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Chaplin, Steve. "Summary of the new EULAR rheumatoid arthritis guideline." Prescriber 31, no. 9 (September 2020): 15–19. http://dx.doi.org/10.1002/psb.1863.
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Lee, M., G. Reynolds, M. Yates, and J. Galloway. "POS1448 EVIDENCE BASED PRACTICE: WHAT IS THE EVIDENCE THAT BRITISH SOCIETY FOR RHEUMATOLOGY GUIDELINES ARE EVIDENCE BASED?" Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1008.2–1008. http://dx.doi.org/10.1136/annrheumdis-2021-eular.822.
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Background:Clinical practice guidelines are designed to ensure that patients are treated according to best evidence, with the goal of optimizing clinical outcomes and reducing unwarranted variation in care. They compile, rate and translate the data available into recommendations that form the basis of evidence-based practice for most clinicians. Despite their importance, the evidence base informing different guidelines varies in quality. A recent study of American College of Rheumatology (ACR) Practice Guidelines demonstrated only 17 of 35 class I (strong benefit to harm ratio) recommendations were supported by level A evidence (high quality randomized controlled trails or meta-analyses)1.Objectives:To review the evidence supporting the British Society for Rheumatology (BSR) guidelines.Methods:Thirteen sets of guidelines that were available on the BSR website as of October 16th 2019 were reviewed (https://www.rheumatology.org.uk/practice-quality/guidelines). A range of methodologies (including Grading of Recommendations Assessment, Development and Evaluation (GRADE), Scottish Intercollegiate Guidelines Network (SIGN), EULAR and Royal College of Physicians (RCP) recommendations) were used to assess the quality of evidence and strength of recommendation. For comparability between guidelines the level of evidence was converted to a score between I (highest quality) and IV (lowest quality) and the strength of recommendation was converted to a rating between A and D. The polymyalgia rheumatica guideline was not assessed due to unclear methodology and lack of level of evidence for all recommendations.Results:Of the 12 BSR guidelines assessed, there were 554 recommendations in total. The number of recommendations per guideline ranged between 13 and 80. Across all assessed guidelines, 94 recommendations (17.0%) were classified as level I, 161 (29.1%) as level 2 and 299 (54.0%) as level 3 or 4. These figures are similar to those reported in the ACR guidelines (23%, 19% and 58% respectively)1. The proportion of level I evidence varied from 46.2% (Axial Spondyloarthropathy guideline) to 0% (Hot Swollen Joint guideline).Conclusion:Over half of all BSR guideline recommendations have level of supporting evidence of III/IV. A wide range of methodologies are used to generate BSR guidelines (GRADE, SIGN, RCP / EULAR). This makes it challenging for readers unfamiliar with these approaches to interpret evidence and hinders comparisons between guidelines. A standardized methodology for future guideline development would overcome these barriers.References:[1]Duarte-Garcia A, Zamore R & Wong JB. The Evidence Basis for the American College of Rheumatology Practice Guidelines. JAMA Intern Med, 2018 Jan 1;178(1):146-148.Disclosure of Interests:None declared
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Babatunde, O., S. Dawson, A. Adebajo, and K. Dziedzic. "OP0191 CONCEPTUALISING PATIENT AND PUBLIC INVOLVEMENT IN MUSCULOSKELETAL GUIDELINES IMPLEMENTATION: THE ALLIANCE FRAMEWORK." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 127.2–127. http://dx.doi.org/10.1136/annrheumdis-2022-eular.48.
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BackgroundPatient and Public Involvement (PPI), have supported high quality Rheumatology research which have now been successfully curated into widely endorsed evidence-based recommendations and guidelines. However, uptake and applicability of guidelines is less than optimal, significant variation exist in care, and health and socio-economic burdens attributed to rheumatic conditions continues to rise, suggesting an implementation challenge.ObjectivesWe conducted a rapid review to investigate the role of PPI in guideline implementation.MethodsA comprehensive search for relevant literature was undertaken (three databases - Medline, Embase, Cinahl, and two large repositories -WHO, G-IN). A priori eligibility criteria and systematic review-based methods were used to identify primary studies with explicit reference to PPI involvement in a rheumatic/musculoskeletal - MSK guideline implementation activity. Extracted data from included studies was interrogated for details regarding activities, contexts, outcomes, and impact of PPI in guidelines implementation and further discussed in review project meetings. Findings were brought together in a narrative synthesis. Recommendations for future research and practice, and a conceptual framework for PPI in Rheumatic and MSK guidelines implementation were co-developed with a public contributor.ResultsTen papers were included, only 1 from the global south. A prevalence of consultative PPI activities in guidelines dissemination (e.g., language translations, patient versions) was found. Few studies explicitly report high-level PPI engagement in relation to care pathway adjustments, care commissioning, institutional operations and policy with a view to MSK guideline implementation. Training, development, and practice of PPI in MSK guideline implementations were not evidenced to have spread much beyond Europe and are also not well reported in literature nor rightly accrued as PPI activities in guideline implementation. The alliance framework (Figure 1) highlighting an iterative process of “creative thinking/co-production” and “strategic doing” helps to conceptualise PPI in MSK guideline implementation. The framework guides knowledge translation from guidelines to real world practice and aims to drive quality improvement for MSK care with patients, for patients, across and within care settings globally.Figure 1.The Alliance framework for conceptualising Patient and Public Involvement in Rheumatic and Musculoskeletal guidelines implementation.ConclusionDespite success of PPI in rheumatology/MSK research, oversight or ineffective PPI in guideline implementation may hamper translation of novel advances in MSK care into real world practice and patient benefit. The Alliance framework prioritises effective PPI in MSK guideline implementation design, delivery, and evaluation, ideally applied in parallel with the development of evidence-based guidance recommendations. It highlights continuous application of innovative thinking, dynamic, and impactful collaborations for bridging the evidence-practice gap and improving quality of care for MSK patients globally through novel partnerships.Disclosure of InterestsNone declared
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Bailly, F., A. P. Trouvin, S. Bercier, S. Dadoun, J. P. Deneuville, R. Faguer, J. B. Fassier, et al. "THU0486 2019 FRENCH GUIDELINES AND CARE PATHWAY ABOUT LOW BACK PAIN MANAGEMENT IN ADULTS." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 481.1–481. http://dx.doi.org/10.1136/annrheumdis-2020-eular.2408.
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Background:Low back pain (LBP) is a frequent, disabling symptom, for which the risk of chronicity is increased by heterogeneous care. Developing and implementing recommendations is likely to improve LBP management.Objectives:To develop French guidelines and care pathway on the management of LBP, coordinated by the French National Authority for Health (FNAH) and based on previous international guidelines in addition to update literature.Methods:A compilation report was constituted on the basis of a systematic review of guidelines between January 2013 and December 2018, and systematic reviews and meta-analysis in the field of LBP between January 2015 and December 2018. This report summarized the state-of-the-art for each predefined area of the guideline. A panel of experts including patients’ representatives and 19 health professionals involved in LBP management was constituted to elaborate the guideline based on the compilation report. A care pathway was constituted to identify the trajectory and the different steps followed by a patient with LBP. Then, the compilation report and the preliminary guidelines were submitted to 24 academic institutions and stakeholders for feedback. Based on the preliminary guideline and the responses of academic institutions and stakeholders, the final recommendations were drawn up by the expert panel. The guideline was finally submitted to an independent committee of the FNAH for final validation. For each area of the guidelines, agreement between experts of the working group was evaluated through the RAND/UCLA method.Results:The initial literature search identified 572 references of recent international guidelines or systematic reviews about LBP. After selection, the compilation report included 101 references. The compilation report was submitted to the expert group during 3 different meetings to reach a consensus on different topics. Thirty-one preliminary recommendations and a care pathway (divided in two parts to facilitate its use and readability) were drafted and submitted to academic institutions and stakeholders. Having considered their comments, final recommendations and care pathway were written. The final guideline was validated by the FNAH. Then, the consensus of the expert panel was assessed about all the final guidelines separately: 32 recommendations (including the care pathway) were evaluated as appropriate; none were evaluated uncertain or inappropriate. Strong approval was obtained for 27 of them (including the care pathway) and weak for 5 of them.Conclusion:This new LBP guideline was based on recent scientific evidence. It introduced several concepts, including the need to identify low back pain at risk of chronicity, in order to provide quicker intensive management if necessary. This guideline should be updated in 5 years’ time, in order to keep it in line with ongoing scientific evidence.Disclosure of Interests: :Florian Bailly Consultant of: Consultation fees from Lilly and Grünenthal laboratories, Anne Priscille Trouvin Speakers bureau: Speaker for menarini, recordati, pfizer, astellas, Sandrine Bercier: None declared, Sabrina Dadoun: None declared, Jean Philippe Deneuville: None declared, Rogatien Faguer: None declared, Jean Baptiste Fassier: None declared, Michèle Koleck: None declared, Louis Lassalle: None declared, Thomas Le Vraux: None declared, Brigitte Liesse: None declared, Karine Petitprez: None declared, Aline Ramond: None declared, Jean François Renard: None declared, Alexandra Roren: None declared, Sylvie Rozenberg Consultant of: Pfizer, Catherine Sebire: None declared, Gilles Viudes: None declared, François Rannou Grant/research support from: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Fondation Arthritis, Consultant of: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Speakers bureau: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Audrey Petit: None declared
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DeLoughery, Thomas. "Guideline: EULAR provided recommendations for thrombotic and obstetric antiphospholipid syndrome." Annals of Internal Medicine 171, no. 6 (September 17, 2019): JC26. http://dx.doi.org/10.7326/acpj201909170-026.
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Bautista-Molano, W., E. Jauregui, L. Saldarriaga, M. X. Rojas, and J. R. Pieschacón. "THU0557 QUALITY ASSESSMENT OF CLINICAL PRACTICE GUIDELINES IN AXIAL AND PERIPHERAL SPONDYLOARTHRITIS: A SYSTEMATIC APPRAISAL." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 519.2–520. http://dx.doi.org/10.1136/annrheumdis-2020-eular.5520.
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Background:Clinical practice guidelines (CPG) in spondyloarthritis (SpA) serves as a tool for rheumatologists, health-care providers and patients in the selection of appropriate treatment framework in common clinical scenarios guiding decision-making processes. However, the quality of these guidelines has not yet been evaluated systematically in the field.Objectives:The aim of the study was to evaluate the quality of the CPG available for the treatment of axial and peripheral SpA.Methods:A systematic and scientific literature search between 2014 and 2019 was performed in order to identify and select CPG focused on the treatment of axial and peripheral SpA. The authors systematically searched the main guideline databases and guideline developer websites completing the search in PUBMED/MEDLINE and EMBASE. Four independent reviewers with methodological and clinical expertise in the field of SpA, assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Their degree of agreement was evaluated with the intra-class correlation coefficient (ICC). The statistical analyses as done using the R psych package.Results:Twelve CPG were selected for evaluation. The scores for each of the AGREE II domains were: scope and purpose 86% (range: 67–99%); stakeholder involvement 71% (range: 22–93%); rigour of development 61% (range: 29–82%); clarity and presentation 79% (range: 68–86%); applicability 48% (range: 21–71%); and editorial independence 72% (range: 19–92%). Most of the appraised guidelines could be recommended (n=12) or recommended with limitations (n=12) for use in clinical practice. The overall agreement among reviewers was moderate (ICC: 0.40; 95% CI 0.16 to 0.82). The CPG with the best quality assessment using the AGREE II instrument was the NICE guideline developed by the National Institute for Health and Care Excellence. A slightly higher quality assessment of CPG developed by research agencies or guideline developers was observed, in comparison to those developed by scientific societies. Figure 1..ssessment cientific societies.eld of ocieties and XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXConclusion:Quality assessment of guidelines for the treatment of axial and peripheral SpA is good with an average of 69%. However, a cut-off point has not been clearly established. Measures should be taken to assure that CPGs are based on the best available evidence and rigorously developed and reported. Additional efforts are needed to provide high-quality guidelines that serve as a useful and reliable instrument for clinical decision-making process in the field of SpA.Disclosure of Interests:None declared
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Henry-Blake, C., K. Treadwell, S. Parmar, J. Higgs, M. Marshall, J. Edwards, and G. Peat. "POS1400 A SYSTEMATIC REVIEW OF INTERNATIONAL GUIDELINES REGARDING THE ROLE OF RADIOGRAPHY IN THE DIAGNOSIS OF OSTEOARTHRITIS." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 983.1–983. http://dx.doi.org/10.1136/annrheumdis-2021-eular.3117.
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Background:A substantial proportion of primary care osteoarthritis (OA) consultations are associated with an X-ray request (1,2). Uncertainty exists regarding the ability of radiography to improve a clinical OA diagnosis, and the over-use of radiography may lead to inappropriate referrals due to severe radiographic features that do not correlate with patients’ symptoms. Additionally, there are cost implications of unnecessarily imaging such a prevalent disease. As evidence questions the utility of routine radiography in OA, the extent to which radiography is supported by international guidelines is unknown.Objectives:To undertake a systematic review and narrative synthesis of UK and international guideline recommendations on the role of radiography in the diagnosis of OA.Methods:A systematic search of eleven electronic databases (including EMBASE, MEDLINE CINAHL, Epistemonikos and Guideline Central) and the websites of nine professional organisations (including NICE, Royal College of Radiologists (RCR), EULAR, and the American College of Radiology (ACR)) identified the most recent evidence-based guidelines produced by professional organisations on the role of imaging in OA. Guidelines not addressing the role of radiography in the diagnosis of OA were excluded, as were non-English and spinal OA guidelines. Each title was screened by one reviewer whilst each abstract and full text underwent dual screening. A single reviewer, using a standard proforma, undertook data extraction. Each guideline was independently appraised by two reviewers using the AGREE II tool. A narrative synthesis of the nature and consistency of OA radiographic recommendations was performed.Results:18 evidence-based OA guidelines published between 1998-2019 were included. These guidelines considered OA at any joint (n=8), or at the knee (n=3), hip (n=2), hand (n=2), wrist (n=1), foot (n=1), and ankle (n=1). Seven guidelines were produced by European organisations; four guidelines were produced by EULAR. Guidelines were targeted at general practitioners (n=11), radiologists (n=7), rheumatologist (n=4) and orthopaedic surgeons (n=3). Using the AGREE II tool, the identified guidelines scored highly on rigour of development (mean score 69%) but poorly on applicability (32%). All 18 guidelines recommended X-rays as the first-line modality, where imaging was indicated. A clinical diagnosis of OA without radiographic confirmation was recommended by all eleven guidelines produced by organisations represented general practitioners, with seven guidelines justifying this due to a poor correlation between radiographic features and clinical symptoms. Only three guidelines explicitly discouraged the routine use of radiography for the diagnosis of OA and only two guidelines reassured practitioners of a low probability of missing serious pathology when not routinely requesting radiographs. Guidelines produced by organisations representing radiologists were more supportive of radiography. The ACR recommended radiographic confirmation in patients suspected to have OA at the hand, wrist, hip, knee, ankle, and foot. Conversely, the RCR recommended radiographic confirmation in patients suspected to have OA at the hand, feet, and hip, but not the knee.Conclusion:Differences in guideline recommendations on the utility of radiography in OA appear related to country/region, professional organisation, and joint. The use and utility of radiography in OA may need to be reviewed in light of a shift towards remote consultations, a change that has been accelerated by COVID-19 in many countries.References:[1]Yu D, Jordan K, Bedson J, Englund M, Blyth F, Turkiewicz A et al. Population trends in the incidence and initial management of osteoarthritis: age-period-cohort analysis of the Clinical Practice Research Datalink, 1992–2013. Rheumatology. 2017;56(11):1902-1917.[2]Brand C, Harrison C, Tropea J, Hinman R, Britt H, Bennell K. Management of Osteoarthritis in General Practice in Australia. Arthritis Care & Research. 2014;66(4):551-558Acknowledgements:JJE is funded by an Academic Clinical Lectureship from the National Institute for Health Research (NIHR) for this research project (CL-2016-10-003). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.Disclosure of Interests:None declared
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Weijers, Julia M., Sanne A. A. Rongen-van Dartel, Dan M. G. M. F. Hoevenaars, Max Rubens, Marlies E. J. L. Hulscher, and Piet L. C. M. van Riel. "Implementation of the EULAR cardiovascular risk management guideline in patients with rheumatoid arthritis: results of a successful collaboration between primary and secondary care." Annals of the Rheumatic Diseases 77, no. 4 (November 22, 2017): 480–83. http://dx.doi.org/10.1136/annrheumdis-2017-212392.
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The updated European League Against Rheumatism (EULAR) guideline recommends cardiovascular disease (CVD) risk assessment at least once every 5 years in all patients with rheumatoid arthritis (RA). This viewpoint starts with a literature overview of studies that investigated the level of CVD risk factor (CVD-RF) screening in patients with RA in general practices or in outpatient clinics. These studies indicate that CVD-RF screening in patients with RA is marginally applied in clinical practice, in primary as well as secondary care. Therefore, the second part of this viewpoint describes an example of the successful implementation of the EULAR cardiovascular disease risk management (CVRM) guideline in patients with RA in a region in the south of the Netherlands where rheumatologists and general practitioners (GPs) closely collaborate to manage the cardiovascular risk of patients with RA. The different components of this collaboration and the responsibilities of respectively primary and secondary care professionals are described. Within this collaboration, lipid profile was used as an indicator to assess whether CVD-RF screening was performed in the previous 5 years. In 72% (n=454) of the 628 patients with RA, a lipid profile was determined in the previous 5 years. As part of routine quality control, a reminder was sent to the GP in case a patient with RA was not screened. After sending the reminder letter, in 88% of all patients with RA, CVD risk assessment was performed. This collaboration can be seen as good practice to provide care in line with the EULAR guideline.
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Batšinskaja, D., K. Korve, and K. Rannus. "AB1557-HPR DEVELOPING THE GUIDELINE FOR OUTPATIENT APPOINTMENT OF A CLINICAL NURSE SPECIALIST AT THE EAST-TALLINN CENTRAL HOSPITAL RHEUMATOLOGY CENTER. DEVELOPMENT PROJECT." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1878.2–1879. http://dx.doi.org/10.1136/annrheumdis-2022-eular.1321.
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BackgroundRheumatic diseases can increase the economic and social burden on the individual and their relatives’ ones, as well as on the health care system and society. Based on international empirical experience, it can be stated that in an exemplary Rheumatology center, both the outpatient appointment of a (general) nurse and the outpatient appointment of a clinical nurse specialist work as a team. The Rheumatology Center of East Tallinn Central Hospital is the only center in Estonia that specializes in rheumatic patients, where (general) nurses are proceed, but the extent to which the current health care service meets the needs of rheumatic patients has not yet been assessed. In addition, the health insurance fund launched a pilot project to clarify the difference between outpatient appointment of a clinical nurse specialist and independent appointment of a (general) nurse. However, there is no evidence-based guideline for outpatient appointments for rheumatic patients.ObjectivesThe aim of the development project was to develop the guideline for outpatient appointment of a clinical nurse specialist for rheumatology based on evidence-based literature and expert opinions at the Rheumatology Center of East-Tallinn Central Hospital.MethodsThe development project process took place as a plan-do-study-act cycle, using the method of systematic review of the literature to develop the guideline and the method of written survey to obtain an expert opinion on it. Verbal responses from experts for organizational diagnostics and the guideline feedback was analyzed using content analysis. Quantitative or numerical responses were analyzed using descriptive statistics to calculate the frequency distributions (n and %) for each response.ResultsThe guideline developed as part of the development project supports the implementation of a new clinical nurse specialist care service for rheumatic patients.ConclusionBased on previous research analyzed and surveys conducted by experts at the Rheumatology Center, it can be argued that the clinical nurse specialist service differs significantly from the (general) nurse outpatient appointment and is more responsive to the needs of rheumatic patients. There are potential benefits for the clinical nurse specialist of the outpatient appointment to the organization and to society, as this service increases the level of reliability, efficiency, and availability of all nursing care.References[1]Batšinskaja, D. Developing the guideline for outpatient appointment of a clinical nurse specialist at the East-Tallinn Central Hospital Rheumatology Center. Development project. Tallinn: Tallinn Healthcare College, 2022[2]Schober, M., Lehwaldt, D., Rogers, M., Steinke, M., Turale, S., Pulcini, J., Roussel, J., Stewart, D. (2020). Guidelines on advanced practice nursing ICN APN report https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdfAcknowledgementsThank you experts for their opinion.Disclosure of InterestsNone declared
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Mendly, S., and G. Boutsalis. "AB0882-HPR ANCA-ASSOCIATED VASCULITIS: A CLINICAL PRACTICE ASSESSMENT." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1464.2–1465. http://dx.doi.org/10.1136/annrheumdis-2021-eular.3684.
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Background:AAV (ANCA-associated vasculitis) is a group of progressive, rare, severe autoimmune diseases1,2. AAV can affect blood vessels in different parts of the body resulting in damage to vital organs such as the lungs, kidneys, nervous system, gastrointestinal system, skin, eyes, and heart.2 There are currently no approved therapies for remission-induction in patients with AAV. The current treatment armamentarium for AAV is comprised of various immunosuppressive therapies in combination with steroid treatment. Understanding clinical practice gaps in the management of AAV, can inform development of tools to improve physician practices.Objectives:This medical education activity aims to assess physicians’ knowledge on the various manifestations of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), current guideline-recommended treatment strategies for remission induction in patients with AAV, as well as recent clinical trial data for combination therapies used for remission induction.Methods:A 24-question survey consisting of multiple-choice knowledge and case-based questions was made available to nephrologists and rheumatologists without monetary compensation or charge. The questions were designed to evaluate knowledge regarding the various manifestations of AAV and the results from clinical trials that have compared the efficacy of combination therapies used for remission induction in patients with AAV. As well as application of guideline-recommended therapies and clinical trial data for remission induction in patients with AAV within clinical practice. The survey launched online on a website dedicated to continuous professional development. (www.medscape.org/viewarticle/920320) on July 15, 2020. Data were collected until October 1, 2020.Results:363 nephrologists and 190 rheumatologists completed the survey. Physicians demonstrated gaps in the following areas:TopicIncorrect Responses to Knowledge and Clinical Decision-Making Questions (%)NephrologistsRheumatologistsSystemic diseases associated with AAV59%45%How to confirm diagnosis of AAV42%25%Therapy selection to induce remission that would be consistent with guidelines recommendations71%51%Guideline-recommended therapy for patients that do not respond to the induction regimen32%34%Definition of refractory disease95%94%Most effective maintenance strategy for a patient once remission is achieved80%64%Where would an emerging therapy such as a C5a receptor inhibitor fit into the therapeutic armamentarium of AAV?62%47%What are the guideline-recommended therapies to reduce remission in patients without organ-threatening disease?71%51%Most effective maintenance strategy for a patient once remission is achieved80%64%Guideline-recommendations on length of time to continue maintenance therapy31%35%Conclusion:This educational research on assessment of physicians’ (nephrologists and rheumatologists) clinical practices yielded important insights into clinical gaps related to understanding of the disease pathophysiology and progression of AAV, guideline recommendations on diagnosing and managing AAV with guideline-directed medical therapies (GDMTs), strategies for the management of relapsing and refractory disease in AAV and positioning of emerging therapies in the treatment paradigm.References:[1]www.medscape.org/viewarticle/920320.[2]Hutton HL, et al. Semin Nephrol 2017;37(5):418–35.[3]Al-Hussain T, et al. Adv Anat Pathol 2017;24(4):226–34.Disclosure of Interests:Sarah Mendly Grant/research support from: Supported by an independent educational grant from Vifor Pharma, George Boutsalis Grant/research support from: Supported by an independent educational grant from Vifor Pharma
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Arumugam, Vanitha, and Joy C. MacDermid. "Appraisal of Clinical Practice Guideline: EULAR revised recommendations for the management of fibromyalgia." Journal of Physiotherapy 65, no. 2 (April 2019): 112. http://dx.doi.org/10.1016/j.jphys.2019.01.003.
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Heelan, B. "SP0055 Licensing New Drugs in SLE: The EMA Draft Guideline." Annals of the Rheumatic Diseases 72, Suppl 3 (June 2013): A13.6—A14. http://dx.doi.org/10.1136/annrheumdis-2013-eular.55.
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Heijstek, M. W., L. M. Ott de Bruin, M. Bijl, R. Borrow, F. van der Klis, I. Koné-Paut, A. Fasth, et al. "EULAR recommendations for vaccination in paediatric patients with rheumatic diseases." Annals of the Rheumatic Diseases 70, no. 10 (August 3, 2011): 1704–12. http://dx.doi.org/10.1136/ard.2011.150193.
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Evidence-based recommendations for vaccination of paediatric patients with rheumatic diseases (PaedRD) were developed by following the EULAR standardised procedures for guideline development. The EULAR task force consisted of (paediatric) rheumatologists/immunologists, one expert in vaccine evaluation, one expert in public health and infectious disease control, and one epidemiologist. A systematic literature review was conducted in MEDLINE, EMBASE, and abstracts of the EULAR and American College of Rheumatology meetings of 2008/9. The level of evidence and strength of recommendation were based on customary scoring systems. Delphi voting was applied to assess the level of agreement between task force members. 107 papers and eight abstracts were used. The majority of papers considered seasonal influenza (41) or pneumococcal (23) vaccination. 26 studies were performed specifically in paediatric patients, and the majority in adult rheumatoid arthritis and systemic lupus erythematosus patients. Fifteen recommendations were developed with an overall agreement of 91.7%. More research is needed on the safety and immunogenicity of (live-attenuated) vaccination in PaedRD, particularly in those using biologicals, and the effect of vaccination on prevention of infections.
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Bitik, B., M. E. Tezcan, and A. E. Yucel. "AB1418 A SYSTEMATIC REVIEW OF CURRENT RHEUMATOLOGY GUIDELINES FOR GERIATRIC PERSPECTIVES." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1814.2–1815. http://dx.doi.org/10.1136/annrheumdis-2022-eular.4931.
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BackgroundGeriatric population (GP) includes people over 65 years of age. GP can also be divided into the 65-75 age group and >75 age group. In the last 50 years, the proportion of the elderly in the society has increased (1). Meanwhile, GP has higher frequency of rheumatological disorders. While managing the treatment of this special patient group, some physiological differences of the elderly should be considered. Elderly patients are at increased risk for adverse drug reactions as a result of age-related changes in pharmacokinetics and pharmacodynamics. Polypharmacy is contributing to increased risk of clinically significant drug interactions. In addition, alterations in cognitive functions may impair drug compliance. On the other hand, clinicians may hesitate to apply more effective treatment due to safety concerns. (2).Rheumatologists should be aware of the problems they may encounter when planning the treatment of this privileged group.ObjectivesWe reviewed rheumatology guidelines to assess rheumatology organizations’ perspective on GP.MethodsGuidelines published by EULAR, ACR and the British Society for Rheumatology (BSR) for adult patients from 1970-2022 were reviewed by two rheumatologists to assess the existence of specific recommendations for the treatment of adult patients over 65 years of age.ResultsIn total, 58 guidelines were reviewed. None of the guidelines grouped patients by age. Seven (12%) guidelines had recommendations or statements about elderly patients (Table 1). As we observe, there are no satisfactory recommendations for the GP with rheumatological diseases. The most propable reason for this result is the lack of studies in the rheumatology literature to lead to guideline recommendations.Table 1.Characteristics of guidelines reviewedNumber of guidelines (n)Guidelines with specific recommandation for GPEULAR381-2-3-4-5-6ACR116BSR971EULAR points to consider for the management of difficult-to-treatrheumatoidarthritis(recommendation 6)2. Points to consider for the development, evaluation and implementation of mobile health applications for self-management in patients with rheumaticdiseases (points to consider 8)3. 2019 update of EULAR recommendations for Vaccination in AdultPatientswithAutoimmuneInflammatoryRheumatics4. EULAR Recommendations for prevention and management of osteoporoticfractures(recommendation 6)5. EULAR Points to consider for monitoring (detection/prevention) comorbidities in inflammatoryrheumaticdiseases (point to consider 10)6. 2015 Recommendations for the management of polymyalgiarheumatica: a European League AgainstRheumatism/American College of Rheumatologycollaborativeinitiative (recommendation 9)7. BSR guidelines for the management of polymyalgiarheumatica (recommendation 6)ConclusionCurrent prominent rheumatology guidelines have insufficiently addressed the management of rheumatological diseases in GP. Additional studies ares needed to delineate specific guidelines for the management of geriatric patients with rheumatological diseases.References[1]OECD (2022), Elderlypopulation (indicator). doi: 10.1787/8d805ea1-en (Accessed on 27 January 2022)[2]Tutuncu Z, Reed G, Kremer JA. Do patients with older-onsetrheumatoidarthritisreceive less aggressivetreatment? Ann Rheum Dis. 2006 Sep;65(9):1226-9.Disclosure of InterestsNone declared
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Grygorieva, N., and V. Povoroznyuk. "POS1112 COMPARISON OF TWO APPROACHES IN FRACTURES RISK ASSESSMENT IN WOMEN WITH RHEUMATOID ARTHRITIS AND GLUCOCORTICOID USE." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 836.1–836. http://dx.doi.org/10.1136/annrheumdis-2021-eular.2448.
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Background:Nowadays, FRAX is the most useful tool for osteoporotic fracture risk assessment that is included in many guidelines. Rheumatoid arthritis (RA) and glucocorticoid (CG) use are two crucial factors for osteoporotic fractures included in FRAX algorithm. According to the last ACR guidelines for the treatment of GC-induced osteoporosis [1], it was recommended to divide the patients into three groups of fracture risk (high, medium and low) that have a great impact on treatment decision. Recently, we received own Ukrainian thresholds [2] for the national version of FRAX that are age-dependent and now widely used in clinical practice.Objectives:Our study was aimed to compare two approaches (ACR-2017 and Ukrainian (2019) recommendations) in fracture risk assessment in women with RA and GC use.Methods:We examined 195 females with RA aged 40-89 years old who took GC (at dose ≥5 mg/d for ≥3 months) due to RA. The 10-year probabilities of major osteoporotic (MOFs) and hip fractures (HFs) were calculated with and without bone mineral density (BMD) using the Ukrainian FRAX model [3]. The DXA was used to measure the lumbar spine, femoral neck and total body BMDs; T and Z scores were calculated (DISCOVERY Wi, Hologic, Inc., USA).Results:FRAX indexes for MOFs and HFs without BMD in patients with RA and GC were (Me [25-75Q]) 12.0 [8.1-18.0] and 4.2 [1.7-7.2] %. The correspondent FRAX indexes with BMD were 13.5 [8.5-20.0] and 5.1 [1.8-8.7] %.50 % of examined women had previous fractures and 20 % had previous vertebral fractures. BMD of the femoral neck consisted of 0.62±0.13 and L1-L4 BMD was 0.85±0.15 g/cm2. 89 % of females had low BMD at the lumbar spine and / or femoral neck (49 % osteoporosis and 40 % osteopenia).61 % of women required antiosteoporotic treatment according to ACR-2017 guideline (17.4 % of them a hadhigh risk of MOF and 43.1 % moderate one) without BMD measurement and 64 % of subjects after DXA scan.According to Ukrainian national guideline, 57 % of patients required antiosteoporotic treatment without BMD measurement and 42 % – after additional DXA examination. After BMD measurement in subjects who required the DXA scan, 78.2 % of females with RA and GC use required antiosteoporotic treatment (additionally to calcium and vitamin D, lifestyle modifications).Conclusion:Approximately 60 % of subjects with RA and GC use required antiosteoporotic treatment without additional DXA measurement according to correspondent FRAX indexes from both guidelines. The proportion of women requiring treatment after DXA scan is slightly higher according to Ukrainian recommendations. It proves that both of them can be used effectively in daily clinical practice for fracture risk assessment in females with RA.References:[1]Buckley L, Guyatt G, Fink HA, Cannon M et al. 2017 American College of Rheumatology Guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis & Rheumatology, 2017;69(8), 1521–1537. DOI:10.1002/art.40137[2]Povoroznyuk V, Grygorieva N, Kanis JA et al. Ukrainian FRAX: criteria for diagnostics and treatment of osteoporosis. Pain. Joint. Spine. 2019;9(4):7-16. DOI: 10.22141/2224-1507.9.4.2019.191921[3]Povoroznyuk VV, Grygorieva NV, Kanis JA et al. Epidemiology of hip fracture and the development of FRAX in Ukraine. Arch Osteoporos. 2017;12(1):53. DOI: 10.1007/s11657-017-0343-2.Disclosure of Interests:Nataliia Grygorieva Consultant of: Servier, Redis, Vladyslav Povoroznyuk: None declared.
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de Barros Lopes, R., D. Murphy, and F. Mclennan Battleday. "AB0913-PARE METHOTREXATE FOR RHEUMATOID ARTHRITIS: PATIENT PERSPECTIVES ON MONITORING IN PRIMARY CARE." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1478.2–1478. http://dx.doi.org/10.1136/annrheumdis-2021-eular.3.
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Background:Monotherapy with methotrexate (MTX) is one first-line option for newly diagnosed Rheumatoid Arthritis (RA)1. Although treatment is usually commenced by a specialist, repeat prescribing and monitoring responsibilities often lie with primary care. While inadequate monitoring is a safety concern, unnecessary duplication of monitoring invariably has cost implications for General Practice (GP).Objectives:To ensure that patients in one South-West GP practice who are taking oral MTX for RA are appropriately monitored in line with current guidance from the British Society of Rheumatology (BSR). Current guidance recommends that once a stable MTX dose is maintained for six weeks, followed by monthly bloods for the next three months, that at least twelve weekly blood monitoring is sufficient from then on1.Methods:A randomised sample of 50 patients registered in one South-West GP practice that were taking a stable dose oral MTX for RA; for at least 6 months; was collected. The length of time between the patient’s two most recent blood tests was recorded. A random selection of ten patients with more frequent monitoring than BSR guidance suggest were asked a series of questions to determine patient perspectives on reasons for monitoring frequency.Results:58% of patients had more frequent monitoring bloods than current BSR guidelines recommend. Within this group, the mode frequency of monitoring was four weeks, in line with the previous National guidance which was superseded in 20172.The most common themes in patient’s perspectives on monitoring frequency were:a.Previous abnormal blood results requiring close monitoringb.Multiple disease modifying anti-rheumatoid drug (DMARD) regimes that included MTXc.Patient preferenced.Unclear or unknown reasonThe purported increased monitoring for multiple DMARD regimes were not in line with current national guidelines1.Conclusion:This audit demonstrates that over half of patients taking MTX for RA in one GP practice are having more frequent blood monitoring than BSR guidance suggests is necessary. Furthermore, it demonstrates that patient’s understanding of their perceived need for increased monitoring is largely inaccurate or unclear to them. There is a clear deficit in patient education surrounding monitoring frequency which must be addressed in order to empower patients, as well as reducing unnecessary duplication of blood tests. As a result of this audit, patient education on MTX monitoring frequency was formally introduced as part of the RA annual patient review. An information sheet with these monitoring requirements was produced to aid practitioners in the education process.References:[1]J, Ledingham et al | BSR/ BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs | Rheumatology 2017; 56: 865-8.[2]Chakravarty K etc al | BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists | Rheumatology 2008; 47: 924–5.Disclosure of Interests:None declared
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Häuser, W., and I. Kopp. "OP0070 Update of the german evidence-based guideline on the management of fibromyalgia syndrome." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 77.1–77. http://dx.doi.org/10.1136/annrheumdis-2012-eular.1753.
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Zhang, W., M. Doherty, E. Pascual, V. Barskova, P.-A. Guerne, T. L. Jansen, B. F. Leeb, et al. "EULAR recommendations for calcium pyrophosphate deposition. Part II: Management." Annals of the Rheumatic Diseases 70, no. 4 (January 20, 2011): 571–75. http://dx.doi.org/10.1136/ard.2010.139360.
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ObjectivesTo develop evidence-based recommendations for management of calcium pyrophosphate deposition (CPPD).MethodsA multidisciplinary guideline development group of 15 experts, representing 10 European countries, generated key propositions for management of CPPD using a Delphi consensus approach. For each recommendation research evidence was searched systematically. Whenever possible, the effect size and number needed to treat for efficacy and RR or OR for side effects were calculated for individual treatment modalities. Strength of recommendation was assessed by the European League Against Rheumatism visual analogue scale.ResultsNine key recommendations were generated, including topics for general management, treatment of acute attacks, prophylaxis against recurrent acute attacks and management of chronic symptoms. It was recommended that optimal treatment requires both non-pharmacological and pharmacological treatments. For acute CPP crystal arthritis, cool packs, temporary rest and joint aspiration combined with steroid injection are often sufficient. For prophylaxis or chronic inflammatory arthritis with CPPD, oral non-steroidal anti-inflammatory drugs with gastroprotective treatment and/or low-dose colchicine 0.5–1.0 mg daily may be used. Other recommendations included parenteral or oral corticosteroid for acute CPP arthritis in those unresponsive or unsuited to other measures, and low-dose corticosteroid, methotrexate or hydroxychloroquine for chronic inflammatory arthritis with CPPD. Asymptomatic CPPD requires no treatment. Strength of recommendations varies from 79% to 95%.ConclusionNine key recommendations for management of CPP crystal associated arthritis were developed using both research evidence and expert consensus. Strength of recommendations was provided to assist the application of these recommendations.
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Dabbagh, Armaghan, and Joy C. MacDermid. "Appraisal of Clinical Practice Guideline: 2018 update of the EULAR recommendations for the management of hand osteoarthritis." Journal of Physiotherapy 67, no. 1 (January 2021): 68. http://dx.doi.org/10.1016/j.jphys.2020.07.002.
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Zhang, W., M. Doherty, G. Peat, M. A. Bierma-Zeinstra, N. K. Arden, B. Bresnihan, G. Herrero-Beaumont, et al. "EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis." Annals of the Rheumatic Diseases 69, no. 3 (September 17, 2009): 483–89. http://dx.doi.org/10.1136/ard.2009.113100.
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ObjectiveTo develop evidence-based recommendations for the diagnosis of knee osteoarthritis (OA).MethodsThe multidisciplinary guideline development group, representing 12 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched systematically. Whenever possible, the sensitivity, specificity and likelihood ratio were calculated for individual diagnostic indicators and a diagnostic ladder was developed using Bayes' method. Secondary analyses were undertaken to test directly the recommendations using multiple predictive models in two populations from the UK and the Netherlands. Strength of recommendation was assessed by the EULAR visual analogue scale.ResultsRecommendations covered the definition of knee OA and its risk factors, subsets, typical symptoms and signs, the use of imaging and laboratory tests and differential diagnosis. Three symptoms (persistent knee pain, limited morning stiffness and reduced function) and three signs (crepitus, restricted movement and bony enlargement) appeared to be the most useful. Assuming a 12.5% background prevalence of knee OA in adults aged ≥45 years, the estimated probability of having radiographic knee OA increased with increasing number of positive features, to 99% when all six symptoms and signs were present. The performance of the recommendations in the study populations varied according to the definition of knee OA, background risk and number of tests applied.Conclusion10 key recommendations for diagnosis of knee OA were developed using both research evidence and expert consensus. Although there is no agreed reference standard, thorough clinical assessment alone can provide a confident rule-in diagnosis.
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Baharuddin, H., N. F. Abdul Manaf, Z. Ismail, K. S. Ibrahim, M. Mohd Zain, and S. S. Ch’ng. "SAT0198 PROBABILITY OF PULMONARY HYPERTENSION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS ACCORDING TO ESC GUIDELINE 2015." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 1041.2–1042. http://dx.doi.org/10.1136/annrheumdis-2020-eular.6401.
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Background:The prevalence of pulmonary hypertension (PH) in systemic lupus erythematosus (SLE) varied according to the definitions and investigations used. Echocardiography should always be performed when PH is suspected, based on symptoms and signs,1which may be difficult to be assessed in patients with SLE because early symptoms of PH, including shortness of breath, fatigue, weakness, angina and syncope can be part of disease manifestation.Objectives:To investigate the probability of PH in patients with SLE based on 2015 ESC Guideline, regardless of symptoms.Methods:A cross-sectional study was conducted in a rheumatology centre in Malaysia which included patients aged 18 years and above, who fulfilled SLICC2012 criteria. Exclusion criteria were diagnosis of overlap syndrome and pregnancy. Demographic data and immunology profile were obtained from electronic medical records. TTE was performed by one technician who was blinded to other clinical details. Low, intermediate or high probability of PH was determined based on 2015 European Society of Cardiology (ESC) echocardiography criteria of PH.Results:A total of 60 patients with SLE were recruited. The mean age was 41.6±10.9 years and SLE disease duration was 11.5±9.4 years. The cardiovascular co-morbidities were hypertension (38.3%), dyslipidaemia (25%), diabetes mellitus (5.0%) and ischemic heart disease (1.6%). Based on 2015 ESC echocardiography criteria for PH, 50 (83.3%) patients had low probability of PH, 8 (13.3%) had intermediate probability of PH and 2 (3.3%) with high probability of PH. (Table 1). Further analysis revealed that two patients with high PH probability were asymptomatic at the time of study. They were treated for active SLE after PH was diagnosed from TTE performed within a year of study period and subsequent RHC confirmed pulmonary arteria hypertension (PAH). Among patients with intermediate probability of PH, one patient had intermittent palpitation and chest pain, while others were asymptomatic including one patient with PAH based on RHC. The most prevalent auto-antibodies among patients with intermediate and high probability of PH were anti-Ro (8 patients), anti-nuclear antibodies (7 patients) and anti-dsDNA (5 patients).Table 1.The details of echocardiographic signs of PH in patients with SLE.Echocardiographic ‘signs’ of PHPH probability (no of patients)Low, n=50Intermediate, n=8High, n=2Peak tricuspid regurgitant velocity, m/s• ≤2.8• 2.9-3.4• >3.45000170002Ventricles• Right/ left ventricle basal diameter ratio >1.0• Flattening of interventricular septum001022Pulmonary artery• Right ventricular outflow Doppler acceleration time <105ms and/or mid-diastolic notching• Early diastolic pulmonary regurgitation velocity >2.2m/s• PA diameter >25mm2804502222Inferior vena cava and right atrium• Inferior cava diameter >21mm with decreased inspiratory collapse• Right atrial area >18cm2000002Conclusion:We found 16.6% patients with SLE who had intermediate and high probability of PH, based on 2015 ESC echocardiography criteria for PH. All except one patient had symptoms suggestive of PH at the time of study. RHC performed subsequently on two patients with high PH probability confirmed PAH.References:[1]Galie N, Humbert M, Vachiery JL, et al. European Heart Journal, 2016; 37(1):67-119Acknowledgments :We are thankful to Mrs Maisarah, our dedicated echocardiography technician.Disclosure of Interests:Hazlyna Baharuddin Speakers bureau: Sanofi, J&J, Nur Farhana Abdul Manaf: None declared, Zaliha Ismail: None declared, Khairul Shafiq Ibrahim: None declared, Mollyza Mohd Zain: None declared, Shereen Suyin Ch’ng Speakers bureau: Novartis, Pfizer, GSK
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Maximov, D., and O. Lesnyak. "THU0451 Implementation of the osteoarthritis clinical guideline: Results of a cluster randomized trial in primary care." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 307.3–308. http://dx.doi.org/10.1136/annrheumdis-2012-eular.2416.
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Md Yusof, M. Y., C. Chattopadhyay, E. Gladston Chelliah, and N. Sathi. "SAT0425 Management of Carpal Tunnel Syndrome in Musculoskeletal Disease Department: Are we Adhering to the Guideline?" Annals of the Rheumatic Diseases 72, Suppl 3 (June 2013): A725.4—A726. http://dx.doi.org/10.1136/annrheumdis-2013-eular.2149.
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Parker, L., A. Mason, M. Coleman, and B. Davidson. "AB0298 PREGNANCY IN RHEUMATIC DISEASE: A REGION WIDE SURVEY OF CURRENT PRACTICE AMONGST CLINICIANS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1175.2–1176. http://dx.doi.org/10.1136/annrheumdis-2021-eular.203.
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Background:Rheumatic diseases frequently affect females of child-bearing age, with implications for foetal and maternal outcomes.Two-thirds (66%) of the women who died in the 2016-18 MBRRACE report were known to have pre-existing medical problems1. The NHS long-term plan supports creation of Maternal Medicine Networks to facilitate access to specialist care and advice in pregnancy.Guidelines exist for use of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy but other aspects of pregnancy related care in rheumatic disease remain less well defined. The Wessex wide connective tissue disease (CTD) network provides a multi-disciplinary forum to discuss cases, to obtain approval for high cost drugs, to compare practice in multiple hospitals but does not specifically discuss pregnancy related uncertainties.Objectives:To survey variations in clinical practice relating to rheumatic disease in pregnancyMethods:Following careful project planning with the tertiary referral centre obstetric lead consultant for maternal medicine, several areas of care were identified which were prone to local and individual variation. An anonymous online survey relating to these specific areas of pregnancy related care was circulated amongst members of the CTD network, including rheumatology consultants, rheumatology practitioners and specialist trainees.Results:16 responses were obtained across 7 hospital sites; 56% were from rheumatology consultants. 12/16 (75%) reported routinely offering contraceptive advice when prescribing DMARDs. Only 4/16 (25%) were aware of a specific pre-natal obstetric clinic available in their hospital. There was major variation in planned frequency of clinical review. 10/16 would increase frequency of review during pregnancy if a patient’s disease became active or unstable; 6/16 would aim to review patients approximately 3 monthly; 3/16 would not routinely increase frequency of review during pregnancy. Planned post-natal care was equally varied. 3/16 would routinely prescribe aspirin to all lupus women during pregnancy despite this being recommended for all women with SLE for prevention of pre-eclampsia2. Prescription of low molecular weight heparin was variable, and several responses were at odds with the current RCOG guidance on the subject3. 8/16 (50%) would prescribe corticosteroids judiciously in case of an acute disease flare.Conclusion:This survey has revealed significant variation in practice relating to rheumatic disease in pregnancy. Integrated care with colleagues from the regional referral centre for maternal medicine is required, in keeping with the recently published NICE guidance on the subject4. Adopting a hub and spoke model, with local centres working closely alongside a tertiary centre, will help optimise peri-partum care and outcome for patients with long-term rheumatic conditions.References:[1]Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Saving Lives, Improving Mothers’ Care Maternal Report (December 2020). Available at https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf [Accessed 28 January 2021][2]National Institute for Health and Care Excellence (2019) Hypertension in pregnancy: diagnosis and management (NICE guideline 133) Available at https://www.nice.org.uk/guidance/ng133 [Accessed 28 January 2021][3]Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium (Green-top Guideline Number 37a) Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf [Accessed 5 January 2021][4]National Institute for Health and Care Excellence (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies (NICE guideline 121) Available at https://www.nice.org.uk/guidance/ng121 [Accessed 5 January 2021]Disclosure of Interests:None declared
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Preece, B., and E. Thomas. "AB1091 THE IMPACT OF COVID-19 PANDEMIC ON DISEASE MONITORING AND MONITORING FOR ADVERSE CLINICAL OUTCOMES IN THOSE ON BIOLOGIC THERAPY." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1664.1–1664. http://dx.doi.org/10.1136/annrheumdis-2022-eular.497.
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BackgroundThe coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2.1 The pandemic has posed major challenges to the National Health Service, with implications for patients with rheumatological diseases. 2 In order to try and prevent transmission of the virus, the delivery of patient care has adapted, involving more telephone and virtual review of patients. The British Society of Rheumatology (BSR) has highlighted the importance of adopting a ‘treat-to-target’ 3 approach in managing these patients to facilitate early treatment escalation in the presence of active disease. Close monitoring of disease is an integral approach to managing these patients. Disruption to previous patterns of care and disease monitoring of biologic patients theoretically may increase the risk of disease flare and adverse clinical outcomes. 4ObjectivesThe BSR recommends all patients receiving biologic therapy should be reviewed for drug safety every 6 months. It recommends that patients prescribed a biologic should have monitoring blood tests every 3–6 months.3, 5 The BSR has published mitigating guidance outlined within the COVID-19 rapid guideline.5 This suggests it’s safe to increase time intervals between blood tests for drug monitoring, particularly if 3-monthly blood tests have been stable for over 2 years.Our aims are to evaluate whether altering our delivery of care has impacted on the ‘treat-to-target’ approach and the frequency of blood monitoring in those on biologic therapy, despite the challenges of an ongoing global pandemic.MethodsOver a period of 1 month a total of 51 patients receiving biologic therapy case notes were reviewed. Data was collected relating to underlying diagnosis, choice of biologic, whether a disease activity score was performed, method of consult and compliance with drug monitoring.ResultsOf the 51 patients 24 patients were receiving adalimumab, 20 baricitinib, 2 filgotinib, 2 upadacitinib and 3 on entarcept. Diagnoses ranged from 33 patients with rheumatoid arthritis, 7 psoriatic arthritis, 5 ankylosing spondylitis, 5 spondyloarthropathy and 1 enteropathic arthritis. Disease activity scores were documented in the majority of patients (75%). In those where disease activity scores were not documented, 11 had rheumatoid arthritis and the remaining 2 psoriatic arthritis. The majority of the patients who didn’t have disease activity scores documented were reviewed via telephone consult (84%). All patients had undergone adequate blood monitoring with 100% compliance with blood tests performed within 6 months.ConclusionThe COVID-19 pandemic has presented an extraordinary necessity for change in how we manage patients suffering from rheumatic disease. The impact of this global pandemic will be long-lasting and thorough analysis of patient outcomes is needed. However, this period presents an exciting opportunity to embrace new ways of working, which may improve efficiency and efficacy of patient care.References[1]Wu, F. et al. A new coronavirus associated with human respiratory disease in China. Nature 579, 265–269 2020[2]Shields S, et al Disease monitoring of biologic treatment in IBD: early impact and future implications of COVID-19 pandemic Frontline Gastroenterology 2021;12:345-347[3]Holroyd et al The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis Rheumatology, Vol 58, Issue 2, Feb 2019:e3–e42[4]Neurath, M.F. COVID-19: biologic and immunosuppressive therapy in gastroenterology and hepatology. Nat Rev Gastroenterol Hepatol 18, 705–715 2021[5]COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders NICE guideline 3 April 2020[6]Wallace et al. The rheumatology community responds to the COVID-19 pandemic: the establishment of the COVID-19 global rheumatology alliance. Rheumatology 2020Disclosure of InterestsBethan Preece: None declared, E Thomas Speakers bureau: Speaker fee for Galapagos
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Stoffer, M., L. van Bodegom-Vos, H. Lund, and T. Vliet Vlieland. "SP0180 Health professionals workshop session: “I’ve been asked to review a clinical guideline – where do I start?”." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 44.2–44. http://dx.doi.org/10.1136/annrheumdis-2012-eular.1655.
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El Miedany, Y., M. H. Abu-Zaid, M. Elgaafary, N. Ali, M. Mansour, W. Hassan, M. A. Mortada, et al. "POS1168 TREAT TO TARGET OF GOUT: AN EVIDENCE-BASED CONSENSUS ON CLINICAL PRACTICE GUIDELINES." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 912.2–912. http://dx.doi.org/10.1136/annrheumdis-2022-eular.3477.
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BackgroundNew therapies, management approaches and evidence regarding the management of gout have become available over the past years. This triggered the need for updated recommendations for the management of gout.Objectivesto develop an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of acute gout flares, optimum usage of urate lowering therapy for chronic gout as well as patient education and lifestyle guidance.MethodsAn extensive systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. For each item, the level of evidence was determined using the Oxford Centre for Evidence-based Medicine (CEBM) system. These were evaluated by a panel of 17-experts via online surveys over a 2-round Delphi process.ResultsAt the end of round 2, a total of 30-recommendation items, categorized into 10 domains to were obtained. Agreement with the recommendations (rank 7-9) ranged from 90-100%. Consensus was reached (i.e.≥75%of respondents strongly agreed or agreed) on the wording, the grade of recommendation and level of evidence of all the 30 clinical standards identified by the scientific committee. The guideline emphasized that all gouty patients should be screened for comorbidities. Based on this, an algorithm for treat to target management approach tailored to the individual patient’s needs and associated comorbidities has been outlined.ConclusionThis work provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gouty arthritis. It provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.Disclosure of InterestsNone declared
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Zhao, J. L., X. Liu, L. Zhan, H. Tang, J. Li, M. Liu, E. Holdsworth, and Y. Zhao. "AB0221 CURRENT IMPLEMENTATION OF TREAT-TO-TARGET APPROACH IN RHEUMATOID ARTHRITIS TREATMENT: THE PERSPECTIVE OF CHINESE RHEUMATOLOGISTS." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1136.2–1137. http://dx.doi.org/10.1136/annrheumdis-2021-eular.1960.
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Background:Treat-to-target (T2T) approach is recommended as a standard management strategy in rheumatoid arthritis (RA) treatment by Chinese guideline for diagnosis and treatment of RA[1]. However, there is little known about its current implementation in China.Objectives:This study aimed to evaluate the implementation and achievement of T2T approach and explore their associated factors in Chinese RA cohort.Methods:A comprehensive cross-sectional survey of rheumatologists and their RA patients was conducted in China. Data were collected during May-Aug 2019 via physician-completed patient record forms. 60 rheumatologists provided data on demographic, clinical characteristics, treatments, and T2T approach implementation for 600 RA patients. Two logistic regressions were used to evaluate factors associated with T2T approach implementation and T2T goal achievement, respectively. Patients with missing data were not included in the models.Results:600 patients were included in this study (48.8±11.7 years, 70.3% female). 39.0% (N=234) of 600 patients were being treated with T2T approach, and 64.9% (N=366) of 564 patients had achieved T2T goal. Patients with longer disease duration (>2 years diagnosis) (odds ratio (OR) [95%CI]=1.61 [1.05, 2.49], vs. diagnosis ≤2 years), higher pain score (OR [95%CI]=1.26 [1.04, 1.51]), or receiving advanced therapy (OR [95%CI]=6.91 [3.64, 13.13]) were more likely to use T2T. Patients with BMI >23.9kg/m2 (OR [95%CI]=2.83 [1.59, 5.04], vs. BMI≤23.9kg/m2), or who worked full-time (OR [95%CI]=2.12 [1.26, 3.57]) were more likely to achieve T2T goal, while patients with more pain (OR [95%CI]=0.77 [0.64, 0.92]) were less likely to achieve T2T goal.Conclusion:Low implementation of T2T approach is observed in Chinese RA treatment. Longer disease duration, more pain, and receiving advanced therapy are associated with higher probability of T2T use, while higher BMI, full-time work and less pain are associated with higher probability of T2T goal achievement. Standard diagnosis and treatment according to guidelines may improve T2T approach implementation.References:[1]Association, C.R., 2018 Chinese guideline for the diagnosis and treatment of rheumatoid arthritis. Zhonghua nei ke za zhi, 2018. 57(4): p. 242.Disclosure of Interests:Jiu-liang Zhao: None declared, Xin Liu Employee of: Eli Lilly and Company, Lujing Zhan Employee of: Eli Lilly and Company, Hongyu Tang Employee of: Eli Lilly and Company (Intern), Jinnan Li Employee of: Eli Lilly and Company, Mengru Liu Employee of: Eli Lilly and Company, Elizabeth Holdsworth Consultant of: Eli Lilly and Company, Employee of: Adelphi Real World, Yan Zhao: None declared
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Pohl, C. "POS1213 SAFETY AND EFFICACY ASSESSMENT OF COVID-19 IMMUNIZATIONS / VACCINATIONS IN PATIENTS OF A GERMAN GENERAL RHEUMATOLOGICAL PRACTICE." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 935–36. http://dx.doi.org/10.1136/annrheumdis-2022-eular.1389.
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BackgroundGerman Covid-19 pandemic immunization program started Dec 26th, 2020 without population representative standardized real world data efficacy study protocols(1). Safety assessment: side effect panel of the Paul-Ehrlich Institute reporting system of suspected side effects (analogue and digital): Comparison of reported side effects against 100000 immunization doses vs historical known medical events against 100000 patient years. Not much is known how long side effect reporting periode after MRNA / Vector immunization is appropiate for the different immunization drugs (Biontech/Pfizer-Comirnaty(2), AstraZeneca-Vaxzevria, Moderna-Spikevax, Johnson&Johnson–Covid-19 vaccine Janssen) because for these no pharmacokinetic and –dynamic data (2,3) are available on spike protein biodistribution and how long it lasts in the human body. EMA / WHO guidelines declare these data not as essential for approval of vaccines, only for drugs (4).ObjectivesReal world safety and efficacy of Covid-19 immunizations.MethodsIn 664 patients (612 patients with rheumatic diseases) planned standardized assessment: Safety parameters before and 3-7 days after immunization (organ, hematology, myositis, thrombosis, inflammatory, autoimmunity parameters), after 5-6 months (before booster decision) d-dimer-levels, routine lab assessment (routine surveillance of rheumatic patients under therapy) and Covid-19-antibody levels (AbL).ResultsMost patients (94.5%) developed Covid19-AbL (except a few under Abatacept and Rituximab). After 5-6 months most patients (77%) still had Covid19 sufficient AbL above 128 BAU/ml (87% above 64 BAU/ml) (1). 37% of all patients developed relevant elevated d-dimers (still 5-6 months after immunization). In most of these patients the suspicion of inflammation of the microvascular system was a reasonable explanation (large vessel or pulmonary thromboembolism was ruled out in 98 %).ConclusionInflammation of the microvascular system as an underestimated side effect of MRNA / Vector immunization should be taken into account if (booster)-immunization decisions in patients with rheumatic diseases (maybe general) are to be made. Most patients with rheumatic diseases under (DMARD) therapy developed Covid-19 AbL (94.5%) (1) 5-6 months after MRNA / Vector immunization. All immunization decisions should also made dependent on AbL, because in case 5.5 % of immunized people do not react with AbL response, high numbers of breakthrough infection rates and hospitalization of immunized patients could be explained. Microvascular inflammation after MRNA / Vector immunization as a side effect in 37 % of rheumatologic patients could cause medical problems later on. Therefore also for safety reasons MRNA / Vector (booster) immunizations should also depend on the amount of already existing humoral response reflected by AbL.References[1]Antibody titers and protection against a SARS-CoV-2 infection, C. Dimeglio et al, J Infect 2021 Sep 21, doi: 10.1016/j.jinf.2021.09.013 [Epub ahead of print][2]Assessment-report BioNTech-immunization drug: https://www.ema.europa.eu/documents/assessment-report/comirnaty-epar-public-assessment-report_en.pdf[3]Assessment of the potential integration of the DNA plasmid vaccine CLYNAV into the salmon genome, R. Houston et al, EFSA Journal 21 December 2016, doi: 10.2903/j.efsa.2017.4689[4]Email answer of the EMA December 6th 2021: „Please note that pharmacokinetic studies are usually not required for authorisation of vaccines either in humans or in animals, and this is in line with the EMA and WHO guidelines on clinical development of vaccines which provide guidance to vaccine developers on regulatory requirements when developing their products“: https://www.ema.europa.eu/en/documents/scientific-guideline/guideline-clinical-evaluation-new-vaccines_en.pdf and https://www.who.int/teams/health-product-and-policy-standards/standards-and-specifications/vaccine-standardization/clinical-evaluation-of-vaccinesAcknowledgementsMy family, my staff, my collegues and all of my patientsDisclosure of InterestsNone declared
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Sandal Uzun, G., O. D. Tatar, N. E. Gezerer, E. Bilgin, G. K. Yardimci, E. C. Bolek, B. Farisogullari, et al. "AB0277 DYSLIPIDEMIA TREATMENT IN RHEUMATOID ARTHRITIS PATIENTS USING bDMARDs IS BETTER THAN PsA, BUT THERE IS STILL A WAY TO GO." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1264.2–1265. http://dx.doi.org/10.1136/annrheumdis-2022-eular.3032.
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BackgroundPatients with inflammatory arthritis have an increased risk of cardiovascular disease. Dyslipidemia is one of the primary modifiable risk factors.ObjectivesComparasion of the frequency of dyslipidemia and the use of anti-hyperlipidemic agents in patients with Rheumatoid Arthritis (RA) and Psoriatic arthritis (PsA) receiving bDMARDs.MethodsThe Hacettepe University biological database (HUR-BIO), was established in 2005 and 581 (75.4% female) patients with RA and 520 (69.4% female) patients with PsA enrolled up to 2021 were analyzed. Dyslipidemia was defined according to the Turkish Endocrine and Metabolism society criteria (TC > 240, Triglycerides (Tg) > 150, LDL-C > 160, HDL-C (< 40 in men, < 50 in women) (1). The anti-hyperlipidemic (anti-HL) agents used by the patients during follow-up and at their last visit were recorded.ResultsThe mean (SD) age of the patients and diseases duration were as follows; RA vs. PsA [age: 52.1 (13.9) vs. 48.7 (12.5) years; disease duration: 5.3 (2.1) vs. 9.2 (6.4) years]. Lipid profiles were known in 289 (49.7%) patients with RA and in 175 (33.6%) patients with PsA at the initiaiton of bDMARD. Lipid profiles were evaluated in 356 (61.2%) patients with RA and 226 (43.4%) patients with PsA during follow-up and at the last visit. Lipid profiles were similar in patients with RA and PsA at the initiation of bDMARDs (Table 1). At the initiation of bDMARD, 29 (5.0%) of RA patients and 10 (3.2%) of PsA patients were receiving anti-HL agents. During the entire follow-up, 65 (12.6%) patients with RA and 22 (4.8%) patients with PsA have used anti-HL agents (p<0.001).Table 1.Lipid values in patients with RA and PsA at the initiation of bDMARD and at the last visitRheumatoid arthritis, n (%)Psoriatic arthritis, n (%)p1*p2**Lipid valuesbDMARD initiationLast visitbDMARD initiationLast visitTotal Cholesterol> 24047/270(17.4)98/339 (28.9)32/161(19.8)57/203 (28.1)0.300.13Triglyseride> 15062/242 (25.6)108/320 (33.7)45/159 (28.3)80/193 (41.4)0.790.20HDL-C< 40 (males),< 50 (females)88/267 (32.9)70/343 (20.4)57/157 (36.3)20/207 (9.6)0.480.001LDL-C > 16053/289 (18.3)91/356 (25.6)43/175 (24.5)65/226 (28.7)0.380.55*p1, bDMARD initiation visit comparison**p2, last visit comparisonConclusionIn real-life cohort, lipid profile was not assesed in half of the patients during entire follow-up. Although, LDL-C levels are high in about a quarter of the patients in both groups, use of anti-hyperlipidemic drug was inadequate. This is even more evident in PsA patients. Despite the significant emphasis on comorbidities in treatment guidelines, there is still a long way to go in real life.References[1]TEMD Obesity Guideline, L.M., Hypertension Working Group, TEMD Dyslipidemia Diagnosis and Treatment Guideline. 9th ed. 2021,Disclosure of InterestsNone declared
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Lim, Y., J. Wong, S. M. Hussain, M. Estee, L. Zolio, M. Page, C. Harrison, A. Wluka, Y. Wang, and F. Cicuttini. "AB0979 Recommendations for weight management in osteoarthritis: a systematic review of clinical practice guidelines." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1616.1–1616. http://dx.doi.org/10.1136/annrheumdis-2022-eular.2284.
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BackgroundWeight loss interventions are often recommended to target overweight and obesity in the clinical practice guidelines (CPGs) for the management of osteoarthritis. This is despite evidence from meta-analyses of clinical trials that significant weight loss results in modest improvements in symptoms and minimal effects on disease progression1,2. There is evidence that weight gain is associated with increase in knee pain3,4. In countries such as USA, adults gain on average 0.5 to 1 kilogram per year from early to middle adulthood Preventing weight gain is easier to achieve and sustain than losing weight.ObjectivesGiven that weight loss is accepted as fundamental to osteoarthritis management, we systematically reviewed the recommendations and approaches for weight management in all current osteoarthritis CPGs.MethodsNine databases were searched (1st January 2010 to 30th September 2021) to identify guidelines informing the non-pharmacological management of osteoarthritis. Three reviewers appraised guidelines according to the AGREE II instrument, and independently extracted data on their characteristics. One author extracted and summarised guideline recommendations on weight management. This systematic review is registered on PROSPERO (CRD42021274195).ResultsFifteen CPGs from developed and developing countries were included. Weight loss was recommended for knee (12 of 13 guidelines) and hip (10 of 11 guidelines) but not hand osteoarthritis (0 of 4 guidelines). Combination approaches of diet and/or exercise were recommended for overweight or obese individuals (knee: 8 of 12; hip: 4 of 10), with 2 guidelines specifying ≥5% weight loss for knee and hip osteoarthritis. One of 15 guidelines specified strategies for weight loss and maintenance of lost weight. Two of 15 guidelines recommended controlling body weight for osteoarthritis, regardless of obesity status.ConclusionMost CPGs for knee and hip osteoarthritis include recommendations for weight loss in those with overweight or obesity as key to managing osteoarthritis, despite evidence of modest at best effect of weight loss on symptoms and no effect on joint structure1,2. Given obesity is a major risk factors for osteoarthritis, the prevention of weight gain may be more effective and practical in improving clinical outcomes for osteoarthritis, and hence should be considered as part of the key management in osteoarthritis.References[1]Chu IJH, Lim AYT, Ng CLW. Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: a systematic review and meta-analysis. Obes Rev. 2018;19(11):1597-1607.[2]Daugaard CL, Hangaard S, Bartels EM, Gudbergsen H, Christensen R, Bliddal H, et al. The effects of weight loss on imaging outcomes in osteoarthritis of the hip or knee in people who are overweight or obese: a systematic review. Osteoarthritis Cartilage. 2020;28(1):10-21.[3]Tanamas SK, Wluka AE, Davies-Tuck M, Wang Y, Strauss BJ, Proietto J, et al. Association of weight gain with incident knee pain, stiffness, and functional difficulties: a longitudinal study. Arthritis Care Res (Hoboken). 2013;65(1):34-43.[4]Teichtahl AJ, Wluka AE, Tanamas SK, Wang Y, Strauss BJ, Proietto J, et al. Weight change and change in tibial cartilage volume and symptoms in obese adults. Annals of the rheumatic diseases. 2015;74(6):1024-1029.[5]Zheng Y, Manson JE, Yuan C, Liang MH, Grodstein F, Stampfer MJ, et al. Associations of Weight Gain From Early to Middle Adulthood With Major Health Outcomes Later in Life. JAMA. 2017;318(3):255-269.Disclosure of InterestsNone declared
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Rook, E. "THU0505 The Development of A New European Regulatory Guideline on The Clinical Investigation of Medicinal Products for The Treatment of Gout." Annals of the Rheumatic Diseases 75, Suppl 2 (June 2016): 374.3–375. http://dx.doi.org/10.1136/annrheumdis-2016-eular.6124.
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Singh, J., D. Hagerty, R. Mischler, and R. Morlock. "FRI0383 Majority of us patients would not meet the proposed acr gout treatment guideline goal of SUA <6 mg/dl." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 444.1–444. http://dx.doi.org/10.1136/annrheumdis-2012-eular.2840.
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Zhang, W., M. Doherty, B. F. Leeb, L. Alekseeva, N. K. Arden, J. W. Bijlsma, F. Dincer, et al. "EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT." Annals of the Rheumatic Diseases 68, no. 1 (February 4, 2008): 8–17. http://dx.doi.org/10.1136/ard.2007.084772.
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Objectives:To develop evidence-based recommendations for the diagnosis of hand osteoarthritis (OA).Methods:The multidisciplinary guideline development group, representing 15 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched for systematically. Whenever possible, the sensitivity, specificity and likelihood ratio (LR) were calculated; relative risk and odds ratios were estimated for risk factors for hand OA. Quality of evidence was categorised using the European League Against Rheumatism (EULAR) hierarchy, and strength of recommendation was assessed by the EULAR visual analogue scale.Results:Diagnostic topics included clinical manifestations, radiographic features, subgroups, differential diagnosis, laboratory tests, risk factors and comorbidities. The sensitivity, specificity and LR varied between tests depending upon the cut-off level, gold standard and controls. Overall, no single test could be used to define hand OA on its own (LR <10) but a composite of the tests greatly increased the chance of the diagnosis. The probability of a subject having hand OA was 20% when Heberden nodes alone were present, but this increased to 88% when in addition the subject was over 40 years old, had a family history of nodes and had joint space narrowing in any finger joint.Conclusion:Ten key recommendations for diagnosis of hand OA were developed using research evidence and expert consensus. Diagnosis of hand OA should be based on assessment of a composite of features.
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Abdelkadir, M. J., M. Kuijper, C. Appels, A. Spoorenberg, J. Hazes, L. Van Hoeven, D. Lopes Barreto, and A. Weel. "OP0282 COST-EFFECTIVENESS ANALYSIS OF A CAFASPA REFERRAL MODEL FOR AXIAL SPONDYLOARTHRITIS." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 175.1–176. http://dx.doi.org/10.1136/annrheumdis-2020-eular.4683.
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Background:Chronic low back pain (CLBP) poses a significant individual and socio-economic burden. A substantial amount of patients with CLBP have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). Guidelines form primary care and secondary care differ in criteria for referral recommendation. The Dutch primary care guideline is restrictive in referring CLBP patients to secondary care whereas ASAS recommend to refer CLBP patients having at least 1 axSPA feature1. Therefore several referral models have been developed to assist GPs. Although the validated CaFaSpA referral model2is able to identify CLBP patients at risk for axSpA, its cost-effectiveness is yet unknown and essential before implementation in daily clinical practice.Objectives:Primary objective to assess the cost-effectiveness of the CaFaSpA referral model for axSpA in primary care. Secondary objective to evaluate the costs made for screening by following the CaFaSpA vs ASAS referral model.Methods:A clustered randomized controlled trial was performed with GPs as clusters. Clusters were randomized into the intervention (CaFaSpA referral, CS) or usual care (UC). Cost-effectiveness analysis from a societal perspective was performed to compare the CS and UC. Clinical outcomes were disability (Roland-Morris Disability Questionnaire (RMDQ)) and health-related quality of life (EuroQol (EQ-5D)) after 12 months. Direct (Medical Consumption Questionnaire IMCQ) and indirect healthcare (Productivity Cost Questionnaire IPCQ) costs were evaluated. Complete case analysis was performed. Incremental cost-effectiveness ratios (ICERs) were calculated for both clinical effects. Fictive costs according to the Dutch standard prices were assessed if the ASAS guideline would be followed (screening costs)3.Results:Of all 679 patients sixty-four percent were female and mean age was 36 (SD) years. In the CS 333 patients were included and in the UC. Non-significant differences in clinical outcomes were for RMDQ: 0.78 (95% CI: -0.38-2.07) and for EQ5D 0.03 (95% CI: -0.04-0.11). Costs were significantly higher in the UC group €19,748 (95% CI: € 15,327-25,022) vs CS € 14,169 (95% CI: € 10,723-18,066).Productivity loss was the largest contributor to the total costs (CS group: 62%, UC group: 96%). The majority of the bootstrapped ICERs presented were located in the south-eastern quadrant of the cost-effectiveness planes (Figure 1a and 1b), indicating that the CS is cost-effective. The ICER for RMDQ was €-5,579, indicating that per point improvement on the RMDQ the intervention saved €5,579. The difference in QALY’s between the CS and UC was very small resulting in a large ICER of €16,9583.The fictive screening costs by using the ASAS referral advice, i.e. referring 85% of 679 patients, results in €876 per patient. The total screening costs per patient by using the CaFaSpA model, i.e. referring 60% of 679 patients is €618.Conclusion:Although the clinical effects between the CaFaSpA referral strategy and usual care were comparable, the CaFaSpA referral strategy resulted in a better cost-effectiveness. Lower costs were mainly driven by the increased productivity.References:[1]Poddubnyy D et al. Ann Rheum Dis 2015;74:1483–7.[2]van Hoeven L et al. PLoS One 2015; 22;10(7):e0131963.[3]van Hoeven L et al. Ann Rheum Dis 2015;74(12):e68.Disclosure of Interests:None declared
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Rollefstad, S., E. Ikdahl, J. Sexton, G. Kitas, P. Van Riel, C. S. Crowson, I. Graham, and A. G. Semb. "OP0121 MANAGEMENT OF DYSLIPIDAEMIA AND HYPERTENSION IN PATIENTS WITH RHEUMATOID ARTHRITIS – DATA FROM 19 COUNTRIES." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 80.2–80. http://dx.doi.org/10.1136/annrheumdis-2020-eular.4236.
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Background:The realisation that subjects with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) has led to a growing interest in risk factor control in such people, but whether this has influenced the management of dyslipidaemia and hypertension (HT) is uncertain. In subjects with coronary heart disease (CHD), audits of CVD risk factor control are regularly performed, which makes it possible to evaluate guideline implementation over time.1Updated surveys on CVD risk management in patients with RA are needed.Objectives:To describe differences in lipid and blood pressure (BP) levels among patients with RA from five world regions. Furthermore, to evaluate attainment of guideline recommended targets for lipid lowering and antihypertensive treatment.Methods:The SUrvey of CVD Risk Factors in patients with RA (SURF-RA) was conducted at 53 centres in 19 countries from 2014 to 2019. Data including demographics, RA disease characteristics, CVD comorbidity, risk factors and use of preventive treatment was collected. HT was defined as self-reported HT, and/or measured BP ≥140/90 mmHg, and/or use of anti HT medication (a-HT). The treatment goal of a-HT was BP <140/90 mmHg. The 10-year risk of a fatal CVD event was calculated by the European CVD risk calculator, the Systematic COronary Risk Evaluation (SCORE), and was thereafter multiplied with 1.5 as recommended by the European League Against Rheumatism. Patients were classified in a high or very high CVD risk group according to the 2012 European Society of Cardiology guidelines, with low density lipoprotein cholesterol (LDL-c) goal at <2.6 and <1.8 mmol/L, respectively.2Results:In total, 14503 RA patients were included. The mean age was 59.8±13.6 years, and it was a strong female preponderance (74%). Nearly 2/3 of the patients were hypertensive. Use of a-HT in the total population differed substantially between the cohorts with limited use in West Europe and Latin America (17.4% and 24.8%), in contrast to North America and East Europe (46.8% and 57.0%). On average, half of those with HT were at the recommended BP goal. The lowest BP goal attainment was seen in Asia, West and East Europe (40.8-43.1%), and the highest in North America (63.5%). Overall 51.5% had an indication for lipid lowering therapy (LLT), and of these 43.5% were taking LLT. Only 34.0% of patients with an indication for LLT were at recommended LDL-c goals. The proportion of RA patients on target for LDL-c varied greatly between regions, from 23.1% in East Europe to 51.0% in North America. The LDL-c goal attainment was higher in RA patients at high risk (45.1%) compared to those at very high risk of CVD (18.0%).Conclusion:This large international survey on RA patients revealed considerable geographical differences in CVD preventive treatment. Lower goal attainment for LLT than reported for subjects with CHD was observed. We conclude that there is a substantial need for improvement in CVD preventive measures in RA patients.References:[1]De Backer G, Jankowski P, Kotseva K,et al.Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries.Atherosclerosis. 2019;285:135-146.[2]Perk J, De Backer G, Gohlke H,et al.European Guide-lines on cardiovascular disease prevention in clinical practice.Eur Heart J.2012:1635-701.Disclosure of Interests:Silvia Rollefstad: None declared, Eirik Ikdahl: None declared, Joe Sexton: None declared, Georeg Kitas: None declared, Piet van Riel: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Ian Graham: None declared, Anne Grete Semb: None declared
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Rook, E. "AB0179 Revision of European Medicine Agency's (EMA) Guideline on Clinical Investigation of Medicinal Products Other than Nsaids for Treatment of Rheumatoid Arthritis, 2016." Annals of the Rheumatic Diseases 75, Suppl 2 (June 2016): 958.1–958. http://dx.doi.org/10.1136/annrheumdis-2016-eular.5721.
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Ansari, G., A. Nandagudi, and S. Pattapola. "AB1012 MANAGEMENT OF BREAST CANCER TREATMENT INDUCED BONE LOSS- RE-AUDIT." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1629.2–1630. http://dx.doi.org/10.1136/annrheumdis-2022-eular.1192.
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BackgroundBreast cancer treatment therapies (aromatase inhibitors (AI)) are associated with early menopause and adverse effect on bone density. Identifying high-risk patients and managing them appropriately will help reduce their fracture risk.ObjectivesWe wanted to ascertain whether our management of breast cancer patients on aromatase inhibitors (AI) referred to osteoporosis clinic were as per guidelines. A consensus position statement from a UK expert group regarding breast cancer treatment induced bone loss, published with the support of the National Osteoporosis Society, the National Cancer Research Institute, Breast Cancer Study Group and the International Foundation.The guideline recommend lifestyle advice for low risk patients; calcium plus vitamin D supplementation and lifestyle advice for medium risk; bisphosphonate, calcium plus vitamin D supplementation and lifestyle advice for high risk.MethodsThis is a re-audit cycle conducted for all patients referred to the osteoporosis clinic who were treated with aromatase inhibitors for breast cancer between 2016-2020. Patients were divided into two algorithms:Algorithm 1: women who had experienced premature menopause associated with ovarian suppression with or without AI.Algorithm 2: Postmenopausal women receiving treatment with an AI.T-scores were used to stratify patients in algorithm 1 into high risk (HR- T score <-2), medium risk (MR-T score -1 to -2) and low risk (LR- T score >-1).Algorithm 2 into high risk (HR-T score <-1) medium risk (MR -T score >-1).Results:Table 1.Showing the results of Audit 1 and Re-auditAudit 1Re-auditTotal Patients5472Data collected2014-20162016-2020GenderFemale 100 (%)Female 100 (%)Age in years45-9638-92Median age7768No of Osteoporotic patients3141No of Osteopenic patients2331Algorithm 1:Total patients=23• 18 HR• 5MR• LR nilTotal patients = 20• 19HR • 1 MRAlgorithm 2:Total patients =31• 31 HR • MR-nil • LR nilTotal patients =52• 45HR • 5MR • 2LRDrug therapy4563Bisphosphonates2149Denosumab2314Teriparatide10Declined treatment01Lifestyle/Vit D & Cal96Lifestyle advice only02ConclusionRe-audit showed all patients were on AI and treated appropriately. As compare to audit 1, all high risk group patients were treated with drug therapy and bisphosphonate was the first line therapy as per guidelines. It was recommended that patients with risk of osteoporosis should be referred and treated according to their risk stratification. It is a collective responsibility of Breast surgeons, Geriatrician, Frailty team, Oncologist, Rheumatology and General Practitioners).All patients should have repeat bone density scan in 2 years’ time after initial bisphosphonate therapy. The next audit cycle will be conducted in five years’ time.Disclosure of InterestsNone declared
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Cernovschi, N., S. Zeb, T. Salter, and M. Lloyd. "AB0891 BARE TO THE BONE - AN AUDIT OF RENAL BONE DISEASE AGAINST KDIGO GUIDELINES." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 1749.1–1750. http://dx.doi.org/10.1136/annrheumdis-2020-eular.1490.
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Background:Chronic kidney disease-mineral and bone disorder (CKD-MBD) is complex and management can be difficult. We aimed to compare management of our CKD patients to 2018 KDIGO guidelines. The guidelines suggest checking calcium and phosphate (Ca/PO4) within 12 mths in CKD 3a and 3b, within 6 mths for CKD 4, and within 3 mths for CKD 5. Parathyroid hormone (PTH) should be checked at baseline in CKD 3a-b, within 12 mths in CKD 4 and within 6mths in CKD 5. Alkaline phosphatase (ALP) should be measured within 12 mths in CKD 4 and 5. 25-(OH)D levels ‘might’ be measured at baseline in CKD 3a to 5D. BMD scanning is suggested if the result will impact treatment decisions. Lateral abdominal X ray is recommended as an alternative to CT for detection of vascular calcification. Calcitriol and vitamin D analogues are no longer routinely advised in CKD 3a-5; 25-(OH)D insufficiency should be corrected as in the normal population.Objectives:To compare management of our CKD patients to 2018 KDIGO guidelinesMethods:We randomly selected 70 patients in whom data was available from renal clinics between May and September 2019.Results:Mean age was 67.3 yrs. 41 male, 29 female. 33 patients had CKD 3a-b; 31 had CKD 4; 6 had CKD 5. Mean duration of CKD was 10.6 yrs. 10 patients were taking activated vitamin D analogues; 13 were taking 25-(OH)D analogues. 25-(OH)D levels ranged from 24-158 nmol/L (mean 65nmol/L). PTH levels ranged from 2- 69pmol/L (mean 23pmol/L). 3 patients were taking bisphosphonates. 44 had previous lumbar spinal imaging; vertebral fractures were evident in 4 (9%). 12 patients had had DXA scans; lowest T score was -2.5. Table 1 - tests within suggested time frames:CKD 3a-3bCKD 4CKD 5Ca/ PO433 (100%)29 (93%)6 (100%)ALP33 (100%)31 (100%)6 (100%)PTH14 (42%) (ever)8 (26%)3 (50%)25-(OH)D8 (24%) (ever)8 (26%) (ever)1 (14%)(ever)Conclusion:Optimum PTH levels in CKD patients are not known, and therapeutic options in CKD-MBD often limited. Nevertheless, our results suggest that bone biochemistry could be checked more consistently in CKD patients. Although detection of vascular calcification may not alter renal management, abdominal imaging provides an opportunity to screen for vertebral fracture, present in a significant number of our patients. The KDIGO guidelines offer a framework to work with our renal colleagues, as many patients will be jointly managed.References:[1]Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney[2]Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease:[3]Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann Int Med 2018Disclosure of Interests:NATALIA CERNOVSCHI: None declared, SHABEENA ZEB: None declared, TRACEY SALTER: None declared, MARK LLOYD Speakers bureau: £700 into department fund
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Mirza, A., Z. Win Naing, P. Khonsari, H. Khan, P. Rezai, A. K. Abbas, and M. Nisar. "OP0244 AROMATASE INHIBITORS AND FRACTURE PREVENTION – DO NEW GUIDELINES WORK IN REAL WORLD?" Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 160.2–161. http://dx.doi.org/10.1136/annrheumdis-2022-eular.3697.
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Background2,261,419 women were diagnosed with breast cancer worldwide in 2020. For postmenopausal women with hormone sensitive disease, aromatase inhibitors (AI) are recommended for their mortality benefit. However, AI bone loss (AIBL) is a recognised adverse event with resultant increase in fracture risk. In 2017, a consensus statement of 7 international bone and cancer societies was published proposing an algorithm based on clinical risk factors and different bone mineral density (BMD) threshold for bone active therapeutic intervention.ObjectivesTo determine the real-world impact of the 2017 consensus guidelines on AIBL and whether bone sparing therapy utilising proposed risk stratification model is effective in fracture prevention.MethodsOver a 7-year study period, 1001 women were prescribed AI at our university teaching hospital. The new guidelines were adopted in July 2017. We split the participants in two groups: 361 (36%) women had commenced their AI prior to the adoption of guidelines and 640 (64%) were in the post implementation group.First group were offered bone active treatment based on NOS 2009 guidelines whereas the second group followed the 2017 consensus guidelines. Women with osteoporosis were all offered treatment, however the difference in guideline is pertinent to osteopenia and we compared the results of that group.Results1001 women were included. Mean age was 64 years (range 29-93). 929 (93%) were Caucasian, 57 (6%) were Asian and 15 (1%) were Afro-Caribbean. 723 women (72%) had invasive ductal carcinoma and 863 women (86%) were postmenopausal. At diagnosis, 428 women (43%) had node positive disease and 35 women (4%) had metastases. 91 women (9%) had sustained fractures prior to their cancer diagnosis.276 women (28%) were offered oral bisphosphonates based on DEXA result, with 58 (6%) offered parenteral therapy.First group: 361 women had a baseline DEXA with a mean left neck of femur (LNOF) BMD of 0.888 g/cm2 (range 0.552-1.222). 143 (40%) women had a normal DEXA, 174 (48%) had osteopenia and 44 (12%) had osteoporosis.Of the women with osteopenia, 44 (25%) women were offered treatment and 33 women had a repeat DEXA after a mean of 4 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.814 g/cm2 to 0.812 g/cm2 at the repeat DEXA (p= 0.94).Of the 174 women with osteopenia, 22 (13%) women had a fracture.Second group: 640 women had a baseline DEXA with a mean LNOF BMD of 0.888 g/cm2 (range 0.512-1.390). 216 (33%) women were normal, 322(50%) had osteopenia and 107 (17%) had osteoporosis.Of the women with osteopenia, 127 (39%) women were offered treatment and 56 women had a repeat DEXA after a mean of 3 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.822 g/cm2 to 0.829 g/cm2 at the repeat DEXA (p= 0.6169).Of the 322 women with osteopenia, 8 (2.5%) women had a fracture.ConclusionOur study provides real world evidence of the success of 2017 consensus statement in lowering fracture risk. Though there has been data for positive impact on BMD decline with this approach, evidence for fracture prevention has been limited. This study showcases the success of lowering bone active therapy threshold employing alternative risk modelling strategy for women with breast cancer commenced on AI. A significant reduction in fractures pre (13%) and post guidelines change (2.5%) was demonstrated (absolute risk reduction of 10.5%) which has implications for healthcare systems worldwide as we have demonstrated this approach can reduce morbidity.References[1]https://www.wcrf.org/dietandcancer/worldwide-cancer-data/. Accessed: 26.01.2022.[2]Reid DM, Doughty J, Eastell R, et al. Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group. Cancer Treat Rev. 2008;34 Suppl 1:S3-S18.[3]Hadji P, Aapro MS, Body JJ, et al. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol. 2017;7:1-12.Disclosure of InterestsNone declared
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Vaghaiwalla, Z., and G. Kaeley. "AB0618 GLUCOCORTICOID INDUCED OSTEOPOROSIS PREVENTION IN THE OUTPATIENT RHEUMATOLOGY CLINIC." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1343.2–1344. http://dx.doi.org/10.1136/annrheumdis-2021-eular.2583.
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Background:Patients with rheumatic disease are at risk of developing glucocorticoid induced osteoporosis (GIOP) as many are prescribed systemic oral glucocorticoids as an adjunct to their maintenance therapy. Based on the 2017 ACR Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis, a good practice recommendation exists that “initial clinical fracture risk assessment should be performed as soon as possible, but at least within six months of the initiation of long term glucocorticoid treatment.1” Long-term glucocorticoid use is defined by duration of 3 months or greater. Fracture risk assessment should include dual energy-ray absorptiometry (DEXA) scan. Patients on greater than or equal to 2.5 mg of prednisone should be treated with an optimal dose of calcium and vitamin D and may benefit from oral bisphosphonate as primary prevention against GIOP if their fracture risk is moderate to high.1Objectives:The aim of this Quality Improvement Project is to assess the current status of provider implementation of GIOP recommendations in the rheumatology clinic. Ultimate goal is to improve osteoporosis prevention in the rheumatology clinic.Methods:We conducted a retrospective chart review of 60 patients in two outpatient rheumatology clinics. Clinic 1 follows patients with lower socioeconomic status and Clinic 2 follows patients with higher socioeconomics. Inclusion criteria were patients on long-term glucocorticoid use, defined as at least 3 months of corticosteroid use of at least 2.5 mg prednisone daily, as well as age less than 65. Females aged 65 or older were omitted to prevent overlap of the United States Preventative Taskforce recommendation for all women ≥ 65 years to be screened for osteoporosis with DEXA scans.2 DEXA scan orders, calcium and vitamin D prescriptions, and osteoporosis medication prescriptions were abstracted. After baseline data obtained, intervention of education of the rheumatology fellows and faculty, and internal medicine residents in the guidelines for GIOP prevention was implemented. In addition, a smartphrase in the electronic medical record was created for provider use when treating patients on chronic corticosteroids. Subsequently, two audit cycles were completed for retrospective chart review.Results:Upon completion of second audit cycle, there was no change in percentage of DEXA scan orders at Clinic 1, however there was a 10% overall improvement in DEXA scan orders in the Clinic 2.In terms of Calcium and Vitamin D prescriptions, there was an overall improvement in both clinics of 19.7% and 13.3% in Clinics 1 and 2 respectfully after the second audit cycle.Additionally, there was a 3.4% increase in osteoporosis medication prescriptions overall subsequent to the second audit cycle in Clinic 1. However in Clinic 2 there was an overall decrease in osteoporosis medication prescriptions of 6.6%.Clinic 1Prior to AuditAudit cycle 1Audit cycle 2Patient percentage without DEXA scan orders30%33.30%30%Patient percentage without Vitamin D/Calcium orders26.40%8.30%6.70%Patient percentage with osteoporosis medication orders23.30%8.30%26.70%Clinic 2Patient percentage without DEXA scan orders50%37.00%40%Patient percentage without Vitamin D/Calcium orders30%26.00%16.70%Patient percentage with osteoporosis medication orders23.30%11.10%16.70%Conclusion:Overall, the results of the intervention were strongest for improvements in Vitamin D and Calcium orders in both clinics. Improvements in DEXA scan orders and osteoporosis medications were present in Clinic 2 and not present in Clinic 1. This reveals continued efforts and education of providers need to be made for improvement in bone health monitoring.References:[1]Buckley, Lenore, et al. “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.” Arthritis & Rheumatology, vol. 69, no. 8, June 2017, pp. 1521–1537., doi:10.1002/art.40137.[2]Final Recommendation Statement: Osteoporosis to Prevent Fractures: Screening. U.S. Preventive Services Task Force. July 2019.Disclosure of Interests:None declared.
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Smink, A., S. Bierma Zeinstra, J. Dekker, T. Vliet-Vlieland, J. Bijlsma, B. Swierstra, J. Kortland, T. Voorn, C. van den Ende, and H. Schers. "OP0201-PC Agreement of General Practitioners with the Guideline-Based Stepped-Care Strategy for Patients with Osteoarthritis of the Hip or Knee: A Cross-Sectional Study." Annals of the Rheumatic Diseases 72, Suppl 3 (June 2013): A120.2—A120. http://dx.doi.org/10.1136/annrheumdis-2013-eular.406.
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Ferrarini, A., D. Benfaremo, G. Rossetti, F. Morgese, C. Tonnini, R. Berardi, A. Gabrielli, and G. Pomponio. "AB1211 IMMUNE-RELATED ADVERSE EVENTS IN PATIENTS RECEIVING PD-1/PD-L1 INHIBITORS: PRELIMINARY RESULTS FROM A PROSPECTIVE COHORT STUDY." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 1896.1–1897. http://dx.doi.org/10.1136/annrheumdis-2020-eular.2850.
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Background:Recent introduction of immune checkpoint inhibitors (ICIs) revolutionized oncological guidelines. Immune-related adverse events (IrAEs) may occur in as many as 85% of patients (10% with toxicity grade 3/4), but detailed epidemiology of irAEs is still lacking, mostly because of data collection and analysis vary widely.Objectives:The purpose of our study is to establish a prospective cohort of patients treated with PD-1/PD-L1 inhibitors in order to determine incidence, risk factors and characteristics of irAEs in a real-world setting.Methods:We conducted a prospective cohort study enrolling patients receiving anti-PD-1/PD-L1 agents for the treatment of metastatic or locally advanced non-small cell lung cancer, renal cell carcinoma, squamous cell carcinoma of the head and neck, Hodgkin lymphoma. Detailed recommendations have been implemented for cases fulfilling criteria for suspected irAEs, including procedures for evaluation and diagnosis, specific treatments and rules for drug discontinuation. IrAEs have been defined and graded according to Common Terminology Criteria for Adverse Events vs 5.0. Management strategies have been adapted by a multidisciplinary panel, basing on the oncological guidelines, which represent the current best clinical practice. AEs screening, physical examination, ECG and clinical laboratory evaluation have been performed at baseline visit and follow up (4, 8, 12 weeks).Results:Fifty-two patients have been enrolled from Jan 2019 to Dec 2020. Characteristics are reported in the Table below. Twelve patients developed irAEs (23%), 6 treated with nivolumab, 4 with pembrolizumab, 1 with atezolizumab and 1 with durvalumab. Mild-to-moderate (G1-G2) irAEs were hepatitis, hypothyroidism, III-V-VII cranial nerve palsy, polymyalgia-like syndrome, skin psoriasis and type-1 diabetes mellitus. Severe cases (G3) of bullous dermatitis, Lichen Planus, interstitial pneumonia and myositis occurred. One patient developed three different irAEs. Median time of onset was 4.5 weeks. IrAEs were successfully treated according to established guideline, but 4 patients stopped anti-neoplastic therapy due to irAEs and 11 for disease progression. Five patients died.Conclusion:Cancer patients receiving PD-1/PD-L1 agents are being prospectively followed. Preliminary results confirm that 1/4 patients may develop irAEs. Innovative tools are required in order to manage irAEs, prevent potential relapse and avoid useless interruption of therapy. Further research needs to get insights into pathophysiological mechanisms and risk factors.References:[1]Arnaud-Coffin P. A systematic review of adverse events in randomized trials assessing immune checkpoint inhibitors. Int J Cancer. 2019; Champiat S, Lambotte O, Barreau E, et al. Management of immune checkpoint blockade dysimmune toxicities: a collaborative position paper. Annals of Oncology 27, 2016.CharacteristicsN = 52Age[years, median (range)]67 (31-92)Gender(F/M)17/35Cancer typeMelanoma12Renal cell carcinoma9Non-small-cell lung carcinoma Hodgkin29lymphoma1Head-neck cancer1AgentsNivolumab24Pembrolizumab16Atezolizumab8Durvalumab4irAEs12 pts (23%)*G14G26G34G40Drug discontinuation20 (39%)due to irAEs4due to disease progression11death5*one patient had more than one eventDisclosure of Interests:None declared
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Sander, C. "OP0021-PARE Patients Become Political - How to Support Patients' Involvement in Guideline Work Groups and the Joint Federal Committee of Physicians and Health Insurance Companies (G-BA)." Annals of the Rheumatic Diseases 73, Suppl 2 (June 2014): 67.3–68. http://dx.doi.org/10.1136/annrheumdis-2014-eular.4387.
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Peter, W. F., P. H. van der Wees, J. Verhoef, Z. de Jong, L. van Bodegom-Vos, W. K. Hilberdink, M. Fiocco, and T. P. VlietVlieland. "OP0077-HPR The effect of an interactive workshop on the adherence with the dutch physical therapy practice guideline for hip and knee osteoarthritis: A randomised controlled trial." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 79.2–79. http://dx.doi.org/10.1136/annrheumdis-2012-eular.1760.
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Verstappen, M., X. Matthijssen, and A. Van der Helm - van Mil. "AB0258 DMARD-TREATMENT OF UNDIFFERENTIATED ARTHRITIS INTENSIFIED DURING THE LAST DECENNIA, BUT DID NOT RESULT IN IMPROVED LONG TERM OUTCOMES." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1155.2–1155. http://dx.doi.org/10.1136/annrheumdis-2021-eular.1559.
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Background:EULAR guidelines stress timely initiation of DMARD-treatment in early arthritis patients also when classification criteria are not yet fulfilled. Consequently, undifferentiated arthritis (UA) patients may be increasingly treated with disease modifying antirheumatic drugs (DMARDs), despite inadequate placebo-controlled evidence for its effectivity. Implementation of this guideline also hampers future placebo-controlled trials in UA. However, historical data, with inclusion period as instrumental variable, can provide insight whether long term outcome is improved with increased DMARD-use, and thus serve to investigate if DMARD-treatment is effective in UA.Objectives:With 25-years of observational data of newly referred UA-patients, we studied whether enhanced treatment strategies resulted in better long term outcomes for UA.Methods:Between 1993 and 2019, 1132 consecutive UA-patients, not fulfilling the 1987/2010 criteria for RA or any other distinct diagnosis, were included in the Leiden Early Arthritis Cohort; patients were divided in 5 inclusion periods (1993-1998, 1999-2005, 2006-2010, 2011-2014, 2015-2019). Frequency of DMARD-initiation after diagnosis was compared. We studied the following outcomes: the course of disease activity scores (DAS28-CRP) and Health assessment questionnaires (HAQ), progression to RA after 1-year (according to the 1987 and/or 2010 criteria) and the frequency of prolonged DMARD-free status within 10-years of follow-up (this was defined as either spontaneous remission or sustained remission after discontinuation of DMARD-treatment).Results:The current population of UA-patients, thus not fulfilling 1987 or 2010 criteria, had rather mild disease: the median SJC was 1, the median TJC 2, 95% was autoantibody-negative and the median HAQ was 0.6. These characteristics were similar in the different inclusion periods. Initiation of DMARD-treatment in UA increased over time: 18%, 35%, 38%, 43% up to 55% in respectively 1993-1998, 1999-2005, 2006-2010, 2011-2014 and 2015-2019, in which methotrexate became more common in the last decade. Frequency of progression to RA after 1-year did not decrease and was 14%, 21%, 26%, 19% and 28% in the respective inclusion periods. Long-term DAS28CRP-scores improved from 2011 onwards (range -0.18, -0.24; p<0.05). However HAQ-score over time did not improve compared to the 1993-1998 period (range -0.00, -0.08; p>0.05). Also the percentages of patients in DMARD-free status after 10-years of follow-up did not significantly improve over time: 57%, 58%, 59% (for 1993-1998, 1999-2005, 2006-2010 respectively, p=0.59).Conclusion:Intensified DMARD-treatment of patients with UA did not result in improved outcomes. These data may indicate overtreatment of UA-patients. Yet, methods to stratify which UA-patients should be treated remains warranted.Disclosure of Interests:None declared
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Sekhon, M., A. De Thurah, G. E. Fragoulis, T. Stamm, T. P. M. Vliet Vlieland, B. A. Esbensen, H. Lempp, et al. "POS1552-HPR A SYNTHESIS OF GUIDANCE AVAILABLE FOR ASSESSING METHODOLOGICAL QUALITY AND GRADING OF EVIDENCE FROM QUALITATIVE RESEARCH TO INFORM CLINICAL RECOMMENDATIONS: A SYSTEMATIC REVIEW." Annals of the Rheumatic Diseases 81, Suppl 1 (May 23, 2022): 1120.2–1121. http://dx.doi.org/10.1136/annrheumdis-2022-eular.4614.
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BackgroundQualitative research is crucial to understand key stakeholders experiences and perspectives of care and health services. However, there is a lack of explicit frameworks and guidelines about how best to use qualitative evidence to formulate clinical recommendations. Part of the problem includes uncertainties about the contributions of qualitative research to the evidence, and the empirical and theoretical basis for appraising and synthesizing qualitative evidence in a standardized manner. In addition, most existing grading systems of qualitative research originates from quantitative research, and there is no clear guidance about how to incorporate qualitative research into the evidence hierarchy.ObjectivesTo conduct a systematic literature review (SLR) to answer two research questions (RQ):RQ1) What guidance (e.g., tools, checklists, frameworks) exists to assess the methodological quality of qualitative research employed to inform clinical recommendations?;RQ2) What methods exist specifically to grade levels of evidence for qualitative research?MethodsThe protocol for this review was registered on www.researchregistry.com (reviewregistry1240). Electronic databases (PubMed/Medline, EMBASE, Web of Science, COCHRANE, Emcare, PsycINFO, ERIC, Academic Search Premier, Sociological Abstracts, ProQuest Dissertations and Thesis Global) were searched for published and unpublished studies. Searches were completed from inception to 23rd October 2020. No restrictions were applied to clinical population. Eligible studies for both questions included primary articles and guideline documents available in English, describing the: i) development; ii) application of validated tools (e.g., checklists); iii) guidance on how to assess methodological quality of qualitive research and iv) guidance on how to grade levels of qualitative evidence. Opinion pieces and conference abstracts were excluded. Manual searches of the reference lists of full text articles were conducted. Two reviewers independently screened the titles, abstracts, and full text. A narrative synthesis was conducted to identify key aspects between the included studies.Results9071 records were retrieved (Figure 1). After de-duplication and title/abstract screening, 51 full-articles articles were assessed for eligibility yielding 15 included articles. For RQ1, six articles were included that described six tools (1) The society for Critical Care Medicine Family – Cantered Care Guidelines; 2) Nursing Management of the Second Stage of Labour evidence based clinical practice guidelines; 3) Jonna Briggs Institute Critical Appraisal of Qualitative Studies; 4) Critical Skill’s Appraisal Programme (CASP) and 6) the Modified CASP checklist). All tools ranged from 10 to 30 items, and evaluated research design, recruitment, ethical rigour, data collection and data analysis. Seven articles described one approach (GRADE CER-Qual) to assess methodological quality of qualitative research. This approach advised on the importance for assessing methodological limitations. For RQ2, two articles were included, one described a qualitative hierarchy of evidence, and another described a research pyramid that included a section on qualitative research.Figure 1.PRISMA diagram of included papersConclusionThis review highlights lack of consensus and limited availability of tools, checklists, and approaches to 1) appraise the methodological quality of qualitative research used to inform clinical recommendations and 2) grade levels of evidence for qualitative research. Current research agendas will need to determine the most relevant and appropriate method for the quality appraisal of qualitative research. This way, qualitative research could be more consistently and appropriately applied to the development of clinical recommendations.ReferencesN/ADisclosure of InterestsMandeep Sekhon: None declared, Annette de Thurah: None declared, George E. Fragoulis: None declared, Tanja Stamm: None declared, T.P.M. Vliet Vlieland: None declared, Bente Appel Esbensen: None declared, Heidi Lempp: None declared, Lindsay Bearne: None declared, Marios Kouloumas: None declared, Polina Pchelnikova: None declared, Thijs W. Swinnen: None declared, Chris Blunt: None declared, Ricardo J. O. Ferreira: None declared, Loreto Carmona: None declared, Elena Nikiphorou Speakers bureau: Celltrion, Pfizer, Sanofi, Gilead, Galapgos, AbbVie, Eli Lilly, Grant/research support from: Pfizer, Eli Lilly
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Ogdie, A., A. Gustafson, A. Lieberman, J. Mason, A. Armstrong, N. Mehta, R. Beidas, and J. Gelfand. "POS1063 RHEUMATOLOGIST AND PATIENT PERSPECTIVES ON IMPLEMENTING CARDIOVASCULAR RISK PREVENTION IN THE MANAGEMENT OF PSORIASIS: A QUALITATIVE STUDY." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 810.2–810. http://dx.doi.org/10.1136/annrheumdis-2021-eular.902.
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Background:Psoriatic arthritis (PsA) is an immune-mediated musculoskeletal disease associated with excess risk for cardiovascular disease (CVD). New US-based guidelines recognize psoriasis as a CVD risk enhancer; however, patients with PsA often do not have CVD risk factors identified nor managed.Objectives:This study examines strategies to improve CVD prevention care from the perspective of rheumatologists and patients with PsA.Methods:Semi-structured qualitative interviews were conducted using an interview guide based on the Consolidated Framework for Implementation Research to examine the perspectives of rheumatologists (N = 8) and patients with psoriatic arthritis managed by rheumatologists (N = 8) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity facilitated by NVivo software.Results:Most rheumatologists confirmed that they were not regularly engaging in CVD prevention care with psoriatic arthritis patients. Providers reported sometimes counseling and screening for CVD risk, but they were not regularly prescribing statins and not as willing to do so. Reasons included a lack of familiarity or comfort with guidelines, concern about working outside of their scope of practice, confusing boundaries between other clinicians, and time constraints. Most patients confirmed that it was uncommon for their rheumatologists to engage them in CVD prevention care but expressed desire for their rheumatologists inform them of the risk, and were open to CVD prevention care from them.Conclusion:We identified several potentially modifiable barriers to CVD screening and management. These findings will inform the design of a clinical trial comparing the effectiveness of rheumatologist implementation of CVD guideline-based counseling, screening and prescribing statins when appropriate in patients with PsA.Figure 1.Barriers to CVD screening and management among patients with PsA in a rheumatology practice setting and potential strategies to address those barriers. Abbreviations: CV = cardiovascular; SOC = standard of care.Disclosure of Interests:Alexis Ogdie Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Pfizer to Penn, Novartis to Penn, Amgen to Forward/NDB, Alix Gustafson: None declared, Adina Lieberman: None declared, Jennifer Mason: None declared, April Armstrong: None declared, Nehal Mehta Consultant of: Amgen, Eli Lilly, and Leo Pharma receiving grants/other payments, Grant/research support from: AbbVie, Celgene, Janssen Pharmaceuticals, Inc, and Novartis receiving grants and/or research funding and as a principal investigator for the National Institute of Health receiving grants and/or research funding., Employee of: NNM is a full-time US government employee, Rinad Beidas Consultant of: Camden Coalition of Healthcare Providers in the past 3 years. She currently is a consultant for United Behavioral Health. She serves on the Optum Behavioral Health Clinical and Scientific Advisory Council. Dr. Beidas receives royalties from Oxford University Press., Joel Gelfand Shareholder of: Dr Gelfand is a co-patent holder of resiquimod for treatment of cutaneous T-cell lymphoma, and he is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology., Paid instructor for: CME work related to psoriasis that was supported indirectly by Eli Lilly and Company and Ortho Dermatologics, Consultant of: Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Janssen Biologics, Novartis Corp, UCB (Data Safety and Monitoring Board), Sanofi, and Pfizer Inc, Grant/research support from: research grants (to the Trustees of the University of Pennsylvania) from AbbVie, Janssen, Novartis Corp, Celgene, OrthoDermatologics, and Pfizer Inc.
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Andel, P., S. Brådland, and G. Haugeberg. "AB0785 TREATING IDIOPATHIC RECURRENT PERICARDITIS WITH INTERLEUKIN-1 INHIBITORS - A SINGLE CENTER EXPERIENCE." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 1418.1–1418. http://dx.doi.org/10.1136/annrheumdis-2021-eular.4037.
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Background:Pericarditis is a common disease with significant morbidity (1). Idiopathic pericarditis, where an underlying cause cannot be identified, makes up for 80% of cases in the Western World (1). Up to 30% of these patients experience recurrence despite optimal treatment (2). Idiopathic recurrent pericarditis (IRP) is thought to represent an auto-inflammatory process rather than a reinfection (3). 2015 European Society of Cardiology (ESC) guidelines have outlined treatment of acute episodes and first recurrence with nonsteroidal anti-inflammatory drugs (NSAID), acetyl salicylic acid (ASS) and Colchicine as first line and Glucocorticoids (GC) as second line treatment (3). However GC treatment increases the risk of relapse, dependence and toxicity (2). Interleukin-1 (IL-1) inhibitors have been proposed as possible treatments in IRP (3, 4).Objectives:The aim of this case study is to outline our first experiences treating IRP with the IL-1 inhibitor anakinra in our Rheumatologic clinic.Methods:All patients referred to our department in 2018/2019 with pericarditis were physically seen in our outpatient clinic. All patients were screened for malignancy, infection or rheumatologic disease as possible cause by clinical measures. Following ESC guideline, patients who suffered either the third recurrence under optimal treatment or significant side effects or dependency from GC were considered for anakinra treatment. Daily injection of anakinra (100mg) were given continuously over at least three months with gradual tapering over at least three months afterwards. Physical emergency department contacts, days hospitalized, colchicine- and GC use, the year prior to Anakinra treatment was recorded retrospectively. During follow up the same data was prospectively recorded.Results:Over the course of two years 20 patients were referred to our clinic. All fulfilled ESC diagnostic criteria for pericarditis at index episode. In none of the patients could a rheumatologic, infectious or malignant cause be identified. 16 patients could be treated according to 2015 ESC guidelines with first or second line agents. Four patients were aligned to anakinra-treatment. Prior to referral, duration of symptoms was 5 - 120 months (mean 61 months). Further relevant patient- characteristics are outlined in Table 1.After initiation of anakinra patients were afterwards regularly followed up in scheduled visits every 3 months.Table 1.Characteristics of the four patients aligned to anakinra prior to anakinra-initiation.PatientNumber of recurrencesNumber emergency hospital contacts related to IRP the year prior to nakinraDays hospitalized related to IRP the year prior to anakinraGC dose prior to anakinraotherI2237.5 mgsteroidglaucomaII72410 mgIII472220 mgIV731220 mgFollow-up after start of anakinra was 6-15 months (mean 11.5 months). No patient was admitted to hospital or emergency department in that period. All four patients could taper and stop GC without recurrence. One patient experienced a mild relapse after discontinuing anakinra and was restarted on a low dose with complete remission. No patient had elevated CRP values at the end of follow-up and no patient experienced tamponade or clinical signs of constriction. No significant side effects were noted, no patient had to stop anakinra-treatment during follow up.Conclusion:Implementation of anakinra treatment in cases of complicated IRP was both secure and successful in our rheumatologic outpatient department. In our small sample we could confirm findings from bigger trials regarding effect- and side effect rates of anakinra treating IRP.References:[1]Klein A et al. Cardiol Rev. 2020 Epub ahead of print. PMID: 32956167.[2]Cremer P et al. J Am Coll Cardiol. 2016;68(21):2311-2328[3]Adler Y et alEuropean Heart Journal, 2015;36(42):2873–2885[4]Imazio M et al Eur J Prev Cardiol. 2020;27(9):956-964Disclosure of Interests:None declared
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Moon, K. W. "THU0106 PREDICTORS OF FLARE IN RHEUMATOID ARTHRITIS PATIENTS WITH LOW DISEASE ACTIVITY." Annals of the Rheumatic Diseases 79, Suppl 1 (June 2020): 267.1–267. http://dx.doi.org/10.1136/annrheumdis-2020-eular.5202.
Full textAbstract:
Background:Low disease activity (LDA) in patients with rheumatoid arthritis (RA) are usually recognized as stable state. In according to most guidelines for RA, monotherapy of disease modifying anti-rheumatic drug (DAMRD) was recommended for RA patents with LDA. But some of patients with LDA suffer from flare in their disease course. Until now, we don’t have enough data on factors that can predict flare in RA patients with LDA.Objectives:The aim of this study is to evaluate predictor of flare in RA patient with LDA from long-term (3 year) cohort data.Methods:Korean observational study network for arthritis (KORONA) registry is a nationwide Korean RA specific cohort registry that collecting data annually from 5,376 RA patients in 23 centers across South Korea. We include the data from 1, 801 RA patients with LDA (28 –joint disease activity score (DAS 28) < 3.2 at enrollment) who had consecutive data of DAS28 for 3 years. Flare was defined as an increase in DAS28 compared with baseline of >1.2 or >0.6 if concurrent DAS28 ≥3.2. Cox regression analysis was used to identify baseline predictors of flare.Results:Among 1,801 RA patients, 673 patients (37.4%) experienced flare in 3 years. When we compare the baseline characteristics of both flare and non-flare group, more women and more non-adherent patients for medication were observed in flare group. Flare group had longer disease duration, lower EuroQol 5D score, higher health assessment questionnaire (HAQ) score, and higher erythrocyte sedimentation rate (ESR) than non-flare group at baseline. In multivariate analysis, physician’s VAS, HAQ score, ESR, and poor adherence for medication were significant predictors of flare (Table 1).Table 1.Multivariate analysis of prediction of flare with baseline variablesMeasureHazard ratio95% Confidence IntervalP-valueFemale1.1300.906-1.4090.280Age0.9960.988-1.0050.414Physician’s VAS1.0081.002-1.013<0.01Pain VAS1.0020.998-1.0060.34EQ5D0.9520.534-1.6960.87HAQ1.4071.109-1.786<0.01ESR1.0081.002-1.014<0.01Poor adherence1.2721.047-1.545<0.05VAS: Visual Analogue Scale; EQ5D: EuroQol 5D; HAQ: Health Assessment Questionnaire; ESR: Erythrocyte Sedimentation RateConclusion:RA patient who have risk factors for flare, even though their disease activity was low, require more proactive treatment.References:[1]Bechman K, Tweehuysen L, Garrood T, Scott DL, Cope AP, Galloway JB, et al. Flares in Rheumatoid Arthritis Patients with Low Disease Activity: Predictability and Association with Worse Clinical Outcomes. J Rheumatol. 2018;45(11):1515-21.[2]Singh JA, Saag KG, Bridges SL, Jr., Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016;68(1):1-26.[3]Sung YK, Cho SK, Choi CB, Park SY, Shim J, Ahn JK, et al. Korean Observational Study Network for Arthritis (KORONA): establishment of a prospective multicenter cohort for rheumatoid arthritis in South Korea. Semin Arthritis Rheum. 2012;41(6):745-51.Disclosure of Interests:None declared