Frances Rees

Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study

Introduction Many doctors believe that patients with gout are unwilling to receive urate-lowering therapy (ULT) and blame them for poor adherence to management. Objective To test the effectiveness of a complex intervention for gout that incorporates key elements of current guidelines, including full patient information, delivered in an optimal setting (specialist hospital clinic). Method Observational study of patients reporting ongoing attacks of gout recruited from primary care lists. 106 participants (94 men, 12 women; mean age 61 years) were enrolled in the study. Patients received a predominantly nurse-delivered intervention that included education, individualised lifestyle advice and appropriate ULT. The predefined goal was to achieve serum uric acid (SUA) levels ≤360 μmol/l after 1 year in at least 70% of participants. Results Of the 106 participants at baseline, 16% had tophi; mean (SD) baseline SUA was 456 (98) µmol/l. All participants agreed to joint aspiration to confirm gout and all wished to receive ULT. At 12 months, 92% of the 106 participants had achieved the therapeutic target (SUA≤360 µmol); 85% had SUA <300 µmol/l. Allopurinol was the most commonly used ULT, requiring a median dose of 400 mg daily to achieve the target. Improvements in Short Form-36 were observed (significant for pain) after 1 year. Conclusion A predominantly nurse-led intervention including education, lifestyle advice and ULT can successfully achieve the recommended treatment target in more than 9 out of 10 patients. Full explanation and discussion about the nature of gout and its treatment options and individualisation of management probably account for this success.

The incidence and prevalence of systemic lupus erythematosus in the UK, 1999–2012

Objectives To estimate the incidence and prevalence of systemic lupus erythematosus (SLE) in the UK over the period 1999–2012. Methods A retrospective cohort study using the Clinical Practice Research Datalink (CPRD). The incidence was calculated per 100 000 person-years and the prevalence was calculated per 100 000 people for the period 1999–2012 and stratified by year, age group, gender, region and ethnicity. Three definitions of SLE were explored: (1) systemic lupus, (2) a fully comprehensive definition of lupus including cutaneous only lupus and (3) requiring supporting evidence of SLE in the medical record. Results Using our primary definition of SLE, the incidence during the study period was 4.91/100 000 person-years (95% CI 4.73 to 5.09), with an annual 1.8% decline (p<0.001). In contrast, the prevalence increased from 64.99/100 000 in 1999 (95% CI 62.04 to 67.93) (0.065%) to 97.04/100 000 in 2012 (95% CI 94.18 to 99.90) (0.097%). SLE was six times more common in women. The peak age of incidence was 50–59 years. There was regional variation in both incidence and prevalence. People of Black Caribbean ethnicity had the highest incidence and prevalence. Alternative definitions of SLE increased (definition 2) or decreased (definition 3) estimates of incidence and prevalence, but similar trends were found. Conclusions The incidence of SLE has been declining but the prevalence has been increasing in the UK in recent years. Age, gender, region and ethnicity are risk factors for SLE. This is the first study to report ethnic differences on the incidence and prevalence of SLE using the CPRD.

Distribution of finger nodes and their association with underlying radiographic features of osteoarthritis

To determine the distribution of clinically palpable hand interphalangeal (IP) nodes at each finger and thumb joint in a population with nodes, the influence of left or right hand dominance and sex on the development of nodes, and the association between nodes and underlying radiographic features of osteoarthritis (OA).

Mortality in systemic lupus erythematosus in the United Kingdom 1999–2012

OBJECTIVES To estimate the mortality associated with SLE during the period 1999-2012 by age, gender and region; and to ascertain the cause of death for people with SLE. METHODS A retrospective cohort study using the UK Clinical Practice Research Datalink. Incident SLE cases diagnosed between 1999 and 2012 were matched by age, sex and practice to four controls. Age-, gender- and region-specific mortality rates were calculated per 1000 person-years and compared with control mortality rates using mortality rate ratios (MRRs). For individuals with linked Office of National Statistics data, cause of death was summarized by International Classification of Disease-10 chapter heading. RESULTS Of 2740 incident cases, 227 died, giving a mortality rate of 15.84/1000 person-years (95% CI 13.91, 18.04). This was 67% higher than in controls (MRR 1.67, 95% CI 1.43, 1.94, P < 0.001). Men with SLE had higher rates of mortality than females with SLE. Compared with controls, the mortality rate for males with SLE was 1.80 times that of male controls (95% CI 1.32, 2.45, P < 0.001); for females the mortality rate was 1.64 times higher (95% CI 1.37, 1.96, P < 0.001). The age-specific mortality rates increased significantly with age; however, the MRR diminished from 3.81 (95% CI 1.43, 10.14) in those aged <40 years to 0.82 (95% CI 0.36, 1.83) in those ⩾90 years. There was no significant difference in mortality between regions. Circulatory system disease and malignancy were the most frequent causes of death in both cases and controls. CONCLUSION There remains an increased mortality for people with SLE compared with matched controls, particularly at younger ages.

The worldwide incidence and prevalence of systemic lupus erythematosus: a systematic review of epidemiological studies

Objectives The aim was to review the worldwide incidence and prevalence of SLE and variation with age, sex, ethnicity and time. Methods A systematic search of MEDLINE and EMBASE search engines was carried out using Medical Subject Headings and keyword search terms for Systemic Lupus Erythematosus combined with incidence, prevalence and epidemiology in August 2013 and updated in September 2016. Author, journal, year of publication, country, region, case-finding method, study period, number of incident or prevalent cases, incidence (per 100 000 person-years) or prevalence (per 100 000 persons) and age, sex or ethnic group-specific incidence or prevalence were collected. Results The highest estimates of incidence and prevalence of SLE were in North America [23.2/100 000 person-years (95% CI: 23.4, 24.0) and 241/100 000 people (95% CI: 130, 352), respectively]. The lowest incidences of SLE were reported in Africa and Ukraine (0.3/100 000 person-years), and the lowest prevalence was in Northern Australia (0 cases in a sample of 847 people). Women were more frequently affected than men for every age and ethnic group. Incidence peaked in middle adulthood and occurred later for men. People of Black ethnicity had the highest incidence and prevalence of SLE, whereas those with White ethnicity had the lowest incidence and prevalence. There appeared to be an increasing trend of SLE prevalence with time. Conclusion There are worldwide differences in the incidence and prevalence of SLE that vary with sex, age, ethnicity and time. Further study of genetic and environmental risk factors may explain the reasons for these differences. More epidemiological studies in Africa are warranted.

Burden of comorbidity in systemic lupus erythematosus in the UK, 1999–2012

To estimate the comorbidity associated with systemic lupus erythematosus (SLE) in the UK during 1999–2012.

Early clinical features in Systemic Lupus Erythematosus: can they be used to achieve earlier diagnosis? A risk prediction model.

To compare the primary care consulting behavior, prior to diagnosis, of people with systemic lupus erythematosus (SLE) with controls, and to develop and validate a risk prediction model to aid earlier SLE diagnosis.

The burden of co‐morbidity in Systemic Lupus Erythematosus in the United Kingdom 1999‐2012

To estimate the comorbidity associated with systemic lupus erythematosus (SLE) in the UK during 1999–2012.

Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial

Summary Background In the UK, gout management is suboptimum, with only 40% of patients receiving urate-lowering therapy, usually without titration to achieve a target serum urate concentration. Nurses successfully manage many diseases in primary care. We compared nurse-led gout care to usual care led by general practitioners (GPs) for people in the community. Methods Research nurses were trained in best practice management of gout, including providing individualised information and engaging patients in shared decision making. Adults who had experienced a gout flare in the previous 12 months were randomly assigned 1:1 to receive nurse-led care or continue with GP-led usual care. We assessed patients at baseline and after 1 and 2 years. The primary outcome was the percentage of participants who achieved serum urate concentrations less than 360 μmol/L (6 mg/dL) at 2 years. Secondary outcomes were flare frequency in year 2, presence of tophi, quality of life, and cost per quality-adjusted life-year (QALY) gained. Risk ratios (RRs) and 95% CIs were calculated based on intention to treat with multiple imputation. This study is registered with www.ClinicalTrials.gov, number NCT01477346. Findings 517 patients were enrolled, of whom 255 were assigned nurse-led care and 262 usual care. Nurse-led care was associated with high uptake of and adherence to urate-lowering therapy. More patients receiving nurse-led care had serum urate concentrations less than 360 μmol/L at 2 years than those receiving usual care (95% vs 30%, RR 3·18, 95% CI 2·42–4·18, p<0·0001). At 2 years all secondary outcomes favoured the nurse-led group. The cost per QALY gained for the nurse-led intervention was £5066 at 2 years. Interpretation Nurse-led gout care is efficacious and cost-effective compared with usual care. Our findings illustrate the benefits of educating and engaging patients in gout management and reaffirm the importance of a treat-to-target urate-lowering treatment strategy to improve patient-centred outcomes. Funding Arthritis Research UK.

AB0569 How Often Does Cutaneous Lupus Evolve Into Systemic Lupus? a Uk Cohort Study

Background Systemic Lupus Erythematosus (SLE) is a chronic connective tissue disease with a varied clinical phenotype. It can be difficult to define and currently there are no diagnostic criteria. Classification criteria have been developed to standardise entry to research studies and often these are used as a surrogate. However, in clinical practice there are people diagnosed with “lupus” who do not meet the classification criteria, for example those with single organ disease or only meeting 3 criteria. Cutaneous manifestations of lupus are common and may appear in isolation. It is not yet possible to predict from clinical presentation who will remain cutaneous only lupus and who will develop systemic disease and whether we can target therapy to prevent progression from single-organ to systemic disease. Objectives We aimed to ascertain from a community perspective 1) the first diagnosis given to people with lupus, 2) what proportion of lupus patients are diagnosed with cutaneous lupus, and 3) what proportion of these people will go on to develop systemic disease. Methods A retrospective cohort study was conducted using the UK Clinical Practice Research Datalink, a longitudinal database of anonymised general practice records deemed to be broadly representative of the UK population. Data are entered at the practice using Read codes, a standard clinical terminology system used in the UK. Incident cases of lupus were identified during the period 1999-2012 as those with any one of 24 Read codes for lupus or a lupus subtype. The first code was taken as the date of diagnosis. For those with a cutaneous only diagnosis subsequent systemic codes were noted. Results 3479 cases of “lupus” were diagnosed between 1999 and 2012 (incidence 6.23/100,000 person-years (95% CI: 6.03-6.44)). The three most common initial diagnoses were SLE (48%), lupus erythematosus (LE) (18%) and discoid lupus (DLE) (21%). 1002 (29%) had only cutaneous lupus at diagnosis and of these 145 (14%) developed a subsequent systemic diagnosis in the medical record (Figure 1). The cutaneous codes at diagnosis in these 145 were DLE 70%, subacute cutaneous LE 26%, lupus erythematosus tumidus 1%, lupus erythematosus profundus 1% and lupus erythematosus chronicus 1%. The subsequent systemic diagnoses for these 145 people were LE in 52%, SLE 41%, disseminated LE 4%, lung disease with SLE 1%, SLE not otherwise specified 1% and polyneuropathy in disseminated LE 1%. Conclusions Although the most common form of lupus in the community is SLE, a quarter of people with lupus have cutaneous only lupus. 14% of patients presenting with cutaneous lupus will develop systemic disease. Further research could examine predictors at diagnosis for disease progression and examine whether targeted therapy in this cohort could prevent disease progression. Disclosure of Interest F. Rees: None declared, M. Doherty Consultant for: Ad hoc advisory boards on osteoarthritis and gout: Astrazeneca, Menarini, Nordic Biosciences, Novartis, Pfizer, M. Grainge: None declared, P. Lanyon Consultant for: Advisory board for Eli Lilly, Speakers bureau: Pfizer, G. Davenport Speakers bureau: MSD, Pfizer, Lilly, Menarini, Servier, Prostrakan, Amgen, GSK, and Consilient, W. Zhang Consultant for: Savient for Pegloticase, Speakers bureau: Daiichi Sankyo for topical loxoprofen patches