Global, regional, and national burden of neck pain, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

BACKGROUND

Neck pain is a highly prevalent condition that leads to considerable pain, disability, and economic cost. We present the most current estimates of neck pain prevalence and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) by age, sex, and location, with forecasted prevalence to 2050.

METHODS

Systematic reviews identified population-representative surveys used to estimate the prevalence of and YLDs from neck pain in 204 countries and territories, spanning from 1990 to 2020, with additional data from opportunistic review. Medical claims data from Taiwan (province of China) were also included. Input data were pooled using DisMod-MR 2.1, a Bayesian meta-regression tool. Prevalence was forecast to 2050 using a mixed-effects model using Socio-demographic Index as a predictor and multiplying by projected population estimates. We present 95% UIs for every metric based on the 2·5th and 97·5th percentiles of 100 draws of the posterior distribution.

FINDINGS

Globally, in 2020, neck pain affected 203 million (95% uncertainty interval [UI] 163-253) people. The global age-standardised prevalence rate of neck pain was estimated to be 2450 (1960-3040) per 100 000 population and global age-standardised YLD rate was estimated to be 244 (165-346) per 100 000. The age-standardised prevalence rate remained stable between 1990 and 2020 (percentage change 0·2% [-1·3 to 1·7]). Globally, females had a higher age-standardised prevalence rate (2890 [2330-3620] per 100 000) than males (2000 [1600-2480] per 100 000), with the prevalence peaking between 45 years and 74 years in male and female sexes. By 2050, the estimated global number of neck pain cases is projected to be 269 million (219-322), with an increase of 32·5% (23·9-42·3) from 2020 to 2050. Decomposition analysis of the projections showed population growth was the primary contributing factor, followed by population ageing.

INTERPRETATION

Although age-standardised rates of neck pain have remained stable over the past three decades, by 2050 the projected case numbers are expected to rise. With the highest prevalence in older adults (higher in females than males), a larger effect expected in low-income and middle-income countries, and a rapidly ageing global population, neck pain continues to pose a challenge in terms of disability burden worldwide. For future planning, it is essential we improve our mechanistic understanding of the different causes and risk factors for neck pain and prioritise the consistent collection of global neck pain data and increase the number of countries with data on neck pain.

FUNDING

Bill & Melinda Gates Foundation and Global Alliance for Musculoskeletal Health.

Global, regional, and national burden of other musculoskeletal disorders, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

Background

Musculoskeletal disorders include more than 150 different conditions affecting joints, muscles, bones, ligaments, tendons, and the spine. To capture all health loss from death and disability due to musculoskeletal disorders, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) includes a residual musculoskeletal category for conditions other than osteoarthritis, rheumatoid arthritis, gout, low back pain, and neck pain. This category is called other musculoskeletal disorders and includes, for example, systemic lupus erythematosus and spondylopathies. We provide updated estimates of the prevalence, mortality, and disability attributable to other musculoskeletal disorders and forecasted prevalence to 2050.

Methods

Prevalence of other musculoskeletal disorders was estimated in 204 countries and territories from 1990 to 2020 using data from 68 sources across 23 countries from which subtraction of cases of rheumatoid arthritis, osteoarthritis, low back pain, neck pain, and gout from the total number of cases of musculoskeletal disorders was possible. Data were analysed with Bayesian meta-regression models to estimate prevalence by year, age, sex, and location. Years lived with disability (YLDs) were estimated from prevalence and disability weights. Mortality attributed to other musculoskeletal disorders was estimated using vital registration data. Prevalence was forecast to 2050 by regressing prevalence estimates from 1990 to 2020 with Socio-demographic Index as a predictor, then multiplying by population forecasts.

Findings

Globally, 494 million (95% uncertainty interval 431-564) people had other musculoskeletal disorders in 2020, an increase of 123·4% (116·9-129·3) in total cases from 221 million (192-253) in 1990. Cases of other musculoskeletal disorders are projected to increase by 115% (107-124) from 2020 to 2050, to an estimated 1060 million (95% UI 964-1170) prevalent cases in 2050; most regions were projected to have at least a 50% increase in cases between 2020 and 2050. The global age-standardised prevalence of other musculoskeletal disorders was 47·4% (44·9-49·4) higher in females than in males and increased with age to a peak at 65-69 years in male and female sexes. In 2020, other musculoskeletal disorders was the sixth ranked cause of YLDs globally (42·7 million [29·4-60·0]) and was associated with 83 100 deaths (73 600-91 600).

Interpretation

Other musculoskeletal disorders were responsible for a large number of global YLDs in 2020. Until individual conditions and risk factors are more explicitly quantified, policy responses to this burden remain a challenge. Temporal trends and geographical differences in estimates of non-fatal disease burden should not be overinterpreted as they are based on sparse, low-quality data.

Funding

Bill & Melinda Gates Foundation.

Global, regional, and national burden of rheumatoid arthritis, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

Background

Rheumatoid arthritis is a chronic autoimmune inflammatory disease associated with disability and premature death. Up-to-date estimates of the burden of rheumatoid arthritis are required for health-care planning, resource allocation, and prevention. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we provide updated estimates of the prevalence of rheumatoid arthritis and its associated deaths and disability-adjusted life-years (DALYs) by age, sex, year, and location, with forecasted prevalence to 2050.

Methods

Rheumatoid arthritis prevalence was estimated in 204 countries and territories from 1990 to 2020 using Bayesian meta-regression models and data from population-based studies and medical claims data (98 prevalence and 25 incidence studies). Mortality was estimated from vital registration data with the Cause of Death Ensemble model (CODEm). Years of life lost (YLL) were calculated with use of standard GBD lifetables, and years lived with disability (YLDs) were estimated from prevalence, a meta-analysed distribution of rheumatoid arthritis severity, and disability weights. DALYs were calculated by summing YLLs and YLDs. Smoking was the only risk factor analysed. Rheumatoid arthritis prevalence was forecast to 2050 by logistic regression with Socio-Demographic Index as a predictor, then multiplying by projected population estimates.

Findings

In 2020, an estimated 17·6 million (95% uncertainty interval 15·8-20·3) people had rheumatoid arthritis worldwide. The age-standardised global prevalence rate was 208·8 cases (186·8-241·1) per 100 000 population, representing a 14·1% (12·7-15·4) increase since 1990. Prevalence was higher in females (age-standardised female-to-male prevalence ratio 2·45 [2·40-2·47]). The age-standardised death rate was 0·47 (0·41-0·54) per 100 000 population (38 300 global deaths [33 500-44 000]), a 23·8% (17·5-29·3) decrease from 1990 to 2020. The 2020 DALY count was 3 060 000 (2 320 000-3 860 000), with an age-standardised DALY rate of 36·4 (27·6-45·9) per 100 000 population. YLDs accounted for 76·4% (68·3-81·0) of DALYs. Smoking risk attribution for rheumatoid arthritis DALYs was 7·1% (3·6-10·3). We forecast that 31·7 million (25·8-39·0) individuals will be living with rheumatoid arthritis worldwide by 2050.

Interpretation

Rheumatoid arthritis mortality has decreased globally over the past three decades. Global age-standardised prevalence rate and YLDs have increased over the same period, and the number of cases is projected to continue to increase to the year 2050. Improved access to early diagnosis and treatment of rheumatoid arthritis globally is required to reduce the future burden of the disease.

Funding

Bill & Melinda Gates Foundation, Institute of Bone and Joint Research, and Global Alliance for Musculoskeletal Health.

Non-pharmacological interventions to promote work participation in people with rheumatic and musculoskeletal diseases: a systematic review and meta-analysis from the EULAR taskforce on healthy and sustainable work participation

OBJECTIVE

To summarise the evidence on effectiveness of non-pharmacological (ie, non-drug, non-surgical) interventions on work participation (sick leave, work status and presenteeism) in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

A systematic review of randomised controlled trials (RCTs) and longitudinal observational studies (LOS) was performed. Qualitative (RCTs/LOS) and quantitative (RCTs) evidence syntheses were conducted. Mixed-effects restricted maximum likelihood models were used to combine effect estimates, using standardised mean differences (SMDs) as the summary measure for each outcome domain separately, with a negative SMD favouring the intervention over comparator. Subgroup analyses were performed for type of RMD, risk status at baseline regarding adverse work outcomes and intervention characteristics.

RESULTS

Of 10 153 records, 64 studies (37 RCTs and 27 LOS; corresponding to k=71 treatment comparisons) were included. Interventions were mostly conducted in clinical settings (44 of 71, 62%). Qualitative synthesis suggested clear beneficial effects of 7 of 64 (11%) interventions for sick leave, 1 of 18 (6%) for work status and 1 of 17 (6%) for presenteeism. Quantitative synthesis (37 RCTs; k=43 treatment comparisons) suggested statistically significant but only small clinical effects on each outcome (SMD_{sick leave} (95% CI)=-0.23 (-0.33 to -0.13; k=42); SMD_{work status}=-0.38 (-0.63 to -0.12; k=9); SMD_presenteeism=-0.25 (-0.39 to -0.12; k=13)).

CONCLUSION

In people with RMDs, empirical evidence shows that non-pharmacological interventions have small effects on work participation. Effectiveness depends on contextual factors such as disease, population risk status, intervention characteristics and outcome of interest, highlighting the importance of tailoring interventions.

2021 EULAR points to consider to support people with rheumatic and musculoskeletal diseases to participate in healthy and sustainable paid work

AIM

As part of its strategic objectives for 2023, EULAR aims to improve the work participation of people with rheumatic and musculoskeletal diseases (RMDs). One strategic initiative focused on the development of overarching points to consider (PtC) to support people with RMDs in healthy and sustainable paid work participation.

METHODS

EULAR's standardised operating procedures were followed. A steering group identified six research areas on paid work participation. Three systematic literature reviews, several non-systematic reviews and two surveys were conducted. A multidisciplinary taskforce of 25 experts from 10 European countries and Canada formulated overarching principles and PtC after discussion of the results of literature reviews and surveys. Consensus was obtained through voting, with levels of agreement obtained anonymously.

RESULTS

Three overarching principles and 11 PtC were formulated. The PtC recognise various stakeholders are important to improving work participation. Five PtC emphasise shared responsibilities (eg, obligation to provide active support) (PtC 1, 2, 3, 5, 6). One encourages people with RMDs to discuss work limitations when necessary at each phase of their working life (PtC 4) and two focus on the role of interventions by healthcare providers or employers (PtC 7, 8). Employers are encouraged to create inclusive and flexible workplaces (PtC 10) and policymakers to make necessary changes in social and labour policies (PtC 9, 11). A research agenda highlights the necessity for stronger evidence aimed at personalising work-related support to the diverse needs of people with RMDs.

CONCLUSION

Implementation of these EULAR PtC will improve healthy and sustainable work participation of people with RMDs.

Consensus statement on blocking interleukin-6 receptor and interleukin-6 in inflammatory conditions: an update

BACKGROUND

Targeting interleukin (IL)-6 has become a major therapeutic strategy in the treatment of immune-mediated inflammatory disease. Interference with the IL-6 pathway can be directed at the specific receptor using anti-IL-6Rα antibodies or by directly inhibiting the IL-6 cytokine. This paper is an update of a previous consensus document, based on most recent evidence and expert opinion, that aims to inform on the medical use of interfering with the IL-6 pathway.

METHODS

A systematic literature research was performed that focused on IL-6-pathway inhibitors in inflammatory diseases. Evidence was put in context by a large group of international experts and patients in a subsequent consensus process. All were involved in formulating the consensus statements, and in the preparation of this document.

RESULTS

The consensus process covered relevant aspects of dosing and populations for different indications of IL-6 pathway inhibitors that are approved across the world, including rheumatoid arthritis, polyarticular-course and systemic juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, Castleman's disease, chimeric antigen receptor-T-cell-induced cytokine release syndrome, neuromyelitis optica spectrum disorder and severe COVID-19. Also addressed were other clinical aspects of the use of IL-6 pathway inhibitors, including pretreatment screening, safety, contraindications and monitoring.

CONCLUSIONS

The document provides a comprehensive consensus on the use of IL-6 inhibition to treat inflammatory disorders to inform healthcare professionals (including researchers), patients, administrators and payers.

POS0160 THE EMPLOYMENT GAP IN PEOPLE WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES COMPARED WITH THE GENERAL POPULATION: A SYSTEMATIC LITERATURE REVIEW

Background

Many people with rheumatic and musculoskeletal diseases (RMDs) experience problems at work and some may even have to stop working due to ill health. In most countries, RMDs are a major cause of worker productivity loss. The peak age of onset of many adult onset RMDs is between ~30-50 years, meaning that the majority of patients are still in employment when diagnosed with their chronic disease. Uncertainty about employment prospects and job attainment is also a major concern for young adults with juvenile idiopathic arthritis (JIA) for whom their first job may influence their future employment prospects. From both a societal and patient perspective it is important to gain an understanding about the impact of juvenile and adult onset RMDs on work outcomes. Data comparing productivity loss with the general population are more relevant for care and healthcare planning. However, these data are more scarce and have not been summarized recently across RMDs.

Objectives

To systematically summarize the literature on work outcomes in people with RMDs compared with the general population.

Methods

A systematic literature review (SLR) was conducted to compare work outcomes in people with various RMDs (i.e. JIA, RA, PsA, AxSpA, SSc, SLE, gout, FM, and OA) with the general population or healthy controls as part of the EULAR Task Force on work. A search for eligible observational studies was performed in Medline, Embase and PsycInfo between 2000 and May 2021. Work outcomes were categorizedaccortding to employment status, work disability/stopped working due to ill health, absenteeism, presenteeism and other.

Results

541 abstracts were extracted and screened for eligibility. Results of 65 studies fulfilling the inclusion criteria were evaluated for this study, including 28 prospective/retrospective longitudinal cohort studies, 34 cross-sectional studies and 3 (nested) case-control studies. The majority of the studies were conducted in Europe (63.1%). The most common RMD evaluated was RA (26.2%) followed by OA (15.4%), SLE (15.4%), AxSpA (12.3%), FM (9.2%), mixed population (7.7%), JIA (7.7%), PsA (3.1%), SSc (1.5%), and gout (1.5%). In papers reporting disease duration (n=38), the majority of the study population had established disease (76.3%). Several work outcomes were evaluated with some papers reporting more than one work outcome: employment/work status (41.5%), unemployment (9.2%), work disability/pension or stopping work due to ill health (38.5%), absenteeism (52.3%), presenteeism (10.8%), and other (e.g. reduced working hours) (29.2%). Fifty-two papers applied statistical tests (e.g. indirect standardisation, logistic regression analysis, Cox regression analysis) to compare work outcomes in people with RMDs with a control/general population. The percentage of papers reporting the work outcomes to be worse, not significantly different or better in the RMD population compared to the control population (n papers included per work outcome; %) was, respectively: employment/work status (n=26; 73.1%, 23.0%, 3.8%), unemployment (n=6; 66.7%, 33.3%, 0%), work disability/stopping work (n=22; 90.9%, 9.4%, 0%), absenteeism (n=26; 92.3%, 7.7%, 0%), presenteeism (n=8; 87.5%, 12.2%, 0%), other (n=19; 84.2%, 15.8%, 0%).

Conclusion

Despite better disease management during the last two decades there is still a significant employment gap between people with RMDs and the general population. It is therefore essential that health professional organisations, policy makers, patient organisations and employers should collaborate to minimize the employment gap and optimize employment opportunities among people with juvenile and adult onset RMDs.

Disclosure of Interests

Suzanne Verstappen Consultant of: EUOSHA, Grant/research support from: BMS, AbbVie, Pfizer, EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Nicola Goodson Consultant of: UCB, Lilly, Abbvie, Novartis and Janssen, Grant/research support from: Novartis, Casper Webers: None declared, Maarten Butink: None declared, Neil Betteridge Consultant of: Amgen, Eli Lilly, EULAR, GAfPA, Grunenthal, Heart Valve Voice and Sanofi, Tanja Stamm Consultant of: AbbVie and Sanofi Genzyme, Grant/research support from: AbbVie and Roche, Dieter Wiek: None declared, Anthony Woolf: None declared, Hans Bijlsma: None declared, Gerd Rüdiger Burmester: None declared

AB1571-PARE SELF-HEALING CONCEPT: AN INTEGRATIVE MEDICINE APPROACH TO PATIENT SELF-MANAGEMENT OF MUSCULOSKELETAL PAIN

Background

Musculoskeletal (MSK) pain affects bones, muscles, ligaments, tendons, fascia and nerves. The pain can occur suddenly (acute) and can become recurrent. The cause is not always clear but triggers can include obesity, trauma and injury, overuse, ageing, inflammation, and mental disorders. Conventional therapies such as rehabilitation, drugs and surgery treat the symptoms of MSK pain but often not the underlying cause. Integrative medicine (IM) is an alternative to conventional therapies as it focuses on the whole person, making use of all therapeutic approaches to promote healing and is being used more world-wide by both patients and healthcare professionals (HCPs). Connected to IM is the concept of self-healing, an intrinsic ability of the whole body that has developed throughout evolution. A recent publication describes the ‘self-healing concept’ as the innate ability of the body and mind to promote body networks to return the body to equilibrium and relieve pain.1 There are five body networks thought to be essential, the nervous system, microcirculation, immune modulation, muscular relaxation/contraction and psychological balance. Integral to the self-healing concept is that the body networks can be boosted and optimised by the use of IM which can act simultaneously through more than one body network (multi-modal). The use of IM is amenable to patients managing their own care (self-management) however, there is a need for both HCPs and patients to be educated on the self-healing concept.

Objectives

A global survey will be conducted to further understand the perception of patient and HCPs about the self-healing concept and its multi-modal IM approaches.

Methods

The multi-modal IM approaches of the self-healing concept are described here as well as the global survey which will inform and request feedback from HCPs and patients on the role of self-healing in supported self-management of MSK pain.

Results

Multi-modal IM approaches that boost and optimise body networks to reduce MSK pain within the self-healing concept include a variety of techniques. The innate ability of both the body and mind are integral to self-healing and psychological techniques such as yoga, mindfulness meditation, cognitive behavioural therapy and hypnosis are therapies that make use the strength of the mind. Regards the body, muscle strengthening through moderate exercise and physiotherapy is linked to an increase in microcirculation associated with muscle contraction/relaxation. Dietary patterns also have an important role in musculoskeletal well-being, as high intakes of protein, fat, and sugar are associated with a lower pain threshold. The use of traditional Chinese medicine has been shown to be effective, along with other natural therapies such as melatonin, menthol and cannabidiol and heat therapy which can be used to relieve pain and muscle cramps, increase blood flow and facilitate tissue healing. An increasing number of devices are being introduced to patients such as transcutaneous electrical nerve stimulation, which provides localised strong yet comfortable muscle contractions to ease musculoskeletal pain, and infra-red technology, which can potentially help enhance blood circulation and metabolism.

The self-healing global survey is being developed for release in mid-2022. Around 15–20 simple questions will be asked of patients and HCPs via a digital platform/app. The insights generated will address unmet need, quality of life, importance of new innovative therapies, impact of treatment options and the impact of self-management, self-healing and sustainability on the healthcare system.

Conclusion

The use of integrative medicine can boost and optimise the body networks within the self-healing concept and there are many options available for patient self-management of MSK. Results from the survey will identify current treatment gaps and what is needed to improve patient outcomes.

This study was funded by Sanofi.

References

[1]McSwan J, Gudin J, et al. Journal of Pain Research. 2021;14:2943-58.

Acknowledgements

This study was funded by Sanofi. Thank you to the international group of experts for their time and efforts in the development of the self-healing concept: Joyce McSwan (PainWISE, Australia), Jeffrey Gudin (University of Miami, USA), Xue-Jun Song (Southern University of Science and Technology, China) Perola Grinberg Plapler (Hospital das Clínicas, Brazil), Hayet Kechemir (Sanofi CHC, France), Iva Igracki-Turudic (Sanofi CHC, Germany) and Gisele Pickering (Clinical Investigation Center CIC Inserm, France).

Disclosure of Interests

Neil Betteridge Consultant of: Amgen, Eli Lilly, EULAR, GAfPA, Grunenthal, Heart Valve Voice and Sanofi

EULAR Points to Consider (PtC) for designing, analysing and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis

BACKGROUND

Clinical studies with work participation (WP) as an outcome domain pose particular methodological challenges that hamper interpretation, comparison between studies and meta-analyses.

OBJECTIVES

To develop Points to Consider (PtC) for design, analysis and reporting of studies of patients with inflammatory arthritis that include WP as a primary or secondary outcome domain.

METHODS

The EULAR Standardised Operating Procedures were followed. A multidisciplinary taskforce with 22 experts including patients with rheumatic diseases, from 10 EULAR countries and Canada, identified methodologic areas of concern. Two systematic literature reviews (SLR) appraised the methodology across these areas. In parallel, two surveys among professional societies and experts outside the taskforce sought for additional methodological areas or existing conducting/reporting recommendations. The taskforce formulated the PtC after presentation of the SLRs and survey results, and discussion. Consensus was obtained through informal voting, with levels of agreement obtained anonymously.

RESULTS

Two overarching principles and nine PtC were formulated. The taskforce recommends to align the work-related study objective to the design, duration, and outcome domains/measurement instruments of the study (PtC: 1-3); to identify contextual factors upfront and account for them in analyses (PtC: 4); to account for interdependence of different work outcome domains and for changes in work status over time (PtC: 5-7); to present results as means as well as proportions of patients reaching predefined meaningful categories (PtC: 8) and to explicitly report volumes of productivity loss when costs are an outcome (PtC:9).

CONCLUSION

Adherence to these EULAR PtC will improve the methodological quality of studies evaluating WP.

Health systems strengthening to arrest the global disability burden: empirical development of prioritised components for a global strategy for improving musculoskeletal health

INTRODUCTION

Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.

METHODS

Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.

RESULTS

Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening.

CONCLUSION

An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

OP0169-PARE DEVELOPMENT OF POINTS TO CONSIDER WHEN SUPPORTING PERSONS WITH REUMATIC AND MUSCULOSKELETAL DISEASES TO PARTICIPATE IN HEALTHY AND SUSTAINABLE PAID WORK

Background:

Despite earlier diagnosis and improved management of rheumatic and musculoskeletal diseases (RMDs), a work participation gap remains when compared to the general population. To bridge this work participation gap, EULAR’s current strategy states that ‘by 2023, EULAR’s activities and related advocacy will have increased participation in work by people with RMDs’. To achieve this goal, guidance is needed how to support people with RMDs to remain in paid work or (re)-enter the labour force.

Objectives:

To develop Points to Consider (PtC) when supporting people with RMD to participate in healthy and sustainable paid work.

Methods:

An international expert group, established by Eular in 2019, convened twice to agree on a protocol for the development of PtC. EULAR’s standard operating procedures were followed. The group (a) defined the target audience, (b) identified areas from which knowledge should be derived to enable formulation of the PtC, (c) agreed on a strategy to collect evidence, (d) established an international taskforce to formulate and agree on the PtC, and (e) proposed an implementation plan.

Results:

The target audience are professionals involved in clinical care for patients with RMDs as well as their organisations, persons with RMDs and their organisations, and administrators responsible for healthcare and work policies. Six knowledge areas are identified (Table). Depending on the specific knowledge area, strategies for collecting evidence comprise synthesis of published and grey literature, surveys among various organisations and collection of case studies from employers. Whenever evidence in RMDs is limited, evidence from other chronic diseases will be sought. The international taskforce includes experts from different disciplines in rheumatology (one in other chronic diseases), EU policy makers, and representatives of PARE, HCP, EULAR Public Affairs and EMEUNET. As part of the implementation, close cooperation with national professional and patients societies is planned. Additionally, results will be included in EULAR‘s activities at the EU policy level.

Table 1.

Knowledge areas and strategy to retrieve evidence

In persons with RMDs:Sources of evidence1Is work relevant for the clinical outcome of diseaseLR; Review of managament recommendations and Care Standards2What are barriers and facilitators to enter or stay in the labor forceSLR3What is the effectiveness of interventions to enter or stay in the labor forceSLR; Survey among professional and patient organisations4Which social security systems are more effective when entering or staying in the labor forceLR5How does disease influence the cycle of workSLR; Grey literature6What (not) to do by employers to let patients enter or stay in the work forceSLR; Survey among large companies; case studies

LR: Literature review; SLR: Systematic literature review

Conclusion:

The proposed initiative to develop PtC should ultimately result in improvement of healthy and sustainable labor force participation of people with RMDs.

Disclosure of Interests:

Annelies Boonen Grant/research support from: Abbvie, Suzanne Verstappen: None declared, Maarten Butink: None declared, Casper Webers: None declared, Neil Betteridge: None declared, Tanja Stamm: None declared, Dieter Wiek: None declared, Anthony Woolf: None declared, Gerd Rüdiger Burmester: None declared, Hans Bijlsma: None declared

Evolving the comprehensive management of rheumatoid arthritis: identification of unmet needs and development of practical and educational tools

OBJECTIVES

Despite availability of efficacious treatments, unmet needs still exist, preventing optimal and comprehensive management of rheumatoid arthritis (RA). Evolving the management of RA (eRA) is a European-wide educational initiative aiming to support improved patient care through practical and educational tools addressing specific unmet needs.

METHODS

A multidisciplinary Steering Committee (17 members, 12 countries) identified unmet needs within the management of RA and prioritised those with the greatest impact on patient outcomes. Practical educational tools addressing priority needs were then developed for dissemination and implementation by the rheumatology community across Europe.

RESULTS

Five areas of priority need were identified: increasing early recognition of RA and treatment initiation; treating RA to target; optimal, holistic approach to selection of treatment strategy, including shared decision-making; improving identification and management of comorbidities; and non-pharmacological patient management. A suite of 14 eRA tools included educational slides, best-practice guidance, self‑assessment questionnaires, clinical checklists, a multidisciplinary team training exercise, an interactive patient infographic, and case scenarios. By April 2020, rheumatology professionals in 17 countries had been actively engaged in the eRA programme; in 11 countries, eRA tools were selected by national leaders in rheumatology and translated for local dissemination. A web platform, with country-specific pages, was developed to support access to the translated tools (https://www.evolvingthemanagementofra.com/).

CONCLUSIONS

The eRA programme supports comprehensive management of RA across Europe through development and dissemination of practical educational tools. The eRA tools address priority needs and are available free of charge to the rheumatology community.

What do people need?

The key question addressed in this Chapter is "What do people need?", with "people" here meaning those who live with a rheumatic or musculoskeletal disease. The word "patient" is avoided at this point as not all of the problems or solutions identified are medical in nature. Many are personal, societal and/or environmental. The lead authors are all people who not only live with a rheumatic or musculoskeletal disease, but who are experienced "patient representatives". Therefore, their insights here stem from a combination of personal and collective experiences and views. Although from different continents, the authors identify a range of common barriers to social participation and optimum management of these conditions, such as late diagnosis, stigma and access to care. However, several solutions are common across these regions too, such as the need for supported self-management and greater public awareness of the impact of these diseases.

Considerations for improving quality of care of patients with rheumatoid arthritis and associated comorbidities

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disorder with a global prevalence of approximately 0.5-1%. Patients with RA are at an increased risk of developing comorbidities (eg, cardiovascular disease, pulmonary disease, diabetes and depression). Despite this, there are limited recommendations for the management and implementation of associated comorbidities. This study aimed to identify good practice interventions in the care of RA and associated comorbidities.

METHODS

A combination of primary research (180+ interviews with specialists across 12 European rheumatology centres) and secondary research (literature review of existing publications and guidelines/recommendations) were used to identify challenges in management and corresponding good practice interventions. Findings were prioritised and reviewed by a group of 18 rheumatology experts including rheumatologists, comorbidity experts, a patient representative and a highly specialised nurse.

RESULTS

Challenges throughout the patient pathway (including delays in diagnosis and referral, shortage of rheumatologists, limited awareness of primary care professionals) and 18 good practice interventions were identified in the study. The expert group segmented and prioritised interventions according to three distinct stages of the disease: (1) suspected RA, (2) recent diagnosis of RA and (3) established RA. Examples of good practice interventions included enabling self-management (self-monitoring and disease management support, for example, lifestyle adaptations); early arthritis clinic; rapid access to care (online referral, triage, ultrasound-guided diagnosis); dedicated comorbidity specialists; enhanced communication with primary care (hotline, education sessions); and integrating patient registries into daily clinical practice.

CONCLUSION

Learning from implementation of good practice interventions in centres across Europe provides an opportunity to more widely improved care for patients with RA and associated comorbidities.

THU0579 “EVOLVING THE MANAGEMENT OF RA” PROGRAMME: EDUCATIONAL TOOLS TO SUPPORT DAILY PRACTICE

Background:

The eRA (evolving the management of RA) programme was initiated in Europe to provide practical educational tools that address unmet needs in the management of rheumatoid arthritis (RA). Several eRA tools – covering early access to care, management of comorbidities, treat-to-target strategies, and patient empowerment – are available to the rheumatology community. Through ongoing activities, the eRA Steering Committee (SC) identified a need for tools on non-pharmacological management of RA.

Objectives:

To improve accessibility to eRA tools for rheumatology professionals; to review the evidence base of non-pharmacological interventions to create new eRA resources that may support management decisions.

Methods:

A web platform providing information on eRA programme and tools was developed in 2019. The platform collects survey-based metrics to quantify perception of eRA and use of eRA tools in clinical practice. Platform and tools are translated to further support access and use across Europe.

To address unmet needs in non-pharmacological patient management, the eRA SC reviewed the core literature on agreed priority interventions, including physical activity, diet, patient education and self-management, psychosocial interventions, occupational therapy and orthotics, hand exercises, and hydrotherapy/balneotherapy. Available evidence for each intervention was assessed and graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.

Results:

The eRA web platform is now live in 3 countries (www.evolvingthemanagementofRA.com), hosting translated copies of the eRA tools, with additional countries launching throughout 2020.

From a review of core literature on non-pharmacological interventions, the eRA SC determined that strong evidence exists to support use of physical activity, patient education and self-management, psychosocial interventions, and occupational therapy and orthotics. Evidence was lacking or conflicting for diet and nutrition, hand exercises, and balneotherapy/hydrotherapy. A set of educational slides was produced by the eRA SC to summarise the evidence (Fig. 1) and provide top-line guidance on use of interventions in practice that should engage relevant members of the multi-disciplinary team. These slides are available through eRA dissemination activities.

Conclusion:

The eRA programme content is now freely available to health care professionals in several countries on a web platform, supported by translations of the eRA tools. An additional slide set on non-pharmacological management serves to further increase the practical guidance of this programme’s educational offering.

Acknowledgments:

The eRA programme is funded by Sanofi Genzyme. Programme direction and content creation are driven by an independent Steering Committee

Disclosure of Interests:

Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Neil Betteridge Consultant of: Amgen, Eli Lilly and Company, Grunenthal, GSK, Sanofi Genzyme, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Ricardo J. O. Ferreira Grant/research support from: Abbvie, Consultant of: Sanofi Genzyme, Amgen, MSD, Paid instructor for: UCB, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Carlomaurizio Montecucco: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme

Treatment Mode Preferences in Rheumatoid Arthritis: Moving Toward Shared Decision-Making

PURPOSE

Current knowledge of the reasons for patients' preference for rheumatoid arthritis (RA) treatment modes is limited. This study was designed to identify preferences for four treatment modes, and to obtain in-depth information on the reasons for these preferences.

PATIENTS AND METHODS

In this multi-national, cross-sectional, qualitative study, in-depth interviews were conducted with adult patients with RA in the United States, France, Germany, Italy, Spain, Switzerland, the United Kingdom, and Brazil. Patients' strength of preference was evaluated using a 100-point allocation task (0-100; 100=strongest) across four treatment modes: oral, self-injection, clinic-injection, and infusion. Qualitative descriptive analysis methods were used to identify, characterize, and summarize patterns found in the interview data relating to reasons for these preferences.

RESULTS

100 patients were interviewed (female, 75.0%; mean age, 53.9 years; mean 11.6 years since diagnosis). Among the four treatment modes, oral administration was allocated the highest mean (standard deviation) preference points (47.3 [33.1]) and was ranked first choice by the greatest percentage of patients (57.0%), followed by self-injection (29.7 [27.7]; 29.0%), infusion (15.4 [24.6]; 16.0%), and clinic-injection (7.5 [14.1]; 2.0%). Overall, 56.0% of patients had a "strong" first-choice preference (ie, point allocation ≥70); most of these patients chose oral (62.5%) vs self-injection (23.2%), infusion (10.7%), or clinic-injection (3.6%). Speed and/or ease of administration were the most commonly reported reasons for patients choosing oral (52.6%) or self-injection (55.2%). The most common reasons for patients not choosing oral or self-injection were not wanting to take another pill (37.2%) and avoiding pain due to needles (46.5%), respectively.

CONCLUSION

These data report factors important to patients regarding preferences for RA treatment modes. Patients may benefit from discussions with their healthcare professionals and/or patient support groups, regarding RA treatment modes, to facilitate shared decision-making.

Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting

OBJECTIVE

Acute postoperative pain is experienced by the majority of hospitalized patients undergoing surgical procedures, with many reporting inadequate pain relief and/or high levels of dissatisfaction with their pain management. Patient-controlled analgesia (PCA) ensures patient involvement in acute pain control, a key component for implementing a quality management system. This narrative article overviews the clinical evidence for conventional PCA and briefly discusses new, non-invasive PCA systems, namely the sufentanil sublingual tablet system (SSTS) and the fentanyl iontophoretic transdermal system (FITS).

METHODS

A Medline literature search ("patient-controlled analgesia" and "acute postoperative pain") was conducted to 1 April 2017; results from the main clinical trials are discussed. Additional literature was identified from the reference lists of cited publications.

RESULTS

Moderate to low quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain. However, despite the benefits of PCA, conventional intravenous PCA is limited by system-, drug- and human-related issues. The non-invasive SSTS and FITS have demonstrated good efficacy and safety in placebo- and intravenous morphine PCA-controlled trials, and are associated with high patient/healthcare practitioner satisfaction/ease of care ratings and offer early patient mobilization.

CONCLUSIONS

Evidence-based guidelines for acute postoperative pain management support the use of multimodal regimens in many situations. As effective and safe alternatives to conventional PCA, and with the added benefits of being non-invasive, easy to use and allowing early patient mobilization, the newer PCA systems may complement multimodal approaches, or potentially replace certain regimens, in hospitalized patients with acute postoperative pain.

Common language description of the term rheumatic and musculoskeletal diseases (RMDs) for use in communication with the lay public, healthcare providers and other stakeholders endorsed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR)

A European League Against Rheumatism-American College of Rheumatology working group consisting of practising and academic rheumatologists, a rheumatology researcher and a patient representative created a succinct general statement describing rheumatic and musculoskeletal diseases (RMDs) in adults and children in language that can be used in conversations with the lay public, media, healthcare providers and other stakeholders. Based on the literature review, several elements were deemed important for inclusion in the description of RMDs. First, RMDs encompass many different diseases that can affect individuals at any age, including children. Second, there are various pathophysiological pathways underlying different RMDs. Third, the impact of RMDs on individuals and society should be emphasised. The working group agreed that the language should be comprehensible to the lay public. Thus, the following description of RMDs has been developed: 'Rheumatic and musculoskeletal diseases (RMDs) are a diverse group of diseases that commonly affect the joints, but can affect any organ of the body. There are more than 200 different RMDs, affecting both children and adults. They are usually caused by problems of the immune system, inflammation, infections or gradual deterioration of joints, muscles and bones. Many of these diseases are long term and worsen over time. They are typically painful and limit function. In severe cases, RMDs can result in significant disability, having a major impact on both quality of life and life expectancy.' This description can be used by rheumatology groups, researchers and those who work in advocacy and education related to RMDs.

Management of acute pain in the postoperative setting: the importance of quality indicators

Despite the introduction of evidence-based recommendations for postoperative pain management (POPM), the consensus is that pain control remains suboptimal. Barriers to achieving patient-satisfactory analgesia include deficient knowledge regarding POPM among staff, lack of instructions, insufficient pain assessments and sub-optimal treatment. Effective monitoring of POPM is essential to enable policy makers and healthcare providers to improve the quality of care. Quality indicators (QIs) are quantitative measures of clinical practice that can monitor, evaluate and guide the quality of care provided to patients. QIs can be used to assess various aspects relating to the care process and they have proven useful in improving health outcomes in diseases such as myocardial infarction. In this commentary we critically analyze the evidence regarding the use of QIs in acute POPM based upon the experience of pain specialists from Europe and the USA who are members of the Change Pain Advisory Board. We also undertook a literature review to see what has been published on QIs in acute pain with the goal of assessing which QIs have been developed and used, and which ones have been successful/unsuccessful. In the hospital sector the development and implementation of QIs is complex. The nature of POPM requires a highly trained, multidisciplinary team and it is at this level that major improvements can be made. Greater involvement of patients regarding pain management is also seen as a priority area for improving clinical outcomes. Changes in structure and processes to deliver high-level quality care need to be regularly audited to ensure translation into better outcomes. QIs can help drive this process by providing an indicator of current levels of performance. In addition, outcomes QIs can be used to benchmark levels of performance between different healthcare providers.

Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force

Therapeutic targets have been defined for axial and peripheral spondyloarthritis (SpA) in 2012, but the evidence for these recommendations was only of indirect nature. These recommendations were re-evaluated in light of new insights. Based on the results of a systematic literature review and expert opinion, a task force of rheumatologists, dermatologists, patients and a health professional developed an update of the 2012 recommendations. These underwent intensive discussions, on site voting and subsequent anonymous electronic voting on levels of agreement with each item. A set of 5 overarching principles and 11 recommendations were developed and voted on. Some items were present in the previous recommendations, while others were significantly changed or newly formulated. The 2017 task force arrived at a single set of recommendations for axial and peripheral SpA, including psoriatic arthritis (PsA). The most exhaustive discussions related to whether PsA should be assessed using unidimensional composite scores for its different domains or multidimensional scores that comprise multiple domains. This question was not resolved and constitutes an important research agenda. There was broad agreement, now better supported by data than in 2012, that remission/inactive disease and, alternatively, low/minimal disease activity are the principal targets for the treatment of PsA. As instruments to assess the patients on the path to the target, the Ankylosing Spondylitis Disease Activity Score (ASDAS) for axial SpA and the Disease Activity index for PSoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA) for PsA were recommended, although not supported by all. Shared decision-making between the clinician and the patient was seen as pivotal to the process. The task force defined the treatment target for SpA as remission or low disease activity and developed a large research agenda to further advance the field.

Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience

Patients with psoriatic arthritis (PsA) may not be optimally treated. The impact of the disease extends beyond skin and joint symptoms, impairing quality of life. This indicates that the adoption of a patient-focused approach to PsA management is necessary. An expert multidisciplinary working group was convened, with the objective of developing an informed perspective on current best practice and needs for the future management of PsA. Topics of discussion included the barriers to current best practice and calls to action for the improvement of three areas in PsA management: early and accurate diagnosis of PsA, management of disease progression and management of the impact of the condition on the patient. The working group agreed that, to make best use of the available of diagnostic tools, clinical care recommendations and effective treatments, there is a clear need for healthcare professionals from different disciplines to collaborate in the management of PsA. By facilitating appropriate and rapid referral, providing high quality information about PsA and its treatment to patients, and actively involving patients when choosing management plans and setting treatment goals, management of PsA can be improved. The perspective of the working group is presented here, with recommendations for the adoption of a multidisciplinary, patient-focused approach to the management of PsA.

Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force

BACKGROUND

Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.

OBJECTIVE

To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.

METHODS

A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.

RESULTS

The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).

CONCLUSIONS

The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.

European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update

BACKGROUND

Since the publication of the European League Against Rheumatism recommendations for the pharmacological treatment of psoriatic arthritis (PsA) in 2012, new evidence and new therapeutic agents have emerged. The objective was to update these recommendations.

METHODS

A systematic literature review was performed regarding pharmacological treatment in PsA. Subsequently, recommendations were formulated based on the evidence and the expert opinion of the 34 Task Force members. Levels of evidence and strengths of recommendations were allocated.

RESULTS

The updated recommendations comprise 5 overarching principles and 10 recommendations, covering pharmacological therapies for PsA from non-steroidal anti-inflammatory drugs (NSAIDs), to conventional synthetic (csDMARD) and biological (bDMARD) disease-modifying antirheumatic drugs, whatever their mode of action, taking articular and extra-articular manifestations of PsA into account, but focusing on musculoskeletal involvement. The overarching principles address the need for shared decision-making and treatment objectives. The recommendations address csDMARDs as an initial therapy after failure of NSAIDs and local therapy for active disease, followed, if necessary, by a bDMARD or a targeted synthetic DMARD (tsDMARD). The first bDMARD would usually be a tumour necrosis factor (TNF) inhibitor. bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. If the first bDMARD strategy fails, any other bDMARD or tsDMARD may be used.

CONCLUSIONS

These recommendations provide stakeholders with an updated consensus on the pharmacological treatment of PsA and strategies to reach optimal outcomes in PsA, based on a combination of evidence and expert opinion.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update

In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.

Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force

BACKGROUND

Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such targets are just emerging for spondyloarthritis (SpA).

OBJECTIVE

To define the treatment target for SpA including ankylosing spondylitis and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy.

METHODS

Based on results of a systematic literature review and expert opinion, a task force of expert physicians and patients developed recommendations which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade and strength of the recommendations were derived by respective means. The commonalities between axial SpA, peripheral SpA and PsA were discussed in detail.

RESULTS

Although the literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated the development of recommendations. The group agreed on 5 overarching principles and 11 recommendations; 9 of these recommendations related commonly to the whole spectrum of SpA and PsA, and only 2 were designed separately for axial SpA, peripheral SpA and PsA. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with the alternative target of low disease activity. Follow-up examinations at regular intervals that depend on the patient's status should safeguard the evolution of disease activity towards the targeted goal. Additional recommendations relate to extra-articular and extramusculoskeletal aspects and other important factors, such as comorbidity. While the level of evidence was generally quite low, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated.

CONCLUSIONS

The task force defined the treatment target as remission or, alternatively, low disease activity, being aware that the evidence base is not strong and needs to be expanded by future research. These recommendations can inform the various stakeholders about expert opinion that aims for reaching optimal outcomes of SpA.

Consensus statement on blocking the effects of interleukin-6 and in particular by interleukin-6 receptor inhibition in rheumatoid arthritis and other inflammatory conditions

BACKGROUND

Since approval of tocilizumab (TCZ) for treatment of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA), interleukin 6 (IL-6) pathway inhibition was evaluated in trials of TCZ and other agents targeting the IL-6 receptor and ligand in various RA populations and other inflammatory diseases. This consensus document informs on interference with the IL-6 pathway based on evidence and expert opinion.

METHODS

Preparation of this document involved international experts in RA treatment and RA patients. A systematic literature search was performed that focused on TCZ and other IL6-pathway inhibitors in RA and other diseases. Subsequently, incorporating available published evidence and expert opinion, the steering committee and a broader expert committee (both including RA patients) formulated the current consensus statement.

RESULTS

The consensus statement covers use of TCZ as combination- or monotherapy in various RA populations and includes clinical, functional and structural aspects. The statement also addresses the second approved indication in Europe JIA and non-approved indications. Also early phase trials involving additional agents that target the IL-6 receptor or IL-6 were evaluated. Safety concerns, including haematological, hepatic and metabolic issues as well as infections, are addressed likewise.

CONCLUSIONS

The consensus statement identifies points to consider when using TCZ, regarding indications, contraindications, screening, dose, comedication, response evaluation and safety. The document is aimed at supporting clinicians and informing patients, administrators and payers on opportunities and limitations of IL-6 pathway inhibition.

Updated consensus statement on the use of rituximab in patients with rheumatoid arthritis

BACKGROUND

Since initial approval for the treatment of rheumatoid arthritis (RA), rituximab has been evaluated in clinical trials involving various populations with RA. Information has also been gathered from registries. This report therefore updates the 2007 consensus document on the use of rituximab in the treatment of RA.

METHODS

Preparation of this new document involved many international experts experienced in the treatment of RA. Following a meeting to agree upon the core agenda, a systematic literature review was undertaken to identify all relevant data. Data were then interrogated by a drafting committee, with subsequent review and discussion by a wider expert committee leading to the formulation of an updated consensus statement. These committees also included patients with RA.

RESULTS

The new statement covers wide-ranging issues including the use of rituximab in earlier RA and impact on structural progression, and aspects particularly pertinent to rituximab such as co-medication, optimal dosage regimens, repeat treatment cycles and how to manage non-response. Biological therapy following rituximab usage is also addressed, and safety concerns including appropriate screening for hepatitis, immunoglobulin levels and infection risk. This consensus statement will support clinicians and inform patients when using B-cell depletion in the management of RA, providing up-to-date information and highlighting areas for further research.

CONCLUSION

New therapeutic strategies and treatment options for RA, a chronic destructive and disabling disease, have expanded over recent years. These have been summarised in general strategic suggestions and specific management recommendations, emphasising the importance of expedient disease-modifying antirheumatic drug implementation and tight disease control. This consensus statement is in line with these fundamental principles of management.

Self-management of rheumatic diseases: state of the art and future perspectives

Self-management interventions are patient-centred and designed to foster active participation of patients in order to promote well-being and to manage symptoms. Over the past two decades, the role of self-management in chronic diseases has gained momentum. Self-management programmes are now acknowledged as a key element of quality care. New modes of delivery allow greater access to information and are tailored to address patient needs. This systematic review presents data from clinical studies of self-management over the past decade, summarises the evidence for programme effectiveness, and suggests future research directions.

Consensus statement on the use of rituximab in patients with rheumatoid arthritis

A large number of experts experienced in the treatment of rheumatoid arthritis were involved in formulating a consensus statement on the use of B cell-targeted treatment with rituximab in patients with rheumatoid arthritis. The statement was supported by data from randomised controlled clinical trials and the substantial literature on oncology. The statement underwent three rounds of discussions until its ultimate formulation. It should guide clinicians in the use of this newly approved biological agent in treating patients with rheumatoid arthritis.

Bone and joint diseases around the world. Arthritis--the greatest health, disability, and civil rights challenge: a UK and international perspective

The Bone and Joint Decade provides the opportunity for arthritis to be put firmly on political agendas worldwide. Greater political priority is crucial for everybody with arthritis, no matter where they live. People are "patients" for part of their lives, and people all the time, bringing to attention the need to address issues such as social exclusion, access to services, and negative attitudes and practices in society. The term "disability" is not synonymous with "inability," and should be embraced by people with arthritis. As a concept the term can be empowering to individuals, bonding those who face similar problems, including social exclusion and discrimination. When it is stripped of negative connotations, disability can also offer a positive identity. In the UK, the Disability Discrimination Act 1995 was the product of 25 years of campaigning by people who strongly believed that such discrimination should be illegal. The Act is not perfect and important parts have still to be implemented, but it exists as a resource for people with arthritis who may face discrimination. Only a minority of nations have disability discrimination legislation. Law alone will not end discrimination. If people with arthritis do not identify with being disabled then many people who meet the legal definition will continue to face unnecessary discrimination daily. A moral responsibility exists to help make the term one that attracts rather than deters those whom we seek to represent.