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BackgroundPredicting progression to clinical arthritis in individuals at-risk of developing rheumatoid arthritis is a prerequisite to developing stratification groups for prevention strategies. Selecting accurate predictive criteria is the critical step to define the population at-risk. While positivity for anti-citrullinated protein antibodies (ACPA) remains the main recruitment biomarker, positivity for other autoantibodies (AutoAbs) identified before the onset of symptoms, may provide additional predictive accuracy for stratification.ObjectiveTo perform a multiple AutoAbs analysis for both the prediction and the time of progression to inflammatory arthritis (IA).Methods392 individuals were recruited based on a new musculoskeletal complaint and positivity for ACPA or rheumatoid factor (RF). ELISAs were performed for ACPA, RF, anti-nuclear Ab, anti-carbamylated protein (anti-CarP) and anti-collagen AutoAbs. Logistic and COX regression were used for analysis.ResultsProgression to IA was observed in 125/392 (32%) of cases, of which 78 progressed within 12 months. The AutoAbs ACPA, RF, anti-CarP were individually associated with progression (p77%; area under the curve (AUC) >0.789), compared with prediction using only demographic/clinical data (72.9%, AUC=0.760). Multiple AutoAbs testing provided added value, with +6.4% accuracy for number of positive AutoAbs (AUC=0.852); +5.4% accuracy for AutoAbs levels (ACPA/anti-CarP, AUC=0.832); and +6.2% accuracy for risk-groups based on high/low levels (ACPA/RF/anti-CarP, AUC=0.837). Time to imminent progression was best predicted using ACPA/anti-CarP levels (AUC=0.779), while the number of positive AutoAbs was/status/risk were as good (AUC=0.778).ConclusionWe confirm added value of multiple AutoAbs testing for identifying progressors to clinical disease, allowing more specific stratification for intervention studies.

ObjectivesCurrent evidence suggests that periodontal disease could be a causal risk factor for rheumatoid arthritis (RA) onset and progression. Earlier periodontal intervention in individuals at risk of RA could provide a unique opportunity to prevent or delay the onset of RA. This study aimed to explore the acceptability of periodontal treatment as a measure to potentially prevent RA among at-risk individuals and healthcare professionals.MethodsSemistructured interviews were conducted with anti-CCP positive at-risk individuals (CCP+ at risk) and a range of healthcare professionals. At-risk participant data were analysed using reflexive thematic analysis; subsequent coding of healthcare professional data was deductive, based on a preidentified set of constructs.ResultsNineteen CCP+ at-risk and 11 healthcare professionals participated. Three themes (six subthemes) were identified: (1) understanding risk (knowledge of shared at-risk factors; information and communication); (2) oral health perceptions and experiences (personal challenges and opportunities for dental intervention and oral health maintenance; external barriers) and (3) oral health treatment and maintenance (making oral health changes with the aim of preventing RA; acceptability of participation in periodontal research).ConclusionsPeriodontal disease is common in individuals at risk of RA, but the impact of poor oral health may not be well understood. Oral health information should be tailored to the individual. CCP+ at-risk participants and healthcare professionals identified seeking dental treatment can be hindered by dental phobia, treatment costs or inability to access dentists. While CCP+ at-risk individuals may be reluctant to take preventive medications, a clinical trial involving preventive periodontal treatment is potentially acceptable.

BackgroundAlthough many predictors of progression to inflammatory arthritis (IA) have been identified at first visit in individuals at risk of developing IA, their fluctuation during follow-up is largely unknown.ObjectivesTo describe the changes in relevant biomarkers, which precede arthritis development in anti-CCP positive at risk individuals.MethodsIn a single centre prospective observational cohort of anti-CCP positive individuals with new musculoskeletal symptoms but without clinical arthritis, 394 individuals with at least 3 available longitudinal datapoints including first, second and last records (progression excluded), were selected. Data on anti-CCP2 antibodies (CCP2), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), early morning stiffness duration (EMS), tender joint count on examination (TJC28), health assessment questionnaire (HAQ), absence from work in the last 3 months (sick days), and ultrasound power Doppler signal (PD) grade ≥ 1 in small joints, were assessed. Mixed model analysis on repeated measures (MANOVA) were performed, missing data were not imputed.ResultsOf the 394 selected individuals, 82 (21%) progressed to IA. In those who progressed, last visit was at a mean (SD) of 6.1 (8) months prior to progression, and total follow-up duration was 33.7 months (26.7) versus 46.5 months (30.2) for those who did not.Within group analysis:in the progressor group there was a significant increase in the value of biomarkers at the visit prior progression for CCP2 +, RF +, EMS, HAQ, and the number of joints with a PD grade ≥ 1 (Figure 1, Table 1). For sick days from work prior last visit, the increase was non-significant.Table 1.Mixed model ANOVA on repeated measures: pairwise comparisonBiomarkerMean (SD)at last visitAnalysis between groupsAnalysis within groupsP-value between groups at last visitP-value between second and last visit within the progressor groupP-value between second and last visit within non- progressor groupWithin subject effectCCP2NP: 71 (108)pP=0.008P=1.000F(2/257)=3P: 169 (131)Pŋ2= 0.017P=0.077RFNP: 37 (73)PP=0.012P=0.973F(2/304)=15P: 185 (180)Pŋ2= 0.084PESRNP: 11 (9)pP=1.000P=0.614F(2/580)=0.1P: 22 (21)Pŋ2< 0.001P=0.877EMSNP: 26 (68)P=0.010P=0.006P=1.000F(2/710)=4Pŋ2= 0.018P:58 (120)P=0.011TJC28NP: 0.5 (1.5)PP=1.000PF(2/784)=10P: 3 (5.5)Pŋ2< 0.025PNumber of joints PD ≥1NP: 0.7 (2)P=0.020P=0.001P=0.055F(2/318)=4P: 1 (2)Pŋ2= 0.025P=0.014HAQNP: 0.5 (0.6)P=0.105P=0.016P=1.000F(2/494)=2.5P: 0.7 (0.8)Pŋ2= 0.0.009P=0.086Number of sick daysNP: 2 (6)P=0.204P=0.457P=0.492F(2/360)=4(Between visit 1 and 3: p=0.042)Pŋ2= 0.021 P=0.021P: 4 (13)NP: Non progressors, P: progressors, Pŋ2: Partial ŋ2+ for these results the assumption of homogeneity of variance was violated, as assessed by Levene’s test for equality of variances.In the non-progressor group, only TJC28 and sick days showed significant decrease between first and last visit.Between groups analysis showed significant differences at last visit for the following biomarkers -CCP2 +, RF +, ESR, EMS, TJC28, and number of joints PD grade ≥ 1. The difference in HAQ and sick days was non-significant (Figure 1, Table 1). A significant difference was also shown in all visits for CCP2 + and RF +, and at the second visit for TJC28.For PD grade ≥ 1, differences at last visit within progressor group and between groups were only significant after selection of last visits < 3 months before progression.ConclusionThese results show for the first time significant changes in relevant biomarkers prior to progression to IA with individual biomarkers having different trajectories. Clinical markers (EMS, TJC28, and HAQ) and ultrasound changed late, whilst immunological (CCP2 and RF values) and inflammation biomarkers (ESR) were different from baseline. These data provide valuable information for longitudinal monitoring of biomarkers, further analysis will show if these changes have predictive value for imminent progression to IA.Disclosure of InterestsLaurence Duquenne: None declared, Kate Harnden: None declared, Leticia Garcia-Montoya: None declared, Navkiran Sidhu: None declared, Jacqueline Nam: None declared, Kulveer Mankia Speakers bureau: AbbVie, Lilly, UCB, Grant/research support from: Gilead, Lilly, Paul Emery Speakers bureau: AbbVie, Gilead, Lilly, Novartis, Consultant of: BMS, AbbVie, MSD, Pfizer, Novartis, Roche, Grant/research support from: Abbvie, BMS, Lilly, Samsung.

Background Giant cell arteritis (GCA), the most common primary vasculitis, can cause irreversible blindness in 20–30% of untreated cases, but glucocorticoid therapy leads to significant toxicity in >80% of patients. Ultrasound has proven to be effective in diagnosing giant cell arteritis (GCA) and has the potential to monitor disease activity. Objectives We reviewed data on all patients referred to a single university hospital between August 2014 and December 2015 who were seen in a “fast-track” service established to diagnose and evaluate suspected GCA or a suspected flare. Methods All patients underwent rapid evaluation by a combination of standard clinical assessment and ultrasound of the temporal and axillary arteries. The ultrasound scan was considered positive when we identified the presence of a dark halo around the temporal artery wall or a homogeneous hypoechoic wall thickness >1.5 mm in the axillary arteries. We performed a retrospective analysis and comparison of the ultrasound findings with the clinical features, temporal artery biopsy (TAB) results and decision to treat patients with suspected or established GCA. Results We performed 206 scans in 169 patients (71% females, mean [SD] age 72 ± 11 years). In 123 cases, patients were referred for suspected GCA: 63% were already receiving high-doses of steroids (mean of 12 ± 10 days); 78% had headache; 60% high inflammatory markers; 33% abnormal vascular examination (e.g. diminished/absent pulse or bruits); 31% scalp tenderness; 28% jaw claudication; 26% polymyalgia rheumatica and 26% visual symptoms. In 39 cases the scan was positive: 9 also had a TAB (4 positive) and all were treated as GCA. In 77 cases the scan was negative: 27 also had a TAB (1 positive) and 9 were treated as GCA. In 7 cases the scan was inconclusive requiring further investigations (e.g. TAB). Patients with a positive scan had a mean CRP of 17.6 ± 30.1 g/dl and a mean ESR of 41.3 ± 43.3 mm/hour; patients with a negative scan had a mean CRP of 13.8 ± 17.9 g/dl and a mean ESR of 16.3 ± 17.6 mm/hour (p=0.979 and p=0.048, respectively). We scanned 83 patients with an established diagnosis of GCA to assess for flare or monitor disease activity: 29 had a positive scan (21 increased medication; 8 were follow-ups with improvement from baseline) and 54 had a negative scan (4 increased medication; 50 allowed a safer taper or withdrawal of glucocorticoids). Patients with a positive scan had a mean CRP of 8.0 ± 10.1 g/dl and a mean ESR of 15.6 ± 17.3 mm/hour; patients with a negative scan had a mean CRP of 9.6 ± 16.9 g/dl and a mean ESR of 20.5 ± 19.3 mm/hour (p=0.970 and p=0.190, respectively). Conclusions The combination of rapid clinical evaluation and ultrasound were key elements in diagnosis and monitoring of GCA, allowing more flexible use of glucocorticoid dose regimens and reducing the number of TABs required. The only patient with a negative scan but a positive TAB had already received 20 days of glucocorticoids, suggesting that delay in investigation after starting therapy could affect the results of the scan. References Luqmani RA, et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis. Arthritis Rheumatol 2015; 67 (suppl 10) Disclosure of Interest C. Ponte: None declared, A. Floris Grant/research support from: Italian Society of Rheumatology, S. Vaggers: None declared, N. Goodfellow: None declared, J. Sznajd: None declared, L. O9Neill: None declared, J. Piper: None declared, J. Gunn: None declared, K. Mankia: None declared, R. Luqmani Grant/research support from: GSK, Nordic, Medimmune, Chemocentryx, Roche, UCB, Consultant for: GSK, Nordic, Medimmune, Chemocentryx

Background Rheumatic conditions can impact significantly on patients’ working lives as highlighted by previous national and international surveys.1,2 Since these studies the economic climate has worsened, with growing pressures on maintaining employment. It is important to understand how patients perceive their condition to affect work in the current climate, and what they feel rheumatologists can do to help. Objectives We sought to assess the impact of rheumatic diseases on working life in our patient population four years since the last national survey. We aimed to characterise patients’ perspectives on the current key obstacles and perceived solutions. Methods Anonymous questionnaires were sent to all patients on our departmental DMARD monitoring database. Data was compared using the chi-square test. Results Of 1455 patients invited, 504 responded (35%). Median age was 65 years. 319 (63%) had RA, 58 (12%) PsA, 14 (3%) ankylosing spondylitis and 34 (7%) other rheumatic diseases. 79 (16%) did not give their diagnosis. 165 patients (33%) were in paid employment. Of the 339 patients not working, 237 were retired (70%); 66 (19%) were not working due to their rheumatic condition. Of those working 53% thought they would still be in their current job in 3 years. 25% of working patients reported their condition had both caused them to change work and hindered career progression. 71% had told their employer about their diagnosis and 37% felt their employer did not understand their condition. More working patients felt their employer had assisted them sufficiently in making changes to their working conditions than those not working (43% vs 22%, p

Background Delivering information effectively to patients is essential for medications such as prednisolone, where dosing is complex and other drugs need to be taken to mitigate against potential side effects. Patients with Giant Cell Arteritis (GCA) are treated with a decreasing prednisolone regimen. Patients are usually elderly, unwell and vulnerable and in need of clear and straightforward information. Only a proportion of verbal information is retained. Written information leaflets can be overwhelming, especially for those with poor literacy skills. Pictorial leaflets have proven useful in our department for drugs such as methotrexate, sulphasalazine and leflunomide. Objectives We hypothesised that a pictorial leaflet would be useful for early GCA patients where a complex prednisolone regimen and the need for additional drugs must be understood. Methods A colour pictorial leaflet was designed to supplement the Arthritis Research UK written information for prednisolone. The A5 leaflet contains photographs of the prednisolone tablets to be taken for each dose. The design allows the clinician to enter the start date for each dose and indicate the desired dosing regimen. Photographs of the additional tablets to be taken, along with clear dosing information and indications, are shown on the reverse of the leaflet. These are alendronic acid, calcium and vitamin D, omeprazole and aspirin as per British Society for Rheumatology (BSR) guidelines for GCA 1 . Pictorial leaflets were shown to patients who were taking or had taken prednisolone treatment. Leaflets were also sent to local General Practitioners (GPs). Patient and GP feedback was obtained using separate questionnaires. Results 37 patients completed feedback. 24 (65%) could not recall being given written information when prednisolone was started. 37 (100%) thought the pictorial information leaflet was clear and easy to read. 33 (89%) rated the pictorial leaflet as more useful than standard written leaflets. Many patients commented that the simplicity and clarity of the leaflet made it a useful memory aid. Feedback was received from 34 GPs. 33 (97%) thought the leaflet was clear and easy for patients to follow. 34 (100%) thought the leaflet would be useful for patients to receive alongside standard written information. Conclusions Patients find pictorial information leaflets clear and easy to follow. For medications with complex dosing and when multiple drugs are prescribed, pictorial leaflets are a useful adjunct to standard written information. Our leaflet allows the desired prednisolone regimen to be clearly recorded and serves as a patient’s personal memory aid. It also highlights important information about osteoprotective, gastroprotective and cardioprotective medications prescribed for GCA. References http://www.rheumatology.org.uk/resources/guidelines/bsr_guidelines.aspx Disclosure of Interest None Declared