A. Chow

Ultrasound of the hands and feet for rheumatological disorders: influence on clinical diagnostic confidence and patient management

PurposeThe purpose of the study was to quantify the impact that ultrasound (US) of the hands and feet has on the rheumatologists diagnostic confidence and on patient management.Materials and methodsThere were 62 consecutive referrals from two rheumatologists for US of the hands and/or feet for this prospective controlled observational study. Measurements of diagnostic confidence for both specific clinical findings as well as overall diagnosis using a Likert scale were made both before and after the US examination in each case. Proposed management was also recorded before US and then with the benefit of the US result. McNemar’s test was performed to determine differences in diagnostic certainty and proposed management before and after US.ResultsThe physician certainty for specific clinical findings increased significantly following US for synovitis (9.7 vs 38.7%), tenosynovitis (9.7 vs 46.8%), erosions (1.6 vs 58.1%), enthesitis (50.0 vs 83.9%) and other (53.2 vs 77.4%). The physician certainty for overall diagnosis increased significantly for seronegative arthritis (46.8 vs 61.3%), inflammatory osteoarthritis (46.8 vs 87.1%), and primary osteoarthritis (46.8 vs 73.0%). A total of 88.7% of patients had disease-modifying antirheumatic drugs as a proposed management option before US vs 48.4% after US. Before US, 4.8% of patients had non-steroidal anti-inflammatory drug as a proposed management option versus 45.2% after US.ConclusionUltrasound of the hands and/or feet significantly influenced the rheumatologists diagnostic confidence in specific clinical findings and management plans.

Belimumab use, clinical outcomes and glucocorticoid reduction in patients with systemic lupus erythematosus receiving belimumab in clinical practice settings: results from the OBSErve Canada Study

To describe the characteristics of patients receiving belimumab, overall patterns of systemic lupus erythematosus (SLE) care, clinical outcomes, and changes in glucocorticoid dose following 6xa0months of therapy with belimumab, and healthcare resource utilization in belimumab users in Canadian clinical practice settings. Retrospective multicenter medical chart review study of adult patients with SLE who were prescribed belimumab as part of usual care and who receivedu2009≥8 infusions or 6xa0months of treatment. Primary endpoints included physician-determined overall clinical improvement from baseline, glucocorticoid use, and physician-determined SLE disease severity at Month 6. In total, 52 patients were included in the study. At belimumab initiation, 5.8/76.9/17.3% of patients had mild/moderate/severe SLE, respectively. Oral glucocorticoids were discontinued in 11.4% of patients and 59.1% received a lower dose at Month 6. At Month 6, 80.8/57.7/17.3% of patients had a physician-determined clinical improvement of ≥20/≥50/≥80%, respectively. Sixteen patients had a SLE Disease Activity Index-2K score at both baseline and Month 6, with a mean improvement of 2.6u2009±u20095.3 from 8.1u2009±u20093.2 at baseline. No formal disease assessment tool was utilized for 42.3% of study patients at baseline. This study provides the first real-world insights into belimumab use in Canada. It demonstrates significant reduction or discontinuation of glucocorticoid dose in 70.5% of patients and clinically significant improvement following 6xa0months’ belimumab therapy. The high number of patients with no formal disease activity assessments highlights a key care gap in SLE treatment in the real-world setting.

Incidence and Management of Infusion Reactions to Infliximab in a Prospective Real-world Community Registry

Objective. Infliximab (IFX) is a therapeutic monoclonal antibody targeting tumor necrosis factor-α indicated in the treatment of chronic inflammatory diseases. IFX is administered by intravenous infusion and may be associated with different types of infusion reactions. Methods. RemiTRAC Infusion (NCT00723905) is a Canadian observational registry in which patients receiving IFX are followed prospectively to document premedication use, adverse events, infusion reactions, and the management of infusion reactions. The primary endpoint was to assess factors associated with infusion reactions. Results. There were 1632 patients enrolled and 24,852 infusions recorded. Most patients (63.1%) were treated for rheumatologic conditions such as rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis. Of the 1632 patients, 201 (12.3%) reported at least 1 infusion reaction. Three hundred twenty-two infusions were associated with an infusion reaction (1.3%), and most were mild to moderate in severity (95%). The most common infusion reactions were pruritus (19.9%), flushing (9.9%), or dyspnea (6.2%). Multivariate analysis showed that antihistamines premedication, number of previous infusion reactions, and female sex were significantly associated with an increased incidence of infusion reactions (p < 0.0011). The use of any concomitant immunosuppressant or corticosteroids did not influence the incidence of infusion reactions. Antihistamine premedication was associated with an increased incidence of infusion reactions (OR 1.58, p = 0.0007). Conclusion. This registry shows that in community-based infusion clinics, infusion reactions to IFX are uncommon and mild to moderate in nature. Antihistamines, intravenous steroids, and acetaminophen are widely used as preventative premedication, although this study showed an absence of benefit with their use.

Effectiveness and Safety of Infliximab in Rheumatoid Arthritis: Analysis From a Canadian Multicenter Prospective Observational Registry

To describe the profile of rheumatoid arthritis (RA) patients treated with infliximab in Canadian routine care and to assess the real‐world effectiveness and safety of infliximab.

Triple therapy versus biologic therapy for Active Rheumatoid Arthritis a cost-effectiveness analysis

BackgroundnThe RACAT (Rheumatoid Arthritis Comparison of Active Therapies) trial found triple therapy to be noninferior to etanercept-methotrexate in patients with active rheumatoid arthritis (RA).nnnObjectivenTo determine the cost-effectiveness of etanercept-methotrexate versus triple therapy as a first-line strategy.nnnDesignnA within-trial analysis based on the 353 participants in the RACAT trial and a lifetime analysis that extrapolated costs and outcomes by using a decision analytic cohort model.nnnData SourcesnThe RACAT trial and sources from the literature.nnnTarget PopulationnPatients with active RA despite at least 12 weeks of methotrexate therapy.nnnTime Horizonn24 weeks and lifetime.nnnPerspectivenSocietal and Medicare.nnnInterventionnEtanercept-methotrexate first versus triple therapy first.nnnOutcome MeasuresnIncremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).nnnResults of Base-Case AnalysisnThe within-trial analysis found that etanercept-methotrexate as first-line therapy provided marginally more QALYs but accumulated substantially higher drug costs. Differences in other costs between strategies were negligible. The ICERs for first-line etanercept-methotrexate and triple therapy were

Real-world validation of the minimal disease activity index in psoriatic arthritis: an analysis from a prospective, observational, biological treatment registry

2.7 million per QALY and

Biologic Treatment Registry Across Canada (BioTRAC): a multicentre, prospective, observational study of patients treated with infliximab for ankylosing spondylitis.

0.98 million per QALY over 24 and 48 weeks, respectively. The lifetime analysis suggested that first-line etanercept-methotrexate would result in 0.15 additional lifetime QALY, but this gain would cost an incremental

Dose Escalation and Co-therapy Intensification Between Etanercept, Adalimumab, and Infliximab: The CADURA Study

77xa0290, leading to an ICER of

SAT0062 What is the Effect of TNF Inhibitors on Employment Status in Rheumatoid Arthritis Patients and what are the Predictors of Progression to Unemployment

521xa0520 per QALY per patient.nnnResults of Sensitivity AnalysisnConsidering a long-term perspective, an initial strategy of etanercept-methotrexate and biologics with similar cost and efficacy is unlikely to be cost-effective compared with using triple therapy first, even under optimistic assumptions.nnnLimitationnData on the long-term benefit of triple therapy are uncertain.nnnConclusionnInitiating biologic therapy without trying triple therapy first increases costs while providing minimal incremental benefit.nnnPrimary Funding SourcenThe Cooperative Studies Program, Department of Veterans Affairs Office of Research and Development, Canadian Institutes for Health Research, and an interagency agreement with the National Institutes of Health-American Recovery and Reinvestment Act.

SAT0565 Correlation of Individual HAQ Questions with Disease Activity Measures in Psoriatic Arthritis: Implications for Instrument Reduction

Objective To describe the minimal disease activity (MDA) rate over time in patients with psoriatic arthritis (PsA) receiving antitumour necrosis factor agents, evaluate prognostic factors of MDA achievement and identify the most common unmet criteria among MDA achievers. Design Biologic Treatment Registry Across Canada (BioTRAC): ongoing, prospective registry of patients initiating treatment for rheumatoid arthritis, ankylosing spondylitis or PsA with infliximab (IFX), golimumab (GLM) or ustekinumab. Setting 46 primary-care Canadian rheumatology practices. Participants 223 patients with PsA receiving IFX (enrolled since 2005) and GLM (enrolled since 2010) with available MDA information at baseline, 6 months and/or 12 months. Primary and secondary outcome measures MDA was defined as ≥5 of the following criteria: 28-item tender joint count (TJC28) ≤1, 28-item swollen joint count (SJC28) ≤1, Psoriasis Area and Severity Index (PASI) ≤1 or body surface area≤3, Pain Visual Analogue Scale (VAS) ≤15u2009mm, patient’s global assessment (PtGA) (VAS) ≤20u2009mm, Health Assessment Questionnaire (HAQ) ≤0.5, tender entheseal points ≤1. Independent prognostic factors of MDA achievement were assessed with multivariate logistic regression. Results MDA was achieved by 11.7% of patients at baseline, 43.5% at 6 months, 44.8% at 12 months and 48.8% at either 6 or 12 months. Among MDA achievers at 6 months, 75.7% had sustained MDA at 12 months. Lower baseline HAQ (OR=0.210; 95%u2009CI: 0.099 to 0.447) and lower TJC28 (OR=0.880; 95%u2009CI: 0.804 to 0.964), were significant prognostic factors of MDA achievement over 12 months of treatment. The most commonly unmet MDA criteria among MDA achievers was patient reported pain (25%), PtGA (15%) and PASI (12%). Conclusions Almost 50% of patients treated with IFX or GLM in routine clinical care achieved MDA within the first year of treatment. Lower baseline HAQ and lower TJC28, were identified as significant prognostic factors of MDA achievement. The most commonly unmet criteria in patients who achieved MDA were pain, PtGA and PASI. Trial registration number BioTRAC (NCT00741793).