Quantifying hospital-associated costs, and accompanying travel costs and productivity losses, before and after withdrawing tumour necrosis factor-alfa inhibitors in juvenile idiopathic arthritis

OBJECTIVE

To quantify differences in hospital-associated costs, and accompanying travel costs and productivity losses, before and after withdrawing TNFi in JIA patients.

METHODS

Retrospective analysis of prospectively collected data from electronic medical records of paediatric JIA patients treated with TNFi, which were either immediately discontinued, spaced (increased treatment interval) or tapered (reduced subsequent doses). Costs of hospital-associated resource use (consultations, medication, radiology procedures, laboratory testing, procedures under general anaesthesia, hospitalisation) and associated travel costs and productivity losses were quantified during clinically inactive disease until TNFi withdrawal (pre-withdrawal period) and compared with costs during the first and second year after withdrawal initiation (first and second year post-withdrawal).

RESULTS

Fifty-six patients were included of whom 26 immediately discontinued TNFi, 30 spaced and zero tapered. Mean annual costs were €9,165/patient on active treatment (pre-withdrawal) and decreased significantly to €5,063/patient (-44.8%) and €6,569/patient (-28.3%) in the first and second year post-withdrawal, respectively (p< 0.05). Of these total annual costs, travel costs plus productivity losses were €834/patient, €1,180/patient, and €1,320/patient, in the three periods respectively. Medication comprised 80.7%, 61.5% and 72.4% of total annual costs in the pre-withdrawal, first, and second year post-withdrawal period, respectively.

CONCLUSION

In the first two years after initiating withdrawal, the total annual costs are decreased compared with the pre-withdrawal period. However, cost reductions were lower in the second year compared with the first year post-withdrawal, primarily due to restarting or intensifying biologics. To support biologic withdraw decisions, future research should assess the full long-term societal cost impacts, and include all biologics.

Discontinuation of biologic DMARDs in non-systemic JIA patients: a scoping review of relapse rates and associated factors

BACKGROUND

Biologic disease-modifying antirheumatic drugs (bDMARDs) have changed the treatment of juvenile idiopathic arthritis (JIA) patients notably, as bDMARDs enable substantially more patients to achieve remission. When sustained remission is achieved, tapering or even discontinuation of the bDMARD is advocated, to reduce side effects and costs. However, when and how to discontinue bDMARD therapy and what happens afterwards, is less known.

OBJECTIVES

With this scoping review we aim to collect available data in current literature on relapse rate, time to relapse (TTR) and possible flare associated variables (such as time spent in remission and method of discontinuation) after discontinuing bDMARDs in non-systemic JIA patients.

METHODS

We performed a literature search until July 2022 using the Pubmed database. All original studies reporting on bDMARD discontinuation in non-systemic JIA patients were eligible. Data on patient- and study characteristics, the applied discontinuation strategy, relapse rates and time to relapse were extracted in a standardized template.

RESULTS

Of the 680 records screened, 28 articles were included in this review with 456 non-systemic JIA patients who tapered and/or stopped bDMARD therapy. Relapse rate after discontinuation of bDMARDs, either abruptly or following tapering, were 40-48%, 36.8-45.0% and 60-78% at 6, 8 and 12 months respectively. Total relapse rate ranged from 26.3% to 100%, with mean time to relapse (TTR) of 2 to 8.4 months, median TTR 3 to 10 months. All studies stated a good response after restart of therapy after flare. JIA subtype, type of bDMARD, concomitant methotrexate use, treatment duration, tapering method, age, sex, and time in remission could not conclusively be related to relapse rate or TTR. However, some studies reported a positive correlation between flare and antinuclear antibodies positivity, younger age at disease onset, male sex, disease duration and delayed remission, which were not confirmed in other studies.

CONCLUSION

Flares seem to be common after bDMARD discontinuation, but little is known about which factors influence these flares in JIA patients. Follow up after discontinuation with careful registration of patient variables, information about tapering methods and flare rates are required to better guide tapering and/or stopping of bDMARDs in JIA patients in the future.

POS0178 GENE SIGNATURE FINGERPRINTS DIVIDE SLE PATIENTS IN SUBGROUPS WITH COMPARABLE BIOLOGICAL DISEASE PROFILES: A MULTICENTRE LONGITUDINAL STUDY

Background:

Even in the hands of experienced clinicians, clinical phenotyping and predicting treatment responses in Systemic Lupus Erythematosus (SLE) patients remains challenging. Therefore, the identification of biomarkers that can help physicians to divide patients into subgroups based upon aberrantly activated pathways is relevant and might guide future treatment strategies. Extensive blood transcriptional profiling has identified various gene modules that seem promising for stratification of SLE patients into subgroups (1). However, the feasibility to implement these complicated and expensive tests for use in the daily practice of routine clinical laboratories is challenging if not impossible.

Objectives:

The aim of this study was to develop gene signatures that stratify patients into groups with comparable disease profiles and are feasible to perform in routine clinical laboratories.

Methods:

To identify coordinated expression of a set of genes and reduce data complexity, genes from 4 previously described modules (Interferon M1.2, Interferon M5.12, Neutrophil- and Plasmablast (PB)(1)) were measured using real-time quantitative PCR expression on whole blood RNA samples. Subsequently, a principle component analysis was used to select 2-5 indicator genes, that represent a specific signature. Expression levels of these genes were measured in healthy donors (n=42) and samples from two independent childhood-onset SLE cohorts (n=51 and n=20). Scores higher than the mean + 2 S.D. score of healthy controls were defined as high gene signature scores. Based on their expression levels, gene signatures were divided over 14 clusters. Associated clusters were subsequently grouped into three gene fingerprints termed 1) all-signatures-low, 2) only high IFN (M1.2 and/or M5.12) and 3) high PB and/or Neutrophil. Disease activity was measured by the SELENA-SLEDAI score.

Results:

All four gene signatures were higher expressed in patients compared to healthy controls and showed a significant correlation with the SLEDAI. The PB signature showed the highest association with disease activity (r= 0.6512, P<0.0001). In longitudinally collected samples, the PB signature was reduced in patients who were on treatment and showed a significant trend with the SLEDAI. When patients were divided into the described gene fingerprints, the highest SLEDAI scores (median score=8) were observed in the high PB-Neutrophil group. The lowest disease activity (median score =2) was observed in the all-signatures-low group. The same distribution was seen when samples from a second time point were divided based on this stratification method and this was also reproduced in samples from an independent SLE cohort (figure 1).

Conclusion:

Various gene signatures are associated with disease activity, which underlines the involvement of different pathophysiological mechanisms in SLE. Combining these signatures into gene fingerprints can help to stratify patients into comparable groups and guide individualized treatment choices for patients in the future.

References:

[1]Banchereau R, Hong S, Cantarel B, Baldwin N, Baisch J, Edens M, et al. Personalized Immunomonitoring Uncovers Molecular Networks that Stratify Lupus Patients. Cell. 2016;165(6):1548-50.

Figure 1.

SELENA-SLEDAI scores based on gene fingerprint distribution. Blue indicates time point one of cohort 1 (n=51); pink indicates time point two of cohort 1 (n=45); red indicates time point one of the replication cohort (n=20)

Disclosure of Interests:

None declared

Dutch patients, caregivers and healthcare professionals generate first nationwide research agenda for juvenile idiopathic arthritis

BACKGROUND

Involving the end-users of scientific research (patients, carers and clinicians) in setting research priorities is important to formulate research questions that truly make a difference and are in tune with the needs of patients. We therefore aimed to generate a national research agenda for Juvenile Idiopathic Arthritis (JIA) together with patients, their caregivers and healthcare professionals through conducting a nationwide survey among these stakeholders.

METHODS

The James Lind Alliance method was used, tailored with additional focus groups held to involve younger patients. First, research questions were gathered through an online and hardcopy survey. The received questions that were in scope were summarised and a literature search was performed to verify that questions were unanswered. Questions were ranked in the interim survey, and the final top 10 was chosen during a prioritisation workshop.

RESULTS

Two hundred and seventy-eight respondents submitted 604 questions, of which 519 were in scope. Of these 604 questions, 81 were generated in the focus groups with younger children. The questions were summarised into 53 summary questions. An evidence checking process verified that all questions were unanswered. A total of 303 respondents prioritised the questions in the interim survey. Focus groups with children generated a top 5 of their most important questions. Combining this top 5 with the top 10s of patients, carers, and clinicians led to a top 21. Out of these, the top 10 research priorities were chosen during a final workshop. Research into pain and fatigue, personalised treatment strategies and aetiology were ranked high in the Top 10.

CONCLUSIONS

Through this study, the top 10 research priorities for JIA of patients, their caregivers and clinicians were identified to inform researchers and research funders of the research topics that matter most to them. The top priority involves the treatment and mechanisms behind persisting pain and fatigue when the disease is in remission.

Dutch juvenile idiopathic arthritis patients, carers and clinicians create a research agenda together following the James Lind Alliance method: a study protocol

BACKGROUND

Research on Juvenile Idiopathic Arthritis (JIA) should support patients, caregivers/parents (carers) and clinicians to make important decisions in the consulting room and eventually to improve the lives of patients with JIA. Thus far these end-users of JIA-research have rarely been involved in the prioritisation of future research.

MAIN BODY

Dutch organisations of patients, carers and clinicians will collaboratively develop a research agenda for JIA, following the James Lind Alliance (JLA) methodology. In a 'Priority Setting Partnership' (PSP), they will gradually establish a top 10 list of the most important unanswered research questions for JIA. In this process the input from clinicians, patients and their carers will be equally valued. Additionally, focus groups will be organised to involve young people with JIA. The involvement of all contributors will be monitored and evaluated. In this manner, the project will contribute to the growing body of literature on how to involve young people in agenda setting in a meaningful way.

CONCLUSION

A JIA research agenda established through the JLA method and thus co-created by patients, carers and clinicians will inform researchers and research funders about the most important research questions for JIA. This will lead to research that really matters.

Primary immunodeficiency associated with chromosomal aberration - an ESID survey

Background

Patients with syndromic features frequently suffer from recurrent respiratory infections, but little is known about the spectrum of immunological abnormalities associated with their underlying chromosomal aberrations outside the well-known examples of Down and DiGeorge syndromes. Therefore, we performed this retrospective, observational survey study.

Methods

All members of the European Society for Immunodeficiencies (ESID) were invited to participate by reporting their patients with chromosomal aberration (excluding Down and DiGeorge syndromes) in combination with one or more identified immunological abnormalities potentially relating to primary immunodeficiency. An online questionnaire was used to collect the patient data.

Results

Forty-six patients were included from 16 centers (24 males, 22 females; median age 10.4 years [range 1.0–69.2 years]; 36 pediatric, 10 adult patients). A variety of chromosomal aberrations associated with immunological abnormalities potentially relating to primary immune deficiency was reported. The most important clinical presentation prompting the immunological evaluation was ‘recurrent ear-nose-throat (ENT) and airway infections’. Immunoglobulin isotype and/or IgG-subclass deficiencies were the most prevalent immunological abnormalities reported.

Conclusions

Our survey yielded a wide variety of chromosomal aberrations associated with immunological abnormalities potentially relating to primary immunodeficiency. Although respiratory tract infections can often also be ascribed to other causes (e.g. aspiration or structural abnormalities), we show that a significant proportion of patients also have an antibody deficiency requiring specific treatment (e.g. immunoglobulin replacement, antibiotic prophylaxis). Therefore, it is important to perform immunological investigations in patients with chromosomal aberrations and recurrent ENT or airway infections, to identify potential immunodeficiency that can be specifically treated.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-016-0492-1) contains supplementary material, which is available to authorized users.