OP0074 A FRAMEWORK OF POTENTIAL INTERVENTIONS TO ACCELERATE GENDER-EQUITABLE CAREER ADVANCEMENT IN ACADEMIC RHEUMATOLOGY

Background:

A growing number of professional societies in clinical and medically related disciplines investigate evidence, make recommendations, and take action to advance gender equity. Evidence on women’s advancement and leadership in the context of the European Alliance of Associations for Rheumatology, EULAR, is limited [1].

Objectives:

The objective of the EULAR Task Force on Gender Equity in Academic Rheumatology was to establish the extent of the unmet need for support of female rheumatologists, health professionals and non-clinical scientists in academic rheumatology and develop a framework to address this through EULAR and Emerging EULAR Network (EMEUNET).

Methods:

Potential interventions to accelerate gender-equitable career advancement in academic rheumatology were gathered from a narrative review of the relevant literature, expert opinion of a multi-disciplinary Task Force (comprised of 23 members from 11 countries), data from the surveys of EULAR scientific member society leaders, EULAR and EMEUNET members, and EULAR Executive Committee members. These interventions were rated by Task Force members, who ranked each according to perceived priority on a five-point numeric scale from 1 = very low to 5 = very high.

Results:

A framework of 29 potential interventions was formulated, which covers six thematic areas, namely, EULAR policies, advocacy and communication, EULAR Congress and associated symposia, training courses, mentoring/peer support, and EULAR funding (Figure 1).

Figure 1.

A framework of potential interventions with the levels of priority, mean and standard deviation (SD)

Conclusion:

The framework provides structured interventions for accelerating gender-equitable career advancement in academic rheumatology.

References:

[1]Andreoli L, Ovseiko PV, Hassan N, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine 2019;86(6):669-72.

Acknowledgements:

The task force is grateful to EULAR for funding this activity under project number EPI 024.

Disclosure of Interests:

None declared

AB0925-PARE A NARRATIVE REVIEW ASSESSING THE ROLE OF DIETARY SALT AS AN ENVIRONMENTAL RISK FACTOR FOR THE ONSET AND SEVERITY OF RHEUMATOID ARTHRITIS

Background:

The role of dietary salt consumption in the etiopathogenesis of Rheumatoid Arthritis (RA), and autoimmune disease in general, has received renewed interest. This has been fueled by the increased prevalence of autoimmune disease worldwide correlating with western diets and heightened consumption of salt rich foods and also studies at the cellular level demonstrating induction of IL 17 producing T helper cells (Th17) by dietary salt.

Objectives:

To conduct a narrative review of observational studies and clinical trials on the role of dietary salt as an environmental risk factor for the onset and development of RA.

Methods:

A comprehensive search was done of the literature from 2010 to 2021, using the search terms dietary salt and RA; the native interfaces EBSCO and Ovid were used. Databases searched included Pubmed, Embase, EMCare, Medline and CINAHL using a Population, Exposure and Outcome framework; the MESH terms RA, risk factors, nutrition and salt were used. Data was extracted by an independent reviewer.

Results:

Out of the 72 studies initially identified, 50 were included in this review. Studies in murine models have demonstrated that high concentrations of sodium chloride promote the differentiation of T helper lymphocytes, via the serum- and glucocorticoid- inducible kinase 1 (SGK1) mediator towards the proinflammatory Th17 driven immune response. Six studies were carried out in human subjects. Study design ranged from cross sectional observational to nested case control studies. Sodium intake amongst participants characterized as having high intake, or being placed in the higher quartiles, ranged from 4.5-5grams per day. 5 out of 6 studies demonstrated that increased dietary salt consumption is associated with earlier onset RA. One study suggested an association between high salt intake and erosive disease at diagnosis and the development of anti-citrullinated protein antibodies (ACPA), although evidence was weak and from a single study only. Another study found that increased consumption of salt was only associated with risk of RA in smokers, highlighting the need to explore confounding variables further.

Conclusion:

This narrative review of the literature provides some evidence that supports a role of excess dietary salt consumption as a risk factor for the onset and severity of RA.

Disclosure of Interests:

None declared

POS0951 ASSOCIATION BETWEEN INDIVIDUAL AND COUNTRY-LEVEL SOCIOECONOMIC FACTORS AND HEALTH OUTCOMES IN AXIAL AND PERIPHERAL SPONDYLOARTHRITIS: ANALYSIS OF THE ASAS PERSPA STUDY

Background:

Health outcomes in spondyloarthritis (SpA) are largely determined by socioeconomic (SE) factors, leading to the great inequity observed between countries across the world. However, the impact of these SE factors on health outcomes across the different SpA phenotypes (axSpA, pSpA and PsA), is less well known.

Objectives:

To investigate (1) the association between individual and country-level SE factors and health outcomes in different SpA phenotypes, and (2) to explore whether any effect of these SE factors is mediated by the use of b/tsDMARD therapy.

Methods:

Patients with axSpA, pSpA or PsA from the multinational cohort ASAS-perSpA were included in the analysis. The effect of individual (age, gender, education and marital status) and country-level SE factors (Gross Domestic Product [GDP], Healthcare Expenditure [HCE], Human Development Index [HDI], Gini Index) over health outcomes (ASDAS≥2.1, continuous ASDAS, BASFI, fatigue and ASAS-HI) were assessed in multivariable mixed-effects logistic and linear regression models (as appropriate), adjusting for confounders. Interactions between each individual and country-level SE factors and disease phenotype and between both levels of SE factors, were tested. Finally, a mediation analysis was conducted to explore whether the impact of country-level SE factors on ASDAS is mediated through b/tsDMARD uptake.

Results:

A total of 4185 patients from 23 countries were included: 61% males, mean age 45 (SD 14), 65% axSpA, 10% pSpA and 25% PsA. Female gender, lower educational level and marital status (single vs married) were associated with higher ASDAS, without significant differences across disease phenotype. Living in lower-(vs higher) GDP countries was also associated with higher ASDAS (β=0.39 [95%CI 0.16; 0.63], with similar results for other economic indicators (Figure 1). 7% of the association between GDP and ASDAS was mediated by b/tsDMARD uptake. The above-mentioned individual and country-level SE factors remained significant to discriminate active disease (ASDAS≥2.1), with greater impact of gender (OR=1.32 [1.13; 1.54]), educational level (primary vs university OR=1.76 [1.40;2.20]) and lower GDP (OR= 1.74 [1.22;2.46]). Higher BASFI was also associated with gender (female vs male: β=0.12 [0.01; 0.24]), lower education (primary vs university: β=0.29 [0.11; 0.46], and marital status (single vs married: β=0.23 [0.09; 0.38]), without effect of country-level SE factors, and no differences across SpA phenotype. Gender and lower educational level were similarly associated with worse ASAS-HI scores (female vs male β=0.88 [0.68;1.09], and primary vs university β=0.61 [0.31;0.91]), while more fatigue was only associated with female gender and, in an opposite direction, with higher country-level SE factors (Figure 1). No interactions were found between individual and country-level SE factors for any of the outcomes.

Conclusion:

Individual (female gender and lower education) and country-level SE factors are independently associated with higher disease activity in SpA. Uptake of b/tsDMARD had a small mediating effect on the association between GDP and ASDAS. Lower education and female gender are also associated with worse outcomes of functional disability, global functioning and fatigue. Country-level SE factors are not associated with functional disability or global functioning; in contrast, there is a paradoxical effect with fatigue: living in a country with a higher SE status is independently associated with higher levels of fatigue. Management of disease outcome in SpA requires also awareness of the role of individual and country level SE-factors.

Figure 1.

Effect of individual and country-level socioeconomic factors on ASDAS and fatigue, derived from multivariable mixed-effects models adjusted by clinical confounders.

Disclosure of Interests:

Dafne Capelusnik Speakers bureau: BMS, Grant/research support from: Pfizer, Sizheng Steven Zhao: None declared, Annelies Boonen: None declared, Nelly Ziade Speakers bureau: Roche, Abbvie, Eli Lilly, Pfizer, Janssen, Novartis, Pierre Fabre, Apotex, Pharmaline, Paid instructor for: Abbvie, Eli Lilly, Sanofi-Aventis, Pfizer, Janssen, Consultant of: Roche, Abbvie, Eli Lilly, Pfizer, Janssen, Novartis, Gilead, NewBridge, Grant/research support from: Abbvie, NewBridge, Algorithm/Celgene, Clementina López-Medina: None declared, Maxime Dougados: None declared, Elena Nikiphorou Speakers bureau: Pfizer, Lilly, AbbVie, Sofia Ramiro Speakers bureau: Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Lilly, MSD, Novartis, UCB, Sanofi, Grant/research support from: MSD

POS0971 HOW DO CLINICAL AND SOCIOECONOMIC FACTORS IMPACT ON WORK DISABILITY IN EARLY AXIAL SPONDYLOARTHRITIS? FIVE-YEAR DATA FROM THE DESIR COHORT

Background:

There remains substantial unmet need to study work disability (WD) in early axSpA. Previous studies suggest that treatment interventions alone do not improve work outcomes and that socioeconomic (SE) as well as clinical factors may play an important role.

Objectives:

To investigate the occurrence of WD and the impact of clinical and SE factors on WD in early axial spondyloarthritis (axSpA).

Methods:

Patients with a clinical diagnosis of axSpA from the DESIR cohort up to 5 years of follow-up (6-month visits in the first 2 years, followed by annual visits) were studied. Time to WD and potential baseline and time-varying predictors were explored, with a focus on SE variables: age, gender, smoking status since last visit, ethnicity (Caucasian vs other), job type based on ‘collar’ (blue vs white), educational status (low vs high -university), marital status (married vs not) and parental status (number of children); and clinical factors: disease activity (ASDAS/BASDAI), function (BASFI), mobility (BASMI), at each time point. The incidence of WD was calculated as the number of WD events over the total number of person-days under observation. Univariable analyses, followed by collinearity and interaction tests, guided subsequent multivariable Cox survival analyses.

Results:

A total of 704 axSpA patients with work-related data, mean (SD) age 33.8 (8.6), were studied. The estimated incidence of WD amongst those at risk and across the five years of DESIR, was 0.05 (95% CI 0.03, 0.06) per 1000 days (total person-days of observation of 999,999). Mean (SD) time to WD was 976 days (SD 476), (min 163, max 2021 days). In people who developed WD, 25% did so at 595 days; 50% and 75% at 1050 and 1433 days, respectively. Significant differences in age, level of education, marital and parental status as well as disease activity, function and mobility, all at baseline, were seen between those developing WD vs those who never did. In multivariable models (Table 1), older age, higher ASDAS and BASFI all strongly predicted more WD (p<0.005). In separate models adjusted for age, gender and education, BASFI and BASMI both predicted WD. SE factors, including education attained, were not associated with a risk for WD. There were no relevant interactions between clinical variables and SE factors.

Table 1.

Univariable and multivariable model analyses with WD as outcome.

Type of analysisUnivariableMultivariable modelFocus on ASDASMultivariable modelFocus on BASFI/BASMIHR (95% CI)HR (95% CI)(N=653)HR (95% CI)(N=639)Explanatory variablesAge1.07 (1.04, 1.11)1.06 (1.02, 1.10)1.03 (0.99, 1.08)Male gender0.68 (0.37, 1.23)1.10 (0.58, 2.08)1.00 (0.50, 2.02)High education0.25 (0.14, 0.48)0.57 (0.29, 1.11)0.42 (0.19, 0.90)Parental status1.36 (1.09, 1.70)NSNSASDAS (CRP)2.40 (1.77, 3.26)1.79 (1.27, 2.54)Not testedBASFI, 0-101.54 (1.36, 1.75)1.42 (1.22, 1.65)1.53 (1.29, 1.81)BASMI, 0-102.13 (1.65, 2.75)NS1.49 (1.10, 2.00)Symptom duration0.79 (0.56, 1.12)NSNSHLA B27 positive0.64 (0.36, 1.13)NSNSHip involvement (baseline) vs not1.98 (1.02, 3.82)NSNSComorbidity count2.33 (1.68, 3.21)NSNSNSAID use last 6m (vs no use)1.01 (1.00, 1.02)NSNSOral Corticosteroid use (vs no)2.72 (1.27, 5.83)NSNScsDMARD use last 6m (vs no)2.20 (0.90, 5.41)NSNSTNFi use2.15 (1.19, 3.87)NSNS

NS=Not significant

Conclusion:

In this early axSpA cohort, WD was an infrequent event. Nevertheless, clinical factors are amongst the strongest predictors of WD, over SE factors, with worse disease activity, function and mobility all independently implicated with more WD in early axSpA. Disease severity remains a strong predictor of adverse work outcome, despite substantial advances in therapeutic strategies in axSpA.

Disclosure of Interests:

None declared.

POS0238 SICK LEAVE AND ITS PREDICTORS IN EARLY AXIAL SPONDYLOARTHRITIS: THE ROLE OF CLINICAL AND SOCIOECONOMIC FACTORS. FIVE-YEAR DATA FROM THE DESIR COHORT

Background:

Sick leave (SL) represents an often poorly studied adverse work outcome especially in early axSpA, with speculation around the potential role of clinical and socioeconomic (SE) factors.

Objectives:

To investigate the occurrence of SL and the impact of clinical and SE factors on SL in early axSpA.

Methods:

Patients with a clinical diagnosis of axSpA from the DESIR cohort up to 5 years of follow-up (6-month visits in the first 2 years, followed by annual visits) were studied. Time to SL and potential baseline and time-varying predictors were explored, with a focus on SE variables: age, gender, smoking status since last visit, ethnicity (Caucasian vs other), job type based on ‘collar’ (blue vs white), educational status (low vs high -university), marital status (married vs not) and parental status (number of children); and clinical factors including disease activity (ASDAS/BASDAI), function (BASFI), mobility (BASMI), at each time point. The incidence of SL was calculated as the number of SL events over the total number of person-days under observation. Univariable analyses, followed by collinearity and interaction tests, guided subsequent multivariable Cox survival model building.

Results:

In total, 704 axSpA patients with work-related data were included in this study: mean (SD) age 33.8 (8.6); 46% male. At baseline, 80% of patients were employed; of these, 5.7% reported being on SL, with people shifting in and out of different work states over time. The distribution of first and recurrent SL episodes over time is shown in the figure 1. The incidence of SL amongst those at risk (n=620, 88%) and across the five years of DESIR was 0.05 (95% CI 0.03, 0.06) per 1000 days calculated in a total of 913,559 observed person-days. In survival analyses, 7% (n=43) of those at risk developed SL at some point. Mean (SD) time to SL was 806 (595) days (min 175, max 2021 days). In people who developed SL, 25% did so at 364 days; 50% and 75% at 545 and 1172 days, respectively. Significant differences were seen between baseline socio-demographic, clinical variables and treatment in patients who developed SL at any point, compared to those who did not. In multivariable models (Table 1) older age, higher disease activity, smoking and use of TNFi, the latter likely a proxy to worse disease, were all significantly associated with more SL. Male gender and higher education were associated with less SL. There were no relevant interactions between SE factors and clinical variables.

Table 1.

Univariable and multivariable model analyses with Sick Leave as outcome.

Type of analysisUnivariable analysisMultivariable modelHR (95% CI)HR (95% CI) (N = 614)Explanatory variablesAge1.04 (1.01, 1.08)1.05 (1.01, 1.09)Male gender0.37 (0.19, 0.74)0.41 (0.20, 0.86)High education0.33 (0.17, 0.61)0.48 (0.24, 0.95)Marital status2.44 (1.12, 5.27)NSASDAS (CRP)1.83 (1.34, 2.50)1.49 (1.04, 2.13)BASFI, 0-101.24 (1.09, 1.40)*BASMI, 0-101.76 (1.31, 2.38)*Comorbidity count1.77 (1.22, 2.57)NSHLA-B27 positive0.51 (0.28, 0.93)NSSmoking (current vs not)2.40 (1.31, 4.37)2.55 (1.32, 4.91)NSAID score last week, 0-4001.01 (1.00, 1.01)NSOral Corticosteroid use (vs no)3.90 (1.80, 8.46)NSTNF use2.86 (1.55, 5.28)2.41 (1.27, 4.58)

*Variables tested in models separate from ASDAS. NS=Not significant in multivariable model.

Figure 1.

Distribution of first and recurrent sick leave episodes over time in the study population at risk.

Conclusion:

In this early axSpA cohort of young, working-age individuals, older age and worse disease activity were associated with more SL, whereas male gender and higher education were associated with less SL. The findings suggest a role of SE factors such as gender and level of education in adverse work outcomes, alongside active disease.

Disclosure of Interests:

None declared

AB0649 INFECTION PROFILE OF IMMUNE-MODULATORY DRUGS USED IN AUTOIMMUNE DISEASES: ANALYSIS OF SUMMARY OF PRODUCT CHARACTERISTIC DATA

Background:

The number of immune-modulatory drugs used to treat immune-mediated inflammatory diseases (IMIDs) has exponentially increased in recent decades. While effective in controlling disease, serious infection remains a concern.

Accurate information on immune-modulatory drugs, including infections, is required to guide prescribing decisions. The “summary of product characteristics” (SmPC) by the European Medicines Agency (EMA) provides a useful repository of information on adverse events e.g. infections, from clinical trials and post-marketing pharmacovigilance (1).

To date, no comparison has been undertaken on reported infection frequencies across SmPCs for immune-modulators.

Objectives:

To compare infection frequency, site and type across the most commonly-prescribed immune-modulatory drugs used to treat IMIDs, using information provided by SmPCs.

Methods:

A drug was included if licensed in Europe for treatment of one of the following: rheumatoid arthritis, axial spondyloarthritis, connective tissue disease, autoimmune vasculitis, autoinflammatory syndromes, inflammatory bowel disease (Crohn’s and ulcerative colitis), psoriasis, multiple sclerosis and other rarer conditions.

The Electronic Medicines Compendium (EMC) was searched for commonly prescribed immune-modulatory drugs used for the above indications. SmPC documents were manually searched for information on infection frequency, extracted from sections 4.4 and 4.8. Infection frequency was recorded as per convention in the SmPC: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) (1), for each drug. Information was further extracted on infection site (e.g. respiratory, skin etc), type (e.g. bacterial, viral etc) and individual pathogenic organisms.

25% of included SmPCs were screened and extracted by a second reviewer. Disagreements were resolved with input from a third reviewer.

Results:

In total, 39 drugs were included, used across 20 indications: nine conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), six targeted synthetic DMARDs (tsDMARDs; four Janus kinase [JAK] inhibitors, two sphingosine 1-phosphate receptor modulators) and 24 biologic DMARDs (17 cytokine-targeted; seven cell-targeted).

Twelve sites of infection were recorded. Minimal or no site information was available for most csDMARDs and siponimod, certolizumab pegol and rituximab. The most common sites of infection are listed by drug group in Figure 1. Upper respiratory tract was the most common site, especially with bDMARDs. Lower respiratory, ear/nose/throat (including sinusitis) and urinary tract infections were moderately common, with clustering within drug groups. No drugs reported risk of cardiac infections; the eye, musculoskeletal, neurological, oral and reproductive sites were the least commonly-reported sites of infection.

Infection data for 27 distinct pathogens were recorded, the majority viruses, especially with bDMARD use. Herpes simplex and zoster were the most frequently listed (mainly with bDMARDs and tsDMARDs), followed by influenza. Common non-viral causes of infection were candida and tinea species.

Variable or absent reporting was noted for opportunistic infections (e.g. tuberculosis and fungi) and certain high-prevalence viruses e.g. Epstein-Barr.

Conclusion:

The SmPC literature reports differences in infection risk, by site and pathogen, between immune-modulatory drugs. The findings can be used to visualise differences and aid treatment decisions. However, some of the patterns we have shown lack face-validity to clinicians familiar with real-world safety data. The data fail to capture risk of rare infections, are likely skewed by trial selection criteria, varying number of trials per drug and quirks of individual study-reporting methodologies.

The findings highlight the need for robust post-marketing pharmacovigilance studies.

References:

[1]A Guideline on Summary of Product Characteristics Module 1.3. 2008.

Disclosure of Interests:

None declared.

POS0495 LARGE JOINT DISEASE IN RHEUMATOID ARTHRITIS AND THE ROLE OF RHEUMATOID FACTOR. RESULTS FROM THE EARLY RHEUMATOID ARTHRITIS STUDY

Background:

Rheumatoid arthritis (RA) is classically described as a symmetric small joint polyarthritis with additional involvement of large joints. There is a paucity of information concerning the time course of damage in large joints, such as shoulder, elbow, hip, knee and ankle, from early to established RA, or of the influence of Rheumatoid Factor (RF) status. There is a historic perception that patients who do not have RF follow a milder less destructive course, which might promote less aggressive treatment strategies in RF-negative patients. The historic nature of the Ealy Rheumatoid Arthritis Study (ERAS) provides a unique opportunity to study RA in the context of less aggressive treatment strategies.

Objectives:

To examine the progression of large joint involvement from early to established RA in terms of range of movement (ROM) and time to joint surgery, according to the presence of RF.

Methods:

ERAS was a multi-centre inception cohort of newly diagnosed RA patients (<2 years disease duration, csDMARD naive), recruited from 1985-2001 with yearly follow-up for up to 25 (median 10) years. First line treatment was csDMARD monotherapy with/without steroids, favouring sulphasalazine for the majority. Outcome data was recorded at baseline, at 12 months and then once yearly. Patients were deemed RF negative if all repeated assessments were negative. ROM of individual shoulder, elbow, wrist, hip, knee, ankle and hindfeet joints was collected at 3, 5, 9 and 12-15 years. The rate of progression from normal to any loss of ROM, from years 3 to 14 was modelled using GEE, adjusting for confounders. Radiographs of wrists taken at years 0, 1, 2, 3, 5, 7, 9 were scored according to the Larsen method. Change in the Larsen wrist damage score was modelled using GEE as a continuous variable, while the erosion score was dichotomised into present/absent. Surgical procedure data were obtained by linking to Hospital Episodes Statistics and the National Joint Registry. Time to joint surgery was analysed using multivariable Cox models.

Results:

A total of 1458 patients from the ERAS cohort were included (66% female, mean age 55 years) and 74% were RF-positive. The prevalence of any loss of ROM, from year 3 through to 14 was highest in the wrist followed by ankle, knee, elbow and hip. The proportion of patients at year 9 with greater than 25% loss of ROM was: wrist 30%, ankle 12%, elbow 7%, knee 7% and hip 5%. Odds of loss of ROM increased over time in all joint regions, at around 7 to 13% per year from year 3 to 14. There was no significant difference between RF-positive and RF-negative patients (see Figure 1). Larsen erosion and damage scores at the wrists progressed in all patients; annual odds of developing any erosions were higher in RF-positives OR 1.28 (95%CI 1.24-1.32) than RF-negatives OR 1.17 (95%CI 1.09-1.26), p 0.013. Time to surgery was similar according to RF-status for the wrist and ankle, but RF-positive cases had a lower hazard of surgery at the elbow (HR 0.37, 0.15-0.90), hip (HR 0.69, 0.48-0.99) and after 10 years at the knee (HR 0.41, 0.25-0.68). Adjustment of the models for Lawrence assessed osteoarthritis of hand and feet radiographs did not influence these results.

Figure 1.

Odds of progression to any loss of ROM (from no loss of ROM) per year in the overall population and stratified by RF status.

Conclusion:

Large joints become progressively involved in RA, most frequently affecting the wrist followed by ankle, which is overlooked in some composite disease activity indices. We confirm a higher burden of erosions and damage at the wrists in RF-positive patients, but have not found RF-negative patients to have a better prognosis over time with respect to involvement of other large joints. In contrast RF-negative patients had more joint surgery at the elbow, hip, and knee after 10 years. There is no justification to adopt a less aggressive treatment strategy for RF-negative RA. High vigilance and treat-to-target approaches should be followed irrespective of RF status.

Disclosure of Interests:

None declared

OP0316 ASSOCIATION BETWEEN INDIVIDUAL AND COUNTRY-LEVEL SOCIOECONOMIC FACTORS AND WORK PARTICIPATION IN PERIPHERAL AND AXIAL SPONDYLOARTHRITIS: ANALYSIS OF THE ASAS perSpA Study

Background:

Work outcomes in spondyloarthritis (SpA) have mostly been studied in axSpA, less in peripheral SpA (pSpA) or PsA. The ASAS-COMOSPA study showed that lower education, female gender and lower healthcare expenditures (HCE) are associated with lower odds of employment in SpA. However, it is unknown whether country-level factors or SpA phenotype (axSpA/pSpA/PsA) modify the effect of individual-level socioeconomic factors.

Objectives:

To examine whether associations between socioeconomic factors and work outcomes differ across SpA phenotype and whether associations for individual-level socioeconomic factors are modified by country-level factors.

Methods:

Working age patients (18-65 years) from the ASAS-perSpA (peripheral involvement in SpA) study were included. Associations between individual- (age, gender, education, marital status) and country-level socioeconomic factors (Human Development Index (HDI), HCE) with work outcomes (employment status (binary), absenteeism, presenteeism (tertiles)) were assessed using mixed-effects logistic and ordinal logistic models. Models were adjusted for confounders. Separate models for ASDAS, BASFI and BASDAI were created in turn due to collinearity. Effect modification by SpA phenotype and country-level factors was tested using interaction terms.

Results:

A total of 3835 patients (mean age 42 years, 61% males) from 23 countries worldwide were included (66% axSpA, 10% pSpA, 23% PsA). Being employed was associated with gender (male vs female OR 2.5; 95%CI 1.9-3.2), education (university vs primary OR 3.7; 2.9-4.7) and being married (vs single OR 1.3; 1.04-1.6) (Table 1). University (vs primary) education was associated with lower odds of absenteeism (OR 0.7; 0.5-0.7) and presenteeism (OR 0.5; 0.3-0.7). Associations were not statistically different across SpA phenotypes. HCE was significantly associated with all work outcomes: employment (OR 2.5; 1.5-4.1), absenteeism (OR 0.6; 0.4-0.9) and presenteeism (OR 0.6; 0.3-0.9). HDI results were similar. Gender discrepancy in odds of employment was greater in countries with lower socioeconomic development; eg, males had 3.5 higher odds of employment than females in countries with low HCE, whereas the difference was 1.8 fold in high HCE countries.

Table 1.

Effect of individual socio-economic factors on work outcomes.

Employment statusOR (95% CI)AbsenteeismOR (95% CI)PresenteeismOR (95% CI)N378022182127Age1.43 (1.36,1.51)1.00 (0.99,1.01)1.00 (0.99,1.01)Age20.996 (0.995, 0.996)NS - uniNS - uniMale (vs female)2.48 (1.92,3.21)1.22 (0.96,1.56)0.97 (0.78,1.20)EducationPrimaryrefrefrefSecondary1.86 (1.48,2.35)0.69 (0.49,0.99)0.69 (0.49,0.99)University3.68 (2.87,4.72)0.67 (0.47,0.96)0.49 (0.34,0.69)Marital statusSinglerefrefrefMarried1.27 (1.04,1.56)0.95 (0.73,1.22)0.98 (0.78,1.22)Divorced or Widowed1.39 (0.98,1.97)1.39 (0.88,2.18)1.16 (0.74,1.82)ASDAS0.78 (0.72,0.84)1.51 (1.33,1.72)2.31 (2.04,2.61)FatigueNS - multi1.14 (1.09,1.21)1.30 (1.24,1.36)Depression0.70 (0.59,0.82)1.45 (1.15,1.82)1.95 (1.59,2.39)FibromyalgiaNS - multi1.62 (1.11,2.35)1.58 (1.03,2.41)BMINS - multi0.99 (0.97,1.02)NS - multiDactylitis1.41 (1.12,1.76)NS - uniNS - uniUveitisNS - multi0.62 (0.46,0.84)NS - uniNSAIDsNS - multi1.53 (1.18,1.99)1.32 (1.07,1.64)bDMARDsNS - multiNS - uni1.23 (1.01,1.51)

Models used ASDAS rather than BASDAI/BASFI, which are collinear. NS, not significant in the univariable or multivariable model.

Conclusion:

Individual- (lower education) and country-level socioeconomic factors (lower healthcare expenditure) were both associated with (lower) work participation, independently of SpA phenotype. The disadvantageous effect of female gender on employment is particularly strong in countries with lower socioeconomic development. This highlights the need for wider societal interventions, such as improving education and healthcare investment, to improve work outcomes.

Disclosure of Interests:

Sizheng Steven Zhao: None declared, Elena Nikiphorou Speakers bureau: Pfizer, Lilly, AbbVie, Annelies Boonen Consultant of: Yes, Grant/research support from: Yes, Clementina López-Medina: None declared, Maxime Dougados: None declared, Sofia Ramiro Speakers bureau: Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Lilly, MSD, Novartis, UCB, Sanofi, Grant/research support from: MSD.

OP0264-HPR “I LITERALLY CONVINCED MYSELF I WAS GOING TO CATCH IT AND DIE”: LIVED EXPERIENCES OF THE COVID-19 PANDEMIC BY PEOPLE WITH RHEUMATIC DISEASES FROM FOUR EUROPEAN COUNTRIES

Background:

The COVID-19 pandemic has resulted in unforeseen challenges for humanity, taking a significant toll, especially the immune-suppressed individuals. In this regard, the health and general well-being of people with rheumatic diseases, the great majority users of immunosuppressives, have been at stake.

Objectives:

To explore the impact of the COVID-19 pandemic on people with rheumatic diseases on immunosuppression during the first wave, concerning a) (self-)management of their disease; b) interaction with the health care team; c) emotional well-being and d) overall health.

Methods:

A qualitative study was conducted following a phenomenological approach. Adults (>18 years) with a rheumatic disease from four European countries (Cyprus, England, Greece, Portugal). Patients were recruited through patient’s associations and social media and were invited to participate in semi-structured, audio-recorded interview or focus groups, between July - August 2020. Following a pilot study the information provided was transcribed verbatim, anonymized and translated into English where necessary. An inductive approach was adopted to carry out a thematic framework analysis with the assistance of ATLAS.ti to identify key themes and subthemes. Data validation strategies were employed, and Ethical approval and informed consent were obtained.

Results:

Participants were 24 patients (21 women, age range 33 to 74 years) divided by 7 focus-groups and 1 individual interview. Most frequent diagnoses were rheumatoid arthritis (n=7), lupus (n=4), juvenile idiopathic arthritis (n=3).

Three key themes with 3-7 subthemes were identified within the analytical framework, centred around the impact of the Covid-19 on patients’ lives (Figure 1): i) individual person (e.g. fear for myself and family, social isolation and lack of personal freedom, more time with family) ii) health settings (e.g. (un)clear information about risks of contamination, fear or risk of shortages of medication, remote consultations), and iii) work and community (e.g. persistent stress due to mass media exposure, lack of awareness by others about patients’ rheumatic disease and its disclosure, hope and suspicion about new vaccine development: “I hear that they will ask vulnerable groups to have the vaccine first (...) Why is that? we will be again the innocent victims”). Findings were similar across countries, except for spirituality (i.e. the pandemic as “the hand of God”), a coping subtheme particular to Portugal. These main themes resonated well with the social ecological model and Walsh’s Family Resilience Process [1,2].

Conclusion:

When experiencing a significant life-event people require some time to process the different lived experiences. This study provides insights on how patients from four countries coped with the new challenges. Such insights are invaluable for health care providers and policy makers, in guiding more meaningful support tailored to individual needs, especially at times of crisis. The study highlights the impact of COVID-19 on the lives of people with rheumatic disease. A follow-up study is currently underway to examine the effect of subsequent waves of the pandemic.

References:

[1]Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39(3):364-72. doi: 10.1177/1090198111418634.

[2]Walsh F. Family resilience: a framework for clinical practice. Fam Process. 2003;42(1):1-18. doi: 10.1111/j.1545-5300.2003.00001.

Acknowledgements:

We thank the participants of this study.

Disclosure of Interests:

None declared

EULAR portfolio for Rheumatology training: a EULAR School of Rheumatology initiative

OBJECTIVE

About half of the rheumatology trainees do not use a portfolio. This project was established to reach consensus about the content of a EULAR portfolio for Rheumatology training and subsequently develop portfolio assessment forms.

METHODS

After establishing a portfolio working group (WG), including nine rheumatologists and one educationalist, a systematic literature review (SLR) on the content and structure of portfolios for postgraduate learning was conducted (November 2018). This was followed by a survey among WG members and members of the EMerging EUlar NETwork, inquiring about the content and structure of existing national portfolios. The portfolio WG selected the key components of the portfolio, taking previous experience and feasibility into account. Assessment forms (eg, case-based discussion) were developed and pilot-tested.

RESULTS

13/2034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on procedural skills, personal reflections, learning goals and multisource feedback was most often included a portfolio. Twenty-five respondents completed the survey (response≈50%). Feedback from assessors, reflective writing and formulation of learning goals were considered important dimensions to be covered in a portfolio. Six key components of the portfolio were established: curriculum vitae, personal development plan, clinical work, professional behaviours, education and research activities. Suggested minimal content for each component was formulated. Four assessment forms were successfully pilot-tested by 11 rheumatologists and their trainees.

CONCLUSION

A EULAR portfolio for Rheumatology training and assessment forms were developed. Portfolio implementation, particularly in countries without an existing portfolio, may promote a higher standard of rheumatology training across Europe.

POS0662 PREDICTORS OF TOXICITY WITH HYDROXYCHLOROQUINE AND CHLOROQUINE USE: A SYSTEMATIC REVIEW

Background:

Hydroxychloroquine (HCQ) has attracted much attention especially during the COVID-19 pandemic. HCQ and closely related chloroquine (CQ) have known ocular and cardiac toxicity. However, although screening guidance now exists from the Royal College of Ophthalmologists for the former (RCOphth)1, little is known regarding predictors of both forms of toxicity.

Objectives:

To systematically explore the literature on predictors of toxicity limited to cardiac and ocular toxicity.

Methods:

A detailed search of the following databases was conducted: PubMed, Medline, Embase, Web of Science, The Cochrane library, EMCare and Academic Search Premier. Studies addressing predictors of HCQ toxicity with relevant search terms used were included. Exclusion criteria were: non-English articles, pre-clinical and paediatric studies. Three authors (SR, NC, PK) independently screened titles and abstracts for inclusion, ensuring each article was screened twice. Disagreement over inclusion was adjudicated by senior reviewers (EN, JG). Data extraction (SR, NC, PK) focused on predictors of toxicity.

Results:

The search strategy retrieved 3103 studies. 147 studies were included for data extraction, of which 92 were eventually excluded due to: not identifying predictors (n=17), reviews (n=19), not ocular or cardiovascular toxicity (n=18), case reports (n=3), paediatrics (n=1), screening articles that focused on detecting retinopathy (n=30), article unobtainable at time of abstract submission (n=4), leaving 55 studies for full review.

Studies addressing cardiac toxicity (n=16) included: cohort, retrospective observational, a comparative pharmacovigilance, systematic monitoring protocol and a randomised control trial (RCT). The majority of these involved high-dose (>5mg/kg/day) use for acute COVID-19 infection. The main significant predictors identified were: Hydroxychloroquine (HCQ) use in combination with azithromycin (6/7 studies), cumulative dose (2 studies), pre-existing cardiovascular morbidity (2/3 studies) and prolonged baseline QTc (2 studies). Individual associations were also identified in the following: longer treatment duration, daily dosage, increased age, male gender, severe COVID-19 infection, abnormal liver function tests (LFTs) and concurrent use of loop-diuretics.

Regarding predictors of ocular toxicity (n=39), only one study was a RCT. The remainder were observational studies: case-control, cohort, retrospective chart reviews and letters to the editor which included original patient data.

Several predictors of retinopathy and maculopathy were examined in two or more studies and included: duration of use (16/18 studies), daily dosage (7/13 studies), cumulative dose (11/14 studies), increased age (10/11 studies), body weight or BMI (3/5 studies), renal impairment (5 studies), HCQ blood levels (2 studies), keratopathy (2 studies) and tamoxifen use (2 studies). Sex (2 studies) and history of cataract surgery (2 studies) were not found to be predictors of toxicity.

Only few studies performed regression analysis presenting odds and/or hazard ratios with confidence intervals.

Conclusion:

The most recognised predictor of cardiac toxicity was co-administration with azithromycin. In ocular toxicity, commonly cited predictors included those already recognised by the RCOphth1, as well as cumulative dose, increased age, weight considerations, HCQ blood levels and keratopathy. Further research is warranted on better characterising predictors of cardiac and ocular toxicity in patients on HCQ and CQ therapy.

References:

[1]The Royal College of Ophthalmologists. Hydroxychloroquine and Chloroquine Retinopathy: Recommendations on Monitoring [Internet]. The Royal College of Ophthalmologists; 2020 [cited 2021 Jan 25].

Disclosure of Interests:

Natasha Citeroni: None declared, Sanketh Rampes: None declared, Pinky Kotecha: None declared, Jan Schoones: None declared, Elena Nikiphorou: None declared, James Galloway Speakers bureau: JG has received honoraria / speaker fees from Abbvie, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB.

Associations of baseline use of biologic or targeted synthetic DMARDs with COVID-19 severity in rheumatoid arthritis: Results from the COVID-19 Global Rheumatology Alliance physician registry

Objective

To investigate baseline use of biologic or targeted synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) and COVID-19 outcomes in rheumatoid arthritis (RA).

Methods

We analysed the COVID-19 Global Rheumatology Alliance physician registry (from 24 March 2020 to 12 April 2021). We investigated b/tsDMARD use for RA at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAKi), interleukin 6 inhibitors (IL-6i) or tumour necrosis factor inhibitors (TNFi, reference group). The ordinal COVID-19 severity outcome was (1) no hospitalisation, (2) hospitalisation without oxygen, (3) hospitalisation with oxygen/ventilation or (4) death. We used ordinal logistic regression to estimate the OR (odds of being one level higher on the ordinal outcome) for each drug class compared with TNFi, adjusting for potential baseline confounders.

Results

Of 2869 people with RA (mean age 56.7 years, 80.8% female) on b/tsDMARD at the onset of COVID-19, there were 237 on ABA, 364 on RTX, 317 on IL-6i, 563 on JAKi and 1388 on TNFi. Overall, 613 (21%) were hospitalised and 157 (5.5%) died. RTX (OR 4.15, 95% CI 3.16 to 5.44) and JAKi (OR 2.06, 95% CI 1.60 to 2.65) were each associated with worse COVID-19 severity compared with TNFi. There were no associations between ABA or IL6i and COVID-19 severity.

Conclusions

People with RA treated with RTX or JAKi had worse COVID-19 severity than those on TNFi. The strong association of RTX and JAKi use with poor COVID-19 outcomes highlights prioritisation of risk mitigation strategies for these people.

OP0006 ASSOCIATIONS OF BASELINE USE OF BIOLOGIC OR TARGETED SYNTHETIC DMARDS WITH COVID-19 SEVERITY IN RHEUMATOID ARTHRITIS: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE

Background:

Targeted DMARDs may dampen the inflammatory response in COVID-19, perhaps leading to a less severe clinical course. However, some DMARD targets may impair viral immune defenses. Due to sample size limitations, previous studies of DMARD use and COVID-19 outcomes have combined several heterogeneous rheumatic diseases and medications, investigating a single outcome (e.g., hospitalization).

Objectives:

To investigate the associations of baseline use of biologic or targeted synthetic (b/ts) DMARDs with a range of poor COVID-19 outcomes in rheumatoid arthritis (RA).

Methods:

We analyzed voluntarily reported cases of COVID-19 in patients with rheumatic diseases in the COVID-19 Global Rheumatology Alliance physician registry (March 12, 2020 - January 6, 2021). We investigated RA treated with b/tsDMARD at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAK), interleukin-6 inhibitors (IL6i), or tumor necrosis factor inhibitors (TNFi). The outcome was an ordinal scale (1-4) for COVID-19 severity: 1) no hospitalization, 2) hospitalization without oxygen need, 3) hospitalization with any oxygen need or ventilation, or 4) death. Baseline covariates including age, sex, smoking, obesity, comorbidities (e.g., cardiovascular disease, cancer, interstitial lung disease [ILD]), concomitant non-biologic DMARD use, glucocorticoid use/dose, RA disease activity, country, and calendar time were used to estimate propensity scores (PS) for b/tsDMARD. The primary analysis used PS matching to compare each drug class to TNFi. Ordinal logistic regression estimated ORs for the COVID-19 severity outcome. In a sensitivity analysis, we used traditional multivariable ordinal logistic regression adjusting for covariates without matching.

Results:

Of the 1,673 patients with RA on b/tsDMARDs at the onset of COVID-19, (mean age 56.7 years, 79.6% female) there were n=154 on ABA, n=224 on RTX, n=306 on JAK, n=180 on IL6i, and n=809 on TNFi. Overall, 498 (34.3%) were hospitalized and 112 (6.7%) died. Among all patients, 353 (25.3%) were ever smokers, 197 (11.8%) were obese, 462 (27.6%) were on glucocorticoids, 1,002 (59.8%) were on concomitant DMARDs, and 299 (21.7%) had moderate/high RA disease activity. RTX users were more likely than TNFi users to have ILD (11.6% vs. 1.7%) and history of cancer (7.1% vs. 2.0%); JAK users were more likely than TNFi users to be obese (17.3% vs. 9.0%). After propensity score matching, RTX was strongly associated with greater odds of having a worse outcome compared to TNFi (OR 3.80, 95% CI 2.47, 5.85; Figure). Among RTX users, 42 (18.8%) died compared to 27 (3.3%) of TNFi users (Table). JAK use was also associated with greater odds of having a worse COVID-19 severity (OR 1.52, 95%CI 1.02, 2.28). ABA or IL6i use were not associated with COVID-19 severity compared to TNFi. Results were similar in the sensitivity analysis and after excluding cancer or ILD.

Table 1.

Frequencies for the ordinal COVID-19 severity outcome for patients with RA on biologic or targeted synthetic DMARDs (n=1673).

COVID-19 outcomes by severity scale (n,%)ABAn=154RTXn=224JAKn=306IL6in=180TNFi n=8091)Not hospitalized113 (73.3%)121 (54.0%)220 (71.9%)150 (83.3%)666 (82.3%)2)Hospitalization without oxygenation10 (6.5%)14 (6.2%)11 (3.6%)9 (5.0%)53 (6.5%)3)Hospitalization with any oxygenation or ventilation16 (10.4%)47 (21.0%)52 (17.0%)16 (8.9%)63 (7.8%)4)Death15 (9.7%)42 (18.8%)23 (7.5%)5 (2.8%)27 (3.3%)

Conclusion:

In this large global registry of patients with RA and COVID-19, baseline use of RTX or JAK was associated with worse severity of COVID-19 compared to TNFi use. The very elevated odds for poor COVID-19 outcomes in RTX users highlights the urgent need for risk-mitigation strategies, such as the optimal timing of vaccination. The novel association of JAK with poor COVID-19 outcomes requires replication.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR, the UK National Health Service, the National Institute for Health Research, the UK Department of Health, or any other organization.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum, unrelated to this work, Grant/research support from: Amgen and Bristol-Myers Squibb, unrelated to this work, Zachary Wallace Consultant of: Viela Bio and MedPace, outside the submitted work., Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Andrea Seet: None declared, Milena Gianfrancesco: None declared, Zara Izadi: None declared, Kimme Hyrich Speakers bureau: Abbvie unrelated to this study, Grant/research support from: BMS, UCB, and Pfizer, all unrelated to this study, Anja Strangfeld Paid instructor for: AbbVie, MSD, Roche, BMS, Pfizer, outside the submitted work, Grant/research support from: grants from a consortium of 13 companies (among them AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB) supporting the German RABBIT register, outside the submitted work, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, unrelated to this study, Grant/research support from: Lilly, Mylan, Pfizer, all unrelated to this study, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: grants from Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA; grants and non-financial support from Pfizer, outside the submitted work, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Leanna Wise: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Manuel F. Ugarte-Gil Grant/research support from: Janssen and Pfizer, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Yes, I have received research funding from Pfizer outside the submitted work., Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

POS1162 PREDICTORS OF HOSPITALISATION IN PATIENTS WITH RHEUMATIC DISEASE AND COVID-19 IN IRELAND: DATA FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE PHYSICIAN-REPORTED REGISTRY

Background:

There is limited data regarding the risk of hospitalisation in patients with rheumatic disease and COVID-19 in Ireland.

Objectives:

We used the COVID-19 Global Rheumatology Alliance (GRA) registry data to study outcomes and their predictors.

Methods:

We examined data on patients and their disease-related characteristics entered into the COVID-19 GRA provider registry from Ireland (24th March 2020 to 31st August 2020). Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with hospitalisation.

Results:

Of 105 patients, 47 (45.6%) were hospitalised and 10 (9.5%) died. Multivariable logistic regression analysis showed age (OR=1.06, 95%CI 1.01 to 1.10), number of comorbidities (OR=1.93, 95%CI 1.11 to 3.35), and glucocorticoid use (OR=15.01, 95%CI 1.77 to 127.16) were significantly associated with hospitalisation. A diagnosis of inflammatory arthritis was associated with a lower odds of hospitalisation (OR=0.09, 95%CI 0.02 to 0.32).

All significant variable modelMost parsimonious modelUnadjusted OR (95% CI)Adjusted OR (95%CI)*Adjusted p-value*Adjusted OR (95%CI)&Adjusted p-value&Female0.45 (0.20-1.02)0.33 (0.05-2.23)0.34 (0.09-1.36)0.128Age (years)1.08 (1.05-1.11)1.04 (0.97-1.10)0.2241.06 (1.01-1.10)0.010Inflammatory arthritis0.11 (0.05-0.28)0.14 (0.02-0.95)0.0440.09 (0.02-0.32)<0.001Connective Tissue Disease and Other1.56 (0.62 - 3.92)No comorbidities0.11 (0.04-0.30)0.76 (0.09-6.58)0.802Most common comorbiditiesCOPD / asthma4.77 (1.23-18.54)3.09 (0.16-60.07)0.456CVD3.40 (1.31-8.85)0.11 (0.01-1.88)0.129Hypertension3.71 (1.52-9.08)0.56 (0.04-7.94)0.668Obesity0.58 (0.10-3.30)Number of comorbidities (Median, IQR)3.01 (1.92-4.72)2.99 (0.59-15.02)0.1841.93 (1.11-3.35)0.020Never Smokerref.0.889Ever Smoker3.17 (1.18-8.89)1.19 (0.10-13.68)Medication prior to COVID-19 diagnosisGlucocorticoids9.26 (1.95-43.89)18.14 (1.13-290.81)0.04115.01 (1.77-127.16)0.013csDMARD monotherapy0.42 (0.17-1.00)b/tsDMARD (monotherapy or in combination with csDMARD)0.24 (0.10-0.58)1.36 (0.19-9.72)0.557

Conclusion:

Increasing age, comorbidity burden, and glucocorticoid use were associated with hospitalisation, while a diagnosis of inflammatory arthritis was associated with lower odds of hospitalization.

Disclosure of Interests:

Richard Conway Speakers bureau: Janssen, Roche, Sanofi, Abbvie, Elena Nikiphorou Speakers bureau: AbbVie, Eli-Lilly, Gilead, Celltrion, Pfizer, Sanofi, Christiana Demetriou: None declared, Candice Low: None declared, Kelly Leamy: None declared, John Ryan: None declared, Ronan Kavanagh: None declared, Alexander Fraser: None declared, John Carey: None declared, Paul O’Connell: None declared, Rachael Flood: None declared, Ronan Mullan: None declared, David Kane: None declared, Philip Robinson Speakers bureau: UCB, Roche, Pfizer, Gilead, Janssen, Novartis, Eli Lilly, Abbvie, Grant/research support from: Abbvie, UCB, Novartis, Janssen, Pfizer, Jean Liew Grant/research support from: Pfizer, Rebecca Grainger Speakers bureau: Pfizer, Cornerstones, Janssen, Novartis, Abbvie, Geraldine McCarthy: None declared.

Rheumatoid arthritis and dietary interventions: systematic review of clinical trials

CONTEXT

The impact of various dietary interventions on rheumatoid arthritis (RA), characterized by immune-inflammatory response, has been subject to increased attention.

OBJECTIVE

A systematic review was conducted to update the current knowledge on the effects of nutritional, dietary supplement, and fasting interventions on RA outcomes.

DATA SOURCES

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with prespecification of all methods, Medline and Embase were systematically searched for relevant articles.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

RESULTS

A total of 70 human studies were identified. Administration of omega-3 polyunsaturated fatty acids at high doses resulted in a reduction in RA disease activity and a lower failure rate of pharmacotherapy. Vitamin D supplementation and dietary sodium restriction were beneficial on some RA outcomes. Fasting resulted in significant but transient subjective improvements. While the Mediterranean diet demonstrated improvements in some RA disease activity measures, outcomes from vegetarian, elimination, peptide, or elemental diets suggested that responses are very individualized.

CONCLUSION

Some dietary approaches may improve RA symptoms and thus it is recommended that nutrition should be routinely addressed.

Syndemics & syndemogenesis in COVID-19 and rheumatic and musculoskeletal diseases: old challenges, new era

People with rheumatic and musculoskeletal diseases (RMDs) are facing several challenges during the COVID-19 pandemic, such as poor access to regular health services and drug shortages, particularly in developing countries. COVID-19 represents a syndemic, synergistic condition that interacts with and exacerbates pre-existing diseases such as RMDs, other co-morbidities and social conditions. The emerging evidence on both biological and non-biological factors implicated in worse outcomes in people with RMDs affected by the COVID-19 pandemic, whether infected by the virus or not, calls for the need to use more novel and holistic frameworks for studying disease. In this context, the use of a syndemic framework becomes particularly relevant. We appeal for a focus on the identification of barriers and facilitators to optimal care of RMDs in the context of the COVID-19 pandemic, in order to tackle both the pandemic itself and the health inequities inherent to it.

2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Background

An important but often insufficient aspect of care in people with inflammatory arthritis (IA) is empowering patients to acquire a good understanding of their disease and building their ability to deal effectively with the practical, physical and psychological impacts of it. Self-management skills can be helpful in this regard.

Objectives

To develop recommendations for the implementation of self-management strategies in IA.

Methods

A multidisciplinary taskforce of 18 members from 11 European countries was convened. A systematic review and other supportive information (survey of healthcare professionals (HCPs) and patient organisations) were used to formulate the recommendations.

Results

Three overarching principles and nine recommendations were formulated. These focused on empowering patients to become active partners of the team and to take a more proactive role. The importance of patient education and key self-management interventions such as problem solving, goal setting and cognitive behavioural therapy were highlighted. Role of patient organisations and HCPs in promoting and signposting patients to available resources has been highlighted through the promotion of physical activity, lifestyle advice, support with mental health aspects and ability to remain at work. Digital healthcare is essential in supporting and optimising self-management and the HCPs need to be aware of available resources to signpost patients.

Conclusion

These recommendations support the inclusion of self-management advice and resources in the routine management of people with IA and aim to empower and support patients and encourage a more holistic, patient-centred approach to care which could result in improved patient experience of care and outcomes.

P131 Defining refractory disease in RA and polyarticular JIA: a systematic review

Background/Aims 

A systematic approach to define patients with rheumatoid arthritis (RA) or polyarticular juvenile idiopathic arthritis (PolyJIA) who do not adequately respond to treatment and experience persistent symptoms (refractory disease) is absent. The objective of the systematic review was to identify how refractory disease (or relevant terminology variations) in RA/PolyJIA is defined and establish the key components/constructs of such definitions.

Methods 

Searches were undertaken of English language articles within six medical databases, including manual searching, from January 1998 to March 2020 (PROSPERO: CRD42019127142). Articles were included if they incorporated a definition of refractory disease, or non-response, in RA/PolyJIA, with clear components to the description (e.g. disease activity assessment specified, patient perspective, number of drugs to classify non-response). A narrative synthesis mapping of the definitions was undertaken to describe refractory disease in RA/PolyJIA and classify each component within each definition through a qualitative content analysis.

Results 

Of 6,251 studies screened, 646 studies met the inclusion criteria; 581 reported non-response criteria and 65 reported refractory disease definitions/descriptions. From the non-response studies, 39 different components included various disease activity measures, emphasising persistent disease activity and symptoms, despite treatment with at least one bDMARD. Of the papers with clear definitions for Refractory disease, 41 components were identified and categorised into three key themes: Resistance to multiple drugs/regimes with different mechanisms of action: descriptions of drugs/regimes failed, not tolerated, discontinued/switched, by specifying name, number or class of drugs failed (range 1-8 but typically ≥2 bDMARDs) and duration of treatment, and steroid use/dependency.Persistency of physical symptoms and disease activity: range of various disease activity criteria (including not achieving remission), descriptions of other patient-reported outcomes or symptoms e.g. patient global or pain VAS, presence or absence of inflammation, disease severity including new joint activity, damage or replacements.Other contributing factors: biomechanical or degenerative drivers, adverse event, co-morbidities or extra-articular manifestations, serology (RF Status) or anti-bodies (anti-CCP) and incorrect diagnosis or not relevant treatment.

The most common labels were “Refractory” (80%), of which 32.7% used the term “Refractory RA” and 13.5% stating “Refractory to (drug name/class)”. “Difficult-to-treat RA” (23.1%) and “Treatment Resistant RA” (15.4%) were the most popular from remaining terms (20%). Only the minority (16.9%) reported explicitly how their definition was generated e.g. clinical experience or statistical methods.

Conclusion 

Refractory disease can be defined as resistance to multiple drugs/regimes with different mechanisms of action as evidenced by persistency of physical symptoms and high disease activity, including contributing factors. There is a need for a clear unifying definition as the plethora of different definitions makes both study comparisons and appropriate identification of patients difficult.

Disclosure 

H. Chaplin: None. L. Carpenter: None. A. Raz: None. E. Nikiphorou: None. H. Lempp: None. S. Norton: None.

Endorsement of the OMERACT core domain set for shared decision making interventions in rheumatology trials: Results from a multi-stepped consensus-building approach

OBJECTIVE

To gain consensus on the Outcome Measures in Rheumatology (OMERACT) core domain set for rheumatology trials of shared decision making (SDM) interventions.

METHODS

The process followed the OMERACT Filter 2.1 methodology, and used consensus-building methods, with patients involved since the inception. After developing the draft core domain set in previous research, we conducted five steps: (i) improving the draft core domain set; (ii) developing and disseminating white-board videos to promote its understanding; (iii) conducting an electronic survey to gather feedback on the draft core domain set; (iv) finalizing the core domain set and developing summaries, a plenary session video and discussion boards to promote its understanding; and (v) conducting virtual workshops with voting to endorse the core domain set.

RESULTS

A total of 167 participants from 28 countries answered the survey (62% were patients/caregivers). Most participants rated domains as relevant (81%-95%) and clear (82%-93%). A total of 149 participants (n = 48 patients/caregivers, 101 clinicians/researchers) participated in virtual workshops and voted on the proposed core domain set which received endorsement by 95%. Endorsed domains are: 1- Knowledge of options, their potential benefits and harms; 2- Chosen option aligned with each patient's values and preferences; 3- Confidence in the chosen option; 4- Satisfaction with the decision-making process; 5- Adherence to the chosen option and 6- Potential negative consequences of the SDM intervention.

CONCLUSION

We achieved consensus among an international group of stakeholders on the OMERACT core domain set for rheumatology trials of SDM interventions. Future research will develop the Core Outcome Measurement Set.

CLINICAL SIGNIFICANCE

Prior to this study, there had been no consensus on the OMERACT core domain set for SDM interventions. The current study shows that the OMERACT core domain set achieved a high level of endorsement by key stakeholders, including patients/caregivers, clinicians and researchers.

Rheumatoid Arthritis Real-world Management Over 20 Years

Clinical trials show which treatments improve rheumatoid arthritis (RA), whereas observational studies show how patients are managed in routine practice. Prospective cohort studies give the most detailed information about what happens to patients, but being a part of a prospective study influences patient management because patients are no longer routine cases.

COVID-19 pandemic impact on people with rheumatic and musculoskeletal diseases: Insights from patient-generated health data on social media

Objectives

During the COVID-19 pandemic, much communication occurred online, through social media. This study aimed to provide patient perspective data on how the COVID-19 pandemic impacted people with rheumatic and musculoskeletal diseases (RMDs), using Twitter-based patient-generated health data (PGHD).

Methods

A convenience sample of Twitter messages in English posted by people with RMDs was extracted between March 1, and July 12, 2020 and examined using thematic analysis. Included were Twitter messages that mentioned keywords and hashtags related to both COVID-19 (or SARS-CoV-2) and select RMDs. The RMDs monitored included inflammatory-driven (joint) conditions (Ankylosing Spondylitis, Rheumatoid Arthritis, Psoriatic Arthritis, Lupus/Systemic Lupus Erythematosus, and Gout).

Results

The analysis included 569 tweets by 375 Twitter users with RMDs across several countries. Eight themes emerged regarding the impact of the COVID-19 pandemic on people with RMDs: (1) lack of understanding of SARS-CoV-2/COVID-19; (2) critical changes in health behaviour; (3) challenges in healthcare practice and communication with healthcare professionals; (4) difficulties with access to medical care; (5) negative impact on physical and mental health, coping strategies; (6) issues around work participation, (7) negative effects of the media; (8) awareness-raising.

Conclusion

The findings show that Twitter serves as a real-time data source to understand the impact of the COVID-19 pandemic on people with RMDs. The platform provided “early signals” of potentially critical health behaviour changes. Future epidemics might benefit from the real-time use of Twitter-based PGHD to identify emerging health needs, facilitate communication, and inform clinical practice decisions.

Innovative approaches to biologic development on the trail of CT-P13: biosimilars, value-added medicines, and biobetters

The biosimilar concept is now well established. Clinical data accumulated pre- and post-approval have supported biosimilar uptake, in turn stimulating competition in the biologics market and increasing patient access to biologics. Following technological advances, other innovative biologics, such as “biobetters” or “value-added medicines,” are now reaching the market. These innovative biologics differ from the reference product by offering additional clinical or non-clinical benefits. We discuss these innovative biologics with reference to CT-P13, initially available as an intravenous (IV) biosimilar of reference infliximab. A subcutaneous (SC) formulation, CT-P13 SC, has now been developed. Relative to CT-P13 IV, CT-P13 SC offers clinical benefits in terms of pharmacokinetics, with comparable efficacy, safety, and immunogenicity, as well as increased convenience for patients and reduced demands on healthcare system resources. As was once the case for biosimilars, nomenclature and regulatory pathways for innovative biologics require clarification to support their uptake and ultimately benefit patients.

Secular changes in the progression of clinical markers and patient-reported outcomes in early rheumatoid arthritis

Objectives

To examine secular trends in the progression of clinical and patient-reported outcomes in early RA.

Methods

A total of 2701 patients recruited to the Early Rheumatoid Arthritis Study or Early Rheumatoid Arthritis Network with year of diagnosis from 1986 to 2011. The 5-year progression rates for patients diagnosed at different points in time were modelled using mixed-effects regression; 1990, 2002 and 2010, were compared. Clinical markers of disease included the 28-joint count DAS and the ESR. Patient-reported markers included the HAQ, visual analogue scale of pain and global health, and the Short-Form 36.

Results

Statistically significant improvements in both 28-joint count DAS and ESR were seen over the 5 years in patients diagnosed with RA compared with those diagnosed earlier. By 5 years, 59% of patients with diagnosis in 2010 were estimated to reach low disease activity compared with 48% with diagnosis in 2002 and 32% with diagnosis in 1990. Whilst HAQ demonstrated statistically significant improvements, these improvements were small, with similar proportions of patients achieving HAQ scores of ≤1.0 by 5 years with a diagnosis in 1990 compared with 2010. Levels of the visual analogue scale and the Mental Component Scores of the Short-Form 36 indicated similar, statistically non-significant levels over the 5 years, irrespective of year diagnosed.

Conclusion

This study demonstrates improvements in inflammatory markers over time in early RA, in line with improved treatment strategies. These have not translated into similar improvements in patient-reported outcomes relating to either physical or mental health.