Background Early diagnosis and early treatment with DMARDs lead to better outcomes in rheumatoid arthritis (RA) (1,2). The 2010 ACR/EULAR criteria for RA were developed for early classification (3) and have good sensitivity, lower specificity and overall moderate accuracy. Their usefulness to lead treatment selection has not been investigated yet. Objectives To compare clinical remission (CR) rates in patients with early polyarthritis in which the decision to start methotrexate (MTX) was based on the 1987 ACR vs 2010 ACR/EULAR criteria, over the first 12 months follow up. Methods This is an observational non concurrent cohort study. Patients classified as RA or undifferentiated arthritis (UA) attending for the first time our early arthritis clinic (2005-2013) were eligible for inclusion. At baseline, before October 2010, patients classified as RA according to the 1987 criteria were treated with MTX (from 10 mg/wk up to 20 mg/wk), while patients with UA received hydroxychloroquine (HCQ) (1987 cohort). After October 2010, patients fulfilling the 2010 criteria received MTX (from 15 mg/wk up to 25mg/wk), while UA received HCQ (2010 cohort). Low-dose prednisone could be given according to clinician's decision. Patients were seen every 2 months in the first six months and every 3 afterwards; treatment was increased in order to achieve low disease activity (DAS28<3.2). CR (DAS28<2.6) was evaluated at every visit. Analyses were performed with a Cox proportional hazard regression analysis, and results presented as hazard ratios (HR) and 95% confidence intervals (CI). Results Out of 676 patients, 467 were included in the 1987 cohort and 209 in the 2010 cohort. There were no significant differences between the two cohorts in terms of age, gender, VAS pain, RF and ACPA positivity. Patients in the 2010 cohort had significantly fewer median (IQR) tender (4 (2-8) vs 5 (2-10), p=0.018) and swollen joints (4 (2-7) vs 6 (3-10), p<0.0001) over 28 joints, ESR (19 (10-34) vs 22 (13-39), p=0.007) and CRP (0.4 (0.3-1.2) vs 0.7 (0.31-2.09), p=0.001), mean (SD) DAS28 (4.44 (1.14) vs 4.74 (1.25), p=0.005) and median (IQR) HAQ (0.75 (0.375-1.25) vs 1 (0.5-1.625), p=0.0001). Comparing the two cohorts, the 2010 cohort was more likely to achieve CR even when the analysis was limited to patients who strictly followed the protocol or actually received MTX, both in crude and adjusted analyses (Tab1). Table 1 Crude HR (95% CI) Adjusted HR (95% CI)* ACR/EULAR 2010 vs ACR 1987 All subjects (N=676) 1.83 (1.50, 2.22) 1.73 (1.34, 2.22) Per protocol (N=413) 1.79 (1.39, 2.29) 1.49 (1.11, 2.02) MTX users (N=265) 1.96 (1.46, 2.64) 2.18 (1.14, 4.17) *Adjusted for age, gender, baseline DAS28, symptom duration, MTX dose, glucocorticoid use. Conclusions Patients with early arthritis in which the decision to start MTX is driven by the 2010 criteria achieve more often CR compared to those treated according to the 1987 criteria. Beside the limited diagnostic accuracy of the 2010 criteria, these results support their usefulness as trea...
BackgroundThe increased availability of modern imaging in clinical practice has led to its more extensive use. In the field of osteoarthritis (OA), recommendations on the use of imaging in clinical trials have been developed, but there has been less focus on routine clinical management.ObjectivesTo develop evidence-based recommendations for the use of imaging in the clinical management of OA.MethodsA task force convened by the European League Against Rheumatism including rheumatologists, radiologists, generalists, methodologists and patients from 9 countries developed recommendations based on both evidence obtained through systematic literature review (SLR) and expert opinion. The task force initially identified the areas of application of imaging in OA and developed research questions to drive the SLR. Imaging modalities included were conventional radiography, ultrasound, magnetic resonance imaging, computed tomography, radioisotope scan. Anatomical areas of interest were knee, hip, hand and foot. Based on the priorities identified by the task force, the role of imaging in making a diagnosis of OA and identifying OA features (including soft tissue, bone and cartilage involvement), in detecting alternative diagnoses, the impact of imaging on disease management, in defining prognosis (natural history of the disease and response to treatment), in the follow up of the disease and to guide treatment were addressed. Research evidence was searched systematically for each question and separately for each anatomic area using PubMed and Embase.ResultsThe systematic review retrieved 6858 references, after the assessment of 1317 full papers, 380 studies were included. The results of the systematic review were presented to the task force, and consensus recommendations derived. These cover areas such as (exact wording not included for brevity reasons): the lack of need for imaging in diagnosis of patients who present with usual OA symptoms; role of imaging in differential diagnosis; consideration of the challenges in using imaging for routine monitoring of OA where there is no change in clinical status; what should be the feasible first choice modality and what issues were relevant to how images were acquired; how anatomical site of OA may influence use and type of imaging; and the role of imaging and intra-articular injection. Significant gaps in the literature underpinned the recommendations for future research that were also developed.ConclusionsBased on the results of a SLR and expert opinion, recommendations on the use of imaging in the clinical management of OA were developed.Disclosure of InterestNone declared
Background:Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients with inflammatory arthritis. The growing attention to the CV risk characterizing patients with autoimmune inflammatory disease led EULAR to provide recommendations on CV risk management (1). To date, there are no data on the adherence to EULAR recommendation among Italian rheumatologists.Objectives:Our objective was to measure the level of awareness and the attitude to manage CV risk.Methods:Italian rheumatologists were invited to anonymously answer a web-based questionnaire designed by the steering committee of the Cardiovascualr and Obesity in Rheumatic Diseases (CORDIS) study group of the Italian Society of Rheumatology. The first part of the questionnaire concerned demographic information; the subsequent questions concerned the attitude to assess CV risk and the limitations for not assessing, the specific CV risks considered in the clinical practice and their management. Data are presented using standard summary statistics and were expressed as mean+/-standard deviation or median (interquartile range) according to variables’ distribution.Results:One thousand-three hundred rheumatologists (of whom 500 are under 40 and 100 over 70 years of age) have been invited by email to complete the survey. The questionnaire has been filled by 102 rheumatologists (7.85%) (53 females and 49 males) with a median age of 38 years (32-48) and a median of 4 (0-15) years of specialization. Most of the physician who answered the questionnaire works in University Hospitals (67/102; 65.7%), 22 out of 102 (21.6%) in non-academic Hospitals, and the remaining 12,7% in territorial outpatient clinics.When asked if they usually evaluate CV risk in patients with autoimmune rheumatic diseases, 67/102 (67.2%) answered positively, 18 no (17.6%) and 7 did not answer the question; 82% of those who routinely assess the CV do it by themselves. The barriers limiting the assessment of CV risk included: i) lack of time (79%); ii) complex management (12%); inadequate training (9%).As for the CV risk factors, lipid profile, hypertension and diabetes are assessed by most of the rheumatologists (90%, 89% and 88%, respectively), family history by 78% and body mass index by 75.3% and waist circumference only by 25% of those who completed the survey.Finally, only 18.6% stated that they manage by themselves CV risk in patients with autoimmune rheumatic diseases while 50% refer patients to other specialists and 23.4% to general practitioner.Conclusion:Despite the growing awareness on the CV risk characterizing patients with autoimmune rheumatic disease, about one third of young Italian rheumatologists does not strictly adhere to the EULAR recommendations on CV management, mostly due to insufficient time during the routine care visits.References:[1] Agca R et al. Ann Rheum Dis 2017; 76: 17-28.Disclosure of Interests:Francesca Romana Spinelli Grant/research support from: Pfizer, Speakers bureau: Lilly, BMS, Celgene, Fabio Cacciapaglia Speakers bureau: BMS; Roche; Pfizer; Abbvie, Fabiola Atzeni: None declared, Gianluca Erre: None declared, Andreina Manfredi: None declared, Elena Bartoloni Bocci: None declared, Matteo Piga: None declared, Garifallia Sakellariou Speakers bureau: Abbvie, Novartis, MSD, Ombretta Viapiana: None declared, Elisa Gremese Speakers bureau: Abbvie, BMS, Celgene, Jannsen, Lilly, MSD, Novartis, Pfizer, Sandoz, UCB
Background:According to guidelines, the use of steroid and/or hyaluronate (HA) intra-articular injections for knee osteoarthritis (KOA) is controversial. Heterogeneity of studies and difference in HAs characteristics does not allow to draw safe conclusions. One of the major concerns is the accuracy of the procedure as up to 1/3 of injections could miss joint space when performed blindly (1), negatively affecting the efficacy of HA that needs to be placed correctly in the joint spaceObjectives:The aim of our study was to evaluate the longterm efficacy of a novel association of a Cross-Linked Sodium Hyaluronate Combined With Triamcinolone Hexacetonide (SHCTH) in patients with KOA in a real life setting.Methods:We retrospectively evaluated the clinical and ultrasonographic (US) data of patients (pts) affected by symptomatic KOA with intra-articular injections of SHCTH (1 injection every 6 months). Pts with concomitant inflammatory arthropaties were excluded. US guidance was carried out with the “in plane” technique choosing either the lateral suprapatellar or midpatellar approach. All pts were evaluated for pain with a VAS 0-10 for pain at baseline and after 2 weeks, 1, 3, 6, 9 and 12 months, with the WOMAC questionnaire and with US, scoring joint effusion, synovial hypertrophy (SH) and power Doppler (PD) synovial signal. Due to the retrospective design, the WOMAC data were available as VAS or Likert scales; to allow comparability these values were standardized. Clinical and US variables at different time points were compared using the Wilcoxon rank sing test, the McNemar test or the paired samples t-test, depending on the variable.Results:49 knees (43 pts, median age 70.6 years, 24 women) were included in the study. Kellgren Lawrence grade was 1 for 5 knees, 2 for 10, 3 for 17 and 4 for 9. SHCTH was delivered correctly in the joint space in all patients as assessed by US check during the injection and no side effects occurred. Of the 49 knees, 28 had an available 6 months follow-up, while 21 completed the 12 months follow-up, with an attrition mostly related to the COVID 19 pandemic. A rapid and sustained statistically significant decrease of both VAS pain and the WOMAC subscales was observed. The reduction of pain was already significant at 2 weeks, probably thanks to the corticosteroid component. At US evaluation, effusion significantly decreased at all time points. Although SH scores also significantly decreased, the effect on the proportion of affected joints was not as relevant. The reduction of PD was significant until month 9. Detailed results are presented in Table 1.Conclusion:Our data show that US guided SHCTH injections provide a rapid and sustained clinical response in patients with symptomatic OA. Besides the effect on pain, the US data confirm the effect of the drug on the inflammation. US guidance guaranteed the correct placement of the product in all patients and eliminated the bias of wrong placement that may occur with blind injections, thus allowing to draw safe conclusions on the efficacy of SHCTH for the treatment of KOA.References:[1]Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993;307:1329–30.Table 1.Table 1. Clinical and US measures. p values refer to the comparison with baseline. WOMAC subscales were compared by paired samples t test. *hypothesis test not applicablebaseline2 weeks1 month3 months6 months9 months12 monthsVAS (median,IQR)6 (5-8)3 (1-4.25) p<0.00012 (0.5-3-5) p<0.00011.5 (0-3) p<0.00011.5 (0-4) p<0.00011 (0-2.75) p<0.00011 (0-3.25) p<0.0001WOMAC pain--p 0.028p 0.0004p 0.0036p 0.0096p 0.0064WOMAC stiffness--p 0.048p 0.040p 0.0388p<0.0001p 0.0083WOMAC function--p 0.043p 0.0005p 0.0014p 0.01p 0.007Effusion 0-3 (median,IQR)2 (1-2)-1 (0-1) p<0.00011 (0-1) p<0.00011 (0-1) p 0.00010 (0-1) p<0.00011 (0-1) p<0.0001Synovial Hypertrophy 0-3 (median,IQR)1 (1-2)-1 (1-1) p 0.0021 (1-1) p 0.00011 (1-1) p 0.00011 (0-1) p 0.00011 (0.5-1) p 0.0001PD 0-3 (median,IQR)0 (0-0)-0 (0-0) p 0.030 (0-0) p 0.030 (0-0) P 0.061 (0-1) p 0.010 (0-0) p 0.31Disclosure of Interests:None declared.
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