Consensus-Based Overarching Principles and Recommendations on the Use of Biosimilars in the Treatment of Inflammatory Arthritis in the Gulf Region

BACKGROUND

Though biologic agents have significantly improved the treatment of inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis), high costs, stringent regulations, strict reimbursement criteria, and existing patents have limited patient access to treatments. While being highly similar in quality, safety, and efficacy to biologic reference products, biosimilars can reduce the financial burden and prevent underutilization of medication.

OBJECTIVE

The objective of this initiative was to develop an evidence-based consensus of overarching principles and recommendations aimed at standardizing the use of biosimilars in treating inflammatory arthritis in the Gulf region.

METHODS

A task force of practicing rheumatologists, a clinical pharmacist, a health economist, patients, regulators, and payors from across the Gulf region developed recommendations and overarching principles based on the outputs of a systematic literature review conducted to address Patient-Intervention-Comparison-Outcome (PICO) questions specific to key challenges regarding the use of biosimilars for the treatment of inflammatory arthritis in the region. As the data before 2017 have been previously reviewed in another publication, the current review focused on data published between January 2017 and August 2022 (PROSPERO ID CRD42022364002). Consensus on each statement required a level of agreement of 70% or greater.

RESULTS

Consensus was reached for five overarching principles and nine recommendations by the task force. The principles emphasize the importance of improving the awareness, understanding, and perception of biosimilars, as well as the need for regulated regional real-world data generation and protocols to make biosimilars a viable and affordable treatment option for all patients. The consensus recommendations advocate the need for shared treatment decisions between rheumatologists and patients when considering biosimilars. They further recommend that confirmation of a biosimilar's efficacy and safety in a single indication is sufficient for extrapolation to other diseases for which the reference product has been approved. Finally, there is a need for pharmacovigilance and national health policies governing the adoption and prescription of biosimilars in clinical practice across the region.

CONCLUSIONS

These are the first consensus recommendations for the Gulf region based on a systematic literature review and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines, integrating clinical evidence with clinical expertise to optimize decision making for the use of biosimilars in patients with inflammatory arthritis. They were formulated based on predominantly international data because of the limited regional data and therefore can be generalized to serve as recommendations for healthcare professionals in other parts of the world.

COVID-19 and reported mortality cases among rheumatic disease patients in Kuwait: Data from the Global Rheumatology Alliance registry

Mycophenolate mofetil and rituximab have been shown to be considerably associated with poorer outcomes following SARS-CoV-2 infection. Such agents were associated with longer hospital stay as well as severe COVID-19 outcomes (infection-related complications, intensive care unit admission, and mortality). Using the data of the COVID-19 Global Rheumatology Alliance (GRA) registry of inflammatory rheumatic disease (IRD) patients in Kuwait, who had COVID-19 from March 2020 to March 2021, revealed 4 mortality cases (3 cases used CD-20 inhibitors as monotherapy and 1 case used mycophenolate mofetil/mycophenolic acid as monotherapy). This article describes the characteristics and course of disease among 4 patients with IRD who died following COVID-19 infection at Jaber Al Ahmed Hospital, Kuwait. The current series raises the intriguing prospect that IRD patients may have a varying risk of unfavorable clinical outcomes depending on the type of biological agents they were given. Rituximab and mycophenolate mofetil should be used with caution in IRD patients, particularly if they have concomitant comorbidities that put them at a high likelihood of developing severe COVID-19 outcomes.

Adherence to the Mediterranean diet is associated with a reduced DAS28 index among patients with rheumatoid arthritis: Case study from KRRD

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, autoimmune disease that mostly affects the synovial joints. It has been hypothesized that dietary and other environmental and lifestyle factors contribute to the development of RA and its severity.

OBJECTIVE

The present study aims to measure the effect of the Mediterranean diet (MedDiet) on the disease activity scores (DAS28) among patients with RA.

METHODS

Adult patients who satisfied the American College of Rheumatology (ACR) classification criteria for RA from major hospitals in Kuwait were evaluated. A cross-sectional study conducted on 754 RA patients visits aged (21-79) years. Patients were evaluated using the DAS28. Patients' levels of adherence to the MedDiet are assessed using a validated 14-item Questionnaire (paper or web-based). The data was analyzed using both multivariate and univariate statistics. Multivariate logistic regression was used to analyze the statistical relationship between MedDiet and RA disease activity.

RESULTS

The finding suggests that a MedDiet can have a positive impact on DAS28 among patients with RA. In the DAS28 cohort (DAS28 < 3.2, DAS28 ≥ 3.2), several Mediterranean survey components showed statistically significant differences. Patients with a Mediterranean score ≤ 5 was more likely to have hazard effects for DAS28 than those with a Mediterranean score of ≥10 (HR = 0.17, CI [0.08-0.37], p < .001). The finding shows that, Mediterranean levels ≤5, on biologics treatment, CRP, and patient global assessment were significantly associated with overall survival. Additionally, the MedDiet was found to be a significant predictor of DAS28 in the random forest decision tree plot, along with tender, RF, and creatinine. MedDiet patients had a lower DAS28 score than others.

CONCLUSION

The findings suggest that optimal drug treatment and a restrictive diet can help to improve DAS28 score for patients with RA. More patients in the cohort DAS28 <3.2 used olive oil, servings of vegetables, fruits, and legumes. In contrast, more patients in the cohort DAS28 ≥ 3.2 consumed red meat, butter, sweetened or soft drinks, cakes, cookies, or biscuits, and tomato sauce.

Is Serum Uric Acid Level Associated with Disease Activity in Rheumatoid Arthritis Patients

Background

An association between serum uric acid (UA) and disease activity in rheumatoid arthritis (RA) patients has not been well studied. We describe RA patients with high and normal UA and study its association with RA activity.

Methods

Adult RA patients from the Kuwait Registry for Rheumatic Diseases (KRRD) were studied from February 2012 through March 2022. Patients with documented UA levels were included. UA of >357 µmol/L (6mg/dL) was considered high. Statistical comparison and correlation were made using multivariate logistic regression.

Results

Overall, 1054 patients with documented UA. A total of 158 patients (15%) had high UA level with a mean of 409± 44.4µmol/L. The mean age for the high UA group and low UA group were 59.3 ± 10.7 years and 54.5 ± 12.4 years, respectively (p<0.001). 49.4% were female in high UA group, and 62.2% were female in low UA group, respectively (p<0.05). Logistic analysis showed an inverse relation between DAS28 and UA, as lower DAS28 score was associated with higher UA level (p=0.032) OR 1.39. There was a direct relation with HAQ, creatinine and UA. A higher HAQ is associated with a higher UA level (p=0.019) OR 0.78. High creatinine level is also associated with high UA level (p<0.001) OR 0.24. The use of antirheumatic drugs was similar among patients with high and normal UA.

Conclusion

RA patients with a higher UA had a lower disease activity despite using similar antirheumatic drugs. The reasons behind this association need to be further studied.

Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

AB0208 LONG-RUN RELATIONSHIP ASSESSMENT OF AIR POLLUTANTS ON RHEUMATOID ARTHRITIS DISEASE ACTIVITY SCORE: EVIDENCE FROM THE VECM APPROACH

Background

Current findings on the impact of air quality conditions on rheumatoid arthritis (RA) are sparse and not conclusive.

Objectives

To investigate the relationship between air pollutants and RA disease activity scores on a short and a long time period using a multivariate time series model.

Methods

Data on RA patients were extracted from the Kuwait Registry for Rheumatic Diseases (KRRD) from four major hospitals in Kuwait from January 2013 to December 2017. Data on air ambient pollutants (ozone O3, sulfur dioxide SO2, nitrogen dioxide NO2) were extracted from four Kuwait Environmental Public Authority (K-EPA) Air Monitoring Stations through Environmental Monitoring Information System of Kuwait (eMISK), corresponding to the patients residential areas from January 2013 till December 2020. A multivariate time series approach using Evidence from vector error correction model (VECM) was employed to investigate the effect of air ambient pollutants emissions on DAS28 over that period.

Results

A total of 1,809 RA patients and 10,215 hospital visits were included, 63% females, mean age 54 years, mean disease duration 9.2 years and 77% had rheumatoid factor positive. A significant correlation was found between DAS-28 and SO2, NO2 and O3 (p=0.012, 0.029, 0.039 respectively). According to the Granger causality test and VECM, emissions of NO2, and O3 had a positive short-term effect on DAS28 among RA patients. Impulse response test results showed that for some locations in Kuwait there is a short-term positive causal relationship between emissions of NO2 and DAS28, due to sources of pollution surrounding the locations. The results showed that the short run effect for NO2 with lags 1 to 4 days had a positive relationship with DAS-28 which means, there is 1% increase in DAS-28 for every 0.0182 increase in NO2 emission. Our results revealed that 36% of discrepancy between the overall relationship between DAS-28 and air pollution is corrected each year.

Conclusion

Increased concentrations of air pollutants may increase the risk of RA activity. VECM time series model can be used as a tool to predict changes in disease activity based on air pollutants up to 8 days. We recommend that a regular broadcast is issued by health authorities to RA patients to help predict changes in disease activity. Warning about air pollution may be tailored according to the patient’s residential area. Government should take serious decisions to help minimize air pollution in the residential areas.

References

[1]Chang, K.-H., Hsu, C.-C., Muo, C.-H., Hsu, C. Y., Liu, H.-C., Kao, C.-H., Chen, C.- Y., Chang, M.-Y., and Hsu, Y.-C. (2016). Air pollution exposure increases the risk of rheumatoid arthritis: a longitudinal and nationwide study. Environment International, 94:495–499.

[2]Alsaber, A., Pan, J., Al-Herz, A., Alkandary, D. S., Al-Hurban, A., Setiya, P., Group, K., et al. (2020). Influence of ambient air pollution on rheumatoid arthritis disease activity score index. International Journal of Environmental Research and Public Health, 17(2):416.

[3]Adami, G., Viapiana, O., Rossini, M., Orsolini, G., Bertoldo, E., Giollo, A., ... & Fassio, A. (2021). Association between environmental air pollution and rheumatoid arthritis flares. Rheumatology.

[4]Al-Herz, A., Al-Awadhi, A., Saleh, K., Al-Kandari, W., Hasan, E., Ghanem, A., Abutiban, F., Alenizi, A., Hussain, M., Ali, Y., et al. (2016). A comparison of rheumatoid arthritis patients in kuwait with other populations: results from the krrd registry. Journal of Advances in Medicine and Medical Research, pages 1–11.

[5]Al-Hurban, A., Khader, S., Alsaber, A., and Pan, J. (2021). Air quality assessment in the state of kuwait during 2012 to 2017. Atmosphere, 12(6):678.

Figure 1.

Long-term (2012-2020) trends of NO2 concentrations and DAS-28 calculated using the smooth trend method based on the mean measurements for four locations in Kuwait

Disclosure of Interests

None declared

COVID-19 outcomes among rheumatic disease patients in Kuwait: Data from the COVID-19 Global Rheumatology Alliance (C19-GRA) physician registry

PURPOSE

We aimed to assess the characteristics of inflammatory rheumatic disease (IRD) patients in Kuwait diagnosed with COVID-19 and the factors linked with hospitalization, complications, and mortality.

METHODS

Data of IRD patients from Kuwait diagnosed with COVID-19 between March 2020 and March 2021, submitted to the COVID-19 Global Rheumatology Alliance physician-reported registry, were included in our analysis. Data on patients' age, gender, smoking, diagnosis, IRD activity, and other comorbidities were collected. Statistical Package for the Social Sciences (SPSS), version 25, was used for statistical analysis.

RESULTS

A total of 52 patients were included, with a mean age of 55 years (±14). The majority of patients were ≤65 years (77%), female (77%), non-smokers (80.8%), and diagnosed with rheumatoid arthritis (67.0%). Of the included patients, 19.2%, 9.6%, and 7.7% reported having methotrexate monotherapy, antimalarials monotherapy, and interleukin-6 inhibitors monotherapy immediately before COVID-19, respectively. Most of the included patients (92.3%) were either in remission or had minimal/low disease activity, while others (7.7%) had moderate disease activity. Forty-three patients (82.7%) were hospitalized, while 11 patients (25.6%) required ventilation (invasive or non-invasive). Ten of the ventilated patients (90.9%) received glucocorticoids as part of the local protocol to treat severe COVID symptoms, and 4 patients (7.69%) died. The duration till symptom-free ranged between 0 to 30 days, with a mean value of 10 days (±6.5).

CONCLUSION

The current study provides timely real-world evidence regarding characteristics and potential risk factors linked to poor COVID-19-related outcomes in the IRD population in Kuwait.

Therapeutic role of immunomodulators during the COVID-19 pandemic- a narrative review

The emergency state caused by COVID-19 saw the use of immunomodulators despite the absence of robust research. To date, the results of relatively few randomized controlled trials have been published, and methodological approaches are riddled with bias and heterogeneity. Anti-SARS-CoV-2 antibodies, convalescent plasma and the JAK inhibitor baricitinib have gained Emergency Use Authorizations and tentative recommendations for their use in clinical practice alone or in combination with other therapies. Anti-SARS-CoV-2 antibodies are predominating the management of non-hospitalized patients, while the inpatient setting is seeing the use of convalescent plasma, baricitinib, tofacitinib, tocilizumab, sarilumab, and corticosteroids, as applicable. Available clinical data also suggest the potential clinical benefit of the early administration of blood-derived products (e.g. convalescent plasma, non-SARS-CoV-2-specific immunoglobins) and the blockade of factors implicated in the hyperinflammatory state of severe COVID-19 (Interleukin 1 and 6; Janus Kinase). Immune therapies seem to have a protective effect and using immunomodulators alone or in combination with viral replication inhibitors and other treatment modalities might prevent progression into severe COVID-19 disease, cytokine storm and death. Future trials should address existing gaps and reshape the landscape of COVID-19 management.

Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region

BACKGROUND

Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a cross-sectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region.

METHODS

RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission.

FINDINGS

A total of 2010 RA patients was included in the study, the overall remission rates were 62•3% (DAS28-CRP), 35•5% (DAS28-ESR), 30•8% (CDAI), 26•5% (SDAI), 24•7% (Boolean), and 17•1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17•9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of GC usage. The favorable related factors were male sex, younger age, fewer comorbidities, fewer extra-articular manifestations (EAM), and use of b/tsDMARDs, while treatment with GC was negatively related to remission.

INTERPRETATION

Remission rates were low and varied in the Asia-Pacific region. Treatment with b/tsDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region.

Handling missing data in a rheumatoid arthritis registry using random forest approach

Missing data in clinical epidemiological research violate the intention-to-treat principle, reduce the power of statistical analysis, and can introduce bias if the cause of missing data is related to a patient's response to treatment. Multiple imputation provides a solution to predict the values of missing data. The main objective of this study is to estimate and impute missing values in patient records. The data from the Kuwait Registry for Rheumatic Diseases was used to deal with missing values among patient records. A number of methods were implemented to deal with missing data; however, choosing the best imputation method was judged by the lowest root mean square error (RMSE). Among 1735 rheumatoid arthritis patients, we found missing values vary from 5% to 65.5% of the total observations. The results show that sequential random forest method can estimate these missing values with a high level of accuracy. The RMSE varied between 2.5 and 5.0. missForest had the lowest imputation error for both continuous and categorical variables under each missing data rate (10%, 20%, and 30%) and had the smallest prediction error difference when the models used the imputed laboratory values.

Recommendation for the Management of Spondyloarthritis Patients in Kuwait

OBJECTIVE

In 2016, ASAS and EULAR made joint recommendations for the management of patients with spondyloarthritis. Although Global and European perspectives are important, they cannot accurately reflect the situation for all patients in all countries and regions. As such, the group worked to tailor the existing international recommendations to suit the specific demographic needs of local populations in the Gulf region, with a specific focus on Kuwait.

METHODS

Recommendations drafted following a PubMed search for relevant literature were reviewed and then underwent Delphi vote to reach consensus on those to be included. Advice for newly approved agents, including targeted synthetic disease-modifying anti-rheumatic drugs, was included based on the group's clinical experience.

RESULTS

The resulting 41 recommendations are grouped into five categories covering key definitions and principles for the management and treatment of both axial and peripheral forms of spondyloarthritis.

CONCLUSION

Through adaptation of existing guidelines and incorporating the current evidence and clinical experience of the members of the group, these recommendations have been developed to reflect the unique situation in Kuwait with regard to differing patient profiles, local culture and approved therapeutic approaches, and are designed to aid in clinical decision-making.

AB0176 RISK OF ANTI-CITRULLINATED PEPTIDE ANTIBODIES AND RHEUMATOID FACTOR IN MALE SMOKERS: DATA FROM KUWAIT REGISTRY FOR RHEUMATIC DISEASES (KRRD)

Background:

Smoking has been proposed to be associated with the development of anti-citrullinated peptide antibodies (ACPA) in rheumatoid arthritis (RA) patients.

Objectives:

To study the relationship between smoking and ACPA as well as smoking and RF in patients with RA in Kuwait Registry for Rheumatic Diseases (KRRD).

Methods:

Data on RA patients were extracted from KRRD from four major hospitals from February 2013 through December 2019. As females rarely smoke in Kuwait with a smoking prevalence of 3% in female RA patients in KRRD, females were excluded from the study population to reach the minimum statistical percentage needed to perform chi square test and assess the association between smoking and other variables. Statistical tests were applied where appropriate. Logistic regression was conducted to adjust for possible confounders including age, disease duration, comorbidities, family history of a rheumatic disease, ANA, treatment agents and disease activity and quality of life assessment tools.

Results:

A total of 863 RA male patients were studied with a mean age of 53.9±12.5 years and a mean disease duration 7.3±5.5 years. 652 (75.6%) had positive RF and 624 (72.3%) had positive ACPA. 431 (50%) had at least one comorbidity. 640 (74.2%) were on conventional disease modifying agents (cDMARD’s) and 223 (25.8%) were on biologic therapy. 183 (21.2%) were smokers. After adjustment of other factors, logistic regression showed that smokers were significantly different than non-smokers in terms of a positive ACPA (β=-1.051,p<0.001, odds=4.019) and a positive RF (β=-0.804,p=0.019, odds=2.517).

Conclusion:

Smokers have a higher risk of expressing a positive RF and a positive ACPA in a male population. Smoking should be considered as a possible risk factor for RA and efforts should be done to educate the population to cease smoking to possibly lower that risk.

References:

[1]Benowitz, N.L., 2009. Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annual review of pharmacology and toxicology, 49, pp.57-71.

[2]Firestein, G.S., 2003. Evolving concepts of rheumatoid arthritis. Nature, 423(6937), p.356.

[3]Heliövaara, M., Aho, K., Aromaa, A., Knekt, P. and Reunanen, A., 1993. Smoking and risk of rheumatoid arthritis. The Journal of rheumatology, 20(11), pp.1830-1835.

[4]Hoy, K. W., 2009. Quantitative Research in Education: A Primer. SAGE. pp. 69-86.

[5]Kerlan-Candon, S., Combe, B., Vincent, R., Clot, J., Pinet, V. and Eliaou, J.F., 2001. HLA-DRB1 gene transcripts in rheumatoid arthritis. Clinical & Experimental Immunology, 124(1), pp.142-149.

[6]Kuada, J., 2012. Research Methodology: A Project Guide for University Students. Samfundslitteratur. pp. 45-56.

[7]Kumar, R., 2010. Research Methodology: A Step-by-Step Guide for Beginners. SAGE. pp. 148-159.

[8]Masdottir, B., Jonsson, T., Manfreðsdóttir, V., Víkingsson, A., Brekkan, Á. and Valdimarsson, H., 2000. Smoking, rheumatoid factor isotypes and severity of rheumatoid arthritis. Rheumatology, 39(11), pp.1202-1205.

[9]Neuman, W., 2009. Understanding research. Boston: Pearson. pp. 230- 255.

Disclosure of Interests:

None declared

THU0556 MISSING DATA AND MULTIPLE IMPUTATION IN RHEUMATOID ARTHRITIS REGISTRIES USING SEQUENTIAL RANDOM FOREST METHOD

Background:

Missing data in clinical epidemiological researches violate the intention to treat principle,

reduce statistical power and can induce bias if they are related to patient’s response to treatment. In multiple imputation (MI), covariates are included in the imputation equation to predict the values of missing data.

Objectives:

To find the best approach to estimate and impute the missing values in Kuwait Registry for Rheumatic Diseases (KRRD) patients data.

Methods:

A number of methods were implemented for dealing with missing data. These includedMultivariate imputation by chained equations(MICE),K-Nearest Neighbors(KNN),Bayesian Principal Component Analysis(BPCA),EM with Bootstrapping(Amelia II),Sequential Random Forest(MissForest) and mean imputation. Choosing the best imputation method was

judged by the minimum scores ofRoot Mean Square Error(RMSE),Mean Absolute Error(MAE) and

Kolmogorov–Smirnov D test statistic(KS) between the imputed datapoints and the original datapoints that were subsequently sat to missing.

Results:

A total of 1,685 rheumatoid arthritis (RA) patients and 10,613 hospital visits were included in the registry. Among them, we found a number of variables that had missing values exceeding 5% of the total values. These included duration of RA (13.0%), smoking history (26.3%), rheumatoid factor (7.93%), anti-citrullinated peptide antibodies (20.5%), anti-nuclear antibodies (20.4%), sicca symptoms (19.2%), family history of a rheumatic disease (28.5%), steroid therapy (5.94%), ESR (5.16%), CRP (22.9%) and SDAI (38.0%), The results showed that among the methods used, MissForest gave the highest level of accuracy to estimate the missing values. It had the least imputation errors for both continuous and categorical variables at each frequency of missingness and it had the smallest prediction differences when the models used imputed laboratory values. In both data sets, MICE had the second least imputation errors and prediction differences, followed by KNN and mean imputation.

Conclusion:

MissForest is a highly accurate method of imputation for missing data in KRRD and outperforms other common imputation techniques in terms of imputation error and maintenance of predictive ability with imputed values in clinical predictive models. This approach can be used in registries to improve the accuracy of data, including the ones for rheumatoid arthritis patients.

References:

[1]Junninen, H.; Niska, H.; Tuppurainen, K.; Ruuskanen, J.; Kolehmainen, M. Methods for imputation of

missing values in air quality data sets.Atmospheric Environment2004,38, 2895–2907.

[2]Norazian, M.N.; Shukri, Y.A.; Azam, R.N.; Al Bakri, A.M.M. Estimation of missing values in air pollution

data using single imputation techniques.ScienceAsia2008,34, 341–345.

[3]Plaia, A.; Bondi, A. Single imputation method of missing values in environmental pollution data sets.

Atmospheric Environment2006,40, 7316–7330.

[4]Kabir, G.; Tesfamariam, S.; Hemsing, J.; Sadiq, R. Handling incomplete and missing data in water network

database using imputation methods.Sustainable and Resilient Infrastructure2019, pp. 1–13.

[5]Di Zio, M.; Guarnera, U.; Luzi, O. Imputation through finite Gaussian mixture models.Computational

Statistics & Data Analysis2007,51, 5305–5316.

Disclosure of Interests:

None declared

P223 Influence of ambient air pollution on RA disease activity scores

Background

This study aims to estimate the influence of air pollution ambients using the Air Quality Index (AQI) to Rheumatoid Arthritis (RA) disease activity. Disease Activity Score with 28 examined joints (DAS-28) and Clinical Disease Activity Index (CDAI) considered as disease activity indices for RA patients in the state of Kuwait.

Methods

Data for patients with RA disease were collected from Kuwait Registry for Rheumatic Diseases (KRRD) from 2013 to 2017. Moreover, data on air pollution obtained from The Kuwait Environmental Public Authority (K-EPA) during the same period. Statistical analysis was conducted using STATA to highlight the significant association between study variables. Descriptive statistics, correlation analysis and linear regression model techniques were employed to estimate the significant associations between RA disease activity represented by DAS-28 and CDAI; with air pollution components (PM10, NO2, SO2, O3, and CO). Multiple Imputation by Chained Equations (MICE) algorithm was also employed to tackle the value of the missing data for air pollution data.

Results

Total of 9,875 patients visits included in the analysis that matching with air pollution information from K-EPA database according to date and patient living address governorate. The study found SO2 and NO2 were significantly associated with RA disease activity using DAS-28 index, also, for CDAI index as well. For the score of RA disease activity using DAS-28 index, the correlation results show a positive significant correlation with exposure of SO2 using AQI (rp = 0.07), also the same results with the with the exposure of NO2 using AQI (rp = 0.07). The final model is demonstrating the effect from air-pollutants gaseous with RA factors (Swollen, RF, anti-CCP, ESR, CRP) on RA disease activity. The AQI of NO2 and SO2 still showed positive associations with disease activity performance of RA. The linear regression model shows a positive effects of NO2 (beta = 0.003, 95% CI: 0.002-0.005) and (beta = 0.048, 95\% CI: 0.030-0.066) for DAS-28 and CDAI respectively, where for SO2, the results shows positive significant effect with (beta = 0.003, 95% CI: 0.0004-0.005) and (beta = 0.044, 95% CI: 0.018-0.070) for DAS-28 and CDAI respectively.

Conclusion

In conclusion, our study showed that air ambients were significantly correlated to RA disease activity scores and should be considered as a possible risk factor for RA activity.

Disclosures

A.R. Alsaber None. J. Pan None. A. Al-Herz None. D.S. Alkandary None. A. Al-Hurban None. P. Setiya None.

Influence of Ambient Air Pollution on Rheumatoid Arthritis Disease Activity Score Index

Rheumatoid arthritis (RA) is a chronic autoimmune of an unknown etiology. Air pollution has been proposed as one of the possible risk factors associated with disease activity, although has not been extensively studied. In this study, we measured the relationship between exposure to air pollutants and RA activity. Data on RA patients were extracted from the Kuwait Registry for Rheumatic Diseases (KRRD). Disease activity was measured using disease activity score with 28 examined joints (DAS-28) and the Clinical Disease Activity Index (CDAI) during their hospital visits from 2013 to 2017. Air pollution was assessed using air pollution components (PM10, NO2, SO2, O3, and CO). Air pollution data were obtained from Kuwait Environmental Public Authority (K-EPA) from six different air quality-monitoring stations during the same period. Multiple imputations by the chained equations (MICE) algorithm were applied to estimate missing air pollution data. Patients data were linked with air pollution data according to date and patient governorate address. Descriptive statistics, correlation analysis, and linear regression techniques were employed using STATA software. In total, 1651 RA patients with 9875 follow-up visits were studied. We detected an increased risk of RA using DAS-28 in participants exposed to SO2 and NO2 with β=0.003 (95% CI: 0.0004–0.005, p<0.01) and β=0.003 (95% CI: 0.002–0.005, p<0.01), respectively, but not to PM10, O3, and CO concentrations. Conclusively, we observed a strong association between air pollution with RA disease activity. This study suggests air pollution as a risk factor for RA and recommends further measures to be taken by the authorities to control this health problem.

Kuwait association of rheumatology 2018 treatment recommendations for patients with rheumatoid arthritis

The Kuwait Association of Rheumatology (KAR) aimed to develop a set of recommendations for the treatment of patients with rheumatoid arthritis (RA), tailored to the unique patient population and healthcare system of Kuwait. Each recommendation was developed based on expert opinion and evaluation of clinical practice guidelines from other international and national rheumatology societies. Online surveys were conducted to collate feedback on each KAR member's level of agreement (LoA) with definitions of disease-/treatment-related terms used and the draft recommendations. Definitions/recommendations achieving a pre-defined cut-off value of ≥ 70% agreement were accepted for inclusion. Remaining statements were discussed and revised at a face-to-face meeting, with further modifications until consensus was reached. A final online survey was used to collect feedback on each KAR member's LoA with the final set of recommendation statements on a scale of 0 (complete disagreement) to 10 (complete agreement). Group consensus was achieved on 66 recommendation statements, including 3 overarching principles addressing the pharmacological treatment and management of RA. Recommendations focused on treatment of early RA, established RA, patients with high-risk comorbidities, women during pregnancy and breastfeeding, and screening and treatment of opportunistic infections. The KAR 2018 Treatment Recommendations for RA reported here are based on a synthesis of other national/international guidelines, supporting literature, and expert consensus considering the Kuwaiti healthcare system and RA patient population. These recommendations aim to inform the clinical decisions of rheumatologists treating patients in Kuwait, and to promote best practices, enhance alignment and improve the treatment experience for patients.

Kuwait Recommendations on Vaccine Use in People with Inflammatory Rheumatic Diseases

People with IRD are at increased risk of infection, and in 2011 EULAR made general recommendations for vaccination in these patients. Global and European perspectives are important, but they cannot accurately reflect the individual situations of patients in different countries and regions. Based on our clinical experience and opinions, we have sought to tailor the original EULAR recommendations to include advice for vaccination with new agents approved in the intervening years-including the new class of targeted synthetic disease-modifying antirheumatic drugs. We have also considered the specific demographic needs of patients in local populations in the Gulf region. The resulting 16 recommendations are grouped into four main categories covering general vaccination guidelines and best-practice for all patients with IRD, followed by a set of recommended vaccines against specific pathogens. The last two categories include recommendations for certain patient subgroups with defined risks and for patients who wish to travel.

Low Prevalence of Nodules in Rheumatoid Arthritis Patients in Kuwait: A Description and a Comparison of Patients from the Kuwait Registry for Rheumatic Diseases

OBJECTIVES

To describe the prevalence of rheumatoid nodules (RN) in patients with rheumatoid arthritis (RA) and to compare their features with those of patients without RN.

SUBJECTS AND METHODS

Adult RA patients (n = 952) in the Kuwait Registry for Rheumatic Diseases from February 2013 to December 2015 were evaluated for RN. Demographic and serological features and disease activity and severity were obtained from the registry.

RESULTS

Of the 952 RA patients, 22 (2.3%) had RN and 930 (97.7%) did not. Age, sex, disease duration, smoking, and family history of an autoimmune rheumatic disease were similar. Obesity was more prevalent in the RN group, i.e. 11 (50%) vs. 326 (35.1%), p = 0.016. There was no difference in rheumatoid factor (RF) or anti-cyclic citrullinated peptide antibody positivity. Patients with RN had more sicca symptoms, i.e. 8 (36.4%) vs. 152 (16.3%), p = 0.025, a higher mean score on the visual analogue scale pain (3 ± 2.9 vs. 2 ± 2.7, p < 0.001), more tender joints (6.4 ± 8.8 vs. 4.2 ± 7.2, p = 0.001), a higher patient global assessment of disease activity (3.3 ± 2.7 vs. 2.3 ± 2.7, p < 0.001), and more deformities, i.e. 3 (13.6%) vs. 74 (8%), p = 0.034. The mean health assessment questionnaire score in RN patients was 1.1 versus 0.9 in patients without RN (p = 0.08). Patients with RN had a low disease activity (means: disease activity score [DAS-28], 3.02; clinical disease activity index, 7.7; and simple disease activity index, 10.4), similar to the other group. While the rates of methotrexate treatment were comparable, biologic therapy was administered more in patients with RN (i.e. 15 [68.2%] vs. 478 [51.4%], p < 0.001).

CONCLUSION

In Kuwait, the prevalence of RN is low among RA patients. Patients with and without RN are similar in terms of demographics and serologic features, except for more obesity. However, patients with RN have more sicca symptoms, joint deformities, and painful and tender joints. Disease activity scores are low with more frequent biologic therapy.

Prevalence of angiotensin-converting enzyme gene insertion-deletion polymorphism in patients with primary knee osteoarthritis

OBJECTIVE

Angiotensin converting enzyme (ACE) plays an important role in a number of inflammatory and immune related disorders. This study was undertaken to investigate an association between Angiotensin converting enzyme (ACE) gene insertion- deletion (I/D) polymorphism and primary knee osteoarthritis (OA) in Kuwait and to explore a correlation between clinical subgroups of OA and ACE I/D polymorphism genotypes.

PATIENTS AND METHODS

The prevalence of ACE gene I/D polymorphism was determined in 115 patients with primary knee OA and 111 ethnically matched healthy controls by using polymerase chain reaction (PCR) of the genomic DNA. The association of ACE gene I/D polymorphism genotypes was also studied with age of disease onset, function and radiological grading.

RESULTS

No significant difference was detected in the frequency of ACE gene I/D polymorphism genotypes and alleles between knee OA patients and the controls. The frequency of ACE gene polymorphism genotypes was also studied in subgroups on the basis of clinical parameters of age of onset of disease, function and radiological grading and no significant difference was detected between subgroups of OA patients and the controls. This is in sharp contrast to a previous report from Korea in which a significant association has been reported between ACE gene polymorphism and knee OA.

CONCLUSION

This study did not find an association between ACE gene I/D polymorphism genotypes in Kuwaiti patients with primary knee osteoarthritis and the onset or severity of the disease, which is very different from Korean knee OA patients in which an association has been reported.

Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis

We evaluated the effect of exercise therapy on back pain, spinal range of motion (ROM), and disability in persons with diffuse idiopathic skeletal hyperostosis (DISH). Persons with symptomatic DISH received a daily exercise program for 24 weeks consisting of mobility, stretching, and strengthening exercises for the cervical, thoracic, and lumbar spine. It included 14 supervised sessions over 8 weeks. Outcomes included visual analogue scales (VAS) for pain, stiffness, and fatigue, 13 spinal measurements, the neck pain and disability scale, the Quebec back pain disability scale, the Bath Spondylitis Functional Index, and the MACTAR patient preference scale. Assessments were made at baseline, 8 weeks, and 24 weeks. Fifteen of 17 completed the study. Comparing week 24 with baseline, Schober's test improved significantly (p = 0.02), and VAS stiffness and left finger-to-floor test demonstrated a trend to improvement (p = 0.07 each). The physical measures, which were expected to improve with the exercise program, all moved in the direction expected, but had p values > 0.10. At 24 weeks, eight (53.3%) participants rated their status as improved, three (20%) as unchanged, and four (27%) were unsure about the benefit. The exercise program designed for DISH and tested in this study led to small improvements in physical measures which achieved significance only for lumbosacral flexion.

Association of angiotensin-converting enzyme (ACE) gene insertion-deletion polymorphism with spondylarthropathies

Low back pain (LBP) is a common medical problem. Interaction between genetic and environmental factors predisposes individuals to LBP even at an early age. Inflammatory back pain or spondylarthropathies include ankylosing spondylitis (AS), psoriatic arthritis (PSA), reactive arthritis enteropathic and undifferentiated arthropathies. Angiotensin-converting enzyme (ACE) plays an important role in circulatory homeostasis, physiology of vasculature and inflammation. The insertion-deletion (I/D) polymorphism of the ACE gene has been shown to determine the plasma and tissue levels of ACE especially in the synovial fluid. The aim of this study was to investigate an association between ACE gene I/D polymorphism and inflammatory back pain (spondylarthropathies) secondary to ankylosing spondylitis (AS), psoriatic arthritis, inflammatory bowel disease and undifferentiated spondylarthropathies. The prevalence of ACE gene I/D polymorphism genotypes was determined in 63 patients with inflammatory back pain by polymerase chain reaction (PCR) and compared with that in 111 healthy controls. Of the 63 patients studied, 45 (71.4%) were with AS, 13 (20.6%) were with PSA, 4 (6.3%) were with reactive arthropathy and 1 (1.6%) manifested undifferentiated arthropathy. There were 43 males and 20 females. Mean age of patients was 39.0+/-11.36 years, age at onset of spondylarthropathy was 27.7+/-7.49 years and disease duration was 10.3+/-7.74 months. The controls were selected to match with the patients group in terms of gender ratio, age and ethnicity. The ACE gene polymorphism showed an overall significant difference between patients and controls (p=0.050). When the ID and II genotype frequency was combined and compared with that for DD genotype amongst patient and control groups, a considerably higher incidence was detected for ID and II genotypes than the DD genotype in spondylarthropathy patients compared to that in the controls (p=0.036). This study showed a significant association of the I-allele of ACE gene I/D polymorphism with spondylarthropathy in Kuwaiti Arabs.

Angiotensin-converting enzyme gene polymorphism in Kuwaiti patients with systemic lupus erythematosus

OBJECTIVE

To investigate the frequency of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism genotypes in patients with systemic lupus erythematosus (SLE), and to study the correlation between I/D polymorphism of the ACE gene and the clinical manifestations of SLE, especially vascular involvement, lupus nephritis and disease severity.

METHODS

The frequency of ACE gene I/D polymorphism genotypes was determined in 92 patients with SLE from Kuwait, and compared to that in 100 ethnically matched healthy controls using the polymerase chain reaction.

RESULTS

The distribution of ACE I/D polymorphism and allele frequencies in SLE patients was not significantly different from controls. Further analyses of SLE patients showed that there was a significant association between DD genotype and Raynaud's phenomenon (p=0.008, odd ratio=5.4, 95% confidence interval: 1.6-18.6). However, there was no significant association between the ACE genotype and lupus nephritis or disease severity.

CONCLUSION

No difference was found between the distribution of the ACE genotype in SLE patients and the general pop-ulation in Kuwait. However, the presence of the DD genotype may confer susceptibility to the development of vascular morbidity.

Incidence of musculoskeletal pain in adult Kuwaitis using the validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire

BACKGROUND

The WHO-ILAR Community Oriented Program for Control of Rheumatic Diseases (COPCORD) primarily aims to estimate the burden of musculoskeletal symptoms/disorders. We estimated the incidence of musculoskeletal pain in the first community-based COPCORD study in Kuwait

SUBJECTS AND METHODS

The validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire was used in a survey of 2500 randomly selected Kuwaiti households to assess the frequency of musculoskeletal pain, disability, and health-seeking behavior in adult Kuwaitis. Those subjects reporting no musculoskeletal pain were identified and followed-up for a period of one year by contacting them every 2 weeks. Once a respondent reported pain, an appointment to report to hospital was offered and the subject was examined by a rheumatologist using American College of Rheumatology (ACR) criteria.

RESULTS

Of 5159 adults who were non-complainers in an earlier prevalence phase of the study, 3341 responded to phone calls (response rate of 65%). The incidence of musculoskeletal pain was 6.6% (95% CI, 3.4%-9.7%) Age- and sex-adjusted incidence rates were 7.2% (95% CI, 3.4%-10.5%) for females and 6.1% (95% CI, 3.1%-9.2%) for males. The incidence rate increased with increasing age, body mass index, and with being married. The common sites of pain were knee, low back and shoulder.

CONCLUSION

The incidence of musculoskeletal pain among Kuwaiti adults is reported for the first time. Further studies adopting the same instrument in other communities are warranted to compare with our findings.

Role of radiation therapy in patients with a diagnosis of both systemic lupus erythematosus and cancer

OBJECTIVE

To determine whether radiation therapy (RT) is denied to patients with lupus and cancer and whether RT causes unusual toxicity in those receiving it.

METHODS

We included patients with lupus followed at the University of Toronto Lupus Clinic between 1972 and 2001 who had developed cancer. Demographic, clinical, and laboratory information were collected prospectively. Pathologic proof of cancer was obtained. Three radiation oncologists blinded for the diagnosis of lupus, the modalities of cancer treatment, and the hypothesis of the study reviewed patient data independently. They assessed the indication for RT and whether it should be curative or symptomatic. Recommendation for RT was considered when at least 2 of the 3 radiation oncologists concurred. A review of the literature was conducted.

RESULTS

Forty cases of cancer in 38 patients were identified. Most frequent cancer sites were breast (8), skin (8), digestive (7), and hematologic (7). Median patient age was 58 years. The radiation oncologists recommended RT in 26 cases, either with a curative (14) or a symptomatic intent (12). Only 4 patients received RT, 3 with a curative intent and 1 with a symptomatic intent. None of these 4 patients developed any unusual toxicity. The literature review did not support the fact that lupus patients do not tolerate RT.

CONCLUSION

Sixty-five percent of our lupus patients with cancer could have received curative or symptomatic RT but only 10% received it. No patient developed any toxicity. RT may be inappropriately withheld from lupus patients with cancer.

Musculoskeletal pain, disability and health-seeking behavior in adult Kuwaitis using a validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire

OBJECTIVE

The WHO-ILAR Community Oriented Program for Control of Rheumatic Diseases (COPCORD) primarily aims to estimate the burden of musculoskeletal symptoms/disorders. We investigated data on musculoskeletal pain, disability and health-seeking behavior in the first community-based COPCORD study in Kuwait.

METHODS

The validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire was used in 2,500 randomly selected Kuwaiti households. The target population comprised Kuwaiti nationals aged 15 years and older. Twenty-four trained field workers completed the survey in 8 weeks. Those subjects reporting musculoskeletal pain were identified (Phase 1), and were asked to complete a self-evaluation questionnaire (Phase 2) prior to rheumatological examination (Phase 3). Phase 2 included questions on the site and severity of pain, traumatic events, functional disability, and treatment. Patients marked their pain sites on a mannequin during their interviews. "Sufferers" were defined as those with musculoskeletal pain and no history of trauma.

RESULTS

A total of 7,670 adults were interviewed (response rate 88%), of whom 2,057 had musculoskeletal pain not related to trauma. Knees, back, and shoulders were the common sites of pain. Most of the sufferers reported the severity of pain as being moderate to severe. Functional disability was reported in 39.1% of the sufferers. The age-sex population adjusted prevalence rate for musculoskeletal pain was 35.7% in females and 20.2% in males. The most common sources for advice on treatment were physicians in hospitals (68.8%) and general practitioners (30.4%). 82% had prescriptions for their medications, while 19.4% had self prescribed tablets.

CONCLUSION

Musculoskeletal pain is a major health problem among Kuwaitis and deserves intense government attention.

Cardiovascular risk factor screening in systemic lupus erythematosus

OBJECTIVE

To evaluate the frequency of cardiovascular (CV) disease risk factor screening in systemic lupus erythematosus (SLE).

METHODS

Medical records of patients from a lupus clinic and 5 private practices were assessed for CV disease risk factors, including hyperlipidemia, hypertension, diabetes mellitus, smoking, family history of CV disease, antiphospholipid antibodies, hyperhomocysteinemia, postmenopausal status, obesity, and nephrotic syndrome.

RESULTS

A total of 183 records were included: 60 (33%) from the lupus clinic and 123 (67%) from private practices. Serum lipid profiles were measured in 56/183 (31%): 37/60 (62%) in the lupus clinic vs 19/123 (15%) private practice. Of the 56 with lipids measured, the individual tests obtained were as follows: total cholesterol in 56 (100%), HDL in 50 (89%), triglycerides in 49 (88%), LDL in 48 (86%), and VLDL in 33 (59%). Thirty-one of 56 patients (55%) had elevated lipids. Only 9/25 (36%) with hyperlipidemia who had a subsequent visit had a response to the hyperlipidemia charted. Of 9 nonlipid risk factors, a median of 8 were assessed in the lupus clinic vs 3 in private practices. The most frequent risk factors screened were nephrotic syndrome (91%), hypertension (74%), and smoking (59%).

CONCLUSION

Despite an inordinately high risk of CV disease in SLE, assessment of CV risk factors was surprisingly uncommon among the practices assessed. Greater attention needs to be paid to CV disease risk factor screening in patients with lupus.

Validation of the Arabic version of the WHO-ILAR COPCORD Core Questionnaire for community screening of rheumatic diseases in Kuwaitis. World Health Organization. International League Against Rheumatism. Community Oriented Program for the Control of Rheumatic Diseases

OBJECTIVE

(1) To adapt the Community Oriented Program for the Control of Rheumatic Disease (COPCORD) Core Questionnaire (CCQ) for use as a rheumatic screening instrument among Kuwaitis, including translation, back translation, assessment of cross cultural equivalence, and reliability. (2) To determine the screening characteristics of the Arabic version of the CCQ for detecting rheumatic diseases compared to clinical examination by a rheumatologist.

METHODS

Translation and assessment of cross cultural equivalence were undertaken using standard methods. Back translation was done by an Arabic-speaking rheumatologist. Interviewer agreement was assessed using a convenience sample. Sensitivity, specificity, and positive and negative predictive values were assessed first by administering the CCQ followed by full clinical examinations of a randomly selected sample of 359 Kuwaiti persons aged 15 years or older.

RESULTS

(1) Cross cultural equivalence and back translation of the translated questionnaire were satisfactory. Interviewer agreement was acceptable. (2) The prevalence of rheumatic diseases based only on CCQ screening was 69% compared to 73% based on clinical examination. The sensitivity and specificity of the Arabic CCQ were 94.4% and 97%, respectively, and the positive and negative predictive values of the instrument were 98.8% and 86.4%, respectively.

CONCLUSION

The Arabic version of the CCQ appears promising as a screening tool to detect rheumatic diseases in Arabic speaking communities. The findings suggest that the Arabic CCQ followed by clinical examinations in positive respondents can provide an acceptable estimate of prevalence of rheumatic diseases. We intend to use this instrument to screen for the prevalence of rheumatic diseases among Kuwaiti nationals.

Survey of antimalarial use in lupus pregnancy and lactation

OBJECTIVE

To obtain the experience of selected experts in the use of antimalarial drugs (AM) in pregnancy and lactation in systemic lupus erythematosus.

METHODS

Seventy-eight lupus experts identified from North America and UK were mailed a 19 question survey regarding their experience using AM in pregnancy and lactation.

RESULTS

The 52 (67%) respondents with usable questionnaires treated a median of 75 lupus patients/year, including 4-5 lupus pregnancies/year. Thirty-five (69%) continued AM sometimes, often, or always during pregnancy. Continuing AM increased with the number of pregnant lupus patients seen (p < 0.01). None reported having seen any fetal toxicity with AM use, and pregnancy was never terminated because of AM, other than at patient insistence (n = 1). Postpartum, 29 (63%) continued AM and advised breast-feeding. Responses were consistent among North American and UK experts.

CONCLUSION

The majority of lupus experts continue AM during pregnancy. This was particularly true for those who treated a larger number of pregnant lupus patients per year. The majority advise breast-feeding and continue AM postpartum. These practices are supported by the limited literature available.