Bogas M

Methotrexate treatment in rheumatoid arthritis: management in clinical remission, common infection and tuberculosis. Results from a systematic literature review

This work was performed as part of the Portuguese participation in the 3E Initiative 2007–2008, dedicated to the use of methotrexate (MTX) in rheumatic conditions. Three questions raised by Portuguese rheumatologists and considered relevant to clinical practice remained out of the selection of a set of ten key questions formulated to further establish multinational recommendations on the use of MTX in rheumatic diseases. The authors collected and analyzed all the evidence available by using a systematic literature search methodology and selection criteria concerning the following issues in rheumatoid arthritis (RA): (1) the management of MTX after clinical remission; (2) the management of MTX during infections and (3) the screening and treatment of tuberculosis in patients on MTX treatment. A total of 1,862 references were identified, of which 163 were selected for detailed analysis and 12 included in the final review. The evidence was appraised according to the Oxford Centre for Evidence-based Medicine (EBM) levels of evidence. Although with limited evidence, the authors concluded that: (1) extending the interval for MTX therapy may be a valid alternative regimen in a subset of RA patients in clinical remission (EBM level 2b); (2) MTX may be safe during some common infections in RA patients (EBM level 3b/4); (3) screening and treatment of TB in patients on MTX should be similar to the general population (EBM level 4). The evidence available to support clinical decisions in this area is very limited in number and quality. There is a need for further research and while that is unavailable, practical decisions have to rely on experience and expert opinion.

Macroscopic features of knee synovitis in early untreated Behçet disease and psoriatic arthritis

In a previous study, we found that synovial immunopathology differs between Behçet disease (BD) and psoriatic arthritis (PsA). The objective of this study is to describe the macroscopic features of early untreated knee synovitis in BD and PsA. Fourteen consecutive patients with active early knee synovitis (seven BD and seven PsA) undergoing rheumatologic arthroscopy were assessed. The following macroscopic synovial features were evaluated and scored by analyzing the video recordings of each procedure: capillary hyperaemia, morphology of synovitis, vascular pattern, fibrinoid membranes, and topographic distribution of these features. Video-recording of 35 early untreated arthritis patients with different diagnoses were also studied looking for BD-like macroscopic features. Six out of seven BD patients had extensive fibrinoid membranes and large areas of erythematous synovitis without villi or a distinctive vascular pattern, while PsA patients had diffuse erythematous villous synovitis with a tortuous vascular morphology. None of the 35 patients with early untreated arthritis exhibited all the characteristic features of BD synovitis. This exploratory study shows some distinctive features between BD and PsA knee synovitis that confirm macroscopic differences in patients with previously reported immunopathological differences.

AB1023 Rheuma Space: Standard Practice Aiming Clinical Excellence in Rheumatology

Background The evaluation of the quality of medical practice and the implementation of corresponding measures to improve it are crucial steps for the development of Rheumatology in Europe. Herein we describe the implementation of a national program, Rheuma Space, aiming at quality improvement in the field of Rheumatology. Objectives To develop standards for the quality of care accepted by most of the rheumatology services in Portugal. Methods Quality indicators were obtained through a four-step RAND-modified Delphi methodology. The first step involved a literature search for international benchmarking of quality of care initiatives and indicators, followed by a pre-selection of a initial set of criteria by a task force. The final steps, aiming at defining a smaller set of criteria that could best analyze rheumatology quality of care, encompassed an online Delphi round with all Portuguese rheumatologists and a consensus meeting with a panel of invited experts representing all the Portuguese Rheumatology Departments of the National Health Service. Results A total of 412 different indicators were collected throughout the first project phase and the final set of 26 quality indicators was defined, within the three Donabedian dimensions of healthcare quality: nine “structure”, eleven “processes” and seven “outcome” indicators. These criteria cover eleven domains of quality of care: personnel and organizational structure, training and research, facilities, equipment and IT, budgeting and financial resources, access to care, clinical records, patient communication, multidisciplinary management, clinical outcomes, and patient and personnel satisfaction. Conclusions The 26 quality indicators set constitutes the basis for a quality management tool, which is now being implemented in all the Portuguese Rheumatology Departments of the National Health Service. Direct surveys derived from the 26 quality indicators are being applied to health professionals and patients allowing to benchmark departments and to identify strengths and weakness for future improvement. This initiative is deemed to improve the process of care for Portuguese rheumatic patients, thereby ensuring quality standards of structure and process criteria, for a patient-oriented clinical practice, favouring desirable continuous quality improvement on health outcomes. Acknowledgement Portuguese Rheumatology participating in the online Delphi and all the participants in the expert consensus meeting Disclosure of Interest None declared

AB0802 Beliefs and treatment satisfaction in patients receiving biological agents

Background Treatment satisfaction represents an important outcome as it is related to adherence and willingness to continue treatment. Patients beliefs related to the medication (eg, about side effects and safety) also influence their satisfaction and, consequently, the treatment success. Satisfied patients are more likely to maintain a good relationship with a healthcare provider and report better health status1. Objectives To evaluate the beliefs and satisfaction of our patients with inflammatory rheumatic diseases with their current biological therapies. Methods Forty-one consecutive patients observed at our day-care unit completed an 18-item questionnaire concerning biological treatment. It included questions addressing their perceptions and satisfaction with their current treatment, information provided by their physician and about the knowledge and satisfaction regarding the cost of these therapies. The questionnaire was applied by the nurses to patients and blinded to provide anonymity. The attending physician was previously asked to record the disease state (remission/not remission) of each patient. Results We included 26 females and 15 males, with a mean age of 47.1±11.9 years. Forty six percent of the patients had rheumatoid arthritis, 27% psoriatic arthritis, 22% ankylosing spondylitis and 5% had undifferentiated spondylarthritis. Forty six percent of the patients were treated with etanercept, 29% with adalimumab, 13% with infliximab, 7% with rituximab and 5% with tocilizumab and 85.4% of patients were in clinical remission. Regarding the information provided by their doctor about the treatment, 95% of patients were satisfied, 97.6% responded that this treatment was effective to control the disease and 100% that their quality of life improved with this medication. Concerning safety, although 82.9% considered this drug safe, 56% responded that they had to take special care about their health, 22% believed to have more health complications and 14.6% experienced some side effects. Regarding convenience, 87.8% responded that their treatment frequency was convenient but 46.6% were unsatisfied with the form of administration and 24.4% reported that their treatment form/frequency interfered with their professional life. In relation to costs of the biologic agents,83% of patients considered that they are expensive and 98% didn’t agreed with the price. However when we tried to understand if patients had a correct notion of the cost, 73% of patients responded <1000 euros (€)/month, 46% <500 €/month and 22% said <100 €/month. Conclusions The majority of our patients were satisfied with the information provided by their doctor, considered the treatment effective in controlling the disease, reported improved in quality of life and considered them as safe drugs. In the negative perspective, we emphasize that 46.6% of patients are unsatisfied with the form of administration and 24.4% reported that it interfered with their professional life. Although most patients considered biological agents as expensive drugs, the majority underestimated their real cost, which reinforces the need for continuous education to raise the awareness of patients to avoid oversights/waste with the drug. References DiMatteo MR, Prince LM, Taranta A. Patient’s perceptions of physician’s behavior: determinants of patient commitment to the therapeutic relationship. J Community Health 1979;4:280-90. Disclosure of Interest None Declared

THU0454 Thyroid Involvement in Patients with Spondyloarthritis

Background The association between chronic inflammatory diseases and thyroid dysfunction is well recognized. This fact can be attributed to hormonal factors and the presence of a facilitator genetic terrain. Increased prevalence of Hashimoto’s thyroiditis (HT) has been described in rheumatoid arthritis, sjögren’s syndrome and systemic lupus erythematosus1. However, there are few data on the association of this disease in other chronic rheumatic disorders such as spondyloarthritis (SpA). Objectives To assess the prevalence of HT in a group of patients with SpA. Methods We included in this study 62 consecutive patients with SpA and 61 age-matched controls with osteoarthritis, primary osteoporosis or fibromyalgia. From January 2012 until January 2013, blood samples were drawn in all subjects. Thyroid-stimulating hormone, free triiodothyronine, free thyroxine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), titers of antithyroglobulin (anti-TG) and antithyroid peroxidase (anti-TPO) antibodies were measured. The thyroid ultrasound was performed in all patients with changes in thyroid function tests. Age, gender, disease duration and medical treatments were collected. To assessdisease activity we evaluated the DAS 28 in peripheral SpA and the BASDAI in axial SpA. In the statistical analysis (chi-Square and student T-test for categorical and continuous variables, respectively), a significant association was considered if p<0.05. Results We found thyroid dysfunction in 12.9% of SpA and in 3.3% of controls (p<0.05). Hypothyroidism was more common than hyperthyroidism in both groups. We found anti-TG or anti-TPO positive in 16.1% of SpA and in 6.6% of controls (p=0.05) and the anti-TPO was the most frequent in both groups. The prevalence of HT (antibody positivity and ultrasonographic changes suggestive of thyroiditis) was higher in patients with SpA than in controls (9.7% vs 1.6% respectively, p<0.05). Among patients with SpA, HT was significantly more frequent in patients with peripheral involvement (83.3%) than in those with axial involvement (16.7%) and in patients with disease duration >5 years (p<0.05). Furthermore, patients treated with biologic therapy and those who were treated with ≥2 conventional DMARDs (in association) had significantly more HT (p<0.05). There was no association between subtype of SpA, actual ESR or CRP, the current DAS28 or BASDAI. Conclusions Our study demonstrates that HT occurs in patients with SpA with a higher prevalence than in controls, similarly as described in other chronic rheumatic diseases. Although we did not find association between HT with the current disease activity, the HT was significantly more frequent in patients with peripheral involvement, long disease duration and those treated with biological agents or with highest number of DMARDs. This suggests a possible relationship between HT and the maintenance of the inflammatory process in patients with SpA. These results suggest that thyroid function tests should be part of the clinical evaluation in patients with SpA. Currently, there is no clear explanation for the coexistence of these two diseases therefore further studies are needed to clarify the etiology of this association. References Chan T, Al-Saffar Z, Bucknall C. Thyroid disease in systemic lupus erythematosus and rheumatoid arthritis. Rheumatology 2001;40:353-4. Disclosure of Interest None Declared

THU0446 Evaluation of Fatigue in Patients with Spondyloarthritis

Background Fatigue is common to all the rheumatic conditions, in varying degrees, and is a frequent, often severe problem that has major consequences on patients life. Objectives To evaluate the fatigue in a group of patients with spondyloarthritis and possible associations with anemia, disease activity index and degree of pain with fatigue experienced by patients. Methods Patient’s demographic data were collected. The Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT F), version 4- Portuguese translation available, was applied for fatigue measurement. Scores range from 0 to 160, with lower scores reflecting greater fatigue. Patients were grouped by predominant axial or peripheral involvement. Clinical measures were collected according to the predominant involvement (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) for the axial and Disease Activity Score in 28 joints- erythrocyte sedimentation rate (DAS28- ESR) for the peripheral). In all, global assessment (PGA) of disease activity, pain on a 0-100-mm visual analog scale (VAS) and laboratory findings were recorded. Correlation studies were performed with Spearman test. Results A total of 51 patients were consecutively included, 32 (62.7%) were male and 19(37.3%) were female, with a mean age of 44.1±13.9 years (17 to 69) and a median disease duration of 137.6±110.1 months (7 to 445). The predominant involvement was axial in 28 (54.9%) patients and peripheral in 23 (45.1%). Nineteen (37.3%) patients were treated with biological therapies and 24 (47.1%) with classical disease-modifying anti-rheumatic drugs (DMARDs). Mean DAS28 was 2.41±1.26 (0.53 to 4.76) and BASDAI 2.78±2.43 (0 to 8.24), mean fatigue question in BASDAI of 3.03±2.98 (0 to 10) and mean BASFI was 3.31±2.89 (0 to 9.3). Mean of PGA and pain scores on a VAS was 31.51±25.44 and 32.57±29.1 respectively. FACIT-F scored from 61 to 158 (mean of 112.37±23.44). Mean FACIT-F was statistically significant lower in women than men (p<0.05) and the functional component of FACIT-F lower in patients with predominant peripheral involvement (p<0.05). Correlation with FACIT-F total score was strongest for BASFI (r= -0.710; p<0.01); BASDAI (r= -0.501; p<0.01); BASDAI-fatigue (r=-0.466; p<0.01), pain (r= -0.505; p<0.01), PGA (r=-0.455; p<0.01) and age (r=-0.404; p<0.01). DAS28, hemoglobin and ESR correlated with the physical component of the FACIT-F (r=-0.538; r=0.356; r=-0.382 with a p<0.05) but not with the total FACIT-F score. Fatigue levels were not significantly different between patients on biologic or other treatments. Conclusions Fatigue is an important symptom in patients with inflammatory arthritis. FACIT-F is a psychometrically sound measure of the fatigue in different domains. The FACIT-F showed a good (negative) correlation with measures of pain, disease assessment and disease function, showing a trend to be lower in patients with higher activity. No association was found with therapy, disease duration, acute-phase reactants or anemia. References Webster k, Cella D, Yost K. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: properties, applications, and interpretation. Health and Quality of Life Outcomes 2003, 1:79 Disclosure of Interest None Declared