Graham Davenport

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.

The British Society for Rheumatology Guideline for the Management of Gout

Gout is the most common cause of inflammatory arthritis worldwide. In UK general practice, the overall prevalence has increased from 1.4% in 1999 to 2.49% in 2012 [1], despite the availability of effective and potentially curative urate-lowering drugs for >50 years and evidence-based British and European management guidelines for nearly a decade [2, 3]. Clinical manifestations of gout resulting from monosodium urate crystal deposition include tophi, chronic arthritis, urolithiasis and renal disease as well as recurrent acute arthritis, bursitis and cellulitis. Gouty arthritis and tophi are associated with chronic disability, impairment of health-related quality of life [4 7], increased use of healthcare resources and reduced productivity [8]. Gout is also frequently associated with co-morbidities such as obesity, dyslipidaemia, diabetes mellitus, chronic renal insufficiency, hypertension, cardiovascular disease, hypothyroidism, anaemia, psoriasis, chronic pulmonary diseases, depression and OA [1] as well as with an increase in all-cause mortality (adjusted hazard ratio 1.13, 95% CI: 1.08, 1.18) and urogenital malignancy [1, 9]. Sustained hyperuricaemia is the single most important risk factor for the development of gout. Hyperuricaemia occurs secondarily to reduced fractional clearance of uric acid in> 90% of patients with gout [10]. Age, male gender, menopausal status in females, impairment of

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.

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.

Diagnosing and managing carpal tunnel syndrome in primary care

#### Clinical Question How can carpal tunnel syndrome be diagnosed and managed in a primary care setting? Carpal tunnel syndrome (CTS) is a symptomatic compression neuropathy of the median nerve at the level of the wrist; characterised by hand pain, numbness, and tingling in the distribution of the median nerve (thumb, index, middle finger, and the radial side of the ring finger) and a reduction in grip strength and hand function. The severity of symptoms can be clinically categorised into mild, moderate, and severe. A figure of 55–65% of CTS cases present bilaterally1 and the condition can be associated with conditions such as hypothyroidism, diabetes, and rheumatoid arthritis. CTS may present in late pregnancy but is usually transient. A study from the UK General Practice Research Database in 2000, calculated the incidence in males to be 88 per 100 000 and in females to be 193 per 100 000, with new presentations being most frequent at ages 45–54 years in females and 75–84 years in males.2 CTS is a recognised work-related musculoskeletal disorder (WMSD) caused by strain and repeated movements (biomechanical overload) and is hence more common in manual workers. Work absence and associated healthcare costs contribute to a significant socioeconomic burden on the UK economy.3 Consultations …

Improving management of gout in primary care: a new UK management guideline

Gout is the most prevalent inflammatory arthritis, affecting 2.5% of adults in the UK.1 Despite its prevalence and the availability of potentially ‘curative’ urate-lowering therapies (ULT) such as allopurinol, gout remains undertreated in both primary and secondary care. Under half of patients receive ULT and many do not have ULT escalated sufficiently to reduce serum uric acid (sUA) below recommended target levels.1 The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) have recently revised their evidence-based guideline for the management of gout,2 first published in 2007.3 The multidisciplinary guideline development group agreed key clinical management questions and undertook a systematic literature review and Delphi process to inform evidence-based consensus management recommendations. These were grouped into three categories: management of acute attacks ( n = 6), modification of lifestyle and risk factors ( n = 5), and optimal use of ULT ( n = 10). The guideline has been reviewed and endorsed by the Royal College of General Practitioners (RCGP). For acute attacks of gout, a non-steroidal anti-inflammatory drug (NSAID) (with gastro-protection) or low-dose colchicine 500 mcg two to four times daily are recommended as first-line treatment, depending on patient preference, renal function, and comorbidities. In patients who are intolerant of, or have contraindications to, NSAIDs and colchicine, intra-articular, intra-muscular, or oral corticosteroids are recommended (for example, oral prednisolone 35 mg daily for 5 days). Patients should be advised to treat attacks as soon as possible after onset to minimise severity and impact. Non-pharmacological …

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