Approaches to optimising access to NICE-approved biologic anti-TNFs for patients with rheumatoid arthritis with moderately active disease

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease that is associated with joint pain and stiffness. Biologics represent some of the most effective treatments for RA, but previous guidance from the National Institute for Health and Care Excellence (NICE) has limited their use to patients with severely active disease. This has meant patients with moderately active RA have been treated as if they have an acceptable disease state, despite many cases where the inflammation has a major impact on joint damage, mobility, pain and quality of life. However, recent guideline changes (NICE TA715) have approved the use of three biologics - adalimumab, etanercept and infliximab - for the treatment of moderately active RA.

MAIN BODY

In response to these changes, we have held discussions with medical teams from across the UK to consider the main implications for implementation of these new recommendations, as well as any differences in approach that may exist at a local level. Several key challenges were identified. These included establishing methods of educating both physicians and patients concerning the new availability of the biologic treatments, with suggestions of various organisations that could be approached to circulate informative material. Identifying which patients with moderately active RA stand to benefit was another discussion topic. Relying solely on scoring systems like Disease Activity Score in 28 Joints (DAS28) was acknowledged to have limitations, and alternative complementary approaches such as ultrasound, as well as assessing a patient's co-morbidities, could also be useful tools in determining those who could benefit from biologics. An additional challenge for the process of patient identification has been the increase in the use of telemedicine consultations in response to the coronavirus disease 2019 (COVID-19) pandemic. More use of patient-reported outcomes was raised as one possible solution, and the importance of maintaining up-to-date databases on patient disease scores and treatment history was also stressed.

CONCLUSION

While challenges exist in education and identifying patients who may benefit from the use of biologics, the NICE TA715 recommendations hold great potential in addressing an unmet need for the treatment of moderate RA.

O30 Variation in immunosuppressant impact on severe COVID-19 outcome: preliminary results from the COVID-19 Scottish Registry of Autoimmune Rheumatic Diseases (SCAR-19)

Background/Aims 

The novel infectious disease COVID-19 is associated with a wide spectrum of clinical severity amongst the general population. Patients with autoimmune rheumatic diseases (ARD) are more likely to experience serious COVID-19 related events, although risk factors for such outcomes have yet to be established. In particular, the risk profiles of specific ARD therapies are unknown.

Methods 

A Scottish wide registry was rapidly developed in March 2020. Clinical characteristics and outcomes of infected cases were collated across all Scottish health boards, leveraging the Scottish Systemic Vasculitis Network and Scottish Society for Rheumatology. Eligible patients included any adult ARD patients with a confirmed (clinically or PCR) diagnosis of COVID-19. Simple descriptive statistics were employed to evaluate associations between ARD therapies and a serious COVID-19 disease outcome, as defined by a requirement of invasive or non-invasive ventilation, and/or death.

Results 

A total of 69 patients (59% female; mean age 65.6, SD15.5) were recruited to the registry ,92% of which required hospitalisation. Cases were most commonly diagnosed with rheumatoid arthritis (n = 32, 46.4%) followed by spondyloarthritis (n = 19, 27.5%) and systemic vasculitis (n = 9, 13.0%). Anti-TNF therapy (n = 8, 11.6%) and methotrexate (n = 31, 44.9%) were the commonest biologic and conventional disease modifying drug (bDMARD and csDMARD) used respectively. N = 20 (29%) received background corticosteroid therapy (15.9% prednisolone >5mg, 13% prednisolone ≤5mg). A severe outcome was observed in n = 25(31.9%); n = 11 required assisted ventilation and n = 19 died. With the exception of Leflunomide, conventional and biologic DMARDs did not appear to confer a higher risk for severe outcome (table 1). Of note, anti-TNF therapy was associated with a non-serious outcome (p = 0.04) and prednisolone>5mg with a serious outcome (p = 0.08).

Conclusion 

Preliminary data from this Scotland-wide ARD COVID-19 registry evidences variation in the impact of standard ARD therapies on the severity of COVID-19 outcome. In general, background csDMARD and bDMARD use does not appear to be a risk factor for severe outcomes. However, anti-TNF therapy may confer a favourable outcome, while leflunomide and corticosteroids may have the opposite effect. Rheumatologists should be aware of these possible risk factors and continue to contribute to registries to help establish whether these putative signals are clinically relevant.

Disclosure 

M. Karabayas: None. J. Brock: None. M. Rutherford: None. G. Fordyce: None. N. Fluck: None. S. Kardash: None. L. Moran: None. R. Richmond: None. A. Tan: None. J. Sznajd: None. S. Lambie: None. M. Khalid: None. S. Else: None. C.A. Davies: None. M. Duncan: None. J. Mclaren: None. S. Duncan: None. S. Murphy5: None. F. Hasan: None. N. Basu: None.

Isolated deafness as a presenting symptom in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis commonly affecting the lungs, upper respiratory tract and kidneys. It is an idiopathic condition but likely due to an autoimmune process, resulting in granulomatous lesions and glomerulonephritis. Upper respiratory tract involvement is commonly seen in patients with GPA. Our case is that of an elderly lady (Mrs C) presenting with sudden onset bilateral deafness. She was later found to have extensive lower respiratory tract involvement although she was never particularly symptomatic of this. The presentation suggested a single organ disorder and led to some initial diagnostic uncertainty. Imaging and laboratory investigations eventually led to the diagnosis and she was successfully treated with corticosteroids and rituximab with good response and hearing improvement. This case highlights the importance of early diagnosis in a rapidly progressive disease which undetected can lead to catastrophic end organ damage and disability.