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The aim was to study the different strategies used to implement cardiovascular risk evaluation and management for patients with rheumatoid arthritis (RA) in daily clinical practice. A questionnaire survey was performed among both the members of the international Trans-Atlantic Cardiovascular Risk Consortium for Rheumatoid Arthritis (ATACC-RA) as well as the Survey of cardiovascular disease risk factors (CVD-RF) in patients with RA (SURF-RA) group. The questionnaire included 18 questions with the overarching topics: (1) organization and responsibility of cardiovascular risk management (CVRM); (2) screening of CVD-RFs; (3) overview current CVRM status; and (4) availability of data regarding CVRM. Based on the answers, two researchers (JW, PR) independently categorized the different strategies. Thirteen out of 27 rheumatology centers responded to the questionnaire. One rheumatology center did not have organized CVRM for their RA patients. Among the other centers, three strategies to organize CVRM in daily practice were distinguished: (1) the rheumatologist performs CVRM during outpatient visits (n = 6); (2) cardiologists and rheumatologists co-operate in a cardio-rheuma-clinic/team with different tasks and responsibilities (n = 3); and (3) the general practitioner screens and intervenes on CVD-RFs (n = 3). Each CVRM strategy was based on agreements between medical professionals and was also dependent on the national healthcare system and available financial resources. Three strategies were identified for CVRM implementation in daily clinical practice based on who is primarily responsible for performing CVRM. More research is warranted to compare their relative merits and effectiveness in relation to CVRM.

Chronic somatic conditions, such as psoriasis, arthritis psoriatica and rheumatoid arthritis, have a large impact on patients’ lives. Tailored therapist-guided internet-based cognitive-behavioural therapy (ICBT) has been shown to be effective in improving physical and psychological well-being in these patients. Two cases are presented here, in order to provide an in-depth illustration of the course and content of this novel treatment and to investigate the therapeutic alliance in an online treatment. After face-to-face intakes, both patients received therapist-guided ICBT tailored to their specific problems and treatment goals. The treatment resulted in improved physical and psychological well-being and these clinically significant improvements were maintained at 6-month follow-up. In addition, the therapeutic relationship was evaluated positively by both patients and increased further during treatment, indicating an adequate therapeutic working alliance in this online treatment. These case reports show that tailored ICBT may contribute to improved care for patients with chronic somatic conditions.

Objective The Checklist Individual Strength (CIS) measures four dimensions of fatigue: Fatigue severity, concentration problems, reduced motivation and activity. On the fatigue severity subscale, a cut-off score of 35 is used. This study 1) investigated the psychometric qualities of the CIS; 2) validated the cut-off score for severe fatigue and 3) provided norms. Methods Representatives of the Dutch general population ( n = 2288) completed the CIS. The factor structure was investigated using an exploratory factor analysis. Internal consistency and test-retest reliability were determined. Concurrent validity was assessed in two additional samples by correlating the CIS with other fatigue scales (Chalder Fatigue Questionnaire, MOS Short form-36 Vitality subscale, EORTC QLQ-C30 fatigue subscale). To validate the fatigue severity cut-off score, a Receiver Operating Characteristics analysis was performed with patients referred to a chronic fatigue treatment centre ( n = 5243) and a healthy group ( n = 1906). Norm scores for CIS subscales were calculated for the general population, patients with chronic fatigue syndrome (CFS; n = 1407) and eight groups with other medical conditions ( n = 1411). Results The original four-factor structure of the CIS was replicated. Internal consistency (α = 0.84–0.95) and test-retest reliability ( r = 0.74–0.86) of the subscales were high. Correlations with other fatigue scales were moderate to high. The 35 points cut-off score for severe fatigue is appropriate, but, given the 17% false positive rate, should be adjusted to 40 for research in CFS. Conclusion The CIS is a valid and reliable tool for the assessment of fatigue, with a validated cut-off score for severe fatigue that can be used in clinical practice.

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Background:The realisation that subjects with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) has led to a growing interest in risk factor control in such people, but whether this has influenced the management of dyslipidaemia and hypertension (HT) is uncertain. In subjects with coronary heart disease (CHD), audits of CVD risk factor control are regularly performed, which makes it possible to evaluate guideline implementation over time.1Updated surveys on CVD risk management in patients with RA are needed.Objectives:To describe differences in lipid and blood pressure (BP) levels among patients with RA from five world regions. Furthermore, to evaluate attainment of guideline recommended targets for lipid lowering and antihypertensive treatment.Methods:The SUrvey of CVD Risk Factors in patients with RA (SURF-RA) was conducted at 53 centres in 19 countries from 2014 to 2019. Data including demographics, RA disease characteristics, CVD comorbidity, risk factors and use of preventive treatment was collected. HT was defined as self-reported HT, and/or measured BP ≥140/90 mmHg, and/or use of anti HT medication (a-HT). The treatment goal of a-HT was BP 2Results:In total, 14503 RA patients were included. The mean age was 59.8±13.6 years, and it was a strong female preponderance (74%). Nearly 2/3 of the patients were hypertensive. Use of a-HT in the total population differed substantially between the cohorts with limited use in West Europe and Latin America (17.4% and 24.8%), in contrast to North America and East Europe (46.8% and 57.0%). On average, half of those with HT were at the recommended BP goal. The lowest BP goal attainment was seen in Asia, West and East Europe (40.8-43.1%), and the highest in North America (63.5%). Overall 51.5% had an indication for lipid lowering therapy (LLT), and of these 43.5% were taking LLT. Only 34.0% of patients with an indication for LLT were at recommended LDL-c goals. The proportion of RA patients on target for LDL-c varied greatly between regions, from 23.1% in East Europe to 51.0% in North America. The LDL-c goal attainment was higher in RA patients at high risk (45.1%) compared to those at very high risk of CVD (18.0%).Conclusion:This large international survey on RA patients revealed considerable geographical differences in CVD preventive treatment. Lower goal attainment for LLT than reported for subjects with CHD was observed. We conclude that there is a substantial need for improvement in CVD preventive measures in RA patients.References:[1]De Backer G, Jankowski P, Kotseva K,et al.Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries.Atherosclerosis. 2019;285:135-146.[2]Perk J, De Backer G, Gohlke H,et al.European Guide-lines on cardiovascular disease prevention in clinical practice.Eur Heart J.2012:1635-701.Disclosure of Interests:Silvia Rollefstad: None declared, Eirik Ikdahl: None declared, Joe Sexton: None declared, Georeg Kitas: None declared, Piet van Riel: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Ian Graham: None declared, Anne Grete Semb: None declared

Background:The cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA) is comparable to that of patients with diabetes mellitus (DM). Although several studies have indicated high prevalences of glucose intolerance and DM in RA patients, little is known about how this affects their CVD risk.Objectives:To examine indications for, and use of antihypertensive treatment (AntiHT) and lipid-lowering therapy (LLT) in RA patients with DM (RA-DM) and RA patients without DM (RAwoDM). Further, to compare the prevalence of various types of CVD across RA-DM and RAwoDM.Methods:The cohort was derived from theSUrvey of cardiovascular diseaseRiskFactor in patients withRheumatoidArthritis (SURF-RA), which was performed in 53 centres across 17 countries in 5 world regions (West and East Europe; North and Latin America; and Asia) from January 2014 to August 2019. Indication for AntiHT was defined as: 1) systolic/diastolic blood pressure (BP) ≥ 140/90 mm Hg, 2) self-reported hypertension, and/or 3) current use of AntiHT. Indication for LLT was defined according to European Society of Cardiology (ESC) guidelines (1), in which the Systematic Coronary Risk Evaluation (SCORE) is applied. SCORE risk estimates were multiplied by 1.5 according to EULAR recommendations. Target treatment targets for blood pressure and lipids were defined according to ESC guidelines applicable at the time when data were recorded.Results:Presence of comorbid DM was available in 10 602 (73.1 %) of the 14 503 RA patients included in SURF-RA, of whom 75 and 1262 patients reported DM type 1 and type 2, respectively (total 1337 patients, 12.6 %). Although less often current smokers, RA-DM patients were more often previous smokers, male sex and had higher body mass index compared to RAwoDM (pConclusion:The effect of RA and comorbid DM on CVD risk appears to be additive. While CVD preventive medications are more often indicated in RA-DM than in RAwoDM patients, they are also more likely to receive such therapy and to reach CVD preventive treatment goals. The latter finding may be due to more developed CVD preventive care in DM compared to RA patients. Improved CVD preventive systems for patients with RA are warranted.References:[1]Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C,et al. European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2012:1635-701.Disclosure of Interests:Eirik Ikdahl: None declared, Silvia Rollefstad: None declared, Joe Sexton: None declared, Birgitte Nellemann: None declared, Georeg Kitas: None declared, Piet Van Riel: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Ian Graham: None declared, Anne Grete Semb: None declared

Background:Patients with rheumatoid arthritis (RA) are at high risk for cardiovascular disease (CVD).Observational data suggest a need for improved risk factor recording and management in such subjects.Objectives:The aim of this survey was to evaluate updated information on CVD risk factors, comorbidities, RA and CVD preventive medication in patient with RA.Methods:The audit is termedSUrvey of cardiovascular diseaseRiskFactors in patients withRheumatoidArthritis (SURF-RA) and was performed in 53 centres in 19 countries across 5 world regions during 2014 and 2019. SURF-RA is part of the SURF family of audits which have been performed in patients with CHD, in primary care2, and now in patients with stroke and SLE. Data including demographics, RA disease characteristics, CVD, risk factors and medications was collected. The survey was approved by the Data Protection Officer (2017/7243) and a General Data Protection evaluation has been performed (10/10-2018).Results:Among 14 503 patients with RA in West (n= 8 493) and East (n=923) Europe, Latin (n=407) and North (n=4030) America and Asia (n=650) the mean (SD) age was 59.9 (13.6) years, and 2/3 or more were female (table). RA disease duration was comparable across the world regions, ranging from 9.9 to 12.6 years. The average disease activity was low [disease activity score including 28 joints and C-reactive protein; DAS28CRP: mean (SD): 2.6 (1.2)]. The prevalence of atherosclerotic CVD (ASCVD) was lowest in Latin America (2.5%) and highest in East Europe (21.4%), and this pattern was similar regarding familial premature CVD. The mean prevalence (% of each entity) of blood pressure above 140/90 mmHg was 5.3%, of low density lipoprotein cholesterol > 2.5 mmol/L: 63.3%. Overall, 29% used anti-hypertensive medication, lowest in West Europe (17.4%) and highest in East Europe (57.0%), and 26.4% used lipid lowering agent(s), lowest in Asia (7.2%) and highest in North America (31.1%). Body mass index > 30 kg/m2 was present in 26.6%, with the smallest waist circumference in Asia [mean (SD): 84.1 (13.6) cm] and highest in East Europe [92.5 (15.5) cm]. The proportion of current smokers was on average: 16.2 %, lowest in Asia (7.8%) and highest in East Europe (28.5%).Conclusion:The high prevalence of CVD risk factors and ASCVD in patients with RA across five world regions shows that there is still an unmet need for vigilance and improved implementation of preventive measures in this high CVD risk patient population.References:[1] Cooney MTet al. SURF-Survey of Risk Factor management: First report of an international audit. Eur J Prev cardiol 2014[2] Zao M, Cooney MT, Klipstein-Grobush K, et al. Simplifying the audit of risk factor recording and control: A report from an international study in 11 countries. Eur J Prev Cardiol 2016AllWest EuropeEastEuropeLatinAmericaNorth AmericaAsiap-valueNumber of patients1450384939234074030650Age mean(SD)59.8 (13.6)60.7 (13.2)58.8 (11.8)52.8 (11.6)59.4 (14.8)55.7 (13.1)Sex female (%)74.574.178.592.472.277.3Disease duration (yrs) mean(SD)10.8 (9.5)10.5 (9.5)12.1 (9.3)9.9 (7.5)12.6 (9.8)10.5 (9.8)DAS28-CRP mean(SD)2.6 (1.2)2.5 (1.1)2.9 (1.2)2.8 (1.3)2.8 (1.2)2.8 (1.4)Atherosclerotic CVD (%)13.311.421.42.516.210.3Lipid lowering medication (%)26.425.128.522.431.17.2Any anti-hypertensive (%)29.017.457.024.846.831.8Disclosure of Interests:Anne Grete Semb: None declared, Eirik Ikdahl: None declared, Joe Sexton: None declared, Georeg Kitas: None declared, Piet van Riel: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Ian Graham: None declared, Silvia Rollefstad: None declared

Background Regular and personalised monitoring of disease activity, physical activity, medication use and side effects is essential to improve and maintain patients’ health-related quality of life in spondyloartritis (SpA). Transparency on outcomes, safety, practice variation and efficiency of care are increasingly demanded. Furthermore, patient empowerment and shared decision making are advocated. An integrated eHealth system including an electronic patient medical record (EMR) and real-time quality management system could provide a solution to meet these demands. Objectives To develop and test the feasibility of a disease-specific integrated eHealth system and quality registry for SpA in the Netherlands (‘SpA-Net’), in order to 1) improve the quality of care for the individual patient, 2) provide transparency on treatment results, practice variation and costs and 3) to produce data for scientific research. Methods The eHealth system was developed in four phases. First, the content and design were discussed with experts in the field of SpA and patients (pts). Second, the database, EMR and quality management system were developed. Third, multiple rounds of internal and external testing were performed in collaboration with IT specialists, care providers and pts. Fourth, the eHealth system was implemented in practice and feasibility was tested among pts and care providers through semi-structured focus interviews. Results SpA-Net was designed and developed in 2015 and implemented into practice in May 2016. All pts entered into SpA-Net have a diagnosis of SpA according to their treating rheumatologist. There are no inclusion or exclusion criteria towards the subtype of SpA or treatment. Information prospectively collected at routine outpatient consultations on diagnosis, demographics, specific SpA manifestations, patient reported outcome measures, clinical outcomes, comorbidities, medication use and safety, supplemented with data from the hospital information system, is directly stored in a database. The comprehensive individual patient data are readily available to the physician and an excerpt of this can be accessed by the patient. Prior to each visit, pts complete online questionnaires. The information is presented in graphs wherever possible (figure 1). In December 2017, 1078 pts participated in SpA-Net (mean [SD] age 53.7 [14.3] years, 46.6% females), and inclusion is ongoing. Focus group interviews were held with 16 pts, 9 rheumatologists, and 5 nurses. Pts considered the layout of SpA-Net as clear, accessible and intuitive. They felt the use of questionnaires resulted in better quality of care and communication, and appreciated having access to their EMR with lay-term explanations. Points of improvement were the login process and providing more details about the care provider’s notes. Care providers appreciated the additional information for (preparing) consultations. Barriers against use of SpA-Net were the initial time required to adopt the EMR and the quantity of data entry. Conclusions SpA-Net enables regular monitoring of pts with SpA and can serve as a first step to optimise knowledge and communication between pts and care providers. Both pts and care providers thought SpA-Net improves quality of care in daily practice. Disclosure of Interest C. Webers: None declared, E. Beckers: None declared, Y. van Eijk: None declared, H. Vonkeman: None declared, M. van de Laar: None declared, P. van Riel: None declared, M. Efde: None declared, A. Boonen: None declared, A. van Tubergen Grant/research support from: AbbVie, Celgene, Janssen-Cilag, MSD, Novartis, Pfizer, UCB

Cardiovascular risk age and vascular age estimations in predicting cardiovascular events in rheumatoid arthritis patients

Background With biological patents expiring, biosimilars are becoming a realistic, less costly alternative to their originator. The data from numerous randomised clinical trials support that it is safe, effective and cost saving to switch to a biosimilar. However, real world data about efficacy, safety, and cost-effectiveness of such a switch are lacking. Since shared decision making (SDM) is a key factor in the treatment of rheumatic diseases, a non-mandatory open label transitioning from Etanercept originator to its biosimilar was performed at the rheumatology department of Bernhoven. Objectives The first goal of this study was to investigate the effect of switching from Etanercept originator to its biosimilar on the effectiveness of treatment. The second aim was to analyse the effect of SDM on the 1 year retention rates and reasons for withdrawal in daily clinical practice. Methods All patients with rheumatoid arthritis (RA), axial spondyloarthritis (SpA) and psoriatic arthritis (PsA) that were using Etanercept originator between 01–06–2016 and 23–10–2017 were informed by letter of the possibility to switch to its biosimilar. During the next outpatient visit with their rheumatologist the possibility to switch was discussed. Patients had the opportunity to ask questions regarding biosimilars and the switch to a biosimilar. If patients agreed the switch was made, with the reservation that they could switch back to the originator if they encountered difficulties with the biosimilar. Using the registry of the rheumatology department at Bernhoven data were collected on disease activity (DA), medication use and adverse events from the moment of switch till 23–10–2017. As measure for DA the DAS28 was used for RA and PsA, the ASDAS was used for SpA. Stop reasons for biosimilars were verified using the health record system of the hospital. Reasons for change in disease activity and discontinuation of biosimilar treatment were assessed. Results Between 01–06–2016 and 23–10%–2017 80% (69 patients) of the Etanercept originator users switched to its biosimilar. These patients switched to biosimilar after a median time of 5.1 (IQR 2.8–8.3) years. By 23–10–2017, median follow-up of 307 (IQR 196–357) days, the mean DA did not significantly differ from the DA at baseline, 3.1 (95%>CI 2.5–3.7) vs. 2.8 (95%>CI 2.5–3.1). At end of follow-up 25% of the patients had discontinued there treatment and either switched back to originator (18%), switched to another biological (3%) or stopped treatment with biologicals (4%). Reasons for switching back to originator were adverse events (58%), lack of effect (17%) and “adverse event and lack of effect” (25%). Only one serious adverse event was reported. This was a drug hypersensitivity reaction. After the patient was recovered, the originator was restarted without any difficulties. Conclusions An open label non-mandatory switch from Etanercept originator to its biosimilar showed that around 80% of the patients is willing to perform this switch. Switching did not affect effectiveness of treatment during one year follow-up. 75% of the patients were able to continue biosimilar therapy. In the 69 patients that switched only one serious adverse effect occurred. Disclosure of Interest None declared

Background Quantitative muscle ultrasound (QMUS) imaging has proven to be a useful, non-invasive technique to visualise normal and pathological skeletal muscle tissue.1 Electromyography (EMG) findings are not always disease specific in patients suspected of idopathic inflammatory myopathies (IIM). Objectives To assess diagnostic value of QMUS in patients suspected for an IIM and to compare results with EMG. Methods In 57 patients, suspected for IIM, panel diagnosis blinded for QMUS was used as reference standard. QMUS results were used to classify patients according an ultrasound neuromuscular disorder (NMD) algorithm (normal/borderline/abnormal). The predictive value of QMUS and EMG was assessed in a two by two table and a multivariate logistic regression model. Results Twenty-two patients (39%) were diagnosed with IIM; 8 polymyositis, 4 dermatomyositis, 4 necrotizing myopathy, 3 inclusion body myositis and 3 non-specific myositis. Sixteen patients were classified with other NMD. We found an increased echointensity of the sternocleidomastoid, biceps, forearm flexor and tibialis anterior in the IIM group. Sensitivity, specificity, positive and negative predictive values (PPV/NPV) were 82%, 51%, 51%, 82% for ultrasound NMD algorithm and 63%, 64%, 50%, 75% for EMG. Multivariate analyses showed area under the curve (AUC) (0.81) (0.69–0.92) for ultrasound NMD algorithm, EMG (0.79) (0.67–0.92) and ultrasound NMD algorithm plus EMG (0.82) (0.70–0.93). Conclusions QMUS with NMD algorithm provides a fair diagnostic value for patients suspected for an IIM and is similar to EMG results. A sizeable NPV indicates a low rate of false negative QMUS results. In addition to the relevant PPV for the presence for NMD, QMUS could serve as a potential screening tool for clinicians to detect possible myopathies and to rule out the presence of IIM. References [1] Zaidman CM, van Alfen N. Ultrasound in the Assessment of Myopathic Disorders. J Clin Neurophysiol. 2016;33(2):103–1 Disclosure of Interest None declared

Different strategies to implement the eular guideline for cardiovascular risk management in daily practice

Background Inflammatory rheumatic diseases (IRDs) such as Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA) are characterised by a fluctuating disease course. Because of these fluctuations, the disease activity in between outpatient visits can be different from the disease activity objectively measured at outpatient visits. In order to capture the in between disease activity and to encourage patients to take an active role in their disease management, iMonitor1 was developed. This online self-monitoring tool allows patients to complete Patient-Reported Outcome Measures (PROMs) in order to get insight in their disease activity. Objectives To gather patient experiences regarding online remote monitoring in IRDs and to provide recommendations in order to efficiently arrange and optimise self-monitoring. Methods This mixed-method study was conducted at a teaching hospital (Bernhoven, Uden, the Netherlands) from April 2016 until August 2017. Adult patients with RA or PsA were eligible to participate and were recruited by means of purposive sampling. Four instruction classes were organised in which patients received instructions regarding how to use iMonitor. Patients indicated which PROM(s) they preferred to complete (HAQ, RAID, and/or RADAI-5) and at which frequency (one-, two-, four-, six-, or eight-weeks). The system generated an alert email accordingly, adherence was determined by checking whether the PROM was completed within the time interval. Level of congruence between DAS28-scores and PROM-values (very poor – very good) were independently determined by two researchers (LR and PvR). Facilitators and barriers with regard to using iMonitor were collected by means of a focus group discussion and four telephone interviews. Results Seven patients with PsA and 32 with RA participated in this study. Most were female (n=23, 59%). Mean (±SD) age was 56.6 (10.7) years. RAID was chosen most often (29 times). Most patients (n=25) chose a four-week PROM-frequency. Mean adherence was 52.9%, patients with a one-week frequency were most compliant (73.8%). Regarding the congruence between DAS28 and PROMs, RAID scored best. Overall, patients were positive about iMonitor. They felt more aware about their disease and its consequences, felt supported in handling their disease, and gained more knowledge about their disease (activity). Based on our first experiences, recommendations for optimal self-monitoring are: 1) Patients need to be actively recruited 2) Tailored education (e.g. instruction class) is useful for some patients in order to get familiar with the program. 3) Patients need to get feedback from their healthcare provider regarding their outcomes. 4) Working with a stand-alone system such as iMonitor is not feasible, it should be integrated in an existing (hospital) system. Conclusions Self-monitoring is a first step towards personalised healthcare. Patients become more aware about their disease and gain more knowledge about their disease (activity), which can result in increased self-management. Future research should investigate the possibility of skipping outpatient visits for those patients with stable disease activity. Reference [1] iMonitor, developed and funded by Pfizer http://www.imonitor-med.co.uk Disclosure of Interest None declared

Background For individuals with rheumatoid arthritis (RA), it is important to be sufficiently physically active. The international recommendation for physical activity states that each adult should perform moderate-intensity aerobic physical activity for at least 30 min, five days a week. In recent years, attention and awareness of the importance of being physically active has increased, including the development of exercise programmes for people with rheumatic diseases. However, it is unknown whether patients with RA actually became more physically active in daily practice in the past years. Objectives Primary, this study will estimate whether the percentage of RA patients that meet the recommended level of physical activity has changed in recent years. Secondary, this study aims to identify RA patients of the outpatient clinic who are physical inactive and motivated to improve their level of physical activity. Methods In 2014, 740 RA patients from seven outpatient clinics across the Netherlands filled out a questionnaire which contained items about self-reported physical activity and sport habits. In 2017, the same items were assessed again by sending a questionnaire to all 727 RA patients of the outpatient clinic in Bernhoven, a hospital in the south of the Netherlands. In addition, questions about motivation to increase the level of physical activity were added. Results In 2014, 52% of the RA patients met the recommendation for physical activity. In 2017, 33% of the 514 RA patients of the outpatient clinic in Bernhoven who filled out the questionnaire reported that they met the recommendation. Walking, cycling, aerobic and strength fitness training and swimming were mentioned as the most popular sports among RA patients in 2014 as well as in 2017. 133 of the 233 (57%) inactive RA patients of the outpatient clinic in Bernhoven reported that they were convinced to be able to improve their physical activity level and 51% reported that they were motivated to become more physically active in the upcoming months. Conclusions Despite the increased attention and awareness of the benefits of being physically active, the percentage of RA patients who meet the recommended level of physical activity did not increase between 2014 and 2017. This could be caused by the fact that the effect of the developed exercise programmes typically wear off after the exercise interventions have stopped. Another reason could be that patients with RA need to be more assisted to overcome barriers to implement physical activities in their daily life. A more personalised approach, based on coaching and shared-decision making to set personal physical activity goals, could increase compliance and reduce barriers to being physically active. Half of the inactive RA patients of the outpatient clinic are motivated to become more physically active. Therefore a new study will examine whether a personalised physical activity programme is effective to increase and sustain the level of physical activity in inactive RA patients. Disclosure of Interest None declared

Background Over the past 15 years, there has been a huge shift in the management of RA: the armamentarium has increased but also the way antirheumatic drug are being used has changed, e.g.treat to target. This has implications for how the communication between professional and patient needs to occur: hence shared decision making part of most guidelines. Therefore, healthcare must be organised in a different way: patients should be more involved in their treatment and patient’s self-management should play a very important role. The use of a personal health environment can be an effective tool to involve patients in their disease management and helps to optimise the communication between the patient and health professionals. Objectives The aim of this project was to create an online personal health environment with self-management tools for patients with rheumatoid arthritis (RA) and determine the factors limiting patients to use this environment. Methods Since April 2017 a new online personal health environment was developed in the Netherlands especially for patients with RA, called Reumanet Bernhoven. It includes: 1. an overview of the medication and comorbidities, 2. a graphic of disease-related values (e.g.DAS28, anti-ccp, SR, BMI, 36-Item Short Form Health Survey (SF-36), Health Assessment Questionnaire (HAQ) and RA Impact of Disease (RAID)), 3. a diary, 4. questionnaires such as the different VAS scales (pain, fatigue, general health), Health Assessment Questionnaire HAQ, SF-36 and RAID questionnaire to prepare the outpatient visit. 5. an application to send messages to the health professional. 6. a library with useful disease-specific information. 7. a graphic overview of the DAS28 in combination with the RAID questionnaire to self monitor disease activity. After six months those patients who did not use Reumanet yet were contacted to reveal the cause. Results By November 2017, 997 RA-patients were included in Reumanet Bernhoven. 56% (n=557) used it at least once in this 6 month period. 13% (n=70) of them used the self monitoring tool. The remaining patients, 44% (n=440) were questioned for not using Reumanet at home. 55% (n=242) of these patients responded and 14% (n=62) do want to participate yet, 26% (n=114) did not have a computer or email address, 16% (n=71) did not want to using a digital environment at home. Conclusions Half of the RA-patients used Reumanet at home of which 13% performed self-monitoring of their disease activity in this online personal health environment. Reumanet will be seen as a promising tool to involve patients in their disease management and can be helpful for shared decision making between patient and health professional. In future, more research is needed to optimise patient self-management in a digital health environment in order to increase its usage. Disclosure of Interest None declared

Background Patient education can be used to support and enable people with Rheumatoid Arthritis (RA) to optimise health and wellbeing. It has been recommended as an integral part in management of RA in order to undertake self-management activities or to adhere to treatments. Disease-specific knowledge can be measured with a Patient Knowledge Questionnaire (PKQ). Because PKQs in RA are outdated, de Jonge et al. developed the Disease and Treatment Associated Knowledge in Rheumatoid Arthritis (DataK-RA) item bank and provided preliminary evidence to support its construct validity. It was developed with input from patients and rheumatology experts. DataK-RA contains 42 multiple choice items with 2–4 response alternatives per item and was calibrated using the two parameter item response model for dichotomous responses. IRT scores are corrected for item characteristics, which allows scores to be compared between measures that include different items. IRT models also provide detailed information about the precision of scores at different levels of knowledge. Various methods are available that can help select optimal items to be administered to patients, given certain criteria. Objectives The objective of this study was to develop two DataK-RA short forms using linear optimal test design. Methods The open source excel add in “solver” was used to program a linear optimisation algorithm to develop two short forms. The algorithm was instructed to optimise precision (i.e. reliability) of the scores for both short forms, subject to the constraints that: 1) each item could only be included in one short form 2) each short form should include 15±1 items, 3) reliability for each short form should be >0.70 for all patients who are within 1 SD of the mean of knowledge scores, and 4) scores on each short form should be similarly precise, defined as maximum allowable difference in information of 0.15. Results Two short forms were derived from the DataK-RA item bank that satisfied all content constraints. The short forms include respectively 15 and 16 unique items. Reliabilities across different score levels ranged from 0.71–0.80 for both short forms, and the maximum difference in information between the short forms was 0.13. Conclusions DataK-RA is a new and promising tool that can be used by healthcare providers to measure disease and treatment related knowledge in patients with RA. The short forms can be used in pre/posttest intervention studies in which disease related knowledge is one of the outcomes Because each short form includes unique items and IRT scores are adjusted for item characteristics, the application of these short forms will allow users of DataK-RA to avoid learning effects commonly associated with using the same items at two occasions. Furthermore, the equal and high reliabilities of both forms ensure that the observed score distributions for both versions will have similar variances. Disclosure of Interest None declared

Background Current guidelines say that there should be a prominent place for patient participation and shared decision making in rheumatic care. To achieve this Bernhoven introduced an online patient health record (OPHR) for patients with rheumatoid arthritis (RA) aiming to facilitate self management and giving insight in the individual disease course in April 2014. This platform enables patients to monitor their disease by completing questionnaires about for instance pain, fatigue and quality of life. It also gives access to their medication history and offers patients information in the form of an online library. Objectives This study analyses how the introduction of an OPHR, aiming to promote patient participation, influences the prescription of DMARD’s and the disease activity (DAS28) in daily clinical practice. A distinction was made between the effects of the PHR on patients recently diagnosed with RA (study A) and the RA population as a whole (study B). Methods In April 2014 anan OPHR for patients with RA was introduced at the rheumatology department of Bernhoven. Using data from the rheumatology department registry, two analyses were performed to evalute this implementation. Study A compared the treatment and course of DAS28 of patients diagnosed in the period three years prior to the implementation (“prior group”) with those diagnosed in the period three years after the implementation (“after group”). Study B was an observational study that examined yearly trends for DMARD use and DAS28 for the whole RA population between April 2011 and April 2017 Results Study A A total of 287 patients were diagnosed with RA of which 127 were in the prior group and 171 in the after group. CsDMARD’s were given 160 days [95%>CI 123–198] after diagnosis in the “prior group” versus (vs.) 32 days [95%>CI 22–43] in the after group. Next to that there was an increase in cumulative time csDMARD’s were used during follow-up, 54% vs. 74% (p-value Study B The trend analysis of DMARD use in the RA population is plotted in figure 1. Between 2011 and 2017 a change in trend can be observed for the use of csDMARD’s, the use of csDMARD combination and the use of bDMARD csDMARD combination therapy. The usage of bDMARD therapy did not change. Conclusions After the introduction of the OPHR patients recently diagnosed with RA got earlier and more intense treatment, with a more prominent role for biologicals. Next to that a bigger proportion of patients recently diagnosed with RA achieved remission and LDA within the first year of DMARD therapy. When looking for trends in the total RA population, an increase of the use of csDMARD’s, the use of csDMARD combination and the use of bDMARD csDMARD combination therapy was observed after April 2014. Disclosure of Interest None declared

Background Within the field of rheumatoid arthritis (RA), patients report decreased health-related quality of life (HRQoL) as a result of living with physical factors such as pain and psychological factors such as negative mood. As these factors are associated with the disease trajectory, health care utilisation, and workplace disability of patients, these factors lead to significant societal health expenses. In a recent randomised controlled trial, improvements in especially psychological functioning (e.g., depressed mood) were found by offering tailored, therapist guided cognitive behavioural therapy online. 1 Although internet-based cognitive behavioural therapy holds promise for implementation and cost-reductions, scarce research is available on the cost-effectiveness of these treatments. Objectives A cost-effectiveness study from a societal perspective was conducted alongside a randomised controlled trial on a tailored and therapist-guided internet-based cognitive behavioural intervention (ICBT) for patients with elevated levels of distress, as an addition to usual care alone in order to inform stake-holders on implementation of this treatment. Methods Data were collected at baseline/pre-intervention, 6 months/post-intervention, and three-monthly thereafter during one year follow-up. Effects were measured in quality-adjusted life years (QALYs) and costs from a societal perspective including healthcare sector costs (including healthcare use, medication, and intervention costs), patient travel costs for healthcare use, and costs associated with loss of labour. Results The intervention improved quality of life compared to usual care alone (Δ QALYs=0.059), but also led to higher costs (Δ=€ 4.211,44), which reduced substantially when medication costs were left out of the equation (Δ=€ 1.862,72). Most (93%) of the simulated ICERS were in the north-east quadrant, suggesting a high probability that the intervention is effective in improving HRQoL, but at a greater monetary cost for society compared to usual care alone. Conclusions A positive effect on quality-adjusted life years is seen in the intervention group compared to the control group. However, cost-ratios show that this comes at a greater cost to society. The substantial costs in this population are generated by medication costs, for which no group differences could be found. The cost-benefit ratio improves when the costs for medication are not taken into account. Based on the effects for improvement of quality of life, implementation of the intervention is recommended, yet on the side of costs, further study is warranted. Reference [1] Ferwerda M, van Beugen S, van Middendorp H, Spillekom-van Koulil S, Donders ART, Visser H, Taal E, Creemers MCW, van Riel PCLM, Evers AWM. A tailored-guided internet-based cognitive-behavioural intervention for patients with rheumatoid arthritis as an adjunct to standard rheumatological care: Results of a randomized controlled trial. Pain2017;158(5):868–78. PMID: 28106666 Disclosure of Interest None declared

OBJECTIVE: Rheumatoid arthritis (RA) fatigue is not being well-managed currently, and evidence of effective interventions is limited. Aerobic exercise may provide benefit to treat fatigue in RA. Therefore, the purpose of this meta-analysis is to analyze the effect of aerobic land-based exercise on fatigue in RA. METHODS: A literature search was conducted using PubMed, Cochrane Library, Embase, and trial registers to identify randomized controlled trials (RCTs) with a supervised land-based aerobic exercise program performed with an intensity between 50% and 90% of maximal heart rate, of at least 15 minutes' duration, performed at least 2 times a week, and lasting for a time period of at least 4 consecutive weeks. Risk of bias was assessed using the Cochrane tool. A meta-analysis of fatigue outcomes was performed by calculating the standardized mean difference (SMD) using a random-effects model. RESULTS: Five RCTs were included. None of the trials selected patients with RA for having fatigue. Risk of bias was low in 3 RCTs and unclear in 2. Land-based aerobic exercise programs had a positive effect on fatigue in RA compared to no exercise at 12 weeks, SMD -0.31 (95% confidence interval [95% CI] -0.55, -0.06). At 24 weeks, the effect of aerobic land-based exercise was smaller and not statistically significant: SMD -0.15 (95% CI -0.33, 0.02). CONCLUSION: There is evidence with low risk of bias that an aerobic exercise program is effective in reducing fatigue among patients with RA, especially in the short term; however, effects are small. To substantiate the evidence, RCTs should be performed in patients with RA selected for having fatigue.

Background To reduce the risk of cardiovascular disease in rheumatoid arthritis (RA) patients, adequate cardiovascular risk management (CVRM) is necessary. CVRM implies assessment, treatment and monitoring of cardiovascular risk factors1. The updated EULAR guideline states that cardiovascular risk assessment should be considered at least once every five years in all patients with RA2. A few studies show suboptimal risk management in daily practice in selected groups of patients. Objectives This study aims to describe current performance of the CVRM recommendation in a hospital based RA population in the South of the Netherlands. In this region, general practitioners (GPs) and rheumatologists closely collaborate into manage RA patients9 cardiovascular risk. Methods Due to the collaboration, CVRM is performed as a part of a transmural care program. The rheumatologist informs the GP when a patient has been diagnosed with RA. The patient is placed on a list for CVRM to be screened by a specialised nurse practitioner. As a part of the collaboration, laboratory results requested by the GPs and rheumatologists are collected in one digital patient record system. This system is used to check whether the RA patient9s lipid profile was determined in the previous five years. If not, a letter with the listed patient is sent to the GP a reminder for screening the patient. In this study, we checked six months later whether lipid testing was ultimately performed. Results In 70% (n=475) of all 679 RA patients (mean age 63 (SD 9 years), 68% women and median disease duration of 7 years (IQR 3–11)) a lipid profile was determined in the previous five years. Of the 204 non-screened RA patients, 98 had been screened after sending the letter to their GP (+48%), see Figure 1. No differences in gender and disease duration were found between the screened and non-screened patients (p=.46 and p=.25 respectively). By contrast screened patients were 10 years older compared to the non-screened patients (66 year (SD12) vs 56 (SD 15) year, p Conclusions As a result of the collaboration between GPs and rheumatologists, 70% of all RA patients was screened for CVRM. A small intervention, sending a reminding letter to the GP, increased this percentage even further, to 84%. This collaboration can be seen as a good practice to provide care in line with the EULAR guideline. References Barber CE et al. Best practices for cardiovascular disease prevention in rheumatoid arthritis: a systematic review of guideline recommendations and quality indicators. Arthritis care & research. 2015;67(2):169–79. Agca R et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Annals of the rheumatic diseases. 2016. Disclosure of Interest None declared

Background Baricitinib (BARI) is a selective inhibitor of Janus kinase,1 improves disease activity in patients (pts) with rheumatoid arthritis (RA), and is associated with inhibition of structural joint damage.2–4 Response to BARI observed at week (wk) 4 may be useful to predict future response.5 Objectives To characterise pts with RA who achieved moderate EULAR responses (MERs)6 at wk 4 and to describe the outcomes through wk 52 while continuing the assigned treatment. Methods Pts enrolled in the RA-BEAM study with active RA who had an inadequate response to methotrexate (MTX) were randomised 3:3:2 to placebo (PBO), BARI 4 mg once daily, or adalimumab (ADA) 40 mg biweekly.1 Pts who showed good or no EULAR responses at wk 4 were excluded. For the MER cohort, the cumulative incidence for first transition to good EULAR response and to no EULAR response from wk 4 through wk 52 was estimated in the presence of competing risks events, which either hinder observation of the events of interest or modify the chance that these events occur.7 Pts who transitioned from MER to no EULAR response or pts who were rescued or discontinued because of an adverse event or lack of efficacy were counted as no EULAR response; pts who discontinued the study for other reasons (eg, lost to follow-up, death) were censored at the time of discontinuation. No formal statistical tests were performed for these post hoc analyses. Results Of 1305 pts who received at least 1 dose of study drug, 683 experienced MERs at wk 4, including 37.3% (182/488), 62.0% (302/487), and 60.3% (199/330) of pts on PBO, BARI, and ADA, respectively. Pts who achieved MERs at wk 4 on BARI and ADA had similar baseline disease activity characteristics (Table 1). The mean age of the MER subgroup was 53 years, and the mean disease duration was 8.7 years. The mean MTX dosage was 15 mg/wk, and 59% of pts were taking concomitant oral glucocorticoids. At wk 4, 27% (131/487) and 11% (54/487) of pts on BARI vs 29% (95/330) and 11% (36/330) of pts on ADA experienced no response or good response, respectively. The cumulative incidence for the first transitions to good EULAR response at wks 12, 24, and 52 was higher in pts who reached MERs at wk 4 on BARI than those on ADA. The cumulative incidence for the first transitions to subsequent no EULAR response was higher in pts who achieved MER at wk 4 on ADA (Figures 1A and 1B, Table 2) than those on BARI. Conclusions Among pts achieving early MER on BARI and ADA, subsequent loss of response was less common for pts on BARI than for those on ADA. Transitions to good EULAR response were more common for pts who achieved MERs on BARI than for those on ADA. Mechanistic explanations warrant future study. References Taylor et el. 2015 ACR Meeting. Abstract 2L. Dougados M, et al. Ann Rheum Dis. 29 Sep 2016. Smolen et al. Ann Rheum Dis. 31 Oct 2016. Fleischmann R et al. Arthritis Rheumatol. 09 Oct 2016. Kremer et al. 2015 ACR Meeting. Abstract 1050. Gestel et al. Arthritis Rheum 1996. Lin G et al. SAS Global Forum 2012. Acknowledgements Inmaculada de la Torre MD, PhD, Senior Medical Advisor, contributed to this abstract. Disclosure of Interest T. K. Kvien Consultant for: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz, and UCB, Speakers bureau: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz, and UCB, P. van Riel Consultant for: Eli Lilly and Company, A. Rubbert-Roth Consultant for: Eli Lilly and Company, R. Blanco Consultant for: Eli Lilly and Company, S. S. Liu-Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, E. Larsson Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, H. Lund Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, P. Lόpez-Romero Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, L. Zaremba-Pechmann Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, P. Emery Consultant for: Pfizer, MSD, Abbvie, BMS, UCB, Roche, Novartis, Samsung, Sandoz, Eli Lilly and Company

Background While practical guidelines and recommendations play an important role in the treatment of RA, rheumatologists often tend to deviate from these guidelines (1). This may result in disparity of quality of care among individual doctors and hospitals. To establish the best possible care, quality measures are needed. These aim to quantify the quality of the delivered care and will form the foundation of quality registries. Standardization of care processes in combination with public reporting of performance (by means of a quality registry) has been suggested to improve quality of care (2). Objectives To develop feasible quality indicators (QIs), endorsed by the different stakeholders of the Dutch Quality registry Rheumatoid Arthritis (DQRA). Methods An expert group of 8 rheumatologists, 2 patient representatives and 1 healthcare insurer representative developed a minimal set of QIs via a Delphi-like procedure (3), endorsed by the Dutch Society for Rheumatology. Since October 2015, these QIs have been registered by rheumatologists and rheumatology nurses, once a year in 26 hospitals, along with a patient evaluation questionnaire regarding the received care. To determine whether it is feasible to collect these QIs in daily practice, retrospective data from three hospitals was obtained (hospital A (university), B and C (non-academic)). Feasibility was determined by evaluation of: Completeness of registered data (figure 1) Possibility to calculate disease activity categories (remission, low-high disease activity) Possibility to calculate changes over time in disease activity categories Extraction of data regarding (b)DMARD use Results Selected QIs are: 1. Percentage of patients in a certain disease activity category 2. Percentage of patients using a certain (b)DMARD 3. Patient reported experience with received care Hospital B provided only data from one year (2014) and was not able to extract data on medication from their electronic record system. Conclusions The DQRA is the first to incorporate perspectives from three stakeholders (patients, physicians and healthcare insurers) and successfully formed a limited set of QI. Collection of these indicators was feasible in two out of the three participating hospitals and offers insight in differences in provided and perceived care for RA patients. References Mahmood et al. Best Pract Res Clin Rheumatol 2015. Chassin et al. Health Aff 2002. Mahmood et al. ARD 2016. Disclosure of Interest None declared

Background/Purpose: The effectiveness of TNF-inhibitors (TNFi) in the treatment of rheumatoid arthritis has already been demonstrated in many studies. However, little is known on stopping TNFi in patients with stable low disease activity and the subsequent likelihood of exacerbation of rheumatoid arthritis. In addition, it is not clear whether TNFi can be restarted effectively and safely. Given the potential risk of serious side-effects and complications and the high costs of TNFi, it is important to examine whether patients in stable low disease activity can effectively stop TNFi. Methods: Multicenter open-label randomized study. Patients diagnosed with rheumatoid arthritis according to the ACR 1987 criteria were included. Patients had been treated with a TNFi for at least 1 year and with stable dose DMARDs for at least 6 months. All included patients had low disease activity in the 6 months prior to inclusion, with at least 2 DAS28 scores 3.2 in this period. Patients were randomized to discontinuing or continuing their current TNFi in a 2:1 ratio. DAS28 flare was defined as DAS28 3.2 with an increase 0.6 compared to the previous DAS28. Results: In total 817 patients from 47 centers were included: 531 patients (65%) in the discontinuation group and 286 patients (35%) in the continuation group. In the discontinuation group significantly more patients (30.8%) experienced a DAS28 flare within the first 6 months than in the continuation group (9.4%, P 0.0001). At 12 months, 46.9% of the patients experienced a DAS28 flare in the discontinuation group vs. 16.6% in the continuation group (P 0.0001). Median time to the first flare in the discontinuation group was 24 weeks. Survival analyses confirmed that flare free survival was significantly (P 0.0001) lower in the discontinuation group. The hazard ratio of DAS28 flare after discontinuing TNFi was 2.15 (95% CI: 1.59–2.91), after adjusting for disease duration, age, sex, and anti-CCP status. Conclusion: Flare-free discontinuation of TNF-inhibitors was possible in 53% of patients with stable low disease activity rheumatoid arthritis during a period of 12 months. Disclosure: H. E. Vonkeman, None; M. Ghiti Moghadam, None; M. A. F. J. van De Laar, None; P. M. ten Klooster, None; T. Jansen, Abbvie, 2, UCB, 2, Abbvie, 5, AstraZeneca, 5, UMS, 5, Janssen Pharmaceutica Product, L.P., 5, Menarini, 5, Novartis Pharmaceutical Corporation, 5, Pfizer Inc, 5, Roche Pharmaceuticals, 5, Abbvie, 8; P. van Riel, None.

Objective Fatigue is generally associated with low physical activity in patients with various chronic medical conditions. However, such an association has not been reported among patients with rheumatoid arthritis (RA). The objectives of this study were to investigate whether daily activity level is associated with fatigue in patients with RA, and whether pain, disability, coping, and/or cognition are associated with the level of daily activity. Methods Patients with RA who visited our outpatient clinic were recruited consecutively. Fatigue severity was measured using the Checklist Individual Strength (CIS20). Physical activity was measured for 14 consecutive days using an ankle-worn actometer. The daily activity level of each patient was calculated, and each patient was classified as having a low or high activity level with respect to the group average. Data were analyzed by linear regression. Results A total of 167 patients were included in the analysis; 25% had a low activity level and 75% had a high activity level. A regression analysis revealed that higher activity levels were associated with reduced fatigue (P = 0.008). The mean ± SD CIS fatigue score was 30.9 ± 12.3 among the patients with a high activity level and 35.7 ± 12.8 among the patients with a low activity level (P = 0.03). Pain, disability, coping, and cognition were not associated significantly with daily activity level. Conclusion Among patients with RA, a higher level of daily physical activity was associated with reduced levels of fatigue. This relationship was not explained by differences in sex, age, disease duration, pain, disability, or other fatigue-related factors.

Item does not contain fulltext Crystal arthritides such as gout can be detected by ultrasonography (US). This study reveals the performance of joint US (double contour sign (DCS), tophus (T), hyperechoic spots cq. "snow storm" (SS)) for diagnosing gout and calcium pyrophosphate dihydrate crystal deposition disease (CPPD) in patients with acute mono- or oligoarthritis (MOA). The gold standard is the presence of monosodium urate (MSU)/CPPD crystals. Fifty-four Dutch patients had an acute MOA. US was performed on the following six joints maximum: the arthritic joint, the contra lateral side, metatarsophalangeal (MTP)-1, and knees bilaterally in case of arthritis in one of these joints. In case of wrist/PIP/MCP-arthritis, the knees and MTP-1 were scanned. These were examined for DCS, T, SS, and intercartilage rim (CPPD). Synovial fluid was aspirated from the affected joint for MSU proof. Twenty-six of the 54 (48 %) patients with MOA had MSU-proven gout. Sensitivity of DCS and any US abnormality (DCS, T, SS) was 77 and 96 %, respectively. The positive likelihood ratio (LR+) for DCS and any ultrasonographic abnormality (USabn) was 3.08 and 2.99, respectively, and the LR- was 0.31 and 0.06, respectively. In MSU-proven gout patients where the affected joint is not MTP-1, MTP-1 still showed USabn in 42 % of the patients. None of the CPPD patients had an intercartilage rim. In dedicated hands, ultrasonography deserves a place early in a screening algorithm of MOA patients, particularly if specificity is high enough to make punctures abundant or when microscopy is not available. In 86 % of the MSU-proven gout patients, the DCS is not present in another joint other than the affected or MTP-1 joint.

Objective Treat-to-target (T2T) leads to improved clinical outcomes in early rheumatoid arthritis (RA). The question is whether these results sustain in the long term. Our objective was to investigate the 3-year results of a protocolized T2T strategy in daily clinical practice. Methods In the Dutch Rheumatoid Arthritis Monitoring remission induction cohort, patients newly diagnosed with RA were treated according to a T2T strategy aimed at remission (Disease Activity Score in 28 joints [DAS28]

Objective Fatigue and pain are important symptoms for patients with rheumatoid arthritis (RA), but their temporal association is unknown. Therefore, the objective of this study was to investigate the longitudinal relationship between fatigue and pain in patients with RA using time-lag models. Methods Consecutive RA outpatients (n = 228) were enrolled for this 1-year study. Fatigue was assessed monthly with the Checklist Individual Strength (CIS; range 8–56) and pain was assessed monthly with the bodily pain subscale (inverted, range 0–100) of the Short Form 36. The association between monthly changes in fatigue and pain was analyzed using longitudinal regression (mixed models), using the same months and with a 1-month time lag. Results A total of 198 patients were included in the analyses. At baseline, the mean ± SD pain score was 35.23 ± 19.82 and the mean ± SD CIS fatigue score was 31.0 ± 12.4. Severe fatigue at baseline (CIS score ≥35) was present in 42% of the patients. The mean ± SD patient-averaged CIS fatigue score over 1 year was 30.9 ± 6.0 and the mean ± SD patient-averaged pain score over 1 year was 36.4 ± 18.3. The longitudinal regression analysis showed a significant positive relationship between fatigue and pain during the same month (β = 2.04; 95% confidence interval 1.82, 2.27). The models using a time lag showed no significant association between changes in pain and changes in fatigue. Conclusion In established RA, pain and fatigue show monthly fluctuations that are synchronous rather than showing a temporal relationship with a time lag; within this timeframe, the results do not indicate that one precedes the other.

Contains fulltext : 172822.pdf (Publisher’s version ) (Open Access) BACKGROUND: Treat to target (T2T) is widely accepted as the standard of care for patients with rheumatoid arthritis (RA) and has been shown to be more effective than traditional routine care. The objective of this study was to compare the effectiveness of two T2T strategies in patients with early RA: a step-up approach starting with methotrexate (MTX) monotherapy (cohort I) versus an initial disease-modifying antirheumatic drug combination approach (cohort II). METHODS: A total of 128 patients from cohort II were case-control-matched with 128 patients from cohort I on gender, age, and baseline disease activity. Twelve-month follow-up data were available for 121 patients in both cohorts. The primary outcome was the proportion of patients having reached at least one 28-joint Disease Activity Score (DAS28) score

Background Itch and pain are common symptoms in skin disease. It has been suggested that negative emotions may play a role in itch and pain. To date, however, the role of emotions has only been studied for pain in experimental studies, not yet for itch. Objectives To investigate the effects of negative and positive emotions on the sensitivity to itch and pain. Methods Film fragments were used to induce a negative or positive emotional state in healthy women. Itch and pain were induced using the following somatosensory stimuli: electrical stimulation, histamine iontophoresis and the cold pressor test. Results Results showed that the scores for itch and pain evoked by histamine and the cold pressor test, respectively, were significantly higher in the negative than in the positive emotion condition, whereas tolerance thresholds to electrical stimulation and the cold pressor test, and stimulus unpleasantness scores did not differ between the two conditions. Conclusions These findings for the first time indicate in an experimental design that emotions play a role in sensitivity to somatosensory sensations of both itch and pain. Itch is a common symptom in patients with skin disease. Approximately 50% of patients with a skin disease suffer from itch on a chronic basis. 1 The sensation of itch is part of the body’s defence system and acts as a warning signal for potential threat to the skin. It is well known that itch has many similarities to pain. 2,3 Both sensations are part of the somatosensory system, informing one about objects in the external environment. Moreover, itch and pain are also nociceptive

Item does not contain fulltext OBJECTIVE: Insufficient data are available on the efficacy of combined conservative interventions recommended by treatment guidelines for knee/hip osteoarthritis (OA). The aims of this observational cohort study were (i) to estimate the results of an evidence-based 12-week tailored multimodal conservative treatment protocol for patients with knee/hip OA and (ii) to identify predictors for response. METHODS: After obtaining data on previous OA-related interventions, multimodal treatment was offered to patients with knee and/or hip OA at a specialized outpatient clinic. Treatment with analgesics was tailored using a numeric rating scale (NRS) for pain, aiming for NRS

Objectives: The aim of this study was to explore whether Bayesian reasoning can be applied to therapeutic questions in a way that is similar to its application in diagnostics.Methods: A clinically relevant, therapeutic question was formulated in accordance with Bayesian reasoning for the clinical management of patients with newly diagnosed rheumatoid arthritis (RA). Prior probability estimates of response to drug treatment (methotrexate, MTX) were obtained from the literature. As a marker of treatment response, changes in the Health Assessment Questionnaire (HAQ) scores were assessed after three months of treatment. Likelihood ratios for this marker were calculated on the basis of data from a clinical registry, using changes in the Disease Activity Score (DAS) as gold standard. Using Bayes’ theorem, prior probability and likelihood ratios were combined to estimate posterior probabilities of treatment response in individual patients.Results: On the basis of the literature, the prior probability of response of RA patients to MTX was estimated 45 percent. At 3 months follow-up, this probability increased to 80 percent or decreased to 23 percent, depending on the changes that were observed in Health Assessment Questionnaire scores.Conclusions: Bayesian reasoning can be applied to therapeutic issues in a way that is conceptually fully compatible with its use in diagnostics. As such, it can be used to bridge the gap between aggregate data and individual patient management.

Contains fulltext : 88603.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To describe the frequency and effectiveness of dose increase of adalimumab, etanercept, and infliximab in the treatment of rheumatoid arthritis (RA) in daily clinical practice. METHODS: All RA patients with a dose increase of tumor necrosis factor (TNF)-blocking therapy between January 1997 and January 2008 were selected from a register including data from RA patients starting a first TNF-blocking agent (the Dutch Rheumatoid Arthritis Monitoring registry). The primary outcome was change in Disease Activity Score in 28 joints (DAS28) at 3 months after dose increase. Secondary outcomes were the change in DAS28 at 6 months after dose increase, the European League Against Rheumatism response rates, and the percentages of patients reaching a DAS28 of

Objective.Toll-like receptors (TLR) have been implicated in the pathogenesis of arthritis. We investigated the role of functional variants of TLR in the disease phenotype and severity of rheumatoid arthritis (RA).Methods.All patients from a longterm observational inception cohort (n = 319) were genotyped for 22 single-nucleotide polymorphisms (SNP) in TLR2, 3, 4, 5, 7, 8, and 9 using multiplex assays. Clinical characteristics including sex, age at disease onset, rheumatoid factor (RF), and shared epitope positivity and disease activity score and radiological progression were taken into account. Genotypes were analyzed for association with Disease Activity Scores (DAS28) and joint damage (Rau scores) at 3 and 6 years.Results.After Bonferroni correction, there was a moderate association between RF positivity and TLR8-rs5741883. No other TLR variant was significantly associated with any RA clinical characteristics.Conclusion.Using a large inception cohort and strict statistical evaluation, we could not identify an association between functional TLR variants and RA phenotype and disease severity. This suggests the functional TLR variants do not play a major role in RA phenotype and disease severity.

Contains fulltext : 80105.pdf (Publisher’s version ) (Closed access) OBJECTIVE: High-density lipoprotein (HDL) antiatherogenic functions seem to be diminished during inflammatory conditions such as rheumatoid arthritis (RA). The aim of this study was to investigate the effects of tumour necrosis factor (TNF) inhibition on the antioxidative capacity of HDL in RA. METHODS: Plasma lipids and paraoxonase (PON-1) activity were investigated in 45 RA patients, before and during 6 months of anti-TNF therapy. In addition, HDL was isolated and tested for its ability to inhibit copper-induced oxidation of low-density lipoprotein in vitro. RESULTS: Plasma HDL concentrations did not change considerably after 6 months of therapy. However, stable increases of PON-1 activities were observed throughout the same period (p

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease. In the majority of patients the course is progressive and leads to destruction of joints, functional disability, reduced quality of life and increased morbidity and mortality. Advances in treatment for RA have been associated with an improvement in the health status of patients with RA in recent years.1 While the management of RA varies widely across Europe,2 the underlying pathophysiology does not differ between countries. A cross-sectional comparison of patients with RA in 15 different countries (largely European) revealed great variation in the drug management of patients with RA, including the delay in starting a disease-modifying antirheumatic drug (DMARD) ranging from 12 months, use of methotrexate ( 40% in France and Ireland vs.

Contains fulltext : 80996.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To validate and compare the definition of the Disease Activity Score 28 based on C-reactive protein (DAS28 (CRP)) to the definition based on erythrocyte sedimentation rate (ESR). METHODS: Data were analysed from two randomised, double-blind, placebo-controlled trials of abatacept of 6-month and 12-month duration in patients with rheumatoid arthritis. European League Against Rheumatism (EULAR) response criteria and the proportion of patients in remission (DAS28

Item does not contain fulltext OBJECTIVE: Chemokine (C-X-C motif) ligand 16 (CXCL16) is secreted by macrophages and dendritic cells (DCs) to attract memory type T cells. CXCL16 expression is increased in arthritic joints of patients with rheumatoid arthritis (RA) and a role for CXCL16 has been suggested in the pathogenesis of RA. To date, little is known about the regulation of CXCL16 on monocytes/macrophages and DCs. The aim of this study was to elucidate how CXCL16 expression is regulated in healthy donors and patients with RA. METHODS: CD14+cells were isolated from the peripheral blood or synovial fluid of patients with RA and healthy controls, differentiated into different types of dendritic cells or macrophages and stimulated with various cytokines or lipopolysaccharide (LPS). Cell surface proteins, including surface CXCL16, were measured by flow cytometry and soluble CXCL16 was measured by ELISA. RESULTS: Distinct types of dendritic cells constitutively express and secrete CXCL16, which is not affected by maturation. Monocytes rapidly upregulate membrane-bound CXCL16 expression and release soluble CXCL16 upon culture. CXCL16 expression by monocytes is transiently inhibited by the Toll-like receptor (TLR)4 ligand LPS. Th2 type cytokines inhibit soluble CXCL16, whereas T helper (Th)1 cell stimulus enhances its release. In RA monocytes/macrophages, neither CXCL16 expression, nor CXCL16 regulation is different from healthy controls. CONCLUSIONS: Culture of monocytes is the main trigger for CXCL16 surface expression in vitro, which is not altered in RA. Together our data suggest that the increased CXCL16 expression in patients with RA is likely to be caused by increased influx of monocytes rather than intrinsic differences in CXCL16 regulation.

Contains fulltext : 70888.pdf (Publisher’s version ) (Closed access) OBJECTIVES: In clinical trials only a small subset of patients with rheumatoid arthritis (RA) benefits from higher than standard dose of infliximab (>3 mg/kg/8 weeks). However, dose escalation of infliximab is frequently applied in clinical practice. Individual adjustment of infliximab treatment based on actual disease activity, instead of subjective clinical judgement, could prevent possible unwarranted dose escalation. METHODS: The infliximab dose of all patients with RA treated at our centre was decreased from 5 mg/kg to 3 mg/kg, leaving dosing intervals unaltered. Subsequently patients were followed for at least three infusions. At every visit, 28-joint Disease Activity Score (DAS28), infliximab serum trough levels and anti-infliximab antibody levels were assessed. Inversed European League Against Rheumatism (EULAR) criteria (flare criteria) were used as the endpoint. RESULTS: A total of 18 patients were included in the study. Mean (SD) DAS28 scores before dose reduction and after first and second low dose were 3.2 (1.2), 3.2 (1.8) and 3.3 (1.2), respectively (values not significant). One patient (6%, 95% CI 0% to 17%) developed a persistent flare that subsided after increasing infliximab doses and one patient stopped infliximab because of a lupus-like reaction. In all other patients (n=16) lowering infliximab resulted in unaltered disease activity. Infliximab levels showed that most patients had either low- (5 mg/litre) serum trough levels. Anti-infliximab antibodies were detected in four patients. CONCLUSION: Infliximab dosages of 5 mg/kg can be lowered in the majority of patients with RA using DAS28-guided dose titration without increase of disease activity. Lowering the dose of infliximab should be considered in every patient receiving higher doses infliximab.

Contains fulltext : 71178.pdf (Publisher’s version ) (Closed access) OBJECTIVE: We recently showed, using a candidate gene approach in a case-control association study, that a 65-kb block encompassing tumor necrosis factor receptor-associated factor 1 (TRAF1) and C5 is strongly associated with rheumatoid arthritis (RA). Compared with case-control association studies, family-based studies have the added advantage of controlling potential differences in population structure and are not likely to be hampered by variation in population allele frequencies, as is seen for many genetic polymorphisms, including the TRAF1/C5 locus. The aim of this study was to confirm this association in populations of European origin by using a family-based approach. METHODS: A total of 1,356 western European white individuals from 452 "trio" families were genotyped for the rs10818488 polymorphism, using the TaqMan allelic discrimination assay. RESULTS: We observed evidence for association, demonstrating departure from Mendel's law, with an overtransmission of the rs10818488 A allele (A = 55%; P = 0.036). By taking into consideration parental phenotypes, we also observed an increased A allele frequency in affected versus unaffected parents (A = 64%; combined P = 0.015). Individuals carrying the A allele had a 1.2-fold increased risk of developing RA (allelic odds ratio 1.24, 95% confidence interval 1.04-1.50). CONCLUSION: Using a family-based study that is robust against population stratification, we provide evidence for the association of the TRAF1/C5 rs10818488 A allele and RA in populations of European descent, further substantiating our previous findings. Future functional studies should yield insight into the biologic relevance of this locus to the pathways involved in RA.

Contains fulltext : 71068.pdf (Publisher’s version ) (Closed access) BACKGROUND: The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms, such as pain-avoidance and pain-persistence patterns, has been proposed to underlie varying treatment outcomes in patients with fibromyalgia (FM). PURPOSE: To investigate the validity of a screening instrument to discriminate between pain-persistence and pain-avoidance patterns in FM. METHOD: In a three-part study, a self-reported screening instrument that assesses pain-avoidance behavior was used to distinguish patients with pain-persistence and pain-avoidance patterns. The resultant groups were compared with regard to several pain-related cognitive-behavioral factors, performance on a physical fitness test, and with regard to the judgments of trained therapists based on a semi-structured interview. RESULTS: The validity of the screening instrument to distinguish between pain-avoidance and pain-persistence patterns was supported by other validated self-report questionnaires for pain-related cognitive-behavioral factors, physical exercise tests, as well as by a high correspondence with blinded therapist judgment after intake assessments. CONCLUSION: These findings suggest that a short self-report screening instrument can be used to distinguish between pain-avoidance and pain-persistence patterns within the heterogeneous population of FM patients, which offers promising possibilities to improve treatment efficacy by tailoring treatment to specific patient patterns.

Contains fulltext : 70343.pdf (Publisher’s version ) (Closed access) OBJECTIVES: Everolimus, a proliferation signal inhibitor with disease-modifying properties, may be useful in treating rheumatoid arthritis (RA). This proof-of-concept study assessed efficacy and safety of everolimus in combination with methotrexate (MTX) in patients with refractory RA. METHODS: A multi-centre, randomised, double-blind, placebo-controlled trial was performed in 121 patients with active RA receiving MTX. Patients were randomised to receive everolimus (6 mg/day) or placebo. The primary endpoint was the American College of Rheumatology criteria for a 20% improvement in measures of disease activity (ACR20) at 12 weeks. RESULTS: There was a rapid onset of action and at 12 weeks the ACR20 response rate was significantly higher in the everolimus group (36.1%) than in the placebo group (16.7%; p = 0.022). Improvements from baseline in tender and swollen joint counts, patient's assessment of pain, and patient's and physician's global assessment of disease activity were significantly greater after treatment with everolimus. The most common adverse events (AEs) in the everolimus group were gastrointestinal (52.5% vs 31.7% in the placebo group), skin (29.5% vs 8.3%), and nervous system disorders (21.3% vs 10.0%); AEs leading to treatment discontinuation were reported for 16.4% and 10.0% of patients, respectively. Changes in haematological parameters, liver function tests, and lipid levels occurred more frequently with everolimus compared to placebo, but were mild and reversible. CONCLUSIONS: The study indicates that everolimus plus MTX provides clinical benefit with an acceptable safety and tolerability profile. It may offer a new treatment option in RA patients with inadequate response to MTX.

Contains fulltext : 71509.pdf (Publisher’s version ) (Closed access) OBJECTIVES: This study assessed the relative efficacy of etanercept (ETN) or etanercept and methotrexate (ETN+MTX) for patients with rheumatoid arthritis (RA) who had an unsatisfactory response to MTX, using patient-reported outcomes (PROs) of function, pain, general health, disease activity and morning stiffness. METHODS: The PROs were secondary assessments in a 16-week, prospective, randomised, parallel-group study conducted at 60 European centres. Patients with RA were randomly assigned either to monotherapy with ETN or combination therapy with ETN+MTX. PRO instruments administered included the Stanford Health Assessment Questionnaire, the pain visual analogue scale, the EuroQoL assessment of current health state (EQ-5D), the EQ-5D visual analogue scale, a patient global assessment of disease activity and an assessment of morning stiffness. Treatment groups were compared by percentage of patients within clinically meaningful categories. The primary endpoint for all PROs was comparison of mean improvement from baseline to week 16 between ETN and ETN+MTX groups. RESULTS: Three hundred and fifteen patients were randomised to ETN or ETN+MTX. Both treatment arms had similar Health Assessment Questionnaire Disability Index DI, EQ-5D, patient global assessment of disease activity, pain or morning stiffness scores and improvement from baseline to week 16. CONCLUSIONS: For patients with active RA and intolerance or unsatisfactory response to MTX, substituting ETN for MTX and adding ETN to MTX are both effective ways of reducing disability, pain, disease activity, morning stiffness, and improving general health.