Background: Methotrexate is one of the Disease Modifying Anti-rheumatic Drugs (DMARDs) of choice in the treatment of inflammatory arthritis and can be given in oral or subcutaneous form.1 A switch from oral to subcutaneous preparation is indicated to increase the bioavailability or when the oral route is not tolerated.2
Methods: Retrospective study of paper medical notes and electronic records. Assessed outcomes including drug tolerance, DAS28CRP and pain in patients with inflammatory arthritis following a switched from oral to subcutaneous methotrexate. Outcomes at 0, 6 and 12 months were analysed.
Results: Of 75 patients identified, 64 could be included in the study. 68% of patients were switched from oral methotrexate due to adverse effects, 28% due to poor response and 4% due to both. Other DMARDs remained stable in 60% (n = 26) of those who continued methotrexate for 12 months (n = 43). In patients switched due to insufficient disease control, all outcomes other than fatigue were improved at 6 and 12 months. Of the patients who were switched to scMTX because of unacceptable adverse effects, 42% reported that adverse effects completely resolved; however, 46% discontinued the treatment within 12 months.
Conclusions: A switch to subcutaneous methotrexate in patients experiencing insufficient disease control on oral methotrexate resulted in a decrease in markers of disease activity except fatigue. 43.5% of patients who experienced adverse effects on oral methotrexate continued to experience adverse effects on scMTX. 33% of the cohort discontinued scMTX within 12 months all of whom had originally switched due to adverse effects.
C/O Rheumatology Department, Royal Alexandra Hospital, Corsebar Road, Paisley
Email: donna.hood@ggc.scot.nhs.uk
Abstract
Background: Rheumatoid flare is associated with accumulation of erosive damage1 and of cumulative cardiovascular risk.2 Difficulty arises in that flare is an unpredictable phenomenon, which poses challenges to a busy clinical Rheumatology service with regard to provision of timely review and escalation of treatment. To further support this, the SSR performed an audit in 20183 which elicited patient reports of delays in accessing services during a flare.
Methods: Flare clinic slots were identified. Eligibility criteria for access to the flare clinic were established based on access via the clinical nurse specialist team. This was a nurse-led service, once a week, in an outpatient clinic, with 20 min slots. 44 Patients were assessed for appropriateness of escalation of therapy and the need for intra articular or intramuscular injections.
Results: The majority who attended were over 40 years old. The gender split was 3:1 Female:Male. DMARD and biologic use were recorded with Methotrexate being the most common DMARD. There appeared to be a deprivation bias with the majority of patients attending from the second quintile of the Scottish index of multiple deprivation.
Conclusions: This pilot of a dedicated flare clinic represents a solution to a potentially unmet need outlined by patients. It demonstrates an easily replicated model. We endeavour to reconfigure our current service to create a more timely response to patients in a flare or time of great clinical need. When extended, patient diagnosis and work status would be recorded and economic benefit would be measured.
Keywords: Inflammatory arthritis, flare
References
MarkusseIMDirvenLGerardsAH, et al.Disease flares in rheumatoid arthritis are associated with joint damage progression and disability: 10-year results from the BeSt study. Arthritis Res Ther2015; 17: 232–232.MyasoedovaEChandranAIlhanB, et al.The role of rheumatoid arthritis (RA) flare and cumulative burden of RA severity in the risk of cardiovascular disease. Ann Rheum Dis2016; 75: 560–565.www.scottishrheumatology.org.uk/documents/audit/audit-forms-2018/SSR%20Patient%20Experience%20Survey%20Report%20v1.0.pdf (accessed 23 December 2018).
Sponsors
SSR Quality Improvement team.
Utilisation of subcutaneous Tocilizumab in rheumatoid arthritis patients in Grampian
M Philobos, A Davidson and Dospinescu Dospinescu
Aberdeen Royal Infirmary, Aberdeen
mariana.philobos@nhs.net
Abstract
Background: Tocilizumab (TCZ) is a humanized monoclonal antibody against interleukin-6 receptor which is licensed for the treatment of rheumatoid arthritis (RA). Initially administered as intravenous (IV) infusion, TCZ subcutaneous (SC) preparation became available in Scotland in 2014. Treatment flexibility, cost reduction and time pressure in secondary care made SC preparation an attractive option.1 We audited utilisation of SC TCZ in patients with RA under the care of Grampian Rheumatology department.
Methods: Sixty-two RA patients commencing treatment with SC TCZ between 09/2014 and 09/2016 were identified.
Patients were divided into two groups: group A switched from IV to SC TCZ, group B newly starters on SC TCZ. Data, including patients’ demographics, previous therapies and disease monitoring were collected retrospectively.
Results: Group A: 22 patients (16 females), mean age of 51.5 years, weight range 56–135 kg. DAS28 score was adequately recorded in 14/22 patients, of which 85% demonstrated clinical improvement or remained in remission; 27% of patients switched back to IV TCZ due to skin site reaction and/or disease progression. Average treatment duration before switching was 8.5 months. Group B: 40 patients (31 females), mean age of 59.6 years, weight range 44–120 kg. DAS28 score was adequately recorded in 23/40 patients, of which 86% demonstrated clinical improvement or remained in remission; 35% of patients stopped SC TCZ (seven due to response failure and five due to side effects). Average SC TCZ treatment duration before switching to another agent was 18.8 months.
Conclusions: Our audit includes a large RA patient cohort undergoing treatment with SC TCZ. The overall clinical improvement or maintenance of remission was comparable to current literature (75%)
BurmesterGRRubbert-RothACantagrelA, et al.Efficacy and safety of subcutaneous tocilizumab versus intravenous tocilizumab in combination with traditional DMARDs in patients with RA at week 97 (SUMMACTA). Ann Rheum Dis2016; 75: 68–74.
Sponsors
None.
Secukinumab significantly improves disease indices in psoriatic arthritis and ankylosing spondylitis within NHS Tayside cohort
SJ Cooper and Bhat Bhat
Department of Rheumatology, Ninewells Hospital and Medical School
Email: smita.bhat@nhs.net
Abstract
Background: Secukinumab1–5 is a novel fully humanised mAb. It has been introduced into NHS Tayside for the treatment of psoriatic arthritis (PsA) and ankylosing spondylitis (AS). PsA is the rheumatological manifestation of psoriasis. AS3,6–9 is characterised by inflammation and osteogenesis of the axial spine, presenting as sacroiliitis and spondylitis. IL-17 A has been implicated in the pathogenesis of AS and PsA.
Methods: A paired t-test was used to compare disease indices. Results were compared to the last previous set of disease indices prior to commencing Secukinumab.
Results: There were 36 patients with PsA in NHS Tayside prescribed Secukinumab. In PsA at three and six months, there was a significant decrease (t(22) = 4.01, p = 0.001) in swollen joints from an average of 5.4 before Secukinumab to 1.0 after (81.6% decrease). Tender joints also significantly decreased (t(22) = 2.58, p = 0.015) from 9.1 joints to 3.2 (65.1% decrease). Four patients out of 36 (11.11%) experienced side effects. 13 patients with documented AS were prescribed Secukinumab. At three and six months, there was a significant decrease (t(9) = 5.01, p = 0.001) in the total BASDAI score from an average of 6.8 before Secukinumab to 3.4 after (49.7% decrease). One patient (7.7%) experienced side effects of fluid-filled blisters in their mouth.
Conclusions: This study provides evidence of the benefit of Secukinumab in PsA and AS within the NHS Tayside. It was effective at three and six months in both conditions and showed a highly significant improvement in disease indices. The tolerability was also good, with few patients reporting any side effects.
ChenKKollsJK. Interleukin-17A (IL17A). Gene2017; 614: 8–14.MeasePJMcInnesIBKirkhamB, et al.Secukinumab inhibition of interleukin-17A in patients with psoriatic arthritis. N Engl J Med2015; 373: 1329–1339.BlairHADhillonS. Secukinumab: a review in ankylosing spondylitis. Drugs2016; 76: 1023–1030.ShirleyMScottLJ. Secukinumab: a review in psoriatic arthritis. Drugs2016; 76: 1135–1145.AmatyaNGargAVGaffenSL. IL-17 Signaling: the Yin and the Yang. Trends Immunol2017; 38: 310–322.WeiJCCBaetenDSieperJ, et al.Efficacy and safety of secukinumab in Asian patients with active ankylosing spondylitis: 52-week pooled results from two phase 3 studies. Int J Rheum Dis2017; 20: 589–596.BraunJBaraliakosXDeodharA, et al.Effect of secukinumab on clinical and radiographic outcomes in ankylosing spondylitis: 2-year results from the randomised phase III MEASURE 1 study. Ann Rheum Dis2017; 76: 1070–1077.BaetenDSieperJBraunJ, et al.Secukinumab, an interleukin-17A inhibitor, in ankylosing spondylitis. N Engl J Med2015; 373: 2534–2548.BurkettPRKuchrooVK. IL-17 blockade in psoriasis. Cell2016; 167: 1669–1669.
Sponsors
None.
A review of electronic rheumatology referrals at the Queen Elizabeth University Hospital, Glasgow
A Laws, S Batool, K Graham, S Noor, L Hannington, G Ingram and Mitchell Mitchell
Rheumatology Department, Queen Elizabeth University Hospital, Glasgow
Email: arrianne.laws@nhs.net
Abstract
Background: Our department launched an electronic referral system for inpatient rheumatology reviews in February 2018. The impact of this system on the Rheumatology on-call service has not been assessed. We performed a baseline review of the new system.
Methods: We reviewed all electronic referrals between 8.2.18 and 31.8.18. We collected data on demographics, timing, reasons for referral and outcomes.
Results: There were 346 referrals (58.4% female, mean age 64 years). Most (78%) were made from medical wards; the mean number of referrals per month was 49.4. Referrals were most frequently made on Fridays (23%). Most were in-hours (81%). The most common reason for referral was a request for review (212), followed by phone advice (70) then procedural requests (50); 207 referrals (59.8%) were made for new patients, 91 (26.3%) for patients known to rheumatology prior to admission, and 48 (13.9%) for patients already seen during the current admission; 50% of procedures were performed on knees and 50% on other joints; 82% of patients were seen within 72 h.
Conclusions: The new electronic referral system has made it simple to review the workload of the rheumatology on-call service. Our work has identified future targets for quality improvement projects: the results will inform inter-specialty teaching sessions regarding common referrals, to improve the patient management. We also identified a lack of confidence in a core general medical procedure: knee aspiration, and we will look to improve the local training. There are also improvements to be made in our documentation of reviews.
Keywords: Rheumatology, quality improvement, service improvement
Sponsors
None.
Helping people to help themselves: An eight-week mindfulness course for people living with a long-term inflammatory condition
J Phillips1 and P Harris2
1Advanced Physiotherapist in Rheumatology, NHS Ayrshire & Arran, University Hospital Ayr (UHA)
2Advanced Physiotherapist in Mental Health, NHS Ayrshire & Arran, University Hospital Ayr (UHA)
Background: Although people with inflammatory arthritis receive medication to control disease activity, many report a lack of support for the emotional and psychological difficulties associated with living with a long-term physical health condition.1 As caring health professionals, we wanted to improve how we support patients to deal with this ‘secondary suffering’; optimise their general health and wellbeing; and improve their self-efficacy and self-management skills.
Methods: In a community setting, we delivered an eight-week experiential mindfulness programme for people attending our rheumatology service. This was based on the ‘Mindfulness Scotland' course handbook entitled ‘Mindfulness Approaches' (2008) and included 2 h weekly sessions plus home practice. We used the following pre and post-course patient-reported outcome measures:
• Arthritis Research UK Musculoskeletal Health Questionnaire (MSK –HQ)
• Self-compassion Scale – Short Form (SCS – SF)
• Participant feedback questionnaire
• Participant focus group
Results: Hopelessness, isolation and powerlessness are reported by people living with long-term rheumatology conditions. These difficult issues are important to patients but often cannot be helped with medication. Some people who attend our rheumatology service participated in an eight-week mindfulness course. We felt helping people to develop mindfulness skills would help them to help themselves.
Conclusions: Results were encouraging:
MSK – HQ: 64% improved.
SCS-SF: 91% improved.
Feedback questionnaire/Focus group feedback: Participant perceived benefits – Participants felt mindfulness helped them develop resilience, self-compassion and better self-management strategies. The participants reported that they had developed alternative ways of coping with illness, experienced reduced anxiety and identified a positive change in their attitude and relationship to pain. They went on to arrange their own support group.
£2300 funding was provided by the Scottish Society for Rheumatology (SSR) for this project (2017).
Declaration
The authors have a personal interest in mindfulness.
The severity of keratoconjunctivitis sicca in rheumatoid arthritis correlates with the medical outcome study 36-item short form health survey (SF-36) score but not the disability index (HAQ-DI)
RO Akintayo and Olaosebikan Olaosebikan
Department of Medicine, University of Ilorin Teaching Hospital
Email: richocounlimited@gmail.com
Abstract
Background: Keratoconjunctivitis sicca (KSC) is the most frequent ocular manifestation of rheumatoid arthritis (RA).1 Whereas a significant proportion of patients with KCS may be asymptomatic, it is unknown if the degree of dryness of the eyes, irrespective of symptomatology, has an association with the overall quality of life and functional ability.2
Methods: A total of 50 Nigerian patients satisfying the 2010 ACR/EULAR classification criteria for RA were studied. Tear production was measured by unstimulated 5 min Schirmer’s test (using 5 mm by 35 mm Whatman filter paper) and ocular staining with flourescein stain. Each patient also completed the SF-36 and HAQ-DI questionnaires.
Results: The mean age of the patients was 47.2 ± 12.5 years. Among them, 42 (84%) were females, giving a female-to-male ratio of 5.25:1. KCS was found in 15 (30%) patients among whom only 6 patients were symptomatic for dry eyes. The mean visual acuity [LogMAR (Snellen equivalent)] among the patients with and without KCS was 0.70 (6/30) and 0.10 (6/7.5), respectively. Among all patients, there was a positive correlation between the mean Schirmer’s score (between each patients two eyes) and the physical component summary (r = 0.292, p = 0.008) as well as the mental component summary (r = 0.228, p = 0.030) of the SF-36. There is, however, no significant correlation between the mean Schirmer’s score and the HAQ-DI (r = 0.148, p = 0.188).
Conclusions: Even in asymptomatic patients, the degree of xerophthalmia may give a reliable insight into both the physical and mental quality of life but not into the degree of functional disability.
Keywords: Keratoconjunctivitis sicca, rheumatoid arthritis, quality of life
References
VigneshAPPSrinivasanR. Ocular manifestations of rheumatoid arthritis and their correlation with anti-cyclic citrullinated peptide antibodies. Clin Ophthalmol2015; 9: 393–397.BronAJTomlinsonAFoulksGN, et al.Rethinking dry eye disease: a perspective on clinical implications. Ocul Surf2014; 12: S1–S31.
Sponsors
None.
Don’t delay, connect Scotland today
LA Bennett, CS Goodyear; CS Goodyear and S Siebert – On behalf of the Rheumatosphere Team
B431, GBRC, 120 University Place, University of Glasgow
Email: louise.bennett@glasgow.ac.uk
Abstract
Background: The European League Against Rheumatism (EULAR) funded projects to implement their public engagement campaign, ‘Don’t Delay, Connect Today’, at a national level. Thus, highlighting the importance of identifying early signs of musculoskeletal disease along with importance of early treatment.
Rheumatosphere, a public engagement initiative based at the University of Glasgow, implemented the ‘Don’t Delay Connect Today’ campaign in one of the hardest to reach areas of Scotland, the Outer Hebridean islands. This location was chosen as those living on these islands have very limited access to some NHS services, including rheumatology clinics. We worked with our partner charity NRAS in order to complete a 185 mile sponsored cycle over the islands, conducting 10 public engagement events and promoting the fundamental messages from the campaign as we travelled. Through this we were able to interact with a wide range of different audiences, including, local residents, school children, patients and healthcare professionals.
We have had an extremely successful campaign that interacted with a high number of individuals on the islands who would not normally be exposed to scientific or clinical public engagement events. The scope of our campaign was significantly increased by the invitation from EULAR to present an international webinar, highlighting our campaign as an exemplar of the work that was funded. The Scottish campaign was also published as a congress feature in the rheumatology edition of the European Medical Journal (EMJ).
Conclusions: Rheumatosphere were internationally recognised for the delivery of their ‘Don’t Delay Connect Today’ campaign, taking this important message to some of the most remote areas of Scotland with limited rheumatology services.
The work was carried out in collaboration with the National Rheumatoid Arthritis Society (NRAS).
Splenic rupture: A rare complication of treatment for methotrexate-induced pancytopenia
Si Han Tan and Duncan Duncan
University Hospital Ayr
Email: sihantan@nhs.net
Abstract
Background: We present the case of a patient with rheumatoid arthritis and methotrexate-induced pancytopenia, who developed acute splenic rupture as a complication of treatment.
Theme: A 48-year-old lady with rheumatoid arthritis on methotrexate and benepali (etanercept biosimilar) was admitted with sepsis. She had a past medical history of chronic kidney disease (CKD) due to focal segmental glomerulosclerosis. She was found to have left basal pneumonia, worsening CKD and pancytopenia, presumed secondary to methotrexate and reduced renal excretion. She was treated with IV antibiotics, blood and platelet transfusions, increased folic acid and G-CSF (Filgrastim). On day 8, she developed acute abdominal and shoulder tip pain. Her haemoglobin fell abruptly. An urgent CT showed a grossly enlarged spleen with evidence of splenic lacerations and rupture. She was transferred to ITU for resuscitation. She underwent laparoscopy and splenectomy, and made a full recovery.
Conclusions: Splenic rupture has been reported as a rare complication of G-CSF treatment.1 Such case reports relate to haemato-oncology patients, and to normal volunteers undergoing harvesting procedures. This is a first case of splenic rupture secondary to G-CSF in RA, in a patient who did not have Felty’s syndrome.2 We present this case to highlight a life-threatening complication of G-CSF treatment.
AykolGPalaC, et al.A rare but severe complication of filgrastim in a healthy donor: splenic rupture. Transfus Apher Sci2014; 50: 53–55.Aubrey-BasslerFSowersN. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systemic review. BMC Emerg Med2012; 12: 11–11.
Sponsors
None.
Dual biologics for the treatment of psoriatic arthritis: A case series
A Tindell, S Kerrigan, M Gallacher, IB McInnes and Siebert Siebert
Glasgow Royal Infirmary, Glasgow
Email: Alistair.tindell@nhs.net
Abstract
Background: Despite an increasing treatment armamentarium, there remain patients who exhaust all options without achieving satisfactory response or who fail to obtain adequate response in all disease domains. Combining biologic therapies targeting different pathways could provide further therapeutic opportunity. We present four patients with psoriatic arthritis (PsA) treated with dual biologics.
Methods: Records search of all patients prescribed biologics attending the Glasgow Royal Infirmary PsA clinic which also acts as a tertiary referral clinic.
Results: Two males, two females aged 40–61 years. All treated for predominantly peripheral synovitic PsA, two had concomitant inflammatory bowel disease. All had previously failed three to five biologic agents as monotherapy. Three previously had stopped a biologic agent in monotherapy due to infection. All biologic combinations initially included ustekinumab (anti-IL-12/23); two combined with etanercept, one with adalimumab, one with tofacitinib. One patient remains on ustekinumab/ etanercept after 22 months with good response. Another patient on ustekinumab/ etanercept (ineffective) switched to ustekinumab/ anakinra (headaches) then to ustekinumab/adalimumab (ineffective) and has now switched to secukinumab monotherapy. Patient on ustekinumab/ adalimumab (ineffective) switched to adalimumab/ secukinumab with subsequent good response. Ustekinumab/ tofacitinib only recently started. In the first months after switching to adalimumab/ secukinumab, one patient had recurrent (four) urinary tract infections which subsequently settled without discontinuation of combination biologics. One patient had headaches on ustekinumab/ anakinra. No other side-effects reported. No hospitalisations and no deaths.
Conclusions: Our experience indicates cautious use of combination biologics may be an option for some patients with refractory or complex PsA.
Fife Rheumatic Diseases Unit, Whyteman’s Brae, Kirkcaldy, Fife
Email: Stephaniehart1@nhs.net
Abstract
Background: In 2016, as a method of improving medicines governance, a weekly Medication Review Meeting (MRM) was introduced at FRDU. This meeting consists of consultant rheumatologists, nurse specialists and a rheumatology pharmacist and involves a case note review of patients failing combination DMARD/biologic therapy and the outcome is an agreed treatment plan. This model has improved the safe initiation of biologic therapy and reduces unwarranted variation in clinical practice. A ‘Once for Scotland’ Biologic Medicines Therapeutic Drug Monitoring Service has been introduced across Scotland.1 Any TDM results were also discussed at the MRM. Since 2010 FRDU has been proactive in tapering the dose of biologic therapy in patients with low disease activity, or remission. TDM will provide a useful tool to ensure these patients are maintained on appropriate treatment.
Methods: TDM testing of patients was undertaken as part of routine clinical care. The results were discussed, also taken into consideration were clinical examination, laboratory results, disease activity scores and where possible, ultrasound scan findings. The decision to taper biologic dose was made in patients with clinically inactive, or low disease activity, with TDM results above the reference range or at the higher end of normal.
Results: Thirty-two TDM results collated May–September 2018; n = 22 Adalimumab, n = 10 infliximab. Patients treated with the current licensed dose. TDM results, in addition to clinical findings, led to the following decisions:
• Continue at current dose = 8/23 (35%)
• Restart biologic treatment = 1/23 (4%)
• Change biologic = 1/23 (4%)
• Stop biologic = 3/23 (13%)
• Increase biologic dose = 3/23 (13%)
• Taper biologic dose = 7/23 (54%)
Patients already on reduced dose. TDM results, in addition to clinical findings, led to the following decisions:
• Continue on reduced dose = 6/9 (67%)
• Stop biologic = 1/9 (11%)
• Taper biologic dose further = 2/9 (2%)
Conclusions: FRDU are reassured patients continued on reduced dose of biologic therapy have therapeutic drug levels. FRDU have successfully implemented TDM as part of routine clinic practice and support its use as a tool to aid in clinical decision making, ensuring the safe and effective use of biologic medicines.
Keywords: Therapeutic drug monitoring, adalimumab, infliximab
Reference
NHS Scotland Effective Prescribing Programme – Biologics Project. ‘Once for Scotland’ Biologics Medicines Therapeutic Drug Monitoring Service. December 2016, www.healthcareimprovementscotland.org/.
Sponsors
None.
Scottish biologic drug monitoring service: The first 100 adalimumab rheumatology patients
Background: The availability of biologic DMARDs has revolutionised the management of inflammatory arthritis, transforming patient outcomes1 despite high costs and the effects of immunogenicity. BDM promotes a patient-tailored approach with the benefit of reducing costs.2 In Q1 2018, the BDM service for Scotland was commenced – allowing speciality-wide measuring of serum levels of Adalimumab (ADA) and Infliximab (IFX). The data promote personalised drug dosing and informs drug choice in secondary non-response.
Methods: Data were made available from TRAKcare and Ordercomms across all Scottish Health Boards.
Results: A total of 1096 IFX patients and 515 ADA patients have had samples sent for analysis; 103 rheumatology patients prescribed ADA include JIA (28), RA (26), PsA (21), AS (16) other (7) with mean ages of 13, 57, 50, 48 and 34, respectively. Most requests were for ‘Maintenance of Treatment Review’ (59), followed by ‘Secondary Loss of Response’ (18), ‘Post Dose Adjustment’ (9) ‘Other’ (9) and ‘Primary Non-Response’ (3). Most patients are on Adalimumab monotherapy (56/103). Secondary loss of response despite concomitant immunosuppression occurred in 13 out of 103 patients; 27 patients were receiving off-label dosing, including 10 patients on weekly 40 mg ADA.
Conclusions: Rheumatologists are increasingly using BDM. These data show paediatric services are high users, with a spread of adult conditions represented. Clinicians are primarily using the service to consider same therapy dose changes rather than switching therapy, as highlighted by the high percentage of patients on ‘off label’ doses of ADA. TDM can be helpful in therapeutic decision making in a variety of clinical situations.3
Keywords: biologic DMARDs, therapeutic drug monitoring, adalimumab
References
EricM. Ruderman: overview of safety of non-biologic and biologic DMARDs. Rheumatology2012; 51: i37–vi43.KrieckaertCLMNairSCNurmohamedMT, et al.Personalised treatment using serum drug levels of adalimumab in patients with rheumatoid arthritis: an evaluation of costs and effects. Ann Rheum Dis2015; 74: 361–368.Current practice for therapeutic drug monitoring of biopharmaceuticals in rheumatoid arthritis. Ther Drug Monit 2017; 39: 3649.
