An Environmental Scan and Appraisal of Patient Online Resources for Managing Rheumatoid Arthritis Flares

OBJECTIVE

To conduct an environmental scan and appraisal of online patient resources to support rheumatoid arthritis (RA) flare self-management.

METHODS

We used the Google search engine (last search March 2023) using the terms "rheumatoid arthritis" and "flare management." Additional searches targeted major arthritis organizations, as well as regional, national, and international resources. Appraisal of the resources was conducted by 2 research team members and 1 patient partner to assess the understandability and actionability of the resource using the Patient Education Materials Assessment Tool (PEMAT). Resources rating ≥ 60% in both domains by either the research team or the patient partner were further considered for content review. During content review, resources were excluded if they contained product advertisements, inaccurate information, or use of noninclusive language. If content review criteria were met, resources were designated as "highly recommended" if both patient partners and researchers' PEMAT ratings were ≥ 60%. If PEMAT ratings were divergent and had a rating ≥ 60% from only 1 group of reviewers, the resource was designated "acceptable."

RESULTS

We identified 44 resources; 12 were excluded as they did not pass the PEMAT assessment. Fourteen resources received ratings ≥ 60% on understandability and actionability from both researchers and patient partners; 10 of these were retained following content review as "highly recommended" flare resources. Of the 18 divergent PEMAT ratings, 8 resources were retained as "acceptable" following content review.

CONCLUSION

There is high variability in the actionability and understandability of online RA flare materials; only 23% of resources were highly recommended by researchers and patient partners.

Rheumatoid Arthritis Care Experiences of Black People Living in Canada: A Qualitative Study to Inform Health Service Improvements

OBJECTIVE

To understand experiences related to rheumatoid arthritis (RA) care and propose service-level strategies to reduce and mitigate inequities for Black people living in Canada.

METHODS

Purposive and respondent driven sampling was used to recruit participants for qualitative interviews to explore population factors relevant to RA care and challenges and facilitators for access to health care services, medications, and enacting preferred treatment plans. Thematic analysis was conducted using the Braun and Clarke method with inductive and deductive coding and critical race theory guiding analysis.

RESULTS

Six women and two men with RA, and two women health care professionals, expressed how their racial identity contributed to their understanding of RA, preferences for treatment, and outcome goals. Health care access was influenced by financial limitations and racism, by exclusion, and discrimination, and also by cultural norms in seeking health care and awareness about RA within the Black community. Participants experienced health system fragmentation and were not connected to ancillary supports. Treatment decision-making was influenced by the legacy of oppression and medical experimentation on Black people and the predominance of biomedical approaches emphasized by health care providers. Holistic and cultural approaches, provided in safe, trauma-informed care environments, with flexibility in service models, are desired. Partnerships between arthritis care services and Black community organizations are proposed to promote community awareness and knowledge about arthritis and provide support mechanisms for patients within their community.

CONCLUSION

Our study highlights unique considerations based on race and ethnicity and provides suggestions for arthritis care to mitigate inequities for Black people living with arthritis.

VEXAS Syndrome: Clinical Case Series From a Canadian Cohort

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic; OMIM #301054) syndrome is an autoinflammatory condition first described in November 2020.1 It is characterized by vacuoles in myeloid and erythroid precursor cells on bone marrow biopsy and caused by a monogenic somatic mutation in the ubiquitin-like modifier activating enzyme 1 (UBA1) gene.1,2.

Non-invasive biomarkers of disease activity and organ damage in ANCA-associated vasculitis: a systematic review

BACKGROUND

In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), histopathological assessment of affected tissue is often necessary for diagnosis and assessment of disease extent. There is a requirement for validated non-invasive biomarkers to avoid the need for serial tissue biopsies.

METHODS

A systematic review of scientific databases from 2012 until present was performed to identify studies fulfilling the inclusion criteria. Studies were assessed for quality using the Strengthening the Reporting of Observational Studies in Epidemiology checklist for cohort, case-control and cross-sectional studies and the Risk of Bias Assessment tool for Non-randomised Studies, or the Cochrane Risk of Bias tool 2.0 for randomised controlled trials. A descriptive synthesis of the data for non-invasive (blood-based or urinary) biomarkers of AAV-related disease activity and organ damage was performed.

RESULTS

Twenty-two high quality studies were included. These articles reported the value of blood-based and urinary biomarkers including anti-neutrophil cytoplasmic antibodies, immune cells, complement factors, gene expression profiles, cytokines, chemokines and other proteins in the assessment of disease activity and/or organ damage in patients with AAV. Many of these biomarkers involve the alternative complement pathway, neutrophil activation and macrophage activation.

CONCLUSION

This is the first contemporary systematic review synthesising the value of non-invasive biomarkers of AAV-related disease activity and organ damage. The incorporation of individual markers in combined biomarker profiles might enhance clinical decision-making. Many unmet needs were identified; few studies involve oeosinophilic granulomatosis with polyangiitis and patients with childhood-onset AAV. Further validation of the candidate biomarkers is warranted in large prospective studies to bridge the existing knowledge gaps and apply precision health to systemic vasculitis.

Investigating the influence of patient eligibility characteristics on the number of deferrable rheumatologist visits: planning for a patient-initiated follow-up (PIFU) strategy

OBJECTIVE

Patient-initiated follow-up (PIFU) for rheumatoid arthritis (RA) is a model of care delivery wherein patients contact the clinic when needed instead of regularly scheduled followups. Our objective was to investigate the influence of different patient eligibility characteristics on the number of potentially deferred visits to inform future implementation of a PIFU strategy.

METHODS

We conducted a retrospective chart review of seven rheumatologists' practices at two university-based clinics between 01/03/2021-28/02/2022. Data extracted included the type and frequency of visits, disease management, comorbidities, and care complexities. Stable disease was defined as remission or low-disease activity with no medication changes at all visits. The influence of patient characteristics on the number of deferrable visits in patients with stable disease was explored in four criteria sets that were based on: early disease duration, medication prescribed, presence of care complexity elements, and comorbidity burden.

RESULTS

Records from 770 visits were reviewed from 365 RA patients (71.5% female, 70.0% seropositive). Among all criteria sets, the proportion of visits that could be redirected varied between 2.5%-20.9%. The highest proportion of deferrable visits was achieved when eligibility criteria included only stable disease activity and RA patients on conventional synthetic disease modifying drugs or no medications (n=161, 20.9%).

CONCLUSION

PIFU may result in a more efficient use of specialist healthcare resources. However, the applicability of such models of care and the number of deferred visits is highly dependent on patient characteristics used to establish eligibility criteria for that model. These findings should be considered when planning implementation trials.

A scoping review of shared care models for rheumatoid arthritis with patient-initiated follow-up

OBJECTIVE

An emerging strategy to address access challenges to rheumatologists for patients with RA is shared care between primary and specialist care, with patient-initiated rheumatologist follow-up as needed. The objective of this scoping review was to explore studies implementing this model of care.

METHODS

Four electronic databases were searched from 01/01/2000-31/03/2022 using three main concepts (RA, shared care, patient-initiated follow-up). English-language studies of any design were included if they described the implementation and/or outcomes of shared care model for RA with patient-initiated follow-up. Two authors reviewed and selected articles in duplicate and extracted data on study characteristics, care model implementation and outcomes according to a pre-specified protocol.

RESULTS

Following duplicate removal, 1578 articles were screened for inclusion and 58 underwent full-text review. Sixteen articles were included, representing 10 unique studies. Five studies had qualitative outcomes and two were pre-implementation studies. Model implementation varied significantly between studies. Effectiveness data was available in 10 studies and demonstrated equivalent outcomes for the model of care (disease activity, radiographic damage, quality of life). Health system costs were equivalent or lower than usual care. While satisfaction with care was equivalent or improved in shared care models with patient-initiated follow-up, some concerns were expressed in qualitative evaluation around appropriate patient selection for such models, and information for health equity evaluation was not reported.

CONCLUSIONS

While shared care models with patient-initiated follow-up may offer comparable outcomes for RA, further work is required to understand patient preferences, health equity considerations and longer-term outcomes for such models of care.

CanVasc consensus recommendations for the use of avacopan in antineutrophil cytoplasm antibody-associated vasculitis: 2022 addendum

OBJECTIVE

In 2020, the Canadian Vasculitis Research Network (CanVasc) published their updated recommendations for the management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV). The current addendum provides further recommendations regarding the use of avacopan in AAV based on a review of newly available evidence.

METHODS

An updated systematic literature review on avacopan (formerly, CCX168) using Medline, Embase, and the Cochrane Library was performed for publications up to September 2022. New recommendations were developed and categorized according to the EULAR grading levels, as done for previous CanVasc recommendations. A modified Delphi procedure and videoconferences were used to reach ≥80% consensus on the inclusion, wording and grading of each recommendation.

RESULTS

Three new recommendations were developed. They focus on avacopan therapy indication and duration, as well as timely glucocorticoid tapering.

CONCLUSION

These 2022 addended recommendations provide rheumatologists, nephrologists, and other specialists caring for patients with AAV with guidance for the use of avacopan, based on current evidence and consensus from Canadian experts.

POS1361 THE CANADIAN RESEARCH GROUP OF RHEUMATOLOGY IN IMMUNO-ONCOLOGY (CanRIO): A NATIONWIDE MULTI-CENTER PROSPECTIVE COHORT

Background

Immune Checkpoint Inhibitors (ICI) have altered the landscape of cancer therapy. However, toxicities are common and up to 80% of patients will develop immune-related adverse events (irAE), including rheumatic irAEs (Rh-irAE), which can often limit their cancer treatment. Our knowledge of clinical manifestations and optimal management of patients with Rh-irAE continues to evolve as these agents are being used to treat a wider variety of cancers. Currently available data is limited to retrospective case series and case reports. There is also scarce data on the use of ICI in patients with pre-existing autoimmune disease (PAD) as these patients are often excluded from clinical trials.

Objectives

To describe the clinical presentation, management and early outcomes of patients exposed to ICI with Rh-irAE or PAD recruited and followed prospectively from multiple sites across Canada.

Methods

Adult patients with Rh-irAE from cancer immunotherapy (CTLA-4, PD-1 or PDL-1 inhibitors) or those with PAD exposed to cancer immunotherapy are prospectively recruited across 9 academic sites in Canada. Standardized clinical and biologic data are also collected. We describe clinical characteristics and management of patients recruited between January 2020 and October 2021, stratified based on the presence or absence of PAD.

Results

103 patients were recruited from 9 sites. From those, 85 had Rh-irAE, 47 had pre-existing musculoskeletal and rheumatic diseases, and 20 had other PAD. The most frequent Rh-irAE were joint manifestations (n = 73). Other Rh-irAE included muscle symptoms (n = 7), connective tissue disease (n = 6), vasculitis (n=2) and sarcoid (n = 3). Prednisone was the most common treatment (n = 53). Intraarticular corticosteroids were used in 7 patients. Eleven patients required conventional synthetic disease-modifying anti-rheumatic drugs (DMARD) and only one required biologic DMARD to control the Rh-irAE. Anti-PD-1 therapies were the most used ICI (56.3%), followed by combination therapy (35.9%). Response to index immunotherapy at 6 months was available for 21 patients. Most patients had partial response (57.1%) and only 4 patients had tumor progression (19.1%). The ICI was permanently discontinued due to an irAE in 21 patients (38.1% with PAD and 61.9% without PAD). There were no deaths related to Rh-irAE.

Conclusion

The initial sample of the CanRIO prospective national cohort suggests that demographic characteristics and tumor representation in people with PAD and without PAD is similar. Patients with PAD are less likely to receive combination therapy (n= 12 vs. n=25) and are less likely to have tumor progression on ICI (n=1) compared to those without PAD (n=3). Selection bias is noted in this initial sample since half of recruited patients have PAD. The CanRIO cohort provides valuable insight into real-world spectrum and management of Rh-irAE secondary to immunotherapy for cancer.

Disclosure of Interests

Shahin Jamal Grant/research support from: CanRIO has received financial support from BMS and Organon, Lourdes Gonzalez Arreola: None declared, Julia Tan: None declared, Carrie Ye: None declared, Janet Roberts: None declared, Aurore Fifi-Mah: None declared, Marie Hudson: None declared, Sabrina Hoa: None declared, Janet Pope: None declared, Ines Colmegna: None declared, C. Thomas Appleton: None declared

CanVasc Consensus Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitis: 2020 Update

OBJECTIVE

In 2015, the Canadian Vasculitis Research Network (CanVasc) created recommendations for the management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada. The current update aims to revise existing recommendations and create additional recommendations, as needed, based on a review of new available evidence.

METHODS

A needs assessment survey of CanVasc members informed questions for an updated systematic literature review (publications spanning May 2014 to September 2019) using Medline, Embase, and Cochrane. New and revised recommendations were developed and categorized according to the level of evidence and strength of each recommendation. The CanVasc working group used a 2-step modified Delphi procedure to reach > 80% consensus on the inclusion, wording, and grading of each new and revised recommendation.

RESULTS

Eleven new and 16 revised recommendations were created and 12 original (2015) recommendations were retained. New and revised recommendations are discussed in detail within this document. Five original recommendations were removed, of which 4 were incorporated into the explanatory text. The supplementary material for practical use was revised to reflect the updated recommendations.

CONCLUSION

The 2020 updated recommendations provide rheumatologists, nephrologists, and other specialists caring for patients with AAV in Canada with new management guidance, based on current evidence and consensus from Canadian experts.

Successful Treatment of Cytokine Release Syndrome with IL-6 Blockade in a Patient Transitioning from Immune-Checkpoint to MEK/BRAF Inhibition: A Case Report and Review of Literature

There are now multiple targeted and immunotherapies available for the treatment of metastatic melanoma. Although these agents have dramatically improved the survival of patients, the appropriate sequencing and the safety during the transition between these drugs remains unknown. Recently two cases of cytokine release syndrome (CRS) following transition from immune-checkpoint inhibitors to BRAF and MEK inhibitors (BRAFi/MEKi) in patients with metastatic melanoma have been reported. CRS is a systemic cytokine-driven inflammatory reaction, previously well reported in chimeric antigen receptor T-cell therapies for hematologic malignancies. Here, we report a third case in which severe CRS resistant to glucocorticoid therapy following transition to a MEKi/BRAFi was treated successfully with tocilizumab, an interleukin-6 (IL-6) inhibitor. CRS should be on the differential diagnosis of immune-related adverse events of immunotherapies or targeted cancer therapies for metastatic melanoma, and clinicians in multiple disciplines should be aware of this rare complication and the potential benefits of IL-6 blockade.

Immune-related Adverse Events Associated with Cancer Immunotherapy: A Review for the Practicing Rheumatologist

Immune checkpoint inhibitors have revolutionized cancer therapy by blocking inhibitory pathways of the immune system to fight cancer cells. Their use is often limited by the development of autoimmune toxicities, which can affect multiple organ systems and are referred to as immune-related adverse events (irAE). Among these are rheumatologic irAE, including inflammatory arthritis, myositis, vasculitis, and others. Rheumatologic irAE seem to be different from irAE in other organs and from traditional autoimmune diseases in that they can occur early or have delayed onset, and can persist chronically, even after cancer therapy is terminated. Because immune checkpoint inhibitors are increasingly used for many types of cancer, it is important for oncologists and rheumatologists to recognize and manage toxicities early. In this review, we discuss currently approved immune checkpoint inhibitors and their mechanisms of action and systemic toxicities, with a focus on the management and effect on further cancer therapy of rheumatic irAE.

Severe skin disease in lupus associated with hemophagocytic lymphohistiocytosis: case reports and review of the literature

Background

Hemophagocytic lymphohistiocytosis (HLH) is a severe clinical entity associated with high mortality in the adult population. HLH has been associated with infections, malignancy and autoimmune conditions such as Systemic Lupus Erythematosus (SLE), however this is often in the context of a disease flare. Currently, there are limited reports of inaugural SLE manifesting as HLH with a lack of consensus on treatment and management of these patients.

Case presentation

Here, we present two rare case reports of severe cutaneous manifestation of lupus associated with HLH. Both patients presented with sinister clinical courses with primarily rheumatologic complaints including malaise, arthralgia, and myalgia with biochemical abnormalities. Both patients were diagnosed with HLH as a result of first presentation from cutaneous lupus. A comprehensive literature review using the PubMed database with cases comprising keywords of HLH and SLE up to September 2017 was conducted, with an emphasis on inaugural cutaneous SLE cases.

Conclusions

Ultimately, we highlight that a keen clinical acumen is required as misdiagnosis may lead to insufficient treatment with adverse clinical outcomes with the unique presentation of HLH from inaugural cases of SLE.

Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

OBJECTIVE

To develop recommendations for the assessment of people with systemic lupus erythematosus (SLE) in Canada.

METHODS

Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. The Canadian SLE Working Group (panel of Canadian rheumatologists and a patient representative from Canadian Arthritis Patient Alliance) was created. Questions for recommendation development were identified based on the results of a previous survey of SLE practice patterns of members of the Canadian Rheumatology Association. Systematic literature reviews of randomized trials and observational studies were conducted. Evidence to Decision tables were prepared and presented to the panel at 2 face-to-face meetings and online.

RESULTS

There are 15 recommendations for assessing and monitoring SLE, with varying applicability to adult and pediatric patients. Three recommendations focus on diagnosis, disease activity, and damage assessment, suggesting the use of a validated disease activity score per visit and annual damage score. Strong recommendations were made for cardiovascular risk assessment and measuring anti-Ro and anti-La antibodies in the peripartum period and conditional recommendations for osteoporosis and osteonecrosis. Two conditional recommendations were made for peripartum assessments, 1 for cervical cancer screening and 2 for hepatitis B and C screening. A strong recommendation was made for annual influenza vaccination.

CONCLUSION

These are considered the first guidelines using the GRADE method for the monitoring of SLE. Existing evidence is largely of low to moderate quality, resulting in more conditional than strong recommendations. Additional rigorous studies and special attention to pediatric SLE populations and patient preferences are needed.

Monitoring of Osteonecrosis in Systemic Lupus Erythematosus: A Systematic Review and Metaanalysis

Objective.

Nontraumatic osteonecrosis (ON) is a well-recognized complication causing disability and affecting quality of life in patients with systemic lupus erythematosus (SLE). The aim of this study was to identify the risk factors for ON, and to identify the minimal investigation(s) needed to optimally monitor the risk of ON in patients with SLE.

Methods.

A systematic review was conducted using MEDLINE and EMBASE. These databases were searched up to January 2016 using the Medical Subject Heading (MeSH) terms “Osteonecrosis,” “Systemic lupus erythematosus,” and synonymous text words. Randomized controlled trials, case control, cohort, and cross-sectional studies were included. Risk factors for ON in patients with SLE were compiled. The quality of each study was assessed using the Newcastle-Ottawa scale for nonrandomized studies. The quality of evidence of each risk factor was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method.

Results.

Of the 545 references yielded, 50 met inclusion criteria. Corticosteroid (CS) use may be strongly associated with ON in patients with SLE. Other clinical variables were moderately associated, including hypertension, serositis, renal disease, vasculitis, arthritis, and central nervous system disease. However, the evidence was low to very low in quality.

Conclusion.

Based on the best evidence available, CS use may be strongly associated with ON in patients with SLE. Results of this review were considered in the development of recommendations for the diagnosis and monitoring of patients with SLE in Canada and will guide clinicians in their assessment of these patients.

Variations in the clinical practice of physicians managing Takayasu arteritis: a nationwide survey

Objective

Takayasu arteritis (TAK) is a large vessel vasculitis that predominately affects young women and can cause severe ischemic complications. Given the rarity of TAK, the management of this condition is challenging. We aim to describe current rheumatologist practices for the management of TAK and identify discrepancies and gaps in knowledge.

Methods

An online survey (developed by the Canadian Vasculitis Network and approved by the Canadian Rheumatology Association) containing 48 questions with regard to the diagnosis, monitoring and treatment of TAK was distributed to 495 Canadian adult and pediatric rheu-matologists by email.

Results

Sixty-six rheumatologists completed the survey (13% response rate): the majority (73%) were from academic centers and ≤25% reported managing more than ten patients in their career. For establishing the diagnosis of TAK, they relied on a combination of signs and symptoms of ischemia, elevations of inflammatory markers and vascular imaging (typically computed tomography and magnetic resonance angiography). The frequency of monitoring for disease activity and the methods employed (clinical, laboratory or imaging) were variable. All physicians used corticosteroids for the treatment of TAK, but 42% would treat for at least 6–12 months, 26% for 12–24 months and 23% would never stop corticosteroids. Fifty-three percent would always use an immunosuppressant (most commonly methotrexate or azathioprine) in addition to corticosteroids and the remainder would only start an immunosuppressant in patients with refractory or relapsing disease.

Conclusion

Physician practices for the management of TAK are variable, suggesting that there are knowledge gaps, which may impact outcomes in patients with TAK.

CanVasc recommendations for the management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides - Executive summary

The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties, including rheumatology and nephrology and researchers with expertise in vasculitis. One of its aims was to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides in Canada. This executive summary features the 19 recommendations and 17 statements addressing general AAV diagnosis and management, developed by CanVasc group based on a synthesis of existing international guidelines, other published supporting evidence and expert consensus considering the Canadian healthcare context.

CanVasc Recommendations for the Management of Antineutrophil Cytoplasm Antibody-associated Vasculitides

Objective.

The Canadian Vasculitis research network (CanVasc) is composed of physicians from different medical specialties and researchers with expertise in vasculitis. One of its aims is to develop recommendations for the diagnosis and management of antineutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) in Canada.

Methods.

Diagnostic and therapeutic questions were developed based on the results of a national needs assessment survey. A systematic review of existing non-Canadian recommendations and guidelines for the diagnosis and management of AAV and studies of AAV published after the 2009 European League Against Rheumatism/European Vasculitis Society recommendations (publication date: January 2009) until November 2014 was performed in the Medline database, Cochrane library, and main vasculitis conference proceedings. Quality of supporting evidence for each therapeutic recommendation was graded. The full working group as well as additional reviewers, including patients, reviewed the developed therapeutic recommendations and nontherapeutic statements using a modified 2-step Delphi technique and through discussion to reach consensus.

Results.

Nineteen recommendations and 17 statements addressing general AAV diagnosis and management were developed, as well as appendices for practical use, for rheumatologists, nephrologists, respirologists, general internists, and all other healthcare professionals more occasionally involved in the management of patients with AAV in community and academic practice settings.

Conclusion.

These recommendations were developed based on a synthesis of existing international guidelines, other published supporting evidence, and expert consensus considering the Canadian healthcare context, with the intention of promoting best practices and improving healthcare delivery for patients with AAV.

Development of Canadian Recommendations for the Management of ANCA-Associated Vasculitides: Results of the National Needs Assessment Questionnaire

Objectives :

To study variations in Canadian clinical practice patterns for the management of ANCA-associated vasculitis (AAV) and identify points to consider for the development of national recommendations.

Material and Methodology :

A 30-item needs assessment questionnaire was sent to all members of the Canadian Vasculitis network (CanVasc), Canadian Rheumatology Association (CRA), Canadian Thoracic Society (CTS) and Canadian Society of Nephrology (CSN). Respondent characteristics, practice patterns, concerns and expectations were analyzed.

Results :

Among 132 physicians who followed at least 1 vasculitis patient and responded to the survey, 39% stated that they felt confident in their management of AAV. Several variations in practice were observed regarding diagnostic procedure, induction and maintenance treatments and use of biologics; some were due to logistic constraints (difficulties in access to some specific tests, drugs or care; lack of health care coverage for the costs). The top 5 topics for which recommendations are expected involve treatment for remission induction, maintenance, refractory disease, and relapse as well as biologics.

Conclusion :

Practice variations identified in this needs assessment survey will serve to formulate key questions for the development of CanVasc recommendations.

Characteristics and outcome of connective tissue diseases in patients with sickle-cell disease: report of 30 cases

OBJECTIVES

To analyze the main characteristics of adults with sickle cell disease (SCD) and concurrent connective tissue disease (CTD).

METHODS

A retrospective investigational study was performed. CTD was diagnosed according to standard international criteria. Severity of SCD was assessed by a clinical severity score.

RESULTS

Thirty patients, 23 women (76%) and 7 men, with hemoglobin S/S (n = 25) or S/C (n = 5) SCD were included. The subtypes of CTD were rheumatoid arthritis (RA) (n = 15), definite systemic lupus erythematosus or "incomplete lupus" requiring treatment (n = 13), primary Sjögren's syndrome with central nervous system involvement (n = 1), and systemic sclerosis (n = 1). Twenty-five of the 30 patients (83%) received steroid treatment, and 15 (50%) received at least 1 immunosuppressive agent (methotrexate in 14 cases) to control CTD. Four RA patients were given antitumor necrosis factor (TNF)alpha and 1 was treated with rituximab without SCD exacerbation. After a median follow-up of 4.5 years [range: 6 months to 30 years] from CTD diagnosis, 11 of the 25 (44%) patients receiving steroids had at least 1 episode of severe infection (mostly due to Staphylococcus aureus or Escherichia coli). SCD exacerbated in 13 of the 30 (43%) patients after CTD onset; 12 of these patients were receiving prednisone and/or methotrexate. Six patients (20%) had died from sepsis (n = 2), stroke (n = 2), or acute chest syndrome (n = 2).

CONCLUSIONS

CTD-related clinical manifestations and outcome were not particularly severe in patients with SCD. However, those with active CTD and undergoing steroid +/- methotrexate treatment had more serious SCD-related manifestations, a higher rate of severe infections, and an overall patient mortality rate of 20%. Thus, the management of patients with CTD and underlying SCD should consider the risk/benefit ratio of each treatment and steroid-sparing strategies should be implemented.