M. Fusama

A case report of a patient with rheumatoid arthritis complicated withMycobacterium aviumduring tocilizumab treatment

Abstract A female patient with rheumatoid arthritis (RA) suffered from Mycobacterium avium (M. avium) infection during tocilizumab treatment. Tocilizumab was discontinued and she was treated with a recommended chemotherapy, resulting in improvement of M. avium. Tocilizumab retreatment did not aggravate M. avium infection, and radiographic abnormalities improved over 1 year after cessation of the recommended therapy. Tocilizumab may be one candidate for intractable RA patients with M. avium if any biologic is required.

Psychological state is related to the remission of the Boolean-based definition of patient global assessment in patients with rheumatoid arthritis

Abstract Objectives. To evaluate whether the psychological state is related to the Boolean-based definition of patient global assessment (PGA) remission in patients with rheumatoid arthritis (RA). Methods. Patients with RA who met the criteria of swollen joint count (SJC) ≤ 1, tender joint count (TJC) ≤ 1 and C-reactive protein (CRP) ≤ 1 were divided into two groups, PGA remission group (PGA ≤ 1 cm) and non-remission group (PGA > 1 cm). Anxiety was evaluated utilizing the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), while depression was evaluated with HADS-Depression (HADS-D) and the Center for Epidemiologic Studies Depression Scale (CES-D). Comparison analyses were done between the PGA remission and non-remission groups in HADS-A, HADS-D and CES-D. Results. Seventy-eight patients met the criteria for SJC ≤ 1, TJC ≤ 1 and CRP ≤ 1. There were no significant differences between the PGA remission group (n = 45) and the non-remission group (n = 33) in age, sex, disease duration and Steinbrockers class and stage. HADS-A, HADS-D and CES-D scores were significantly lower in the PGA remission group. Conclusions. Patients with RA who did not meet the PGA remission criteria despite good disease condition were in a poorer psychological state than those who satisfied the Boolean-based definition of clinical remission. Psychological support might be effective for improvement of PGA, resulting in the attainment of true remission.

AB0485 Tocilizumab is Effective for the Patient with Sjogren's Syndrome Complicated with Rheumatoid Arthritis

Background Interleukin-6 (IL-6) has been reported to be related with the pathogenesis of sjogrens syndrome (SS). However, there is no report clinically describing in detail that IL-6 inhibition is effective for SS. Objectives We evaluated the efficacy of tocilizumab (TCZ) for the patient with SS complicated with rheumatoid arthritis (RA). Methods Tocilizumab was administered at 8mg/kg every 4 weeks. Clinical, laboratory and image data were obtained from the records in our hospital. Results A 39-year-old woman was diagnosed as SS in 1997 and treated with 3 g/day of sodium bicarbonate and 3600 mg/day of potassium citrate because she was complicated with renal tubular acidosis (RTA) and hypokalemia. Her complaints were dry mouth and arthralgia. Laboratory findings under usage of sodium bicarbonate and potassium citrate were as follow: WBC 8600/mm3, Hb 12.1 g/dl, BUN 12 mg/dl, Cr 0.7 mg/dl, CRP 2.2 mg/dl, Na 138 mEq/l, K 3.5 mEq/l, and Cl 109 mEq/l. Antinuclear antibody titer was 1:320 with speckled pattern, and anti-SS-A and anti-SS-B antibodies was positive. RF and anti-CCP antibody were 45 IU/ml and >100 U/ml, respectively. Urine beta-2-MG level was markedly elevated to 15800 mg/l. Shirmers test was positive (right: 3mm, left: 1mm). Salivary flow rate in gum test was 0.29 ml/min and lip biopsy revealed extensive lymphocytic infiltration with fibrotic changes in salivary gland. Majority of infiltrating cells was T cells, in which, CD4+ T cells were predominantly seen rather than CD8+ T cells. Cytoplasma of duct and infiltrating cells were stained with anti-IL-6 antibody. Specimen of renal biopsy was almost comparable to that of lip biopsy including immuostaining. Regarding her RA, SJC, TJC and DAS28-CRP were 19, 23 and 6.38, respectively. Tocilizumab treatment was started in July, 2009 because she was refractory to conventional DMARDs and side effects. Tocilizumab normalized CRP at week 12. At week 24, TJC, TJC and DAS28-CRP improved to 4, 2 and 2.38 respectively and, thereafter, in remission. Salivary flow rate increased from 0.22 ml/min at baseline to 0.81 ml/min at week 24 in gum test. Urinary beta-2-MG decreased from 15800 mg/l to 1210 mg/l, thereafter, improved in normal level, while serum beta-2-MG levels did not change during 24 weeks of tocilizumab therapy. Second lip biopsy was performed after 2 years of tocilizumab therapy. Infiltration of inflammatory cells almost disappeared and cytoplasma of duct and residual cells were not stained with anti-IL-6 antibody. Ophthalmological consultation confirmed slightly improvement of Shirmers test (right: 4mm, left: 4mm) after 4 years of tocilizumab treatment. Tocilizumab therapy continued its efficacy for SS and RA and no side effect has been shown over 4 years. Conclusions This is the first report indicating the efficacy of tocilizumab for the patient with SS complicated with RA. Tocilizumab may be effective for preventing dysfunction of the salivary gland and inhibiting interstitial nephritis and, therefore, may be one candidate for SS patients with RA. References Grisius MM, et al. J Rheumatol 1997; 24: 1089-91. Halse A, et al. Scand J Immunol 1999; 49: 533-8. Fox RI, et al. J Immunol 1994; 152: 5532-9 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4416

Survey on attitudes regarding EULAR recommendations for the role of nurses involved in medical care of patients with chronic inflammatory arthritis in Japan.

Abstract Objective: We seek to evaluate the opinions of nurses and doctors in Japan regarding EULAR recommendations for nurses’ roles in the management of chronic inflammatory arthritis. Methods: This is a cross-sectional survey within Japan. We randomly selected nurses and doctors engaged in consultation of patients with rheumatoid arthritis (RA) and assessed their agreement and opinions on the feasibility of implementing EULAR recommendations, including potential barriers. Results: 431 nurses and 128 doctors completed the questionnaire. For both nurses and doctors, levels of feasibility showed statistically significant lower results compared with those of agreement for all items. When compared between nurses and doctors, agreement showed no statistically significant differences, while nurses’ answers were statistically significant lower for feasibility. Insufficient time, staff and knowledge, lack of established procedures and facilities, and lack of an education system for nurses were cited as barriers to the feasibility of implementing EULAR recommendations. Conclusions: This is the first survey within Japan evaluating opinions regarding EULAR recommendations for nurses’ roles. We found that while agreement was high, feasibility was generally believed to be low. We recommend further research and collaboration between medical professionals in order to implement these recommendations in Japan.

AB1216-HPR A Study of Possible Correlations of Sleep Disturbance with Disease Activity, Psychological State and Health Status in Patients with Rheumatoid Arthritis

Background Sleep disturbance occasionally occurs in patients with rheumatoid arthritis (RA). It is not clear which factor mostly influences sleep disturbance in patients with RA. Objectives We evaluated which factors are correlated with sleep disturbance in patients with RA. Methods Patients with RA who met the 1987 revised criteria of ACR for RA or the 2010 ACR/EULAR classification criteria for RA were selected for this study. The levels of disease activity of RA was evaluated using swollen joint count (SJC), tender joint count (TJC), evaluator global assessment (EGA) and patient global assessment (PGA). Sleep disturbance was evaluated utilizing the Pittsburgh Sleep Quality Index (PSQI). Psychological factors were examined utilizing the Center for Epidemiological Studies Depression Scale (CES-D), the Hospital Anxiety and Depression Scale-Anxiety-Depression (HADS-D) and Anxiety (HADS-A) and the State-Trait Anxiety Inventory (STAI). Health status was evaluated with Short Form-36 (SF-36). We assessed the correlation of sleep disturbance with disease activity, psychological factors and health status. Data analyses were performed using Spearman correlation analysis. Results 112 patients with RA were recruited. Average of age: 54.8 years old, disease duration: 11.4 years, SJC: 2.7, TJC: 2.2, PGA: 23.2mm, EGA: 16.2mm. PSQI was not correlated with age, duration, SJC, TJC and EGA, while it was weakly statistically correlated with PGA (r=0.2592, p=0.0058). With regard to psychological state, PSQI was significantly correlated with CES-D (r=0.5165, p<0.0001), HADS-A (r=0.4139, p<0.0001), HADS-D (r=0.4182, p<0.0001), STAI (State) (r=0.476, p<0.0001), while there was no statistically significant difference between PSQI and STAI (Trait). With regards to health status, physical summary score (PCS) of SF-36 was not correlated with PSQI statistically, while mental summary score (MCS) was significantly correlated with PSQI (r=0.4186, p<0.0001). Conclusions Sleep disturbance was more strongly correlated with psychological state rather than disease activity and physical state. Psychological state is correlated with PGA [1] and PGA is reported to be a limiting factor for reaching remission of RA [2]. Addressing sleep disturbance symptoms may improve not only psychological state but also PGA, resulting in achievement of remission. References Fusama M, et al. Mod Rheumatol in press. Studenic P, et al. Ann Rheum Dis 2012; 71: 1702-5. Disclosure of Interest None declared

THU0580-HPR Psychological Remission May BE Effective to Attain Remission of Boolean-Based Definition of Patient Global Assessment in Patients with Rheumatoid Arthritis

Background The patients with rheumatoid arthritis (RA) often do not meet patient global assessment (PGA) remission criterion despite a good clinical disease state and, therefore, PGA is not solely influenced by RA disease activity. It has been reported that PGA is a limiting factor for reaching remission. Objectives We evaluated whether psychological state is related to Boolean-based definition of PGA remission for patients with RA. Methods The patients with RA (n=146) were recruited. Swollen joint counts (SJC), tender joint counts (TJC), PGA and CRP were evaluated. Among patients with RA enrolled, those with good disease activity of RA (SJC≤1, TJC≤1, CRP≤1) were selected. These patients were divided into 2 groups, PGA remission group (PGA≤1cm) and PGA non-remission group (PGA>1cm). We compared psychological states between these 2 groups. Anxiety and depression were examined utilizing the Hospital Anxiety and Depression Scale-Depression (HADS-D) and -Anxiety (HADS-A), respectively. Depression was also evaluated with the Center for Epidemiologic Studies Depression Scale (CES-D). Comparison analyses were performed between PGA remission group (VAS≤1cm) and PGA non-remission group (VAS>1cm) in HADS-A, HADS-D and CES-D. Data analyses were performed utilizing Wilcoxon rank sum test. Results The patients with RA satisfied with SJC≤1, TJC≤1 and CRP≤1 were selected (n=76). Patient characteristics of PGA remission group (n=45) and PGA non-remission group (n=31) were as follows: mean ± SD of age (53.02±1.75, 55.39±2.29 years) and duration (8.85±6.68, 8.93±7.09, years), male/female (9/39, 8/25, patients). There was no significant difference between PGA remission group and PGA non-remission group in age, sex, Steinbrockers class and stage and disease duration (p=0.4043, p=0.7827, p=0.3936, p=0.5024 and p=0.9619, respectively). HADS-A was significantly lower in PGA remission group compared with that in PGA non-remission group (mean ± SD; 2.71±3.14, 4.32±3.57, respectively, p=0.026). HADS-D was also significantly lower in PGA remission group compared with that in PGA non-remission group (mean ± SD; 2.71±3.03, 4.77±3.87, respectively, p=0.010). Another measure of depression, CES-D, was also significantly better in PGA remission group compared with that in PGA non-remission group (mean ± SD; 9.16±6.00, 14.48±8.41, respectively, p=0.0017). Conclusions The patients with RA who do not meet PGA remission criterion despite a good clinical disease state were in worse psychological state compared with those satisfied with Boolean-based definition of clinical remission. As PGA remission is thought to be a limiting factor for Boolean remission and PGA relates to psychological state, support for psychological state might be important to attain true remission. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2438