Approaches to optimising access to NICE-approved biologic anti-TNFs for patients with rheumatoid arthritis with moderately active disease.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic inflammatory disease that is associated with joint pain and stiffness. Biologics represent some of the most effective treatments for RA, but previous guidance from the National Institute for Health and Care Excellence (NICE) has limited their use to patients with severely active disease. This has meant patients with moderately active RA have been treated as if they have an acceptable disease state, despite many cases where the inflammation has a major impact on joint damage, mobility, pain and quality of life. However, recent guideline changes (NICE TA715) have approved the use of three biologics - adalimumab, etanercept and infliximab - for the treatment of moderately active RA. MAIN BODY: In response to these changes, we have held discussions with medical teams from across the UK to consider the main implications for implementation of these new recommendations, as well as any differences in approach that may exist at a local level. Several key challenges were identified. These included establishing methods of educating both physicians and patients concerning the new availability of the biologic treatments, with suggestions of various organisations that could be approached to circulate informative material. Identifying which patients with moderately active RA stand to benefit was another discussion topic. Relying solely on scoring systems like Disease Activity Score in 28 Joints (DAS28) was acknowledged to have limitations, and alternative complementary approaches such as ultrasound, as well as assessing a patient's co-morbidities, could also be useful tools in determining those who could benefit from biologics. An additional challenge for the process of patient identification has been the increase in the use of telemedicine consultations in response to the coronavirus disease 2019 (COVID-19) pandemic. More use of patient-reported outcomes was raised as one possible solution, and the importance of maintaining up-to-date databases on patient disease scores and treatment history was also stressed. CONCLUSION: While challenges exist in education and identifying patients who may benefit from the use of biologics, the NICE TA715 recommendations hold great potential in addressing an unmet need for the treatment of moderate RA.

Isolated deafness as a presenting symptom in granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA) is a rare small vessel vasculitis commonly affecting the lungs, upper respiratory tract and kidneys. It is an idiopathic condition but likely due to an autoimmune process, resulting in granulomatous lesions and glomerulonephritis. Upper respiratory tract involvement is commonly seen in patients with GPA. Our case is that of an elderly lady (Mrs C) presenting with sudden onset bilateral deafness. She was later found to have extensive lower respiratory tract involvement although she was never particularly symptomatic of this. The presentation suggested a single organ disorder and led to some initial diagnostic uncertainty. Imaging and laboratory investigations eventually led to the diagnosis and she was successfully treated with corticosteroids and rituximab with good response and hearing improvement. This case highlights the importance of early diagnosis in a rapidly progressive disease which undetected can lead to catastrophic end organ damage and disability.