I. Tchetverikov

Prevalence of Psoriatic Arthritis in Primary Care Patients with Psoriasis

To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care.

Tapering conventional synthetic DMARDs in patients with early arthritis in sustained remission: 2-year follow-up of the tREACH trial

Objectives With early and intensive treatment many patients with early RA attain remission. Aims were to investigate (1) the frequency and time to sustained remission and subsequent tapering in patients initially treated with conventional synthetic disease modifying anti-rheumatic drug ((cs)DMARD) strategies and (2) the frequency and time to flare and regained remission in patients tapering csDMARDs and biological (b)DMARDs during 2 years of follow-up. Methods Two-year follow-up data from the treatment in the Rotterdam Early Arthritis Cohort (tREACH) cohort were used. Patients were randomised to initial treatment with triple DMARD therapy (iTDT) with glucocorticoid (GC) bridging or methotrexate monotherapy (iMM) with GC bridging. Patients were evaluated every 3 months. In case Disease Activity Score (DAS) was >2.4 treatment was switched to a TNF-blocker. In case DAS<1.6 at 2 consecutive time points, tapering was initiated according to protocol. Outcomes were rates of sustained remission (DAS<1.6 at 2 consecutive time points), flare (medication increase after tapering) and remission after flare (DAS<1.6). Data were analysed using Kaplan-Meier analyses. Results During 2 years of follow-up, sustained remission was achieved at least once by 159 (57%) of patients, of whom 118 and 23 patients initiated tapering of csDMARDs and bDMARDs, respectively. Thirty-four patients achieved drug-free remission. Flare rates were 41% and 37% and within 1 year, respectively. After flare, 65% of patients tapering csDMARDs re-achieved remission within 6 months after treatment intensification. Conclusions Regardless of initial treatment strategy, 57% of patients achieved sustained remission during 2 years of follow-up. Flare rates were 41% and 37% within 12 months in patients tapering csDMARDs and bDMARDs, respectively. Trial registration number ISRCTN26791028; Post-results.

Performance of screening tools for psoriatic arthritis: a cross-sectional study in primary care

Objective . To compare the screening performance of the Psoriasis Epidemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE) and Early Arthritis for Psoriatic Patients (EARP) questionnaires for detecting PsA among psoriasis patients in a primary care setting. Methods. In a cross‐sectional study, 473 primary care psoriasis patients at risk for PsA completed the PEST, PASE and EARP questionnaires and were clinically evaluated by a trained research nurse. A PsA case was defined by a rheumatologist according to the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut‐offs (≥3) and the PASE cut‐offs (≥44 and ≥47). Results. PsA was diagnosed in 53 patients. The PEST had a sensitivity of 0.68 and a specificity of 0.71. The PASE was validated for two different cut‐offs. The cut‐off of 47 led to a sensitivity of 0.59 and a specificity of 0.66, whereas the lower cut‐off of 44 led to a sensitivity of 0.66 and a specificity of 0.57. For the EARP we found a sensitivity of 0.87 with a specificity of 0.34. Conclusion. The PEST questionnaire has the most favourable trade‐off between sensitivity and specificity to screen for PsA. However, as the prevalence of psoriasis and PsA is fairly low in primary care, screening only psoriasis patients with musculoskeletal complaints may be a better allocation of resources.

Extreme elevation of serum angiotensin-converting enzyme (ACE) activity: always consider familial ACE hyperactivity.

Measurement of serum angiotensin-converting enzyme (ACE) activity can be helpful in the diagnosis and disease monitoring of sarcoidosis. Elevated serum ACE activity is found in 60–70% of sarcoidosis patients. Usually, the ACE activity is mildly increased (<3-fold the upper limit of the reference range) in sarcoidosis patients. Extremely elevated ACE activity is suggestive of the benign condition known as ‘familial hyperactivity of ACE’. Familial hyperactivity of ACE is a relatively rare condition and can be confirmed by genetic testing. Considering a genetic cause of strongly elevated serum ACE activity is important to prevent possible overdiagnostics. Here, we highlight the factors that may complicate the interpretation of serum ACE activity measurements, and we present two cases that illustrate the importance of interdisciplinary consultation when extremely elevated serum ACE activity is measured.

THU0108 No Clear Association Between the Presence of Subclinical Synovitis and Patient Reported Outcomes in RA Patients in Remission

Background Several studies assessed disease activity with ultrasound in rheumatoid arthritis (RA) patients who were in clinical remission. These studies found subclinical synovitis in 48-73% of the patients. Subclinical synovitis is associated with radiographic progression and predicts short-term relapse in RA patients. So far, little is known about the association between subclinical synovitis and patient reported outcomes (PROs). Objectives We evaluated the frequency of subclinical synovitis detected by ultrasound in RA patients in clinical remission while they are continuing synthetic and biological DMARDs. Our second objective was to compare PROs between patients with and without subclinical synovitis. Methods Patients who are treated with the combination of a synthetic DMARD and biological DMARD (adalimumab or etanercept) and have low disease activity (DAS44<2.4 and SJC ≤1) were examined by ultrasound at baseline and after three months follow-up. Ultrasound examination included 26 joints (MCP2-5, PIP2-5, wrists, MTP2-5) graded on greyscale (GS; 0-3) and power Doppler (PD; 0-3). A joint with subclinical synovitis was defined as GS>1 and/or PD>0. Data on clinical and psychological characteristics, demographics, pain scores, functional ability (HAQ) and health-related quality of life (SF-36) were collected at baseline and at three months. Coping (Pain Coping and Cognition List [PCCL]), depression/anxiety symptoms (Hospital Anxiety and Depression Scale [HADS]) and fatigue (Bristol RA Fatigue Multi-Dimensional Questionnaire [BRAF-MDQ] and Fatigue Assessment Scale [FAS]) were collected at three months follow-up. Ultrasound subclinical synovitis positive and negative patients were compared on their PROs using the Wilcoxon-Mann-Whitney test and Chi-square test. Results At baseline, 89 patients were included of which 71 patients had had their three months evaluation. Ultrasound revealed subclinical synovitis in 64% of the patients at baseline and in 68% at three months. In 44% of the patients subclinical synovitis was detected at both measurements. figure 1 shows baseline characteristics and patient reported outcomes at baseline and after three months. No clear pattern emerged on the PROs scores between subclinical synovitis positive and negative patients. At baseline functional ability differed between the two groups while health-related quality of life was similar. At three months similar levels were observed for functional ability, health-related quality of life, coping, depression symptoms and fatigue. HADS anxiety differed at 3 months. Conclusions Subclinical synovitis is common in RA patients in clinical remission while they continue synthetic and biological DMARDs. In our study population we could not find a clear association between subclinical synovitis and PROs. Disclosure of Interest None declared

FRI0562 Ultrasound Enthesitis in Primary Care Psoriasis Patients with Musculoskeletal Complaints

Background Psoriasis patients with enthesitis can classify as psoriatic arthritis since the introduction of the CASPAR classification criteria in 2006. However, clinical assessment of the entheses could be challenging. In addition, the presence of a tender enthesis is not necessarily indicative for underlying inflammatory disease as it could be related to overuse, metabolic disease or ageing. Therefore, we need a better way to identify the inflammatory component of entheseal involvement in psoriasis. To detect these inflammatory components in the entheses, ultrasound (US) examination can be used to identify inflammatory disease at the entheses. Objectives Our aims were to determine the prevalence of US abnormalities among psoriasis patients in primary care and to determine the concordance of clinical and US information at individual entheseal sites. Methods Adult patients with psoriasis were invited to participate in the SENSOR study. Patients who reported pain in joints, entheses or the lower back were eligible for clinical evaluation. If physical examination indicated a painful enthesis on the LEI/MASES or if arthritis was present, US examination of the entheses was performed. The six entheses of the Madrid Sonographic Enthesis Index (MASEI) and the lateral epicondyle tendon insertion (elbow) were evaluated according to the MASEI scoring system. Enthesitis was defined as US inflammation (positive power Doppler (PD) signal or a thickened enthesis of the plantar fascia) in combination with one clinical feature at the same enthesis. Structural changes detected by ultrasound were calcifications, increased thickness, irregular fibre structure and erosions. Results Of 524 patients who participated in the SENSOR study, 111 patients were assessed both by physical examination and by US. In 106 (95%) patients we detected US abnormalities. In 56 (50%) patients we found structural changes without indication for inflammatory disease. In 50 (45%) patients we found US abnormalities indicating inflammatory disease at the enthesis (positive PD: n=35; thickened plantar fascia: n=15). When we combined the US data with the clinical information, 36% of US inflammatory disease were confirmed [Figure 1]. Conclusions We found US abnormalities in 95% of the primary care psoriasis patients with musculoskeletal complaints, which is a combination of both structural and inflammatory US components. In 45% of primary care psoriasis patients we observed US inflammatory disease, which was confirmed in 36% of the patients by clinical information. Acknowledgements This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Influence of Disease Manifestations on Health-related Quality of Life in Early Psoriatic Arthritis

Objective. Psoriatic arthritis (PsA) is a multifaceted disease. Affecting joints, skin, entheses, and dactylitis, its effect on health-related quality of life (HRQOL) could be substantial. We aim to assess HRQOL in patients newly diagnosed with PsA and analyze its associations with disease manifestations. Methods. Data collected at time of diagnosis from patients with PsA included in the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR) study were used. HRQOL was assessed using 8 domains of the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Patients were classified based on primary manifestation in arthritis subtypes (i.e., mono-, oligo-, or polyarthritis) and other subtypes (i.e., enthesitis, dactylitis, and axial disease). In all patients, presence of arthritis, enthesitis, dactylitis, psoriasis, and chronic inflammatory back pain was determined. Multivariable linear regression was used to determine associations of PsA manifestations with HRQOL. Results. Of 405 patients, primary manifestation was peripheral arthritis in 320 (78 monoarthritis, 151 oligoarthritis, and 91 polyarthritis), enthesitis in 37, axial disease in 9, and dactylitis in 39. Mean scores of SF-36 domains were lower than the Dutch reference population and similar across arthritis subtypes. A higher number of enthesitis locations and tender joints, and presence of chronic back pain, were independently associated with worse SF-36 scores. Psoriasis and dactylitis were not associated with worse scores. Conclusion. HRQOL was diminished in PsA at time of diagnosis compared to the Dutch reference population, and tender joints, enthesitis at clinical examination, and back pain as indicators of pain affected HRQOL.

Modification of a sonographic enthesitis score to differentiate between psoriatic arthritis and young healthy volunteers

Objectives: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison. Method: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI. Results: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002). Conclusions: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volunteers. After recoding of PD severity and excluding thickness of knee entheses, marked differences between PsA patients and healthy controls were observed.

Effects of psychosocial factors on monitoring treatment effect in newly diagnosed rheumatoid arthritis patients over time: response data from the tREACH study

Objectives: To investigate whether, apart from effects of patient- and disease-related factors, psychosocial factors have additional effects on disease activity; and which factors are most influential during the first year of treatment in early rheumatoid arthritis (RA). Method: The study assessed 15 month follow-up data from patients in tREACH, a randomized clinical trial comparing initial triple disease-modifying anti-rheumatic drug therapy to methotrexate monotherapy, with glucocorticoid bridging in both groups. Patients were evaluated every 3 months and treated to target. Associations between Disease Activity Score (DAS) at 3, 9, and 15 months and psychosocial factors (anxiety, depression, fatigue, and coping with pain) at the previous visit were assessed by multivariable linear regression correcting for demographic, clinical, and treatment-related factors. Results: At 3, 9, and 15 months of follow-up, 265, 251, and 162 patients, respectively, were available for analysis. Baseline anxiety and coping with pain were associated with DAS at 3 months; coping with pain at 6 months was associated with DAS at 9 months, and fatigue at 12 months with DAS at 15 months. Psychosocial factors were moderately correlated. Effects on DAS were mainly due to tender joint count and global health. Conclusion: Psychosocial factors have additional effects on DAS throughout the first year of treatment in early RA. A change was observed from anxiety and coping with pain at baseline being associated with subsequent DAS towards fatigue being associated with subsequent DAS at 12 months. Owing to the explorative nature of this study, more research is needed to confirm this pattern.

Impact of Stopping Tumor Necrosis Factor-inhibitors on Rheumatoid Arthritis Patients' Burden of Disease.

To determine the impact of stopping tumor necrosis factor inhibitor (TNFi) treatment on patient‐reported outcomes (PROs) of physical and mental health status, health utility, pain, disability, and fatigue in patients with established rheumatoid arthritis (RA).