity in the first 2 years 4 Maintained disease activity in the first 2 years 5 Acute phase reactants persistently elevated 5 Acute phase reactants persistently elevated 6 Extra-articular manifestations 6 Extra-articular manifestations 7 Failure to reach remission 7 Failure to reach remission 8 Need for aggressive therapy in the first 2 years 8 Need for aggressive therapy in the first 2 years 9 Presence of erosions at diagnosis 9 Presence of erosions by at diagnosis 10 Number of erosions at 2 years of follow-up 10 Number of erosions at 2 years of follow-up 11 Lack of improvement in the HAQ-DI 11 Lack of improvement in the HAQ-DI 12 Need for prosthetic surgery 12 Need for prosthetic surgery 13 Hospital Admissions 13 Hospital Admissions 14 Cortico-dependence 14 Cortico-dependence 15 MTX withdrawal due to loss of efficacy 15 Refractoriness 16 Completely absent response to MTX 17 Number of drugs with lack of efficacy Underlined variables on the left were merged into a new variable called “Refractoriness”. HAQ-DI: Health Assessment Questionnaire-Disability Index Disclosure of Interests: Sebastián C Rodriguez-García Speakers bureau: Roche, Sanofi, MSD, UCB-Pharma, Bristol-Myers-Squibb, Novartis, janssen, Consultant of: Bristol-Myers-Squibb, Galapagos, ESTHER TOLEDANO MARTINEZ: None declared, María Jesús García de Yébenes: None declared, Loreto Carmona Grant/research support from: Novartis Farmacéutica, SA, Pfizer, S.L.U., Merck Sharp &amp; Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA, Isidoro González-Álvaro Speakers bureau: Abbvie, MSD, Roche, Lilly, Paid instructor for: Lilly, Consultant of: Lilly, Sanofi, Grant/research support from: Roche