Effectiveness of self-management interventions in inflammatory arthritis: a systematic review informing the 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

OBJECTIVE

To perform a systematic review (SR) on the effectiveness of self-management interventions, in order to inform the European League Against Rheumatism Recommendations for its implementation in patients with inflammatory arthritis (IA).

METHODS

The SR was conducted according to the Cochrane Handbook and included adults (≥18 years) with IA. The search strategy was run in Medline through PubMed, Embase, Cochrane Library, CINAHL Plus with Full Text, and PEDro. The assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. A narrative Summary of Findings was provided according to the Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

From a total 1577 references, 57 were selected for a full-text review, and 32 studies fulfilled the inclusion criteria (19 randomised controlled trials (RCTs) and 13 SRs). The most studied self-management components were specific interactive disease education in ten RCTs, problem solving in nine RCTs, cognitive-behavioural therapy in eight RCTs, goal setting in six RCTs, patient education in five RCTs and response training in two RCTs. The most studied interventions were multicomponent or single exercise/physical activity in six SRs, psychosocial interventions in five SRs and education in two SRs. Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes.

CONCLUSIONS

The findings confirm the beneficial effect of the self-management interventions in IA and the importance of their implementation. Further research should focus on the understanding that self-management is a complex intervention to allow the isolation of the effectiveness of its different components.

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.

Disease impact of rheumatoid arthritis in patients not treated with advanced therapies; survey findings from the National Rheumatoid Arthritis Society

Objective

The aim was to reveal the everyday impact of living with RA in people not treated with advanced therapies (i.e. biologic or targeted synthetic DMARDs).

Methods

People with RA, with disease duration >2 years, not currently treated with advanced therapies, completed an online survey promoted by the National Rheumatoid Arthritis Society. Items covered demographics, current treatment, RA flare frequency, the Rheumatoid Arthritis Impact of Disease (RAID) tool and questions reflecting work status and ability. Descriptive and multivariable regression analyses were performed.

Results

There were 612 responses from patients having a mean age of 59 years, 88% female, 37.7% with disease duration 2–5 years and 27.9% with disease duration 5–10 years. In the last year, 90% reported an RA flare, with more than six flares in 23%. A RAID patient acceptable state was recorded in 12.4%. Each of the seven domains was scored in the high range by >50% respondents; 74.3% scored sleep problems and 72% fatigue in the high range. A need to change working hours was reported by 70%. Multivariable analyses revealed that increasing difficulties with daily physical activities, reduced emotional and physical well-being in the past week were all significantly associated with pain, number of flares and ability to cope (P < 0.005). The RAID score was significantly predictive of the number of flares.

Conclusion

Patients not currently treated with advanced therapies experience profound difficulties in everyday living with RA, across a broad range of measures. We advocate that patient-reported measures be used to facilitate holistic care, addressing inflammation and other consequences of RA on everyday life.

EULAR definition of difficult-to-treat rheumatoid arthritis

BACKGROUND

Despite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have 'difficult-to-treat RA'. However, uniform terminology and an appropriate definition are lacking.

OBJECTIVE

The Task Force in charge of the "Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis" aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to-treat RA, as the first step.

METHODS

The Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting).

RESULTS

The following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: (1) Treatment according to European League Against Rheumatism (EULAR) recommendation and failure of ≥2 biological disease-modifying antirheumatic drugs (DMARDs)/targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy (unless contraindicated); (2) presence of at least one of the following: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and (3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient.

CONCLUSIONS

The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.

Position Statement on Exercise Dosage in Rheumatic and Musculoskeletal Diseases: The Fole of the IMPACT-RMD Toolkit

There is convincing evidence to suggest that exercise interventions can significantly improve disease-related outcomes as well as comorbidities in rheumatic and musculoskeletal diseases (RMDs). All exercise interventions should be appropriately defined by their dose, which comprises of two components: a) the FITT (frequency, intensity, time and type) and b) the training (ie, specificity, overload, progression, initial values, reversibility, and diminishing returns) principles. In the published RMD literature, exercise dosage is often misreported, which in “pharmaceutical treatment terms”, this would be the equivalent of receiving the wrong medication dosage. Lack of appropriately reporting exercise dosage in RMDs, therefore, results in limited clarity on the effects of exercise interventions on different outcomes while it also hinders reproducibility, generalisability and accuracy of research findings. Based on the collective but limited current knowledge, the main purpose of the present Position Statement is to provide specific guidance for RMD researchers to help improve the reporting of exercise dosage and help advance research into this important field of investigation. We also propose the use of the IMPACT-RMD toolkit, a tool that can be used in the design and reporting phase of every trial.

Cardiovascular Risk in Rheumatoid Arthritis and Mechanistic Links: From Pathophysiology to Treatment

Rheumatoid arthritis (RA) is an autoimmune inflammatory arthritis. Inflammation, however, can spread beyond the joints to involve other organs. During the past few years, it has been well recognized that RA associates with increased risk for cardiovascular (CV) disease (CVD) compared with the general population. This seems to be due not only to the increased occurrence in RA of classical CVD risk factors and comorbidities like smoking, obesity, hypertension, diabetes, metabolic syndrome, and others but also to the inflammatory burden that RA itself carries. This is not unexpected given the strong links between inflammation and atherosclerosis and CVD. It has been shown that inflammatory cytokines which are present in abundance in RA play a significant role in every step of plaque formation and rupture. Most of the therapeutic regimes used in RA treatment seem to offer significant benefits to that end. However, more studies are needed to clarify the effect of these drugs on various parameters, including the lipid profile. Of note, although pharmacological intervention significantly helps reduce the inflammatory burden and therefore the CVD risk, control of the so-called classical risk factors is equally important. Herein, we review the current evidence for the underlying pathogenic mechanisms linking inflammation with CVD in the context of RA and reflect on the possible impact of treatments used in RA.

Overview of IgG4-related aortitis and periaortitis. A decade since their first description

Aortic involvement is relatively common in the context of IgG4-related disease (IgG4-RD). It includes IgG4-aortitis, and IgG4-(chronic) periaortitis (IgG4-CP). The latter overlaps with IgG4-retroperitoneal fibrosis (IgG4-RPF). Aortic wall thickening which characterizes these entities along with the presence of periaortic tissue in IgG4-CP, are often accompanied by aortic aneurysms, which belong to the group of the so-called inflammatory aneurysms. Both the thoracic and abdominal aorta can be affected. Aortitis appears to involve more often the former, while the opposite is the case for IgG4-CP. There is a lack of definitions and different classification criteria have been used to describe these entities. This report provides an overview on the current evidence of aortic involvement in IgG4-RD. It discusses the clinical, epidemiologic, serologic and histopathologic characteristics, as well as the imaging techniques used for their diagnosis and the therapeutic options and treatment outcomes. The differential diagnosis and underlying pathogenetic mechanisms are also discussed.

The clinical effectiveness of intensive management in moderate established rheumatoid arthritis: The titrate trial

OBJECTIVES

Many trials have shown that intensive management is effective in patients with early active rheumatoid arthritis (RA). But its benefits are unproven for the large number of RA patients seen in routine care who have established, moderately active RA and are already taking conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). The TITRATE trial studied whether these patients also benefit from intensive management and, in particular, achieve more remissions.

METHODS

A 12-month multicentre individually randomised trial compared standard care with monthly intensive management appointments which was delivered by specially trained healthcare professionals and incorporated monthly clinical assessments, medication titration and psychosocial support. The primary outcome was 12-month remission assessed using the Disease Activity Score for 28 joints using ESR (DAS28-ESR). Secondary outcomes included fatigue, disability, harms and healthcare costs. Intention-to-treat multivariable logistic- and linear regression analyses compared treatment arms with multiple imputation used for missing data.

RESULTS

459 patients were screened and 335 were randomised (168 intensive management; 167 standard care); 303 (90%) patients provided 12-month outcomes. Intensive management increased DAS28-ESR 12-month remissions compared to standard care (32% vs 18%, p = 0.004). Intensive management also significantly increased remissions using a range of alternative remission criteria and increased patients with DAS28-ESR low disease activity scores. (48% vs 32%, p = 0.005). In addition it substantially reduced fatigue (mean difference -18; 95% CI: -24, -11, p<0.001). There was no evidence that serious adverse events (intensive management =15 vs standard care =11) or other adverse events (114 vs 151) significantly increase with intensive management.

INTERPRETATION

The trial shows that intensive management incorporating psychosocial support delivered by specially trained healthcare professions is effective in moderately active established RA. More patients achieve remissions, there were greater improvements in fatigue, and there were no more harms.

Do Smoking and Socioeconomic Factors Influence Imaging Outcomes in Axial Spondyloarthritis? Five-Year Data From the DESIR Cohort

Objective

To investigate the relationship between smoking and imaging outcomes over 5 years in axial spondyloarthritis (SpA) and to assess whether socioeconomic factors influence these relationships.

Methods

Axial SpA patients from the Devenir des Spondylarthropathies Indifferérenciées Récentes cohort were included. The following 4 imaging outcomes were assessed by 3 central readers at baseline, 2 years, and 5 years: spine radiographs (using the modified Stoke Ankylosing Spondylitis Spine Score [mSASSS]), sacroiliac (SI) joint radiographs (using the modified New York criteria), magnetic resonance imaging (MRI) of the spine (using the Spondyloarthritis Research Consortium of Canada [SPARCC] score), and MRI of the SI joint (using the SPARCC score). The explanatory variable of interest was smoking status at baseline. Interactions between smoking and socioeconomic factors (i.e., job type [blue‐collar or manual work versus white‐collar or nonmanual work] and education [low versus high]) were first tested, and if significant, analyses were run using separate strata. Generalized estimating equations models were used, with adjustments for confounders.

Results

In total, 406 axial SpA patients were included (52% male, 40% smokers, and 18% blue collar). Smoking was independently associated with more MRI‐detected SI joint inflammation at each visit over the 5 years, an effect that was seen only in patients with blue‐collar professions (β = 5.41 [95% confidence interval (95% CI) 1.35, 9.48]) and in patients with low education levels (β = 2.65 [95% CI 0.42,4.88]), using separate models. Smoking was also significantly associated with spinal inflammation (β = 1.69 [95% CI 0.45, 2.93]) and SI joint damage (β = 0.57 [95% CI 0.18, 0.96]) across all patients, irrespective of socioeconomic factors and other potential confounders.

Conclusion

Strong associations were found between smoking at baseline and MRI‐detected SI joint inflammation at each visit over a time period of 5 years in axial SpA patients with a blue‐collar job or low education level. These findings suggest a possible role for mechanical stress amplifying the effect of smoking on axial inflammation in axial SpA.

Remission vs low disease activity: function, quality of life and structural outcomes in the Early Rheumatoid Arthritis Study and Network

Objectives

To examine associations between function, quality of life and structural outcomes in patients achieving remission vs low disease activity in early RA.

Methods

Demographic, clinical and radiographic variables were collected at baseline and then annually from the Early Rheumatoid Arthritis Study (ERAS) and Early Rheumatoid Arthritis Network (ERAN) inception cohorts in routine care from 1986 to 2012. Disease activity was categorized: mean DAS28 score between years 1 and 5: remission [mean remission DAS (mRDAS) <2.6] or low [mean low DAS (mLDAS) 2.6–3.2]; sustained low/remission DAS28 (sLDAS/sRDAS) at years 1 and 2; and sustained Boolean remission (sBR) at years 1 and 2. Changes in HAQ and Short Form 36 Health Survey Questionnaire [SF-36; physical (PCS) and mental (MCS) component score]) and total Sharp van der Heijde (SvdH) scores for each disease activity category were modelled using multi-level models. Covariates included year of onset, age, gender and DMARD use at first visit.

Results

Of 2701 patients, 562 (21%) were categorized mRDAS, 330 (12%) mLDAS, 279 (10%) sRDAS, 203 (7.5%) sLDAS and 93 (3%) sBR. Patients categorized as mRDAS had increasingly divergent improved HAQ, SF-36 PCS, MCS and total SvdH scores compared with mLDAS (P-values 0.001 to <0.0001, all time points). Patients categorized as sRDAS had better HAQ, SF-36 PCS and MCS scores (P-values 0.05 to <0.0001, all time points) and SvdH scores (P = 0.05, years 3–5) over sLDAS. sBR was associated with better HAQ, and SF-36 PCS and MCS scores over sLDAS (P-values 0.002 to <0.0001, all time points).

Conclusion

These findings from routine care support ACR/EULAR guidelines that remission is a preferable goal over low disease activity in early RA.

2019 EULAR points to consider for the assessment of competences in rheumatology specialty training

BACKGROUND AND AIM

Striving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training.

METHODS

A systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online.

RESULTS

Four overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2-4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6-8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0-10) ranged from 8.75 to 9.9.

CONCLUSION

These EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.

Work Disability in Axial Spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that typically affects people of working age. Work-related outcomes are therefore important to study, both from an individual but also a societal perspective. Through this review of the literature, we explore the impact of axSpA on key work outcomes including work and productivity loss and predictors for these.

RECENT FINDINGS

Recent evidence confirms that axSpA is associated with substantial consequences on the ability to work. Reassuringly, early treatment and use of biologics have been associated with improved wok outcomes highlighting the importance of prompt diagnosis and management. High disease activity, labour-intensive jobs, poor physical function and impaired spinal mobility are among identified predictors of adverse work outcomes in axSpA. The impact of axSpA on work outcomes is considerable and necessitates optimal intervention, including suppression of disease activity, to enhance people's chances of remaining in work.

THU0586 ESTABLISHING THE KEY COMPONENTS OF A EULAR PORTFOLIO FOR TRAINING IN RHEUMATOLOGY: A EULAR SCHOOL OF RHEUMATOLOGY INITIATIVE

Background:

In clinical training, a portfolio is expected to stimulate learning and encourage critical reflection. Some, but not all, European countries use a portfolio in rheumatology training, and their scope varies widely. A EULAR portfolio for Rheumatology trainees could contribute to improve overall training, raise educational standards, foster the setting of common goals and harmonize rheumatology training across countries.

Objectives:

Develop key components that should be included in a EULAR portfolio of Rheumatology.

Methods:

A working group (WG) composed of 9 rheumatologists and 1 educationalist was established. A systematic literature review (SLR) was conducted in November 2018, according to the PIM structure: Population: trainees; Instrument of interest: portfolio; Measurement of properties of interest: content portfolio. A survey was disseminated among the WG group and WG members of the EMerging EUlar NETwork (EMEUNET), inquiring about the content and structure of existing national portfolios. Portfolio materials of selected countries were reviewed. Last, the WG elected the key components of the portfolio.

Results:

13/2,034 articles were included in the SLR (12 high/1 moderate risk of bias). Information on direct observation of procedural skills (DOPS) (9/13), personal reflections (8/13), learning goals (5/13) and multisource feedback (5/13) were most often included in the portfolio. Twenty-five respondents filled out the survey (response rate ≈ 50%). Reflective writing (n=7), learning goals (n=4) and feedback (n=4) were considered the most useful components of a portfolio. About half indicated that a portfolio was a bureaucratic burden; 4 respondents mentioned lack of feedback by supervisors as a barrier. Portfolio materials of 7 European countries were reviewed. Several portfolios (Germany, Italy, Greece and Spain) were logbooks, i.e. a record of clinical activities. Other portfolios (UK, Denmark, The Netherlands) also included information on workplace-based assessments, learning goals, and personal reflections. The proposed key components of the portfolio are included in Table 1.

Table 1.

Key components of the EULAR portfolio of Rheumatology.

Key componentContentCurriculum vitaePersonal record of achievements, experiences, knowledge and skillsPersonal Development PlanLearning goals and action planClinical workInformation on managing patients (e.g. rheumatoid arthritis)Skills (e.g. joint aspiration)Assessments (summative and formative)Personal reflectionsProfessional behaviourMultisource feedbackPersonal reflectionsEducationContinuing professional development, list of formal and non-formal learning activitiesAssessments (e.g. teaching assessment, evidence based medicine assignment)Personal reflectionsResearchList of abstracts, published articlesInformation on research funding, scholarships, bursaries, academic posts

Conclusion:

This initiative resulted in the establishment of a list of key components to be included in a EULAR portfolio of Rheumatology. Assessment forms for each key portfolio component are currently being developed. Portfolio implementation, particularly in countries that do not use it yet, may contribute significantly to promote a higher standard of patient care across Europe.

Disclosure of Interests:

Marloes van Onna: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Catherine Haines: None declared, M. Holland-Fischer: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Jean Dudler: None declared, Christopher Edwards Grant/research support from: Abbvie, Biogen, Roche, Consultant of: Abbvie, Samsung, Speakers bureau: Abbvie, BMS, Biogen, Celgene, Fresenius, Gilead, Janssen, Lilly, Mundipharma, Pfizer, MSD, Novartis, Roche, Samsung, Sanofi, UCB,

Alessia Alunno: None declared, Elena Nikiphorou: None declared, L. Falzon: None declared, Francisca Sivera: None declared

AB0673 SHINING LIGHT ON AXIAL SPONDYLOARTHRITIS: DISEASE ACTIVITY AND VITAMIN D. WHAT’S THE LINK?

Background:

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease predominantly involving the axial skeleton and sacroiliac joints. Although the exact aetiology remains largely unknown, there is thought to be an immune-driven element. Vitamin D deficiency has been associated with a number of autoimmune diseases and is thought to play an important role in modulating the immune system. Low vitamin D levels may contribute to the development and progression of axSpA1.

Objectives:

To study the possible associations between low vitamin D and disease activity in axSpA.

Methods:

A systematic literature search using Medline, Embase and Cochrane was performed using MESH search terms “ankylosing spondylitis”, “axial spondyloarthropathy” and “vitamin D”. Articles examining disease activity measured by BASDAI, ASDAS-CRP, ESR and CRP identified through title/abstract screening, were included in the study, with relevant information extracted.

Results:

Out of 495 articles identified from the initial search, 19 observational studies which were mostly (89%) cross-sectional studies were identified. There was considerable heterogeneity between studies, including in the definition of vitamin D deficiency, latitude where study took place and seasonal variation. Vitamin D levels were often lower in patients with axSpA compared to controls. Seventeen studies found no association with vitamin D deficiency and disease activity. The exceptions included one study which measured serum vitamin D receptor levels as opposed to serum 25 (OH) D or 1,25 (OH)2 D concentrations, and another study whose recruitment occurred over four years and therefore seasonal variation may conflict results. Patients taking NSAIDs or anti-TNF had no difference in vitamin D levels.

Conclusion:

Vitamin D deficiency is more prevalent in axSpA but does not seem to associate with increased disease activity. Longitudinal studies are required to better define these links.

References:

[1]Sizheng Z, et al. Systematic review of association between vitamin D levels and susceptibility and disease activity of ankylosing spondylitis. Rheumatology 2014; 53:1595-1603.

Disclosure of Interests:

None declared

SAT0056 INITIAL PRESENTATION OF RHEUMATOID ARTHRITIS (RA) – IS IT STILL “SYMMETRIC POLYARTHRITIS”?

Background:

RA is traditionally described as a symmetric polyarthritis. The ACR/EULAR 2010 criteria are met if patient has high positive ACPA, symptoms >=6 wks and one small joint swollen. The public and all steps of health care have been informed for many years that RA should be found early.

Objectives:

To study variations in pattern on first presentation of RA.

Methods:

All patients with the new diagnosis of RA were extracted from the GoTreatIT clinical database between 2008 to 2019 at a single RA clinic that covers a population of 250.000. Demographic data, clinical variables, labs, x-rays, joint status and PROs at baseline were included in the analysis. Appropriate parametric/non-parametric tests were used to study differences between groups.

Results:

A total of 1044 (73.5% CCP+) patients with no prior diagnosis of RA were included; 683 (65%) female, mean age 56; 361 (35%) male, mean age 61. At initial presentation in 2008, 60% had >=6 swollen joints (Figure) and a mean DAS28 of 4.4 compared to 22% and 3.8 respectively, in 2019 (p<0.007). Duration of symptoms prior to diagnosis decreased from 6 to 4 months (p=0.033), and the proportion of patients with erosions from 20% in 2008 to 14% in 2019 (ns). Symptoms (PROs) such as pain, fatigue and global health were similar/slightly worse in 2019 compared to 2008.

Conclusion:

RA cannot be marketed as “symmetric polyarthritis”, as more than half of the patients have a maximum of 2 swollen joints at the time of the diagnosis at the most recent years. Patients with RA can be identified earlier, with less disease activity and damage, compared to previous years.

Figure:

Disclosure of Interests:

None declared

AB1362-HPR COMMON PRACTICE IN DELIVERY OF INTRA-ARTICULAR THERAPIES IN RMDS BY HEALTH PROFESSIONALS: RESULTS FROM A EUROPEAN SURVEY

Background:

Intra-articular therapies (IAT) are routinely used in rheumatic and musculoskeletal diseases (RMDs); however large variability exists regarding current practice of delivery amongst health professionals.

Objectives:

To inquire about common practice aspects to inform the EULAR Taskforce for the IAT of arthropathies.

Methods:

A steering committee prepared a 160-item questionnaire based on the information needs of the Taskforce. The survey was disseminated via EULAR professional associations and social media and it was open to any health professional treating persons with RMDs, regardless of using IAT personally.

Results:

The survey was answered by 186 health professionals from 26 countries, the large majority of whom (77%) were rheumatologists, followed by nurses (12%), general practitioners (2%) and orthopaedic surgeons (2%). The two collectives that perform IAT routinely are rheumatologists (97%) and orthopaedic surgeons (89%), with other professionals <50%. Specific training was compulsory for 32%. The most frequent indication for IAT is inflammatory arthritis (76%), followed by osteoarthritis (74%), crystal arthritis (71%) and bursitis (70%); and all joints are injected, with knee (78%) and shoulder (70%) being the most frequent. When questioned about specific contexts, such as pre-surgical, diabetic or hypertensive patients, variability among respondents was evident, with around 30 to 69% of professionals considering it acceptable to inject glucocorticoids (GC), while in others there was less variability (prosthetic or septic joints, <1%). GCs are the most used compounds, followed by hyaluronic acid and saline/dry puncture. Only 66 (36%) use ultrasound to guide IAT. In their opinion, to be accurately in the joint is moderately to largely important for large joints (80%) and very important in small joints. The maximum number of injections to perform safely in the same joint within one year was “2 to 3” for 65% (2% thought there is “No limit”). The majority reported that they informed patients about side-effects (73%), benefits (72%), and the nature of the procedure (72%), and less frequently about other aspects; with 10% obtaining written consent and 56% oral consent (mandatory only for 32%). Other questions help to understand the setting and procedures followed, including use of local anaesthetics and care after injection.

Conclusion:

Although often performed in clinical practice for RMDs, there is apparent variability in several elements related to delivery of this treatment. This information, together with patient input, will help design current recommendations where research evidence is not available.

Acknowledgments:

Eular Taskforce grant CL109

Disclosure of Interests:

Jenny de la Torre-Aboki: None declared, IRENE Pitsillidou: None declared, Jacqueline Uson Jaeger: None declared, Esperanza Naredo: None declared, Lene Terslev: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Hemant Pandit Grant/research support from: Glaxo Smith Kline (GSK) for work on Diclofenac Gel, Speakers bureau: Bristol Myers Squibb for teaching their employees about hip and knee replacement, Ingrid Möller: None declared, Maria Antonietta D’Agostino Consultant of: AbbVie, BMS, Novartis, and Roche, Speakers bureau: AbbVie, BMS, Novartis, and Roche, Willm Uwe Kampen: None declared, Terence O’Neill: None declared, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Francis Berenbaum Grant/research support from: TRB Chemedica (through institution), MSD (through institution), Pfizer (through institution), Consultant of: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Bone Therapeutics, Regulaxis, Peptinov, 4P Pharma, Paid instructor for: Sandoz, Speakers bureau: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Sandoz, Valentina Vardanyan: None declared, Elena Nikiphorou: None declared, Sebastian C Rodriguez-García Speakers bureau: Novartis Farmaceutica, S.A., Merck Sharp & Dohme España, S.A., Sanofi Aventis, UCB Pharma, Raul Castellanos-Moreira: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)