Agnete Malm Gulati

On the HUNT for cardiovascular risk factors and disease in patients with psoriatic arthritis: population-based data from the Nord-Trøndelag Health Study

Objective To compare the presence of cardiovascular (CV) risk factors and established CV disease in patients with psoriatic arthritis (PsA) and the general population and to compare the 10-year risk of a fatal CV event calculated by the Systematic Coronary Risk Evaluation (SCORE) algorithm. Methods Patients with PsA (n=338) and controls (n=50 468) were recruited from the Nord-Trøndelag Health Study 3. Age-adjusted and sex-adjusted prevalence rates of CV risk factors and comorbidity were calculated and the SCORE algorithm was applied. Results There was an increased prevalence of angina pectoris (5.0% vs 3.6%, p=0.01), history of percutaneous coronary intervention (2.4% vs 1.4%, p=0.04), hypertension (45.3% vs 39.3%, p=0.01), obesity (32.0% vs 22.4%) and tobacco smoking (21.3% vs 16.4%, p=0.02) in patients with PsA compared with controls. Patients with PsA had elevated levels of C reactive protein (CRP; p<0.001), body mass index (BMI; p<0.001) and triglycerides (p=0.01). The median calculated CV risk in patients with PsA was low and comparable with controls (0.87 vs 0.83, p=0.24). The distribution across CV risk classes was similar among patients with PsA and controls. Conclusions Patients with PsA have a higher risk of CV disease than the background population, although there was no difference between groups in 10-year risk of a fatal CV event estimated by SCORE. However, patients with PsA had elevated levels of CV risk factors not included in the SCORE algorithm, such as BMI, triglycerides and CRP.

Prevalence and incidence rates of psoriatic arthritis in central Norway: data from the Nord-Trøndelag Health Study (HUNT)

Background A wide range in the prevalence (<0.01–0.25%) and incidence (0.5–23.1/100 000) of psoriatic arthritis (PsA) is reported. The main objective of this study was to examine the prevalence and incidence of PsA in central Norway. Method The patients were recruited from the Nord-Trøndelag Health Study 3, a population study carried out in 2006–2008. All 94 194 inhabitants aged >20 years were invited and 50 806 (54%) responded. The study consisted of a questionnaire (Q1) and a brief medical examination. Q1 included questions if the persons suffered from psoriasis, rheumatoid arthritis (RA) or ankylosing spondylitis (AS). Patients with self-reported psoriasis further answered a specific questionnaire on psoriasis including a questionnaire concerning PsA. In order to identify patients with PsA we used the following criteria: Persons reporting they had or may have PsA; persons answering that they had psoriasis and RA; and persons answering that they had psoriasis and AS. Using this approach, 1278 patients were identified. Hospital files were evaluated by a rheumatologist according to a predefined protocol to verify the diagnosis of PsA. Results 338 patients, 144 men and 194 women, were verified to have PsA. The prevalence of PsA was 6.7 (95% CI 5.9 to 7.4) per 1000 inhabitants >20 years with no significant difference between men and women. In the 9-year period of 2000–2008, a total of 188 patients were diagnosed with PsA, which give an incidence rate of 41.3/100 000 (35.8–47.6). Conclusions The prevalence of PsA in central Norway appears to be higher than previously reported. The reason for this is unknown and may include environmental factors, life style factors and genetic differences.

Surgery for Lumbar Spinal Stenosis in Individuals Aged 80 and Older: A Multicenter Observational Study

To compare clinical outcomes after decompressive surgery for central lumbar spinal stenosis (LSS) in individuals aged 80 and older with those of individuals aged 18–79.

Risk of intracranial hemorrhage in users of oral antithrombotic drugs: Study protocol for a nationwide study

Background A wide range of antithrombotic medications can be used in the prevention and treatment of thrombosis. Among hemorrhagic complications of antithrombotic drugs, intracranial hemorrhage may have particularly devastating consequences with high morbidity, disability and mortality rates. The incidence and risks of intracranial hemorrhage in patients on antithrombotic treatments from regular clinical practice outside clinical trials remain largely unknown. It is not known if results from clinical trials can be extrapolated to everyday clinical practice. We will conduct a nationwide study to investigate the risks and incidence rates of intracranial hemorrhage in users oral antithrombotic drugs in Norway from 2008 through 2014. Methods and design The aim of this nationwide study is to investigate the incidence rates of intracranial hemorrhage requiring hospitalization in users of oral antithrombotic drugs. The study will be conducted within the approximately 4.7 million inhabitants of Norway from January 1 st, 2008, to December 31 st, 2014. Treatment and outcome data are obtained from the Norwegian patient registry and the Norwegian prescription database. Trial registration number Clinicaltrials.gov (NCT02481011)

Bone mineral density in patients with psoriatic arthritis: data from the Nord-Trøndelag Health Study 3

Background The risk of osteoporosis in patients with psoriatic arthritis (PsA) remains unclear. The aim of this study was to compare bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) in patients with PsA and controls. Patients and methods Patients with PsA and controls were recruited from the Nord-Trøndelag Health Study (HUNT) 3. Results Patients with PsA (n=69) and controls (n=11 703) were comparable in terms of age (56.8 vs 55.3 years, p=0.32), gender distribution (females 65.2% vs 64.3%, p=0.87) and postmenopausal status (75.6% vs 62.8%, p=0.08). Body mass index (BMI) was higher in patients with PsA compared with controls (28.5 vs 27.2 kg/m2, p=0.01). After adjusting for potential confounding factors (including BMI), BMD was higher in patients with PsA compared with controls at lumbar spine 1–4 (1.213 vs 1.147 g/cm2, p=0.003) and femoral neck (0.960 vs 0.926 g/cm2, p=0.02), but not at total hip (1.013 vs 0.982 g/cm2, p=0.11). Controls had significantly higher odds of having osteopenia or osteoporosis based on measurements of BMD in both the femoral neck (p=0.001), total hip (p=0.033) and lumbar spine (p=0.033). Conclusion Our population-based data showed comparable BMD in patients with PsA and controls. This supports that the PsA population is not at increased risk of osteoporosis.

Change in cardiovascular risk factors in patients who develop psoriatic arthritis: longitudinal data from the Nord-Trøndelag Health Study (HUNT)

Objectives The aim of this population-based study was to compare changes in cardiovascular (CV) risk factors over a decade-long period in patients who developed psoriatic arthritis (PsA) and the background population. Methods Patients diagnosed with PsA (n=151) between 1998 and 2008 and matched controls (n=755) who participated in both the Nord-Trøndelag Health Study (HUNT) 2 (1995–1997) and HUNT3 (2006–2008) were included. Mixed linear and logistic models were used to analyse the difference in mean change between HUNT2 and HUNT3 in patients and controls for body mass index (BMI), total cholesterol (TC), triglycerides, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c) and blood pressure (BP). Results At baseline (HUNT2), the patients who developed PsA compared with controls had higher BMI (27.2 vs 25.9 kg/m2, p<0.001) and lower HDL-c (1.32 vs 1.40 mmol/L, p<0.03) and more were smokers (41.1 vs 28.5%, p<0.01). Seventy-eight per cent had skin psoriasis. The mean PsA disease duration at HUNT3 was 4.8 (+/–3.0) years. The patients who developed PsA gained less weight from HUNT2 to HUNT3 compared with the control group (2.1 vs 3.9 kg, difference in mean change −1.8 kg, 95% CI −3.9 to −0.5, p<0.01). TC, triglycerides, LDL-c or HDL-c values and BP declined in both groups, with no significant differences between groups. Conclusion Longitudinal 10-year data did not show an increase in CV risk factors in patients who developed PsA compared with controls. This study implies that unfavourable CV risk factors in PsA were present before the diagnosis was established.

Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population

Background The risk of osteoporosis in patients with psoriatic arthritis (PsA) still remains unclear. The aim of this study was to investigate bone mineral density (BMD) at the hip and lumbar spine measured by dual-energy X-ray absorptiometry in patients with PsA. Methods From an outpatient clinic in southern Norway, 140 patients with PsA were consecutively recruited and assessed for osteoporosis as part of a prospective study from January 2013 to May 2014. An extensive data collection was performed including demographic data and measures reflecting disease activity and health status. Results Mean age was 52.4 years and 71 (50.7%) were women. Median disease duration was 7.8 years. The proportion of patients with low BMD (defined as Z score≤−1.0 SD) was comparable to the expected value of 16%, according to the normal distribution of the Z score in the population. Osteoporosis was only found in 6.4% (95% CI3% to 11%) of the patients. No significant associations were found between BMD and disease activity measures. Conclusion The prevalence of PsA patients with osteoporosis or low BMD was low and in the range seen in the reference population. This supports that patients with PsA are not at high risk for osteoporosis compared with the general population. Therefore, clinicians may follow the general population guidelines for monitoring of osteoporosis for patients with PsA.

Risk of intracranial hemorrhage (RICH) in users of oral antithrombotic drugs: Nationwide pharmacoepidemiological study

Background The risks of intracranial haemorrhage (ICH) associated with antithrombotic drugs outside clinical trials are gaining increased attention. The aim of this nationwide study was to investigate the risk of ICH requiring hospital admission in users of antithrombotic drugs. Methods and findings Data from the Norwegian Patient Registry and Norwegian Prescription Database were linked on an individual level. The primary outcome was incidence rates of ICH associated with use of antithrombotic drugs. Secondary endpoints were risk of ICH and fatal outcome following ICH assessed by Cox models. Among 3,131,270 individuals ≥18 years old observed from 2008 through 2014, there were 729,818 users of antithrombotic medications and 22,111 ICH hospitalizations. Annual crude ICH rates per 100 person-years were 0.076 (95% CI, 0.075–0.077) in non-users and 0.30 (95% CI, 0.30–0.31) in users of antithrombotic medication, with the highest age and sex adjusted rates observed for aspirin-dipyridamole plus clopidogrel (0.44; 95% CI, 0.19–0.69), rivaroxaban plus aspirin (0.36; 95% CI, 0.16–0.56), warfarin plus aspirin (0.34; 95% CI, 0.26–0.43), and warfarin plus aspirin and clopidogrel (0.33; 95% CI, 0.073–0.60). With no antithrombotic medication as reference, the highest adjusted hazard ratios (HR) for ICH were observed for aspirin-dypiridamole plus clopidogrel (6.29; 95% CI 3.71–10.7), warfarin plus aspirin and clopidogrel (4.38; 95% CI 2.71–7.09), rivaroxaban plus aspirin (3.82; 95% CI, 2.46–5.95), and warfarin plus aspirin (3.40; 95% CI, 2.99–3.86). All antithrombotic medication regimens were associated with an increased risk of ICH, except dabigatran monotherapy (HR 1.20; 95% CI, 0.88–1.65) and dabigatran plus aspirin (HR 1.79; 95% CI, 0.96–3.34). Fatal outcome within 90 days was more common in users (2,603 of 8,055) than non-users (3,228 of 14,056) of antithrombotic medication (32.3% vs 23.0%, p<0.001), and was associated with use of warfarin plus aspirin and clopidogrel (HR 2.89; 95% CI, 1.49–5.60), warfarin plus aspirin (HR 1.37; 95% CI, 1.11–1.68), aspirin plus clopidogrel (HR 1.30; 95% CI, 1.05–1.61), and warfarin (HR 1.19; 95% CI, 1.09–1.31). Increased one-year mortality was observed in users of antithrombotic medication following hemorrhagic stroke, subdural hemorrhage, subarachnoid hemorrhage, and traumatic ICH (all p<0.001). Limitations include those inherent to observational studies including the inability to make causal inferences, certain assumptions regarding drug exposure, and the possibility of residual confounding. Conclusions The real-world incidence rates and risks of ICH were generally higher than reported in randomized controlled trials. There is still major room for improvement in terms of antithrombotic medication safety (clinicaltrials.gov NCT02481011).

SAT0381 On the Hunt for Cardiovascular Risk Factors and Disease in Patients with Psoriatic Arthritis – Results from the Norwegian Hunt Study

Background Controversies exist regarding increased risk of cardiovascular (CV) disease in patients with psoriatic arthritis (PsA). Objectives To compare the presence of CV risk factors and disease in patients with PsA and the normal population. Further to estimate the 10-year risk of a fatal CV event by using the Systematic Coronary Evaluation (SCORE) algorithm.1 Methods Patients and control subjects were recruited from the Nord-Trøndelag Health Study (HUNT) 3, and the diagnoses of PsA (n=338) were verified according to the Classification of Psoriatic Arthritis (CASPAR) criteria.2 The control group (n=50468) consisted of other individuals enrolled in the HUNT 3 study. Age and sex adjusted prevalence rates of CV risk factors and co morbidity were calculated. Results Mean (SD) age was 54.3±11.9 years and 53.9±16.1 years in PsA and controls, respectively (p=0.58) and the gender ratio was nearly equally distributed in both groups (p=0.31). Patients with PsA were more often smokers compared to controls (p=0.02). The other traditional CV risk factors included in the SCORE CV risk algorithm (age, gender, systolic blood pressure and total cholesterol/HDL) were comparable between PsA patients and controls. Of untraditional CV risk factors; CRP, body mass index (BMI) and triglycerides were elevated in PsA patients compared to controls, (p<0.001, p<0.001 and p=0.01, respectively). The mean calculated CV risk (SD) in PsA patients was low (1.45±1.79) and comparable to controls (1.59±1.95) (p=0.63). The distribution across CV risk classes (low, moderate and high + very high) was comparable amongst PsA patients and controls (figure 1). There was no difference in the prevalence of established CV disease in the PsA cohort and the control group (p=0.2). Conclusions The low CV risk in patients with PsA was related to low levels of traditional risk factors. Although, PsA patients had elevated levels of untraditional CV risk factors such as CRP, BMI and triglycerides, which are not included in the SCORE risk algorithm. Whether these factors will affect long term CV outcome is not known. References Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 2007; 28(19):2375-2414. Hoff M, Gulati AM, Romundstad PR, Kavanaugh A, Haugeberg G. Prevalence and incidence rates of psoriatic arthritis in central Norway: data from the Nord-Trondelag Health Study (HUNT). Ann Rheum Dis 2013 Aug 20. doi: 10.1136/annrheumdis-2013-203862. Disclosure of Interest A. Gulati: None declared, G. Haugeberg Grant/research support: Has received unrestricted grant from Pfizer., A. G. Semb: None declared, P. Romunstad: None declared, A. Kavanaugh: None declared, S. Gulati: None declared, S. C. Rollefstad: None declared, M. Hoff: None declared DOI 10.1136/annrheumdis-2014-eular.5282

AB0585 High prevalence of psoriatic arthritis in the middle of norway

Background Studies indicate that the prevalence of psoriatic arthritis (PsA) range from 0.02-0.25 % in various parts of the world [1] Objectives To explore the prevalence of PsA based on the Norwegian population survey “Helse undersøkelsen i Nord Trøndelag” (HUNT-3) performed in 2006-08. Methods In HUNT 3 an invitation letter was mailed to all 94,194 adult inhabitants (aged > 20 yrs) in the county Nord-Trøndelag. A total of 50,806 (54%) responded and answered a questionnaire (Q1) and underwent a brief medical examination. Q1 included questions if patients suffered from psoriasis, rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Patients answering they suffer from psoriasis further answered a second questionnaire (Q2) specific about psoriasis including if they had PsA In order to identify as many patients with PsA as possible we then used the following criteria to identify individual’s potential to have PsA: Persons who answered “Yes” or “I do not know” at the question: “Do you have PsA” in Q2. Persons answering that they had psoriasis and RA (Q1). Persons answering that they had psoriasis and AS (Q1). In addition we included persons answering they had psoriasis and cardiovascular disease, but had not filled out Q2. This approach identified 1,238 patients from HUNT 3. The diagnosis for each identified individual was validated by an experienced rheumatologist (MH) reviewing the medical hospital records in the county. The evaluation was based on joint involvement, serology, X-ray and skin involvement. Treatment and organ manifestations were noticed and the CASPAR criteria were applied. Patients found to have PsA who did not fulfill the CASPAR criteria were evaluated by two rheumatologists (MH and GH). Results Finally a total of 338 patients were found to have PsA. Mean age was 54 yr, 57.4% were female and disease duration 9,2 yr. 52.1% were current or previous users of MTX and 18.6% of anti-TNF therapy. 95.6 % fulfilled the Caspar criteria. All the 15 patients evaluated to have PsA without fulfilling the Caspar criteria had psoriasis and arthritis but data on serology was not available. The total prevalence of PsA (per 1,000) was 6.7 (95% CI 5.9-7.4). Age and gender were distributed as shown in table 1. Conclusions The prevalence of PsA in the middle of Norway appears to be higher than previously reported both in Norway [2] and other countries[1]. The reason for this is unknown and may include environmental factors, life style factors and genetic differences. Further studies are warranted to explore for these differences in prevalence of PsA. References Setty AR et al. Curr Rheumatol Rep2007;9(6):449. Madland TM et al. J Rheumatol 2005;32(10):1918 Disclosure of Interest M. Hoff: None Declared, A. Kavanaugh : None Declared, P. Romundstad: None Declared, A. Gulati: None Declared, G. Haugeberg Grant/research support from: Unrestricted research grant from Pfizer