Search

Background The Assessments of Spondyloarthritis international Society (ASAS) classification criteria for axial spondyloarthritis (axSpA) have been criticized because of insufficient differentiation towards FM. The aim of this study was to compare the performance of currently used classification criteria in patients diagnosed with axSpA or FM. Methods Patients were prospectively included if diagnosed with axSpA or FM by the treating rheumatologist and evaluated by an independent examiner for fulfilment of the classification criteria for axSpA (ASAS criteria) and/or FM (1990 ACR classification and 2010 ACR diagnostic criteria). Patients with axSpA were stratified based on classification as non-radiographic axSpA (nr-axSpA) or AS. Symptom severity was assessed by established disease-related questionnaires. Results Overall, 300 patients were included, 100 with FM and 200 with axSpA of which 100 each had nr-axSpA and AS. Almost all FM patients fulfilled the 2010 (100%) and 1990 ACR criteria (98%) for FM, but only 2% fulfilled the ASAS criteria. When calculations were based on only the FM patients with available HLA-B27 results (n = 40), the proportion fulfilling the ASAS criteria was 5%. All axSpA patients met the ASAS criteria but also the 2010 (24%) and 1990 (13.5%) FM criteria. More patients with AS (29% and 19%) than with nr-axSpA (19% and 8%) fulfilled the 2010 and 1990 FM criteria, respectively. Conclusion FM patients only rarely fulfil classification criteria for axSpA but some axSpA patients also fulfil FM criteria. Since this was more frequent in patients with AS it may be related to the severity and duration of chronic pain in axSpA patients. Assessment instruments evaluated in axSpA are not disease-specific. The phenomenon of central pain sensitization in rheumatic diseases deserves more study.

Background In patients with tender and swollen finger joints, the differential diagnosis between rheumatoid arthritis (RA) and osteoarthritis (OA) of the hands can be initially difficult. This prospective study (the TryCort study) was performed to study the diagnostic value of prednisolone in differentiating between RA and hand OA. We present the results of this potentially diagnostic test in patients with possible RA in daily clinical practice by demonstrating the results of a pilot and a validation part of this ‘prednisolone test’ (pred-test). Methods We investigated the response to a 3-day course of 20 mg of prednisolone in patients with suspicion of RA. All patients received 1 g of paracetamol per day for 5 days for pain relief. On days 3–5, a morning dose of 20 mg of prednisolone was added. Hand pain was quantified on a 0–10 Numerical Rating Scale, and the subjective percentage of improvement (0–100%) was recorded. Thresholds for response to prednisolone were investigated in a pilot phase with differentiation in response between patients with RA and patients with OA of the hands, both with pain in the hands ≥4. In a validation phase, the best differentiating cut-off of the pilot phase was applied to discriminate responders from non-responders in consecutive patients with hand pain ≥4 referred because of suspected RA. Final diagnoses were made by the expert upon re-examination at week 12. Primary outcomes were the sensitivity and specificity of a positive test in relation to the diagnosis. Results A percentage of 40% subjective improvement of pain in the hands on day 3 discriminated best between RA and OA in the pilot phase. Among 95 patients with complete data in the validation phase, RA was diagnosed in about 50%. Patients with RA had more swollen joints, higher C-reactive protein levels and slightly higher Health Assessment Questionnaire scores. The pred-test was positive in 42.1% of all patients (40 of 95). The median percentage of improvement on day 5 was higher in RA than in non-RA: 50% (IQR 30–60%) vs. 20% (IQR 10–30%) (p

Objective.Neck pain is common in rheumatoid arthritis (RA) and ankylosing spondylitis (AS). We investigated the correlation of bone marrow edema (BME) on magnetic resonance imaging (MRI) in RA and AS and its association with clinical complaints of neck pain.Methods.Cervical spine short-tau inversion recovery-MRI and T1w-MRI of 34 patients with RA and 6 patients with AS complaining about neck pain were obtained. Clinical and laboratory data were available. BME was scored by 2 blinded readers using a modification of a published score, including various cervical sites. Degenerative changes were also quantified.Results.Patients were predominantly women (82.5%), and mean ± SD age was 57.5 ± 11.8 years, C-reactive protein (CRP) was 0.8 ± 1.3 mg/dl, and pain score was 46.0 ± 17.5. BME was detected in 24/40 patients (60%) involving the atlantoaxial region (21%), vertebral bodies (75%), facet joints (29%), and spinous processes (46%). Degenerative changes were identified in 21/40 patients (52.5%), 13 (62%) of whom also had BME in vertebral bodies. No differences were found between patients with versus without cervical BME for clinical assessments: numeric rating scale pain (median ± interquartile range) 5.5 ± 3.0 vs 6.0 ± 4.0 (p = 0.69), Funktionsfragebogen Hannover 68.2 ± 41.0 vs 42.0 ± 55.5 (p = 0.19), Northwick pain score 44.4 ± 21.8 vs 47.2 ± 27.0 (p = 0.83), or CRP 0.40 ± 0.80 vs 0.60 ± 0.66 (p = 0.94). For patients with degenerative changes, symptom duration was longer than for patients without (10 ± 12.5 vs 5.0 ± 18.0 yrs, p = 0.73).Conclusion.In this small study of patients with RA and AS complaining about neck pain, BME was found in many different cervical sites, including the facet joints and the spinous processes. However, the occurrence and severity of BME did not correlate with the severity of neck pain.

Objective NSAIDs are first-line therapy in axial SpA (axSpA). The proportion of patients responding to NSAIDs and differences between AS and non-radiographic axSpA (nr-axSpA) in this regard have not been studied in detail to date. The aim of this study was to examine the proportion of patients with AS and nr-axSpA responding to NSAIDs according to current treatment recommendations. Methods Consecutive anti-TNF-naive patients with nr-axSpA and AS (n = 50 each) were included if their BASDAI score was ⩾4 without having received maximal NSAID doses. In case of a BASDAI score ⩾4 1 week later, another NSAID was prescribed. For the next 3 weeks, continuous intake of maximal doses was recommended but patients could reduce doses in case of intolerance or improvement. MRI of the SI joints was performed at baseline and week 4. Results All outcomes except for CRP and MRI scores improved significantly after 4 weeks of NSAIDs, with no difference between axSpA subgroups. An Assessment of SpondyloArthritis international Society 40% (ASAS40) response and partial remission rates were 35 and 16% at week 4, respectively. At the same time point, a BASDAI score ⩾4 was still present in 44% of patients, 30% of which had reduced NSAID doses, partly due to intolerance (38%). Only 13% of all patients had continuously taken NSAIDs at the maximal dosage, but there was no difference in the efficacy outcome compared with those who had taken reduced doses. Conclusion AS and nr-axSpA patients had similar response rates to NSAIDs while objective signs of inflammation did not change over 4 weeks. Only a minority of patients was willing to take maximal doses of NSAIDs, and ⩾40% patients remained candidates for TNF blockers. These results may influence future trial designs.

Background Imaging has an essential role in the new spondyloarthritis (SpA) classification criteria for axial but not for peripheral manifestations. We evaluated the impact of imaging findings for identification and treatment decisions in patients with peripheral spondyloarthritis (pSpA) and controls (non-SpA). Methods Patients with pSpA (Assessment of SpA international Society criteria, n=30) and non-SpA (n=30), aged

Background Both patients with axial spondyloarthritis (axSpA) and patients with fibromyalgia (FM) are suffering from pain. The new ASAS classification criteria for axSpA have been recently challenged by arguing that FM patients could easily fulfill the clinical arm of the criteria, which could lead to overdiagnosis of axSpA and wrong treatment decisions. Objectives To study similarities and differences between axSpA and FM using different sets of classification criteria and to assess the severity of wide-spread pain in both diseases. Methods In this prospective study, patients were consecutively included if they were diagnosed with axSpA, or FM by a rheumatologist. Patients with rheumatoid arthritis (RA) were also included as an inflammatory control group. Patients on anti-TNF treatment were not included. Established classification and outcome parameters as well as standardized instruments were used in all patients. MRIs were performed in all axSpA and 20 FM patients. All axSpA and FM patients had radiographs. The Mann-Whitney-U test was used for statistical comparisons between groups. Results A total of 214 patients was included: 93 with FM (7.5% HLA B27+), 91 with axSpA (79.1% HLA-B27+) and 30 with RA (53.3% seropositive). The mean age was 50.7±9.1, 43.0±12 and 58.4±11.9 years, respectively, and the mean symptom duration was comparable between groups: 6.6±6.9, 6.4±7.8 and 6.2±11.3, respectively. Expectedly, the gender ratio differed: FM and RA patients were mostly female (93.4% and 76.7%, respectively), as compared to axSpA patients (28.3%). The ASAS classification criteria were not fulfilled by any FM patient. In contrast, the 1990 and 2010 FM criteria were fulfilled by 98.3% and 100% of patients with FM, but also by 14.3% and 34.1% of axSpA (no differences between AS and nr-axSpA) and 30% and 46.7% of RA patients, respectively. The Fibromyalgia impact questionnaire (FIQ) values were 69.5±13.0, 45.4±19.3 (p Conclusions Importantly, no FM patients fulfilled ASAS classification criteria. Only a small proportion of patients with axSpA fulfilled any of the FM classification criteria. There was less overlap between patients with FM, axSpA and RA using the 1990 criteria as compared to the more sophisticated 2010 FM criteria. FM patients reported higher pain scores and more functional deficits. Some patients with widespread pain may have underlying axSpA - this differential diagnosis needs to be taken into account when dealing with the diagnosis of FM in daily practice. Disclosure of Interest None declared

Background In patients with tender and swollen finger joints, the differential diagnosis between rheumatoid arthritis (RA) and osteoarthritis (OA) of the hands can be initially difficult. In a previous pilot study we have shown that the positive response to a 3-day-course of 20 mg prednisolone (the “pred-test”) differentiates between RA and OA of the hands. An subjective percentage of improvement of 40% was found to discriminate best. Objectives To study the diagnostic value of the pred-test in patients with possible RA. Methods Consecutive patients with hand pain referred because of suspected RA (n=100) were included in the study. Clinical examination by one experienced rheumatologist, laboratory tests, and magnetic resonance imaging (MRI) were regularly performed. All patients received 1g paracetamol/day for 5 days. On days 3-5 a morning dose of 20 mg of prednisolone was added. Hand pain was quantified on a numerical rating scale (NRS 0–10) and the subjective percentage of improvement recorded. The predefined cut-off of 40% improvement was applied to differentiate between responders and non-responders. Diagnoses were made by the expert who was unaware of the treatment result. Patients were reexamined at week 12 to confirm the diagnosis. Results There were 95 patients with complete data (Tab.1). RA was diagnosed in about half of the patients. RA patients had more swollen joints, higher CRP levels and a comparable HAQ (Tab.1). The pred test was positive in 42.1% of the patients (40/95). The median percentage of improvement after 3 days of 20 mg of prednisolone was higher in RA than in OA: 50% (IQR 30%>60%) vs. 20% (IQR 10%>30%), p Conclusions This is the first evaluation of the widely used pred-test that has ever been performed. We found that this test has a moderate sensitivity and good specificity. We propose that rheumatologists use this test in uncertain clinical situations to be able to better differentiate between inflammatory arthritis and osteoarthritis. Finally, we hope that a negative test result will prevent patients to receive unnecessary glucocorticoid treatment, while a positive test will help to identify patients with inflammatory arthritis who can then receive proper treatment. Disclosure of Interest None declared

Background The use of biologic agents has changed treatment paradigms of rheumatic diseases in the past decade. However, the optimal strategy and dosing with this therapy is still not really clear. For example, many biologic agents have not adapted the dosage to the body weight of patients. Furthermore, it is well known that patients in clinical trials and in daily practice may differ substantially. Finally, medication costs is quite an issue in this part of Germany. Objectives To provide real life data including costs of treatment with biologic agents in rheumatology private practices in Westfalia. Methods A total of 13 rheumatologists in Westfalia participated in this retrospective study in 2012 and 2013. Thus, anonymized pooled data of 10.704 patients were analysed with focus on the expenses for medication in general and for biologics. In a second approach Data were extracted from a software tool (RheumaDok). Thus, the annual number of patients treated for inflammatory rheumatic diseases, their diagnosis and biologic agent therapy could be determined. Complete data of 8345 patients could be analysed. Costs were calculated from standard dosing based on the summary of product characteristics (SPC). Results In total, 3083 patients (36.94%) with sero+ and 1958 (23.46%) with sero- rheumatoid arthritis (RA), together 5041 patients (60.41%) with RA were identified, while 778 patients (9.32%) had psoriatic arthritis (PsA) and 956 (11.46%) axial spondyloarthritis (axSpA). Another 1570 (18.81%) had other rheumatic diseases and were excluded from the study. The biologic agent ratio was 7.9% (range 5.5 to 8.7%). Disease specific ratios on RA, PsoA and axSpA are shown in Fig.1. with axSpA as the largest fraction. The overall budget of 11 rheumatologists was 14.3 Mio € per year for all drugs. Of these, 10.47 Mio € (74.37%) were spent for 733 patients (6.85%) on biologics. This reveals annual costs of 14.286 € per patient on biologics, a rate of 65-68% compared to that expected for Etanercept (ETA) or Adalimunab (ADA) by their SPC. Out of allbiological agents employed, the proportion of ETA was 35.1%, of ADA 29.4%, Infliximab 12.3% and others 23.2%. Conclusions The fact that the largest proportion of patients treated with biologics had a diagnosis of axSpA is surprising and deserves further study. The most likely explanation is that rheumatologists take care much more frequently for mild to moderate RA than for axSpA patients. ETA and ADA are the most sold biologics in Germany, this was confirmed for Westfalia. Compared to the official price lists, biologic agents were on average prescribed in a reduced schedule of about 2/3 of the standard dosing. In 2013, the ratio of RA patients on biologic agents was only 6.7%. This is a considerably low figure compared to data of the German core set documentation (25%) 1 . References S. Bischoff et al. (2012) Kerndokumentation, http://dgrh.de/fileadmin/media/Forschung/Versorgungsforschung/ErwachsenenKerndok/standardpraesentation_2012_dgrh_extern.pdf Acknowledgements Partially sponsored by an unrestricted grant by Pfizer Disclosure of Interest None declared

Background/Aims: Compared with alcoholic pancreatitis, little is known about the natural history of idiopathic pancreatitis. Two hundred forty-nine patients with alcoholic pancreatitis and 66 patients with idiopathic chronic pancreatitis seen at our institution between 1976 and 1982 were investigated. Methods: Records were analyzed retrospectively from the onset of symptomatic disease, and patients were followed up prospectively until 1985. Patients with early-onset (n =25) and late-onset (n = 41) idiopathic chronic pancreatitis had a median age at onset of symptoms of 19 and 56 years, respectively. Results: The gender distribution was nearly equal in idiopathic chronic pancreatitis, but 72% of patients with alcoholic pancreatitis were men ( P = 0.001 vs. idiopathic). In early-onset idiopathic pancreatitis, calcification and exocrine and endocrine insufficiency developed more slowly than in late-onset idiopathic and alcoholic pancreatitis ( P = 0.03). However, in early idiopathic chronic pancreatitis, pain frequently occurred initially ( P = 0.003 vs. late and alcoholic) and was more severe ( P = 0.04 vs. late and alcoholic). In late-onset idiopathic pancreatitis, pain was absent in nearly 50% of patients. Conclusions: There are two distinct forms of idiopathic chronic pancreatitis. Patients with early-onset pancreatitis have initially and thereafter a long course of severe pain but slowly develop morphological and functional pancreatic damage, whereas patients with late-onset pancreatitis have a mild and often a painless course. Both forms differ from alcoholic pancreatitis in their equal gender distribution and a much slower rate of calcification.