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Background:There is considerable interest within the medical research community in the identification of individuals at risk of developing rheumatoid arthritis (RA), to identify those who may benefit from preventive interventions. However, it is important to understand the views of those who may be candidates for such predictive tests, to inform the development of effective approaches. First degree relatives (FDRs) of patients with RA are at an increased risk of developing RA. RA patients can provide access to FDRs. Qualitative investigations have explored the views of these groups about predictive testing for RA1,2, but quantitative approaches are needed to develop a robust understanding.Objectives:To identify predictors of interest in predictive testing for FDRs and patients, and to assess the likelihood of patients communicating information about RA risk to their FDRs.Methods:Surveys were completed by 482 RA patients and 397 of their FDRs. Patients were invited to complete the survey and to provide another to their relatives. Spearman’s Rank Correlations were used to assess relationships between interest in predictive testing/ likelihood of risk communication and potential predictor variables.Results:FDRs had a median age of 41 years, 64% were female. 57% were definitely interested and 36% were probably interested in taking a predictive test for RA. Several predictors were found to be associated with interest (table 1).Table 1.Spearman’s correlations for relatives’ and patients’ interest in predictive testing. After applying a Bonferonni adjustment, p values were taken as statistically significant at p≤0.003.FDRsPatientsPredictors of interest in predictive testingrsPrsPBrief Illness Perception Questionnaire0.110.030.090.05 Consequences0.16*0.002*0.100.03 Timeline0.090.07-0.050.28 Personal control-0.030.59-0.020.68 Treatment control-0.020.760.020.74 Identity0.090.090.120.01 Concern0.21*0.16* Coherence0.110.030.0070.88 Emotional0.120.020.110.02Information Seeking0.35*0.22*Decision making-0.050.330.070.13Health literacy0.030.520.020.62Health numeracy-0.060.23-0.020.72Brief Avoidance Coping Questionnaire0.120.02-0.010.76Optimism0.060.26-0.070.12Health anxiety0.16*0.001*--Perceived risk0.37*--Rheumatoid Arthritis Impact of Disease--0.050.31– not applicablePatients had a median age of 65 years, 71% were female. 47% were definitely interested and 30% were probably interested in their children taking a predictive test. Several predictors were found to be associated with interest (table 1). On a Likert scale from extremely unlikely (0) to extremely likely (4), most patients indicated that they were likely to communicate RA risk information to their children (median score=3).Conclusion:Interest in predictive testing for RA was high amongst FDRs, and factors including information seeking preference, RA risk perception, concern about RA, perceived consequences of RA and health anxiety were significantly associated with interest. Patients were also willing to communicate information about RA risk to their children. These findings increase understanding of perceptual variation in those at risk of RA, and will inform the development of information to support decision making in individuals considering predictive tests and preventive interventions. We are currently extending this preliminary analysis by building multivariate models incorporating a range of attitudes about predictive testing, assessing predictors of patients’ likelihood of communicating to their FDRs about risk, and the relationship between patients’ and FDRs’ responses.References:[1]Stack RJ et al. BMJ open. 2016; 6(6):e010555.[2]Falahee M et al. Arthritis care & research. 2017; 69(10):1558-65.Acknowledgments:This work was supported by Versus Arthritis; Grant reference: 21560.Disclosure of Interests:Imogen Wells: None declared, Gwenda Simons: None declared, Rebecca Stack: None declared, Christian Mallen Grant/research support from: My department has received financial grants from BMS for a cardiology trial., Peter Nightingale: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, M. Falahee: None declared

A systematic review of qualitative peer-reviewed publications was conducted to identify drivers of and barriers to help-seeking behaviour in adults with new-onset rheumatoid arthritis (RA). 1058 abstracts were searched to identify relevant publications. 21 relevant publications were identified assessed for quality and subjected to analysis informed by thematic and grounded theory frameworks. Several interacting themes were identified including the early experience of symptoms in relation to disease prototypes, minimising the impact of symptoms, speaking to others, gathering information and seeking alternative treatments, and issues related to accessing health services and attitudes towards healthcare professionals. Many people suggested that they had little knowledge of RA before diagnosis, believing RA to be a mild condition that affected older people. These misperceptions made correct symptom interpretation unlikely. Normalising and ignoring symptoms led people to delay in help-seeking. However, when symptoms impacted on daily activities help was usually sought. Individual interpretations of symptoms are both drivers of and barriers to help seeking. Targeted public health interventions are required to inform symptom interpretation and reduce delays.

Background A range of clinical symptoms can be present in people at risk of rheumatoid arthritis (RA). However, information on location, timing, severity and predictive value of symptoms is still largely lacking. The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire has been developed with support of EULAR to provide more insight into these symptoms 1,2 . Objectives To validate the SPARRA questionnaire in an international group of arthralgia patients at risk of RA. Methods Questions on presence, severity, impact and location of 13 symptoms were derived from a qualitative study in seropositive arthralgia patients 1 . The items are: joint pain or swelling, joint stiffness, burning and tingling sensations, numbness, change in skin colour, muscle cramps, weakness, fatigue, emotional distress, concentration difficulties and sleep problems. Answers are given on an ordinal scale. The number of days with a symptom per month (0, 1–5, 6–15, 16–30 days), severity (none, mild, moderate and severe) and influence on daily activities (no, small, moderate or high impact) were recorded. Finally, patients were asked to describe the pattern of symptom development over time. For this initial analysis of validity, patients were selected from the Dutch arthralgia cohort. We first administered the questionnaire to 30 patients to ask for ambiguities. Thereafter, 46 patients did a test-retest within one week to assess intra-rater agreement using the % agreement and the kappa score. Results Feedback on the questionnaire was received from 5/30 patients. There were only minor comments that did not lead to adaptations, such as difficulty distinguishing pain from stiffness (n=1) and difficulty describing muscle cramps (n=1). 46 arthralgia patients were assessed at 2 time points. The rater agreement was moderate to good for most items with kappa9s of 0.42 to 0.93. We also found acceptable percentages of agreement of 65 to 91 (Table 1). Only tingling sensations and numbness scored low in agreement, with kappa9s of 0.37 and 0.15, respectively. The kappa9s were good across the presence, severity and impact of the item categories. Data on clinical variables and follow-up questionnaires to assess the construct and criterion validity will be presented at the congress. Conclusions The SPARRA questionnaire seems to be a reliable scale for evaluating symptoms in persons at risk for RA. More follow-up and data from collaborating centers within Europe is necessary for assessment of the construct, criterion and external validity. References Stack, Rheumatology 2014; van Tuyl, Musculoskel Care 2015 Disclosure of Interest None declared

Background Persons at risk of rheumatoid arthritis (RA) may experience a variety of symptoms 1,2 . However, information on location, timing, severity and predictive value of these symptoms is largely lacking. The Symptoms in Persons At Risk of Rheumatoid Arthritis (SPARRA) questionnaire has been developed with support of EULAR to provide more insight into these symptoms. Objectives Report the symptoms and symptom complexes using the SPARRA questionnaire in an international group of arthralgia patients at risk of developing RA. Methods The SPARRA questionnaire contains questions on presence, severity, impact and location of 13 symptoms derived from a qualitative study in seropositive arthralgia patients 1 . The items are: joint pain or swelling, joint stiffness, burning and tingling sensations, numbness, changes in skin colour, muscle cramps, weakness, fatigue, emotional distress, concentration difficulties and sleep problems. Answers are given on an ordinal scale. If present, number of days with a symptom per month (0, 1–5, 6–15, 16–30 days), severity (none, mild, moderate and severe) and influence (no, small, moderate or high impact) were recorded. Secondly, we recorded the location of joint pain. Finally, patients were asked to describe the pattern of symptom development over time. Patients were included in the Netherlands (N=68), United Kingdom (N=16), Sweden (N=15), Austria (N=11) and Switzerland (N=21). Validation of the questionnaire is ongoing. Results Of 131 arthralgia patients included, 85 were positive for anti-citrullinated protein antibodies (ACPA), 29 were positive for rheumatoid factor only, and 17 were seronegative with clinically suspect arthralgia. Most symptoms were present in a high percentage of patients, with pain as the most often experienced symptom and change of skin color rarely reported. When a symptom was present, it was usually experienced as moderate to severe, and with moderate impact by half of the patients (Table 1). The mean presence of symptoms was similar in the ACPA positive and negative groups, however, ACPA positive patients more often had severe symptoms (mean 61% versus 54%, NS) with higher impact (48% versus 41%, NS). Joint pain was most frequently located in the fingers. The most frequently reported pattern of symptoms was “coming and going, but always present” (32%). Conclusions The first results of the SPARRA questionnaire show multiple symptoms to be present in a high percentage of persons at risk for RA. These are often experienced as severe, with a high impact. References Stack, Rheumatology 2014; van Tuyl, Musculoskel Care 2015 Disclosure of Interest None declared

Background Early treatment of rheumatoid arthritis (RA) is associated with improved clinical outcomes. There is a growing research interest in the identification of biomarkers to predict the development of RA in order to facilitate early treatment and preventive interventions. First degree relatives of individuals with a diagnosis of RA are at an increased risk of developing RA and are therefore likely candidates for predictive/preventive approaches. However access to this group is currently dependent on the cooperation of existing RA patients. Objectives To understand patients9 perceptions of risk and predictive testing for RA, and their likelihood of communicating with their relatives about the risk of developing RA in the future. Methods Twenty-one RA patients (15 females and 6 males; aged 35 – 80 years) took part in semi-structured interviews. The interviews explored perceptions of risk of RA, family communication about risk, predictive testing, and risk reduction strategies. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Results Many patients were aware of genetic risk factors for RA and identified one or more relatives who they felt were at risk of developing RA in the future. Some patients described feelings of responsibility or guilt for their relatives9 increased risk of developing RA. Environmental risk factors such as infection and psychosocial stress were also suggested, though few patients mentioned that smoking is associated with an elevated risk of RA. Patients described a lack of public awareness about RA and the causes of RA. They also referred to a lack of understanding, by their relatives as well as by the general public, of the negative impact that this condition has on their quality of life. Many patients held positive views of predictive testing for RA and were of the opinion that prediction would typically be associated with timely and positive preventive intervention. Those with negative views attributed these to their uncertainty about the accuracy of predictive tests, the availability of approaches (including therapeutic ones) to reduce RA risk and the potential for risk knowledge to cause unnecessary worry. Patients generally expressed willingness to communicate with their relatives about their risk of RA. However many patients identified relatives that they were not in contact with, or communicated with infrequently. Some mentioned that they would not pass on information to particular relatives who they did not get on with. Patients referred to choosing which relatives to communicate with, and described likely variation amongst relatives in their receptivity to risk information, and their likelihood of acting on such information. Reasons suggested for this included relatives being too busy, being in denial of their susceptibility, preferring to deal with things when they happen, being likely to worry, and feeling that RA is not serious enough to warrant action. Conclusions Accurate information about risk factors for RA, and the potential impact of RA on quality of life, is needed to support family communication about RA risk. Strategies for the management of RA that target relatives of existing patients need to take into account that communication of risk information via patients is likely to be restricted and/or selective. Disclosure of Interest None declared

Background Rheumatoid arthritis (RA) requires treatment in its earliest stages in order to reduce the likelihood of permanent joint damage and disability. However, this therapeutic window is often missed as a result of delayed help-seeking by patients. In order to understand symptom recognition by members of the general public in the context of RA, we conducted two studies which compared symptom recognition and its effect on help-seeking for RA symptoms with symptom recognition in the context of angina and bowel cancer. Objectives To investigate the role of symptom recognition in the decision to seek appropriate and timely medical attention for RA and other illnesses. Methods We conducted a qualitative interview study with 31 individuals and a postal survey of 1088 members of the general public. Both studies used vignettes developed specifically for this study describing the symptoms of RA, bowel cancer and angina. In the case of RA one vignette described joint pain and stiffness in hands and wrists; one had joint swelling as an additional feature and we included a variation with symptoms in feet and ankles instead of hands and wrists. For each vignette, participants made causal attributions and rated the seriousness of the symptoms and the urgency with which they would seek medical attention. Results Participants were less likely to recognise the symptoms of RA than those of other conditions. This effect was more pronounced when the symptoms did not include joint swelling. In contrast, the symptoms of bowel cancer and angina were more readily recognised and were considered to be more serious than those of RA. Survey respondents rated bowel cancer and angina symptoms to be significantly more serious than any of the given combinations of RA symptoms ( Z values of 16.3 to 25.3, all p Conclusions Accurate symptom attribution and the perception that symptoms are indicative of a serious underlying condition are both important drivers for rapid help seeking. In the case of angina and bowel cancer, recent public health campaigns have promoted not only symptom recognition and seriousness, but have also emphasised the consequences of not seeking timely help. Our results suggest that these consequences should also be addressed in any public health campaign for RA. Acknowledgement This research is supported by The Dunhill Medical Trust (grant number R226/1111). The authors would also like to thank the interviewees, survey respondents and the patient research partners who have been involved in the development of the research. Disclosure of Interest None declared

Background Understanding the persistence of biologic treatment in different ethnic groups is important for efficient healthcare delivery. We previously reported that patients with Rheumatoid Arthritis (RA) from South Asian background had high level of side effect concerns about conventional DMARDs (cDMARDs) compared with patients of White British origin. These concerns may have an impact on treatment persistence; however, there is little data on biologic DMARDs (bDMARDs) treatment persistence among different ethnic groups. Objectives To investigate biologic DMARDs treatment persistence and reasons for switching among patients with RA from South Asian and White British background. Methods This service evaluation project identified 336 patients with active RA diagnosed by Consultant Rheumatologists at the Sandwell and West Birmingham Hospitals NHS Trust, UK. All patients were commenced on bDMARDs according to NICE guidelines between May 2001 and August 2013. Frequency of loss of efficacy, number of bDMARDs switches and treatment duration for each bDMARD, were compared between South Asian and White British patients. Loss of efficacy was defined as a drop of DAS-28 score ≤1.2 after at least three months of therapy, or by loss of efficacy in the opinion of the treating physician. Results The sample included 77 (23%) South Asian and 259 (77%) White British patients with active RA commencing bDMARDs therapy. The frequency of side effects was similar in both groups. Loss of efficacy was more common among South Asian compared with White British patients (65.6% vs. 52.2%; p=0.03). Regarding the number of biologic DMARDs switches, South Asian patients switched bDMARDs more frequently compared to their White British counterparts (South Asian vs White British; one switch: 24.7% vs 21.6%; two switches: 19.5% vs 15.8%; ≥3 switches 13.0% vs 5.8%; p=0.01). The first biologic drug survival times of infliximab and adalimumab were significantly longer in the White British group compared to the South Asian group (South Asian vs. White British; median time on infliximab: 10 months vs. 26 months; p=0.032, median time on adalimumab; 9 months vs. undefined p=0.006; proportion of South Asian vs. White British group on adalimumab after 60 months; 27.3% vs. 57.4%). There were no significant differences in the first biologic drug survival times of etanercept and certolizumab between the two groups (White British vs. South Asian median time on etanercept: 50 months vs. 55 months; p=0.593; median time on certolizumab: 25 months vs. 13 months, p=0.860). There was no significant difference in the DAS28 score between the two groups after three months of biologic therapy [South Asian vs White British, median (IQR); 5.2 (4.2-6.1) vs 4.8 (3.4-6.0)]. Conclusions Our data indicates that there are ethnic differences in the persistence of bDMARDs among patients with RA. This has clinical implications when determining the choice of biologic therapy for patients from different ethnic backgrounds. Disclosure of Interest K. Kumar: None declared, I. Sahbudin: None declared, A. Filer Grant/research support from: Pfizer, C. D. Buckley: None declared, K. Raza Speakers bureau: K Raza has received honoraria from Pfizer, AbbVie and BMS., R. Stack: None declared, P. Nightingale: None declared, A. Deeming: None declared, D. Situnayake: None declared, P. de Pablo: None declared

Background To achieve better prediction of the development of rheumatoid arthritis (RA) a EULAR study group recommended identification and assessment of symptoms in those with arthralgia and during the earliest phases of clinical arthritis as a research priority. Objectives The aim of this study was to explore early symptom experiences in individuals with arthralgia at risk of RA and in individuals with new onset RA. Methods Focus groups with fifteen arthralgia patients (positive anti-CCP) and in-depth interviews with eleven newly presenting RA patients (2010 criteria) were conducted. An active feedback procedure was used to share experiences of arthralgia patients with early RA patients and vice versa. When saturation was reached transcripts were analysed using thematic analysis and major themes were identified. The analyses were merged to explore similarities and differences in themes between groups. Results Themes common to arthralgia and early RA patients included: pain (described in the joints and also in muscles and tendons); tingling sensations; loss of strength and weakness; fatigue and sleeping difficulties; self-reported swelling, redness and warmth; joint stiffness and intermittent symptoms. However, some differences were noted. Arthralgia patients described pain that was often concentrated in their hands and feet as bothersome and annoying. Early RA patients described pain that had intensified to excruciating levels before diagnosis; in some cases pain was likened to a broken bone. Arthralgia patients reported short episodes of intermittent swelling which often involved feelings of pain and fatigue. RA patients recalled that changes in their experience of swelling marked a significant change in the course of their illness, with the nature and pattern of swelling (such as intensification, development of symmetry, translocation) changing shortly before being diagnosed. Such changes were reported to be triggers for patient consultation and physician referral. Fatigue and sleeping difficulties were a dominant problem for arthralgia patients, they noted intense and troubling pain at night. RA patients also reported that night pain was one of the first symptoms they recalled. Conclusions Understanding the features and patterns of symptoms characterising the earliest stages of RA is important if patients are to be identified and started on treatment early. Arthralgia and early RA patients shared symptoms which characterised the onset of disease, however, this detailed exploration of symptoms highlighted how the intensity (e.g. pain), and the pattern (e.g. changes in the pattern of swelling) differ between the two groups. Further research to develop measures of symptom patterns and clusters which occur in arthralgia patients and may signal the emergence of RA is required. This research should be followed by quantitative explorations of symptom clusters and their associated features. Disclosure of Interest None Declared