Showing papers by "Elena Nikiphorou published in 2014"

Hand and foot surgery rates in rheumatoid arthritis have declined from 1986 to 2011, but large-joint replacement rates remain unchanged : results from two UK inception cohorts

Abstract: Objective To assess whether there have been any secular changes in orthopedic interventions in patients with rheumatoid arthritis (RA) since 1986, as examined in 2 early rheumatoid arthritis (RA) inception cohorts with up to 25 years of followup. Methods The study examined orthopedic data from the UK Early RA Study (1986–1999, 9 centers; n = 1,465) and the UK Early RA Network (2002–2012, 23 centers; n = 1,236) with linkage to national data sets (Hospital Episode Statistics, National Joint Registry, and Office of National Statistics). Clinical and laboratory measures and hand and foot radiographs were standardized and obtained yearly in both cohorts. The use of disease-modifying antirheumatic drugs (DMARDs), corticosteroids, and biologic therapies reflected the contemporary conventional practices and guidelines of the time frames examined. Recruitment years were grouped into 6 periods, and interventions were classified into major, intermediate, and minor categories. Results A total of 1,602 orthopedic surgical procedures were performed in 770 patients (29%) over a maximum of 25 years of followup. The 25-year cumulative incidence rate of major interventions was 21.7% (range 19.4–24.0%), and that of intermediate interventions was 21.5% (range 17.8–25.5%). There was a decline in the 10-year cumulative incidence of intermediate surgeries over time (P < 0.001), but not of major/minor surgery. This decline coincided with a gradual shift from sequential monotherapy to combination DMARD therapies and biologic agents in recent recruitment periods. Conclusion Orthopedic surgery is an important and common outcome in RA. Only the rates of hand/foot surgery showed a consistent decline from 1986 to 2011. Possible explanations include differences in the pathophysiologic processes affecting the joints, variations in the responses to therapy between large-joint and small-joint destructive processes, and changes in service provision and thresholds for surgery over time.

Indispensable or intolerable? Methotrexate in patients with rheumatoid and psoriatic arthritis: a retrospective review of discontinuation rates from a large UK cohort

Abstract: Methotrexate (MTX) has become the first-line treatment for rheumatoid (RA) and psoriatic arthritis (PsA); however, few studies have focused on its tolerability. The objective of our analyses was to study RA and PsA patients in whom MTX was discontinued, the reasons for this and the duration of MTX treatment prior to withdrawal. A retrospective electronic database review was undertaken to identify all patients who had received MTX for RA or PsA. Patients who had discontinued MTX were then identified, and the reasons for this were categorised. The duration of MTX treatment was assessed in those who had stopped treatment due to intolerability. A total of 1,257 patients who had received MTX were identified [762 (61 %) RA and 193 (15 %) PsA]. MTX had been stopped in 260 (34 %) patients with RA and 71 (36 %) patients with PsA most commonly due to gastrointestinal intolerability. The median duration of MTX treatment was 10 months in both groups, mean duration 21 and 18.6 months in RA and PsA groups, respectively. Overall, one third of patients with RA and PsA stop MTX most commonly due to poor tolerability. In the context of chronic disease, the median duration of treatment is short (10 months). Our analysis did not include patients who suffer from side effects but continue therapy; thus, the magnitude of the problem may be substantially greater therefore as poor tolerability impacts treatment adherence.

The surgical treatment of rheumatoid arthritis: a new era?

Abstract: There has been an in increase in the availability of effective biological agents for the treatment of rheumatoid arthritis as well as a shift towards early diagnosis and management of the inflammatory process. This article explores the impact this may have on the place of orthopaedic surgery in the management of patients with rheumatoid arthritis.

FRI0014 Examining Baseline and 1 Year Predictors of Radiographic Progression over 5 Years Using Mixed Effects Negative Binomial Models: Results from the Early Rheumatoid Arthritis Study (ERAS) Cohort

Abstract: Background Radiographic damage is regarded as one of the most important outcomes in Rheumatoid Arthritis (RA). The Larsen score is one common method of scoring radiographic damage. While presence of erosions by 3 years in patients with RA is common, there are large numbers of patients with zero scores in early disease, which results in skewed distributions of Larsen data. To date, no model has been developed to examine predictors for radiographic progression over 5 years, which also accounts for the non-normal distribution of Larsen data, and also models all available data over a 5-year period. Objectives To identify potential predictors of radiographic progression over 5 years in early RA, using standard clinical and laboratory variables recorded at baseline and 1 year. Methods The analysis involved data from the Early Rheumatoid Arthritis Study (ERAS, n=1465), a UK inception cohort of patients with early RA. The analysis was restricted to a sub-group of patients with digitised radiographs scored with Larsen for first 5 years of follow-up (Larsen data was available for 76%, 70%, 71%, 68%, 36% and 55% of patients at baseline, 1, 2, 3, 4, and 5 year respectively). A mixed effects negative binomial regression model examined predictors of radiographic progression over the first 5 years of disease. Two models were run. Both models included sex, age at presentation and rheumatoid factor. One model included BMI, ESR, HAQ, DAS, haemoglobin (HB) and time to first RA visit from symptom onset at baseline, the other included the same variables at 1-year and time to first DMARD from symptom onset. Results Of the 1465 patients recruited into ERAS, 1031 patients (contributing 4908 observations, with an average of 4.8 observations per patient) were included in the baseline analysis, and 1005 (contributing 4818 observations, with an average of 4.8 observations per patient) were included in the 1-year analysis. There was a significant progression of Larsen scores over 5 years, indicating an average increase of 46% in Larsen for every 1 year increase (IRR 1.46, P Conclusions The rate of radiographic progression over 5 years increased significantly, following a linear function. While RF and BMI have been shown to be significant predictors in previous models, this is the first model to indicate the possible predictive power of HB and HAQ in the first years of disease. Increased time from symptom onset to secondary care predicted higher radiographic progression, suggesting that early referral plays a crucial role in the progression of erosions over the first 5-years. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5714

THU0447 Defining a Process for the Development of a National Minimum Core Dataset (MCD) for Observational Cohort Studies in RA. A Multidisciplinary Exercise

Abstract: Background Development of a minimum core dataset (MCD) for a specific disease presents an invaluable way of collecting data in a consistent manner, allowing for clear definitions for individual items and standardised tools for data collection. Objectives To outline the process in developing a national MCD for observational cohort studies in rheumatoid arthritis (RA) that could be adapted for other rheumatic conditions. Methods The process involved three main stages, centering on two multi-stakeholder meetings and a teleconference (TC). Individuals with diverse ranges of expertise and backgrounds participated, including clinical and academic rheumatology, epidemiology, stratified medicine, health economics, RA patients, OMERACT, BSR, ARUK and Clinical Studies Group (CSG) for RA. Using the OMERACT Filter 2.0 methodology aims and objectives, definition of scope, identification of important and feasible research questions and selection of key domains were discussed. Two item-specific workshops were held in parallel with the meetings. Results Stage 1 of this process focused on establishing an important research question of a general nature in RA which could be answered by a MCD alone. 31 items were identified as potential candidates for a MCD, based on four key OMERACT-recommended domains: Life Impact (e.g. QoL, pain, function,); Pathophysiological manifestations (e.g. Disease Activity); Resource use (e.g. drug use, joint surgery); Date of death. 14 items achieved consensus as essential and adequate for achieving meaningful long term outcome data for simple research questions. Stage 2 involved primarily email communications. All MCD members were asked to vote on the relative importance of the items which were considered essential but lacked consensus, and the most appropriate measurement instruments for inclusion. Comments were collated and recirculated to MCD members. Consensus was reached on 20 items, including demographics, and at least one item in each of the four key domains. The group took into account the needs of clinical engagement with both general hospital and academic settings, and patient perspectives. In stage 3 , a TC meeting agreed on the essential items and most appropriate measurement tools, and also identified items suitable for add-on studies. For three essential items, consensus was lacking for a measurement tool: participation/work/social, fatigue and comorbidity. For fatigue and comorbidity, two dedicated workshops were undertaken during this process, both of which recognised the importance of these items and identified lack of consensus on their measurement tools. Further work is currently in progress, including an online voting survey to agree on the most suitable tools for data collection on these two items. Conclusions The development of a MCD for observational studies has involved three main stages and two workshops, and achieved consensus on 20 essential items. Further work is required to agree on measurement tools for fatigue, comorbidity and participation/work/social. Novel challenges and opportunities were identified as part of this process, which could be adapted for MCDs in other disease areas and to answer more complex questions at both national and international level. Paradigms taken from interventional clinical trials may need to be re-evaluated in light of this. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.3603