Katja Thiele

Performance of the 2011 ACR/EULAR preliminary remission criteria compared with DAS28 remission in unselected patients with rheumatoid arthritis

Objective To compare the performance of the preliminary American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria with the 28-joint count Disease Activity Score (DAS28) remission in unselected ‘real-life’ patients. Methods Remission was calculated according to the DAS28 and to both versions of the ACR/EULAR criteria (Boolean or Simplified Disease Activity Index (SDAI)-based) for 6864 patients with rheumatoid arthritis (RA) who were enrolled in the national database of the German Collaborative Arthritis Centres between 2007 and 2009. Logistic regression analyses identified factors that were responsible for patients in DAS28 remission to miss the new criteria. In addition, the functional status of patients who fulfilled the different remission criteria was compared with that of an age- and sex-matched population sample. Results Of all patients, 28% were in DAS28, 7% in Boolean and 11% in SDAI remission. Of those in DAS28 remission, 21.0% were also in Boolean and 34% also in SDAI remission. Higher scores for pain and fatigue, the presence of degenerative spine disease, longer disease duration and male gender were significantly associated with missing the new criteria despite being in DAS28 remission. Compared with age- and sex-matched samples from the general population, patients in DAS28 remission had a similar functional ability while patients in remission according to the new criteria had better functional scores. Conclusions Patients fulfilling the new remission criteria tend to be not only free from active RA, but also from other disabling diseases. If these criteria are applied in clinical practice to guide treatment decisions, the impact of comorbidity should be taken into account.

Health care and burden of illness in systemic lupus erythematosus compared to rheumatoid arthritis: results from the national database of the German Collaborative Arthritis Centres

During the past 20 years, outcome studies in the rheumatic diseases have, on the one hand, given increasing evidence of the unfavourable long-term prognosis of rheumatoid arthritis (RA) and on the other hand determined continuous improvement of prognosis in systemic lupus erythematosus (SLE). The aim of the study was to investigate how this translates into the current spectrum of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) seen by rheumatologists in Germany and to compare aspects of the burden of disease, disease outcomes and treatment between these two important rheumatic diseases using a large clinical database. Current health care was analysed with data from the German rheumatological database of 10 068 patients with RA and 1248 patients with SLE seen by rheumatologists in 2001. In addition, of a total of 3546 patients with SLE and 24 969 patients with RA seen at the German Collaborative Arthritis Centres between 1994 and 2001, 3465 cases of SLE were matched by age, sex, disease duration and referral status with a corresponding RA case. There were considerable differences in treatment of patients before referral to a rheumatologist and in rheumatologic care. In 2001, patients with SLE were treated by their rheumatologists mainly with antimalarials (AM, 37%), azathioprine (29%) and nonselective NSAIDs (16%). Of them, 61% received at least one immunosuppressive drug (including AM) plus glucocorticoids. In RA, methotrexate was the predominant medication (63%), and 56% received at least one immunosuppressive drug plus glucocorticoids. Matched pairs analysis showed that SLE patients with a short disease duration were almost equally burdened by pain, functional limitations and reduced health status as RA patients. After a disease duration of .10 years, however, patients with RA showed poorer outcomes than those with SLE: RA patients reported significantly more often severe pain (30% in RA versus 17% in SLE) and poor global health status (52 versus 38%), and their disease activity as well as severity was rated higher by the rheumatologists. In conclusion, comparing large groups of RA and SLE patients we found a similar burden in early but not in late disease. Taking into account limitations as to the generalizability of the results (recruitment in rheumatologic care, cross-sectional data, underestimation of SLE-specific outcomes), the discrepancy between the high increase in disease-related negative outcomes with longer disease duration in RA but not in SLE indicates a better long-term prognosis in SLE concerning the items observed. The great disparity in treatment intensity between rheumatologists and nonrheumatologists shows that the involvement of a specialist is needed equally in both diseases.

Trends in treatment and outcomes of ankylosing spondylitis in outpatient rheumatological care in Germany between 2000 and 2012.

Objectives To describe changes in drug treatment and clinical outcomes of ankylosing spondylitis (AS) during the past decade. Methods The national database of the German collaborative arthritis centres collects clinical and patient-derived data from unselected outpatients with inflammatory rheumatic diseases. Cross-sectional data from 2000 to 2012 of around 1000 patients with AS per year were compared with regard to clinical presentation and quality of life indicators. Results Non-steroidal anti-inflammatory drugs (NSAIDs) have been the predominant treatment choice in AS over the years with a prescription rate of 67% of patients in 2012. Currently, almost half of the patients with AS in German rheumatology centres are treated with tumour necrosis factor inhibitors (TNFi). Often, both treatments are used in combination (33%), followed by combinations of NSAIDs and synthetic disease modifying antirheumatic drugs (sDMARDs) with 23% or TNFi alone (21%). In 2012, 10% of patients each received NSAID or sDMARD monotherapy. Methotrexate, sulfasalazine, glucocorticoids and analgaesics alone or in combination with other treatments were given to 10% of patients, respectively. Over the years, we have seen remarkable improvements in disease control and patient reported outcomes. These developments are consistent with enhanced functional status, increasing employment rates and decreasing sick leave, hospitalisation and work disability. Conclusions In the German rheumatology secondary/tertiary care setting, routine care of patients with AS has changed tremendously during the past decade. Increasingly, more efficacious treatment options are reflected in improved clinical outcomes, quality of life and participation in the labour force.

Changes in referral, treatment and outcomes in patients with systemic lupus erythematosus in Germany in the 1990s and the 2000s

Objective To evaluate trends in the referral, treatment and outcome of patients with systemic lupus erythematosus (SLE) in Germany over two decades. Methods From 1993 to 2012, ∼1200 patients with SLE were recorded annually in the national database of the German Collaborative Arthritis Centres. Treatment patterns, healthcare use and outcomes, such as disease activity, function and work participation, were evaluated over time. Furthermore, two distinct cohorts of patients (enrolment 1994–1998, n=467; and 2004–2008, n=376) observed over 5 years were assessed for changes in outcomes. Results The mean disease duration at the first visit to a rheumatologist decreased from 2.6 (1994) to 1.5 (2012) years. Glucocorticoids (69%), antimalarials (56%), azathioprine (22%), non-steroidal anti-inflammatory drugs (23%) and mycophenolate mofetil (15%) were the most frequently used treatments in 2012. A significant increase was observed in the use of antimalarials and mycophenolate mofetil. The use of glucocorticoids at >7.5 mg/day decreased from 27% (1994) to 10% (2012). The average length of sick leave taken due to SLE declined from 9 weeks (1997) to 6 weeks (2012). When comparing the two longitudinal cohorts, in the cohort from the 2000s, the intraindividual decline of disease activity was significantly stronger (p<0.001), and fewer patients retired early (36% vs 46%). Conclusions The disease activity and resource use declined considerably over the observation period, and more patients remained in the labour force. Earlier treatment onset, faster modification of the treatment regimen and more intensive use of anti-inflammatory therapy may account for the improved outcomes in patients with SLE across the years.

Verordnung von Glucocorticoiden bei rheumatologisch betreuten Patienten mit rheumatoider Arthritis in Deutschland

ZusammenfassungGlucocorticoide (GC) sind unverzichtbarer Bestandteil einer zeitgemäßen Behandlung in der Rheumatologie. Aufgrund des schnellen Wirkungseintritts und des hohen antiinflammatorischen Potentials sind sie in vielen Fällen unverzichtbar. Dies gilt trotz des bekannten Spektrums an unerwünschten Wirkungen und trotz einer eher bescheidenen Evidenz aus kontrollierten klinischen Studien. Umso bedeutsamer sind in dieser Situation Ergebnisse aus Beobachtungsdaten, die sowohl Auskunft geben über typische Therapieentscheidungen von Rheumatologen im Hinblick auf die Verordnung von GC und die Kombination mit anderen Medikamenten als auch im Hinblick auf die Vermeidung der wichtigsten unerwünschten Wirkung, der GCinduzierten Osteoporose. Diese Daten liefert die Kerndokumentation der Rheumazentren. Sie zeigt als Querschnitt durch die rheumatologische Versorgung, dass 60% der Patienten mit rheumatoider Arthritis unter einer Therapie mit GC stehen, 85% davon mit einer Dosierung bis zu 7,5 mg/d. GC ersetzen nicht die Therapie mit DMARDs sondern sie werden verstärkt in Kombination mit neueren oder als besonders wirksam geltenden DMARDs eingesetzt, was die Orientierung der Therapie am Schweregrad der Krankheit unterstreicht. Die Variationsbreite zwischen den rheumatologischen Einrichtungen hinsichtlich des Einsatzes von GC ist groß und verdeutlicht die insgesamt ungesicherte empirische Evidenz.Hinsichtlich der GC-induzierten Osteoporose wird unter Rheumatologen eine umfangreiche, risikoadaptierte Therapie vorgenommen. Zwei Drittel der Patienten unter GC-Therapie erhalten eine Osteoporoseprophylaxe, Hochrisikogruppen deutlich mehr. Die Daten unterstreichen den hohen Stellenwert der GC in der modernen Rheumatherapie.SummarySystemic GCs are among the most important therapeutic options in modern rheumatology. Due to their fast clinical effects and their high anti-inflammatory potential, they are indispensable in a large number of cases. This applies despite the well-known spectrum of adverse events and despite limited evidence from randomized clinical trials. In this situation, the results of observational studies gain additional importance. They provide information on therapeutic decisions of rheumatologists concerning GC therapy and their combination with other drugs as well as concerning the prevention of adverse events such as GC induced osteoporosis. The data gathered in the national database of the German Collaborative Arthritis Centers show that at the time of documentation 60% of all RA patients were under therapy with GCs, 85% of these were treated with a dosage of up to 7.5 mg/d. GCs are especially frequently used in combination with new or highly potent DMARDs. This underlines that rheumatologists take activity and severity into account in deciding both about GCs and DMARDs. However, there is high practice variation regarding the frequency of GC use among the rheumatological facilities which demonstrates the lack of good evidence.Rheumatologists are aware of various patient risks when prescribing GCs and adapt their therapies to these risks. Two thirds of all patients under GCs were receiving therapy for the prevention or treatment of osteoporosis at documentation, high risk groups such as women over 50 even more frequently. The data emphasize the high importance of GCs in modern rheumatology.

AB0726 Severe Obesity Is Frequent in Patients with Psoriatic Arthritis and Is Accompanied by Increased Cardiovascular Risk

Background It is known that patients with psoriatic arthritis (PsA) are at increased risk of obesity and associated cardiovascular comorbidity, in particular those with severe and long-standing disease (>10 years). There is less information on the frequency of obesity and cardiovascular risk in patients with incident or medium-term disease. Objectives To investigate the prevalence of obesity compared to the population, disease presentation and the cardiovascular morbidity at onset of disease and after a mean of five years disease. Methods We selected two discrete groups of patients with a PsA diagnosis (M07.0-M07.3) enrolled in the national database of the German Collaborative Arthritis Centres between 2003 and 2014: patients with either short (≤0.5 years) or longer disease duration (between 4 and 6 years). Stratified by BMI classes, disease activity and cardiovascular comorbidity, as well as the deviation of the BMI from the age- and sex-matched normal population were analysed. Results 421 patients were enrolled with incident disease (mean disease duration 3.0 months) and 965 with medium-term PsA (mean 5.0 years). Both the BMI distribution in general and the portion of patients with severe obesity (BMI≥35, ∼8%) were similar in incident and medium-term PsA. In comparison to the age- and sex-matched population, obesity was more frequent in patients with incident (23.5% vs. 16.1%) as well as in medium-term PsA (24.7% vs. 17.4%). Obesity was associated with higher disease activity, higher patient-reported burden and substantially higher prevalence of cardiovascular risk factors already in early PsA except for significantly lower smoking rates (Table1). In medium-term PsA, 23.6% of all patients (mean age 52 years) and 36.1% of the obese patients (mean age 54 years) presented with any cardiovascular risk factor (diabetes, hypertension, hypercholesterolemia or heart disease); in obese patients the prevalence of coronary heart disease (10.1%) was doubled compared to incident patients. Table 1 shows patient characteristics in incident PsA. Conclusions One quarter of the patients with PsA are obese, already at the onset of the disease, and they present with more severe obesity than the age and sex matched normal population. The high cardiovascular comorbidity at onset of PsA is further significantly increased in obese patients already after five years of disease. This should be considered in the treatment of these patients. Acknowledgement The database was funded by the German Federal Minister of Research from 1999 to 2007 (grant #01 GI 0344/3). Since 2007, the Working group of the regional collaborative arthritis centres and a consortium of pharmaceutical companies has been funding the National Database by an unconditional grant to the German Society for Rheumatology. Disclosure of Interest None declared

THU0351 Current Smoking is a Risk Factor for Giant Cell Arteritis in Patients with Polymyalgia Rheumatica

Background Polymyalgia rheumatica (PMR) can present alone or with concomitant giant cell arteritis (GCA). They are closely related but implicate different treatment intensity. While PMR is diagnosed clinically, GCA should be confirmed with biopsy or vascular imaging. Objectives To compare patient characteristics, clinical values and treatment of patients with PMR and GCA. Methods Between 2007 and 2013, a total of 1,092 patients with diagnosis of PMR and a disease duration <2 years were recorded in the National Database of the German Collaborative Arthritis Centres. Patients with PMR (ICD-10 M35.3) were compared to patients with GCA in PMR (M31.5) with regard to patient characteristics (age, sex, smoking, BMI, education, comorbidities), markers of inflammation (ESR, CRP), and therapy. Patients aged <50 years (n=8) and with additional inflammatory rheumatic diseases (n=118) were excluded. Results A total of 966 patients with PMR were available for analysis. 820 patients were diagnosed with PMR and 146 patients with GCA. Mean age was 70 years in both groups, mean disease duration 8 vs. 7 months for PMR and GCA, respectively. Patients with GCA were more often female (69% vs. 61%) and more frequently current smokers (21.9% vs. 10.2%). The level of education was similar, as were BMI (26.6 vs. 25.8) and comorbid conditions. 90% of all patients were treated with glucococorticoids. The average dose during the past 6 months was 19.4 mg/d (GCA) vs. 9.2 mg/d. 30% (GCA) vs. 18% were treated additionally with synthetic DMARDs, methotrexate being the most frequently used substance. In a multivariate logistic regression analysis, current smoking remained associated with an increased risk of having GCA (OR=2.8, p=0.005), dominating gender, which was not selected due to its high association with smoking status (p<0.001). Conclusions Compared to PMR alone, patients with GCA present with a higher disease activity and a substantially higher need of immunosuppressive therapy. The association of GCA with current smoking is an additional argument for counselling patients to quit smoking if diagnosed with PMR. Acknowledgements The database was funded by the German Federal Minister of Research from 1999 to 2007 (grant #01 GI 0344/3). Since 2007, the Working Group of the regional corporate arthritis centers and a consortium of pharmaceutical companies has been funding the National Database by an unconditional grant to the German Rheumatological Society. Disclosure of Interest None declared

Verordnung von Glucocorticoiden bei rheumatologisch betreuten Patienten mit rheumatoider Arthritis in Deutschland@@@Prescription of glucocorticoids in patients with rheumatoid arthritis in Germany

ZusammenfassungGlucocorticoide (GC) sind unverzichtbarer Bestandteil einer zeitgemäßen Behandlung in der Rheumatologie. Aufgrund des schnellen Wirkungseintritts und des hohen antiinflammatorischen Potentials sind sie in vielen Fällen unverzichtbar. Dies gilt trotz des bekannten Spektrums an unerwünschten Wirkungen und trotz einer eher bescheidenen Evidenz aus kontrollierten klinischen Studien. Umso bedeutsamer sind in dieser Situation Ergebnisse aus Beobachtungsdaten, die sowohl Auskunft geben über typische Therapieentscheidungen von Rheumatologen im Hinblick auf die Verordnung von GC und die Kombination mit anderen Medikamenten als auch im Hinblick auf die Vermeidung der wichtigsten unerwünschten Wirkung, der GCinduzierten Osteoporose. Diese Daten liefert die Kerndokumentation der Rheumazentren. Sie zeigt als Querschnitt durch die rheumatologische Versorgung, dass 60% der Patienten mit rheumatoider Arthritis unter einer Therapie mit GC stehen, 85% davon mit einer Dosierung bis zu 7,5 mg/d. GC ersetzen nicht die Therapie mit DMARDs sondern sie werden verstärkt in Kombination mit neueren oder als besonders wirksam geltenden DMARDs eingesetzt, was die Orientierung der Therapie am Schweregrad der Krankheit unterstreicht. Die Variationsbreite zwischen den rheumatologischen Einrichtungen hinsichtlich des Einsatzes von GC ist groß und verdeutlicht die insgesamt ungesicherte empirische Evidenz.Hinsichtlich der GC-induzierten Osteoporose wird unter Rheumatologen eine umfangreiche, risikoadaptierte Therapie vorgenommen. Zwei Drittel der Patienten unter GC-Therapie erhalten eine Osteoporoseprophylaxe, Hochrisikogruppen deutlich mehr. Die Daten unterstreichen den hohen Stellenwert der GC in der modernen Rheumatherapie.SummarySystemic GCs are among the most important therapeutic options in modern rheumatology. Due to their fast clinical effects and their high anti-inflammatory potential, they are indispensable in a large number of cases. This applies despite the well-known spectrum of adverse events and despite limited evidence from randomized clinical trials. In this situation, the results of observational studies gain additional importance. They provide information on therapeutic decisions of rheumatologists concerning GC therapy and their combination with other drugs as well as concerning the prevention of adverse events such as GC induced osteoporosis. The data gathered in the national database of the German Collaborative Arthritis Centers show that at the time of documentation 60% of all RA patients were under therapy with GCs, 85% of these were treated with a dosage of up to 7.5 mg/d. GCs are especially frequently used in combination with new or highly potent DMARDs. This underlines that rheumatologists take activity and severity into account in deciding both about GCs and DMARDs. However, there is high practice variation regarding the frequency of GC use among the rheumatological facilities which demonstrates the lack of good evidence.Rheumatologists are aware of various patient risks when prescribing GCs and adapt their therapies to these risks. Two thirds of all patients under GCs were receiving therapy for the prevention or treatment of osteoporosis at documentation, high risk groups such as women over 50 even more frequently. The data emphasize the high importance of GCs in modern rheumatology.