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Background: Managing rheumatic disease activity using pregnancy-compatible medications is essential for reducing adverse maternal and fetal outcomes. We characterized medication use and discontinuation before, during, and after pregnancy, among female patients with rheumatic diseases attending a targeted pregnancy and rheumatic diseases clinic., Methods: We conducted a cross-sectional medical record review of female patients with rheumatic diseases at a Canadian clinic between January 2017 and July 2020. Patients were categorized by pregnancy stage at their latest clinic visit: (1) preconception; (2) pregnant; (3) postpartum. We assessed use of conventional, biologic, and targeted synthetic disease-modifying antirheumatic drugs (DMARDs), prednisone, and nonsteroidal anti-inflammatory drugs across 6 perinatal windows: 24 and 12 months preconception, each pregnancy trimester, and 3 months postpartum. We reported adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for medication discontinuation in the first trimester and subsequent disease flare., Results: Of 230 included patients, 85 (37.0%), 12 (5.2%), and 133 (57.8%) were preconception, pregnant, and postpartum, respectively. Approximately half experienced at least 1 disease flare during each pregnancy stage (56.4% preconception, 58.1% during pregnancy, and 53.7% postpartum). Most used at least 1 DMARD throughout the perinatal period (82.6% preconception, 55.6% during pregnancy, and 45.1% postpartum). Overall, 25.5% discontinued at least 1 DMARD in the first trimester. DMARD discontinuation was associated with disease flare during pregnancy (aOR, 1.49; 95% CI, 0.55-4.03; p = 0.87) and postpartum (aOR, 3.09; 95% CI, 0.83-11.47; p = 0.09)., Conclusions: Patients receiving care at a pregnancy and rheumatic disease clinic show perinatal medication use patterns consistent with recent recommendations and clinical guidelines., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Osteoporotic fractures are an important cause of morbidity in children with glucocorticoid-treated rheumatic disorders., Objective: This work aims to evaluate the incidence and predictors of osteoporotic fractures and potential for recovery over six years following glucocorticoid (GC) initiation in children with rheumatic disorders., Methods: Children with GC-treated rheumatic disorders were evaluated through a prospective inception cohort study led by the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium. Clinical outcomes included lumbar spine bone mineral density (LS BMD), vertebral fractures (VF), non-VF, and vertebral body reshaping., Results: A total of 136 children with GC-treated rheumatic disorders were enrolled (mean age 9.9 years, SD 4.4). The 6-year cumulative fracture incidence was 16.3% for VF, and 10.1% for non-VF. GC exposure was highest in the first 6 months, and 24 of 38 VF (63%) occurred in the first 2 years. Following VF, 16 of 19 children (84%) had complete vertebral body reshaping. Increases in disease activity and body mass index z scores in the first year and declines in LS BMD z scores in the first 6 months predicted incident VF over the 6 years, while higher average daily GC doses predicted both incident VF and non-VF. LS BMD z scores were lowest at 6 months (mean -0.9, SD 1.2) and remained low by 6 years even when adjusted for height z scores (-0.6, SD 0.9)., Conclusion: VF occurred early and were more common than non-VF in children with GC-treated rheumatic disorders. Eighty-four percent of children with VF underwent complete vertebral body reshaping, whereas vertebral deformity persisted in the remainder of children. On average, LS BMD z scores remained low at 6 years, consistent with incomplete recovery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The purpose of this systematic review was to identify existing guidelines for antimalarial prescribing and monitoring, specifically for hydroxychloroquine, and how these guidelines compare and have evolved over time., Methods: A literature search was conducted using Embase and Medline to identify guidelines published from 1946-2018. MeSH terms were used and alternative spelling and related words were entered as keywords to broaden results., Results: 243 results were reviewed to obtain 11 recommendations. Ophthalmology sources included the American Academy of Ophthalmology, Royal College of Ophthalmologists and Canadian editorials. The American College of Rheumatology and Canadian Rheumatology Association consensus statements summarised rheumatology recommendations. Recently, American and British guidelines changed from suggesting hydroxychloroquine doses ≤6.5 mg/kg/day to ≤5 mg/kg/day. American guidelines recommended baseline visual field (VF) testing and annual screening after five years. Visual field (VF) testing evolved from the Amsler grid to current recommendations of 10-2 automated VF and spectral-domain optical coherence tomography (SD-OCT). The 2012 Canadian recommendations suggested initial VF testing every two years, with SD-OCT after 10 years. Older British guidelines advocated for baseline and annual assessment with Amsler grids during rheumatology clinic visits. The 2018 British guidelines supported baseline and annual screening after five years with 10-2 VF, SD-OCT and fundus autofluorescence., Conclusions: The newest recommendations are heterogeneous suggesting lower hydroxychloroquine dosing. Retinal toxicity is irreversible and the risk increases over time. Annual screening after five years with automated VF and SD-OCT may be warranted to detect early changes and discontinue therapy if necessary.

In 2018, TNFα inhibitors were the highest cost drug class for Canadian public drug programs. In 2019, two Canadian provinces announced mandatory nonmedical switching policies in an attempt to reduce their costs by increasing biosimilar uptake. The national impact of similar policies across Canada is unknown. We conducted a cross-sectional analysis of monthly publicly funded prescription claims for infliximab, etanercept, and adalimumab between June 2015 and December 2019. We reported the market share of biosimilars for infliximab and etanercept in 2019 for each province and estimated the cost savings that public payers could have realized in 2019 if mandatory switching policies had been implemented across Canada, including a sensitivity analysis, which assumed that governments receive a 25% rebate on all biologics. Provincial drug programs spent CAD $991.84 million on infliximab, etanercept, and adalimumab in 2019, and, when biosimilars were available, they constituted only 15.5% of national utilization of these drugs. In British Columbia, the implementation of a mandatory switching policy for patients with rheumatic conditions increased the biosimilar market share of infliximab and etanercept by 299% (from 19.7% to 78.5%). If applied nationwide to all three biologics for all indications, we estimate such policies could lead to annual savings of between CAD $179.71 million and CAD $425.64 million nationally. The overall market share of biosimilars remains low in all provinces where mandatory switching policies have not been introduced. The cost implications of successfully increasing biosimilar uptake would be substantial, particularly as more biosimilars reach the Canadian market., (© 2020 The Authors Clinical Pharmacology & Therapeutics © 2020 American Society for Clinical Pharmacology and Therapeutics.)

Objectives: Epidemiologic studies evaluating associations between specific arthritis medications and perinatal outcomes are limited. We evaluated the association between conventional synthetic DMARD (csDMARD) use among women with rheumatic disease (RD) and neonatal outcomes., Methods: We linked population-based data in British Columbia, Canada from 01/01/2002 to 12/31/2012 on all inpatient/outpatient visits and medications with a perinatal registry. For small-for-gestational-age (SGA) births, we assessed csDMARD exposure 90 days preconception or during pregnancy until date of delivery. For congenital anomalies, we determined csDMARD exposure 90 days preconception or during the first trimester. We used multivariable logistic regression models fitted with generalised estimating equations and calculated post-hoc power., Results: There were 185 pregnancies in 175 women (31.3±5.4 years) and 6,064 pregnancies in 4,387 women (31.1±5.4 years) in the csDMARD exposed and unexposed groups, respectively. Hydroxychloroquine, azathioprine, sulfasalazine, and methotrexate exposure before or during pregnancy were not associated with SGA births. The most sufficiently powered analyses were those for hydroxychloroquine, where exposure during pregnancy resulted in an adjusted odds ratio (aOR) of 1.12 (95% confidence interval [CI], 0.65-1.94) for SGA births. Although post-hoc power calculations indicate less power to detect associations between csDMARDs and congenital anomalies, results indicate methotrexate exposure during the first trimester is associated with elevated odds for congenital anomalies (aOR 6.58, 95% CI 1.15-37.75)., Conclusions: Findings are consistent with current guidelines regarding specific csDMARD use during the perinatal period for women with RD. It is important to report well-designed epidemiologic studies to facilitate future RD/csDMARD-specific meta-analyses.

Objective: Two surveys were conducted with patients with rheumatologic diseases to evaluate perceptions of different routes of administration (intravenous [IV] or subcutaneous [SC]) for biologic therapy., Methods: In Survey I, patient preferences toward biologic treatment were evaluated at a rheumatology practice in Buffalo, New York. In Survey II, Canadian patients enrolled in the BioAdvance patient support program and scheduled to receive IV biologic therapy were asked about their opinions of IV treatment., Results: In Survey I, 243 rheumatology patients participated. Median patient age was 60 years, 76% were female, and 44% were naive to treatment with biologic agents. Among biologic-naive patients, the majority (56%) were open to either SC or IV treatment; biologic-naive women were more likely than men to express a preference for the route of administration. In Survey II, 1,598 patients from the BioAdvance program (including 306 rheumatology patients) completed the full survey. Among the rheumatology patients, the median age was 49 years, 58% were female, and 61% had not previously taken biologics before enrolling in the BioAdvance program. The median rating of IV favorability (on a 10-point scale, with higher numbers indicating increased favorability) recalled by rheumatology patients was 5 prior to their first program infusion, which increased to 9 after multiple treatment infusions., Conclusion: These survey results indicate that patients with rheumatoid arthritis are generally open to IV treatment and express high satisfaction with IV therapy. Additional patient and provider education may improve shared decision-making regarding biologic therapy administration options., (© 2018, American College of Rheumatology.)

Objective: Pain is one reason some rheumatology patients may consider use of medical cannabis, a product increasingly perceived as a safe and neglected natural treatment option for many conditions. Legalization of recreational cannabis in Canada will promote access to cannabis. Physicians must therefore provide patients with the best evidence-based information regarding the medicinal effects and harm of cannabis., Methods: The Canadian Rheumatology Association (CRA) mandated the development of a position statement for medical cannabis and the rheumatology patient. The current literature regarding the effects of medical cannabis for rheumatology patients was assessed, and a pragmatic position statement to facilitate patient care was developed by the Therapeutics Committee of the CRA and approved by the CRA board., Results: There are no clinical trials of medical cannabis in rheumatology patients. Evidence is insufficient about the benefit of pharmaceutical cannabinoids in fibromyalgia, osteoarthritis, rheumatoid arthritis, and back pain, but there is evidence of a high risk of harm. Extrapolating from other conditions, medical cannabis may provide some symptom relief for some patients. Short-term risks of psychomotor effects can be anticipated, but longterm risks have not been determined and are of concern., Conclusion: Despite lack of evidence for use of medical cannabis in rheumatology patients, we acknowledge the need to provide empathetic and pragmatic guidance for patient care. This position statement aims to facilitate the dialogue between patients and healthcare professionals in a mutually respectful manner to ensure harm reduction for patients and society.

Globally, patents on several well established biologic agents used to treat rheumatic diseases have already or will expire over the next few years, allowing for the availability of subsequent entry biologics (SEBs or biosimilars). The objective of this study was to identify gaps in knowledge and attitudes towards SEBs among Canadian rheumatologists. Eighty-one rheumatologists completed the survey and were included in the analysis (22 % of the 369 who were contacted). We found that one third of physicians (31 %) were familiar with SEBs and that physicians with greater than 20 years of practice were significantly more likely to be familiar or very familiar with SEBs compared to respondents with less than 10 years or 10-20 years of experience (OR 11.1, 95 % CI: 2.1-55.5, p = 0.004 and OR 4.5, 95 % CI: 1.2-16.2, p = 0.023, respectively). A third (32 %) of physicians agreed or strongly agreed that they would be comfortable with indication extrapolation. Most respondents (88 %) would feel concerned or very concerned if a pharmacist had the ability to substitute a biologic drug for an SEB without the physician's approval. This survey was the first study that evaluated the position of rheumatologists on key areas surrounding SEBs from a nationwide Canadian perspective. Current physician attitudes and perceptions of SEBs can inform future educational initiatives and highlight important issues for payers, policy makers, and other stakeholders.

Objective: To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids)., Methods: A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada., Results: Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to "miscommunication" (34.9%), "treatment/test/procedure" (22.9%), "adverse drug reactions" (12.0%), and "medication errors" (8.4%). Category A events ("an event that has the capacity to cause error") were the most common with 39.8% of the cases, followed by Category C events ("an event occurred that reached the patient, but did not cause harm") with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as "information" (58.4%), followed by 11 "rules and policies" recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing., Conclusion: The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.

The aging population is impacting subspecialty areas outside of geriatrics. Rheumatic diseases increase with age. Therapy for these diseases can add to polypharmacy and negatively impact other comorbidities. This is a retrospective chart review of all patients attending a rheumatology subspeciality clinic over 1 year. Referrals were prescreened and excluded probable degenerative axial and peripheral disease and chronic pain syndromes. Data were collected on demographics, diagnoses, and medications. Two hundred ninety-five new patients were seen. Seventy-eight (26%) were seniors (age, >65 years) with a mean age of 73 years (65-90). Comparing the >65 to <65 age groups, the prevalence of inflammatory arthritides (rheumatoid arthritis (RA), psoriatic arthritis, palindromic rheumatism) was comparable: 48% vs 53%; however, osteoarthritis and polymyalgia rheumatica were twice as common in the older group. Comorbidities in the >65 age group included hypertension (31%), osteoporosis (27%), diabetes (15%), hypothyroidism (11%), and coronary artery disease (9%). Only one patient had documented dementia. There were no cases of uncontrolled hypertension identified, and all patients were receiving a mixture of anti-hypertensives. Eighty-one percent of osteoporosis patients were on antiresorptives, but only 40% of prednisone users were taking bisphosphonates. For RA, treatment was somewhat comparable between the groups, with all but two patients receiving disease-modifying antirheumatic drugs. Eleven percent were on biologics. Seniors comprise a significant number of referrals. Pharmacotherapy differs in seniors, with more use of prednisone and a probable contribution of polypharmacy. This study highlights the need for reciprocal knowledge by both geriatricians and rheumatologists to optimize the management of these complex patients.

Musculoskeletal pain in the elderly is common and disabling. As the conditions causing rheumatic pain, including osteoarthritis, inflammatory arthritis and soft-tissue conditions such as tendonitis and bursitis, are, for the most part, not curable, pain control is paramount in order to maintain quality of life. Pain management should be multimodal and tailored to the individual patient, and will likely include a combination of both nonpharmacological and pharmacological interventions. Nonpharmacological treatments begin with education of the patient, encouragement to practise self-management strategies and attention to healthy life habits such as weight control and regular physical activity and exercise. Advice in this regard may be effectively given by healthcare professionals other than physicians. Although herbal products and nutritional supplements are commonly used by patients, studies of their efficacy and safety, especially in the elderly, are limited. In contrast, topical applications, and in particular those containing NSAIDs, are being used more frequently, are associated with fewer adverse effects than oral preparations and offer a new and safer treatment alternative. Similarly, intra-articular and soft-tissue injections of corticosteroids provide an easy and cost-effective option for symptom relief with minimal risk. The use of any pharmacological agent in the elderly should be tempered with caution regarding increased sensitivity to medications, drug-drug interactions and associated co-morbidities. Therefore, the elderly will often require down-adjustment of dosage and careful attention to the risk/benefit ratio of the treatment. There is, however, no single ideal pain medication for management of rheumatic pain. The four broad categories of treatments, namely simple analgesics (i.e. paracetamol [acetaminophen]), NSAIDs, stronger analgesics (i.e. opioids) and adjuvant drugs, each have unique and particular concerns regarding their adverse effect profiles. The continued use of any medication should also be repeatedly assessed to ensure that efficacy is maintained. Throughout the treatment period, physicians must remain vigilant for emergent adverse effects. Patients and physicians should have realistic outcome goals for effective rheumatic pain management. Although complete pain relief is seldom achieved, modulation of pain and the associated components of sleep disturbance, fatigue and mood disorder will improve overall quality of life in the elderly. However, barriers to effective pain management from both the patient and the healthcare professional perspectives still exist, and will be overcome only by educational efforts. Successful rheumatic pain management in the elderly should begin with an accurate diagnosis by the physician, and patients must be realistic in their expectations. Treatments should be multimodal, with attention given to the co-morbidities of pain as well as the global health status of the patient. Whether or not an outcome is favourable should be determined not only by the treatment's impact on pain but also by its capacity to improve function and enhance quality of life. The wider range of treatment options now available is both useful and encouraging for the physician managing musculoskeletal aches and pain in the elderly.

Objective: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases., Methods: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist-epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference., Results: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment)., Conclusion: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

Objective: To assess the extent to which quantitative clinical measurement is performed by rheumatologists in the longitudinal followup of patients with rheumatoid arthritis (RA), osteoarthritis (OA), ankylosing spondylitis (AS), and fibromyalgia (FM) in routine outpatient practice in Canada., Methods: A cross sectional postal survey was conducted using an 18 item self-administered questionnaire sent to Canadian Rheumatology Association members., Results: Rheumatologists (response rate 85%) were more likely to longitudinally follow patients with RA and AS than those with OA or FM. There was a high degree of variability in the methods used to monitor patients longitudinally. Many measures used in clinical research were used infrequently in routine clinical practice. In general, the major health status measures surveyed were not used in clinical monitoring. There was a high level of agreement (>80%) that the characteristics required of an outcome measure for use in clinical practice should include simplicity, brevity, ease of scoring, reliability, validity, and sensitivity to change., Conclusion: The majority of Canadian rheumatologists perform outcome measurement during the longitudinal followup of their outpatients with RA, AS, OA, and FM. However, the process lacks standardization. High performance health status measures, developed for clinical research, have not been widely adopted in rheumatology practices. There is agreement on the characteristics required by Canadian rheumatologists for measurement procedures used in routine clinical care. Quantitative measurement in clinical practice using standardized procedures is an attainable, but as yet, unrealized opportunity.