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Background: We aimed to describe the uptake of newer biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in psoriatic arthritis (PsA) in the Nordic countries and to compare their retention and effectiveness.Methods: Patients with PsA starting a b/tsDMARD in 2012-2020 in five Nordic rheumatology registers were included. Uptake and patient characteristics were described, with comorbidities identified from linkages to national patient registries. One-year retention and 6-month effectiveness (proportions achieving low disease activity (LDA) on the Disease Activity Index for PSoriatic Arthritis based on 28-joint evaluation) for the newer b/tsDMARDs (abatacept/apremilast/ixekizumab/secukinumab/tofacitinib/ustekinumab) were compared with adalimumab through adjusted regression models stratified by treatment course (first, second/third, and fourth or more).Results: In total, 5659 treatment courses with adalimumab (56% biologic-naïve) and 4767 courses with a newer b/tsDMARD (21% biologic-naïve) were included. The uptake of newer b/tsDMARDs increased from 2014 and plateaued in 2018. Patient characteristics appeared similar across treatments at treatment start. Adalimumab was more often used as the first course and newer b/tsDMARDs more often in biologic-experienced patients. Used as a second/third b/tsDMARD, the retention rate and the proportion achieving LDA were significantly better for adalimumab (rate 65%, proportion 59%) compared with abatacept (45%, 37%), apremilast (43%, 35%), ixekizumab (LDA only, 40%) and ustekinumab (LDA only, 40%), but not significantly different from other b/tsDMARDs.Conclusion: Uptake of newer b/tsDMARDs occurred mainly in biologic-experienced patients. Regardless of mode of action, only a minority of patients starting a second or later b/tsDMARD course remained on drug and achieved LDA. Superior outcomes for adalimumab indicate that the positioning of newer b/tsDMARDs in the PsA treatment algorithm remains to be established. Background: We aimed to describe the uptake of newer biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in psoriatic arthritis (PsA) in the Nordic countries and to compare their retention and effectiveness. Methods: Patients with PsA starting a b/tsDMARD in 2012-2020 in five Nordic rheumatology registers were included. Uptake and patient characteristics were described, with comorbidities identified from linkages to national patient registries. One-year retention and 6-month effectiveness (proportions achieving low disease activity (LDA) on the Disease Activity Index for PSoriatic Arthritis based on 28-joint evaluation) for the newer b/tsDMARDs (abatacept/apremilast/ixekizumab/secukinumab/tofacitinib/ustekinumab) were compared with adalimumab through adjusted regression models stratified by treatment course (first, second/third, and fourth or more). Results: In total, 5659 treatment courses with adalimumab (56% biologic-naïve) and 4767 courses with a newer b/tsDMARD (21% biologic-naïve) were included. The uptake of newer b/tsDMARDs increased from 2014 and plateaued in 2018. Patient characteristics appeared similar across treatments at treatment start. Adalimumab was more often used as the first course and newer b/tsDMARDs more often in biologic-experienced patients. Used as a second/third b/tsDMARD, the retention rate and the proportion achieving LDA were significantly better for adalimumab (rate 65%, proportion 59%) compared with abatacept (45%, 37%), apremilast (43%, 35%), ixekizumab (LDA only, 40%) and ustekinumab (LDA only, 40%), but not significantly different from other b/tsDMARDs. Conclusion: Uptake of newer b/tsDMARDs occurred mainly in biologic-experienced patients. Regardless of mode of action, only a minority of patients starting a second or later b/tsDMARD course remained on drug and achieved LDA. Superior outcomes for adalimumab indicate that the positioning of newer b/tsDMARDs in the PsA treatment algorithm remains to be established.

Background The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma). Methods Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed. Results A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used. Conclusions We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

Background/Aims In axial spondyloarthritis, it has been shown that while some adverse lifestyle factors (smoking and high body mass index (BMI)) are less likely to respond to TNF inhibition (TNFi), those who drink alcohol are more likely to respond to treatment - a result currently unexplained, and unlikely to be causal. We aimed to investigate these associations in psoriatic arthritis (PsA) and to quantify the impact of lifestyle factors on TNFi treatment response. Methods Adults with PsA commencing TNFi were identified via the European Spondyloarthritis Research Collaboration Network (https://eurospa.eu). Participants were required to have data on lifestyle factors (smoking, alcohol consumption, and/or BMI) recorded within ±30 days of commencing TNFi. The relationship between lifestyle factors and treatment outcome (ACR-50 response criteria at 12 months) was assessed using logistic regression, adjusted for age, sex, country, year of TNFi initiation, disease duration and baseline disease activity (DAS28). The analysis was then repeated for other treatment response criteria: ACR-20, ACR-70, DAPSA28-remission, DAPSA68-remission and Minimal Disease Activity. Results From 12 PsA registries, 9409 participants were included, 21% of whom were current smokers, 54% drank alcohol, 38% were overweight and 29% were obese. Other baseline characteristics are shown in Table 1. Among smokers, 18% met ACR-50 response criteria at 12 months, versus 26% of non-smokers, an association that remained after adjusting for potential confounders (adjusted odds ratio: 0.59; 95%CI: 0.48-0.72). Participants who were overweight (adjusted odds ratio: 0.80; 0.64-0.99) or obese (0.57; 0.44-0.72) were also less likely to achieve treatment response, compared to patients of normal weight. Similar results were seen across other outcome measures. The proportion who achieved ACR-50 response did not differ between patients who did/did not consume alcohol (both 22%). Conclusion Smoking and high BMI were associated with substantial decreases in the likelihood of TNFi response. The addition of non-pharmacological therapy, including the modification of adverse lifestyle factors, may offer the potential to enhance treatment outcomes. For example, if 100 patients were able to give up smoking when commencing TNFi, an additional eight would achieve ACR-50 at 12 months. Previous findings regarding alcohol and treatment response in axSpA were not replicated in PsA. Disclosure G.T. Jones: None. O. Rotariu: None. B. Michelsen: None. B. Glintborg: None. B. Gudbjornsson: None. T.J. Love: None. D. Nordström: None. T. Sokka: None. J. Vencovský: None. P. Horák: None. Z. Rotar: None. M. Tomšič: None. M. van der Sande: None. M.J. Nissen: None. B. Möller: None. C. Codreanu: None. J.K. Wallman: None. K.M. Fagerli: None. S.H. Rasmussen: None. L.M. Ørnbjerg: None. M.J. Santos: None. P. Carvalho: None. M.L. Hetland: None. M. Østergaard: None. G.J. Macfarlane: None.

To study 10-year outcomes in patients with early seropositive rheumatoid arthritis (RA) whether the outcomes improve over time.Data of 1754 patients with early RA, diagnosed in 1997-2011 were explored; 66% (n=1151) were seropositive and included in the analyses. Patients were divided into five groups by diagnosis year: 1997-1999, 2000-2002, 2003-2005, 2006-2008 and 2009-2011. Clinical parameters including disease activity and function were compared between the groups.A total of 832 (72%) patients attended the 10-year visit, while 319 did not (e.g. 196 had died and 49 moved). The median (IQR) DAS28 decreased from 2.9 (2.2, 3.7) to 2.3 (1.4, 3.0) (p0.001) between groups 1997-1999 and 2009-2011. The proportion of patients with 2 or more swollen joints on 46 joint count decreased from 33% to 13%, respectively. Median (IQR) pain decreased from 30 (15, 52) to 25 (6, 51) (p=0.03) and fatigue from 31 (12, 52) to 15 (2, 50) (p=0.012). Median (IQR) dr.global decreased from 20 (5, 40) to 0 (0, 5) p0.001. The proportion of patients with a HAQ-score of ≤0.5 increased from 39% to 49% (p=0.002). The proportion of patients that had used methotrexate by the 10-year visit increased from 79% to 96% (p0.001) and the proportion of patients who had used bDMARDs increased from 11% to 28% (p=0.001), respectively.Several clinical outcomes were better in patients who were diagnosed more recently. More intensive use of medications over time might have contributed to these improvements.

Objectives Many axial spondylarthritis (axSpA) patients receive a conventional synthetic DMARD (csDMARD) in combination with a TNF inhibitor (TNFi). However, the value of this co-therapy remains unclear. The objectives were to describe the characteristics of axSpA patients initiating a first TNFi as monotherapy compared with co-therapy with csDMARD, to compare one-year TNFi retention and remission rates, and to explore the impact of peripheral arthritis. Methods Data was collected from 13 European registries. One-year outcomes included TNFi retention and hazard ratios (HR) for discontinuation with 95% CIs. Logistic regression was performed with adjusted odds ratios (OR) of achieving remission (Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP Results Amongst 24 171 axSpA patients, 32% received csDMARD co-therapy (range across countries: 13.5% to 71.2%). The co-therapy group had more baseline peripheral arthritis and higher CRP than the monotherapy group. One-year TNFi-retention rates (95% CI): 79% (78, 79%) for TNFi monotherapy vs 82% (81, 83%) with co-therapy (P Conclusion This large European study of axial SpA patients showed similar one-year treatment outcomes for TNFi monotherapy and csDMARD co-therapy, although considerable heterogeneity across countries limited the identification of certain subgroups (e.g. peripheral arthritis) that may benefit from co-therapy.

Background: Rheumatoid arthritis is a chronic inflammatory disease with a well-recognised female preponderance. In this post-hoc analysis of the NORD-STAR trial, we aimed to examine sex differences in remission rates with three different biological treatments combined with methotrexate versus active conventional treatment over 24 weeks, in patients with early rheumatoid arthritis. Methods: NORD-STAR was a multicentre, investigator-initiated, assessor-blinded, phase 4, randomised, controlled trial of early rheumatoid arthritis, done in Denmark, Finland, Iceland, Norway, Sweden, and the Netherlands. Newly diagnosed patients, naive to disease-modifying antirheumatic drugs, aged 18 years or older with early rheumatoid arthritis and with a symptom duration less than 24 months were randomly assigned (1:1:1:1) to receive active conventional treatment, certolizumab-pegol, abatacept, or tocilizumab. Sex was reported in case report forms by study physicians or by study nurses. Data on gender were not collected. Remission outcomes were analysed with logistic generalised estimating equations (GEE), using a logit link and exchangeable correlation matrix. The model included treatment, time, sex, and the relevant interactions. For this post-hoc analysis, the co-primary outcomes were differences in Clinical Disease Activity Index (CDAI) remission (CDAI score ≤2·8) between sexes over time and at week 24, assessed with interaction terms (men vs women within each treatment comparison) and using active conventional treatment as the reference. We present adjusted average marginal differences in remission rates (risk differences) with 95% CIs. Findings: Between Dec 14, 2012, and Dec 11, 2018, 812 patients were enrolled and randomly assigned; 217 received active conventional treatment, 203 received certolizumab-pegol, 204 received abatacept, and 188 received tocilizumab. All 812 patients were included in this analysis; 561 (69%) were women and 251 (31%) were men. Observed CDAI remission rates at 24 weeks were numerically higher among men than among women despite comparable disease activity at baseline (55% vs 50% with active conventional treatment, 57% vs 52% with certolizumab-pegol, 65% vs 51% with abatacept, and 61% vs 40% with tocilizumab). In the adjusted analysis, with active conventional treatment as the reference, the only significant difference between men and women was in the tocilizumab group (pinteraction=0·015); men in the tocilizumab group had a higher probability of CDAI remission, on average over time, than did men in the active conventional treatment group (0·12; 95% CI 0·00 to 0·23), whereas women in the tocilizumab group had a lower probability of remission than did women in the active conventional treatment group (–0·05, 95% CI –0·13 to 0·02). Interpretation: Numerically higher remission rates were observed in men than in women in all four treatment groups at week 24, suggesting that this generalised sex difference is not related to the treatment. The difference between men and women was significantly greater with tocilizumab, an interleukin (IL)-6 inhibitor, than with active conventional treatment, suggesting a possible additional sex-based effect specific for IL-6 blockade. Funding: None.

The therapeutic armamentarium available for treatment of rheumatoid arthritis (RA) has changed significantly over the past 30 years, transforming the therapeutic landscape and prognosis for a substantial proportion of patients with RA. Combination therapies represent an important therapeutic paradigm for management of rheumatoid arthritis. The rationale for combination therapies is clear and demonstrated to bring treatment benefit to patients achieving lower disease activity scores and reduced radiologic progression according to ‘treat-to-target’ principles. A rigorous evidence-based debate is required involving not only parameters related to disease activity scores and radiologic progression, but related to the cost-effectiveness analysis of using many of these newer agents compared to older csDMARDs. This chapter addresses the evidence related to the utilization of combination strategies for the management of RA as compared to monotherapy.

OP0018 (2020) A MULTICENTER RANDOMIZED STUDY IN EARLY RHEUMATOID ARTHRITIS TO COMPARE ACTIVE CONVENTIONAL THERAPY VERSUS THREE BIOLOGICAL TREATMENTS: 24 WEEK EFFICACY RESULTS OF THE NORD-STAR TRIAL M. L. Hetland1, E. A. Haavardsholm1, A. Rudin1, D. Nordström1, M. Nurmohamed1, B. Gudbjornsson1, J. Lampa1, K. Hørslev-Petersen1, T. Uhlig1, G. Gröndal1, M. Ǿstergaard1, M. Heiberg1, J. Twisk1, S. Krabbe1, K. Lend1, I. Olsen1, J. Lindqvist1, A. K. H. Ekwall1, K. L. Grøn1, M. C. Kapetanovic1, F. Faustini1, R. Tuompo1, T. Lorenzen1, G. Cagnotto1, E. Baecklund1, O. Hendricks1, D. Vedder1, T. Sokka-Isler1, T. Husmark1, M. K. A. Ljosa1, E. Brodin1, T. Ellingsen1, A. Soderbergh1, M. Rizk1, Å. Reckner1, P. Larsson1, L. Uhrenholt1, S. A. Just1, D. Stevens1, T. B. Laurberg1, G. Bakland1, R. Van Vollenhoven1 1Denmark, Finland, Iceland, Netherlands, Norway, Sweden Background: The optimal first-line treatment of patients (pts) with early rheumatoid arthritis (RA) is yet to be established. Objectives: The primary aim was to assess and compare the proportion of pts who achieved remission with active conventional therapy (ACT) and with three different biologic therapies after 24 wks. Secondary aims were to assess and compare other efficacy measures. Methods: The investigator-initiated NORD-STAR trial (NCT01491815) was conducted in the Nordic countries and Netherlands. In this multicenter, randomized, open-label, blinded-assessor study pts with treatment-naïve, early RA with DAS28>3.2, and positive RF or ACPA, or CRP >10mg/L were randomized 1:1:1:1. Methotrexate (25 mg/week after one month) was combined with: 1) (ACT): oral prednisolone (tapered quickly); or : sulphasalazine, hydroxychloroquine and mandatory intra-articular (IA) glucocorticoid (GC) injections in swollen joints

Objectives The classification of seronegative arthritides can be challenging. Our aim was to examine the incidence of SpA diagnosis among patients initially diagnosed as seronegative RA. Methods Using nationwide Finnish registers from social insurance institutions, we identified all adult patients who were diagnosed with incident seronegative RA [International Classification of Diseases (ICD)-10 code M06] from 1 January 2000 to 31 December 2014. The patients whose diagnoses subsequently changed to the ICD-10 codes of SpA (M07, M45, M46, K50 and K51) were identified in the national care register, until 31 December 2016. Results A total of 9784 adult seronegative RA patients were identified. Of these, 564 patients had their diagnosis subsequently changed to SpA: 275 (48.7%) patients with PsA, 245 (43.4%) patients with axial SpA and 44 (7.8%) patients with diagnoses related to IBD. The cumulative incidence of SpA diagnoses in 15 years was 10.4% (95% CI 8.9, 12.1) and 8.1% (95% CI 7.1, 9.3) in men and women, respectively. Conclusion This study calls for vigilance in seronegative RA patients, especially those with more atypical presentations, since the diagnosis could change. The possibility of SpA diagnosis should be considered and specifically looked for, as this could impact on management and response to treatment.

The objective of this study is to examine 25-hydroxyvitamin D [25(OH)D] (D-25) levels and associations with patient- and disease-related factors in rheumatic diseases. This is a register-based study of D-25 levels in adult patients seen at the Central Finland Hospital rheumatology clinic (January 2011–April 2015). Demographic, clinical, laboratory, and patient-reported outcomes (PROs) were collected as part of the normal infrastructure of the outpatient clinic and examined for their association with D-25 level. Statistical analysis included descriptive statistics and univariable and multivariable regression analyses adjusting for age and gender. D-25 was measured in 3203 patients (age range 15–91 years, mean 54; 68% female) with diagnoses including RA (n = 1386), unspecified arthralgia/myalgia (n = 413), and connective tissues diseases (n = 213). The overall D-25 mean (SD) level was 78 (31) and median (IQR) 75 (55, 97). At baseline, 17.8% had D-25 deficiency, and only 1.6% severe deficiency (< 25 nmol/l); 34%/49% had sufficient/optimal D-25 levels. Higher D-25 levels were associated with older age, lower BMI, and regular exercise (all p < 0.001) among other factors. In multivariable analyses, younger age, non-white background, higher BMI, smoking, less frequent exercise (p < 0.001), and first visit to the clinic (p = 0.033) remained significantly associated with D-25 deficiency. Among those with sub-optimal D-25 levels, 64% had improved to sufficient/optimal levels after a median (IQR) of 13 (7.8, 22) months. The proportion of patients with D-25 deficiency in this study was generally low. Older patients had considerably higher D-25 levels compared to younger patients. Lower physical exercise and higher BMI were associated with higher risk of deficiency. The study supports the benefit of strategies to help minimize the risk of D-25 deficiency., published version, peerReviewed

To assess what proportion of patients with disease-modifying anti-rheumatic drug (DMARD)-naïve early rheumatoid arthritis (ERA) reach 28-joint Disease Activity Score (DAS28) remission over 1 year, and remission variability across clinics in Finland.Patients with DMARD-naïve newly diagnosed inflammatory arthritis were recruited. The proportion of patients in 28-joint Disease Activity Score with three variables (DAS28-3) remission was compared across sites. Repeated measures were analysed using a mixed models approach with appropriate distribution and link function.In total, 611 patients were recruited at five sites: 67% were female; the mean (sd) age was 57 (16) years; 71% and 68% were positive for rheumatoid factor and anti-cyclic citrullinated peptides, respectively; and 23% had radiographic erosions. A total of 506 (83%) fulfilled the American College of Rheumatology/European League Against Rheumatism 2010 classification criteria for rheumatoid arthritis for further analyses. DAS28-3 remission was met by 68% and 75% at 3 and 12 months, respectively. The clinical site had no effect on remission when adjusted for confounders. At baseline, 68% used methotrexate-based combination therapy, and 31% used triple therapy with methotrexate, hydroxychloroquine, and sulphasalazine (the Fin-RACo regimen). In multivariate analysis, the only independent predictors of DAS28-3 remission at 12 months were lower baseline DAS28-3 and triple therapy as the initial treatment.Three out of four DMARD-naïve ERA patients in Finland are in remission during the first year from the diagnosis. High remission rates were achieved for most patients with the use of conventional synthetic DMARDs in combination. Treatment of DMARD-naïve ERA patients with the FIN-RACo regimen is a predictor of DAS28-3 remission in real-life rheumatology settings.

We aimed to characterise the clinical and radiographical phenotype of calcium pyrophosphate dihydrate deposition (CPPD) disease in patients initially diagnosed with seronegative RA, and to increase the awareness that CPPD disease can be falsely diagnosed as seronegative rheumatoid arthritis (RA).Altogether 435 early seronegative RA patients were clinically diagnosed in a single rheumatology centre and scheduled for a 10-year follow-up. All clinical data were collected and reviewed. CPPD-related arthritis was suspected if a patient had typical radiographical findings and suitable clinical pattern of CPPD or calcium pyrophosphate crystals were found in the synovial fluid. These patients are the subjects of this study.Among 435 seronegative RA patients, 17 patients (3.9%) (baseline mean age 71.2 years, 82% women) with CPPD disease were identified. CPPD resembling clinical patterns in these patients were: chronic CPP crystal inflammatory arthritis (9 patients), acute CPP crystal arthritis (6 patients) and OA with CPPD (2 patients). All had typical radiographical findings of CPPD: Chondrocalcinosis (CC) of triangular fibrocartilage (17 patients [100%]), CC of knee (9 patients [53%]), CC or narrowing of metacarpophalangeal joints (7 patients [41.2%]), CC of metatarsophalangeal joints (4 patients [23.5%]), CC of symphysis pubis (1 patient [5.8%]), CC of glenohumeral joint (1 patient [5.8%]) and scapholunate advanced collapse (5 patients [29.4%]). None of these patients developed typical RA-like erosions.CPPD disease can mimic seronegative RA at baseline and is important in the differential diagnosis of seronegative arthritis at baseline and during follow-up. The prevalence of CPPD patients in our early seronegative RA patients was 3.9%, the percentage was 7.0% among patients ≥60 years at baseline.

Background Calcium pyrophosphate deposition (CPPD) disease is caused by calcium pyrophosphate (CPP) crystals and seen mainly in elderly. Clinical presentation can be heterogeneous. The arthropathy of CPPD may mimic RA, particularly if involving common joints seen in RA. Diagnosis of CPPD arthritis is based on CPP crystals seen in synovial fluid (SF) analysis, chondrocalcinosis (CC) seen in radiographs and/or on typical clinical presentation for CPPD. Early diagnosis of CPPD can be challenging and a proportion of CPPD patients may be misdiagnosed. We demonstrate 17 cases with CPPD initially diagnosed and treated as seronegative RA. Objectives To increase awareness that CPPD disease may resemble seronegative RA and to characterise clinical and radiographic phenotypes of these CPPD patients. Methods Altogether 435 early seronegative early RA patients were clinically diagnosed in a single rheumatology centre and scheduled for 10 year follow-up. All clinical data and radiographs were collected and reviewed. Patients were re-diagnosed as CPPD related arthritis if they had typical radiographic findings and suitable clinical pattern of CPPD or positive CPP crystal finding in SF. These patients are the subjects of this study. Results 17 patients were identified with a CPPD disease. The mean age at baseline was 71.2 years, and 82% were women. In 7 (41.2%) patients baseline symptoms were polyarticular, and in all these patients` wrist, MCP or PIP joints were affected; other symptomatic joints were hip (1 patient) and ankle (3 patients). The initial symptoms of 6 (35.3%) patients were oligoarticular, including MCP and PIP joint involvement (2 patients) or wrist and MCP, PIP or MTP joint symptoms (4 patients). Four (23.5%) patients were diagnosed as monoarthritis including ankle (1 patient) and wrist (3 patients). Seven patients (41.2%) fulfilled 1987 ACR criteria for RA and the diagnosis of early RA of the other 10 patients (58.8%) was based on clinical judgement. During the follow up period the SF analysis of 4 patients was available, 3 SFs showing positivity for CPP crystals. In 13 patients, SF had not been taken. In retrospect the baseline radiographs of 10 patients showed evidence of CC, either in wrists or knees. During follow up all patients developed typical clinical pattern for CPPD disease: chronic CPP crystal inflammatory arthritis (9 patients), acute CPP crystal arthritis (6 patients) and OA with CPPD (2 patients). All developed similar radiographic findings compatible with CPPD, including CC of triangular fibrocartilage (17 patients), CC of knee (9 patients), CC or narrowing of MCP joints (7 patients), CC of metatarsophalangeal (MTP) joints (4 patients), CC of symphysis pubis (1 patient), CC of glenohumeral joint (1 patient) and SLAC (5 patients). None of these patients developed typical RA-like erosions. Conclusions The prevalence of CPPD patients in our early seronegative RA patients was 3.9%. CPPD disease can mimic seronegative RA at baseline and is important in the differential diagnosis of seronegative arthritis. Reference [1] Zhang W, Doherty M, Bardin T, et al. European league against rheumatism recommendations for calcium pyrophosphate deposition. Part I: Terminology and diagnosis. Ann Rheum Dis. 2011;70(4):563–570. Disclosure of Interest None declared

Reports to-date indicate similarity between infliximab biosimilar (IB) and infliximab bio-original (IO) in clinical efficacy and safety. This study examines the survival of IB and IO using routinely collected data over a 2-year period.Routinely collected clinical data inputted directly in an electronic database at a large rheumatology centre were analysed. Adult patients taking IO or IB for any rheumatological diagnosis were included. Kaplan-Meier survival analyses were used to examine IB and IO survival, with a sub-group analysis among those starting infliximab from 2008 onwards.Out of 395 patients analysed, 53% (n=209) were female; the majority had rheumatoid arthritis (31%) followed by spondyloarthritis (28%). Ninety-nine patients had IB as the first infliximab drug. Patients who started on IB vs. IO as their first infliximab product, had better survival over the first 2 years (log rank=0.001). Discontinuation due to inefficacy was much commoner in IO versus IB users (18 vs. 5%). In patients switching from IO to IB, drug survival was better versus those receiving IB as the first infliximab drug (log rank=0.073).IB was well-tolerated and comparable to IO, with no additional safety signals identified. The results suggest superior survival of IB over IO over the first 2 years.

To gain clinical experience on the effectiveness and safety of switching from infliximab-Remicade(INX) to infliximab-biosimilar-CT-P13(INB) in patients with established rheumatic disease.Patients receiving INX treatment at a rheumatology clinic consented to switching from INX to INB. Patient reported outcomes (PROs), disease-activity, and inflammatory markers were recorded at every visit. Generalized estimating equation models and time-dependent area under the curve (AUC) before/during INX and INB treatments were employed.Thirty-nine consecutive patients [mean (SD) age 53 (11), 17 F] with various rheumatic diseases were switched to INB after a mean (SD) of 4.1 (2.3) years on INX. Thirty-one patients were on concomitant methotrexate. At a median (range) of 11 (7.5-13) months following the first administration of INB, AUCs for disease activity and PROs were similar for INX and INB. They were better compared to those prior to INX. Eleven patients (28.2%) discontinued INB, due to INX antidrug antibodies detected prior to INB infusion (n = 3); latent tuberculosis (n = 1); new-onset neurofibromatosis (n = 1); subjective reasons with no objective deterioration of disease (n = 6).The clinical effectiveness of INB in both PROs and disease-activity measures was comparable to INX during the first year of switching, with no immediate safety signals. Subjective reasons (negative expectations) may play a role among discontinuations of biosimilars. Larger patient numbers and longer follow-up are necessary for confirming this clinical experience.

The creation of the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis (RA; Figure 1)1 sought to address some of the criticisms of the previous ACR criteria set published in 1987 (Figure 2)2 — namely that they were insensitive, particularly early in the disease course, and that this led to the exclusion of many patients with early disease from clinical trials and research studies3. As a result, there was an absence of evidence regarding the efficacy of new treatments in this group of patients, who may have had the potential to benefit the most4,5. Thus, 1 aim of the 2010 criteria was to identify those patients with early RA with the key purpose of rapid disease-modifying antirheumatic drug (DMARD) initiation. However, the ability to classify patients as having RA is important at all phases of the disease, early and late. A case definition is required as an entry criterion not only to clinical trials, but also a consensus for inclusion in longterm observational studies and the whole spectrum of research in RA. Numerous studies have tested the validity of the new criteria since their publication against various standards6, but they have generally been applied in patients with relatively short duration of symptoms, ranging from < 3 months to < 2 years. Thus, the question remains, can we extend these classification criteria to patients with established disease? Figure 1. 2010 ACR/EULAR Classification criteria for RA1. ACR: American College of Rheumatology; EULAR: European League Against Rheumatism; RF: rheumatoid factor; ACPA: anticitrullinated protein antibodies; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; RA: rheumatoid arthritis. From Aletaha, et al. Ann Rheum Dis 2010;69:1580–8; with permission. Figure 2. 1987 ACR Classification criteria for RA2. ACR: American … Address correspondence to Professor D.P.M. Symmons, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, The University of Manchester, Manchester Academic Health Science Centre, UK. E-mail: deborah.symmons{at}manchester.ac.uk

Objective.Because of the role of tumor necrosis factor (TNF) in host defense, it was hypothesized that its inhibition might lead to an increased risk of malignancies and infections. The objective of our study was to assess the incidence of serious infections leading to hospitalization and malignancies among patients with rheumatoid arthritis (RA) receiving either TNF inhibitor or rituximab (RTX) therapy.Methods.The study population was identified from the National Register for Biologic Treatment in Finland and the hospital records of Central Finland Central Hospital for conventional disease-modifying antirheumatic drug (cDMARD) users. Data on infections and malignancies were acquired from national healthcare registers. A Poisson model was used to calculate the adjusted incidence rate ratios (aIRR) and was composed of age, sex, time from diagnosis, year of the beginning of the followup, rheumatoid factor status, Disease Activity Score at 28 joints, Health Assessment Questionnaire, prior malignancy, prior serious infection, prior biologic use, and time-updated use of methotrexate, sulfasalazine, hydroxychloroquine, and oral corticosteroids as confounders.Results.In total, during the followup of 10,994 patient-years, 92 malignancies and 341 serious infections were included in the analyses. The aIRR of infections compared to cDMARD users were 1.2 (95% CI 0.63–2.3), 0.84 (95% CI 0.53–1.3), 0.98 (95% CI 0.60–1.6), and 1.1 (95% CI 0.59–1.9) for the patients treated with infliximab (IFX), etanercept, adalimumab, and RTX, respectively. The crude rates of malignancies were highest among the users of cDMARD and RTX, and lowest among patients treated with IFX with no differences in aIRR.Conclusion.Our results provide some reassurance of the safety of biologic treatments in the treatment of RA.

Background Despite demonstrated influence of country of residence on labour force participation among patients with RA, little attempt has been made to understand the users9 perceptions of support and social security (SS) systems. Objectives To explore the patterns in perceptions among patients with RA and rheumatologists from different European countries across five domains (1) importance and support to remain employed, (2) process of applying for WD, (3) obtaining and living with WD pension, (4) role of the rheumatologists in support to remain employed or apply for WD pension and (5) performance of the system. Methods A survey among RA patients and rheumatologists was conducted in 44 countries of European WHO Region. For each domain, several questions (4 to 6 questions per domain, each on a 1–5 Likert answer scale, dichotomized as 1 (“totally (agree)”) and 0 (“not agree, not disagree”, “totally (disagree)”) were asked (Table). Next, sum scores were calculated for each domain and averaged per country. The domain “remaining employed” was assessed in patients who currently have or ever had work. Analyses in domains “process of applying for WD” and “obtaining and living with WD” were limited to patients who currently have or ever considered applying for WD. Comparisons of scores in all domains were explored by: EU-15, new EU member states and non-EU countries, the five types of social welfare system (Anglo-Saxon, Bismarckian, Mediterranean, Post-Communist, and Scandinavian) and by countries9 wealth (GDP per capita adjusted for purchasing power parity [PPP]) using ANOVA or Pearson correlation, as appropriate. Results Of 44 countries, 31 (70%) and 30 (68%) have provided data for patients and rheumatologists, respectively. In total, 646 patients (mean age (SD) 53 (12), 76% female, 519 (78%) ever worked) and 500 rheumatologists filled in the questionnaires. Overall, positive weak to no relationships were present between the GDP per capita and perceptions from rheumatologists or patients about SS arrangements. However, significant differences were observed across the systems type with the Scandinavian type (Finland, Norway, Sweden) consistently scoring higher than the others on most domains (table). Remarkably, rheumatologists in less wealthy and non-EU countries felt more confident in their role related to WD pension. Conclusions Patients9a nd rheumatologists9 perceptions of systems to support persons with RA encountering work restrictions varied mostly according to the type of the social welfare system, while remarkably little differences were related to country9s wealth and membership in EU. Scandinavian employment support and social security system appeared to most adequately meet the expectations of patients and rheumatologists in questions of remaining at work and application to WD pension. Disclosure of Interest None declared

Background and objectives: Tumor necrosis factor (TNF)-inhibitors are used to treat psoriatic arthritis (PsA), but only a limited number of observational studies on this subject have been published thus far. The aim of this research was to analyze the effectiveness and drug survival of TNF-inhibitors in the treatment of PsA. Methods: PsA patients identified from the National Register for Biologic Treatment in Finland (ROB-FIN) starting their first, second, or third TNF-inhibitor treatment between 2004 and 2014 were included. Effectiveness was measured using ACR and EULAR response criteria and modeled using ordinal logistic regression. Treatment persistence was analyzed using Kaplan-Meier survival analysis and Cox proportional hazards model. Results: The study comprised 765 patients and 990 TNF-inhibitor treatment courses. EULAR moderate treatment responses at 6 months were achieved by 68% and 37% of the users of the first and the second or the third biologic, respectively. The probabilities of discontinuing the treatment within 12 and 24 months were 20% and 28%, respectively. Adjusted treatment responses to all TNF-inhibitors were similar; however, co-therapy with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) was not associated with better effectiveness. Adalimumab [hazard ratio (HR) = 0.62; 95% confidence interval (CD: 0.44-0.88] was superior to infliximab in drug survival while etanercept (HR = 0.77, 95% CI: 0.55-1.1) and golimumab (HR = 0.75, 95% CI: 0.46-1.2) did not differ from it. Co-medication with csDMARDs did not statistically improve drug survival. Conclusion: All available TNF-inhibitors showed similar treatment responses with or without csDMARDs. Adalimumab was associated with better drug survival when compared to infliximab. (C) 2017 Elsevier Inc. All rights reserved.

Background Up to 20–30% of patients enrolled into RA cohorts and clinical trials are seronegative. However, in studies examining predictors, prognosis, and response to treatment, seropositive and seronegative groups of patients seem to behave differently. Only a few studies have focused on the long term follow up of seronegative arthritis. Objectives To investigate long-term outcomes of patients with seronegative arthritis during a 10-year follow-up period including clinical outcomes and reclassification of diagnosis when applicable. Methods A total of 1046 patients were classified as early RA in 1997–2005 at single rheumatology center and scheduled for a ten year follow-up, including 434 seronegative patients who are subjects of the present analysis. Follow-up examinations were carried out for at least 2 years and then at 5 and 10 years by the treating specialist including complete clinical examination and patient reported outcomes. In addition, case –reviews were performed, with re-classification of the cases when applicable Results Among the 434 seronegative patients (69,4% women, mean age 58), 271 subjects were seen for the 10 year visit with the mean disease activity DAS28 of 2,3 (SD 1,02) and the mean HAQ of 0,71 (SD 0,72). Out of the remaining 146 patients, 88 had died and 53 did not attend the 10-year visit due to altered diagnosis, refusal or comorbidity. Five patients had dropped out and files of 17 patients were missing. During the follow-up of 10 years, 12/434 (2,7%) patients could be classified as seropositive or erosive RA: 4 turned seropositive (2 for ACPA and 2 for RF [>2x normal level]) and 8 developed erosions typical for RA. Reclassification revealed 70 (16,1%) cases of polymyalgia rheumatica, 47 (10,8%) cases of osteoarthrosis without evidence of inflammatory disease, 47 (10,8%) cases of psoriatic arthritis, 39 (9,0%) cases of spondylarthritis and 16 (3,7%) cases of plausible reactive arthritis. Few cases were reclassified as gout (11 cases (2,5%)) and pseudogout (3 cases (0,7%)). Also paraneoplastic arthritis (6 cases (1,4%)), juvenile arthritis (5 cases (1,2%)), hemochromatosis (2 cases (0,5%)), ankylosing spondylitis (2 cases (0,5%)) and temporal arteritis (2 cases (0,5%)) were revealed during follow up. One case of each reflex sympathetic dystrophy, trauma-induced arthritis, meniscal injury, optional Nasu Hakola disease, microscopic polyangiitis (MPA), granulomatous polyangiitis (GPA), antisynthetase syndrome and colitis ulcerosa were also found. The remaining 147 patient (33,8%) could not be reclassified in any clear cut diagnosis. A total of 44 of these undifferentiated cases had transient arthritis, 43 cases had features of seronegative spondylarthritis and 57 cases remained totally unspecified, while three patients had features of inflammatory connective tissue disease (SLE and Sjogren9s syndrome), but they did not meet available classification criteria. In addition, files of 17 (3,9%) patients were missing from the analyses. Conclusions Over a 10-year period, 97% of seronegative patients remained seronegative and did not develop RA-like erosions. Reclassification revealed significant heterogeneity in the diagnosis of seronegative RA. Therefore, seronegative arthritis should not be studied as a homogenous disease entity. References Padyukov, Arthritis Rheum 2004, 50: 3085–3092. van Dongen, Arthritis Rheum 2007, 56: 1424–1432. Jantti, Clin Rheumatol 2002, 21: 353–356. Disclosure of Interest None declared

Rheumatology clinics traditionally provide management for rheumatic diseases. Awareness of the impact of comorbidities on patients’ performance and survival challenges rheumatology clinics also to address comorbidities in daily clinical practice. The comorbidities of major interest, according to the EULAR initiative, include cardiovascular diseases, kidney diseases, lung diseases, infections, malignancies, osteoporosis, gastrointestinal diseases and depression. However, any other disease may appear as a comorbidity in patients with rheumatic or other chronic diseases and need attention. Rheumatology practice may have a key role in discovering comorbidities as patients may not see any other health professionals. Therefore, the infrastructure of the clinic needs to support in screening, preventing and reporting of comorbidities and involves the following aspects: the vision of the daily practice of long-term benefits to the patient, the structure of the clinic with predefined treatment paths and multidisciplinary care with predefined tasks to the rheumatologist, to the nurse and to the physiotherapist. The role of a user-friendly IT solution is crucial for continuing monitoring of effectiveness of therapies and monitoring of comorbidities, integrated into the everyday clinical work. We provide here a practical example of targeting comorbidities in routine rheumatology care.

Quantitative observations are presented concerning treatment with glucocorticoids of 308 patients with rheumatoid arthritis (RA) at a weekly academic rheumatology setting over 25 years from 1980 to 2004. A database of all visits included medications and multidimensional health assessment questionnaire scores for physical function, pain and routine assessment of patient index data (RAPID3; and a surrogate RAPID3-EST), completed by each patient at each visit in routine care. Over the 5-year periods of 1980-1984, 1985-1989, 1990-1994, 1995-1999 and 2000-2004, the mean initial prednisone daily dose declined from 10.3 to 6.5, 5.1, 4.1 and 3.6 mg/day, as initial doses were >5 mg/day in 49, 16, 7, 7 and 3% of patients, 5 mg/day in 51, 80, 70, 26 and 10%, and

Objective.To investigate the effect of depression, anxiety, fatigue, and fibromyalgia (FM) on the remission status in patients with rheumatoid arthritis (RA), defined according to the 28-joint count Disease Activity Score (DAS28)-erythrocyte sedimentation rate (ESR) and the Boolean-based new American College of Rheumatology/European League Against Rheumatism remission criteria.Methods.The subjects were patients with RA who participated in a hospital-based observational cohort. Patients who met the DAS28-ESR remission criteria at their latest visit were invited to participate in our study. The patient groups fulfilling or not fulfilling the Boolean remission criteria were identified and compared with each other with regard to the presence of depression, anxiety, fatigue (0–50), and FM. The relationship between psychosocial factors and Simplified Disease Activity Index (SDAI) remission, which is the index-based definition of remission in RA, was also investigated.Results.A total of 87 out of 428 patients (20%) with RA met the DAS28-ESR remission criteria and 32 (37%) of these also met the Boolean remission criteria, while 55 (63%) did not. Forty patients were also in SDAI remission. In the Boolean remission group, 2 patients had depression and 2 had anxiety (p = 0.004). In the Boolean nonremission group, 19 patients had depression and 13 had anxiety (p = 0.04). Continuous scales of anxiety (3.34 ± 3.76 vs 5.83 ± 4.70, p = 0.012) and depression (2.18 ± 2.75 vs 4.63 ± 4.10, p = 0.001) were also lower in the Boolean remission group in comparison with the nonremission group. Though FM syndrome was detected in only 1 patient of the Boolean remission group and in 7 patients of the Boolean nonremission group (p = 0.249), patients’ polysymptomatic distress scores of FM in the Boolean remission group were significantly lower than those of the nonremission group (3.12 ± 3.25 vs 6.27 ± 5.19, p = 0.001). The mean fatigue scores were 9.5 ± 10.6 in the Boolean remission group and 16.8 ± 12.8 in the Boolean nonremission group (p = 0.006). In multivariate analysis, patient’s global assessment (PtGA) and depression were found as the independent discriminators of Boolean-based definition. Similar relationships were also observed between psychosocial factors and SDAI remission.Conclusion.In patients with RA who do not fulfill the Boolean remission criteria, to avoid overtreatment, assessment of anxiety, fatigue, FM, and especially depression must be considered if PtGA scores and disease activity variables are significantly different.

Contains fulltext : 137860.pdf (Publisher’s version ) (Open Access) In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.

Objective: A systematic review found that an average of 27% of rheumatoid arthritis (RA) patients using tumour necrosis factor (TNF) inhibitors discontinue their treatment within 1year. The aim of this study was to assess drug survival on TNF inhibitors among patients with RA.Methods: Patients were identified from the National Register for Biologic Treatment in Finland (ROB-FIN), which is a longitudinal cohort study established to monitor the effectiveness and safety of biologic drugs in rheumatic diseases. Inclusion was limited to TNF-inhibitor treatments started as the patient's first, second, or third biologic treatment between 2004 and 2014. Follow-up was truncated at 36months. The results of a time-dependent Cox proportional hazards model were reported as adjusted hazard ratios (HRs) with 95% confidence intervals (CIs).Results: Of the 4200 TNF-inhibitor treatment periods identified from ROB-FIN, 3443 periods from 2687 patients met the inclusion criteria. Twenty-seven per cent of the patients discontinued their treatment within 12months. Infliximab (HR 1.8, 95% CI 1.3-2.5) and certolizumab pegol (HR 1.7, 95% CI 1.2-2.3) had lower drug survival compared to golimumab. A similar trend was seen with adalimumab (HR 1.2, 95% CI 0.90-1.7) and etanercept (HR 1.2, 95% CI 0.87-1.6). Concomitant use of methotrexate (MTX) was associated with improved drug survival (HR 0.76, 95% CI 0.64-0.90) in comparison with TNF-inhibitor monotherapy.Conclusions: Golimumab was better in terms of drug survival than infliximab or certolizumab pegol and at least as good as adalimumab and etanercept. Concomitant use of MTX improved drug survival on TNF inhibitors.

The treatment of rheumatoid arthritis (RA) has dramatically changed in the past 2 decades, with emphasis placed on prompt diagnosis and treatment aiming for early and sustained remission. The concept of “treat to target” (T2T) represents a therapeutic paradigm of modern rheumatology practice and there exists a strong evidence base supporting early and intensive therapeutic approaches to target and eradicate inflammation. This has been possible with new, improved treatments and combination regimens1,2,3,4. However, while inflammation can be reversed, the extent of reversibility of disease outcomes such as joint destruction and functional capacity is dependent both on the duration and degree of inflammation. The timing of intervention is thus important, highlighting an important aspect of disease: the early phase of RA and the therapeutic “window of opportunity.”5 The latter is supported by many observations on disease course and outcomes, including progression of radiographic damage and reduced opportunity for disease-modifying antirheumatic drug (DMARD)-free sustained remission with prolonged symptom duration6. In this issue of The Journal , Littlejohn and colleagues report on disease activity trends in RA based on 5-year data (2009–2014) from the OPAL-QUMI (Optimising Patient outcome in Australian Rheumatology-Quality Use of Medicines Initiative) study7, a multicenter, cross-sectional, non-interventional study of patients with RA treated in Australia. Although predominantly descriptive, their study is highly relevant and informative regarding conventional, real-world rheumatology practice, treatment strategies, and disease activity states. Almost 9000 patients were included in the study, with age and sex distributions typical of RA cohorts. The high number of patients and participating rheumatologists are an important strength of the study. Over 37,000 Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) test results were available, with the largest part (46.2%) falling in the remission … Address correspondence to Prof. T. Sokka, Jyvaskyla Central Hospital, 40620 Jyvaskyla, Finland. E-mail: tuulikki.sokka-isler{at}ksshp.fi

The aim was to study the incidence of joint replacements among biologic drug and disease-modifying anti-rheumatic drug (DMARD) users as well as to investigate the plausible effect of biologic treatment on survival of prostheses in patients with Rheumatoid arthritis (RA).The study population comprised 2 cohorts of patients [Register of biologic treatment in Finland (ROB-FIN) and the Central Finland RA database] from 1999 to 2010. Records of joint replacements performed in the study population between 1980 and 2010 were retrieved from the Finnish Arthroplasty Register. Propensity score matching was used to equalize patient characteristics between biologics and DMARD users. The incidence rates of primary and revision operations were compared between the 2 treatment groups. Kaplan-Meier survival analysis was used to analyze prosthesis survival.Of the 2102 biologics and 2710 DMARD users identified from the registries, 1587 were included in both groups after the matching. Median follow-up times were 3.1 and 8.0 years, respectively. There were more primary operations per 100 patient years in the biologics (3.89, CI 95% 3.41-4.41) vs. DMARD (2.63, 2.35-2.94) group but slightly fewer revisions (0.65, 0.46-0.88 vs. 0.83, 0.68-1.01). Biologics users were more likely to receive a joint replacement to small joints (p0.001). The survival of the prostheses installed during or prior to follow-up was similar in both treatment groups.The use of biologic drugs did not reduce the need for joint replacement surgery in patients with a similar on-medication disease activity. Despite possibly lower rate of revisions among biologic users, the durability of prostheses was not improved.

Objective To analyze prednisone treatment from 1980–2004 in 308 patients with rheumatoid arthritis (RA), including 75 monitored over 4–8 years and 73 monitored over >8 years, for initial dose, long-term doses and effectiveness, and adverse events. Methods A database of all patients of a single rheumatologist included medications and Multidimensional Health Assessment Questionnaire (MDHAQ) scores at each visit. Proportions of patients whose initial prednisone dosages were >5, 5, or 8 years. Results In the respective 5-year periods, the mean initial prednisone dosages were 10.3, 6.5, 5.1, 4.1, and 3.6 mg/day, with >5 mg/day in 49%, 16%, 7%, 7%, and 3% of patients, 5 mg/day in 51%, 80%, 70%, 26%, and 10% of patients, and

To explore patterns of real-world early RA (ERA) care across countries.An online survey was disseminated to practising rheumatologists across Europe and the US, also made accessible on social media between April and May 2015. Survey questions (n=38) assessed the structure and setting of ERA clinics, times to diagnosis and treatment, patient monitoring, guideline use and data recording.A total of 212 rheumatologists from 39 countries (76% European) completed the survey. 62% had an ERA clinic based at a university hospital. Patient referral to rheumatology was mainly (78%) via primary care; 44% had an agreed ERA local referral pathway, 15% a national pathway. Only 16% had dedicated ERA clinics, the majority being practitioners in Northern Europe with access to a local or national referral pathway. Data for research were collected by 42%. Treatment guidelines were followed by the majority, especially rheumatologists practising in Europe. Variations existed in the use of initial DMARDs with treatment decisions reported to be influenced by international/national guidelines in 71%/61%. No significant relationship between country gross national income and the availability of ERA clinics was seen.This study provides comparative benchmark information regarding the global provision of ERA care. Substantial variations exist in referral and early assessment pathways with guidelines having a most apparent impact in Northern Europe. Provision of an ERA service does not appear to be constrained by cost, with conceptual factors, e.g. clinician engagement, perhaps playing a role. These initial insights could potentially help harmonise ERA management across countries.

Patient monitoring has been emphasised in rheumatology for decades. However, many obstacles must be overcome before successful monitoring is part of routine care. We describe one model: GoTreatIT.

Background: Seronegative rheumatoid arthritis is associated with a milder course of progression compared to seropositive disease. However, long-term follow-up data of the clinical course of seronegative rheumatoid arthritis are sparse. Here we describe four cases with a rare disease entity of aggressive destructive seronegative (rheumatoid) arthritis with 20-35 years of follow-up. Case presentation: The four cases are women with an initial presentation of seronegative rheumatoid arthritis in 1980-1996 and have received disease-modifying anti-rheumatic drugs since the diagnosis. In all cases, the condition has been refractory to treatments and evolved into a severe disease with destructions of the wrists, sub-talar and ankle joints, as well as large joints but not small joints of fingers and toes. All cases are negative with regard to rheumatoid factor, anti-cyclic citrullinated peptide antibodies and antibodies against carbamylated proteins. Conclusions: This report adds to the existing literature, making the reader aware of this sub-type of inflammatory arthritis which despite being seronegative, can have devastating disease consequences. The report highlights the need for further research into this field in order to better understand this disease sub-type, the pathogenesis, disease course and outcomes. Funding Agencies|Swedish Society for Medical Research; EULAR Scientific Training bursary

Article, Objective: To describe a one-stop, integrated rheumatology service and assess patient satisfaction. Methods: A descriptive report and patient satisfaction survey of a rheumatology clinic model first developed in 1996 to enhance the patient “journey” through rheumatology services. A patient-satisfaction survey over a 3-week period assessed several aspects of care including quality of services, consultations, and patient education. Results: All referrals are screened by a rheumatologist to pre-schedule laboratory/radiology/other tests for the visit. Upon arrival to the clinic, patients check-in at an electronic desk, and then complete the electronic GoTreatIT monitoring system which assesses patient-reported outcomes. The patient is reviewed by a doctor in a 30- to 60-min consultation, and then by a nurse (for diagnosis/treatment education, vaccinations). An ultrasound machine and capillaroscopy are available for use in the clinic. Patients can be scheduled on the same day to see a nutritionist, physiotherapist, or other heath professionals as necessary. An “early-rheumatoid arthritis treatment path” is available to ensure early, intensive treatment. A patient satisfaction survey revealed high rating of the overall service (90.6/100). None of the patients felt that they lacked education on their disease or medication. Only 6% of the respondents gave negative feedback, reasons including feeling overwhelmed with information or not being given a cause for their symptoms. The multi-disciplinary approach was highly valued and only 3% would rather see a doctor and nurse on separate days. Conclusion: The specific clinic model provides an ideal setting for a one-stop service, avoiding unnecessary visits, collecting patient data, and enhancing the patient experience and journey through the system. Where possible, the specific clinic model could be used or adapted to build similar models in other rheumatology departments. The clinic model could also form the basis for services in other specialties dealing with chronic conditions., published version, peerReviewed

Quantitative assessment of disease activity and patient-reported outcomes are recognized as valuable in the management of rheumatoid arthritis (RA). Complexities of assessment of RA include challenges concerning measures themselves, as a gold standard measure for disease status does not exist. This article discusses the hurdles in the implementation of quantitative assessment of RA in usual clinical care and also provides an example to monitor patients with early RA.

Objective.We analyzed remission rates at 3 and 12 months in patients with rheumatoid arthritis (RA) who were naive for disease-modifying antirheumatic drugs (DMARD) and who were treated in a Finnish rheumatology clinic from 2008 to 2011. We compared remission rates and drug treatments between patients with RA and patients with undifferentiated arthritis (UA).Methods.Data from all DMARD-naive RA and UA patients from the healthcare district were collected using software that includes demographic and clinical characteristics, disease activity, medications, and patient-reported outcomes. Our rheumatology clinic applies the treat-to-target principle, electronic monitoring of patients, and multidisciplinary care.Results.Out of 409 patients, 406 had data for classification by the 2010 RA criteria of the American College of Rheumatology/European League Against Rheumatism. A total of 68% were female, and mean age (SD) was 58 (16) years. Respectively, 56%, 60%, and 68% were positive for anticyclic citrullinated peptide antibodies (anti-CCP), rheumatoid factor (RF), and RF/anti-CCP, and 19% had erosive disease. The median (interquartile range) duration of symptoms was 6 (4–12) months. A total of 310 were classified as RA and 96 as UA. The patients with UA were younger, had better functional status and lower disease activity, and were more often seronegative than the patients with RA. The 28-joint Disease Activity Score (3 variables) remission rates of RA and UA patients at 3 months were 67% and 58% (p = 0.13), and at 12 months, 71% and 79%, respectively (p = 0.16). Sustained remission was observed in 57%/56% of RA/UA patients. Patients with RA used more conventional synthetic DMARD combinations than did patients with UA. None used biological DMARD at 3 months, and only 2.7%/1.1% of the patients (RA/UA) used them at 12 months (p = 0.36).Conclusion.Remarkably high remission rates are achievable in real-world DMARD-naive patients with RA or UA.