Estimation of the burden of shielding among a cross-section of patients attending rheumatology clinics with SLE-data from the BSR audit of systemic lupus erythematosus.

OBJECTIVES: We aimed to estimate what proportion of people with SLE attending UK rheumatology clinics would be categorized as being at high risk from coronavirus disease 2019 (COVID-19) and therefore asked to shield, and explore what implications this has for rheumatology clinical practice. METHODS: We used data from the British Society for Rheumatology multicentre audit of SLE, which included a large, representative cross-sectional sample of patients attending UK Rheumatology clinics with SLE. We calculated who would receive shielding advice using the British Society for Rheumatology's risk stratification guidance and accompanying scoring grid, and assessed whether ethnicity and history of nephritis were over-represented in the shielding group. RESULTS: The audit included 1003 patients from 51 centres across all 4 nations of the UK. Overall 344 (34.3%) patients had a shielding score ≥3 and would have been advised to shield. People with previous or current LN were 2.6 (1.9-3.4) times more likely to be in the shielding group than people with no previous LN (P < 0.001). Ethnicity was not evenly distributed between the groups (chi-squared P < 0.001). Compared with White people, people of Black ethnicity were 1.9 (1.3-2.8) and Asian 1.9 (1.3-2.7) times more likely to be in the shielding group. Increased risk persisted after controlling for LN. CONCLUSION: Our study demonstrates the large number of people with SLE who are likely to be shielding. Implications for clinical practice include considering communication across language and cultural differences, and ways to conduct renal assessment including urinalysis, during telephone and video consultations for patients who are shielding.

BSR guideline on the management of adults with systemic lupus erythematosus (SLE) 2018: baseline multi-centre audit in the UK.

OBJECTIVES: To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published BSR guideline for the management of adults with SLE, the NICE technology appraisal for belimumab, and NHS England's clinical commissioning policy for rituximab. METHODS: SLE cases attending outpatient clinics during any 4-week period between February and June 2018 were retrospectively audited to assess care at the preceding visit. The effect of clinical environment (general vs dedicated CTD/vasculitis clinic and specialized vs non-specialized centre) were tested. Bonferroni's correction was applied to the significance level. RESULTS: Fifty-one units participated. We audited 1021 episodes of care in 1003 patients (median age 48 years, 74% diagnosed >5 years ago). Despite this disease duration, 286 (28.5%) patients had active disease. Overall in 497 (49%) clinic visits, it was recorded that the patient was receiving prednisolone, including in 28.5% of visits where disease was assessed as inactive. Low documented compliance (<60% clinic visits) was identified for audit standards relating to formal disease-activity assessment, reduction of drug-related toxicity and protection against comorbidities and damage. Compared with general clinics, dedicated clinics had higher compliance with standards for appropriate urine protein quantification (85.1% vs 78.1%, P ≤ 0.001). Specialized centres had higher compliance with BILAG Biologics Register recruitment (89.4% vs 44.4%, P ≤ 0.001) and blood pressure recording (95.3% vs 84.1%). CONCLUSIONS: This audit highlights significant unmet need for better disease control and reduction in corticosteroid toxicity and is an opportunity to improve compliance with national guidelines. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery model.

The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice.

BACKGROUND: Biologic drugs are expensive treatments used in rheumatoid arthritis (RA). Switching among them is common practice in patients who have had an inadequate response or intolerable adverse events. The National Institute of Health and Clinical Excellence (NICE) UK, which aims to curtail postcode prescribing, has provided guidance on the sequential prescription of these drugs. This study sought to evaluate the extent to which rheumatology centres across the Midlands were complying with NICE guidance on the switching of biologic drugs in RA, as well as analyse the various prescribing patterns of these drugs. METHODS: Data was collected via a web-based tool on RA patients who had undergone at least one switch of a biologic drug during 2011. The standards specified in NICE technology appraisals (TA130, TA186, TA195, TA198, and TA225) were used to assess compliance with NICE guidance. Descriptive statistical analysis was performed. RESULTS: There were 335 biologic drug switches in 317 patients. The most common reason given for switching to a drug was NICE guidelines (242, 72.2%), followed by Physician's choice (122, 33.4%). Lack of effect was the most common reason for discontinuing a drug (224, 67%). For patients on Rituximab, Methotrexate was used in 133 switches (76.9% of the time). Overall NICE compliance for all units was 65% (range 50 to 100%), with anti-TNFα to anti-TNFα switches for inefficacy making up the majority of non-compliant switches. CONCLUSION: This study draws attention to the enigma and disparity of commissioning and prescribing of biologic drugs in RA. Currently the evidence would not support switching of a biologic drug for non-clinical purposes such as economic pressures. Flexibility in prescribing should be encouraged: biologic therapy should be individualised based on the mode of action and likely tolerability of these drugs. Further work should focus on the evidence for using particular sequences of biologic drugs.

To what extent is NICE guidance on the management of rheumatoid arthritis in adults being implemented in clinical practice? A regional survey.

Rheumatoid arthritis (RA) is a chronic disease associated with significant morbidity. The 2009 NICE guidance advises on the management of patients with RA. In this study, we undertook a survey to assess the implementation of the guidance into practice across the Midlands. In total, 19 rheumatology units participated, of which nine have designated early inflammatory arthritis clinics (EIAC). Data for 311 patients with RA attending clinics were collected during a two week period. The median time from symptom onset to first visit was four months. Of the patients, 95.6% were seen within 12 weeks of referral. Of those seen in EIAC, 75.9% had erosions documented on X-rays versus 49.4% of non-EIAC patients. In addition, 57.9% of patients were offered combination disease-modifying antirheumatic drugs (DMARD) therapy in EIAC, versus 30.4% in non-EIAC units. Monthly disease-activity scores were calculated more in patients attending EIAC than non-EIAC units (51.1% versus 25.4%). Based on our results, there is significant regional variation in implementation of the NICE guidance. In addition, patients with RA attending EIACs are more likely to receive a treat-to-target approach.

Compliance with NICE guidance on the use of anti-TNFalpha agents in ankylosing spondylitis: an east and west Midlands regional audit.

Here we report on an audit performed to examine compliance with National Institute for Health and Clinical Excellence (NICE) guidelines for the use of anti-tumour necrosis factor alpha (anti-TNFalpha) in treating patients with ankylosing spondylitis (AS). Data from 17 rheumatology centres across the Midlands were collected prospectively from patients with AS attending outpatient clinics and retrospectively in patients receiving anti-TNFalpha but not attending outpatient clinics during the audit. In total, 80% of the 416 patients for whom data were collected were male. Of the 238 patients recruited prospectively, 41% were receiving anti-TNFalpha. Reviewing all patients on anti-TNFalpha (N=275), pre-treatment assessments 12 weeks apart were documented in 55% of patients. After anti-TNFalpha treatment had started, regular 12-weekly assessments occurred in 46% of patients. Therefore, compliance with NICE guidance was found to vary among centres. Based on our audit, clinical capacity, and clinical or patient choice might be influencing the suboptimal adherence seen in assessment timing suggested by NICE guidelines relating to the use of anti-TNFalpha in treating patients with AS.

A 24-hour study to investigate persistent chemical exposures associated with clandestine methamphetamine laboratories.

The clandestine manufacture of methamphetamine continues to be a concern across the United States. Although the exposures associated with the actual production process have been evaluated, the persistence of those exposures in a residential setting have not been investigated. This study was designed to document the contamination associated with two red phosphorous methamphetamine "cooks" conducted in a residence and the associated exposures up to 24 hours after the cook. The two cooks were conducted on the first day of the study, and exposures associated with different occupant activity levels were measured the following day. Airborne methamphetamine levels during the cook ranged from 520 microg/m(3) to 760 microg/m(3). On Day 2, airborne levels of methamphetamine ranged from 70 microg/m(3) to 210 microg/m(3) and increased with moderate to high activity levels within the residence. The majority of the methamphetamine measured during both days had a particle size of less than 1 mum, suggesting that the methamphetamine is formed as a condensation aerosol and is readily resuspended from contaminated surfaces. Significant methamphetamine contamination was found in the carpeting and likely was associated with the elevated levels of methamphetamine during activity. Levels of hydrogen chloride and iodine were also detected on Day 2 of the project although at very low levels. The study concluded that exposures may still present a significant inhalation exposure well after the actual cook.

An assessment of back pain and the prevalence of sacroiliitis in sarcoidosis.

OBJECTIVES: Sarcoidosis is a chronic granulomatous multisystem disease in which arthritis is relatively common. Arthritis of the sacroiliac joints (sacroiliitis) has been described in sarcoidosis but is thought to be rare. The objective of this study was to determine the prevalence of sacroiliitis in a secondary-care population of patients with sarcoidosis. METHODS: Patients attending a specialist secondary-care sarcoidosis clinic underwent evaluation of spinal symptoms using a standard back pain questionnaire, examination of spinal mobility, and laboratory measurements of erythrocyte sedimentation rate, C-reactive protein, serum angiotensin-converting enzyme, and neopterin/creatinine ratio. Tissue typing for the presence of the human leukocyte antigen (HLA)-B27 allele was undertaken. Radiographs of the sacroiliac joints were obtained in each patient and reviewed independently by two observers; a further observer reviewed disputed radiographs. RESULTS: Sixty-one patients completed the assessments (80.3% of all patients invited to participate). Forty-nine of 61 patients (80.3%) reported having back pain at some point in their lives. Thirty-one of 61 patients (50.8%) had a score on the back pain questionnaire suggestive of inflammatory spinal disease, but only 3 of these patients had erosive damage of the sacroiliac joints on radiography indicating sacroiliitis. One further patient had erosive damage on radiography, making a total of four individuals with evidence of sacroiliitis, a prevalence of 6.6%. Four patients (one patient with sacroiliitis) were positive for HLA-B27. The back pain questionnaire had a sensitivity of 75% and a specificity of 51% for sacroiliitis in this population. CONCLUSION: The prevalence of spondyloarthropathy in the normal population has been estimated to be 1.9%. In the sarcoid population studied the prevalence was 6.6% suggesting a possible association between these two conditions. The standard back pain questionnaire for the identification of inflammatory spinal disease had a low sensitivity and specificity in this population.