Development and testing of a bespoke cultural intervention to support healthcare professionals with patients from a diverse background

OBJECTIVE

Development and test of a culturally sensitive intervention for rheumatology healthcare professionals (HCPs).

METHODS

Using a before and after study design, 15 HCPs were recruited to undertake the bespoke intervention from four National Health Service sites across England, in areas serving a diverse population. The intervention was evaluated using two validated outcomes: (i) Patient Reported Physician Cultural Competency (PRPCC); and (ii) Patient Enablement Instrument (PEI), measuring patients' perceptions of their overall healthcare delivery. Additionally, HCPs completed the COM-B questionnaire for capability (C), opportunity (O) and motivation (M) to perform behaviour (B), measuring behaviour change.

RESULTS

Two hundred patients were recruited before HCPs undertook the intervention (cohort 1), and 200 were recruited after (cohort 2) from 15 HCPs; after exclusions 178 patients remained in cohort 1 and 186 in cohort 2. Sixty percent of patients identified as white in both recruited cohorts, compared with 29% and 33% of patients (cohorts 1 and 2, respectively) who identified as being of South Asian origin. After the intervention, the COM-B scores indicated that HCPs felt more skilled and equipped for consultations. No significant differences were noted in the average overall cultural competency score between the two cohorts in white patients (57.3 vs 56.8, P = 0.8), however in the South Asian cohort there was a statistically significant improvement in mean scores (64.1 vs 56.7, P = 0.014). Overall, the enablement score also showed a statistically significant improvement following intervention (7.3 vs 4.3, P < 0.001) in the white patients and in the South Asian patients (8.0 vs 2.2, P < 0.001).

CONCLUSION

This novel study provides evidence for improving cultural competency and patient enablement in rheumatology settings.

Clinical efficacy of JAK inhibitors on enthesitis in spondyloarthropathy: A scoping literature review

BACKGROUND

Enthesitis is a key feature of spondyloarthropathy (SpA). In recent years, JAK inhibitors have emerged as efficacious drugs in the landscape of advanced therapies for patients with SpA.

METHOD

The aim of this scoping literature review was to search the published literature for studies on JAK inhibitors and their effects on enthesitis in patients with SpA and evaluate the data and summarise the findings. The clinical trials reviewed used the Leeds Enthesitis Index, Spondyloarthritis Research Consortium of Canada Enthesitis Index, and Maastrich Ankylosing Spondylitis Enthesitis Score as outcome measures.

RESULTS

Tofacitinib, upadacitinib, and filgotinib had numerically greater reductions in the enthesitis scores when compared with placebo.

CONCLUSION

While the JAK inhibitors are therapeutic options for enthesitis in SpA, head-to-head studies are needed to compare the JAK inhibitors against the biological drugs (targeting TNF, IL-17, and IL-12/23) as well as studies showing the effects of JAK inhibitors on enthesitis imaging.

Ethnic differences in cellular and humoral immune responses to SARS-CoV-2 vaccination in UK healthcare workers: a cross-sectional analysis

Background

Few studies have compared SARS-CoV-2 vaccine immunogenicity by ethnic group. We sought to establish whether cellular and humoral immune responses to SARS-CoV-2 vaccination differ according to ethnicity in UK Healthcare workers (HCWs).

Methods

In this cross-sectional analysis, we used baseline data from two immunological cohort studies conducted in HCWs in Leicester, UK. Blood samples were collected between March 3, and September 16, 2021. We excluded HCW who had not received two doses of SARS-CoV-2 vaccine at the time of sampling and those who had serological evidence of previous SARS-CoV-2 infection. Outcome measures were SARS-CoV-2 spike-specific total antibody titre, neutralising antibody titre and ELISpot count. We compared our outcome measures by ethnic group using univariable (t tests and rank-sum tests depending on distribution) and multivariable (linear regression for antibody titres and negative binomial regression for ELISpot counts) tests. Multivariable analyses were adjusted for age, sex, vaccine type, length of interval between vaccine doses and time between vaccine administration and sample collection and expressed as adjusted geometric mean ratios (aGMRs) or adjusted incidence rate ratios (aIRRs). To assess differences in the early immune response to vaccination we also conducted analyses in a subcohort who provided samples between 14 and 50 days after their second dose of vaccine.

Findings

The total number of HCWs in each analysis were 401 for anti-spike antibody titres, 345 for neutralising antibody titres and 191 for ELISpot. Overall, 25.4% (19.7% South Asian and 5.7% Black/Mixed/Other) were from ethnic minority groups. In analyses including the whole cohort, neutralising antibody titres were higher in South Asian HCWs than White HCWs (aGMR 1.47, 95% CI [1.06-2.06], P = 0.02) as were T cell responses to SARS-CoV-2 S1 peptides (aIRR 1.75, 95% CI [1.05-2.89], P = 0.03). In a subcohort sampled between 14 and 50 days after second vaccine dose, SARS-CoV-2 spike-specific antibody and neutralising antibody geometric mean titre (GMT) was higher in South Asian HCWs compared to White HCWs (9616 binding antibody units (BAU)/ml, 95% CI [7178-12,852] vs 5888 BAU/ml [5023-6902], P = 0.008 and 2851 95% CI [1811-4487] vs 1199 [984-1462], P < 0.001 respectively), increments which persisted after adjustment (aGMR 1.26, 95% CI [1.01-1.58], P = 0.04 and aGMR 2.01, 95% CI [1.34-3.01], P = 0.001). SARS-CoV-2 ELISpot responses to S1 and whole spike peptides (S1 + S2 response) were higher in HCWs from South Asian ethnic groups than those from White groups (S1: aIRR 2.33, 95% CI [1.09-4.94], P = 0.03; spike: aIRR, 2.04, 95% CI [1.02-4.08]).

Interpretation

This study provides evidence that, in an infection naïve cohort, humoral and cellular immune responses to SARS-CoV-2 vaccination are stronger in South Asian HCWs than White HCWs. These differences are most clearly seen in the early period following vaccination. Further research is required to understand the underlying mechanisms, whether differences persist with further exposure to vaccine or virus, and the potential impact on vaccine effectiveness.

Funding

DIRECT and BELIEVE have received funding from UK Research and Innovation (UKRI) through the COVID-19 National Core Studies Immunity (NCSi) programme (MC_PC_20060).

An update on the considerations for patients with rheumatic disease being treated with rituximab during the COVID-19 pandemic and the potential drug treatment strategies

INTRODUCTION

Over the last two decades, rituximab has become an increasingly popular drug in the treatment of a wide range of rheumatic diseases. However, with the advent of the COVID-19 pandemic, clinicians face challenges in weighing risk against benefit in its use.

AREAS COVERED

A review of existing data was performed to examine the relationship between rituximab use, morbidity and mortality from COVID-19, and vaccine efficacy in patients with rheumatic diseases, aiming to guide clinicians in continued use of the medication and consider the direction of future research. A literature review was performed through a search of the PubMed database, using the terms ((SARS-CoV-2) OR (COVID-19)) AND (rituximab) AND (rheumatic), which generated an initial 55 results, with relevant articles then selected for inclusion.

EXPERT OPINION

In order to safeguard patients with an ongoing need for rituximab therapy, vaccination remains the primary concern. A target of performing booster doses 6 months after last rituximab dose is a reasonable estimate, which may be made more precise by use of B cell counts, although primary immunization should not be delayed. In those patients who remain seronegative, the use of newer antivirals and broadly neutralizing antibody infusions may help provide further safeguards.

P32 Therapeutic dilemma due to gut complications with spondyloarthritis

Introduction/Background

Tumor necrosis factor (TNF) inhibitor therapy is one of the primary modalities of treating spondyloarthritis. However, infections secondary to biologic use is a common complication. Clostridium difficile is a gut colonizer which may become pathogenic in the presence of dysbiosis and antibiotic use. Symptomatic clostridium difficile infection(CDI) due to adalimumab(ADA) use causing lymphocytic colitis(LC) is rarely reported. We present a case of axial plus peripheral spondyloarthritis on adalimumab who developed CDI and presented a therapy related dilemma.

Description/Method

We present a case of a 52-year-old lady who was diagnosed as HLAB27 positive axial spondyloarthritis with bilateral sacroiliitis on MRI bilateral sacroiliac joint in 2016. She failed two non-steroidal antinflammatory drugs (NSAID) with high disease activity scores(BASDAI 8.6, BASFI 6.2, Spinal VAS 9). She was eventually initiated on injection adalimumab in 2017. There was clinical improvement after 6 months of initiating ADA. Repeat MRI spine and SI joint showed resolution of inflammatory changes with adalimumab. Sulfasalazine was added in the treatment protocol due to peripheral arthralgia, however she developed a drug rash to it and it was stopped. In September 2021, she developed recurrent non-bloody watery diarrhoeal episodes. Adalimumab was stopped and she tested positive for Clostridium difficile on three occasions. She received multiple courses of vancomycin, fidoxamycin and metronidazole with partial resolution of diarrhoea. Adalimumab was rechallended in January 2022 since her disease activity was worsening in the absence of NSAID and biologic use. However, it was paused again due to worsening of diarrhoea. Gastroenterology conducted a Colonoscopy and biopsy of colonic polyps which showed increased number of intraepithelial lymphocytes with no thickening of subepithelial collagen plate suggestive of lymphocytic colitis (LC). It was postulated that CDI may have been the trigger for her LC. She has been started on local corticosteroid therapy(budesonide) for her LC. At this junction, we were faced with the decision of restarting adalimumab for her which may have been the original cause of her CDI.

Discussion/Results

We present this case in view of a dilemma regarding which problem occurred first Did immunosuppression due to adalimumab lead to CDI? Literature is not suggestive of increased risk of CDI with adalimumab, especially in a non-inflammatory bowel disease (IBD) background. Was the lymphocytic colitis triggered by the CDI or was clostridium difficile just incidentally detected on a background of LC? There is a well documented associated of LC with autoimmune conditions and use of NSAIDs along with proton pump inhibitor is another trigger for it. TNF alpha inhibitor is one of the treatment modalities of refractory LC. Would it be appropriate to restart ADA for her since she responded well despite there being a risk of recurrence of a CDI? Finally, what is the role of gut dysbiosis in the role of CDI and LC in this situation. Presently, she is planned to be treated with local steroid therapy for her LC. ADA will be rechallenged once her gut has responded to the steroid course. In the event of her gut worsening on a rechallenge, she will be given a trial of Infliximab.

Key learning points/Conclusion

The case highlights the crucial point of thinking of causes of diarrhea apart from well documented conditions of ulcerative colitis/Crohn’s disease in an immunosuppressed spondyloarthritis patient. A detailed stool examination including bacterial and parasitic examination is crucial in recurrent diarrhea. The threshold for colonoscopy should be low when episodes are refractory to treatment. The case-based conference gives us an opportunity to receive feedback regarding further management approaches in this case.

P26 Challenging Scenario: Scleroderma/Sjogren overlap with dysautonomia

Introduction/Background

Scleroderma Overlap conditions are well defined and often behave differently than their limited or diffuse counterparts. The treatment for such patients is usually tailored around the organ system involvement and severity. We present a challenging case of Scleroderma/Sjogren overlap with refractory Raynaud's phenomenon who posed treatment challenges due to severe autonomic dysfunction.

Description/Method

76-year-old Caucasian lady, non-smoker, who presented in 1990’s with dry eyes, dry mouth and severe Raynaud's phenomenon with recurrent digital ulceration which became infected on multiple occasions. ANA was 1:400 with Extractable nuclear antigen Ro and La positive. Anti DsDNA was negative and C4 was low. Antiphospholipid antibodies and cryoglobulins are negative. She failed calcium channels blockers and phosphodiesterase 5 inhibitors and was intolerant to intravenous (IV) Iloprost which was tried on multiple occasions. IV latanoprost was tried as well. This treatment was complicated when she developed postural hypotension and multiple fall episodes during vasodilator use. This was attributed to autonomic dysfunction secondary to her Sjogren syndrome. She was initiated on Injection Fludrocortisone, however her hypotensive episodes continued. She received monthly intravenous immunoglobulins 20gm (over two days) infusion for a few months for autonomic dysfunction with some response. She eventually developed recurrent diarrhoea and abdominal pain and bloating which was attributed to small bowel overgrowth with rapid bowel transit on a gastric emptying scan. She had a blocked bile duct as well which was unblocked using Endoscopic Retrograde Cholangiopancreatography. Over the next 8 years, she continued struggling with refractory Raynaud’s, having failed IV regional guanethidine blocks and digital sympathectomy. Her postural hypotension decompensated on multiple occasions necessitating plasmapheresis which provided some benefit. In 2020, she was detected to have a PET avid slowly progressing left upper lobe lung lesion. She underwent left video assisted thoracoscopy surgery with upper lobectomy. Histology was suggestive of adenocarcinoma. In 2021, she had another fall episode due to an acute/subacute infarct of left pons. She continues having postural hypotension and requires regular plasmapheresis sessions to manage her symptoms. She is also presently on Bosentan for her raynaud’s phenomenon.

Discussion/Results

This is a case of overlap of Sjogren syndrome with scleroderma features. Management of Refractory Raynaud’s as part of her scleroderma phenotype was challenging. This case gave us the opportunity to explore all the treatment options available for Raynaud’s phenomenon albeit with poor outcome. She also struggled with autonomic dysfunction leading to postural hypotension and gastrointestinal symptoms which can be seen in upto 50% of patients with Sjogren syndrome. Autonomic failure is often thought to be immune mediated in Sjogren syndrome. This makes way for the use of intravenous immunoglobulin and plasmapheresis to treat these conditions as was done in this case. Increased risk of lung carcinoma with scleroderma is well documented. Autonomic dysfunction can also present as paraneoplastic syndrome with lung carcinoma, however it is more common with small cell lung carcinoma and our patient was diagnosed with Adenocarcinoma. We would have to wait and see if the resection of the tumour has any demonstrable effect on her dysautonomia.

Key learning points/Conclusion

Overlap connective tissue diseases are often difficult to manage in view of extensive disease heterogeneity. Clinicians need to be aware of challenges in managing Difficult Raynaud’s with Autonomic dysfunction. Treating physicians need to be aware of the high risk of lung malignancy and regular close monitoring is required. This case-based conference gives us the opportunity to discuss further management approaches for her.

AB1439 IS THERE AN INCREASED PREVALENCE OF DIABETES MELLITUS IN THE AXIAL SPONDYLOARTHROPATHY PATIENT GROUP: A REVIEW FROM A UK TEACHING HOSPITAL SPONDYLOARTHROPATHY SERVICE

Background

The prevalence of diabetes mellitus (DM) has often been found to be increased in patients with axial spondyloarthropathy (axSpA) compared to the general population. However, studies conducted in the United Kingdom (UK) have found varying results with regards to prevalence. One study1 found that 5% of patients with axSpA had DM, compared to 4% of patients without axSpA and another UK study2 reported that although findings showed a 1.8% increase in DM in patients with axSpA compared to controls, this result was not significant. There is also the influence of ethnicity to consider as DM is more prevalent in the Asian and Afro-Caribbean population. Therefore, it is evident that more research is required into the relationship between DM and axSpA.

Objectives

This study aims to investigate the correlation between DM and axSpA, and also explore the influence of ethnicity on DM and axSpA.

Methods

Retrospective analysis was carried out for axSpA patients attending University Hospitals of Leicester axSpA services. Inclusion criteria entailed an axSpA diagnosis and a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) within a year of MRI spine and sacroiliac joints before starting biological therapy. Patients were excluded if they had an active infection or malignancy, BASDAI was not documented before starting biological therapy or within a year of MRI, or if clinical information was not able to be obtained. Data was obtained from electronic medical records, including age, gender, ethnicity, date of diagnosis of axSpA and DM, and cardiovascular comorbidities.

Results

Of the 149 patients, 8 (5.37%) had a diagnosis of DM. 4 (50%) of these patients were diagnosed with DM prior to diagnosis of axSpA, and 4 (50%) were diagnosed with DM post diagnosis of axSpA. Differences in ethnicity were analysed. Of the 149 axSpA patients, 102 (68.46%) were Caucasian, 45 (30.20%) were Asian, and 2 (1.34%) were Afro-Caribbean. Of the 102 Caucasian patients, 3 (2.94%) had DM, of whom 1 was diagnosed with axSpA prior to diagnosis of DM. Of the 45 Asian patients, 5 (11.11%) had DM, of whom 3 were diagnosed with axSpA prior to diagnosis of DM. Looking at cardiovascular comorbidities, of the 8 patients with axSpA and DM, 2 (25%) had hypertension, and were both diagnosed with axSpA prior to diagnosis of DM.

Conclusion

This small study has found a similar prevalence of DM in patients with axSpA (5.37%) compared to the general UK population (6%), which contrasts with published international studies which have found a higher prevalence of DM in the axSpA group. However, the study did find a higher prevalence in the Asian population (11.11%) which is in keeping with ethnic variation for DM. Larger epidemiological studies are needed to understand the reason for reported higher prevalence of DM in patients with axSpA in other countries compared to the UK.

References

[1]Dregan A, Chowienczyk P, Molokhia M. Cardiovascular and type 2 diabetes morbidity and all-cause mortality among diverse chronic inflammatory disorders. Heart (British Cardiac Society). 2017;103(23):1867-1873.

[2]Ahmed N, Prior JA, Chen Y, Hayward R, Mallen CD, Hider SL. Prevalence of cardiovascular-related comorbidity in ankylosing spondylitis, psoriatic arthritis and psoriasis in primary care: a matched retrospective cohort study. Clinical Rheumatology. 2016;35(12):3069-3073.

Disclosure of Interests

None declared

POS1275 A RETROSPECTIVE STUDY ON UVEITIS FLARES FOLLOWING COVID19 VACCINATION: SHARING EXPERIENCE FROM A TEACHING HOSPITAL COMBINED RHEUMATOLOGY AND UVEITIS CLINIC

Background

Uveitis is a sight threatening disease caused by inflammation of the uveal tract of the eye. Uveitis is a manifestation of many autoimmune conditions and is associated with seronegative axial spondyloarthritis, reactive arthritis, Behçet’s disease, inflammatory bowel disease, and psoriatic arthritis. Acute anterior uveitis is the most common presentation and is most commonly idiopathic or associated with the HLA-B27 gene (around 20% of cases). Studies have shown that anterior uveitis frequently recurs in patients after it has previously remitted. (1) Patients suffering from autoimmune conditions are frequently prescribed immunosuppressant drugs to control their illness, thus leaving them more susceptible to bacterial and viral illnesses including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Previous studies have shown that some patients suffer exacerbation of their autoimmune condition after coronavirus vaccination, including uveitis(2). We aim to evaluate our cohort of patients suffering from autoimmune conditions treated at Leicester Uveitis Service at Leicester Royal Infirmary and explore any proposed link.

Objectives

To assess if COVID19 vaccination is associated with uveitis flares in immunosuppressed patients.

Methods

A retrospective study, to determine if patients diagnosed with autoimmune conditions suffered from uveitis following COVID-19 vaccination. A data collection sheet was used to document demographic and clinical data: age, sex, ethnicity, autoimmune condition, dates of COVID-19 vaccination(s), type of vaccine, medication at the time of vaccine, symptoms of autoimmune recurrence, date of uveitis onset and number of days between uveitis onset and latest vaccine. We used an already existing uveitis database with an active register of 2346 patients, of which 246 were on immunomodulation.

Results

After reviewing the first 50 patients on immunosuppression for uveitis, we found a total of 4 patients had a uveitis flare despite tight control previously; 3 are female and 1 male, their median age was 39.5 years. They experienced a recurrence of uveitis in the last 6 months. Of these 4 patients 3 were on synthetic DMARDS (2 mycophenolate mofetil, 1 azathioprine), 1 was on steroids and 1 was on a biological DMARD (adalimumab). 2 of the patients suffered from posterior uveitis and 2 from anterior uveitis. All the 50 patients had been vaccinated against COVID19 however there was no clear record of booster dose.

Conclusion

Our study showed that of 50 immunosuppressed patients, 4 had a uveitis flare following vaccination. Clinicians need to be aware of uvetis flares in rheumatology patients following vaccination. This is a small retrospective analysis of our cohort however a large observational study on flare of uveitis following COVID-19 primary vaccination and booster vaccination would be useful to get meaningful data.

References

[1]Grunwald L, Newcomb CW, Daniel E, Kaçmaz RO, Jabs DA, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Kempen JH; Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Risk of relapse in primary acute anterior uveitis. Ophthalmology. 2011 Oct;118(10):1911-5. doi: 10.1016/j.ophtha.2011.02.044. Epub 2011 Jun 16. PMID: 21680024; PMCID: PMC3179829.

[2]Bolletta E, Iannetta D, Mastrofilippo V, De Simone L, Gozzi F, Croci S, Bonacini M, Belloni L, Zerbini A, Adani C, Fontana L, Salvarani C, Cimino L. Uveitis and Other Ocular Complications Following COVID-19 Vaccination. J Clin Med. 2021 Dec 19;10(24):5960. doi: 10.3390/jcm10245960. PMID: 34945256; PMCID: PMC8704915.

Disclosure of Interests

None declared

Complications of an uncovered metallic tracheal stent managed by veno-venous extracorporeal membrane oxygenation: a case report

Airway stents are primarily inserted for the management of airway obstruction associated with an inoperable malignancy and are rarely indicated in benign disease. We outline the complications associated with tracheal stents and describe the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) to facilitate open tracheal surgery in an apnoeic patient who had an uncovered metallic tracheal stent left in place for an inappropriately long period. Computerised tomography imaging of the neck and thorax provided information for operative planning and described of the stent in addition to the extensive granulation tissue at the distal end of the stent. Veno-venous extracorporeal membrane oxygenation was used to facilitate open tracheal surgery, removal of the tracheal stent and formation of a surgical tracheostomy. Prolonged use of an uncovered metallic airway stent in younger patients with benign disease may lead to the stent being difficult to remove. There may be an accumulation of granulation tissue with the risk of airway obstruction.

AB0873 Ethnicity and patient reported outcome BASDAI in the monitoring of axial spondyloarthropathy: Does it matter?

Background

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is a patient reported outcome (PRO) used in the monitoring of axial spondyloarthropathy (axSpA). It is completed by the patient and based on their assessment of disease severity and therefore quite a subjective measure of disease (1). There has been research around the relationship between ethnicity and patient perception in Rheumatology. Many studies have demonstrated that non-Caucasian patients especially South Asians are less likely to engage with patient education, abandon their disease modifying therapy early and have more mistrust with the medical establishment (2). Quite a large population study in America examining axSpA severity in Caucasians, Afro-Caribbean’s and Latinos found Afro-Caribbean and Latino patients to score themselves higher on BASDAI compared to Caucasians (3).

With Leicester being such a diverse area, with a particularly high South Asian population we took this opportunity to investigate whether there were ethnic variations in disease severity.

Objectives

The aim was to investigate whether there is a relationship between patient-reported outcome BASDAI and ethnicity. The secondary aim was to investigate the relationship between ethnicity and radiographic findings and extra-articular manifestations.

Methods

Data was collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. Inclusion criteria entailed a diagnosis of axSpA with a documented BASDAI within a year of MRI spine + sacroiliac joints, prior to starting any biological treatment.

Data of 149 patients was collected on demographic characteristics, extra-articular manifestations (uveitis, inflammatory back pain, enthesitis, peripheral arthritis, dactylitis, psoriasis, and inflammatory bowel disease), family history, response to NSAIDs, and HLA-B27 status.

Data was analysed using Statistical Package for the Social Sciences (SPSS) software to assess the relationship between ethnicity and collected data using Pearson’s chi squared.

Results

Of the 149 patients 68% were White Caucasian, 30% Asian and 1% Black. The average age was 43 and 66% were male and 34% female. The mean BASDAI was 6.5, there was no observable correlation between BASDAI and ethnicity (p=0.668).

There was no significant relationship between ethnicity and active sacroiliitis (p=0.926), chronic sacroiliitis (p= 0.218) or axial disease (p=0.307). 64 Caucasian patients were HLA-B27 positive compared with 27 Asian and no Black patients were positive however there was no statistical correlation between ethnicity and HLA-B27 (p=0.383). Overall, Caucasians consistently had a greater incidence of extra-articular manifestations compared with non-Caucasians however no significant p values were observed here or with response to NSAIDs, family history or familial HLA-B27 and BASDAI scores, results are summarised in Table 1.

Table 1.

Correlation with ethnicity and extra-articular manifestations, family history and HLA-B27.

Number of patientsCorrelation with ethnicityUveitis36p=0.470Peripheral arthritis24p=0.304Enthesitis22p=0.959Psoriasis7p=0.062Inflammatory bowel disease7P=0.947Dactylitis6P=0.173HLA-B27103p=0.383Inflammatory back pain139p=0.062Response to NSAIDs46p=0.718Family history of axSpA20p=0.800HLA-B27 in family10p=0.221

HLA-B27= Human leukocyte antigen B27, NSAIDs= non-steroidal anti-inflammatory drugs, axSpA= Axial Spondyloarthropathy.

Conclusion

This study did not demonstrate statistically significant finding of ethnic variations in BASDAI. There was also no relationship between ethnicity and other data sets. However, the main limitation of this study is the sample size and unequal representation of ethnicities with there being far more Caucasians than non-Caucasian patients. Though this study provides an insight into quite a limited area of research, a larger study with equal ethnic patient population samples is required to obtain more meaningful results.

References

[1]Zochling J. Measures of symptoms and disease status in ankylosing spondylitis: Ankylosing Spondylitis Disease Activity Score (ASDAS), Ankylosing Spondylitis Quality of Life Scale (ASQoL), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Global Score (BAS-G), Bath Ankylosing Spondylitis Metrology Index (BASMI), Dougados Functional Index (DFI), and Health Assessment Questionnaire for the Spondylarthropathies (HAQ-S). Arthritis Care Res (Hoboken). 2011;63(11):47-58.

[2]Kumar K, Klocke R. Ethnicity in rheumatic disease. Clin Med (Lond). 2010;10(4):370-372.

[3]Jamalyaria F, Ward M, Assassi S, Learch T, Lee M. Gensler L et al. Ethnicity and disease severity in ankylosing spondylitis a cross-sectional analysis of three ethnic groups. Clin Rheumatol. 2017;36(10):2359-2364.

Disclosure of Interests

None declared

Cannabinoids in rheumatology: Friend, foe or a bystander?

OBJECTIVES

Cannabinoids have gained popularity recently with special emphasis on their use for chronic pain. Although NICE guidelines advise against their usage for management of chronic pain, almost all rheumatologists encounter a few patients in their daily practice who either use them or are curious about them. We reviewed the mechanism of action of cannabinoids, current knowledge about their role in rheumatology and potential drug interactions with common drugs used in Rheumatology. We attempted to answer the question "If cannabinoids are friend, foe or just a mere bystander?"

METHODS

We adhered to a search strategy for writing narrative reviews as per available guidelines. We searched PubMed with the search terms "Cannabinoids", "Rheumatology" and "Chronic pain" for published articles and retrieved 613 articles. The abstracts and titles of these articles were screened to identify relevant studies focusing on mechanism of actions, adverse effects and drug interactions. We also availed the services of a musculoskeletal librarian.

RESULTS

Despite the NHS guidelines against the usage of cannabinoids and associated significant stigma, cannabinoids are increasingly used for the management of pain in rheumatology without prescription. Cannabinoids act through two major receptors CB1 and CB2, which are important modulators of the stress response with potential analgesic effects. Their role in various rheumatological diseases including Rheumatoid arthritis, Osteoarthritis and Fibromyalgia have been explored with some benefits. However, in addition to the adverse effects, cannabinoids also have some potential interactions with common drugs used in rheumatology, which many users are unaware of.

CONCLUSION

While the current studies and patient reported outcomes suggest cannabinoids to be a "friend" of rheumatology, their adverse events and drug interactions prove to be a "Foe". We were unable to arrive at a definite answer for our question posed, however on the balance of probabilities we can conclude cannabinoids to be a "foe". Under these circumstances, a disease and drug focussed research is need of the hour to answer the unresolved question.

P269 Is there a correlation between ethnicity and severity of axial spondyloarthropathy?

Background/Aims

Axial spondyloarthropathy (axSpA) is more prevalent in the Caucasian population. This is in part due to genetics; HLA-B27, the main contributing gene, is more prevalent in the Caucasian population, with up to 90% of patients being positive. Incidence is much lower in the Asian and Black population. There are few studies which have compared the relationship between ethnicity and severity of axSpA. Existing studies show that, despite lower incidence of HLA-B27, Black patients actually suffer more severe disease. However, there are few studies investigating the relationship in the Asian population. With Leicester, UK being such a diverse area, we took this opportunity to investigate the correlation between ethnicity and severity of axSpA, including radiographic and extra-articular manifestations.

Methods

Data was collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. Inclusion criteria entailed a diagnosis of axSpA with a documented BASDAI within a year of MRI spine and sacroiliac joints, prior to starting any biological treatment. Exclusion criteria included active infection and/or malignancy, or BASDAI not documented prior to starting biological therapy or within a year of MRI. Data on demographic characteristics, extra-articular manifestations (uveitis, inflammatory back pain, enthesitis, peripheral arthritis, dactylitis, psoriasis, and inflammatory bowel disease), family history, response to NSAIDs, and HLA-B27 status were collected from 149 patients. Relationship with ethnicity was assessed using Pearson’s chi-squared, which we conducted via Statistical Package for the Social Sciences (SPSS) software.

Results

Of the 149 patients, 68% were White Caucasian, 30% Asian and 1% Black. The average age was 43, with 66% male and 34% female. There was no significant relationship between ethnicity and active sacroiliitis (p = 0.926), chronic sacroiliitis (p = 0.218) or axial disease (p = 0.307). 64 Caucasian patients were HLA-B27 positive compared to 27 Asian patients, and no Black patients were positive. Despite this, there was no statistical correlation between ethnicity and HLA-B27 (p = 0.383). Overall, Caucasians consistently had a greater incidence of extra-articular manifestations compared with non-Caucasians. However, no significant p values were observed here or with response to NSAIDs, family history or familial HLA-B27 and BASDAI scores.

Conclusion

From this study, demographics show a larger proportion of Caucasians affected with axSpA compared to other ethnicities, as well as a higher proportion of HLA-B27 positivity, which is in keeping with population studies. It would seem there is a higher incidence of extra-articular manifestations in the White population - however, no statistical significance can be observed. This study was useful to gain further insights into the Asian population but has demonstrated that it is difficult to predict how an axSpA patient will behave based on ethnicity alone. Larger population studies will be needed to further evaluate the relationship between axSpA and ethnicity.

Disclosure

S. Byravan: None. A. Moorthy: None.

P184 Are there any ethnic differences in the response to Janus Kinase Inhibitor therapy for the treatment of rheumatoid arthritis?

Background/Aims

Baricitinib is an oral, synthetic Janus Kinase inhibitor. It has become a commonly used drug in the treatment of rheumatoid arthritis (RA), both as combination therapy and monotherapy. Previous studies have compared drug efficacy in different ethnicities, but no studies have compared the efficacy of baricitinib for the treatment of RA in different ethnicities. Given the large South Asian population in Leicestershire, we reviewed our cohort of RA patients on baricitinib to see whether there is any difference in drug response rates between the Asian and Caucasian cohorts.

Methods

This was a retrospective study. Patients included were those under the care of rheumatology at University Hospitals of Leicester (UHL) with a diagnosis of RA and either receiving baricitinib, or had received it in the past. Data was collected using the UHL IT systems, clinic letters, and pharmacy records. In addition to ethnicity, we reviewed patient age, gender, concurrent DMARDs used, previous biologics used, baseline and post-treatment DAS28, dropout from therapy, baseline biochemical assays (anti-CCP and RF status) and radiographic findings. Independent T-test was used to compare continuous data and the Pearson Chi-Square test was used to compare categorical data. SPSS was used to analyse the results.

Results

120 patients were included in the analysis and data was analysed with PFA. There was no statistically significant difference in the mean DAS28 at baseline (Asian 5.17 vs Caucasian 4.65, p value 0.107) and post-treatment (Asian 2.83 vs Caucasian 3.33, p value 0.404) (see table 1). Comparing both ethnicities, there was no statistically significant difference in previous biologics used, the presence or absence of anti-CCP and RF, and radiographic findings of erosions. Limitations of the study include the low proportion of post treatment DAS28 values recorded and absence of data comparing primary or secondary biologic failure.

Conclusion

This is the first study of its kind and found no significant difference in baricitinib response between the Asian and Caucasian cohorts. Future studies are needed to evaluate this subject further. Such data is important as it can contribute to a body of evidence that may in future help inform clinical decision making.

Disclosure

A. Jubber: None. W.H.Z. Hussain: None. A. Moorthy: None.

Lifestyle modification and inflammation in people with axial spondyloarthropathy-A scoping review

INTRODUCTION

People with axial spondyloarthritis (AS) have an inflammatory profile, increasing the risk of hypertension, type 2 diabetes, obesity, and dyslipidaemia. Consequently, AS is linked with co-morbidities such as cardiovascular disease (CVD). Physical inactivity, diet, smoking, alcohol consumption, and obesity influence inflammation, but knowledge of the interaction between these with inflammation, disease activity, and CVD risk in AS is dominated by cross-sectional research.

METHODS

A review of the literature was conducted between July 2020 and December 2021. The focus of the scoping review is to summarise longitudinal and randomised control trials in humans to investigate how tracking or modifying lifestyle influences inflammation and disease burden in patients with AS. KEY MESSAGES: (1) Lifestyle modifications, especially increased physical activity (PA), exercise, and smoking cessation, are critical in managing AS. (2) Smoking is negatively associated with patient reported outcome measures with AS, plus pharmaceutical treatment adherence, but links with structural radiographic progression are inconclusive. (3) Paucity of data warrant structured studies measuring inflammatory cytokine responses to lifestyle modification in AS.

CONCLUSION

Increased PA, exercise, and smoking cessation should be supported at every given opportunity to improve health outcomes in patients with AS. The link between smoking and radiographic progression needs further investigation. Studies investigating the longitudinal effect of body weight, alcohol, and psychosocial factors on disease activity and physical function in patients with AS are needed. Given the link between inflammation and AS, future studies should also incorporate markers of chronic inflammation beyond the standard C-reactive protein and erythrocyte sedimentation rate measurements.

Testing the Water: Osteoporosis Management in Primary Care

Introduction: Osteoporosis is a common bone condition in the United Kingdom (UK). The risk of osteoporosis and fragility fractures increases with age, and with the ageing population in the UK, the incidence is growing. It is imperative that General Practitioners (GPs) correctly diagnose and manage their patients with osteoporosis. To improve the awareness, a treatment pathway was developed in secondary care to guide local GPs. The aim of this study was to investigate whether patients at a GP practice with a population of 14,000 have been appropriately identified, coded as osteoporosis, treated, and have followed the recommended treatment pathway.

Methods: This retrospective study identified three patient groups through a search of the practice IT system, using the words ‘osteoporosis’, ‘fragility fracture’, ‘Quality and Outcomes Framework’, and names of all medications that are used to treat osteoporosis. Group 1 consisted of patients currently on the practice osteoporosis register. Group 2 consisted of patients with a coding of ‘osteoporosis’ or ‘fragility fracture’, but not currently on osteoporosis treatment. Group 3 consisted of patients currently on osteoporosis treatment with no coding for ‘osteoporosis’ or ‘fragility fracture’.

Results: In Group 1, 62% were found to be following the local treatment pathway in the first cycle of the study, and 70% in the second cycle. In Group 2, 45% were found to be following the local treatment pathway in the first cycle of the study, and 43% in the second cycle. In Group 3, 86% were found to be following the local treatment pathway in the first cycle of the study, and 96% in the second cycle. The completed study cycle shows an improvement of adherence of the pathway, from 75% in the first cycle to 81% in the second cycle. The first cycle of the study was presented at the GP practice meeting, which improved the awareness of the treatment pathway.

Conclusion: This study illustrates that there is a need for improvement in the diagnosis and management of osteoporosis in primary care. This can be achieved by improving awareness through continuing medical education about following the appropriate pathway to enhance the management of osteoporosis. Resources need to be allocated for prioritising osteoporosis care to prevent falls and fragility fractures, which have devastating effects on individual patients and the healthcare system.

Is There a Correlation Between Patient-Reported Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) Score and MRI Findings in Axial Spondyloarthropathy in Routine Clinical Practice?

Background

The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the patient-reported outcome (PRO) that is routinely used in clinical practice to monitor and measure disease activity in axial spondyloarthropathy (axSpA). BASDAI scores greater than four are thought to indicate active disease and require better control. Magnetic resonance imaging (MRI) is the most objective measure of disease activity in axSpA with its ability to pick up active inflammation both in the spine and sacroiliac joints. Previous studies have shown conflicting correlations between BASDAI and MRI, and therefore, there is the question of whether BASDAI is the best tool to monitor disease activity when it is subjective and potentially influenced by other patient factors. We, therefore, conducted a retrospective study to investigate the correlation between BASDAI and MRI in axSpA patients.

Methodology

Data were collected by retrospective analysis of axSpA patients attending University of Leicester (UHL) axSpA services. BASDAI scores were done within a year and closest to the time of MRI spine + sacroiliac joints were collected. The results prior to the initiation of biologic therapy were used. Data of one hundred and forty-nine patients were collected on their MRI results and BASDAI scores. Data were analysed using Statistical Package for the Social Sciences (SPSS) software and Pearson’s chi-squared applied to assess the correlation between BASDAI and MRI findings.

Results

Out of one hundred and forty-nine patients, 61.7% had active sacroiliitis on their MRI, 57.7% had chronic sacroiliitis, 53% had active spinal inflammation, and 17.4% had other MRI findings of active disease. There was a significant correlation between active sacroiliitis and BASDAI (p=0.014), but similar results were not found with other radiological features. A significant correlation was also found with males having higher BASDAI scores compared to females (p=0.027).

Conclusion

This study demonstrates a statistically significant correlation between BASDAI and active sacroiliitis with those having higher scores more likely to have active disease on their MRI. 

Are There Any Ethnic Differences in the Response to Baricitinib for the Treatment of Rheumatoid Arthritis?

Introduction Baricitinib is an oral synthetic Janus Kinase inhibitor that inhibits JAK1 and JAK2, and the new kid on the block in the treatment of rheumatoid arthritis (RA). To date, there are no studies comparing the clinical benefit of baricitinib in RA between different ethnicities. Ethnicity plays a role in the effectiveness of therapeutic agents. Given the large multi-ethnic population of Leicestershire in the United Kingdom and the range of new therapeutics in RA, we reviewed our cohort of patients with RA to see whether there is any difference in baricitinib Disease Activity Score 28 (DAS28) response between the Asian and White cohorts. Methods This was a retrospective study. The patients included were those under the care of rheumatology at University Hospitals of Leicester (UHL) with a diagnosis of RA and either receiving baricitinib or had received it in the past. Data was collected using the UHL information technology systems, clinic letters and pharmacy records. In addition to ethnicity, we reviewed patient age, gender, concurrent disease-modifying anti-rheumatic drugs (DMARDs) used, previous biologics used, baseline and post-treatment DAS28, dropout from therapy, baseline biochemical assays (anti-cyclic citrullinated peptide (anti-CCP) and rheumatoid factor (RF) status) and radiographic findings. An independent t-test was used to compare continuous data, and Pearson's chi-squared test was used to compare categorical data. Results A total of 120 patients were included in the analysis, and data were analysed with Portable Format for Analytics (PFA). There was no statistically significant difference in the mean DAS28 at baseline (Asian: 5.17 versus White: 4.65; p-value = 0.107) and post-treatment (Asian: 2.8 versus White: 3.3; p-value = 0.404). Comparing both ethnicities, there was no statistically significant difference in previous biologics used, anti-CCP and RF titres, and radiographic findings of erosions. Conclusion This is the first study of its kind, and it found no significant difference in baricitinib response between the Asian and White cohorts. Our study had certain limitations, and future studies will be needed to evaluate this subject further. Such data is important as it can contribute to a body of evidence that may in the future help inform clinical decision-making.

P34 The value of combined ophthalmology and rheumatology review- an unmet need

Case report - Introduction

Rheumatic diseases manifest in different specialties including ophthalmology. Presentation with eye symptoms may be a sight-threatening emergency such as GCA. Other inflammatory symptoms such as uveitis present to the Eye Casualty frequently, which need prompt rheumatologist input for a holistic management.

Case report - Case description

We present an interesting case with multiple learning points for both rheumatologists as well as ophthalmologists.

We present a case of a 73-year-old Caucasian lady who initially presented to the Eye Department. She was diagnosed as having bilateral uveitis by the ophthalmologist with an interest in uveitis. She had various investigations which showed positive HLA-B27 status, ENA, ANA, serum ACE level were normal; however, she was found to have raised immunoglobulins and plasma viscosity. She was treated with steroid eye drops and intravitreal dexamethasone implant in both eyes. She is a steroid responder and unfortunately developed glaucoma which needed two surgical procedures. She developed chronic cystoid macular oedema in Left eye.

She did not have any symptoms of psoriasis or gut symptoms suggestive of inflammatory bowel disease. She did report symptoms of inflammatory bowel disease. She had an MRI of axial spine as per AS protocol, which confirmed inflammatory spondyloarthropathy. She was diagnosed to have non-radiographic spondyloarthropathy which is managed by simple anti-inflammatories. Her BASDAI is less than 3 and does not qualify for biologic treatment for her axial spondyloarthropathy. Her main symptoms were ocular, which is very active and she is not able to escalate to biologic therapy.

Case report - Discussion

This is a patient presenting with late-onset inflammatory back pain without any articular or extra-articular activity. Her main manifestation is spectrum of spondyloarthropathy with uveitis; however, we could not escalate her to biologics. She has been on topical, intraocular and oral steroids which has led on to complications. The combined clinic between rheumatologists and ophthalmologists is key in managing such patients.

Case report - Key learning points

O31 Giant cell arteritis - a rare ocular presentation

Case report - Introduction

Giant cell arteritis (GCA) is a systemic vasculitis primarily affecting large- and medium-sized arteries. Classic symptoms include headache, scalp tenderness, jaw claudication and visual disturbances.

Ophthalmic artery involvement commonly causes anterior ischaemic optic neuropathy. Uncommon ocular features include anterior segment ischaemia, hypotony, tonic pupil or rarely choroidal ischaemia. Heterogenicity of presentation can make diagnosis difficult leading irreversible visual loss.

We report a case of bilateral macular choroidal ischaemia with atypical symptoms of GCA. It emphasises the need of complete evaluation in elderly patients with GCA and visual symptoms and the need to start aggressive treatment to prevent visual loss.

Case report - Case description

73-year-old caucasian lady presented to the eye emergency department with diplopia. Medical history includes systemic hypertension, hypothyroidism and hyperlipidaemia, no past ocular history. Eye examination was normal except decompensated fourth nerve paresis. Thyroid function was normal. Diplopia resolved spontaneously.

Patient re-presented with a floater in the right eye and left-sided atypical headache without jaw claudication. Investigations: normal FBC, CRP 126, ESR 100, PV 1.67. Following rheumatologist review she was commenced on oral prednisolone 60 mg with clinical suspicion of GCA. Temporal artery biopsy confirmed GCA. She had TIA subsequently. MRI revealed small area of acute infarct in left ganglio-capsular region. Clopidogrel was started for secondary prevention.

In the ophthalmology clinic she saw a lacy pattern. Her Log MAR VA in right and left eye was 0.64 and 0.76, respectively. Fundoscopy revealed retinal pigment epithelial (RPE) mottling at the maculae, right more than left eye. Optical Coherence Tomography (OCT) macula revealed bilateral RPE elevations and serous pigment epithelial detachment bilaterally, patchy central RPE atrophy with external limiting membrane disruption, more pronounced in the right eye. Fundus fluorescein angiogram and indocyanine green angiography confirmed bilateral choroidal ischaemia (triangular shaped with the base at the equator) at the macula worse in right than left eye.

Oral prednisolone was continued with gradual tapering. VA improved to Log MAR 0.5 and Log MAR 0.2 in right and left eye at six weeks. OCT showed signs of RPE re-modelling with resolution of sub retinal fluid (resolution of inflammation).

At recent follow up Log MAR VA is 0.26 and 0.06 in right and left eye respectively. She is on oral prednisolone 20 mg once a day tapering 2.5 mg every 2 weeks. OCT shows further re-modelling of the ellipsoid zone in the left eye, but her right eye shows more RPE atrophy and thinning with RPE degeneration.

Case report - Discussion

We report an unusual case of GCA with atypical symptoms and bilateral choroidal ischaemia.

Patients with GCA usually present with systemic symptoms and signs like headache, scalp tenderness, fever, and jaw claudication. Variable presentation can often lead to misdiagnosis and consequent irreversible loss of vision. Visual symptoms as the first and only sign of GCA was first reported in 1952.

Posterior ciliary arteries in the eye can be affected leading to optic nerve infarction and subsequent anterior ischaemic optic neuropathy (AION). AION and visual field loss accounts for 80—90% of cases with ocular signs of GCA. Posterior ciliary artery occlusion can rarely cause patches of choroidal infarcts which appear as chorio-retinal degeneration in a couple of weeks. These patches are usually in the mid-peripheral fundus, usually triangular shaped with the base towards equator and apex toward posterior pole.

In our case the presentation was very atypical in the sequence of symptoms. Her raised inflammatory markers raised the suspicion of GCA and prompt referral to rheumatology was done. Aggressive treatment with oral steroids was started with stomach and bone protection. Temporal artery biopsy confirmed the diagnosis. The bilateral triangular ischaemic areas found on FFA and ICG confirmed the macular choroidal ischemia. Her OCT also showed bilateral RPE mottling showing degenerative changes due to choroidal infarct from posterior ciliary artery occlusion.

We managed to preserve the vision in our case by starting the timely aggressive steroid treatment.

In summary, we report an unusual case of GCA with atypical symptoms and bilateral choroidal ischaemia where further visual loss was avoided due to timely intervention. GCA has variety of presentations; a combined team approach of ophthalmologists and rheumatologists can prevent irreversible visual loss in such cases.

Case report - Key learning points

GCA is a chronic idiopathic inflammation more commonly seen in the large- and medium-sized vessels.

Posterior ciliary arteries in the eye can be affected in GCA leading to optic nerve infarction and subsequent anterior ischaemic optic neuropathy (AION). AION and visual field loss accounts for 80—90% of cases with ocular signs of GCA. Posterior ciliary artery occlusion can rarely cause patches of choroidal infarcts which appear as chorio-retinal degeneration in a couple of weeks. These patches are usually in the mid-peripheral fundus, usually triangular shaped with the base towards equator and apex toward posterior pole.

Prompt diagnosis and aggressive treatment with corticosteroids can prevent visual loss in one or both eyes. Any patient over 50 years of age presenting with visual symptoms of amaurosis fugax, diplopia, or visual loss with ocular signs of anterior or posterior ischaemic optic neuropathy, central retinal artery occlusion or cilioretinal artery occlusion should create a high suspicion for GCA. This group of patients should have urgent ESR, CRP and PV evaluation. If suspected, high-dose corticosteroids must be started followed by temporal artery biopsy for confirmation. It is imperative to diagnose GCA early and start treatment urgently to prevent visual loss.

A multidisciplinary team approach in patients with GCA can prevent sight loss and life too.

Reactive arthritis: a clinical review

Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.

Patient Empowerment: Apni Jung (Our Fight) against Rheumatoid Arthritis for South Asian Population

Covid-19 has affected many populations in the UK, and ethnic minority communities in particular. People from ethnic minority communities living with long-term chronic diseases have shown to be less engaging with self-management and report having poor medication adherence. The main reason to this problem is the way information is delivered to non-English speaking patients. This editorial discusses an innovation to over this barriers in rheumatology practice.

Promising Treatment Options for Axial Spondyloarthritis: An Overview of Experimental Pharmacological Agents

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition that predominantly affects the axial skeleton. All patients receive conservative management measures which include physiotherapy, patient education and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Those with significant active disease will require escalation of their treatment with the use of biologics. Currently, there are five approved TNF inhibitors and two approved IL-17 inhibitors for use in axSpA. However, despite this up to 40% of patients do not respond or are intolerant to current available treatment. This leaves a significant number of patients with uncontrolled disease and unmet need for additional therapies. Though many drug classes have been trialed for axSpA they show poor efficacy; however, over the last few years there are three which demonstrate much greater promise as novel therapies for axSpA, these include dual neutralization of IL-17A and IL-17F, Janus kinase (JAK) inhibitors, and granulocyte-macrophage colony-stimulating factor (GM-CSF) inhibitors. This article reviews the evidence for these novel emerging therapeutic options for axSpA.

An Ethnic Variation in the Acceptance of Biological Disease-Modifying Therapies: A University Hospital Experience

Ethnic variations in the outcomes of rheumatological diseases are well documented. While physiological differences may account for these disparities, attitude to treatment is also likely to be a significant modifiable contributor. We sought to determine if an ethnic variation exists in the uptake of biological disease-modifying anti-rheumatic drugs (DMARD) among a multi-ethnic cohort when offered in-person through a healthcare system free at the point of access. We conducted a retrospective cross-sectional study of patients seen in a biologic therapy counselling clinic between December 2016 and April 2017. Clinic letters from consultations were reviewed, and data including ethnicity, language spoken, and decision to accept or reject the therapy were extracted. We chose to measure uptake over adherence, as we believe it is an earlier, more direct marker of attitudes to joint saving medications. Ninety-one cases were included in the analysis. Over 13.2% (12/91) of the cohort declined a biologic treatment when it was offered as the standard of care for joint disease. Non-Caucasian patients accepted treatment less often than Caucasian (White British) patients (OR 0.265, CI 0.73-0.959, p = 0.043), as did those who did not speak English as a first language (OR 0.094, CI 0.18-0.497, p = 0.005). Age, sex, and diagnosis were well matched between those who accepted and declined therapy. We demonstrate a disparity in the uptake of biologic therapies between the White British population and patients from other ethnicities. The reasons for this are likely multifactorial and could be related to socio-economic factors, language barriers, and cultural differences. Addressing this discrepancy is a crucial first step to tackling preventable disparities in the outcomes of rheumatological disease between different ethnicities.

P198 Efficacy and safety of secukinumab in ankylosing spondylitis: real-world data from Midlands Ankylosing Spondylitis Collaboration (MASC)

Background/Aims 

Secukinumab is an interleukin-17 inhibitor has been found to be effective in the treatment of ankylosing spondylitis (AS) in studies, including phase 3 clinical trials, however these are conducted in highly selected patients and it is important to confirm the efficacy and safety in a real world data. Response to secukinumab should be assessed after 16-weeks and continued if there has been sufficient response to treatment according to the BASDAI and spinal VAS scores.

Methods 

This was a multicentre cross-sectional observational study in collaboration with Midland Ankylosing Spondylitis Collaboration. Consecutive baseline and 16th week data of all AS patients on Secukinumab from 2017 to 2019 were collected and analysed to assess treatment response. All data were compiled in excel sheets and analysed using Medcalc calculator. Data were collected from collaborative efforts of the Royal Wolverhampton NHS trust, Queen’s Hospital (Burton on Trent), Leicester Royal Infirmary and Robert Jones and Agnes Hunt hospital.

Results 

Total 92 patients with radiographic AS on standard dose of secukinumab were included at baseline and 88 were followed up till week 16. Mean age was 45.9(SD ± 15) (Median=44years) and 67% were male. Baseline Mean BASDAI was 7 (SD ± 1.7); Mean CRP was 16.6 (SD ± 11.2), Mean VAS was 7.6(SD ± 1.6). There was statistical significant change in BASDAI, VAS and CRP levels at week 16th. ΔBASDAI=2.2 (SD ± 2) (p = 0.002), ΔVAS=3.2 (SD ± 2.1) (p = 0.001), ΔCRP=6.9 (SD ± 17) (p = 0.03). At 16th week, 68% had clinical improvement while 4 patients discontinued therapy (2-colitis, 1-uveitis and 1-patient choice). 10% overall had some adverse effects with most common being upper respiratory tract infection. We also compared patients with previous anti-TNF exposure (TE) to Anti-TNF naïve (TN). 63% were in TE group vs 37% in TN. 69% of TE and 76% of TN showed clinical improvement at week 16.Mean ΔBASDAI was more in TN group vs TE (p = 0.01), however there was no difference in ΔVAS and ΔCRP levels. (p = 0.0 & p = 0.2 respectively).

Conclusion 

This multi-centre retrospective analysis found secukinumab to be clinically effective in 68% of patients with AS. There was significant improvement in BASDAI, VAS and CRP levels at week16. Compared to anti-TNF resistant patients, TNF-Naïve responded better to secukinumab, although both showed good clinical improvement. These findings support the use of secukinumab in the treatment of AS, as a first line therapy or for those who have failed anti-TNF therapy. Safety signals observed in the real-word data set were consistent with those seen in the clinical trials and the Summary of Product Characteristics.

Disclosure 

N. Jain: None. R. Laxminarayan: Honoraria; Honorarium from Novartis, Lilly, Pfizer and Abvie. A. Moorthy: Honoraria; Speaker and conference fee MSD, Novartis, Abbvie. R. Amarasena: None. N. Cleaton: None. G. Kakade: None. A. Gunawardane: None. T. Khan: None. H. Sapkota: None. N. Barkham: Grants/research support; research funding from Novartis, Eli Lilly, UCB.

P179 Perpetual dilemma: international multicentre study correlating BASDAI and ASDAS (CRP) as a marker of disease activity in spondyloarthritis

Background/Aims 

While BASDAI is one of the most widely used tool it has limited face and construct validity. ASDAS on the other hand is considered more objective ,however in absence of blood investigations, it might not be an ideal measure. We aimed to study correlation and agreement between ASDAS-CRP with BASDAI score. We correlated these outcome measures with MRI activity

Methods 

This was a multi-centre study, conducted at rheumatology department of two teaching hospitals in United Kingdom and India. Anonymised data of all consecutive patients with the clinical diagnosis of SpA were analysed. We compared outcome measure variables ASDAS-CRP with BASDAI at baseline and follow-up with subgroup analysis of BASDAI cutoff of 4. We also analysed radiological parameters and compared disease activity of patients with active changes of SpA in MRI versus those with inactive changes . SPSS software and Cohen’s kappa statistics used

Results 

Total 250 patients with SpA were analysed with median age of 34 years and total duration of 5.9 +6 years. Mean BASDAI 4.9 +8.8, Mean ASDAS-CRP 3.04 + 3.5, Mean CRP 19.32 +12.8 mg/l. The Correlation between BASDAI and ASDAS-CRP (r) was 0.76 and the correlation coefficient of agreement between ASDAS-CRP and BASDAI &gt;4 was 0.75.The cutoff point of ASDAS with the best agreement with BASDAI was 3.5 (global agreement 78%, kappa 0.55). Both BASDAI and ASDAS showed a higher correlation with patient’s global assessment (PtGA) (r = 0.82 and 0.74, respectively) than with physician’s global assessment(PhyGA) (r = 0.76 and 0.7) The discriminant validity analysis showed that both ASDAS and BASDAI were able to discriminate patients above and below median PtGA (d = 1.15 &d=1.3) and PhyGA (d = 0.75 and d = 0.9) respectively however BASDAI was better than ASDAS to discriminate patients above and below the median PhyGA (p = 0.05)60 patients were followed up with mean duration of follow-up of 6.2 +1.6 months. Both ASDAS and BASDAI decrease significantly (p = 0.03 and 0.02 respectively) however effect size was greater for ASDAS(0.8) than BASDAI (0.6). There was no difference noted in the degree of spinal inflammation as evidenced by MRI when patients with BASDAI &gt;4 were compared to &lt; 4. (p = 0.43, OR 0.6). The correlation between ASDAS and BASDAI was much higher in patients with active MRI lesions (r = 0.84), without any difference in CRP or BASDAI (p = 0.8 and p = 0.66 respectively)

Conclusion 

This is a first study involving India and UK, which systematically compares the disease activity and outcome measures. Although BASDAI and ASDAS correlate well, the agreement is better for patients with high disease activity. ASDAS is more sensitive to change and shows larger effect size on follow-up. The outcome measures correlated more with active MRI lesions. Thus the cutoff value of BASDAI &gt;4 for active disease might need a revision in clinical practice

Disclosure 

N. Jain: None. S. Pandya: None. P. Srivastava: None. D. Shukla: None. A. Moorthy: Honoraria; Speaker and Conference fee MSD, Novartis Abbvie.

O23 Testing the waters: COVID-19 first wave and shielding among Black, Asian and Minority Ethnic patients with rheumatological conditions in the UK

Background/Aims 

COVID-19 has created numerous challenges for people globally. In the UK, few studies have reported poorer outcomes for certain ethnic populations. UK government introduced shielding guidance to protect the most vulnerable patients and this was in force for a number of months. However, shielding guidance was initially released only in English, which resulted in further disenfranchisement of the Black, Asian and Minority Ethnic community (BAME). We undertook an audit to understand experiences of shielding particularly in rheumatological BAME patients in multi-ethnic communities in 3 centres - Wolverhampton, Leicester and Oxford.

Methods 

This study was approved in all three sites as an audit. Patients contacting rheumatology helpline or having routine consultations were included. Each centre aimed to recruit at least 20 patients. A questionnaire was developed to capture important data on shielding. The study was conducted between May and June 2020 during the peak of the first wave of Covid 19.

Results 

We recruited 79 patients into this audit, of these 54 were of BAME and 25 of Caucasian ethnicity with 17 males and 62 females. Rheumatoid Arthritis (RA) was the commonest diagnosis in 49 of these patients (62%) and these patients were older (median ages 56 vs. 46 years, p = 0.14). BSR risk scoring algorithm was used to determine need for shielding (BSR score of 3 or more) - 38 patients fell into this category. The remaining patients had scored lower and had the option of shielding or enhanced social distancing. Of the 13 Caucasian patients who should have been shielding, 11 were (85%). Of the 25 BAME patients who should have been shielding: 17 were, and 8 were not (68%, p = 0.26; 65% looking at South Asian patients alone). Understanding of reasons for shielding was clear for 21 out of 25 Caucasian patients (84%). In contrast, 33 of 54 patients from BAME backgrounds (61%) were clear on this (p = 0.10). Within Wolverhampton and Leicester, the numbers are starker with 20 out of 37 (54%) being clear on this. Very few Caucasian patients made changes to their existing medications with 84% carrying on their medications as they were before the onset of COVID 19. However, of 54 BAME patients, 14 patients had stopped medications - either by themselves or as per advice of health professionals (74%, p = 0.16). There was a significant difference between centres in patients stopping medications with patients from Leicester much more likely (p < 0.001).

Conclusion 

Despite the small numbers, the data clearly suggest that BAME patients were less likely to understand the reasons for shielding, to follow shielding advice, and more likely to change their medications, thereby risking a flare. Addressing culturally competent educational needs and health equality for BAME rheumatology patients continues to remain a challenge.

Disclosure 

S. Dubey: None. K. Kumar: None. H. Bunting: None. T. Sheeran: None. B. Douglas: None. J. Sabu: None. M. Attwal: None. A. Moorthy: Honoraria; UCB, MSD, AbbVie.

COVID-19: The disease of loneliness and solitary demise

The birth of the COVID-19 pandemic has transformed working lives of British Asian general practitioners (GPs), such as one of the authors. The effects of the national lockdown and the subsequent loneliness have impacted every aspect of our lives and increased mental health problems. The added social isolation of local lockdowns, such as in Leicester, will undoubtedly exacerbate some health problems due to a lack of patient willingness to attend healthcare services and the postponement of some appointments. The lack of culturally competent support is likely to add to the isolation in non-English-speaking people. Thus, we should pre-empt these issues in a culturally effective manner. To prepare for subsequent waves, GPs are risk-stratifying patients for COVID-19 and have commenced ReSPECT care-plan conversations with higher-risk patients. But with the increased risk from COVID-19 to Black, Asian and minority ethnic patients, should this and other groups of patients also have a ReSPECT care plan? Is now the time to consider community-hospice settings for our palliative COVID-19 patients? This pandemic has uncovered a training need for healthcare professionals to feel more comfortable in discussing end of life as an integral consultation component. We should focus our efforts in alleviating suffering by achieving 'shared understanding' and 'negotiating management' of our ReSPECT conversations.

Perception and Belief on Cannabinoids: A Comparative Study of Rheumatology Patients and Primary Care Physicians on the Use of Cannabinoids for Pain Management

Introduction

With the recent increase in popularity of cannabinoids in the management of chronic pain, the inquisitiveness among our patients and health care professionals are probably now at its peak. Many treating health care professionals in their clinical practice come across patients who either use cannabinoids or are interested in their efficacy and side effects. As there is paucity of data and research about their use in rheumatology, patient's self-reported responses and experience of primary care physicians (General Practitioners [GPs]) can guide in expanding our knowledge.

Methods

Ours was an observational, cross-sectional study among rheumatology patients and GPs in the Leicestershire area. Initial questionnaire was designed by authors addressing demographics, knowledge, experience and perception. This was piloted among patients and GPs and improvised, redesigned and used for the study. The study design consisted of two arms: first arm including GPs and second arm rheumatology patients.

Results

Arm 1 consisted of 100 GPs with median age group of 30-40 years. 34% GPs experienced their patients inquiring about cannabinoids. 78% did not believe cannabinoids benefited the patients. On a scale of 0-10, the mean benefit in managing pain 3.2 + 2.5. Arm 2 consisted of 102 patients. 16% reported using cannabinoids for managing their chronic pain. The users reported significant improvement in pain compared to non-users (p=0.002). On comparing the perception of cannabinoids between GPs and patients, there was a statistically significant difference regarding awareness and effectiveness (p<0.001).

Conclusion

With the paucity of data and research about the use of cannabinoids in rheumatology, the patient self-reported responses provided an estimate as to their efficacy. This was significantly different from the GP perception. Disease and drug-focused research is need of the hour. To our knowledge, this is the First Single Centre study in the UK evaluating GP and rheumatology patient perception on cannabinoids.

Digital health strategies in the war against COVID-19 and beyond

This editorial explores how technology has helped clinicians during the COVID-19 pandemic, from patient care to education, the changes that have been made and the numerous exciting possibilities of where technology can amalgamate with health care.

Impact of Secukinumab on Patient-Reported Outcomes in the Treatment of Ankylosing Spondylitis: Current Perspectives

Ankylosing spondylitis (AS) is a chronic rheumatic disease involving inflammation of the joints and spine, which carries a substantial, life-long burden for the patient. Secukinumab is a fully human anti-interleukin-17A monoclonal antibody, approved in the USA and EU for the treatment of AS. In this narrative review, we searched PubMed with the aim of consolidating the recent literature regarding the impact of secukinumab on patient-reported outcomes in patients with AS. A large clinical trial program has demonstrated the efficacy of secukinumab in relieving the signs and symptoms of AS. Most importantly from a patient perspective, secukinumab has produced improvements in a range of patient-reported outcomes (PROs), including pain, fatigue, quality of life and work productivity, as well as composite measures including patient-reported elements, such as the Bath indices and Assessment of SpondyloArthritis international Society (ASAS) response criteria. Benefits to patients were rapid, and sustained in the long term (up to 5 years). The positive effect of secukinumab was seen regardless of whether patients had previously been treated with anti-tumor necrosis factor (TNF) therapies. Greater improvements in PROs were associated with patients being anti-TNF-naïve, of a younger age, with shorter disease duration and higher objective measures of inflammation at baseline. The available real-world evidence suggests that the effects of secukinumab on PROs in clinical practice are consistent with those seen in clinical trials, and evidence in a real-world setting continues to be collected.

Emerging public health challenge in UK: perception and belief on increased COVID19 death among BAME healthcare workers

BACKGROUND

Coronavirus infection Disease 19 impacted every part of the world and routine life. Recent report from the Office of national statistics in UK reported disproportionate death among Black Asian and minority ethnic (BAME) population. NHS is heavily relied on the BAME work force both in front line and in the community. We attempted to explore the beliefs and perception about reported worrying issue among BAME health work force in a Diverse city of Leicester.

METHODS

This is a cross-sectional survey using 20 questions in an electronic format. The target population was identified through Leicester Asian Doctors Society and Leicester Asian Nurses Society. The questionnaire was then distributed electronically to the members. Survey questionnaire was accessed by 372, incomplete response (172) were excluded and 200 completed responses were analysed.

RESULTS

Majority of BAME workforce are routinely involved in front line duties. More than 70% were anxious about their role during this pandemic. The Personal Protective Equipment (PPE) supply was adequate, and the support received from the local healthcare providers was more than satisfactory. The work force perceived co-morbidity, lack of PPE and testing were one of the few reasons for increased death in BAME. BAME group felt adequate provision of PPE, increased testing and improving mental health well-being is required to alleviate concerns and improve BAME working life in NHS.

CONCLUSION

BAME workforce are routinely involved in front line work and current anxiety level is very high. Adequate provision of mental health support with clear risk stratification for return to work is required urgently.

AB1169 RHEUMATOLOGY PATIENT PERCEPTION OF CARDIOVASCULAR RISKS: A SURVEY AT A TEACHING HOSPITAL

Background:

It is well known that individuals with rheumatological conditions are at an increased risk for developing cardiovascular diseases (CVS) and they are the most common cause of mortality. However, there is still lack of awareness about the CVS risk among Rheumatology patients. We carried out a patient survey to assess their awareness and perception of CVS risk associated with their condition. We also assessed if the health professionals attending to these patients gave adequate education to the patients regarding the CVS risk.

Objectives:

To study awareness about CVS risks among rheumatology patients

Methods:

This was a prospective cross sectional survey where in multiple-choice questionnaires were distributed to consecutive patients attending rheumatology clinic. The questionnaire contained 18 questions including demographics, diagnosis, medications and their awareness of cardiovascular risks associated with their underlying rheumatic conditions. We also explored as patient attempted any Primary preventive measures for reducing the CVS risk.

Results:

We collected data of 57 patients with 47% of patients were above 60 years of age with Female: Male ratio of 3:1. Rheumatoid arthritis was the most common diagnosis (60%) with others including AS (22%), SLE(5%). 32% of patients had been suffering from inflammatory disorder for >10 years and 44% believed their disease was still not fully controlled. 37% had family history of heart diseases.

More than half of the patients (56%) were unaware of cardiovascular risks associated with their condition and 65% overall reported that they were not personally informed about these risks by the treating health professionals. When we analysed the newly diagnosed patients (<5years) 64% were unaware about the CVS risks which is higher compared to patients with diagnosis of >5 years. We tried to explore any ethnic differences, however the number is too small to compare. We noted that around 60% of white British with rheumatological diagnosis were not aware of CVS risk in our group. When further asked about the primary preventive measures, only 23% engage in exercise, 21% have made diet changes, 12% take aspirin, 16% have quit smoking and only 5% quit alcohol.

Conclusion:

This was a small pilot study to look at the patient awareness of CVS risks associated with rheumatological conditions. Clearly there is lack of awareness among patients about CVS risks. Furthermore, most of the patients reported they were not educated about the risks from the health professionals. Majority do not engage in any kind of primary preventive measure for heart diseases. It is crucial that the health professionals actively educate patients regarding the CVS risks and the various methods through which these can be prevented. We believe patient-targeted educational programmes and behavioural interventions can be incorporated for holistic patient management.

References:

[1]John, Holly et al. Inflammatory arthritis as a novel risk factor for cardiovascular disease European Journal of Internal Medicine, Volume 23, Issue 7, 575 – 579

Disclosure of Interests:

Nibha Jain: None declared, Anukripa Manivannan: None declared, Aswin Mahesh: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0694 IS THERE ANY HETEROGENEITY OF SPONDYLOARTHRITIS DISEASE MANIFESTATIONS BETWEEN TWO ETHNIC SUBGROUPS?:A MULTICENTRE INTERNATIONAL COMPARATIVE STUDY BETWEEN INDIA AND UK

Background:

Pathogenesis of Spondyloarthritis (SpA) multifactorial and remains unclear. Various hypothesis have been postulated genetics, HLAB27, IL17, Gut microbiome and Biomechanical stress. Many of these factors can be attributed to ethnic background and environment. HLAB27 accounts for 20–25 % of total heritability and 40% of genetic risk while <10% of HLA-B27 carriers in general population develop SpA1. Higher faecal calprotectin levels in SpA compared to control point towards microscopic gut inflammation2. Thus dietary habits and geographical factors can influence pathogenesis of disease. We looked in clinical manifestations of SpA patients of two very different ethnic background Caucasians and Indians from UK and India to shed more light in understanding the disease

Objectives:

To study any differences in the clinical manifestations of SpA patients of two ethnic groups

To compare outcome measure (BASDAI and ASDAS) between Caucasians and Indians

To study the difference in disease activity between Indian patients and British Asians

Methods:

Multicentre observation study where data of SpA patients attending rheumatology clinics from two major teaching hospitals collected. In India data collected from Sheth VS Hospital and NHL Medical College, Gujarat and in United Kingdom from University Hospitals Leicester, NHS trust. Leicester has a multi-ethnic demography wherein almost 30%3of population is of south Asian ethnicity, making this study unique.

Baseline demographic and clinical data was collected. Clinical and outcome measures compared to see any heterogeneity in disease manifestations. SPSS software used

Results:

Total 200 patients analysed with 148 Indians and 52 Caucasians. The Indian cohort was subdivided into British Asians (second generation Indians) and those form Gujarat, India

We found Indian subgroups were younger with shorter disease duration. Comparison in Table 1

Table 1.CaucasianIndianPAge45.9±1231±12<0.001M:F34:193:10.74TDI years9.6 ±5.93.5± 5.2<0.001BASDAI4.05±2.173.1±1.70.002ASDAS2±0.82.4±1.20.02CRP12.8±23.624±12<0.001HLAB2767%26%<0.001Uveitis25%12%0.02IBP78%90%0.03Enthesitis21%60%<0.001Peripheral Arthritis19%36%0.02Dactylitis2%10%0.07Psoriasis10%20%0.1IBD2%5%0.35Comparing British Asians to Indians, Gujarat no significant difference in clinical parameters. (Table 2)British AsianIndianPBASDAI5.16±2.763.1±1.70.006ASDAS2.53±1.32.4±1.20.74CRP15.2 ±15.424±12<0.001

Conclusion:

We found Caucasians had more HLAB27 positivity and extra-articular manifestation of uveitis however the Indian population has more enthesitis and peripheral arthritis. Enthesitis is initiated during a mechano-sensation and the cultural difference including style of footwear could probably be one of the factors explaining our findings inflammatory back pain has been reported to be higher in Indians compared to Caucasians which could be due to life style

The fact that ASDAS CRP behaves similarly in Indian patients across the two countries and is more when compared to Caucasians might point towards overall higher burden of disease in Indian population

To our knowledge this is a first study comparing clinical manifestations of SpA between Indians and Caucasians

References:

[1]Brown MAet al. Susceptibility to ankylosing spondylitis in twins: the role of genes, HLAand environment.Arthritis Rheum 1997;40: 1823–8

[2]J Simione, et al. Fecal Calprotectin, GutInflammation and SpA Archives of Medical Research. 2019;50:41-46

[3]http://www.ons.gov.uk/census

Disclosure of Interests:

Nibha Jain: None declared, Sapan Pandya: None declared, Puja Srivastava: None declared, Prashant Chotalia: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0953 CANNABINOIDS: FRIEND OR FOE OR A BYSTANDER?

Background:

Cannabinoids has recently gained popularity for use in chronic pain. There is a lot of inquisitiveness among our patients wherein health care professionals are asked about its efficacy, side effects and sometimes even ask for a prescription! As there is paucity of data and research about its use in rheumatology, patient reported outcome(PROM) can guide ahead in expanding our knowledge and experience.

Objectives:

To study usage of cannabinoids by rheumatology patients

To study awareness among primary physicians regarding Cannabinoid usage in rheumatology.

Methods:

Cross sectional survey with two arms. Arm 1 Information from patients attending tertiary rheumatology clinic,including perception regarding the use of Cannabinoids.

Arm 2 consisted of collecting data via web-based survey with20-question from 100 GPs of Leicestershire. Questions on demographics, perspectives on and knowledge of cannabinoid use. Statistical analysis SPSS software.

Results:

Arm1 Total 102 rheumatology patients with 60%were females and 45% secondary education. 48% were unemployed. 75% Caucasians, 18% Asians. RA most common diagnosis followed by OA and FMS. 40 % depression and anxiety in addition to Rheumatic disease. 94% reported ongoing pain with 6-8 on a VAS scale. 79% were satisfied with their current therapy. 65% had heard about complementary medicine and 15% reported using cannabinoids.

Most common form Cannabinoids oil 60% followed by smoking 20%. 56% reported using >3 months and majority 72% use daily. Median age 55 years. 88% users Caucasians. Mean disease duration 6.25 years among users indicates chronicity of disease has a direct proportion in usage. All users had ongoing pain of 7 on VAS. 87% believed it helps them managing pain effectively with a pain free state. On an average spends between 50-100 pounds per week. More than half believe cannabinoids should be available as a prescription drug in NHS and 30% interested to know more about it.

In Arm 2 consisting of Primary care physicians, response rate 50%. Average clinical experience 5 years. Only 20% heard about usage of complementary medicine by rheumatology patient. Most replied that 10% of their patients use Cannabinoids for pain management. Most did not believe use of cannabinoids benefited the patients. Only 4% recommend its usage. 25% think it should be available as prescription. 40% experienced patients asking about cannabinoids during appointment. 88% of respondents did not know much about cannabinoid usage in rheumatology and have never prescribed it in their practice.

Conclusion:

Cannabinoids widely used by the rheumatology patients with PROM favouring its efficacy for control of chronic pain. Preclinical data suggest that cannabinoids might have a therapeutic potential RA1, OA, FMS2. Clinical data regarding cannabinoid treatment for rheumatic diseases are scarce, therefore, recommendations concerning cannabinoid treatment cannot be made. All patients who reported using it suffered from moderate to severe chronic pain. Thus main indication of usage was pain rather than recreational purpose. Although a small survey it clearly highlights lack of knowledge among primary physicians. These results emphasise the need for further research regarding the benefits and risks of cannabinoids in rheumatology.

References:

[1]RichardsonD. etal Characterisation ofthe cannabinoid receptor system in synovial tissue andfluid in patients with OA and RA Arthritis Res.Ther. 10, R43 (2008).

[2]Walitt, B etal Cannabinoids for fibromyalgia. Cochrane DatabaseSyst. Rev. 7, CD011694 (2016).

Disclosure of Interests:

Nibha Jain: None declared, Neelima Reddy: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

2. Pregnancy and myositis

Introduction

Inflammatory disorders can appear as a spectrum and pose diagnostic challenges. Inflammatory myositis affects women of childbearing age. This situation presents challenges in management of disease during pregnancy. Myositis specific antibodies are expected to lead to certain clinical presentation but cases outside known information always occur as we learn from this case report.

Case description

A 26-year-old Asian lady was referred to rheumatology for inflammatory arthritis and Raynaud’s on a background of scalp psoriasis and family history of psoriatic arthritis. She had hip pain with no spinal inflammation and was commenced on low dose methotrexate. ANA 1:6400 but autoimmune screen negative. She was intolerant to higher doses of methotrexate. She developed severe hip pain which was not septic and eventually developed reduced hip movements and forward flexion of spine. X-ray showed soft tissue calcification around hip methotrexate was stopped due to respiratory symptoms but HRCT and pulmonary function were normal. Unfortunately, she was lost to follow-up.

She was then referred after a year with skin tightening (indurated plaque) over loin and chest. CK was elevated without clinical evidence of muscle weakness and ANA 1:1600 positive with negative ENA and normal DsDNA/Compliments. Dermatologists felt that indurated plaque was morphea as the histology was inconclusive. She developed pelvic girdle weakness along with left hip calcification and progression of skin tightening of fingers and forearm. Although biopsy and MRI thigh were negative for myositis, nerve conduction studies showed severe active polymyositis. Her extended myositis panel now showed Mi-2 antibody.

As she was intolerant to azathioprine with a progressive illness and was keen to have children soon, she was started on IvIG. Despite being on IvIg she developed refractory calcium discharging sinus over her hip. Rituximab was not licensed for myositis then and she was not keen to start on any other medications recommended by the myositis specialist centre. She had a successful pregnancy after 6 months of disease control under joint care of maternal foetal medicine and rheumatology. On repeat autoimmune testing prior to pregnancy, anti-Ro was equivocal (previously negative) hence antepartum surveillance was carried out.The baby had no evidence of congenital heart block.

She has progressive extrarticular calcification with otherwise well controlled disease and prefers to remain on IvIg.

Discussion

We present the first case of psoriasis with Raynaud’s developing progressive skin and soft calcification resulting in discharging sinuses. She developed myositis scleroderma overlap with suspected cardiac involvement posing challenge due to intended pregnancy. There was limited data to go by on outcomes of pregnancy in dermatomyositis and no there are similar cases in literature.

In retrospect, her joint symptoms could have stemmed from extra-articular calcification around hip but does not explain skin tightening around fingers. It makes one wonder if resistant scalp psoriasis initially could be related to dermatomyositis and not true psoriasis. She was managed with regular advice from the myositis specialist unit and declined to go on any drugs which could have an impact on fertility or pregnancy. Hence options for treatment were limited and complicated by intolerance to conventional DMARDS. IvIG was selected based on those preferences due to progressive myositis but there were initial reactions to IvIG infusions at which point use of rituximab was considered. The NICE rituximab in myositis guidelines were not present at that time and the individual funding request was declined.

Myositis is an idiopathic inflammatory immune mediated disorder that may be existent in an isolated form or in combination with other autoimmune or connective tissue disorders. It is a T-cell mediated cytotoxic process directed toward unknown muscle antigens. Psoriasis on the other hand is a relapsing skin disease; the diagnosis is of which is made on clinical grounds and can be associated with SpA.

In a retrospective review of psoriasis patients seen at the Mayo Clinic the frequency of pathologically confirmed myopathies or inflammation in muscle in patients with psoriasis was estimated to be 0.13%. However, this could be an overestimate, given potential referral bias. Concomitant autoimmune disorders, psoriatic arthritis, and exposure to anti-TNF-α therapy were the proposed associations with increased risk of developing myopathy in psoriasis patients. Most had inclusion of body myositis.

Key learning points

Evidence suggests that the appropriate treatment with immunosuppressants allows a normal pregnancy without major problems and with no further risk for post-partum relapse. This is presuming the disease is well-controlled for 6 months prior to conception.

There is no definite impact of pregnancy on a well-controlled myositis, although case reports have variable outcomes.

Pregnancy outcomes are better if the disease is fully controlled preconception and there is no cardiac or respiratory involvement. Hence, preconception work up is done in liaison with maternal foetal medicine and includes disease activity measurements, repeat investigations for systemic involvement (commonly ECHO and pulmonary function test), repeat autoimmune screen and individualised preconception counselling.

Poorly controlled disease can increase risk of intrauterine growth retardation, stillbirth or preterm birth. Uncontrolled inflammation is thought to result in poor placental circulation due to inflammatory fibrillin deposition.

Autoimmune disorders are conventionally known to flare postpartum but experiences are variable. We observed a slight CK rise postpartum which settled without needing further treatment.

Treatment options available for women considering pregnancy include glucocorticoids and intravenous immunoglobulin for induction of remission and remission with azathioprine, cyclosporin or tacrolimus.

Data available is from case series and experiences of specialist centres only, hence there is scope for further research.

Owing to limited data on the long-term use of intravenous immunoglobulins in myositis, absence of evidence-based treatment options for calcification in myositis and push for switch to rituximab due to cost implications, further management of patients in similar situations will be challenging.

Conflicts of interest

The authors have declared no conflicts of interest.

36. All headaches are not GCA

Introduction

Vasculitis is a heterogeneous group of autoimmune disorders having multisystem involvement. In many cases, the neurological disorders have an atypical clinical course or even an early onset, and the healthcare professionals should be aware of them.

Case description

We report a case of 57-year-old Asian male without any significant past medical history admitted under the urology department. He had presented with abdominal pain and fever and was being treated for presumptive pyelonephritis (on antibiotics). He was referred to rheumatology when he developed severe unilateral headache on right side with significant scalp tenderness. Headache involved temporal and fronto-parietal-occipital area with no jaw claudication or any significant visual disturbance. There was no limb claudication or polymyalgia symptoms. On examination he had new onset hypertension (BP:174/94mmHg), rest of the systemic examination was normal with no bruit. Musculoskeletal and skin examination was normal.

Investigations included CRP of 204, hemoglobin 133, white cell count 15.2 (neutrophils: 12.06), creatinine 118 (eGFR 59). Liver function: normal. Urine dip: Normal and blood/urine culture: negative. Immunological profile and viral screen was negative. Urgent CT head was done for severe headache which was normal. 

Patient was referred to rheumatology with provisional diagnosis of giant cell arteritis due to headache and raised inflammatory markers. On reviewing his CT abdomen, the renal parenchyma showed symmetrical well demarcated bilateral involvement which was more in favor of renal infarct rather than pyelonephritis. CT angiography of abdomen was requested which showed multiple vessel involvement including mesenteric artery and bilateral renal arteries with beaded appearance and stenosis. 

MR angiogram showed 6mm aneurysm of PICA with stenosis of P1 segment of PCA. Currently he is being screened for ADA2 deficiency. During his stay his renal function deteriorated, not responding previously to antibiotics. 

He was started on methylprednisolone pulse and antibiotics stopped in view of worsening liver function. On day 3 of methylprednisolone pulse he had significant improvement of his headache with stabilization of renal and liver function. Our plan is to start him on steroid sparing therapy based on the ADA2 levels.

Discussion

The classification of vasculitis is still unsatisfactory as the patho-genetic mechanisms have not been fully understood. Existing criteria classify based on predominant vessel involvement but there is still some overlap between them. The prevalence of CNS involvement in medium vessel vasculitis ranges as widely as 2-10% and does not usually occur until late in the course of the disease. The most commonly reported CNS manifestation is diffuse encephalopathy, followed in frequency by focal deficits and seizures. Intracranial aneurysms are rare with around 15 reported cases usually multiple and located in supra- as well as infra-tentorial compartments. Most of the cases presented with subarachnoid or parenchymal hemorrhage. Treatment guidelines are still not clear and most are treated conservatively by medical management. Repeat hemorrhages or re-bleed in spite of medical treatment have also been reported 

Deficiency of ADA2 (DADA2) has been recently recognized first molecularly described monogenic vasculitis having biallelic hypomorphic mutation in ADA2 gene. CNS involvement is one of the main features of DADA2 which presents with a wide spectrum of clinical manifestations ranging from systemic inflammation to cutaneous or visceral PAN like vasculopathy and early onset stroke.

Our patient had presented with primary CNS and renal involvement with impending rupture aneurysm. Timely control of inflammation is pertinent in such cases with remission induction and maintenance to prevent stroke. Although cyclophosphamide is still used in such cases DADA2 usually require anti-TNF therapy. Our patient had good response to primary steroid therapy.

Key learning points

Acute GCA-like neurological presentation of medium vessel vasculitis with cerebral involvement is rare. If not recognised in a timely fashion, it can lead to sub-arachnoid haemorrhage which is the most common presentation of such cases. 

DADA2 is a recently recognised entity that presents with stroke and vasculitis/vasculopathy and responds to anti-TNF therapy.

Conflicts of interest

The authors have declared no conflicts of interest.