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Background/Aims JAK inhibitors (JAKi) are relatively recently licenced for treatment of inflammatory arthritis. Therefore, long term data regarding outcomes for patients cycling through multiple JAKi are lacking. However, one recent international cohort study (Pombo Suarez et al) suggested cycling JAKi is similarly efficacious as switching to an alternative biologic DMARD after initial treatment failure. The aim of this study was to assess outcomes for patients switching JAKi in a large, UK teaching hospital. Methods This was a retrospective cohort study of patients prescribed a JAKi for inflammatory arthritis at Sheffield Teaching Hospitals. Patients who had received two or more JAKi were identified through a local biologic database. Demographic data, antibody status, concomitant medications, previous biologics, and reasons for switching therapy were collected. Results We identified 20 patients who had cycled through JAKi. The diagnosis was Rheumatoid arthritis in 75% (n = 15) of patients. The remaining patients had Psoriatic arthritis (n = 3), seronegative inflammatory arthritis (n = 1) or axial spondyloarthritis (n = 1). 95% (n = 19) of patients were female. 50% of patients used concomitant DMARD therapy and 15% were prescribed concomitant steroids. 85% (n = 17) of patients had received two JAKi and 15% (n = 3) had received three. Initial JAKi prescribed was Baricitinib in 40%, Tofacitinib in 40%, Filgotinib in 10% and Upadacitinib in 10% of patients. The most frequent reason for cycling JAKi was secondary loss of efficacy, affecting 40% (n = 8) of patients. The duration of treatment before loss of effect ranged from 6-45 months (IQR 12-31 months). 100% of these patients remain on their second JAKi with good response. 35% (n = 7) of patients stopped initial JAKi therapy due to side effects. These included gastrointestinal upset, headaches, and rash. 86% (n = 6) of these patients did not tolerate a second JAKi due to re-occurrence of the same side effect, including one patient with recurrence of the same side effect on a third JAKi. One patient who had headaches with their first JAKi has remained well on their second JAKi. 20% (n = 4) of patients changed therapy due to primary nonresponse to initial JAKi. One patient failed to respond sufficiently to either JAKi and alternative treatment was commenced. Three patients responded to a second JAKi, although two later lost efficacy and are currently responding well to a third JAKi. One patient switched JAKi due to cardiovascular risk with Tofacitinib. Conclusion This study supports recent studies in finding that cycling JAKi in patients who lose efficacy or do not respond to initial JAKi can be an effective treatment strategy. However, in patients who stop initial JAKi due to side effects, cycling to a further JAKi is less likely to be successful, with recurrence of side effects in most cases. Disclosure E.M. Quinlan: None. M. Cox: None. J.R. Maxwell: Honoraria; BMS, Pfizer, Abbvie, Lilly, Gilead.

Background/Aims Biological disease-modifying anti-rheumatic drugs (bDMARDs) account for a significant proportion of pharmaceutical expenditure in the NHS. In 2016, Manchester Royal Infirmary implemented the first Biological Rheumatology MDT to reduce variation in biologic prescribing. A similar care model was implemented in Sheffield Teaching Hospitals (STH), which we evaluate here. This evaluation aimed to answer the following questions: has the MDT improved the cost-effectiveness of biologic prescribing in STH, do anti-drug antibodies (ADAB) influence subsequent biologic treatment, are IL-6 or JAK inhibitor monotherapies more clinically effective than anti-TNF monotherapy in rheumatoid arthritis (RA) and what happens when no biologic treatment is advised? Methods The MDT keeps a real-time record of discussions containing patient demographics, previous therapies, and MDT decisions. This includes all MDT meetings over a 32-month period. This was merged with a database containing the current biologic therapy of all STH rheumatology patients, and a notes-review confirmed accuracy. For economic evaluation, a similar database was produced for patients commenced on biologics in the 6 months prior the MDTs introduction. Results Over the 32-month period of the MDT, there were 994 discussions about 796 patients. Concomitant conventional DMARD therapy was used in 63% of patients. 89% of patients discussed continue to use biologic therapies. The biologic MDT resulted in a 26% decrease in cost during the first 6 months of the MDT when compared to 6 months before the MDT. This was attributed to the increased use of biosimilars and evidence-based decision making. There was improved drug survival, with 28% of pre-MDT patients requiring a subsequent change to an alternative biologic, compared to 21% of patients in the MDT group. Secondary ADAB-positive failure is the commonest cause of ADAB-forming anti-TNF failure across all diagnoses. This commonly prompts a class switch in RA (where there are a wider range of NICE approved therapies), and a switch to etanercept (with the advantage of reduced immunogenicity when compared to other Anti-TNFs) in ankylosing spondylitis and psoriatic arthritis. IL-6 inhibitors and JAK inhibitors perform more favourably as monotherapies than anti-TNFs. 21% of patients in each of the IL6 inhibitor and JAK inhibitor monotherapy groups required alternative biologic therapy, compared to 42% in the anti-TNF monotherapy group. Of the 51 patients in whom no biologic was initially advised, 61% went on to receive a biologic. Conclusion The bDMARD MDT in STH has improved the standardisation of biologic prescribing across the rheumatology team. This evaluation has demonstrated significant improvements in cost-effectiveness and treatment retention compared to the 6-month period prior to the MDTs introduction. The evidence-base is effectively enforced by the MDT, which improves patient experience by improving drug survival. We recommend implementing a biologics MDT within other services to ensure equitable and cost-effective prescribing. Disclosure R.J. Nock: None. J.R. Maxwell: Other; JRM has served on advisory boards for Abbvie, Pfizer, BMS and Lilly and has received speaking honoraria from Pfizer, BMS, Novartis and Lilly.