Using Polygenic Risk Scores to Aid Diagnosis of Patients With Early Inflammatory Arthritis: Results From the Norfolk Arthritis Register

OBJECTIVE

There is growing evidence that genetic data are of benefit in the rheumatology outpatient setting by aiding early diagnosis. A genetic probability tool (G-PROB) has been developed to aid diagnosis has not yet been tested in a real-world setting. Our aim was to assess whether G-PROB could aid diagnosis in the rheumatology outpatient setting using data from the Norfolk Arthritis Register (NOAR), a prospective observational cohort of patients presenting with early inflammatory arthritis.

METHODS

Genotypes and clinician diagnoses were obtained from patients from NOAR. Six G-probabilities (0%-100%) were created for each patient based on known disease-associated odds ratios of published genetic risk variants, each corresponding to one disease of rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, spondyloarthropathy, gout, or "other diseases." Performance of the G-probabilities compared with clinician diagnosis was assessed.

RESULTS

We tested G-PROB on 1,047 patients. Calibration of G-probabilities with clinician diagnosis was high, with regression coefficients of 1.047, where 1.00 is ideal. G-probabilities discriminated clinician diagnosis with pooled areas under the curve (95% confidence interval) of 0.85 (0.84-0.86). G-probabilities <5% corresponded to a negative predictive value of 96.0%, for which it was possible to suggest >2 unlikely diseases for 94% of patients and >3 for 53.7% of patients. G-probabilities >50% corresponded to a positive predictive value of 70.4%. In 55.7% of patients, the disease with the highest G-probability corresponded to clinician diagnosis.

CONCLUSION

G-PROB converts complex genetic information into meaningful and interpretable conditional probabilities, which may be especially helpful at eliminating unlikely diagnoses in the rheumatology outpatient setting.

Socioeconomic deprivation is associated with reduced response and lower treatment persistence with TNF inhibitors in rheumatoid arthritis

OBJECTIVE

To investigate the association between socioeconomic deprivation and outcomes following TNF inhibitor (TNFi) treatment.

METHODS

Individuals commencing their first TNFi in the British Society for Rheumatology Biologics Register for RA (BSRBR-RA) and Biologics in RA Genetics and Genomics Study Syndicate (BRAGGSS) cohort were included. Socioeconomic deprivation was proxied using the Index of Multiple Deprivation and categorized as 20% most deprived, middle 40% or 40% least deprived. DAS28-derived outcomes at 6 months (BSRBR-RA) and 3 months (BRAGGSS) were compared using regression models with the least deprived as referent. Risks of all-cause and cause-specific drug discontinuation were compared using Cox models in the BSRBR-RA. Additional analyses adjusted for lifestyle factors (e.g. smoking, BMI) as potential mediators.

RESULTS

16 085 individuals in the BSRBR-RA were included (mean age 56 years, 76% female), of whom 18%, 41% and 41% were in the most, middle and least deprived groups, respectively. Of 3459 included in BRAGGSS (mean age 57, 77% female), proportions were 22%, 36% and 41%, respectively. The most deprived group had 0.3-unit higher 6-month DAS28 (95% CI 0.22, 0.37) and were less likely to achieve low disease activity (odds ratio [OR] 0.76; 95% CI 0.68, 0.84) in unadjusted models. Results were similar for 3-month DAS28 (β = 0.23; 95% CI 0.11, 0.36) and low disease activity (OR 0.77; 95% CI 0.63, 0.94). The most deprived were more likely to discontinue treatment (hazard ratio 1.18; 95% CI 1.12, 1.25), driven by ineffectiveness rather than adverse events. Adjusted estimates were generally attenuated.

CONCLUSION

Socioeconomic deprivation is associated with reduced response to TNFi. Improvements in determinants of health other than lifestyle factors are needed to address socioeconomic inequities.

Addressing education and employment outcomes in the provision of healthcare for young people with physical long-term conditions: A systematic review and mixed methods synthesis

OBJECTIVE

To identify and synthesise the experiences and benefits of addressing vocational issues in the provision of healthcare for young people (YP) with long-term conditions (LTCs).

METHODS

We searched 10 bibliographic databases. Restrictions were applied on publication date (1996-2020) and language (English). Two reviewers independently screened records against eligibility criteria. Articles reporting relevant qualitative and/or quantitative research were included. Quality appraisal was undertaken following study selection. Qualitative data were synthesised thematically, and quantitative data narratively. A cross-study synthesis integrated qualitative and quantitative findings.

RESULTS

43 articles were included. Thematic synthesis of qualitative studies (n = 23) resulted in seven recommendations for intervention (psychological support; information/signposting; skills training; career advice; healthcare-school/workplace collaboration; social support; flexible/responsive care). The narrative synthesis summarised results of 17 interventions (n = 20 quantitative studies). The cross-study synthesis mapped interventions against recommendations. Transitional care was the intervention type that most comprehensively met our proposed recommendations.

CONCLUSIONS

Evidence from YP perspectives highlights that vocational development is an important area to address in healthcare provision. Robust intervention studies in this area are lacking.

PRACTICE IMPLICATIONS

Our evidence-based recommendations for intervention can support health professionals to better address vocational issues/outcomes. With minimal adaptations, transitional care interventions would be particularly well suited to deliver this.

Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake

A clinical guideline is a document with the aim of guiding decisions based on evidence regarding diagnosis, management and treatment in specific areas of healthcare. Specific to rheumatic and musculoskeletal diseases (RMDs), adherence to clinical guidelines recommendations impacts the outcomes of people with these diseases. However, currently, the implementation of recommendations is less than optimal in rheumatology.The WHO has described the implementation of evidence-based recommendations as one of the greatest challenges facing the global health community and has identified the importance of scaling up these recommendations. But closing the evidence-to-practice gap is often complex, time-consuming and difficult. In this context, the implementation science offers a framework to overcome this scenario.This article describes the principles of implementation science to facilitate and optimise the implementation of clinical recommendations in RMDs. Embedding implementation science methods and techniques into recommendation development and daily practice can help maximise the likelihood that implementation is successful in improving the quality of healthcare and healthcare services.

P50 Addressing the vocational development of young people with long-term health conditions in health care settings: a systematic review and mixed methods synthesis

Introduction/Background

Long term health conditions (LTHC) such as rheumatic conditions have significant impact on the biopsychosocial development of young people (YP) including vocational development. Educational transitions are prominent during adolescence and young adulthood yet not all transitional care programmes in rheumatology address this area [1]. The aim of this study was to identify and synthesise the benefits and experiences of addressing the vocational development of YP with LTHC in health care settings.

Description/Method

A mixed methods synthesis approach [2] was employed. We systematically searched 10 bibliographic databases. Restrictions were applied on publication date (1996-2020) and publication language (English). Articles reporting quantitative and/or qualitative primary research on addressing vocational needs/issues of YP with LTHC in health care settings were included. YP was defined as 10-24 years [3]. Two reviewers independently screened records using predetermined inclusion/exclusion criteria [4]. Quality appraisal was undertaken following study selection. Qualitative data were synthesised thematically. Quantitative data were synthesised narratively, given that a pooled synthesis was not considered appropriate. A cross-study synthesis integrated findings from both the qualitative and quantitative syntheses.

Discussion/Results

43 articles were included. The quality of qualitative evidence was good; however, the quality of quantitative evidence was poor. The thematic synthesis of stakeholders’ perspectives (n = 23 qualitative studies) resulted in seven recommendations for interventions: provide skills training; provide psychological support; offer to liaise with key stakeholders in educational/workplace settings; provide specialist career advice; provide information, signposting and facilitate access to supporting services; provide/facilitate access to social support; provide flexible care and optimal disease management to support education/employment transitions. The narrative synthesis summarised the results of 17 interventions. The cross-study synthesis mapped interventions against the set of recommendations arising from stakeholders’ perspectives: four interventions met five recommendations; two interventions met four recommendations; five interventions met three recommendations; six interventions met two recommendations. Transitional care interventions were the type of intervention that most comprehensively met the recommendations. The way in which interventions addressed vocational issues was not always clear, with some interventions addressing them directly and others indirectly. No interventions had vocational issues as the core, defining component of the intervention.

Key learning points/Conclusion

Existing stakeholder evidence highlights that vocational development is an important area to address in the care of YP with LTHC such as rheumatic diseases. The resulting set of recommendations provides guidance for future research in this area and transitional care developments in rheumatology. Further work in this area should address these aspects to enable better quality evidence and ensure consistency.

References

[1] Clemente D et al. Pediatr Rheumatol Online J. 2017 Jun 9;15(1):49.

[2] Kavanagh, J et al Synthesizing Qualitative Research: Choosing the Right Approach. Wiley-Blackwell, Chichester, UK, pp. 113–136

[3] World Health Organization, 2001. The second decade: improving adolescent health and development. Geneva.

[4] Farre A et al. PROSPERO 2016 CRD42016051359.

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

POS0011 COMPARISON OF PSYCHOMETRIC PROPERTIES OF FOUR GLOBAL MEASURES OF PRESENTEEISM IN PATIENTS WITH OSTEOARTHRITIS AND INFLAMMATORY ARTHRITIS: A EULAR-PRO STUDY

Background

Work is an important outcome for people with inflammatory arthritis (IA including PsA, RA, AxSpA) and osteoarthritis (OA). It is known that people with IA and OA are at increased risk of sick leave and have to stop working early due to ill health. In addition to being at increased risk of becoming work disabled and increased absenteeism, high levels of presenteeism (i.e. reduced productivity/limited ability to work due to ill health whilst at work) have also been reported. Several instruments exist to measure presenteeism, including single-item global measures and multi-item instruments. In some studies using single-item global instruments may be more feasible. However, available global instruments differ in concept, recall period and reference. It is important to understand which of the measures have good psychometric properties before using them in clinical studies.

Objectives

To assess the psychometric properties of four global presenteeism instruments.

Methods

Patients with IA or OA were recruited via rheumatology outpatient clinics to a large international, longitudinal observational study including 8 European countries and Canada. Participants completed a survey at baseline, 1, 2, 3, 4 wks, 2 months and 3 months. The four global measures of presenteeism included: Work Productivity and Activity Impairment Questionnaire (WPAI), Work Productivity Scale–Rheumatoid Arthritis (WPS-RA), Work Ability Index (WAI) and the Quality*Quantity questionnaire (QQtotal/10) scale. To facilitate score interpretation the WAI and QQtotal were reversed. Pain was measured using an 11-point Likert scale. Spearman correlations were calculated between the presenteeism measures and the Workplace Activity Limitations Scale (WALS), a validated multi-item measure of presenteeism, and HAQ to evaluate construct validity (validity: r <0.50=low; r >0.50-<0.70=moderate; r >0.70=high). Test-retest reliability of the 4 presenteeism scales (baseline-1wk) was measured applying ICC in patients with stable disease (i.e. same pain score at baseline and 1wk) (reliability: ICC<0.40=poor; ICC 0.40-0.75=fair to good; ICC >0.75=excellent). Responsiveness during 3 months was measured comparing patients with improvement in pain score (>1 point improvement in pain score (~MCID pain)) with patients with no change or worsening in pain score. The two groups were compared applying Mann Whitney U test.

Results

This international study included 550 patients with a mean age of 47.8 (SD 9.9) yrs and 61.4% were female. Mean (SD) disease duration since diagnosis was 10.8 (10.4) yrs and 91.2% had IA. Mean (SD) presenteeism scores at baseline were: WPAI=2.9 (2.7); WPS-RA=3.4 (2.7); WAI=2.7 (2.4); and QQtotal=3.1 (3.2). The correlations between the global measures and with WALS and HAQ were moderate to good, except for QQtotal and HAQ which was low (Table 1). In patients with the same stable pain scores at baseline-1wk (n=141) ICC scores were good to excellent, respectively: WPAI (0.771), WPS-RA (0.752), WAI (0.663), and QQtotal (0.650). An improvement in pain during the 3 month study duration was observed in 145/381 (38%) of the patients. In these patients a significant reduction in mean (SD) change presenteeism was observed for all four presenteeism scales compared to those with no change or worsening of the pain score: WPAI (-1.0 (2.37) vs 0.68 (2.40), p<0.01); WPS-RA (-0.76 (2.57) vs 0.43 (2.10), p<0.001); WAI (-0.09 (2.34) vs 0.41 (2.46), p<0.001); QQtotal (-0.57 (3.16) vs 0.79 (3.1), p<0.01).

Table 1.WPAIWPS-RAWAIQQtotalWALSHAQWPAI-0.81640.59920.51840.62690.5592WPS-RA-0.58360.52170.60550.5669WAI-0.58660.52310.5168QQtotal-0.50250.4367

Conclusion

The psychometric properties of all 4 global presenteeism scales were moderate to good, with slightly better scores for both the WPS-RA and WPAI instruments both measuring the impact of OA and IA on productivity.

Disclosure of Interests

Suzanne Verstappen Consultant of: EUOSHA, Grant/research support from: AbbVie, BMS. EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Sarah Wilkinson: None declared, Dorcas Beaton: None declared, Ailsa Bosworth: None declared, José Canas da Silva: None declared, Gloria Crepaldi: None declared, Sabrina Dadoun: None declared, Cathie Hofstetter: None declared, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Roche, Boehringer-Ingelheim, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: Grant: AbbVie, Galapagos, Novartis, Pfizer, UCB, Garifallia Sakellariou Consultant of: Abbvie, BMS and Galapagos., Grant/research support from: Abbvie, BMS and Galapagos., Sandra Meisalu: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer., Diane Lacaille: None declared

POS0202 CONTROL OF RHEUMATIC DISEASE AND COVID-19: RESULTS FROM THE INTERNATIONAL COVID-19 EUROPEAN PATIENT REGISTRY

Background

A major concern across rheumatology in recent years is how contracting COVID-19 may impact the control of rheumatic diseases.

Objectives

To quantify any difference in rheumatic disease control between those who did and did not contract COVID-19 between March and December 2020 and whether rheumatic disease control changed after COVID-19 was contracted.

Methods

Adults with rheumatic diseases recruited to the COVID-19 European Patient Registry, a patient-led, online, self-referred prospective cohort recruiting participants from around the globe, were included if enrolled between March and December 2020. Rheumatic disease control was self-reported weekly on a scale of 0 (very poor) to 10 (very well). Dates of contracting COVID-19 were self-reported.

Differences in rheumatic disease control trends between those who did and did not contract COVID-19 over the study period were tested via multilevel linear regression. Within those who contracted COVID-19, differences in rheumatic disease control trends were tested via segmented multilevel, multivariable linear regression, adjusting for month of COVID-19 contraction and with the interruption point set at the point of COVID-19 contraction.

Results

Of 3646 adults with rheumatic diseases, the majority were female (89%), most commonly from the UK (82%) and the most common rheumatic disease diagnosis was RA (63%). Between March and December 2020, 3% of the cohort contracted COVID-19 (n=103).

Over the study period, rheumatic disease control for adults who did not contract COVID-19 decreased weekly by 0.01 points (95% CI 0.01, 0.02, p<0.001). In those who contracted COVID-19, rheumatic disease control decreased weekly by 0.03 points (95% CI 0.2, 0.05, p<0.001), with a significant weekly difference of 0.86 points between groups (95% CI 0.28, 1.44, p=0.004) (Figure 1a).

Figure 1.

Trends in rheumatic disease control in those who did and did not contract COVID-19 between March and December 2020 a) overall and b) before and after contracting COVID-19

Within those that contracted COVID-19, there were significant differences in rheumatic disease control trends before and after contracting COVID-19 (p=0.001). In the run up to contracting COVID-19, rheumatic disease control significantly decreased weekly by 0.03 points (95% CI 0.02, 0.04, p<0.001), dropped significantly by 0.53 points (95% CI 0.23, 0.83, p=0.001) at the point of COVID contraction and then stabilised with no further reductions or improvement in rheumatic disease control for the remainder of follow-up (p=0.831) (Figure 1b).

Conclusion

People who contracted COVID-19 had initial decreases in rheumatic disease control before contracting the virus, after which their disease control stabilised at a lower level. Those with disease flares should consider increased screening for COVID-19 and COVID-19 mitigation measures. The stabilising lower disease control post-COVID is concerning and should prompt further work into restoring disease control pre-COVID-19 levels.

Acknowledgements

The authors thank all of the participants and families involved in the international COVID-19 European Patient Registry, as well as the team of volunteers who helped translate the surveys. We also thank ENCA, PRES and representatives from the international rheumatology community for their expertise and support.

Disclosure of Interests

Stephanie Shoop-Worrall: None declared, Suzanne Verstappen: None declared, Wendy Costello: None declared, Saskya Angevare: None declared, Yosef Uziel: None declared, Carine Wouters: None declared, Nico Wulffraat Speakers bureau: Sobi, Grant/research support from: AbbVie, Richard Beesley: None declared

AB1435 CLINICAL PREDICTION MODELS FOR METHOTREXATE OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS: SYSTEMATIC REVIEW AND CRITICAL APPRAISAL

Background

Methotrexate (MTX) is the preferred first line therapy for rheumatoid arthritis (RA). MTX has several advantages over other treatments including effectiveness and low cost; however, around 40% of patients are classed as non-responders after 6 months (1). Therefore, there is a clinical need to identify patients at high-risk of poor outcomes, such that patients could potentially be fast tracked onto alternative therapies to improve their clinical outcomes and quality of life. Such risk stratification is possible through prognostic prediction models, although models which have previously been developed appear to have had little impact on practice. This may be in part due to methodological features of their development and validation but, to date, no review has collated the evidence in this field.

Objectives

This systematic review aimed to (i) identify and summarise multivariable prediction models of MTX treatment outcomes in biologic-naïve adult RA patients, and (ii) critically appraise their methodological properties.

Methods

The electronic databases Medline and Embase were searched to identify studies developing or validating prediction models of MTX outcomes in the population of interest, including demographic, disease-specific or treatment-related covariates, published after 2005. Models were stratified by outcome definition, and information on participants, predictors, model performance, handling of missing data and model validation were extracted. A risk of bias (ROB) assessment using PROBAST (prediction model risk of bias assessment tool) was carried out. Two reviewers were independently involved in screening, data extraction, and ROB stages.

Results

The included studies used three main outcome definitions: a state of disease activity, such as low disease activity or remission; the EULAR response criteria; or discontinuation due to adverse events (AEs). Some studies incorporated AEs into a composite outcome with disease activity and few accounted for potential competing risks, which are events that preclude the occurrence of the primary outcome of interest. Not handling competing risks may result in under-prediction, leading to potentially compromised risk stratification. There was a lack of internal validation using cross sampling techniques, which is critical for reducing overfitting, as well as external validation in new data, a process necessary to ensure reproducibility and generalisability of a prediction model to the larger patient population. Missing data was mostly handled using complete case analysis, leading to potentially biased risk estimates. The ROB assessment showed overall high ROB of the included studies.

Conclusion

This systematic review summarises current prediction models of MTX treatment outcomes in RA. It highlights several methodological shortcomings, such as poor handling of missing data and competing risks to the primary outcome, and a lack of internal and external validation. These should be addressed in future model development and validation to improve accuracy of predictions. Without tackling these issues, prediction of MTX treatment outcomes will remain at high risk of bias and should not be recommended for informing risk stratification for RA treatment decisions.

References

[1]Sergeant JC, Hyrich KL, Anderson J, Kopec-Harding K, Hope HF, Symmons DPM, et al. Prediction of primary non-response to methotrexate therapy using demographic, clinical and psychosocial variables: Results from the UK Rheumatoid Arthritis Medication Study (RAMS). Arthritis Res Ther. 2018;20(1):1–11.

Disclosure of Interests

Celina Gehringer: None declared, Glen Martin: None declared, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: BMS and Pfizer, Suzanne Verstappen: None declared, Jamie Sergeant: None declared

POS0395 EXPLORING THE POTENTIAL OF GENOMIC RISK PREDICTION FOR CORONARY ARTERY DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Patients with rheumatoid arthritis (RA) have a higher prevalence of coronary artery disease (CAD) than the general population which contributes to early mortality. However, CAD screeing tools developed in the general population are less effective for estimating CAD risk in RA patients. This is mainly due to the differing contribution from traditional risk factors and the contribution from disease-specific factors. Understanding of the genetic basis of CAD has improved over recent years and shows promise for improving risk prediction in the form of genetic risk scores (GRs), in particular with the development of the metaGRS approach, which combines multiple polygenic risk scores.

Objectives

This study hypothesise that the metaGRS approach can help us improve CAD risk prediction in patients with RA.

Methods

Patients were recruited from the Norfolk Arthritis Register (NOAR), a longitudinal observational study focused on the cause and outcome of inflammatory polyarthritis. Analysis was restricted to patients who satisfied the 2010 ACR criteria cumulatively over five years and had detailed clinical history at baseline and follow-up for ten years. We developed a prediction model based on traditional risk factors[1], and explored the inclusion of a metaGRS. We used a meta-analytic approach to calculate a new metaGRS for CAD, using the effect-sizes from three large-scale, genome-wide, and targeted GRs derived from 1,745,179 [2], 6,630,150 [3], and 40,079 SNPs [4]. We tested the metaGRS in combination with available data on traditional risk factors in a subset of patients with available genetic data. Cox proportional hazards models were used to derive risk equations for evaluation of 10-year risk of CAD. We applied multiple imputations with chained equations to replace missing values. Calibration and discrimination were determined in a separate cohort of 423 individuals.

Results

A total of 2123 patients were included in the analysis with 136 incident cases of self-reported CAD (defined as a composite outcome of myocardial infarction, angina, heart attack, arrhythmia, angioplasty, and coronary artery bypass grafting).The model using only traditional risk factors achieved an AUC of 0.81 (95% CI 0.80, 0.82), with a calibration slope of 1.10, and explained approximately 71% (95% CI 69, 72%) of the variance of the outcome. The hazard ratio for age was found to be 1.00 (95% CI 0.99, 1.01) indicating risk remains the same across all age groups. Inclusion of a CAD metaGRS improves the AUC to 0.82 (95% CI 0.80, 0.83), explains more of the variance at 81% (95% CI 79, 82%) but worsens calibration slope to 0.93. A likelihood ratio test indicates that the integrated model is a better fit (p = 0.04).

Conclusion

An integrated risk score, that combines traditional risk factors with a metaGRS, improves CAD prediction in patients with RA. Further research is required to better understand the role of heritable components contributing to CAD risk in RA patients. By refining the underlying GRS, we hope to further improve risk prediction, through this integrated approach.

References

[1]Hippisley-Cox, Julia, Carol Coupland, and Peter Brindle. “Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.” bmj 357 (2017).

[2]Inouye M, Abraham G, Nelson CP, Wood AM, Sweeting MJ, Dudbridge F, et al. Genomic Risk Prediction of Coronary Artery Disease in 480,000 Adults: Implications for Primary Prevention. J Am Coll Cardiol. 2018;72(16):1883–93.

[3]Khera A V., Chaffin M, Aragam KG, Haas ME, Roselli C, Choi SH, et al. Genome-wide polygenic scores for common diseases identify individuals with risk equivalent to monogenic mutations. Nat Genet [Internet]. 2018;50(9):1219–24. Available from: http://dx.doi.org/10.1038/s41588-018-0183-z

[4]Elliott J, Bodinier B, Bond TA, Chadeau-Hyam M, Evangelou E, Moons KGM, et al. Predictive Accuracy of a Polygenic Risk Score-Enhanced Prediction Model vs a Clinical Risk Score for Coronary Artery Disease. JAMA - J Am Med Assoc. 2020;323(7):636–45.

Disclosure of Interests

None declared.

OP0088 STRATIFIED MEDICINE: GENETIC PREDICTORS OF RADIOGRAPHIC OUTCOME IN RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) displays great heterogeneity between patients for susceptibility to developing erosions. Genetic variations within the HLA-DRB1 gene (the shared epitope (SE) and polymorphisms coding for Valine at position 11) have been consistently associated with both susceptibility and radiographic outcome in RA.(1) However, associations of non-HLA markers are much less conclusive. Most studies looking outside the HLA have been candidate gene studies and very few have been replicated in independent cohorts.

Objectives:

1. Identify all single nucleotide polymorphisms (SNPs) outside the HLA that have ever been associated with radiographic outcome in RA

2. To perform a replication study to determine which of these are associated with radiographic outcome in the Norfolk Arthritis Register (NOAR), the worldwide largest prospective cohort with genetic and radiographic outcome data.

Methods

A systematic literature search was conducted as shown in the Figure 1.

Figure 1.

Flow chart for systematic review.

The Norfolk Arthritis register (NOAR) is a large primary care-based inception cohort of patients diagnosed with inflammatory polyarthritis. Patients were recruited at baseline from 1989 and followed up prospectively for up to 20 years with serial X-rays. Genome-wide genotyping was performed on the Illumina Human/Infinium Core Exome array and imputed with Minimac4 to the Haplotype Reference Consortium panel. Quality control resulted in 7.5 million SNPs available in each patient. SNPs identified from the literature were extracted and tested for an association with the presence of erosions (as a longitudinal binary variable) using a generalized estimating equation (GEE) model in STATA/IC 14.0.in NOAR.

Results

A total of 2119 participants (2440 radiographs) were identified with both genetic and radiographic data available. 66.2% of these patients were female and 33.3% were anti-CCP positive. Median age of onset was 54.5 and 74.9% satisfied the American College of Rheumatology (ACR) 1987 criteria for rheumatoid arthritis.

A total of 113 different non-HLA SNPs associated with radiographic outcome in RA were identified from the literature. Of these, 102 were successfully identified within NOAR and 91 were deemed to be independent SNPs based on R2 of 0.6. 14 SNPs were found to be significantly associated with the presence of erosions within NOAR (Table 1).

Table 1.

SNPs found to be associated with radiographic severity within NOAR. *Significant results only; Dominant models used (Odds ratios displayed in relation to minor alleles)

GeneChromosomeSNP (single nucleotide polymorphismOdds ratio (95% CI)P valueIL2RB2rs7437771.23 (1.01, 1.05)0.0398IL154rs68211710.82 (0.67, 1.00)0.0451IL45rs22432501.36 (1.08, 1.70)0.0094FOX036rs122120670.75 (0.58, 0.97)0.0278OPG8rs20736180.79 (0.64, 0.98)0.0295TRAF19rs107601301.33 (1.06, 1.65)0.0118TRAF19rs108184881.32 (1.06, 1.64)0.0141TRAF19rs29001801.32 (1.07, 1.61)0.0079IL4r16rs18050101.25 (1.01, 1.56)0.0393IL4r16rs18050111.31 (1.03, 1.66)0.0260LGALS917rs37639591.28 (1.03, 1.59)0.0260SOST17rs47929091.34 (1.09, 1.65)0.0052LILRA319rs1032940.80 (0.65, 0.98)0.0334MMP920rs119083520.70 (0.57, 0.85)0.0005

Conclusion

113 non-HLA SNPs have been previously reported to be associated with radiographic outcome in RA. Of these, only ~15% also showed an association in NOAR, the largest cohort with genetic and radiographic outcome data worldwide. Interestingly, rs2243250, a SNP located on chromosome 5 (IL4), previously found to be associated in a small Egyptian cohort, has been replicated in NOAR.(2) Current work consists of assessing the added clinical value of a genetic risk score based on HLA and non-HLA markers in predicting radiographic outcome when combined with clinical/serological/demographic markers.

References

[1]S. Viatte et al., JAMA313, 1645-1656 (2015).

[2]Y. M. Hussein, A. S. El-Shal, N. A. Rezk, S. M. Abdel Galil, S. S. Alzahrani, Cytokine61, 849-855 (2013).

Disclosure of Interests

None declared.

POS0325 THE ASSOCIATION BETWEEN OBESITY, SOCIOECONOMIC POSITION AND KNEE JOINT REPLACEMENT SURGERY IN PATIENTS WITH OSTEOARTHRITIS: RESULTS FROM THE ENGLISH LONGITUDINAL STUDY OF AGEING

Background

Evidence suggests that associations of lower socioeconomic position (SEP) with increased incidence of osteoarthritis (OA) are partially mediated by obesity. Obesity and lower SEP are also associated with increased symptoms in OA (i.e. pain/function). However, few studies have investigated whether obesity and lower SEP are also associated with increased risk of knee joint replacement surgeries (kJRS).

Objectives

To investigate the relationships of obesity and SEP at time of diagnosis with kJRS at follow-up in people with knee OA (kOA).

Methods

The English Longitudinal Study of Ageing is a nationally representative panel study of adults aged ≥50 years with biannual waves of data collection (2002–2019). Participants who self-reported OA diagnosis for the first time in waves 2–8 and knee pain in the same or previous wave of diagnosis were defined as having kOA (baseline). Participants with at least one body mass index (BMI) measurement and one follow-up assessment were included. Underweight/normal weight, overweight and obesity were defined using BMI <25 kg/m2, 25–30 kg/m2 and ≥30kg/m2, respectively. Education, occupation (current or last occupation if retired), wealth quintiles (all individual-based) and index of multiple deprivation quintiles (area-based) were used as SEP indicators. Outcome was the first self-reported kJRS (left or right knee) in waves 3–9. Cox proportional hazards models were used to investigate the associations of obesity and SEP with kJRS, controlling for baseline covariates. Person year follow up was calculated from baseline to either a) date of self-reported kJRS, b) loss to follow-up, c) end of follow-up (wave 9).

Results

The analysis sample included 1499 people who reported kOA and had ≥1 BMI measure (62.3% female; mean age 66.5y (SD 9.4); 96% white; 47.4% obese). Number of person-years included in the analysis was 8427. Over a mean follow-up of 4.7 years (SD 2.8), 144 (9.6%) reported having kJRS. Obese kOA patients were more likely to report kJRS than non-obese patients (adjHR 1.89 (95% CI 1.33, 2.68)), independent of age, gender, SEP, cardiovascular disease (self-reported) and HbA1c values (measured from collected blood samples). Education and occupation were not associated with kJRS. However, those living in the most deprived areas and with the least amount of wealth were less likely to undergo kJRS compared with the least deprived and wealthiest (HRs adjusted for age and gender 0.37 (95% CI 0.19, 0.73) and 0.55 (95% CI 0.33, 0.93), respectively). There was no evidence of interactions between obesity and SEP indicators.

Conclusion

Obesity increased the likelihood of undergoing kJRS in kOA patients. Therefore, reducing obesity in kOA patients may help to reduce the need for kJRS. Area-deprivation and lower wealth were associated with lower likelihood of kJRS. Taken together with findings from other studies which report associations between lower SEP and worse OA symptoms, our results suggest that there may be social inequalities in the provision of kJRS in England.

Table 1.

The relationships between obesity at baseline and rates of knee joint replacement surgery over a mean of 4.7 (SD 2.8) years in follow-up in those with knee OA at baseline in the English Longitudinal Study of Ageing

PredictorsHR (95% CI)UnadjustedAdjusted for age and genderAdjusted for age, gender and SEPAdjusted for age, gender, SEP, CVD and HbA1cObesity1.56 (1.12, 2.17)1.63 (1.17, 2.28)1.77 (1.26, 2.50)1.89 (1.33, 2.68)Non-obesityrefrefrefrefObesity3.53 (1.77, 7.02)3.58 (1.80, 7.12)4.01 (2.01, 8.03)4.35 (2.16, 8.74)Overweight2.91 (1.43, 5.91)2.81 (1.38, 5.73)2.93 (1.44, 5.98)2.98 (1.46, 6.09)Underweight/normal weightrefrefrefrefBMI per 1 kg/m2 increment1.05 (1.02, 1.07)1.05 (1.03, 1.08)1.06 (1.04, 1.09)1.07 (1.04, 1.10)

HR, hazard ratio; CI, confidence interval; SEP, socioeconomic position; CVD, cardiovascular disease; ref, reference category; BMI, body mass index.

Disclosure of Interests

None declared

POS0504 LOW SOCIAL SUPPORT, WORSE FINANCIAL STATUS AND LIMITED PHYSICAL ACTIVITY AT RHEUMATOID ARTHRITIS ONSET PREDICTS EXCESS DISABILITY OVER 10 YEARS

Background

Previous research has identified trajectory groups of people with rheumatoid arthritis (RA) characterised by excess disability (with respect to inflammation)1. These excess disability trajectories were relatively fixed from symptom onset, indicating that sociodemographic and lifestyle factors prior to onset may partially determine the disability trajectories of people with RA, potentially mediated by patient reported outcomes (PROMs).

Objectives

To (i) investigate the relationship between social support, financial status and lifestyle factors and excess disability group membership in RA, and (ii) evaluate the mediating effect of pain, fatigue, anxiety and depression on this relationship.

Methods

Data came from the Etude et Suivi des Polyarthrites Indifférenciées Récentes (ESPOIR) study, a prospective cohort from 14 centres across France. Inclusion criteria were: >2 swollen joints for 6 weeks-6 months, certain / possible diagnosis of RA, aged 18-70 years, and no disease modifying treatments or glucocorticoids for >2 weeks. A previous study applying trajectory analysis to the 10-year disability and inflammation scores of the ESPOIR participants identified pairs of trajectories characterised by similar inflammation but different disability1. For the current analysis, those in the higher disability trajectories of each pair were allocated into the “excess disability” group. At baseline, participants reported demographics, patient reported outcomes (pain / fatigue visual analogue scales; anxiety / depression: Arthritis Impact Measurement Scales), social support (availability of financial and accommodation support, family contact, married / co-habiting), financial status (personal and family income, job status and level, home owner, ability to go to the cinema/shows / go on holiday) and lifestyle factors (smoking, alcohol, body mass index [BMI; from height and weight], physical activity). Structural equation modelling was used to combine the social support and financial status data into latent variables, and then assess the direct and indirect (mediated by PROMs) effects of these variables as well as lifestyle factors on excess disability (adjusted for age and gender).

Results

In total, 538 people with RA were included (mean [standard deviation] age: 48.3 [12.2] years; 79.2% women), 200 (37.2%) of whom had excess disability over 10 years. The excess disability group were older, included more women, and had worse PROMs at baseline compared with the no excess disability group (Table 1). Less social support (β 0.17, 95% CI 0.08, 0.26) and worse financial status (β 0.30, 95% CI 0.19, 0.41) both predicted excess disability group membership, as did lower physical activity (β 0.17, 95% CI 0.09, 0.25) (Figure 1), whereas smoking, alcohol and BMI at baseline did not. Only a small proportion of this effect was mediated by the PROMs (social support: 21%, financial status: 31%, physical activity: 28%; Figure 1).

Table 1.

Baseline characteristics

Excess disability,No excess disability,Mean (SD) / N (%)Mean (SD) / N (%)N200338Age, years50.4 (10.7)47.0 (12.8)Women, N(%)174 (87.0%)252 (74.6%)Symptom duration, months3.63 (2.02)3.36 (1.62)Pain VAS47.1 (27.4)37.0 (26.9)Fatigue VAS59.3 (27.2)46.5 (26.5)AIMS anxiety5.61 (2.25)4.71 (2.27)AIMS depression4.47 (2.24)3.47 (1.97)Health Assessment Questionnaire1.39 (0.64)0.93 (0.61)DAS28-2C4.04 (1.28)3.99 (1.34)

AIMS = Arthritis Impact Measurement Scales, DAS28-2C = two-component Disease Activity Score, SD = standard deviation, VAS = visual analogue scale

Conclusion

Disability resulting from RA is a complex phenomenon, arising from more than just joint inflammation. This analysis indicates that lack of social support, financial instability and lower physical fitness at symptom onset may explain the excess disability associated with RA. As only a small portion of the effect is mediated by PROMs, health and social inequalities may need to be targeted directly by interventions.

References

[1]Gwinnutt et al (2021), Ann Rheum Dis, 80(Suppl 1)

Disclosure of Interests

James Gwinnutt: None declared, Sam Norton: None declared, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Bristol-Myers Squibb, Pfizer, Mark Lunt: None declared, Bernard Combe: None declared, Nathalie Rincheval: None declared, Adeline Ruyssen-Witrand: None declared, Bruno Fautrel: None declared, Suzanne Verstappen: None declared.

AB1430 COMPARISON OF COGNITIVE ABILITY ACROSS THE IMMUNE MEDIATED INFLAMMATORY DISEASES: SYSTEMATIC REVIEW AND META-REGRESSION

Background

Age strongly influences cognitive ability. Previous studies have tried to compare the cognitive ability of people with different immune mediated inflammatory diseases (IMIDS: systemic lupus erythematosus [SLE], rheumatoid arthritis [RA], axial spondyloarthritis [axSpA], psoriatic arthritis [PsA], psoriasis [PsO]) in age-matched analyses. However, given the varying age of onset of these conditions, within direct age-matched comparisons one of the disease groups is necessarily older/younger than typical.

Objectives

(i) To perform a systematic review of the cognitive ability of people with IMIDs compared with age-matched controls, and (ii) use meta-regression to indirectly compare the cognitive ability of people with different IMIDs.

Methods

A search strategy was implemented in the Medline, Embase and PsychInfo databases on 29.5.2021. Identified studies were screened by two reviewers, selecting observational studies comparing the cognitive ability of people with an IMID against healthy controls. This abstract only includes studies reporting overall cognition scores, memory scores and attention scores. The standardised mean differences (SMDs) of the cognitive assessments between people with IMIDs and controls were pooled using random-effects meta-analysis, stratified by IMID. The IMIDs were compared using meta-regression, to identify the IMID with the greatest impairment in cognitive ability compared with healthy people of a similar age (inclusion cut-off: ≥5 studies).

Results

In total, 62 studies (SLE: 37, RA: 18, axSpA: 1, PsA: 2, PsO: 4) were included in the meta-analyses. People with IMIDs had moderate impairments in overall cognition, memory and attention compared with controls (Table 1), with similar results seen when limiting analyses to studies which included age-matched controls (N=48 studies). People with SLE and RA had similar levels of impairment compared with controls of comparable age in terms of overall cognition (coef: -0.12 (95% CI -0.42, 0.19) and attention (coef: -0.35 (95% CI -0.73, 0.04)). Other IMIDs and cognition dimensions were not included in the meta-regression analysis due to lack of studies.

Table 1.

Results of meta-analyses

Standardised mean difference (95% Confidence Interval) [N studies]Systemic lupus erythematosusRheumatoid arthritisAxial spondyloarthritisPsoriatic arthritisPsoriasisOverall cognitionAll-0.55 (-0.70. -0.39) [18]-0.59 (-0.82, -0.35) [13]-0.66 (-1.11, -0.21) [1]-0.50 (-0.78, -0.21) [2]-0.51 (-1.09, 0.07) [3]Age-matched-0.55 (-0.72, -0.38) [14]-0.66 (-0.92, -0.41) [11]-0.66 (-0.11, -0.21) [1]-0.61 (-1.08, -0.14) [1]-0.77 (-1.39, -0.16) [2]AttentionAll-0.51 (-0.63, -0.38) [27]-0.79 (-1.10, -0.47) [9]-0.58 (-1.03, -0.13) [1]--0.14 (-0.42, 0.14) [2]Age-matched-0.51 (-0.67, -0.36) [21]-0.87 (-1.35, -0.39) [6]-0.58 (-1.03, -0.14) [1]--0.36 (-0.75, 0.04) [1]Verbal memory (immediate)All-0.59 (-0.79, -0.38) [19]-1.00 (-1.47, -0.53) [7]---0.52 (-1.05, 0.02) [3]Age-matched-0.61 (-0.90, -0.32) [12]-1.42 (-1.73, -1.12) [4]---0.72 (-1.42, -0.02) [2]Verbal memory (delayed)All-0.44 (-0.57, -0.31) [18]-0.93 (-1.48, -0.38) [5]-0.23 (-0.67, 0.21) [1]--0.52 (-1.52, 0.49) [2]Age-matched-0.39 (-0.56, -0.21) [12]-1.40 (-1.76, -1.03) [3]-0.23 (-0.67, 0.21) [1]--1.05 (-1.47, -0.63) [1]Non-Verbal memory (immediate)All-0.41 (-0.57, -0.25) [15]-0.32 (-1.23, 0.58) [1]-0.21 (-0.62, 0.23) [1]--Age-matched-0.34 (-0.52, -0.16) [10]--0.21 (-0.62, 0.23) [1]--Non-Verbal memory (delayed)All-0.45 (-0.63, -0.27) [16]-0.41 (-0.91, 0.08) [1]-0.14 (-0.58, 0.30) [1]--Age-matched-0.46 (-0.75, -0.17) [10]-0.41 (-0.91, 0.08) [1]-0.14 (-0.58, 0.30) [1]--

Conclusion

People with IMIDs have significant impairments in terms of overall cognition, memory and attention. Whilst this indirect analysis shows that people with SLE and RA have a similar magnitude of impairment compared with healthy controls of a similar age, a number of factors could be influencing this finding (e.g. selection bias, demographic differences).

Disclosure of Interests

None declared

POS1501-HPR ADDRESSING THE VOCATIONAL DEVELOPMENT OF YOUNG PEOPLE WITH LONG-TERM HEALTH CONDITIONS IN HEALTH CARE SETTINGS: A SYSTEMATIC REVIEW AND MIXED METHODS SYNTHESIS

Background

Long term health conditions (LTHC) such as rheumatic conditions have significant impact on the biopsychosocial development of young people (YP) including vocational development. Educational transitions are prominent during adolescence and young adulthood yet not all transitional care programmes in rheumatology address this area [1].

Objectives

To identify and synthesise the benefits and experiences of addressing the vocational development of YP with LTHC in health care settings.

Methods

A mixed methods synthesis approach [2] was employed. We systematically searched 10 bibliographic databases. Restrictions were applied on publication date (1996-2020) and publication language (English). Articles reporting quantitative and/or qualitative primary research on addressing vocational needs/issues of YP with LTHC in health care settings were included. YP was defined as 10-24 years [3]. Two reviewers independently screened records using predetermined inclusion/exclusion criteria [4]. Quality appraisal was undertaken following study selection. Qualitative data were synthesised thematically. Quantitative data were synthesised narratively, given that a pooled synthesis was not considered appropriate. A cross-study synthesis integrated findings from both the qualitative and quantitative syntheses.

Results

43 articles were included. The quality of qualitative evidence was generally good; but the quality of quantitative evidence was generally poor. The thematic synthesis of stakeholders’ perspectives (n=23 qualitative studies) resulted in seven recommendations for interventions: provide skills training; provide psychological support; offer to liaise with key stakeholders in educational/workplace settings; provide specialist career advice; provide information, signposting and facilitate access to supporting services; provide/facilitate access to social support; provide flexible care and optimal disease management to support education/employment transitions. The narrative synthesis summarised results of 17 interventions (n=20 quantitative studies). The cross-study synthesis mapped interventions against recommendations arising from stakeholders’ perspectives: Four interventions met five recommendations; two interventions met four recommendations; five interventions met three recommendations; six interventions met two recommendations. Transitional care interventions were the type of intervention that most comprehensively met the recommendations. The way in which interventions addressed vocational issues was not always clear, with some interventions addressing them explicitly/directly (reporting vocational intervention components) and others implicitly/indirectly (reporting vocational outcomes only). Interventions where vocational issues were the core, defining component of the intervention were lacking.

Conclusion

Stakeholder evidence suggests vocational development is an important area to address in the care of YP with LTHC such as rheumatic diseases. The resulting set of recommendations provides guidance for future research in this area and transitional care developments in rheumatology. Further work in this area should address these aspects to enable better quality evidence and ensure consistency.

References

[1]Clemente D, Leon L, Foster H, Carmona L, Minden K. Transitional care for rheumatic conditions in Europe: current clinical practice and available resources. Pediatr Rheumatol Online J. 2017 Jun 9;15(1):49.

[2]Kavanagh J, Campbell F, Harden A, Thomas J. Mixed Methods Synthesis: A Worked Example, in: Hannes, K., Craig, L. (Eds.), Synthesizing Qualitative Research: Choosing the Right Approach. Wiley-Blackwell, Chichester, UK, 2012, pp. 113–136

[3]World Health Organization. The second decade: improving adolescent health and development. Geneva, 2001.

[4]Farre A, Lunt L, McDonagh JE. Addressing the vocational development of young people with chronic conditions. PROSPERO 2016 CRD42016051359.

Disclosure of Interests

None declared

OP0033 EFFECTIVENESS OF NON-PHARMACOLOGICAL INTERVENTIONS TO PROMOTE WORK PARTICIPATION IN PEOPLE WITH RMDs: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Work participation among people with rheumatic and musculoskeletal diseases (RMDs) remains reduced when compared to the general population. A EULAR taskforce was established to agree on Points to Consider (PtC) to support people with RMD in healthy and sustainable work participation. Non-pharmacological interventions (NPI) could have an important role in improving work participation in RMDs. However, a comprehensive evidence synthesis of the effectiveness of NPIs in people with RMDs is lacking.

Objectives

To summarise the literature on effectiveness of NPIs on work participation in people with RMDs.

Methods

A search in four databases (MEDLINE, EMBASE, CENTRAL and CINAHL) was performed. Randomised Controlled Trials (RCTs) and Longitudinal Observational Studies (LOS) assessing non-pharmacological/non-surgical interventions until August 2020 were screened. Studies including people with any RMD (except low back pain or work-related RMDs) and assessing a work participation outcome domain (sick leave, work status, presenteeism) were considered eligible. For qualitative evidence synthesis, RCTs and LOS were considered. For quantitative evidence synthesis, only RCTs were considered. For each randomized comparison, standardised mean differences (SMDs) were calculated for the three outcome domains and used as effect size in the meta-analyses; i.e. a negative SMD favouring the NPI over control. Next, Mixed Effects Meta-Regression Analyses were performed, with random effects for randomised comparisons, and a fixed effect factor for the stratified subgroups of clinical interest. Subgroups within diseases (musculoskeletal pain disorders vs. other types of RMDs), risk status for sick leave at baseline (on sick leave or at risk for sick leave; not at risk for sick leave; a combination; or not specified) and single vs. multiple component NPIs were pre-defined. Risk of Bias (RoB) of RCTs was assessed using the Cochrain tool.

Results

Out of 8,864 records, 64 studies (71 treatment comparisons) were included. Studies usually included a mixed population of several RMDs (42%). Most NPIs were conducted in a clinical setting (n=44, 62%) and NPIs usually had multiple components (n=57, 80%), such as vocational support combined with physical training (n=18, 25%). Sick leave was the most frequently reported outcome domain (n=56, 88%). In the qualitative syntheses, 30%/50%/29% of interventions were considered plausible in improving sick leave, work status and presenteeism, respectively.

In the quantitative synthesis, NPIs (37 RCTs, 42 comparisons with mostly moderate to high RoB) showed small to moderate effect sizes, favouring NPIs over comparators for sick leave (SMD=-0.23, 95%CI -0.33 to -0.13), work status (SMD=-0.38, 95%CI -0.63 to -0.12) and presenteeism (SMD=-0.25, 95%CI -0.39 to -0.12). The forest plot for sick leave is shown (Figure 1).

Subgroup analyses for sick leave revealed that, compared to control, NPIs were not effective in musculoskeletal pain disorders, in contrast to the other types of RMDs. For both other subgroup analyses (baseline risk for sick leave; single vs. multicomponent NPI), NPIs improved sick leave similarly in subgroups compared to the control. Subgroup analyses for work status and presenteeism had generally similar effects in subgroups, but the interpretation requires caution in view of the small number of comparisons. Of note, clinical and methodological heterogeneity between studies was substantial, with some concerns about methodological quality related blinding and completeness of follow up.

Conclusion

Overall, NPIs seem to have significant, but on the average population level only small to moderate effects on sick leave, work status and presenteeism in RMDs. However, effects on sick leave varied substantially between subgroups. This synthesis suggests that tailoring NPIs to individuals’ needs and context could be clinically valuable.

Disclosure of Interests

None declared.

Follow-up regimes for sick-listed employees: A comparison of nine north-western European countries

The Covid-19 pandemic has revealed the importance of social protection systems, including income security, when health problems arise. The aims of this study are to compare the follow-up regimes for sick-listed employees across nine European countries, and to conduct a qualitative assessment of the differences with respect to burden and responsibility sharing between the social protection system, employers and employees. The tendency highlighted is that countries with shorter employer periods of sick-pay typically have stricter follow-up responsibility for employers because, in practice, they become gatekeepers of the public sickness benefit scheme. In Germany and the UK, employers have few requirements for follow-up compared with the Nordic countries because they bear most of the costs of sickness absence themselves. The same applies in Iceland, where employers carry most of the costs and have no obligation to follow up sick-listed employees. The situation in the Netherlands is paradoxical: employers have strict obligations in the follow-up regime even though they cover all the costs of the sick-leave themselves. During the pandemic, the majority of countries have adjusted their sick-pay system and increased coverage to reduce the risk of spreading Covid-19 because employees are going to work sick or when they should self-quarantine, except for the Netherlands and Belgium, which considered that the current schemes were already sufficient to reduce that risk.

HLA-DRB1 haplotypes predict cardiovascular mortality in inflammatory polyarthritis independent of CRP and anti-CCP status

BACKGROUND

Haplotypes defined by amino acids at HLA-DRB1 positions 11, 71 and 74 associated with susceptibility to rheumatoid arthritis (RA) are associated with radiological outcome, anti-TNF response and all cause-mortality in RA. RA is associated with cardiovascular (CV) morbidity and mortality, but the increased prevalence of risk factors of CV disease in RA only partially explains this association. The aim of this study was to investigate whether amino acids at positions 11, 71 and 74 of HLA-DRB1 are associated with cardiovascular (CV) mortality in inflammatory polyarthritis (IP).

METHODS

The Norfolk Arthritis Register (NOAR) is an incidence register of IP: recruitment 1990-2007, final follow-up 2011. Two thousand five hundred fourteen patients had available genetic and mortality data. Amino acids at positions 11, 71 and 74 of HLA-DRB1 were determined. Univariate Cox proportional hazard models were applied to assess the association of genetic markers and both all-cause mortality and cardiovascular mortality.

RESULTS

Among 2514 participants, 643 (25.6%) died during the study, and 343 (53.3%) of these deaths were attributed to CV causes. One thousand six hundred fifty (65.6%) participants were female, 709 (32.3%) were anti-CCP-positive and the median age of participants was 54. HLA-DRB1 haplotypes associated with susceptibility to rheumatoid arthritis (RA) consistently show the same magnitude and direction of association for overall and CV mortality in IP. For example, the SEA-haplotype, associated with the lowest susceptibility to RA, and the best radiographic outcome, was found to be associated with decreased CV mortality (HR 0.67, 95% CI 0.47, 0.91, p=0.023). Mediation analysis revealed associations were independent of anti-CCP status.

CONCLUSIONS

HLA-DRB1 haplotypes associated with susceptibility to RA also predispose to increased risk of CV mortality in IP, independent of known CV risk factors. Associations were independent of anti-CCP status, which suggests in the future, genetic factors will add to the prediction of risk of cardiovascular mortality beyond serological markers.

OA28 Exploring the potential of polygenic risk scores for predicting coronary artery disease in patients with rheumatoid arthritis

Background/Aims

Patients with rheumatoid arthritis (RA) have a higher prevalence of coronary artery disease (CAD) than the general population which contributes to early mortality. Current screening tools for CAD, which are developed in the general population, are less effective for estimating CAD risk in patients with RA. This reduced performance is mainly due to the differing contribution from traditional risk factors and the contribution from disease-specific factors. Our understanding of the genetic basis of CAD has improved over recent years and shows promise for improving risk prediction in the form of polygenic risk scores (PRS). We hypothesise that PRS can help us improve CAD risk prediction in patients with RA by providing more accurate models of risk.

Methods

Patients were recruited from the Norfolk Arthritis Register (NOAR), a detailed community-based longitudinal observational study focused on the cause and outcome of inflammatory polyarthritis, between 1990 and 2017. Analysis was restricted to patients who satisfied the 2010 ACR criteria cumulatively over five years and had detailed clinical history at baseline and follow-up. We developed a prediction model based on traditional risk factors and explored the inclusion of a PRS (49K SNPs) in a subset of patients with available genetic data. Cox proportional hazards models were used to derive risk equations for evaluation of 10-year risk of CAD. We applied multiple imputations with chained equations using the Random Forest algorithm to replace missing values. Measures of calibration and discrimination were determined in the validation cohort of 423 individuals.

Results

A total of 2123 patients were included in the analysis with 136 incident cases of self-reported CAD. The model using only traditional risk factors achieved an AUC of 0.72 (95% CI 0.71, 0.73), with a calibration slope of 1.03, and explained approximately 50% (95% CI 47, 52%) of the variance of the outcome. We found that being male reduces the risk by a factor of 0.82 (95% CI 0.68, 1.00). The hazard ratio for age was found to be 1.00 (95% CI 0.99, 1.01) indicating risk remains the same across all age groups. Inclusion of a CAD PRS increased the performance with an AUC of 0.76 (95% CI 0.75, 0.77), explained variance of 53% (95% CI 49, 56%) but with a slightly worse calibration slope of 0.91.

Conclusion

An integrated risk score, that combines traditional risk factors with a PRS, improves CAD prediction in patients with RA. Further research is required to better understand the role of heritable components contributing to CAD risk in RA patients. By refining the underlying PRS, we hope to further improve CAD risk prediction in RA patients, through this integrated approach.

Disclosure

M. Soomro: None. M. Stadler: None. S. Viatte: None. A. MacGregor: None. S. Verstappen: None. A. Barton: None. J. Bowes: None.

P187 Pre-defined Gene Co-expression Modules in Rheumatoid Arthritis Transition towards Molecular Health following Tumour Necrosis Factor Inhibitor Therapy

Background/Aims

Tumour necrosis factor inhibitors (TNFi) have advanced the clinical management of rheumatoid arthritis (RA); however, only 30-40% of patients who receive initial treatment with a TNFi experience a beneficial response. The discovery of biomarkers of TNFi response would facilitate improved response rates and more objective monitoring of inflammation. Gene transcript levels measured in the blood of RA patients represent an attractive source of biomarkers. For example, a study by Oswald et al demonstrated reproducible changes in gene expression modules in RA patients treated effectively with a TNFi. Such gene modules were previously defined by Chaussabel et al following the assessment of gene co-expression patterns, transcript clustering patterns and functional associations amongst transcripts from several inflammatory diseases.

We aim to replicate the changes in modular gene co-expression reported to occur in response to TNFi therapy in RA in a UK cohort described by Oswald et al; to test if changes in modular expression are specific to TNFi therapy by analysing change in gene co-expression in response to methotrexate (MTX); and to determine if module expression transitions towards a disease-free state in responding patients.

Methods

Published whole blood transcriptomic data from disease-free controls (n = 10) and RA patients treated with either the TNFi adalimumab (n = 70) or MTX (n = 85) were studied. Transcriptomic data were available at pre-treatment and at 3-months (TNFi) and 4-weeks (MTX) post-treatment. Response to treatment was assessed using the EULAR response criteria following 3/6-months on-drug. For each of the 27 modules, the fraction of probes that significantly (p &lt; 0.05) changed in expression between time-points was recorded. Linear mixed models were used to test if module expression transitioned towards a disease-free state following treatment.

Results

In the TNFi cohort, 25 of the 27 modules significantly changed in expression between pre- and post-treatment, replicating published findings by Oswald et al. Six of these 27 modules transitioned towards a disease-free state by 3-months. Transition in module expression was irrespective of treatment response in 5 of the 6 modules, however one module (module 3.2) appeared to be dependent on good response to adalimumab. This module was linked to pathways of inflammation and TNF signalling. Similar patterns of modular expression changes were observed in the MTX cohort, but with reduced significance compared to TNFi treated patients.

Conclusion

This study provides independent replication of changes in modular gene expression in TNFi treated RA patients. Gene expression changes were observed regardless of treatment response and were not specific to TNFi therapy. These results suggest that some factors of biological response are not detected by clinical classifiers of treatment response. Further research is now needed to test the utility of gene modules for prediction of clinical response, or for objective monitoring of molecular pathways that are responsive to treatment.

Disclosure

M.A. Sutcliffe: None. N. Nair: None. J. Oliver: None. A. Morgan: None. J. Isaacs: None. G. Wilson: None. S. Verstappen: None. S. Viatte: None. K. Hyrich: None. A. Morris: None. A. Barton: None. D. Plant: None.

P090 Clinical prediction models for methotrexate treatment outcomes in rheumatoid arthritis patients: a review of existing models and summary of their limitations

Background/Aims

Methotrexate (MTX) is the preferred first line therapy for rheumatoid arthritis (RA), according to NICE guidelines. MTX has several advantages over other treatments including effectiveness and low cost; however, around 40% of patients are classed as non-responders after 6 months. Therefore, there is a clinical need to identify patients at high-risk of poor outcomes, such that patients could potentially be fast tracked onto alternative therapies to improve their clinical outcomes and quality of life. Such risk stratification is possible through prognostic prediction models, although models which have previously been developed appear to have had little impact on practice. This may be in part due to methodological features of their development and validation but, to date, no review has collated the evidence in this field. This review therefore aimed to (i) identify and summarise multivariable prediction models of MTX treatment outcomes in biologic-naïve adult RA patients, and (ii) appraise their methodological properties.

Methods

A systematic search was carried out using Medline Ovid to identify studies developing or validating prediction models of MTX outcomes in the population of interest, including demographic, disease-specific or treatment-related covariates, published between 2005 and 2020. Models were stratified by outcome definition, and information on predictors, predictor associations with the outcome, model performance, handling of missing data and model validation were extracted.

Results

Twenty-two studies (14 (64%) using data from observational studies and 8 (36%) from randomised controlled trials) were identified. Of these, 15 (68%) based their outcome on a state of disease activity, such as low disease activity or remission, 4 (18%) used the EULAR response criteria, and 3 (14%) predicted discontinuation due to adverse events (AEs). AEs were also incorporated into the composite outcome with disease activity in 3 (14%) studies, 1 (5%) investigated both outcomes in separate models, and only 1 (5%) accounted for potential competing risks to their primary outcome. Internal validation using cross sampling techniques, which is critical for reducing overfitting, was completed in only 5 (23%) studies. Only 4 (18%) studies carried out external validation in new data. Missing data was appropriately handled using multiple imputation in 5 (23%) studies, whilst others used single imputation (n = 1, 4%) or complete case analysis (n = 13, 59%), resulting in potentially biased risk estimates, or did not report how they handled missing data (n = 3, 14%).

Conclusion

This review summarises current prediction models of MTX treatment outcomes in RA. It highlights several methodological shortcomings that should be addressed in future model development and validation to improve accuracy of predictions. Without tackling these issues, prediction of MTX treatment outcomes will remain at high risk of bias and should not be recommended for informing risk stratification for RA treatment decisions.

Disclosure

C. Gehringer: None. G. Martin: None. K. Hyrich: None. S. Verstappen: None. J. Sergeant: None.

Researchers' perspectives on methodological challenges and outcomes selection in interventional studies targeting medication adherence in rheumatic diseases: an OMERACT-adherence study

Background

Research on adherence interventions in rheumatology is limited by methodological issues, particularly heterogeneous outcomes. We aimed to describe researchers’ experiences with conducting interventional studies targeting medication adherence in rheumatology and their perspectives on establishing core outcomes.

Methods

Semi-structured interviews using audio conference were conducted with researchers who had conducted an adherence study of any design in the past 10 years. Data collection and thematic analysis were performed iteratively, until saturation.

Results

We interviewed 13 researchers, most of whom worked in academia and specialized in epidemiology and/or health services research. We identified three themes: 1) improving measurement of adherence (considering all phases of adherence, using appropriate and relevant measures, and establishing clinically meaningful thresholds); 2) challenges in designing and appraising adherence intervention studies (considering the confusion over a plethora of outcomes, difficulties with powering studies to demonstrate meaningful changes, and suboptimal descriptions of adherence interventions in published studies); and 3) advancing outcome assessment in adherence intervention studies (capturing rationale for developing a core domain set as well as recommendations and anticipated challenges by participants).

Conclusions

Uniquely gathering perspectives from international adherence researchers, our findings led to researcher-informed recommendations for improving adherence research including specifying the targeted adherence phase in designing interventions and studies and providing a glossary of terms to promote consistency in reporting. We also identified recommendations for developing a core domain set for interventional studies targeting medication adherence including involvement of patients, clinicians, and other stakeholders and methodological and practical considerations to establish rigor and support uptake.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00193-4.

POS0348 GENETIC SUSCEPTIBILITY VARIANTS FOR RHEUMATOID ARTHRITIS ARE NOT ASSOCIATED WITH EARLY REMISSION; A MULTI-COHORT STUDY

Background:

Patients who achieve remission promptly could have a specific genetic risk profile that supports regaining immune tolerance. The identification of these genes could provide novel drug targets.

Objectives:

To test the association between RA genetic risk variants with achieving remission at 6 months.

Methods:

We computed genetic risk scores (GRS) comprising of the RA susceptibility variants1 and HLA-SE status separately in 4425 patients across eight datasets from inception cohorts. Remission was defined as DAS28CRP<2.6 at 6 months. Missing DAS28CRP values in patients were imputed using predictive mean matching by MICE. We first tested whether baseline DAS28CRP changed with increasing GRS using linear regression. Next, we calculated odds ratios for GRS and HLA-SE on remission using logistic regression. Heterogeneity of the outcome between datasets was mitigated by running inverse variance meta-analysis.

Results:

Evaluation of the complete dataset, baseline clinical variables did not differ between patients achieving remission and those who did not (Table 1). Distribution of GRS was consistent between datasets. Neither GRS nor HLA-SE was associated with baseline DAS2DAS (OR1.01; 95% CI 0.99-1.04). A fixed effect meta-analysis (Figure 1.) showed no significant effect of the GRS (OR 0.99; 95% CI 0.94-1.03) or HLA-SE (OR 0.8CRP87; 95% CI 0.75-1.01) on remission at 6 months.

Table 1.

Summary of the data separated by disease activity after 6 months.

allRemission at 6 monthsNo remission at 6 monthsN4425*15582430Age, mean (sd)55.38 (13.87)5517 (14.09)55.62 (13.59)Female %68.98%65.43%70.73%ACPA+ %61.94%63.53%61.67%Baseline DAS28, mean (sd)4.76 (1.22)4.47 (1.23)5.1 (1.15)

*not all patients had 6 months data

Conclusion:

In these combined cohorts, RA genetics risk variants are not associated with early disease remission. At baseline there was no difference in genetic risk between patients achieving remission or not. Studies encompassing other genetic variants are needed to elucidate the genetics of RA remission.

References:

[1]Knevel R et al. Sci Transl Med. 2020;12(545):eaay1548.

Acknowledgements:

This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777357, RTCure.

This project has received funding from Pfizer Inc.

Disclosure of Interests:

Samantha Jurado Zapata: None declared, Marc Maurits: None declared, Yann Abraham Employee of: Pfizer, Erik van den Akker: None declared, Anne Barton: None declared, Philip Brown: None declared, Andrew Cope: None declared, Isidoro González-Álvaro: None declared, Carl Goodyear: None declared, Annette van der Helm - van Mil: None declared, Xinli Hu Employee of: Pfizer, Thomas Huizinga: None declared, Martina Johannesson: None declared, Lars Klareskog: None declared, Dennis Lendrem: None declared, Iain McInnes: None declared, Fraser Morton: None declared, Caron Paterson: None declared, Duncan Porter: None declared, Arthur Pratt: None declared, Luis Rodriguez Rodriguez: None declared, Daniela Sieghart: None declared, Paul Studenic: None declared, Suzanne Verstappen: None declared, Leonid Padyukov: None declared, Aaron Winkler Employee of: Pfizer, John D Isaacs: None declared, Rachel Knevel Grant/research support from: Pfizer

AB0681 HOW COMMON IS COVID-19 IN CHILDREN, YOUNG PEOPLE AND ADULTS WITH RHEUMATIC DISEASES? RESULTS FROM THE INTERNATIONAL COVID-19 EUROPEAN PATIENT REGISTRY

Background:

People with rheumatic diseases may be at increased risk of contracting COVID-19 due to their rheumatic disease or immunosuppressive treatments. It is currently unclear what the COVID-19 disease burden is for these people and whether any of their personal or disease characteristics are associated with contracting COVID-19.

Objectives:

To explore the proportion of, and characteristics associated with, contracting COVID-19 in children and young people (CYP) with rheumatic diseases and adults with rheumatic diseases from March 2020 to December 2020 during the COVID-19 pandemic.

Methods:

CYP and adults recruited to the international COVID-19 European Patient Registry, a parent-led, online, self-referred prospective cohort recruiting participants from around the globe, were included in current study if enrolled between 20th March 2020 and 30th December 2020. Demographic information was collected at enrolment and rheumatic disease, diagnoses of COVID-19 and lifestyle factors were collected at weekly intervals.

The proportion of CYP and adults diagnosed with COVID-19 were assessed separately. Associations between contraction of COVID-19 at any point over follow-up and participant demographics, rheumatic disease and lifestyle factors at enrolment were assessed descriptively and via Mann-Whitney U-tests, Chi-squared tests and Fisher’s exact tests.

Results:

Within 642 CYP and 3646 adults, the majority were female (67%, 89%) and most commonly from the UK (43%, 82%), respectively. The most frequent diagnoses were polyarticular JIA (37%) in the CYP cohort and RA in the adults (63%). Comorbidities were common (45%, 61%) and the majority were taking one or more immunosuppressive therapies (88%, 92%), respectively. At the time of enrolment, 51% and 54% were practising social distancing, respectively.

In both cohorts ~3% contracted COVID-19 at some point during follow-up (n=18 (2.8%) in CYP and n=103 (2.8%) in the adult cohort).

In CYP, those who contracted COVID-19 were older (no COVID, median: 10, IQR: 7, 13, vs COVID, median: 14, IQR: 12, 16, p<0.001) and less often had oligoarticular JIA (no COVID: 31%, COVID: 22%) or polyarticular JIA (No COVID: 38%, COVID: 11%). Systemic JIA (no COVID: 7%, COVID: 11%) and enthesitis-related JIA (no COVID: 5%, COVID: 22%) were more common in those who contracted COVID. No other differences between those with and without COVID-19 were observed with respect to country of residence (p=0.335), gender (p=0.624), control of rheumatic disease (p=0.459), comorbidities (p=0.752), immunosuppressive medication (p=0.713) or social distancing (p=0.729).

In the adult cohort, those contracting COVID-19 were more commonly from Russia (no COVID: 2%, COVID: 14%) and less commonly from the UK (no COVID: 82%, COVID: 71%, p<0.001). There was greater female representation in those that contracted COVID-19 (no COVID: 88%, COVID: 93%, p=0.022). Although there were no differences in overall presence of comorbidity (p=0.923), kidney disease was overrepresented in those that had contracted COVID-19 (no COVID: 2%, COVID: 8%, p<0.001). Finally, there were lower levels of social distancing in those who contracted COVID (no COVID: 54%, COVID: 44%, p=0.047). There were no significant differences in age (p=0.203), BMI (p=0.617), smoking status (p=0.120), rheumatic disease (p=0.181) and its control (p=0.218) or immunosuppressive use (p=0.208) between those who did and did not contract COVID-19 in the adult cohort.

Conclusion:

A low proportion of CYP and adults with rheumatic diseases contracted COVID-19 in the 9 months since March 2020. However, given the self-reported nature of the survey and limited testing available across many countries, this study may underestimate the true burden of COVID-19 in the rheumatic disease community. Factors associated with COVID-19 differ between CYP and adults, with age and type of rheumatic disease associated in CYP and gender, kidney comorbidity and social distancing associated in adults.

Acknowledgements:

The authors thank all of the participants and families involved in the international COVID-19 European Patient Registry, as well as administrators. We also thank the team of volunteers who helped translate the surveys. We also thank ENCA, PRES and representatives from the international rheumatology community for their expertise and support.

Disclosure of Interests:

Stephanie Shoop-Worrall: None declared, Suzanne Verstappen: None declared, Wendy Costello: None declared, Saskya Angevare: None declared, Yosef Uziel: None declared, Carine Wouters: None declared, Nico Wulffraat Speakers bureau: Sobi, Grant/research support from: AbbVie, Richard Beesley: None declared

OP0183 IDENTIFICATION OF A SUBGROUP OF PEOPLE WITH RHEUMATOID ARTHRITIS CHARACTERISED BY HIGH DISABILITY OVER 10 YEARS, DESPITE LOW INFLAMMATION: RESULTS FROM TWO EUROPEAN PROSPECTIVE COHORT STUDIES

Background:

Long-term studies in rheumatoid arthritis (RA) have reported low inflammation yet high disability over time. It is important to determine which factors are driving this disparity, so appropriate interventions can be used to reduce this gap.

Objectives:

To identify a subgroup of people with RA with low inflammation yet high disability over 10 years, and describe their characteristics.

Methods:

Data came from two cohorts of inflammatory arthritis with regular assessments over 10 years: the Norfolk Arthritis Register (NOAR, inclusion: ≥2 swollen joints for ≥4 weeks) from the UK and the Etude et Suivi des Polyarthrites Indifférenciées Récentes study (ESPOIR, inclusion: early RA) from France. Participants provided demographic data and completed patient reported outcomes (PROs, including the Health Assessment Questionnaire [HAQ]). The 2-component Disease Activity Score (DAS28-2C)1, a measure of inflammation, was calculated from swollen joint counts and C-reactive protein level. Inclusion criteria for this analyis: <2 years baseline symptom duration; HAQ and DAS28-2C at baseline and one other follow-up; recruited after 1/1/2000. HAQ and DAS28-2C were modelled simultaneously using a multivariate group-based trajectory model, to identify groups of participants with similar trajectories of HAQ and DAS28-2C over 10 years. Baseline demographics and PROs were compared between the trajectory groups using logistic regression. Analyses performed separately in NOAR and ESPOIR.

Results:

1001 NOAR and 767 ESPOIR participants were included. In both cohorts, a four group trajectory model had the best fit (Figure). Two subgroups were identified in each cohort that demonstrated the hypothesised relationship: similar DAS28-2C but differing HAQ scores (red trajectories in Figure), titled “High HAQ” and “Low HAQ” (mean difference in HAQ over follow-up [95% confidence interval (CI)]: NOAR 0.76 [0.73, 0.80]; ESPOIR 0.89 [0.82, 0.96]). At baseline, the High HAQ groups in both NOAR and ESPOIR were older, had a higher proportion of women, and had higher levels of fatigue (NOAR: odds ratio [OR] 1.16 [95% CI 1.06, 1.28]; ESPOIR: OR 1.20 [95% CI 1.05, 1.36] [Table]) and pain (NOAR only).

Table 1.

Baseline characteristics / logistic regression analysis

NOARESPOIRVariableLow HAQ trajectory, mean (SD)High HAQ trajectory, mean (SD)OR (95% CI)Low HAQ trajectory, mean (SD)High HAQ trajectory, mean (SD)OR (95% CI)N (%)343 (59%)239 (41%)-131 (55%)108 (45%)-Age, years54.9 (14.2)62.1 (13.8)1.07 (1.05, 1.08)47.8 (13.3)51.8 (11.2)1.04 (1.01, 1.06)Women, N (%)224 (65.3%)176 (73.6%)1.82 (1.12, 2.78)100 (76.3%)95 (88.0%)2.73 (1.20, 6.23)Symptom duration, months7.8 (5.1)8 (5.4)1.10 (0.98, 1.05)3.4 (1.8)3.6 (1.8)1.16 (0.98, 1.37)Current smoker, N (%)77 (22.4%)50 (20.9%)1.19 (0.71, 2.00)61 (46.6%)52 (48.1%)1.52 (0.82, 2.83)DAS28-2C3.14 (1.46)3.21 (1.56)-4.65 (1.31)4.41 (1.35)-HAQ0.8 (0.6)1.4 (0.5)-1.1 (0.6)1.6 (0.6)-Pain (0-10)3.7 (2.4)4.6 (2.5)1.16 (1.07, 1.26)4.1 (2.8)5.1 (2.6)1.07 (0.95, 1.20)Fatigue (0-10)4.3 (2.8)5.3 (2.5)1.16 (1.06, 1.28)5.0 (2.6)6.5 (2.5)1.20 (1.05, 1.36)AIMS anxiety3.99 (1.96)4.42 (1.99)1.06 (0.88, 1.29)4.9 (2.26)5.98 (2.25)1.10 (0.94, 1.29)AIMS depression2.85 (1.87)3.38 (1.87)1.10 (0.94, 1.29)3.96 (1.99)5.08 (2.32)1.12 (0.94, 1.33)RF+, N (%)142 (41.4%)106 (44.4%)0.94 (0.60, 1.46)79 (60.3%)50 (46.3%)0.77 (0.34, 1.75)Anti-CCP+, N (%)113 (32.9%)86 (36.0%)1.35 (0.84, 2.17)76 (58.0%)45 (41.7%)0.89 (0.39, 2.05)

Conclusion:

There is a group of people with RA with high levels of disability, despite low inflammation. These results underline the potential need for pain and fatigue management in people with RA, even when inflammation is low.

References:

[1]Hensor et al (2019). Rheumatology (Oxford) 58(8)

Acknowledgements:

Thanks to the participants of NOAR and ESPOIR and those working in the recruiting centres

ESPOIR Funding:

An unrestricted grant from Merck Sharp and Dohme (MSD) was allocated for the first 5 years of the cohort study. Two additional grants from INSERM supported part of the biological database. The French Society of Rheumatology, Abbvie, Pfizer, Lilly and more recently Fresenius and Biogen supported the ESPOIR cohort study.

Disclosure of Interests:

James Gwinnutt Grant/research support from: Research grant from Bristol Myers Squibb unrelated to this project, Sam Norton Consultant of: Pfizer and AstraZeneca, Kimme Hyrich Consultant of: Abbvie, Grant/research support from: Pfizer and BMS, Mark Lunt: None declared, Bernard Combe: None declared, Nathalie Rincheval: None declared, Adeline Ruyssen-Witrand: None declared, Bruno Fautrel: None declared, Jacqueline Chipping: None declared, Alex MacGregor: None declared, Suzanne Verstappen: None declared

POS0471 ASSOCIATION OF HLA-DRB1 HAPLOTYPES WITH CARDIOVASCULAR MORTALITY IN INFLAMMATORY POLYARTHRITIS: RESULTS FROM THE NORFOLK ARTHRITIS REGISTER

Background:

Haplotypes defined by amino acids at HLA-DRB1 positions 11, 71 and 74 associated with susceptibility to rheumatoid arthritis (RA), are associated with radiological outcome, anti-TNF response and all cause-mortality in RA.(1, 2) RA is associated with cardiovascular (CV) morbidity and mortality, but the increased prevalence of risk factors of CV disease in RA only partially explains this association.

Objectives:

The aim was to investigate whether haplotypes associated with RA disease susceptibility and disease severity are also associated with CV mortality.

Methods:

The Norfolk Arthritis register (NOAR) is a primary care-based inception cohort of patients with inflammatory polyarthritis (IP).(1, 2) NOAR patients with at least 2 years of follow-up and available mortality and genetic data were included in this study. Mortality data was provided by the Office for National Statistics.

Univariate Cox proportional hazard models were applied using STATA/IC 14.0. Models for CV mortality were adjusted for CV risk factors selected using stepwise regression: namely obesity, gender and hypertension. Hazard models were applied to the entire cohort of patients with inflammatory polyarthritis (IP). When calculating differences between highest and lowest risk genetic factors, bivariate analysis was used.

Results:

HLA-DRB1 amino acids, haplotypes or haplotype groups associated with RA susceptibility are also associated with CV mortality as shown in the table 1. HLA-DRB1 polymorphisms encoding amino-acid haplotypes associated with an increased or decreased susceptibility to RA consistently show the same magnitude and direction of association for overall and CV mortality in IP. For example, the SEA-haplotype, associated with the lowest susceptibility to RA, and the best radiographic outcome, was found to be associated with decreased CV mortality (HR 0.67, 95% CI 0.47, 0.91, p=0.023). The relative difference in CV mortality between carriers of the high susceptibility VKA haplotype and carriers of the SEA haplotype was significant (HR 1.67, 95% CI 1.13, 2.48, p=0.01).

Table 1.

Hazard ratios for CV mortality by genetic factors among patients with IP. Total number (n) of deaths are also displayed alongside the total number (n) of patients included in each analysis.

Amino acid / Haplotype /GroupHazard Ratio (95% CI)Nvaline 111.10 (0.93, 1.30)343 (2514)serine 110.82 (0.70, 0.96)*343 (2514)Difference1.23 (1.01, 1.49)*VKA haplotype1.16 (0.94, 1.43)310 (2328)SEA haplotype0.67 (0.47, 0.94) *310 (2328)Difference1.67 (1.13, 2.48)*Group 1 †1.10 (0.93, 1.31)319 (2328)Group 4 †0.73 (0.60, 0.89)*319 (2328)Difference1.37 (1.09, 1.72)*

* p<0.05

†Haplotype groups as defined previously (2)

HLA-DRB1 haplotypes can be ranked according to the magnitude of their association with RA susceptibility and this hierarchy is conserved for various measures of disease outcome and overall mortality.(2, 3) The figure 1 shows that this risk hierarchy is also conserved for CV mortality: HLA-DRB1 haplotypes that predispose to RA also predispose to increased CV mortality, independent of known CV risk factors.

Figure 1.

Haplotypes with frequency >12% in NOAR are shown. X axis: susceptibility to ACPA-positive RA as ORs.(2) Y axis: CV mortality risk in IP as HRs, derived from multi-variate cox-proportional hazard models adjusted for CV risk factors. Values are on a logarithmic scale. A one-tailed p value was calculated using linear regression to determine the association between β coefficients of susceptibility and CV mortality.

Conclusion:

The originally reported genetic associations between HLA-DRB1 polymorphisms and overall mortality were likely driven by associations with CV mortality.

References:

[1]S. Viatte et al., JAMA313, 1645-1656 (2015).

[2]S. Raychaudhuri et al., Nat Genet44, 291-296 (2012).

[3]D. P. Symmons, A. J. Silman, Clin Exp Rheumatol21, S94-99 (2003).

Disclosure of Interests:

None declared

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

The effect on work presenteeism of job retention vocational rehabilitation compared to a written self-help work advice pack for employed people with inflammatory arthritis: protocol for a multi-centre randomised controlled trial (the WORKWELL trial)

Background

Work problems are common in people with inflammatory arthritis. Up to 50% stop work within 10 years due to their condition and up to 67% report presenteeism (i.e. reduced work productivity), even amongst those with low disease activity. Job retention vocational rehabilitation (JRVR) may help prevent or postpone job loss and reduce presenteeism through work assessment, work-related rehabilitation and enabling job accommodations. This aims to create a better match between the person’s abilities and their job demands. The objectives of the Workwell trial are to test the overall effectiveness and cost-effectiveness of JRVR (WORKWELL) provided by additionally trained National Health Service (NHS) occupational therapists compared to a control group who receive self-help information both in addition to usual care.

Methods

Based on the learning from a feasibility trial (the WORK-IA trial: ISRCTN76777720), the WORKWELL trial is a multi-centre, pragmatic, individually-randomised parallel group superiority trial, including economic evaluation, contextual factors analysis and process evaluation. Two hundred forty employed adults with rheumatoid arthritis, undifferentiated inflammatory arthritis or psoriatic arthritis (in secondary care), aged 18 years or older with work instability will be randomised to one of two groups: a self-help written work advice pack plus usual care (control intervention); or WORKWELL JRVR plus a self-help written work advice pack and usual care. WORKWELL will be delivered by occupational therapists provided with additional JRVR training from the research team. The primary outcome is presenteeism as measured using the Work Limitations Questionnaire-25. A comprehensive range of secondary outcomes of work, health, contextual factors and health resource use are included. Outcomes are measured at 6- and 12- months (with 12-months as the primary end-point). A multi-perspective within-trial cost-effectiveness analyses will also be conducted.

Discussion

This trial will contribute to the evidence base for provision of JRVR to people with inflammatory arthritis. If JRVR is found to be effective in enabling people to keep working, the findings will support decision-making about provision of JRVR by rheumatology teams, therapy services and healthcare commissioners, and providing evidence of the effectiveness of JRVR and the economic impact of its implementation.

Trial registration

Clinical Trials.Gov: NCT03942783. Registered 08/05/2019 (https://clinicaltrials.gov/ct2/show/NCT03942783); ISRCTN Registry: ISRCTN61762297. Registered:13/05/2019 (http://www.isrctn.com/ISRCTN61762297). Retrospectively registered.

SAT0072 THE IMPACT OF COMORBIDITIES ON ABSENTEEISM, PRESENTEEISM AND EMPLOYMENT STATUS IN PEOPLE LIVING WITH RHEUMATOID ARTHRITIS

Background:

Many people with rheumatoid arthritis (RA) have comorbidities. However, there is limited research on the impact of multimorbidity on absenteeism (e.g. sick leave) and presenteeism (i.e. reduced productivity while at work due to ill health) in people with RA.

Objectives:

i) to explore the impact of comorbidities on absenteeism and presenteeism in patients with RA and ii) to evaluate the association between multimorbidity and employment status.

Methods:

A cross-sectional survey was conducted by the National Rheumatoid Arthritis Society (NRAS), UK, collecting information on: demographics, education, employment status (i.e. employed (Empl), stopped/retired early because of RA (Stop_RA), stopped/retired early because of other health issues (Stop_Health)), and disease related variables (e.g. symptom duration, rheumatoid arthritis impact of disease (RAID) questionnaire). Participants were asked to report whether they had or were treated for any of 15 predefined comorbidities (categorised into 0, 1, 2, 3, or ≥4 (Table)). Percentage of number of hours missed due RA (i.e. absenteeism) and presenteeism (10-point Likert scale) were assessed using the Work Productivity and Activity Impairment Questionnaire (WPAI-RA). For the purpose of this study both absenteeism and presenteeism outcomes were dichotomized (no presenteeism/absenteeism versus any) and only patients aged <65yrs were included. Logistic regression analysis were applied to assess the association between number of comorbidities and absenteeism/presenteeism, adjusting for the categorical variables age, gender and education. Chi2-square test was applied to assess frequencies of individual comorbidities between the three employment status groups.

Results:

868 participants were included; 91.7% women with a median symptom duration of 8.3 years [IQR 4.4-13.7]. The average RAID score was 5.2 (SD 2.2). 80.4% were in paid employment, including those currently on sick leave, 16.9% stopped early because of their RA and 2.7% reported stopping early because of other health reasons. In those employed most commonly occurring comorbidities were: back pain (28.8%%), osteoarthritis (21.5%), depression (26.3%) and anxiety (22.6%). Compared to people with RA with no comorbidities, the odds associated with time off work due to RA increased from 1.7 up to 3.4 with increasing number of comorbidities (Table). Although a similar trend was observed for presenteeism, the effect sizes were smaller. Significant differences (p<0.05) in frequencies of the following comorbidities were observed between the three employment status groups (Empl, Stop_RA, Stop_Health, respectively): heart disease (3.9%, 7.9%, 20.0%), blood pressure (18.0%, 29.5%, 36.7%), lung disease (5.7%, 16.3%, 26.7%), diabetes (4.4%, 4.2%, 26.7%), ulcer (6.1%, 11.1%, 13.3%), cancer (3.3%, 2.6%, 13.3%), depression (26.3%, 33.6%, 50.0%), OA (21.5%, 44.7%, 63.33%), and back pain (28.8%, 48.4%, 60.0%).

Absenteeism (yes/no)Presenteeism (yes/no)Number of comorbiditiesNOR95%CIOR95%CI0206Ref.Ref.11741.701.06-2.711.661.00-2.7321361.771.08-2.921.991.13-2.863851.751.00-3.081.530.82-2.864-15max863.381.98-5.782.641.28-5.44

OR=odds ratio; 95%CI=95% confidence interval; Comorbidities included: heart disease, blood pressure, lung disease, diabetes, ulcer or stomach disease, kidney disease, liver disease, anaemia or other blood disease, cancer, depression, anxiety, OA, back pain, osteoporosis and Sjögren. Bold figuresP<0.05.

Conclusion:

Although the study is cross-sectional and no temporal association can be determined, this study shows that not only personal and work related contextual factors should be considered when preventing worker productivity loss, but also other comorbidities.

Disclosure of Interests:

A. Bradshaw: None declared, Ailsa Bosworth Speakers bureau: a number of pharmaceutical companies for reasons of inhouse training, advisory boards etc., K. Walker-Bone: None declared, Laura Lunt: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

THU0130 PATTERNS OF COGNITIVE DECLINE IN RHEUMATOID ARTHRITIS: RESULTS OF CASE CONTROL STUDY NESTED IN A POPULATION-BASED COHORT

Background:

The risk of cognitive decline and dementia is of particular interest for patients exposed to prolonged inflammation. In rheumatoid arthritis (RA), the inflammatory mechanisms that are central to the disease’s pathology share many features with those seen in Alzheimer’s disease (AD). However, published reports on the strength and direction of the putative associations with cognitive decline and dementia in RA are conflicting and the potential impact of immunomodulation has not been fully established. This study reports on a case control analysis comparing the results of a cognitive test conducted in RA cases from a longitudinal population register with healthy controls. The relationship between test outcomes, disease characteristics, and treatment is examined.

Objectives:

To characterise differences in cognitive function as assessed by a validated test battery between a group of patients with RA and a matched sample of healthy controls.

To investigate disease and treatment related factors that might have an impact on the cognitive function of patients with RA.

Methods:

A total of 38 people with RA were selected at random from subjects who had enrolled on the Norfolk Arthritis Register as part of the ICORA (Investigation of Cognition in RA) Study. The register is a large longitudinal inception cohort of patients recruited from both primary and secondary care. The study subjects were over 55 years old with a diagnosis of RA defined by the ACR criteria. Cognitive function was assessed using the Addenbrooke’s Cognitive Examination III (ACE-III) battery. The ACE-III is a validated screening test for dementia that evaluates five cognitive domains (attention, memory, verbal fluency, language and visuospatial skills). A cut off value of 82 is indicative of cognitive impairment. The ACE-III scores in the cases were compared with scores from 29 healthy population-based controls matched for age and sex.

Results:

The mean age of the patient and control groups was 69 years. The RA patients had a mean disease duration of 9.8 years and had been taking DMARDs for 7.1 years. Among the patient group with RA, 14 (37%) scored below 82 compared with none in the group of healthy controls. The mean ACE-III scores of both groups are shown in the table below:

Controls N=29RA N=38ACE-III Total95.2 (3.7)85.2 (7.4)•Attention17.7 (0.5)16.5 (1.9)•Memory24.6 (1.9)19.8 (4.0)•Fluency12 (1.4)9.9 (2.6)•Language25.5 (0.8)24.6 (1.7)•Visuospatial15.8 (0.5)14.4 (1.5)

After adjusting for age, sex, BMI and smoking status, significant differences were seen in the ACE-III total (adjusted mean difference(SE)=8.67(1.77); p<0.001), memory (adjusted mean difference(SE)=4.16(1.03); p<0.001), fluency (adjusted mean difference(SE)=2.29(0.67); p=0.001) and visuospatial (adjusted mean difference(SE)=1.36(0.38); p<0.001). There was no difference in attention (p=0.19) or language (p=0.10).

Among the patients with RA there was no clear association between disease duration and ACE-III Total scores; however, there was a trend for increasing cognitive scores in those who had been taking DMARDs for longer (<5 years: mean ACE-III Total=84.1; 5-10 years: 85.0: 11-14 years: 85.4; >14 years: 89.6).

Conclusion:

This study provides evidence to suggest that patients with established RA are at increased risk of cognitive decline when compared with healthy controls. The pattern of cognitive deficit, predominantly involving visuospatial and memory function, is consistent with an Alzheimer’s disease profile. Our data suggest a potential role for DMARDs in reducing the rate of cognitive decline in patients with RA.

Disclosure of Interests:

Tasuku Toyoda: None declared, Jacqueline Chipping: None declared, Jack Dainty: None declared, Stephen Jeffs: None declared, Michael Hornberger: None declared, Eneida Mioshi: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Max Yates: None declared, Alex MacGregor: None declared

SAT0038 CHANGES IN ILLNESS PERCEPTIONS IN PEOPLE WITH RHEUMATOID ARTHRITIS OVER THE FIRST YEAR OF TREATMENT WITH METHOTREXATE

Background:

Illness perceptions at treatment onset are known to be important predictors of treatment response in rheumatoid arthritis (RA). Yet it is unknown how these perceptions change over time after the initiation of treatment, or which factors are associated with changing perceptions.

Objectives:

To identify groups of patients with early RA who have similar changes in illness perceptions over the first year following treatment, and assess predictors of these changes.

Methods:

Patients starting methotrexate (MTX) for the first time were recruited to the Rheumatoid Arthritis Medication Study (RAMS), a one-year prospective cohort. The DAS28 was calculated and patients completed a questionnaire at baseline and 12 months, reporting demographics and completing the HAQ, the Hospital Anxiety and Depression Scale (HADS), pain and fatigue visual analogue scales (VAS) and the Brief Illness Perception Questionnaire (B-IPQ). The B-IPQ consists of eight Likert scales: five represent cognitive illness perceptions (B-IPQ1-5), two represent emotional representations (B-IPQ6 & 8) and one represents illness comprehensibility (B-IPQ7). Change in illness perceptions and EULAR response were calculated over 12 months in those with data at both timepoints. Latent profile analysis was used to identify profiles of patients with similar changes in illness perceptions. Candidate predictors of profile membership were assessed using logistic regression. The association between profile and EULAR response was assessed using ordered logistic regression.

Results:

In total 1188 patients were included (mean [SD] age: 59.8 [12.7], 781 [65.7%] women). On average, illness perceptions for the whole cohort improved over 12 months, other than patients’ perception of longevity of arthritis (B-IPQ2) and of treatment helpfulness (B-IPQ4). Three profiles were identified: Small Improvers (N=900), Small Deteriorators (N=78) and Large Improvers (N=210) (Figure). Small Improvers improved on all B-IPQ items other than their perception of longevity of arthritis (B-IPQ2) and of treatment helpfulness (B-IPQ4). All B-IPQ items improved in the Large Improvers group to a greater extent than the Small Improvers, other than arthritis longevity (B-IPQ2). The perceptions of Small Deteriorators all worsened, other than arthritis comprehensibility (B-IPQ7). Higher baseline pain was associated with greater odds of being in both the Small Deteriorators and Large Improvers compared to Small Improvers (Small Deteriorators: OR 1.56 per standard deviation (SD) increase in pain [95% CI 1.11, 2.18]; Large Improvers: OR 1.46 per SD increase in pain [95% CI 1.15, 1.85]). Odds of better EULAR response were greater in the Large Improvers (OR 4.37 [95% CI 3.01, 6.33]) and worse in the Small Deteriorators (OR 0.50 [95% CI 0.29, 0.87]) compared to Small Improvers.

Conclusion:

In general, illness perceptions improved over the first year of MTX treatment and improvements were associated with better treatment response. Worsening illness perceptions may be driven by poor treatment response. These poor illness perceptions at follow-up may compound poor treatment response in the future. Greater understanding of patients’ initial and subsequent illness perceptions is crucial, given the association with treatment response.

Figure:

Disclosure of Interests:

James Gwinnutt Grant/research support from: BMS, Sam Norton: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Mark Lunt: None declared, Anne Barton Consultant of: AbbVie, Lis Cordingley Grant/research support from: Unrestricted award from Pfizer unrelated to current abstract, Speakers bureau: Janssen, AbbVie, Celgene, Sanofi, Eli Lilly, Novartis all unrelated to current abstract, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

SAT0054 PREVALENCE AND PREDICTORS OF METHOTREXATE-ASSOCIATED ADVERSE EVENTS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Methotrexate (MTX) is the first-choice treatment for rheumatoid arthritis (RA), but the exact prevalence rates and predictors of important adverse events (AEs) associated with MTX treatment are less well investigated.

Objectives:

To determine the prevalence of MTX AEs (gastrointestinal (GI), mucocutaneous, neurological, haematological, pulmonary, and liver enzymes elevation), and to identify baseline demographic, clinical and drug related predictors of liver and GI AEs.

Methods:

The Rheumatoid Arthritis Medication Study (RAMS) is a UK multi-centre prospective cohort study of patients with RA commencing MTX for the first time. Relevant demographic, medication, clinical and disease related data, and blood samples were collected from patients at baseline. Data on MTX therapy and occurrence of AEs were reported at six and twelve month follow-ups, and include recorded laboratory values of alanine transaminase (ALT) enzyme.

The prevalence rates of AEs were calculated based on the number of patients who reported the AE at either 6 or 12 month follow-up visits. The association between candidate baseline predictors and occurrence of GI or liver AEs was assessed using multivariable logistic regression.

Results:

In total, 2089 participants were included (mean age=58.4±13.5 years; 1390 [66.5%] women). Of those, 1816 and 1584 completed their visits at 6 and 12 months, respectively.

The frequency of abnormal ALT values (>1xULN) was 10.8% (183/1685) and 11.6% (170/1461) at 6 and 12 month follow-up visits, and 15.5% (286/1845) for either visits. The number of patients who reported GI AEs was 777 (40.6%) within 1 year of follow-up. The prevalence of mucocutaneous, neurological, haematological and pulmonary AEs were 441 (23.1%), 487 (25.5%), 116 (6.1%), and 406 (21.3%), respectively.

Male sex, having high ALT at baseline and a history of diabetes were all associated with increased risk of ALT elevation during the study period (Table 1). Contrarily men were 47% less likely to report GI AEs compared to women. Furthermore, younger age and higher baseline disease activity score (DAS28-CRP) were associated with increased risk of GI AEs occurrence.

Table 1.

Baseline predictors of elevated alanine transaminase (ALT) and gastrointestinal (GI) adverse events

VariableElevated ALTGI adverse eventsAdjusted Odds Ratio (95% CI)Age (years)1.00 (0.99, 1.01)0.99 (0.98, 1.00)Male sex1.39 (1.02, 1.90)0.53 (0.42, 0.67)Drink alcohol1.23 (0.88, 1.73)1.09 (0.86, 1.37)Current or past smoking1.10 (0.80, 1.49)1.10 (0.88, 1.37)BMI (kg/m2)1.01 (0.98, 1.03)1.02 (1.00, 1.03)Symptoms duration (months)1.00 (1.00, 1.00)1.00 (1.00, 1.00)RF positivity0.81 (0.60, 1.10)0.93 (0.75, 1.16)DAS28-CRP0.97 (0.87, 1.08)1.13 (1.04, 1.23)ALT at baseline (IU)1.03 (1.02, 1.04)–History of diabetes1.94 (1.22, 3.08)0.91 (0.62, 1.34)History of liver disease1.73 (0.43, 6.95)–History of renal disease1.29 (0.42, 3.96)1.13 (0.50, 2.52)MTX starting dose (mg/week)1.03 (0.98, 1.08)1.03 (0.99, 1.06)

Conclusion:

GI events were the most commonly reported AEs among patients with RA in the first year of MTX treatment, followed by neurological, mucocutaneous and pulmonary AEs. Identifying predictors of AEs may help to optimise drug therapy in RA by tailoring the dosing strategy or frequency of monitoring. This may lead to increased adherence and consequently improved effectiveness.

Disclosure of Interests:

Ahmad Sherbini: None declared, James Gwinnutt Grant/research support from: BMS, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

SAT0137 METHOTREXATE ASSOCIATED ADVERSE EVENTS AND THEIR PREDICTORS IN METHOTREXATE-NAÏVE PATIENTS WITH RHEUMATOID ARTHRITIS: A SYSTEMATIC REVIEW

Background:

The adverse events (AEs) associated with methotrexate (MTX) treatment for rheumatoid arthritis (RA) have been studied extensively, but precise estimates of the incidence and prevalence of AEs are lacking. There is also limited published data on the predictors of AEs.

Objectives:

To summarise and pool incidence and prevalence rates of AEs in patients treated with MTX for RA, and to identify treatment, clinical and disease related predictors of AEs.

Methods:

A systematic literature search was carried out using Embase, Medline, and CENTRAL databases to identify relevant studies published between 1/1/2005 and 12/2/2019. The eligibility criteria included RCTs, non-randomized trials, and observational studies of first-time users of MTX in adults (≥ 18 years old) with RA and reported incidence, prevalence or predictors of the most common MTX related AEs, including: any AE, serious AEs, discontinuation due to AEs, elevated liver enzymes, gastrointestinal (GI), mucocutaneous (MC), central nervous system (CNS), and pulmonary AEs. Pooled proportions of GI AEs and elevated liver enzymes of patients treated with MTX monotherapy were estimated using random effects meta-analysis.

Results:

Of 3142 records screened, we included 46 articles (35 clinical trials and 11 cohort studies) with a total of 9646 patients, and a mean follow-up duration of 70±35 weeks (range: 13 - 104 weeks for RCTs, 40 - 156 weeks for observational cohorts).

Six studies reported incidence rate (IR) of any AE (range: 196 - 595 per 100 person-years), and eight studies reported IR of serious AEs (range: 3.7 - 15.9 per 100 person-years). The percentage of patients with any AE, reported in 32 studies, varied between 37% and 100% in RCTs, and between 13% and 34% in observational studies. Discontinuation of MTX due to AEs ranged between 1% and 29% in RCTs, and between 8% and 38% in observational studies. The reported prevalence of MC events (4% - 54%), CNS events (12% - 59%) and pulmonary events (10% - 67%) varied between studies.

The estimated pooled prevalence from studies with a MTX monotherapy arm was 14% (95% CI: 9%, 19%; N=7 studies) for liver enzymes elevation (Figure 1), and 29% (95% CI: 13%, 44%; N=7 studies) for GI AEs (Figure 2).

Figure 1.

Forest plot of pooled prevalence of elevated liver enzymes

Figure 2.

Forest plot of pooled prevalence of gastrointestinal adverse events

No statistically significant predictors of “any AE” were identified. For discontinuation of MTX due to AEs, RF positivity was associated with lower risk of MTX discontinuation due to MTX (HR 0.37, 95%CI: 0.21, 0.64), while other studies found that baseline HAQ score (OR 1.87, 95%CI: 1.11, 3.15) and BMI (OR 1.21, 95%CI: 1.02, 1.44) were associated with increased risk of MTX discontinuation due to AEs. ACPA positivity (OR 1.8, 95%CI: 1.1, 3.1), and high baseline alanine aminotransferase (ALT) (OR 3.1, 95%CI: 1.6, 6.2) were both independent predictors of two-fold elevation of ALT in one paper, and baseline creatinine (OR 1.03, 95%CI: 1.00, 1.07) and high baseline ALT (OR 1.03, 95%CI: 1.00, 1.06) were associated with increased risk of elevated ALT above the upper limit of normal in a different study.

Conclusion:

These findings affirm the high prevalence of GI AEs and elevated liver enzymes among patients treated with MTX for RA. The identified predictors of MTX withdrawal and elevated ALTs may be useful for identifying future patients likely to experience these AEs early in the course of treatment. However, the results of the predictors should be interpreted with caution, and further work is needed to replicate the results in studies with larger sample sizes and to assess the prognostic value of established predictors.

Disclosure of Interests:

Ahmad Sherbini: None declared, Seema Sharma: None declared, James Gwinnutt Grant/research support from: BMS, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer

THU0565 RESEARCHERS’ PERSPECTIVES ON ADHERENCE INTERVENTION RESEARCH AND OUTCOMES IN RHEUMATOLOGY: AN INTERNATIONAL QUALITATIVE STUDY

Background:

Medication non-adherence is a significant problem among patients with rheumatic diseases. Research on adherence interventions in rheumatology is limited and disappointing, with studies using heterogeneous outcomes. Understanding these limitations is needed to inform the design of better interventions and research studies.

Objectives:

To describe researchers’ perspectives and experiences on adherence intervention research and outcomes in rheumatology.

Methods:

Semi-structured interviews using video conference were conducted with researchers who had been an investigator on an adherence study of any design in the past 10 years. Interviews were recorded and transcribed verbatim. Participants were asked about their experiences with conducting adherence research and perspectives on introduction of a core domain set of outcomes for adherence intervention trials in rheumatology. Data collection and thematic analysis were conducted iteratively, until saturation.

Results:

We interviewed 13 researchers from seven countries (Australia, Belgium, Canada, Netherland, Thailand, UK, and USA). A majority worked in academia (75%), specialized in epidemiology and/or health services research (62%) and had led between 2-5 adherence studies in the past five years (62%).

Three themes were identified:1) challenges in designing, conducting and evaluating adherence studies;2) current outcomes in adherence intervention studies and their relevance; and3) implementing a core domain set of outcomes for adherence intervention studies.

Major challenges in conducting adherence research included inconsistent adherence terminology and measurement. Participants noted a lack of guidance on outcome selection and measurement when evaluating the effectiveness of an adherence intervention and indicated their preference for research to report adherence, intervention-specific, and health-related outcomes. Finally, implementing a core domain set of outcomes was thought to be challenging but valuable in strengthening the evidence (by facilitating meta-analysis), and improving clinical outcomes (by informing clinicians about the effectiveness of interventions).

Conclusion:

Adherence research in rheumatology has been hindered by lack of standardization and guidance on terminology, measurement and outcome selection. Our findings form the basis for recommendations for improving the design, conduct and evaluation of adherence intervention studies in rheumatology, particularly for developing a core domain set of outcomes to improve consistency and facilitate comparisons.

Table 1.

Themes and representative quotations.

Theme 1: Challenges in designing, conducting and evaluating studies of adherence interventions“…the people you often most want in your sample are the people who are non-adherent and often the people who are non-adherent are the people who are hardest to recruit.”“Long term the issue has been about measurements because people confuse and conflate various aspects of medication adherence.Theme 2: Current outcomes in adherence intervention studies and their relevance“you have a whole range of outcomes…psychological outcomes…there’s measures of health care utilization and things like attendance at hospital, nurse appointments and duration, things like times off work,, and also all the relevant clinical outcomes.”Theme 3: Implementing a core domain set of outcomes for adherence intervention studies“…will make trials more comparable and increase the likelihood that you’d be able to combine efforts internationally”

Disclosure of Interests:

Shahrzad Salmasi: None declared, Ayano Kelly: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Lyn March: None declared, Allison Tong: None declared, Peter Tugwell: None declared, Kathleen Tymms: None declared, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Mary De Vera: None declared

AB1203 INVESTIGATING THE VIEWS OF COMMUNITY PHARMACISTS ON THEIR ROLE IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS

Background:

Medicines optimisation is essential in the long-term management of rheumatoid arthritis (RA), particularly when considering combinations of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Community pharmacists are ideally placed to optimise medicines use including monitoring side effects, counselling on dose and frequency and improving medicines adherence; however, in some countries, such as the UK, there are currently no community pharmacy services that address csDMARD use and little is known about the role community pharmacists play in managing RA as a long-term condition.

Objectives:

The objectives of this qualitative study were to understand community pharmacists’ views of their training, knowledge and current role in the management of RA.

Methods:

We conducted 9 semi-structured, face-to-face or telephone interviews with community pharmacists based in the UK; all were transcribed verbatim. A topic guide, used to inform the interviews, covered four key areas: 1) knowledge and training, 2) pharmacological management 3) patients and services, 4) potential role. The transcriptions were then imported into NVivo for thematic analysis. A coding framework was developed from continual emerging themes and applied to the transcripts.

Results:

Five male/4 female participants, the median age was 39 years (range 27 to 42) with a median number of years qualified as a pharmacist of 12 years (range 5 to 20) were included. The participants covered a range of roles including: pharmacist non-manager, pharmacist manager, locum pharmacist, superintendent pharmacist and relief pharmacist.

In assessing the current role of community pharmacists, 4 main themes were identified: (1) access to information about the patient’s condition as a barrier, (2) their lack of knowledge in the management of RA, (3) providing practical advice about taking csDMARDs, and (4) exploring the reasons for non-adherence before taking further action. In assessing the potential role of community pharmacists, a further 2 themes were identified: improving access to information about the patient’s condition before the current role can be increased and other barriers to an additional role, including time and funding.

In the theme ‘access to information as a barrier’ the most common point made was about the lack of information available to pharmacists on the individual indication for medicines. Pharmacists said this posed a barrier both to current practice and their potential role. No participants suggested the potential for an additional service specifically for RA, but some suggested that current services could be expanded to include RA as a target group. Participants discussed side effect counselling and ensuring access to medicines in detail with patients, but only 2 briefly mentioned discussing the benefits of csDMARDs.

Conclusion:

This is the first in-depth exploration of the perspectives of community pharmacists on the management of RA in community pharmacy. This study has highlighted several important barriers both environmental and personal including time, education and resources that, if addressed, could allow community pharmacists to play a greater role in the management of RA.

Disclosure of Interests:

Sarah Wood: None declared, Kimme Hyrich Grant/research support from: Pfizer, UCB, BMS, Speakers bureau: Abbvie, Suzanne Verstappen Grant/research support from: BMS, Consultant of: Celltrion, Speakers bureau: Pfizer, Douglas Steinke: None declared

P17 Prediction of response of methotrexate in patients with rheumatoid arthritis using serum lipidomics

Background

For patients with rheumatoid arthritis (RA), introduction of early, effective therapy has consistently been shown to improve long-term outcomes. Low-dose methotrexate (MTX) is commonly prescribed as first-line treatment for RA. However, MTX is not effective for a large minority of patients and there is currently no way to determine ahead of therapy which patients are most likely to benefit. Metabolomics and lipidomics are emerging approaches for studying patient stratification in RA and have the potential to identify disease processes that underpin treatment outcomes. Here we apply state-of-the-art machine learning algorithms to predict MTX treatment response, by testing serum lipid levels measured at two time-points (pre-treatment and following 4 weeks on drug) to predict MTX response by 6 months.

Methods

This study included patients from the Rheumatoid Arthritis Medication Study (RAMS), a UK multi-centre one-year prospective observational study investigating predictors of response to MTX in patients with RA. Since 2008, patients who are about to start MTX for the first time are asked to provide demographic and clinical data, as well as blood samples to permit DNA, RNA and serum-based biomarker studies. Patients about to commence MTX treatment were followed longitudinally and those categorised as good or non-responders following 6 months on-drug using EULAR response criteria were analysed. Serum lipid levels were measured at pre-treatment and following 4 weeks on drug using ultra-performance liquid chromatography tailored for complex lipid analysis, coupled to mass spectrometry. State-of-the-art supervised machine learning methods were then applied to predict EULAR response at 6 months. Models including lipid levels were compared to models including clinical covariates (including: MTX start dose, steroid use at inclusion, BMI, number of swollen joints, number of tender joints, CRP levels, patients’ assessment of their overall wellbeing, gender, age-at-inclusion, age-at-onset, disease duration, HAQ score and pre-treatment smoking habits).

Results

Following quality control, 3,366 features (1,060 in negatively-charged mode and 2,306 in positive mode) were available for analysis at pre-treatment and 4 weeks from 100 RA patients categorised as good (GR, n = 50) or poor (NR, n = 50) responders to MTX following 6 months on drug. The best model performance for the classifier including clinical covariates was observed using L1/L2-regularised logistic regression (ROC AUC 0.68 ± 0.02). However, the clinical covariate model outperformed the classifier including lipid levels when either pre- or on-treatment time-points were investigated (ROC AUC 0.61 ± 0.02).

Conclusion

These data do not support the utility of early treatment lipidomic monitoring in routine clinical practice in patients started on MTX for their RA.

Disclosures

M. Maciejewski: Shareholder/stock ownership; owns stock or stock options in Pfizer. C. Sands None. N. Nair None. S. Ling None. S. Verstappen None. K. Hyrich None. A. Barton None. D. Ziemek Shareholder/stock ownership; owns stock or stock options in Pfizer. M. Lewis None. D. Plant None.

EP14 Association between initial csDMARD strategy and disease activity at 6 months in patients with new onset rheumatoid arthritis

Background

Until 2018, NICE guidance recommended the use of a combination of disease-modifying anti-rheumatic drugs (DMARDs), including methotrexate (MTX), in the initial management of people with rheumatoid arthritis (RA). In 2018 the guideline was updated to recommend monotherapy with MTX due to uncertainties in the evidence for combination therapy. However, it remains a requirement for progression onto any biologic that the patient should have persistent high disease activity and/or have intolerance to, a minimum of two DMARDs. The aim of this study was to understand the association between initial treatment strategy and EULAR response at 6 months.

Methods

This analysis included patients recruited to the longitudinal observational Rheumatoid Arthritis Medication Study (RAMS) in the UK who were DMARD naïve and had symptoms for less than 1 year. Patients were defined as either starting MTX monotherapy or MTX in combination with another DMARD (6 weeks either side of MTX start date) and categorised into EULAR non responders or moderate/ good responders after 6 months. A logistic regression model was applied to test the association between initial treatment strategy and EULAR response at 6 months, adjusting for confounders.

Results

A total of 948 participants were included in the analysis. MTX monotherapy was prescribed in 72% (n = 678) of patients and combination therapy was prescribed in 28% (n = 270) of patients, the majority of whom received MTX plus hydroxychloroquine (HCQ) (n = 236, 87%). There was no significant difference between the MTX monotherapy and combination therapy groups in EULAR response at 6-months (adjusted odds ratio [aOR] 0.77, 95% CI 0.53 to 1.14).

Conclusion

In this large UK observational study investigating the effect of treatment strategy within the first 6 weeks of presentation and treatment response at 6 months, there was no significant difference between combination DMARD therapy and MTX monotherapy on EULAR response. Most patients received MTX in combination with HCQ, for which little evidence exists.

Disclosures

S. Wood None. K. Hyrich Consultancies; ABBVIE. Grants/research support; BMS, PFIZER, UCB. S. Verstappen None. D. Steinke None.

Scope of Outcomes in Trials and Observational Studies of Interventions Targeting Medication Adherence in Rheumatic Conditions: A Systematic Review

OBJECTIVE

Nonadherence to medications is common in rheumatic conditions and associated with increased morbidity. Heterogeneous outcome reporting by researchers compromises the synthesis of evidence of interventions targeting adherence. We aimed to assess the scope of outcomes in interventional studies of medication adherence.

METHODS

We searched electronic databases to February 2019 for published randomized controlled trials and observational studies of interventions with the primary outcome of medication adherence including adults with any rheumatic condition, written in English. We extracted and analyzed all outcome domains and adherence measures with prespecified extraction and analysis protocols.

RESULTS

Overall, 53 studies reported 71 outcome domains classified into adherence (1 domain), health outcomes (38 domains), and adherence-related factors (e.g., medication knowledge; 32 domains). We subdivided adherence into 3 phases: initiation (n = 13 studies, 25%), implementation (n = 32, 60%), persistence (n = 27, 51%), and phase unclear (n = 20, 38%). Thirty-seven different instruments reported adherence in 115 unique ways (this includes different adherence definitions and calculations, metric, and method of aggregation). Forty-one studies (77%) reported health outcomes. The most frequently reported were medication adverse events (n = 24, 45%), disease activity (n = 11, 21%), bone turnover markers/physical function/quality of life (each n = 10, 19%). Thirty-three studies (62%) reported adherence-related factors. The most frequently reported were medication beliefs (n = 8, 15%), illness perception/medication satisfaction/satisfaction with medication information (each n = 5, 9%), condition knowledge/medication knowledge/trust in doctor (each n = 3, 6%).

CONCLUSION

The outcome domains and adherence measures in interventional studies targeting adherence are heterogeneous. Consensus on relevant outcomes will improve the comparison of different strategies to support medication adherence in rheumatology.

Secular changes in functional disability, pain, fatigue and mental well-being in early rheumatoid arthritis. A longitudinal meta-analysis

OBJECTIVES

To conduct a systematic review and longitudinal meta-analysis of early rheumatoid arthritis (RA) cohorts with long-term data on pain, fatigue or mental well-being.

METHODS

Searches using PUBMED, EMBASE and PyscInfo were performed to identify all early RA cohorts with longitudinal measures of pain, fatigue or mental well-being, along with clinical measures. Using longitudinal meta-analyses, the progression of each outcome over the first 60-months was estimated. Cohorts were stratified based on the median recruitment year to investigate secular trends in disease progression.

RESULTS

Of 7,319 papers identified, 75 met the inclusion criteria and 46 cohorts from 41 publications provided sufficient data on 18,046 patients for meta-analysis. The Disease Activity Scores (DAS28) and the Short-Form 36 (SF-36) Physical Component Score (PCS) indicated that post-2002 cohorts had statistically significant improvements over the first 60-months compared to pre-2002 cohorts, with standardised mean differences (SMD) of 0.86 (95% Confidence Intervals 0.34 to 1.37) and 0.76 (95% CI 0.25 to 1.27) respectively at month-60. However, post-2002 cohorts indicated statistically non-significant improvements in pain, fatigue, functional disability and SF-36 Mental Component Score (MCS) compared to pre-2002 cohorts, with SMD of 0.24 (95% CI -0.25 to 0.74), 0.38 (95% CI -0.11 to 0.88), 0.34 (95% CI -0.15-0.84) and -0.08 (95% CI -0.41 to 0.58) at month-60 respectively.

CONCLUSIONS

Recent cohorts indicate improved levels of disease activity and physical quality of life, however this has not translated into similar improvements in levels of pain, fatigue and functional disability by 60-months.

Profiling of Gene Expression Biomarkers as a Classifier of Methotrexate Nonresponse in Patients With Rheumatoid Arthritis

Objective

Approximately 30–40% of rheumatoid arthritis (RA) patients who are initially started on low‐dose methotrexate (MTX) will not benefit from the treatment. To date, no reliable biomarkers of MTX inefficacy in RA have been identified. The aim of this study was to analyze whole blood samples from RA patients at 2 time points (pretreatment and 4 weeks following initiation of MTX), to identify gene expression biomarkers of the MTX response.

Methods

RA patients who were about to commence treatment with MTX were selected from the Rheumatoid Arthritis Medication Study. Using European League Against Rheumatism (EULAR) response criteria, 42 patients were categorized as good responders and 43 as nonresponders at 6 months following the initation of MTX treatment. Data on whole blood transcript expression were generated, and supervised machine learning methods were used to predict a EULAR nonresponse. Models in which transcript levels were included were compared to models in which clinical covariates alone (e.g., baseline disease activity, sex) were included. Gene network and ontology analysis was also performed.

Results

Based on the ratio of transcript values (i.e., the difference in log₂‐transformed expression values between 4 weeks of treatment and pretreatment), a highly predictive classifier of MTX nonresponse was developed using L2‐regularized logistic regression (mean ± SEM area under the receiver operating characteristic [ROC] curve [AUC] 0.78 ± 0.11). This classifier was superior to models that included clinical covariates (ROC AUC 0.63 ± 0.06). Pathway analysis of gene networks revealed significant overrepresentation of type I interferon signaling pathway genes in nonresponders at pretreatment (P = 2.8 × 10⁻²⁵) and at 4 weeks after treatment initiation (P = 4.9 × 10⁻²⁸).

Conclusion

Testing for changes in gene expression between pretreatment and 4 weeks post–treatment initiation may provide an early classifier of the MTX treatment response in RA patients who are unlikely to benefit from MTX over 6 months. Such patients should, therefore, have their treatment escalated more rapidly, which would thus potentially impact treatment pathways. These findings emphasize the importance of a role for early treatment biomarker monitoring in RA patients started on MTX.