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(1) Background: Patients with systemic lupus erythematous (SLE) experience profound effects on health-related quality of life (HRQoL) that cannot be explained by objective indicators of mortality and morbidity. This study aimed to adapt the SLE Quality of Life (SLEQoL) questionnaire to the European Portuguese population and to assess its reliability and validity for patients with SLE. (2) Methods: Two independent translators translated the original version of the SLEQoL questionnaire into Portuguese. A back-translated version was produced. The Portuguese version of the questionnaire was reviewed and tested for validity and reliability. Cronbach’s alpha and the internal validity index were calculated to verify the internal reliability and validity of the content. Rheumatologists filled out the SLE Disease Activity Score (SLE-DAS) and Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index SLICC/ACR-DI questionnaires. (3) Results: This study involved 180 patients, of which 93.8% were females. The results indicated very high internal consistency reliability (α = 0.949), low correlations between the SLEQoL and the SLE-DAS, a correlation between all SLEQoL dimensions and all SF-36 dimensions (except for “response to treatment” and “self-image”), and good correlation scores with both the EQ-5D-5L index and VAS. (4) Conclusion: The Portuguese version of the SLEQoL questionnaire is valid and reliable for the measurement of HRQoL in SLE patients.

Objectives To investigate time trends in baseline characteristics and retention, remission and response rates in bio-naïve axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients initiating TNF inhibitor (TNFi) treatment. Methods Prospectively collected data on bio-naïve axSpA and PsA patients from routine care in 15 European countries were pooled. Three cohorts were defined according to year of TNFi initiation: A (1999–2008), B (2009–2014) and C (2015–2018). Retention, remission and response rates were assessed at 6, 12 and 24 months. Results In total, 27 149 axSpA and 17 446 PsA patients were included. Cohort A patients had longer disease duration compared with B and C. In axSpA, cohort A had the largest proportion of male and HLA-B27 positive patients. In PsA, baseline disease activity was highest in cohort A. Retention rates in axSpA/PsA were highest in cohort A and differed only slightly between B and C. For all cohorts, disease activity decreased markedly from 0 to 6 months. In axSpA, disease activity at 24 months was highest in cohort A, where also remission and response rates were lowest. In PsA, remission rates at 6 and 12 months tended to be lowest in cohort A. Response rates were at all time points comparable across cohorts, and less between-cohort disease activity differences were seen at 24 months. Conclusion Our findings indicate that over the past decades, clinicians have implemented more aggressive treatment strategies in spondyloarthritis. This was illustrated by shorter disease duration at treatment initiation, decreased retention rates and higher remission rates during recent years.

The authors present the case of a 76-year-old female patient with progressive decrease in proximal muscle strength, fatigue, dyspnea, diffuse hand edema and painful triphasic Raynaud's phenomenon. Anti-SRP and anti-SSA antibodies were detected, muscle biopsy revealed changes consistent with necrotizing myopathy and capillaroscopy had findings compatible with systemic sclerosis. High-resolution chest computed tomography revealed interstitial lung disease with a non-specific interstitial pneumonia pattern. Lung function tests demonstrated a forced vital capacity 93% and a diffusing capacity for carbon monoxide of 65% predicted. After multidisciplinary discussion, she was diagnosed with immune-mediated necrotizing myopathy/systemic sclerosis overlap syndrome with pulmonary involvement. Initially, dual immunomodulation therapy with high-dose steroids and intravenous immunoglobulin was started, but after 4 weeks, the patient had clinical and analytical deterioration. At this time, she was started on rituximab, with an excellent and sustained response at both muscle and lung, sustained after 12 months.

Systemic lupus erythematosus (SLE) is an autoimmune disease with potential multisystemic involvement. Mesenteric panniculitis (MP) has been described as a rare feature in patients with SLE. The authors present a case of a 26 years old patient with previous diagnosis of SLE presenting with abdominal pain and distension and a peri-umbilical mass. Imagological findings were compatible with MP and ganglion biopsy revealed inflammatory pattern. Corticosteroid therapy was initiated with a resolution of pain after 6 months of treatment, with image reevaluation showing improvement of previous findings.

Axial spondyloarthritis (axSpA), particularly ankylosing spondylitis was historically considered a male's disease and has been under-recognized in women. Emerging evidence reveals sex differences in pathophysiology, disease presentation and therapeutic efficacy.To identify differences between sexes in a Portuguese cohort of patients with axSpA regarding clinical manifestations, disease activity, functional capacity, patient related outcomes and presence of sacroiliitis on x-ray or magnetic resonance imaging.Patients with ≥18 years fulfilling the ASAS- Assessment of Spondyloarthritis International Society classification criteria for axSpA registered in the electronic Rheumatic Diseases Portuguese Register (Reuma.pt) were included in this multicentric cross-sectional study. Sociodemographic data, clinical features and imaging were collected from the first record in Reuma.pt. These variables were compared between sexes using Mann-Whitney test and Chi-Square test. Variables with a significant association with variable sex were considered in the multiple variable analysis to adjust the sex effect on the outcome variables. Statistical analysis was performed with R version 4.0.2 and p0.05 was considered statistically significant.A total of 1995 patients were included, 1114 (55.9%) men and 881 (44.1%) women. Men had an earlier disease onset (25.1 vs 28.4, p0.001), were younger at diagnosis (26.9 vs 30.4, p0.001) and were more frequently smokers (32.1% vs 15.7%, p0.001). Comparing to women, men had worse Bath Ankylosing Spondylitis Metrological Index scores (4.0 vs 3.4, p0.001), higher levels of C-Reactive Protein (10.5 vs 6.9 mg/L, p0.001) and were more often Human Leukocyte Antigen-B27 positive (67.8% vs 54%, p0.001). In contrast, women more frequently had inflammatory bowel disease (8.8% vs 4.9%, p =0.004), higher levels of erythrocyte sedimentation rate (25.0 vs 21.0mm/h, p=0.003) and worse patient-related outcomes- Bath Ankylosing Spondylitis Disease Activity Index (5.7 vs 4.5, p0.001), Patient Global Assessment (60.0 vs 50.0, p0.001) and fatigue (6.2 vs 5.0, p0.001).In this large multicentric study from a Portuguese axSpA cohort, we confirmed sex differences in patients with axSpA. This work brings awareness to these differences, resulting in less underdiagnosis and misdiagnosis, optimizing treatment strategies, and improving outcomes in axSpA.

Funding: This research received no external funding. CEISUC/CIBB is funded by national funds through FCT Foundation for Science and Technology, I.P., under the Multiannual Financing of R&D Units 2020–2023. (1) Background: The UCLA GIT 2.0 questionnaire has been recognized as a feasible and reliable instrument to assess gastrointestinal (GI) symptoms in systemic sclerosis (SSc) patients and their impact on quality of life. The aim of this study was to create and validate UCLA GIT 2.0 for Portuguese patients with SSc. (2) Methods: A multi-center study was conducted enrolling SSc patients. UCLA GIT 2.0 was validated in Portuguese using reliability (internal consistency, item –total correlation, and reproducibility) and validity (content, construct, and criterion) tests. Criterion tests included EQ-5D and SF-36v2. Social–demographic and clinical data were collected. (3) Results: 102 SSc patients were included, 82.4% of them female, and with a mean sample age of 57.0 ± 12.5 years old. The limited form of SSc was present in 62% of the patients and 56.9% had fewer than five years of disease duration. Almost 60% presented with SSc-GI involvement with a negative impact on quality of life. The means for SF-36v2 were 39.3 ± 10.3 in the physical component summary and 47.5 ± 12.1 in the mental component summary. Total GI score, reported as mild in 57.8% of the patients, was highly reliable (ICC = 0.912) and the Cronbach’s alpha was 0.954. There was a high correlation between the total GI score and EQ-5D-5L and SF-36v2 scores. (4) Conclusion: The Portuguese version of UCLA GIT 2.0 showed good psychometric properties and can be used in research and clinical practice. publishersversion published

Purpose: COVID-19 changed the dynamics of all healthcare system, leading to the restructuring of inpatient teams as well as the emergency department. Scheduled surgeries were suspended, operating rooms were closed, and anesthesiologists redistributed among the various intensive care units. At the Centro Hospitalar do Baixo Vouga the number of patients admitted to the emergency department decreased to approximately 8.000 during the period of lockdown which ranged from 18th March to 1st June 2020. The aim of this study was to compare the number of patients presenting with hip fractures during the first wave of the COVID-19 pandemic with the equivalent period in 2019 and to analyze postoperative outcomes. Methods: An observational retrospective study was conducted in two different periods. Patients over the age of 50 years admitted with hip fracture were included for analysis. The data was collected from the hospital database. A general descriptive analysis was performed. Results: There was an overall reduction in the number of admissions due to hip fractures in Period 2020 compared with homologous Period in 2019 (68 patients and 94 patients, respectively). No statistically significant differences could be found regarding age, gender, ASA grade and pre-admission residence among patients admitted during these both periods. Nursing home patients in Period 2020 had a longer hospital stay (p=0.03), independently of the functional status (p=0.07). There were no statistically significant differences in the time it took the patient to go to the emergency department after the fall, place where the fracture had occurred, waiting time to perform the surgery, type of treatment performed, post-surgical complications and mortality. There was no relationship between mortality and the time it took the patient to access the emergency department (p=0,487), or mortality and the mean length of stay in the hospital (p=0,151). All the patients admitted to the emergency department in Period 2020 were negative to PCR test for SARS-CoV-2. Conclusion: The measures taken by the hospital during the pandemic had no impact in the healthcare provided to the admitted patients. This should be taken into account in order to optimize the efficiency of the health care system in future outbreaks.

Introduction Multimorbidity is a worldwide health problem, especially in elderly patients who have a higher risk of fragility fracture. Currently, there is insufficient knowledge about the burden of multimorbidity in patients with previous fragility fracture. The aim of this study was to evaluate the association between multimorbidity and previous fragility fracture, and to assess the effect of fragility fracture and/or multimorbidity in the perception of quality-of-life and physical function, in women 50 years of age and older. Methods Women aged ≥50 years from the EpiReumaPt study (2011-2013), a nationwide population-based study, were evaluated. Self-reported data regarding sociodemographics, health-related quality of life, physical functioning, fragility fracture, and multimorbidity were collected using a semi-structured questionnaire. Multimorbidity was defined as 2 or more chronic non-communicable diseases. Descriptive exploratory analysis of the data was performed using hypothesis testing. Multiple logistic regression modelling was used to assess the association between multimorbidity and fragility fractures, and linear regression was used for the quality-of-life and physical function outcomes. Results The estimated prevalence of fragility fracture in women older than 50 years was 17.5%. A higher prevalence of multimorbidity (74.6%) was found in the group of women with previous fragility fracture than in those without previous fragility fracture. Multivariate logistic regression analysis revealed that women with multimorbidity had a higher odds of fragility fracture (adjusted odds ratio, 1.38; 95% confidence interval, 1.12-1.69), compared with women with 1 or no self-reported non-communicable chronic diseases. In women with previous fragility fracture, rheumatic diseases (62.7%) and hypertension (58.6%) were the most frequently self-reported non-communicable chronic diseases. The combination of fragility fracture and multimorbidity was associated with a lower quality of life and higher degree of disability. Conclusions Women 50 years and older with multimorbidity had a significantly increased odds of fragility fracture. Fragility fracture combined with multimorbidity was negatively associated with quality of life and positively associated with disability. This study emphasizes the need to redesign health services to care for patients to prevent non-communicable chronic diseases and fragility fracture, particularly in women 50 years and older, in whom these diseases are likely to potentiate the risk of fragility fracture.

Background Osteoporosis is a public health problem worldwide responsible for fragility fractures (FF). All osteoporotic fractures, correspond to an estimated 40 000 annual osteoporotic fractures in Portugal. The social and economic burden of these fractures is enormous. Most patients die within one year after the fracture and 50% become dependent on others to perform basic self-care. The aim of this research is to study the association between sociodemographic and clinical factors that can influence the occurrence of FF in Portuguese women ≥ 50 years. Methods Data were collected from women ≥ 50 years participating in the prospective population-based cohort study called Epidemiology of Chronic Diseases, who self-reported to surfered FF during 2011 and 2015. Were collected sociodemographic and clinical data, and quality of life (EQ-5D). We divided this group in 2 subgroups: with and without prevalent FF. Descriptive, bivariate analysis and Odds Ratio were estimated. All statistical tests were performed using the SPSS 26, considering the significance level of 5%. Results A total of 3,662 women ≥ 50 years of age were included and divided into 2 subgroups with (N = 646) and without FF (N = 2,978). In the group of women with FF, rheumatic disease was the most self-reported chronic disease (62.9%), followed by hypertension (58.8%) and mental illness (30.0%). There was a significant association between the existence of FF and hypertension (OR = 0.82 (0.68-0.98); p-0.03), diabetes mellitus (OR = 0.78 (0.63-0.97); p-0.02) and mental illness (OR = 0.70 (0.57-0.85); p Conclusions FF are associated with non-communicable chronic diseases and this should awareness to the need to have health policies that focus on prevention. Key messages Osteoporosis is a public health problem worldwide responsible for fragility fractures. It is urgent address this problem as a non-communicable chronic diseases and start to work in prevention. Population aging combined with new professions and lifestyles, predict that this problem will tend to increase exponentially in the next years.

© The Author(s). 2020 Open Access. This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visithttp://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data., Background: To investigate whether the reason to discontinue the first TNF inhibitor (TNFi) affects the response to the second TNFi in axial spondyloarthritis (axSpA). Methods: Patients with axSpA from the Rheumatic Diseases Portuguese Register (ReumaPt), who discontinued their first TNFi and started the second TNFi between June 2008 and May 2018, were included. Response was assessed by the Ankylosing Spondylitis Disease Activity Score (ASDAS) clinically important improvement (ASDAS-CII), major important improvement (ASDAS-MI), low disease activity (ASDAS-LDA), and inactive disease (ASDAS-ID). The reason for discontinuation of the first TNFi was defined, according to ASDAS-CII as primary failure (no response ≤ 6 months), secondary failure (response ≤ 6 months but lost thereafter), adverse events, and others. The association between the reason for discontinuation of the first TNFi and response to the second TNFi over time was assessed in multivariable generalized equation (GEE) models. Results: In total, 193 patients were included. The reason for discontinuation of the first TNFi did not influence the response to the second TNFi, according to the ASDAS-CII. However, a difference was found with more stringent outcomes, e.g., there was a higher likelihood to achieve ASDAS-ID with the second TNFi for patients discontinuing the first TNFi due to secondary failure (OR 7.3 [95%CI 1.9; 27.7]), adverse events (OR 9.1 [2.5; 33.3]), or other reasons (OR 7.7 [1.6; 37.9]) compared to primary failure. Conclusion: Patients with axSpA with secondary failure to their first TNFi, compared to those with primary failure, have a better response to the second TNFi according to stringent outcomes., This work was supported by a research grant from Merck Sharp & Dohme Corp., a division of Merck & Co., Inc., Kenilworth, NJ, USA [IIS# 57763]. AS is supported by a doctoral grant from “Fundação para a Ciência e Tecnologia”(SFRH/BD/108246/2015)

Objective To investigate TNF inhibitor (TNFi) retention and response rates in European biologic-naïve patients with PsA. Methods Prospectively collected data on PsA patients in routine care from 12 European registries were pooled. Heterogeneity in baseline characteristics between registries were explored (analysis of variance and pairwise comparison). Retention rates (Kaplan–Meier), clinical remission [28-joint count DAS (DAS28) Results Overall, 14 261 patients with PsA initiated a first TNFi. Considerable heterogeneity of baseline characteristics between registries was observed. The median 12-month retention rate (95% CI) was 77% (76, 78%), ranging from 68 to 90% across registries. Overall, DAS28/28 joint Disease Activity index for Psoriatic Arthritis remission rates at 6 months were 56%/27% (LUNDEX: 45%/22%). Six-month ACR20/50/70 responses were 53%/38%/22%, respectively. In patients initiating a first TNFi after 2009 with registered fulfilment of ClASsification for Psoriatic ARthritis (CASPAR) criteria (n = 1980) or registered one or more swollen joint at baseline (n = 5803), the retention rates and response rates were similar to those found overall. Conclusion Approximately half of >14 000 patients with PsA who initiated first TNFi treatment in routine care were in DAS28 remission after 6 months, and three-quarters were still on the drug after 1 year. Considerable heterogeneity in baseline characteristics and outcomes across registries was observed. The feasibility of creating a large European database of PsA patients treated in routine care was demonstrated, offering unique opportunities for research with real-world data.

Background Lupus Mastitis is rare and can be easily confounded with infection or breast cancer. Methods We report two cases of lupus mastitis, in different clinical settings. Results The first patient was a 34-year-old female with Systemic Lupus Erythematosus (SLE) with renal, hematological, musculoskeletal and cutaneous involvement, medicated with hydroxychloroquine (HCQ) 400 mg/day, mycophenolate mofetil 2000 mg/day and prednisolone 7.5 mg/day. She presented to the emergency department with painful right breast. On the examination, the breast was swollen, warm and painful to palpation. Breast ultrasound revealed a vascularized and lobulated mass at the upper external quadrant, with liquid areas inside, suggesting possible abscess, which was drained and biopsied. Histopathological analysis demonstrated a fibroinflammatory process, with fibrotic and abscedated areas, ductitis, lobulitis and vasculitis, compatible with lupus mastitis. Cultures from the aspirated fluid were negative. The patient was medicated with antibiotic, NSAIDs and prednisolone dose was increased to 10 mg/day with significant improvement. The second case refers to a 48-year-old female patient, with SLE with cutaneous, immunological and musculoskeletal involvement, who had withdrawn HCQ due to ocular toxicity. In the following months, the patient presented recurrent episodes of mastitis, on the same location. Breast ultrasound performed during one of the episodes revealed a hyperecogenic area of the fibroglandular tissue, with cystic areas. In spite of repeated treatment with antibiotics and NSAIDs, mastitis recurred, in a total of seven times. Because of worsening of the cutaneous lupus, the patient was medicated with methotrexate up to 15 mg/week. No more episodes of mastitis were recorded and biopsy of the breast, which had been considered, was not performed due to total recovery. The gynecology and rheumatology teams concluded that lupus was the etiology of the recurrent mastitis. Conclusions Clinicians should be aware of this entity to avoid unnecessary invasive procedures, which may increase inflammation involved in lupus mastitis. Therapeutic approach usually demands increasing immunomodulation.

Osteoarthritis (OA) is the most prevalent rheumatic disease and is a leading cause of decreased quality of life (QoL). The OA Quality of Life questionnaire (OAQoL) is an OA-specific patient-reported outcome measures. The aim of this study was to translate and validate the original UK English version of the Osteoarthritis Quality of Life (OAQoL) questionnaire into European Portuguese. The translation of the questionnaire was carried out according to a dual panel methodology (bilingual panel followed by lay panel). This was followed by cognitive debriefing interviews (CDIs) with OA patients to assess comprehension and relevance of the translated questionnaire. Finally, a validation survey was conducted to assess its psychometric properties. The Portuguese OAQoL, a comparator scale (the Nottingham Health Profile-NHP) as well as questions relating to demographic and disease information were administered to OA patients. A sub-sample of patients also completed the Portuguese OAQoL two weeks later, to assess test-retest reliability. The internal consistency, construct validity and known group validity (according to perceived OA severity) of the scale was also assessed. Both the bilingual and lay panels consisted of five individuals and no major difficulties relating to the translation process were identified. A total of ten patients with OA participated in the CDIs. The mean time to complete the questionnaire was 5 min. These interviews revealed that the Portuguese version of the OAQoL was clear, relevant and easy to complete. Finally, 53 OA patients (44 females; mean age of 67.6 years) completed the validation survey. Cronbach's alpha coefficient was 0.87, demonstrating high internal consistency. Test-retest reliability, assessed by Spearman's rank correlation coefficient, was 0.86. Moderate correlations were found with the majority of the NHP sections, providing evidence of construct validity. Significant differences in OAQoL scores were found between patients who differed according to their perceived OA severity, providing evidence of known group validity. The Portuguese version of the OAQoL is a valid and reliable questionnaire that can be used to assess QoL in OA, both in clinical practice and for research purposes.

Temporomandibular joint dysfunction (TMD) is characterized by the presence of signs and symptoms that lead to functional changes in this joint. Most of the times with a multifactorial etiology, it can be associated to systemic diseases, such as rheumatoid arthritis (RA). Objectives: to evaluate the prevalence of TMD in a cohort of women with RA, as well as possible links between its presence and disease activity and duration, smoking and frequent consumption of chewing gum, compared with a control group of healthy controls.

Objectives: Early diagnosis and treatment of Rheumatoid Arthritis (RA) and axial Spondylarthritis (axial SpA) can limit the impact of disease outcomes. This study evaluated the effectiveness of a referral program on the identification of patients with RA and axial SpA. Methods: This was an observational, prospective, randomized (by clusters) study conducted in Portugal to evaluate the impact of the implementation of a set of referral support actions (RSA). The study was divided in two sub-studies, the RA sub-study and the axial SpA sub-study. 28 participating primary care units were randomly (by clusters) assigned to RSA or control group (with no intervention). Both RSA and control groups identified and referred patients with suspected RA or axial SpA to the rheumatology unit of the reference hospital. The primary objective was to evaluate the correct diagnosis of RA or axial SpA cases confirmed by the rheumatologist of the reference hospital. Results: RA-Substudy: A total of 340 patients were recruited (144 in the RSA-exposed group; 196 in the control). RA diagnosis confirmation was 7.3% (95%CI, 2.1-12.5%) in RSA group versus 2.7% (95%CI, 0.0-5.7%) in control group RSA effect was positive but moderate (4.6%) and not statistically significant (95% CI, 0.0%-11.8%; p=0.222, adjusted for clustering effect). Rate of confirmed arthritis of any type was 16.9% (n=14/83) in the RSA group and 6.0% (n=5/83) in the control group. This difference was statistically significant and favorable to RSA group (OR=3.2; 95% CI 1.1-9.2; p=0.028). Axial SpA-Substudy: A total of 231 patients were recruited (108 in the RSA-exposed group; 123 in the control). Axial SpA diagnosis confirmation was 8.7% (95% CI, 2.1-15.4%) in RSA group versus 5.6% (95% CI, 0.0-11.73%) in control group. RSA effect was positive (3.1%) but not statistically significant (95% CI, -7.5- 12.9%; p=0.568, adjusted for clustering effect). Conclusions: This study showed a positive tendency for the RSA program, most relevantly on the diagnosis of patients with any type of arthritis in the RA sub-study. It is possible that a referral program more comprehensive than the one herein tested might improve early diagnosis of RA and SpA.

Background:Knowledge of changes over time in baseline characteristics and tumor necrosis factor inhibitor (TNFi) response in bio-naïve axial spondyloarthritis (axSpA) patients treated in routine care is limited.Objectives:To investigate secular trends in baseline characteristics and retention, remission and response rates in axSpA patients initiating a first TNFi.Methods:Prospectively collected data on bio-naïve axSpA patients starting TNFi in routine care from 15 European countries were pooled. According to year of TNFi initiation, three groups were defined a priori based on bDMARD availability: Group A (1999–2008), Group B (2009–2014) and Group C (2015–2018). Retention rates (Kaplan-Meier), crude and LUNDEX adjusted1 remission (Ankylosing Spondylitis Disease Activity Score (ASDAS) Results:In total, 27189 axSpA patients were included (5945, 11255 and 9989 in groups A, B and C).At baseline, patients in group A were older, had longer disease duration and a larger proportion of male and HLA-B27 positive patients compared to B and C, whereas disease activity was similar across groups.Retention rates at 6, 12 and 24 months were highest in group A (88%/81%/71%) but differed little between B (84%/74%/64%) and C (85%/76%/67%).In all groups, median ASDAS and BASDAI had decreased markedly at 6 months (Table 1). The ASDAS values at 12 and 24 months and BASDAI at 24 months were higher in group A compared with groups B and C. Similarly, crude remission and response rates were lowest in group A. After adjustments for drug retention (LUNDEX), remission and response rates showed less pronounced between-group differences regarding ASDAS measures and no relevant differences regarding BASDAI measures.Conclusion:Nowadays, axSpA patients initiating TNFi are younger with shorter disease duration and more frequently female and HLA-B27 negative than previously, while baseline disease activity is unchanged. Drug retention rates have decreased, whereas crude remission and response rates have increased. This may indicate expanded indication but also a stable disease activity threshold for TNFi initiation over time, an increased focus on targeting disease remission and more available treatment options.References:[1]Arthritis Rheum 2006; 54: 600-6.Table 1.Secular trends in baseline characteristics, treatment retention, remission and response rates in European axSpA patients initiating a 1st TNFiBaseline characteristicsGroup A(1999–2008)Group B(2009–2014)Group C(2015–2018)Age, years, median (IQR)57 (49–66)51 (42–60)46 (37–56)Male, %666057HLA-B27, %877772Years since diagnosis, median (IQR)5 (1–12)2 (0–8)2 (0–7)Smokers, %232425ASDAS, median (IQR)3.5 (2.8–4.1)3.4 (2.8–4.1)3.5 (2.8–4.1)BASDAI, median, (IQR)57 (42–71)59 (43–72)57 (41–71)TNFi drug, % (Adalimumab /Etanercept / Infliximab /Certolizumab / Golimumab)22 / 35 / 43 / 0 / 037 / 21 / 20 / 4 / 1827 / 28 / 24 / 8 / 13Follow up6 months12 months24 monthsGr AGr BGr CGr AGr BGr CGr AGr BGr CRetention rates, %, (95% CI)88 (88–89)84 (83–85)85 (84–86)81 (80–82)74 (74–75)76 (75–76)71 (70–72)64 (63–65)67 (66–68)ASDAS, median, (IQR)1.8 (1.2–2.8)1.9 (1.2–2.8)1.8 (1.2–2.6)1.9 (1.3–2.6)1.7 (1.2–2.5)1.6 (1.1–2.4)1.9 (1.4–2.6)1.7 (1.1–2.4)1.5 (1.1–2.2)ASDAS inactive disease, %, c/L28 / 2528 / 2430 / 2624 / 1932 / 2434 / 2623 / 1634 / 2039 / 23ASDAS CII, %, c/L57 / 5159 / 5063 / 5461 / 5063 / 4767 / 5159 / 4168 / 4074 / 45ASDAS MI, %, c/L31 / 2732 / 2737 / 3232 / 2637 / 2741 / 3130 / 2042 / 2546 / 28BASDAI, median, (IQR)23 (10–40)26 (11–48)24 (10–44)21 (10–38)23 (10–42)20 (8–39)22 (9–40)20 (8–39)16 (6–35)BASDAI remission, %, c/L44 / 4040 / 3443 / 3645 / 3645 / 3450 / 3844 / 3048 / 2956 / 34BASDAI 50 response, %, c/L53 / 4750 / 4253 / 4557 / 4656 / 4258 / 4457 / 3960 / 3563 / 38Gr, Group; c/L, crude/LUNDEX adjusted.Acknowledgements:Novartis Pharma AG and IQVIA for supporting the EuroSpA Research Collaboration Network.Disclosure of Interests:Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Sara Nysom Christiansen Speakers bureau: BMS and GE, Grant/research support from: Novartis, Simon Horskjær Rasmussen: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Grant/research support from: Novartis, Ulf Lindström: None declared, Jakub Zavada: None declared, Florenzo Iannone: None declared, Fatos Onen: None declared, Michael J. Nissen Speakers bureau: Novartis, Eli Lilly, Celgene, and Pfizer, Consultant of: Novartis, Eli Lilly, Celgene, and Pfizer, Brigitte Michelsen Consultant of: Novartis, Grant/research support from: Novartis, Maria Jose Santos Speakers bureau: AbbVie, Novartis, Pfizer, Gary Macfarlane Grant/research support from: GlaxoSmithKline, Dan Nordström Consultant of: Abbvie, BMS, MSD, Novartis, Pfizer, Roche, UCB, Manuel Pombo-Suarez: None declared, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Irene van der Horst-Bruinsma Speakers bureau: Abbvie, BMS, MSD, Novartis, Pfizer, Lilly, UCB, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, Johan Askling: None declared, Bente Glintborg Grant/research support from: Pfizer, Biogen, AbbVie, Karel Pavelka Speakers bureau: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Consultant of: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Elisa Gremese: None declared, Nurullah Akkoc: None declared, Adrian Ciurea Speakers bureau: Abbvie, Eli-Lilly, MSD, Novartis, Pfizer, Eirik kristianslund: None declared, Anabela Barcelos: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene, Amgen, GSK, Anna-Mari Hokkanen Grant/research support from: MSD, Carlos Sánchez-Piedra: None declared, Ruxandra Ionescu Speakers bureau: Abbvie, Amgen, Boehringer-Ingelheim Eli-Lilly,Novartis, Pfizer, Sandoz, UCB, Ziga Rotar Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Marleen G.H. van de Sande: None declared, Arni Jon Geirsson: None declared, Mikkel Østergaard Speakers bureau: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth, Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth, Merete L. Hetland Speakers bureau: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis.

OBJECTIVE: To update the recommendations for the treatment of Rheumatoid Arthritis (RA) with biological therapies, endorsed by the Portuguese Society of Rheumatology (SPR). METHODS: These treatment recommendations were formulated by Portuguese rheumatologists based on literature evidence and consensus opinion. At a national meeting the 10 recommendations were discussed and updated. The document resulting from this meeting circulated to all Portuguese rheumatologists, who anonymously voted online on the level of agreement with the recommendations. RESULTS: These recommendations cover general aspects as shared decision, prospective registry in Reuma.pt, assessment of activity and RA impact and treatment objective. Consensus was also achieved regarding specific aspects as initiation of biologic therapy, assessment of response, switching and definition of persistent remission. CONCLUSION: These recommendations may be used for guidance of treatment with biological therapies in patients with RA. As more evidence becomes available and more therapies are licensed, these recommendations will be updated. publishersversion published

Background Tumour necrosis factor inhibitors (TNFi) are efficacious in patients with axial spondyloarthritis (axSpA), but some patients switch to a different TNFi because of adverse effects (AE) or lack of effect (LOE). The EuroSpA Collaboration has previously demonstrated a 1-year retention rate of 79% and 6 months LUNDEX adjusted BASDAI Objectives Firstly, to investigate retention and response rates at 6, 12 and 24 months in patients with axSpA initiating the 2nd and 3rd TNFi in clinical practice across Europe. Secondly, to investigate whether the outcomes were associated with the reason for withdrawal (AE or LOE) from the previous treatment. Methods Prospectively collected data on axSpA patients in routine care from 12 European registries were pooled. Kaplan-Meier estimation was used to investigate TNFi retention rates. LUNDEX adjusted2 response rates were calculated for BASDAI Results A total of 7953 patients initiating their 2nd TNFi and 2782 patients initiating 3rd TNFi were included. Baseline characteristics are shown in the Table. The overall retention rates for both 2nd and 3rd TNFi at 12 months were 72% (Figure). Corresponding retention rates for the individual registries ranged from 52-90% and 54-89%, respectively. In both patients who stopped 1st TNFi due to AE or LOE, 12-month retention rate for the 2nd TNFi treatment was 68%. In patients who stopped the 2nd TNFi due to AE or LOE, 12-month retention rates for the 3rd TNFi treatment were 68% and 69%, respectively. For the 2nd and 3rd TNFi, 6 months LUNDEX adjusted BASDAI Conclusion Data from 12 European countries demonstrated decreasing response rates with increasing number of previous TNFi, although with only minor difference between 2nd and 3rd. Patients who had withdrawn from the previous TNFi due to LOE had retention rates and remission rates similar to those who had withdrawn due to AE. References [1] Brahe, et al. ACR2018 [2] Arthritis Rheum, 2006, 54(2), p:600-6. Acknowledgement Novartis Pharma AG and IQVIA for supporting the EuroSpA collaboration Disclosure of Interests Lykke Ornbjerg Grant/research support from: Unrestricted grant: Novartis, Cecilie Heegaard Brahe Grant/research support from: Unrestricted grant: Novartis, Anne Gitte Loft: None declared, Johan Askling Grant/research support from: Karolinska Institutet (JA) has or has had research agreements with the following pharmaceutical companies, mainly in the context of the ATRIS national safety monitoring programme for rheumatology biologicals: Abbvie, BMS, MSD, Eli Lilly, Pfizer, Roche, Samsung Bioepis, and UCB., Consultant for: Karolinska Institutet has received remuneration for JA participating in ad boards arranged by Lilly, Novartis, and Pfizer., Adrian Ciurea Consultant for: AbbVie, Celgene, Janssen-Cilag, MSD, Eli Lilly, Novartis, Pfizer, UCB, Speakers bureau: Abbvie, Celgene, Janssen-Cilag, MSD, Eli Lilly, Novartis, Pfizer, UCB, Heřman Mann Consultant for: Pfizer, Eli Lilly, Sanofi, Speakers bureau: AbbVie, Roche, Pfizer, MSD, Eli Lilly, Sanofi, Servet Akar Grant/research support from: MSD, Abbvie, Roche, UCB, Novartis, Pfizer, Amgen, Consultant for: MSD, Abbvie, Roche, UCB, Novartis, Pfizer, Amgen, Speakers bureau: Pfizer, Eirik kristianslund: None declared, Dan Nordstrom Grant/research support from: MSD, Pfizer, Consultant for: AbbVie, BMS, MSD, Novartis, Roche, Pfizer, UCB, Speakers bureau: Novartis, UCB, Maria Jose Santos: None declared, Catalin Codreanu: None declared, Manuel Pombo-Suarez: None declared, Ziga Rotar: None declared, Bjorn Gudbjornsson: None declared, Daniela Di Giuseppe: None declared, Michael Nissen Consultant for: AbbVie, Lilly, Novartis, and Pfizer, Karel Pavelka: None declared, Soner Senel: None declared, Joe Sexton: None declared, Kari Eklund: None declared, Anabela Barcelos: None declared, Ruxandra Ionescu: None declared, Carlos Sanchez-Piedra: None declared, Matija Tomsic: None declared, Arni Jon Geirsson: None declared, Irene van der Horst-Bruinsma Grant/research support from: MSD, Pfizer, AbbVie, Consultant for: Abbvie, UCB, MSD, Novartis, Speakers bureau: BMS, AbbVie, Pfizer, MSD, Gary Macfarlane Grant/research support from: Have received research grants (not current) from Abbvie and Pfizer. Have received research grants (not current) from the British Society for Rheumatology, who received the funds from Abbive, Pfizer and UCB. Have received research grant (current) from the British Society for Rheumatology, who received the funds from Celgene., Florenzo Iannone Consultant for: F Iannone has received consultancy fees and/or speaker honoraria from Pfizer, AbbVie, MSD, BMS, Novartis, Lilly, UCB outside this work, Speakers bureau: F Iannone has received consultancy fees and/or speaker honoraria from Pfizer, AbbVie, MSD, BMS, Novartis, Lilly, UCB outside this work, Brigitte Michelsen: None declared, Lise Hyldstrup: None declared, Niels Steen Krogh: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen, Pfizer, Consultant for: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck, Samsung Bioepis, Mikkel Ǿstergaard Grant/research support from: Abbvie, Celgene, Centocor, Merck, Novartis, Consultant for: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, and UCB, Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, and UCB

Background The efficacy of Tumour Necrosis Factor inhibitor (TNFi) in patients with psoriatic arthritis (PsA) has been investigated in randomized controlled trials (RCTs) with strict inclusion and exclusion criteria. Patients treated in routine care are more heterogeneous and only ≈20-30% of patients receiving TNFi in routine care would have been eligible to be enrolled in the RCTs1. This emphasizes the need for real-world observational data as a valuable supplement to RCTs. Studying large patient groups from several European countries would increase the external validity of the results. Objectives To investigate Tumour Necrosis Factor inhibitor (TNFi) retention rates at 12 months (primary objective), 6 and 24 months, and remission rates at the same time-points in biologic-naive patients with PsA from the EuroSpA Collaboration. Methods Prospectively collected data on PsA patients from 12 European registries were uploaded through the secure Virtual Private Network pipelines to the EuroSpA server, and pooled. Baseline characteristics were investigated with non-parametric descriptive statistics. TNFi retention rates (Kaplan-Meier statistics), and 28-joint count Disease activity Score (DAS28) Results Overall, 14,261 patients with PsA initiated a 1st TNFi. Baseline characteristics of the pooled population are shown in the Table. The median 12-month retention rate (95%CI) was 77% (76-78%), ranging from 68-90% across registries (Figure). Overall, DAS28/DAPSA28 remission rates at 6 months were 56%/27% (LUNDEX-adjusted: 45%/22%). In patients initiating a 1stTNFi after 2009 with registered fulfillment of CASPAR criteria (n=1,980) or registered ≥1 swollen joint at baseline (n=5,803), the retention rates and remission rates were similar to those found overall (Table). Conclusion Approximately half of >14,000 patients with PsA who initiated 1st TNFi treatment in routine care were in DAS28-remission after 6 months, and three out of four were still on the drug after 1 year. References [1] Clin Exp Rheumatol, 2018, 36(6):1068-1073 [2] arthritis Rheum, 2006, 54(2): 600-6 Acknowledgement Novartis Pharma aG and IQVIA for supporting the EuroSpA collaboration. Disclosure of interests Cecilie Heegaard Brahe Grant/research support from: Unrestricted grant: Novartis, Lykke Ornbjerg Grant/research support from: Unrestricted grant: Novartis, Lennart T.H. Jacobsson Consultant for: LJ has received lecture and consulting fees from Pfizer, abbvie, Novartis, Eli-Lily and Janssen, Michael Nissen Consultant for: abbVie, Lilly, Novartis, and Pfizer, Eirik kristianslund: None declared, Heřman Mann Consultant for: Pfizer, Eli Lilly, Sanofi, Speakers bureau: abbVie, Roche, Pfizer, MSD, Eli Lilly, Sanofi, Maria Jose Santos: None declared, Manuel Pombo-Suarez: None declared, Dan Nordstrom Grant/research support from: MSD, Pfizer, Consultant for: abbVie, BMS, MSD, Novartis, Roche, Pfizer, UCB, Speakers bureau: Novartis, UCB, Ziga Rotar: None declared, Bjorn Gudbjornsson: None declared, Fatos onen: None declared, Catalin Codreanu: None declared, Ulf Lindstrom: None declared, Burkhard Moeller Consultant for: Swissmedic Human Medicines Expert Committee Member (regulatory agency), Joe Sexton: None declared, Karel Pavelka: None declared, anabela Barcelos: None declared, Carlos Sanchez-Piedra: None declared, Kari Eklund: None declared, Matija Tomsic: None declared, Thorvardur Jon Love Consultant for: Received reimbursment from Celgene for speaking about guidelines for the treatment of psoriatic arthritis, Gercek Can: None declared, Ruxandra Ionescu: None declared, anne Gitte Loft: None declared, Marleen van de Sande Grant/research support from: van Janssen, Novartis, Eli Lily, Consultant for: Novartis and abbvie, Irene van der Horst-Bruinsma Grant/research support from: MSD, Pfizer, abbVie, Consultant for: abbvie, UCB, MSD, Novartis, Speakers bureau: BMS, abbVie, Pfizer, MSD, Gary Macfarlane Grant/research support from: Have received research grants (not current) from abbvie and Pfizer. Have received research grants (not current) from the British Society for Rheumatology, who received the funds from abbive, Pfizer and UCB. Have received research grant (current) from the British Society for Rheumatology, who received the funds from Celgene., Florenzo Iannone Consultant for: F Iannone has received consultancy fees and/or speaker honoraria from Pfizer, abbVie, MSD, BMS, Novartis, Lilly, UCB outside this work, Speakers bureau: F Iannone has received consultancy fees and/or speaker honoraria from Pfizer, abbVie, MSD, BMS, Novartis, Lilly, UCB outside this work, Lise Hyldstrup: None declared, Niels Steen Krogh: None declared, Mikkel Ǿstergaard Grant/research support from: abbvie, Celgene, Centocor, Merck, Novartis, Consultant for: abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, and UCB, Speakers bureau: abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, and UCB, Merete L. Hetland Grant/research support from: BMS, MSD, abbVie, Roche, Novartis, Biogen, Pfizer, Consultant for: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck, Samsung Bioepis

Background Work disability is a common consequence of Rheumatoid Arthritis (RA) with economic implications for both the patient and society. Scarce information is available on work and disease-related factors associated with early retirement in Portugal. Objectives To evaluate the rate of early retirement due to RA. Secondary aim consists in the identification of its main predictors, both work and disease-related. Methods Retrospective cohort study involving two national rheumatology centers, including patients with RA according the ACR/EULAR 2010 or the 1987 ACR Classification Criteria for RA. Patients retired prior to RA diagnosis, never-employed or with missing information on current work status were excluded. Type of work was independently classified as non-manual/manual/heavy manual by two authors based on patient’s occupation with excellent inter-agreement (Cohen’s kappa coefficient 0.91). Retirement due to RA versus retirement for other reasons were compared using T-test and Chi-2 test as adequate. Variables with p Results 492 patients were included (80.3% female, aged 60.9 ±13.1 years-old, mean disease duration 15.9 ±10.5 years). Until the present time, 45.1% (n=222) of the patients retired, this being due to RA in 59.5% of the cases. Early retirement due to RA translated into 6.5 years of active work lost, compared to retirement due to other causes. Patients who retired due to RA are more likely to be younger at diagnosis (49.6 ± 9.0 vs. 56.1 ± 8.6 years-old; p Conclusion Early retirement is still common among patients with RA: 60% in this cohort. The main reasons for early retirement are associated with the disease itself, but work-related factors also play a relevant role. References [1] P. A. Laires, M. Gouveia. Association of rheumatic diseases with early exit from paid employment in Portugal. Rheumatol Int (2014) 34:491–502. [2] K. Puolakka, H. Kautiainen, T. Mottonen, P. Hannonen, et al. Predictors of productivity loss in early rheumatoid arthritis: a 5 year follow up study. Ann Rheum Dis2005;64:130–133. [3] D. Lacaille, S. Sheps, J. J. Spinelli, A. Chalmers, J. M. Escaile. Identification of modifiable work-related factors that influence the risk of work disability in rheumatoid arthritis. Arthritis Rheum. 2004Oct15;51(5):843-52. Disclosure of Interests None declared