Development and testing of a bespoke cultural intervention to support healthcare professionals with patients from a diverse background.

OBJECTIVE: Development and test of a culturally sensitive intervention for rheumatology healthcare professionals (HCPs). METHODS: Using a before and after study design, fifteen HCPs were recruited to undertake the bespoke intervention from four NHS sites across England, in areas serving a diverse population. The intervention was evaluated using the validated outcomes: [1] Patient Reported Physician Cultural Competency (PRPCC); and [2] Patient Enablement Instrument (PEI), measuring patients' perceptions of their overall healthcare delivery. Additionally, HCPs completed the Capability COM-B questionnaire (C), Opportunity (O) and Motivation (M) to perform Behaviour (B), measuring behaviour change. RESULTS: 200 patients were recruited before HCPs undertook the intervention (cohort 1), and 200 were recruited after (cohort 2) from fifteen HCPs, after exclusions 178 patients remained in cohort 1 and 186 in cohort 2. Patients identifying as White in both recruited cohorts were 60% compared with 29% and 33% of patients (cohorts 1 and 2 respectively) who identified as of South Asian origin. After the intervention, the COM-B scores indicated HCPs felt more skilled and equipped for consultations. No significant differences were noted in the average overall cultural competency score between the two cohorts in White patients (57.3 vs 56.8, p= 0.8), however, in the South Asian cohort, there was a statistically significant improvement in mean scores (64.1 vs 56.7, p= 0.014). Overall, the enablement score also showed a statistically significant improvement following intervention (7.3 vs 4.3, p< 0.001) in the White patients; and in the South Asian patients (8.0 vs 2.2, p< 0.001). CONCLUSION: This novel study provides evidence for improving cultural competency and patient enablement in rheumatology settings.

Emerging public health challenge in UK: perception and belief on increased COVID19 death among BAME healthcare workers.

BACKGROUND: Coronavirus infection Disease 19 impacted every part of the world and routine life. Recent report from the Office of national statistics in UK reported disproportionate death among Black Asian and minority ethnic (BAME) population. NHS is heavily relied on the BAME work force both in front line and in the community. We attempted to explore the beliefs and perception about reported worrying issue among BAME health work force in a Diverse city of Leicester. METHODS: This is a cross-sectional survey using 20 questions in an electronic format. The target population was identified through Leicester Asian Doctors Society and Leicester Asian Nurses Society. The questionnaire was then distributed electronically to the members. Survey questionnaire was accessed by 372, incomplete response (172) were excluded and 200 completed responses were analysed. RESULTS: Majority of BAME workforce are routinely involved in front line duties. More than 70% were anxious about their role during this pandemic. The Personal Protective Equipment (PPE) supply was adequate, and the support received from the local healthcare providers was more than satisfactory. The work force perceived co-morbidity, lack of PPE and testing were one of the few reasons for increased death in BAME. BAME group felt adequate provision of PPE, increased testing and improving mental health well-being is required to alleviate concerns and improve BAME working life in NHS. CONCLUSION: BAME workforce are routinely involved in front line work and current anxiety level is very high. Adequate provision of mental health support with clear risk stratification for return to work is required urgently.

Concurrent Joint Hypermobility Syndrome and Spondyloarthropathy: A New Spondyloarthropathy Subgroup With a Less Severe Disease Phenotype?

BACKGROUND: The coexistence of joint hypermobility syndrome (JHS) and spondyloarthropathy (SpA) presents a challenging clinical conundrum due to the contradictory clinical signs that may be present. Classic features such as restricted spinal movement or early morning back stiffness may not be present. Timely diagnosis and appropriate management of these patients are difficult as they tend to have lower scores on validated objective measures. METHODS: We performed a medical records review study to identify patients with both JHS and SpA who had presented to the Leicester Spondyloarthropathy clinic. Patients were diagnosed with axial SpA if they met the Assessment of SpondyloArthritis international Society classification criteria. Their imaging was reviewed by a consultant musculoskeletal radiologist. RESULTS: Four cases were identified from the patient database (female; average age, 37.5 years). All patients presented with lower back pain or sacroiliac joint pain but preserved spinal movement with a negative Schober's test. Two had a history of symptoms for more than 10 years. All had a Beighton score of greater than 6. Three of the patients were HLA positive, and 3 had a positive family history. All patients thus far have had their symptoms adequately controlled on nonsteroidal anti-inflammatory drugs and physiotherapy. CONCLUSIONS: The coexistence of JHS and SpA is rare but important to recognize. These patients are difficult to diagnose as they may present late because of preserved spinal movements. It is unclear whether the preserved flexibility masks the true extent of disease or whether clinically they represent a less severe disease phenotype.

Differences and similarities in rheumatology specialty training programmes across European countries.

OBJECTIVES: To analyse the similarities and discrepancies between the official rheumatology specialty training programmes across Europe. METHODS: A steering committee defined the main aspects of training to be assessed. In 2013, the rheumatology official training programmes were reviewed for each of the European League Against Rheumatism (EULAR) countries and two local physicians independently extracted data on the structure of training, included competencies and assessments performed. Analyses were descriptive. RESULTS: 41 of the 45 EULAR countries currently provide specialist training in rheumatology; in the remaining four rheumatologists are trained abroad. 36 (88%) had a single national curriculum, one country had two national curricula and four had only local or university-specific curricula. The mean length of training programmes in rheumatology was 45 (SD 19) months, ranging between 3 and 72 months. General internal medicine training was mandatory in 40 (98%) countries, and was performed prior to and/or during the rheumatology training programme (mean length: 33 (19) months). 33 (80%) countries had a formal final examination. CONCLUSIONS: Most European countries provide training in rheumatology, but the length, structure, contents and assessments of these training programmes are quite heterogeneous. In order to promote excellence in standards of care and to support physicians' mobility, a certain degree of harmonisation should be encouraged.

Exercise as an anti-inflammatory Therapy in Axial Spondyloarthritis Therapeutic Intervention (EXTASI) study: a randomized controlled trial.

Objectives: Axial SpA (axSpA) is a chronic inflammatory disease, yet despite known anti-inflammatory effects of exercise, the effect of exercise on inflammatory immune cell populations and associated inflammatory profiles in axSpA is unknown. This randomized controlled trial investigated the effect of 12 weeks of walking on symptom severity, cardiometabolic health, inflammatory biomarkers and immune cell populations. Methods: Twenty people (60% male) living with axSpA who were on a stable dose of NSAIDs participated. Participants were randomly assigned to control or exercise (30 min of walking five times per week). Participants were invited back every 4 weeks for assessment. Results: There was a 0% dropout rate and no adverse events in the exercise group, showing walking exercise was well tolerated. Home-based walking for 12 weeks lowered the proportion of pro-inflammatory monocytes, whereas they increased in the control group. Changes were associated with lower IL-6 and CRP concentrations, lower spinal pain and lower systolic blood pressure in the exercise group, whereas these markers increased in the control group. Reductions in IL-6 and pro-inflammatory monocytes with exercise were independent of lower body fat percentage. Conclusions: Supplementing NSAID therapy with walking exercise can improve inflammatory immune profiles in people with axSpA, coinciding with reductions in spinal pain. Importantly, the exercise was well tolerated, suggesting walking exercise can be used as an adjuvant anti-inflammatory therapy for NSAID treatments. This should now be explored in people living with axSpA who have had high enough disease activity to necessitate the prescription of biologic or synthetic DMARD treatments. Trial registration: ClinicalTrials.gov (http://clinicaltrials.gov), NCT04368494.

From bench to bedside - is there a role of IL-17 drugs in rheumatoid arthritis?

INTRODUCTION: IL-17 has been described as a pro-inflammatory cytokine that is relevant in the seronegative spondylarthritides with IL-17 targeted therapies being licensed for their treatment.There is evidence to demonstrate that IL-17 is found in RA joints and contributes to the pro-inflammatory cascade. This results in synovial hyperplasia and osteoclastogenesis thus causing joint destruction and bony erosions. AREAS COVERED: This review article summarizes trials that have studied the use of IL-17 targeted therapies in RA patients who have failed conventional synthetic disease-modifying therapy (C-DMARDS) and biologic DMARDS. EXPERT OPINION: The trials that have studied IL-17 inhibitors in RA patients have only shown a modest improvement in disease activity. In several trials, the primary endpoint was not achieved whilst in others, when comparing with existing licensed biologics for RA, did not demonstrate any superiority.Tissue Necrosis Factor-alpha (TNF-α) likely plays more of a pivotal role in the pathogenesis of RA with IL-17 having a synergistic effect. Therefore, in our opinion, IL-17 inhibitors as an independent therapy for RA are less likely to provide a cost-effective benefit. There may be scope to potentially combine it with TNF-α-inhibitors (TNF-i), but this requires further research especially with the potential concerns related to increased immunosuppression.

Catch me if you can: a national survey of rheumatologists and obstetricians on the use of DMARDs during pregnancy.

The use of disease-modifying anti-rheumatic drugs and biological therapy is variable throughout pregnancy. This questionnaire-based study was undertaken to explore and compare the current practice amongst rheumatologists and obstetricians across the UK, regarding the use of drugs during pregnancy. A questionnaire was devised to address issues regarding individual drugs used during preconception, pregnancy and lactation. Members of the British Society of Rheumatology, Midlands Rheumatology Society and the British Maternal Fetal Medicine Society were emailed. Results were analysed by the online survey software and Fisher's exact testing. Our results show differences between rheumatologists and obstetricians. A total of 500 members of each society were emailed. There were 102 (20 %) versus 33 (7 %) respondents. With regard to medication, in relation to advice given before conception, hydroxychloroquine 80 versus 61 % continue, 19 versus 15 % discontinue (p = 1.0); sulphasalazine 59 versus 70 % continue, 41 versus 6 % discontinue (p = 0.002); azathioprine 62 versus 58 % continue, 36 versus 21 % discontinue (p = 0.37); methotrexate 0 versus 3 % continue, 100 versus 76 % discontinue (p = 0.2); leflunomide 0 versus 0 % continue, 98 versus 42 % discontinue (p = 1.0); anti-TNF therapy 7 versus 15 % continue, 54 versus 54 % discontinue (p = 0.05); and rituximab 2 versus 12 % continue, 95 versus 52 % (p = 0.01) would discontinue prior to conception. This survey is the first of its nature amongst rheumatologists and obstetricians. Most would give advice to continue with sulphasalazine, azathioprine and stop methotrexate and leflunomide. We observed no uniform practice and therefore recommend guidelines.

Clinical efficacy of JAK inhibitors on enthesitis in spondyloarthropathy: A scoping literature review.

BACKGROUND: Enthesitis is a key feature of spondyloarthropathy (SpA). In recent years, JAK inhibitors have emerged as efficacious drugs in the landscape of advanced therapies for patients with SpA. METHOD: The aim of this scoping literature review was to search the published literature for studies on JAK inhibitors and their effects on enthesitis in patients with SpA and evaluate the data and summarise the findings. The clinical trials reviewed used the Leeds Enthesitis Index, Spondyloarthritis Research Consortium of Canada Enthesitis Index, and Maastrich Ankylosing Spondylitis Enthesitis Score as outcome measures. RESULTS: Tofacitinib, upadacitinib, and filgotinib had numerically greater reductions in the enthesitis scores when compared with placebo. CONCLUSION: While the JAK inhibitors are therapeutic options for enthesitis in SpA, head-to-head studies are needed to compare the JAK inhibitors against the biological drugs (targeting TNF, IL-17, and IL-12/23) as well as studies showing the effects of JAK inhibitors on enthesitis imaging.

Ethnic differences in cellular and humoral immune responses to SARS-CoV-2 vaccination in UK healthcare workers: a cross-sectional analysis.

Background: Few studies have compared SARS-CoV-2 vaccine immunogenicity by ethnic group. We sought to establish whether cellular and humoral immune responses to SARS-CoV-2 vaccination differ according to ethnicity in UK Healthcare workers (HCWs). Methods: In this cross-sectional analysis, we used baseline data from two immunological cohort studies conducted in HCWs in Leicester, UK. Blood samples were collected between March 3, and September 16, 2021. We excluded HCW who had not received two doses of SARS-CoV-2 vaccine at the time of sampling and those who had serological evidence of previous SARS-CoV-2 infection. Outcome measures were SARS-CoV-2 spike-specific total antibody titre, neutralising antibody titre and ELISpot count. We compared our outcome measures by ethnic group using univariable (t tests and rank-sum tests depending on distribution) and multivariable (linear regression for antibody titres and negative binomial regression for ELISpot counts) tests. Multivariable analyses were adjusted for age, sex, vaccine type, length of interval between vaccine doses and time between vaccine administration and sample collection and expressed as adjusted geometric mean ratios (aGMRs) or adjusted incidence rate ratios (aIRRs). To assess differences in the early immune response to vaccination we also conducted analyses in a subcohort who provided samples between 14 and 50 days after their second dose of vaccine. Findings: The total number of HCWs in each analysis were 401 for anti-spike antibody titres, 345 for neutralising antibody titres and 191 for ELISpot. Overall, 25.4% (19.7% South Asian and 5.7% Black/Mixed/Other) were from ethnic minority groups. In analyses including the whole cohort, neutralising antibody titres were higher in South Asian HCWs than White HCWs (aGMR 1.47, 95% CI [1.06-2.06], P = 0.02) as were T cell responses to SARS-CoV-2 S1 peptides (aIRR 1.75, 95% CI [1.05-2.89], P = 0.03). In a subcohort sampled between 14 and 50 days after second vaccine dose, SARS-CoV-2 spike-specific antibody and neutralising antibody geometric mean titre (GMT) was higher in South Asian HCWs compared to White HCWs (9616 binding antibody units (BAU)/ml, 95% CI [7178-12,852] vs 5888 BAU/ml [5023-6902], P = 0.008 and 2851 95% CI [1811-4487] vs 1199 [984-1462], P < 0.001 respectively), increments which persisted after adjustment (aGMR 1.26, 95% CI [1.01-1.58], P = 0.04 and aGMR 2.01, 95% CI [1.34-3.01], P = 0.001). SARS-CoV-2 ELISpot responses to S1 and whole spike peptides (S1 + S2 response) were higher in HCWs from South Asian ethnic groups than those from White groups (S1: aIRR 2.33, 95% CI [1.09-4.94], P = 0.03; spike: aIRR, 2.04, 95% CI [1.02-4.08]). Interpretation: This study provides evidence that, in an infection naïve cohort, humoral and cellular immune responses to SARS-CoV-2 vaccination are stronger in South Asian HCWs than White HCWs. These differences are most clearly seen in the early period following vaccination. Further research is required to understand the underlying mechanisms, whether differences persist with further exposure to vaccine or virus, and the potential impact on vaccine effectiveness. Funding: DIRECT and BELIEVE have received funding from UK Research and Innovation (UKRI) through the COVID-19 National Core Studies Immunity (NCSi) programme (MC_PC_20060).

Cannabinoids in rheumatology: Friend, foe or a bystander?

OBJECTIVES: Cannabinoids have gained popularity recently with special emphasis on their use for chronic pain. Although NICE guidelines advise against their usage for management of chronic pain, almost all rheumatologists encounter a few patients in their daily practice who either use them or are curious about them. We reviewed the mechanism of action of cannabinoids, current knowledge about their role in rheumatology and potential drug interactions with common drugs used in Rheumatology. We attempted to answer the question "If cannabinoids are friend, foe or just a mere bystander?" METHODS: We adhered to a search strategy for writing narrative reviews as per available guidelines. We searched PubMed with the search terms "Cannabinoids", "Rheumatology" and "Chronic pain" for published articles and retrieved 613 articles. The abstracts and titles of these articles were screened to identify relevant studies focusing on mechanism of actions, adverse effects and drug interactions. We also availed the services of a musculoskeletal librarian. RESULTS: Despite the NHS guidelines against the usage of cannabinoids and associated significant stigma, cannabinoids are increasingly used for the management of pain in rheumatology without prescription. Cannabinoids act through two major receptors CB1 and CB2, which are important modulators of the stress response with potential analgesic effects. Their role in various rheumatological diseases including Rheumatoid arthritis, Osteoarthritis and Fibromyalgia have been explored with some benefits. However, in addition to the adverse effects, cannabinoids also have some potential interactions with common drugs used in rheumatology, which many users are unaware of. CONCLUSION: While the current studies and patient reported outcomes suggest cannabinoids to be a "friend" of rheumatology, their adverse events and drug interactions prove to be a "Foe". We were unable to arrive at a definite answer for our question posed, however on the balance of probabilities we can conclude cannabinoids to be a "foe". Under these circumstances, a disease and drug focussed research is need of the hour to answer the unresolved question.

An update on the considerations for patients with rheumatic disease being treated with rituximab during the COVID-19 pandemic and the potential drug treatment strategies.

INTRODUCTION: Over the last two decades, rituximab has become an increasingly popular drug in the treatment of a wide range of rheumatic diseases. However, with the advent of the COVID-19 pandemic, clinicians face challenges in weighing risk against benefit in its use. AREAS COVERED: A review of existing data was performed to examine the relationship between rituximab use, morbidity and mortality from COVID-19, and vaccine efficacy in patients with rheumatic diseases, aiming to guide clinicians in continued use of the medication and consider the direction of future research. A literature review was performed through a search of the PubMed database, using the terms ((SARS-CoV-2) OR (COVID-19)) AND (rituximab) AND (rheumatic), which generated an initial 55 results, with relevant articles then selected for inclusion. EXPERT OPINION: In order to safeguard patients with an ongoing need for rituximab therapy, vaccination remains the primary concern. A target of performing booster doses 6 months after last rituximab dose is a reasonable estimate, which may be made more precise by use of B cell counts, although primary immunization should not be delayed. In those patients who remain seronegative, the use of newer antivirals and broadly neutralizing antibody infusions may help provide further safeguards.

Lifestyle modification and inflammation in people with axial spondyloarthropathy-A scoping review.

INTRODUCTION: People with axial spondyloarthritis (AS) have an inflammatory profile, increasing the risk of hypertension, type 2 diabetes, obesity, and dyslipidaemia. Consequently, AS is linked with co-morbidities such as cardiovascular disease (CVD). Physical inactivity, diet, smoking, alcohol consumption, and obesity influence inflammation, but knowledge of the interaction between these with inflammation, disease activity, and CVD risk in AS is dominated by cross-sectional research. METHODS: A review of the literature was conducted between July 2020 and December 2021. The focus of the scoping review is to summarise longitudinal and randomised control trials in humans to investigate how tracking or modifying lifestyle influences inflammation and disease burden in patients with AS. KEY MESSAGES: (1) Lifestyle modifications, especially increased physical activity (PA), exercise, and smoking cessation, are critical in managing AS. (2) Smoking is negatively associated with patient reported outcome measures with AS, plus pharmaceutical treatment adherence, but links with structural radiographic progression are inconclusive. (3) Paucity of data warrant structured studies measuring inflammatory cytokine responses to lifestyle modification in AS. CONCLUSION: Increased PA, exercise, and smoking cessation should be supported at every given opportunity to improve health outcomes in patients with AS. The link between smoking and radiographic progression needs further investigation. Studies investigating the longitudinal effect of body weight, alcohol, and psychosocial factors on disease activity and physical function in patients with AS are needed. Given the link between inflammation and AS, future studies should also incorporate markers of chronic inflammation beyond the standard C-reactive protein and erythrocyte sedimentation rate measurements.

Testing the Water: Osteoporosis Management in Primary Care.

INTRODUCTION: Osteoporosis is a common bone condition in the United Kingdom (UK). The risk of osteoporosis and fragility fractures increases with age, and with the ageing population in the UK, the incidence is growing. It is imperative that General Practitioners (GPs) correctly diagnose and manage their patients with osteoporosis. To improve the awareness, a treatment pathway was developed in secondary care to guide local GPs. The aim of this study was to investigate whether patients at a GP practice with a population of 14,000 have been appropriately identified, coded as osteoporosis, treated, and have followed the recommended treatment pathway. METHODS: This retrospective study identified three patient groups through a search of the practice IT system, using the words 'osteoporosis', 'fragility fracture', 'Quality and Outcomes Framework', and names of all medications that are used to treat osteoporosis. Group 1 consisted of patients currently on the practice osteoporosis register. Group 2 consisted of patients with a coding of 'osteoporosis' or 'fragility fracture', but not currently on osteoporosis treatment. Group 3 consisted of patients currently on osteoporosis treatment with no coding for 'osteoporosis' or 'fragility fracture'. RESULTS: In Group 1, 62% were found to be following the local treatment pathway in the first cycle of the study, and 70% in the second cycle. In Group 2, 45% were found to be following the local treatment pathway in the first cycle of the study, and 43% in the second cycle. In Group 3, 86% were found to be following the local treatment pathway in the first cycle of the study, and 96% in the second cycle. The completed study cycle shows an improvement of adherence of the pathway, from 75% in the first cycle to 81% in the second cycle. The first cycle of the study was presented at the GP practice meeting, which improved the awareness of the treatment pathway. CONCLUSION: This study illustrates that there is a need for improvement in the diagnosis and management of osteoporosis in primary care. This can be achieved by improving awareness through continuing medical education about following the appropriate pathway to enhance the management of osteoporosis. Resources need to be allocated for prioritising osteoporosis care to prevent falls and fragility fractures, which have devastating effects on individual patients and the healthcare system.

Reactive arthritis: a clinical review.

Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.

An Ethnic Variation in the Acceptance of Biological Disease-Modifying Therapies: A University Hospital Experience.

Ethnic variations in the outcomes of rheumatological diseases are well documented. While physiological differences may account for these disparities, attitude to treatment is also likely to be a significant modifiable contributor. We sought to determine if an ethnic variation exists in the uptake of biological disease-modifying anti-rheumatic drugs (DMARD) among a multi-ethnic cohort when offered in-person through a healthcare system free at the point of access. We conducted a retrospective cross-sectional study of patients seen in a biologic therapy counselling clinic between December 2016 and April 2017. Clinic letters from consultations were reviewed, and data including ethnicity, language spoken, and decision to accept or reject the therapy were extracted. We chose to measure uptake over adherence, as we believe it is an earlier, more direct marker of attitudes to joint saving medications. Ninety-one cases were included in the analysis. Over 13.2% (12/91) of the cohort declined a biologic treatment when it was offered as the standard of care for joint disease. Non-Caucasian patients accepted treatment less often than Caucasian (White British) patients (OR 0.265, CI 0.73-0.959, p = 0.043), as did those who did not speak English as a first language (OR 0.094, CI 0.18-0.497, p = 0.005). Age, sex, and diagnosis were well matched between those who accepted and declined therapy. We demonstrate a disparity in the uptake of biologic therapies between the White British population and patients from other ethnicities. The reasons for this are likely multifactorial and could be related to socio-economic factors, language barriers, and cultural differences. Addressing this discrepancy is a crucial first step to tackling preventable disparities in the outcomes of rheumatological disease between different ethnicities.

COVID-19: The disease of loneliness and solitary demise.

The birth of the COVID-19 pandemic has transformed working lives of British Asian general practitioners (GPs), such as one of the authors. The effects of the national lockdown and the subsequent loneliness have impacted every aspect of our lives and increased mental health problems. The added social isolation of local lockdowns, such as in Leicester, will undoubtedly exacerbate some health problems due to a lack of patient willingness to attend healthcare services and the postponement of some appointments. The lack of culturally competent support is likely to add to the isolation in non-English-speaking people. Thus, we should pre-empt these issues in a culturally effective manner. To prepare for subsequent waves, GPs are risk-stratifying patients for COVID-19 and have commenced ReSPECT care-plan conversations with higher-risk patients. But with the increased risk from COVID-19 to Black, Asian and minority ethnic patients, should this and other groups of patients also have a ReSPECT care plan? Is now the time to consider community-hospice settings for our palliative COVID-19 patients? This pandemic has uncovered a training need for healthcare professionals to feel more comfortable in discussing end of life as an integral consultation component. We should focus our efforts in alleviating suffering by achieving 'shared understanding' and 'negotiating management' of our ReSPECT conversations.

Perception and Belief on Cannabinoids: A Comparative Study of Rheumatology Patients and Primary Care Physicians on the Use of Cannabinoids for Pain Management.

Introduction With the recent increase in popularity of cannabinoids in the management of chronic pain, the inquisitiveness among our patients and health care professionals are probably now at its peak. Many treating health care professionals in their clinical practice come across patients who either use cannabinoids or are interested in their efficacy and side effects. As there is paucity of data and research about their use in rheumatology, patient's self-reported responses and experience of primary care physicians (General Practitioners [GPs]) can guide in expanding our knowledge. Methods Ours was an observational, cross-sectional study among rheumatology patients and GPs in the Leicestershire area. Initial questionnaire was designed by authors addressing demographics, knowledge, experience and perception. This was piloted among patients and GPs and improvised, redesigned and used for the study. The study design consisted of two arms: first arm including GPs and second arm rheumatology patients. Results Arm 1 consisted of 100 GPs with median age group of 30-40 years. 34% GPs experienced their patients inquiring about cannabinoids. 78% did not believe cannabinoids benefited the patients. On a scale of 0-10, the mean benefit in managing pain 3.2 + 2.5. Arm 2 consisted of 102 patients. 16% reported using cannabinoids for managing their chronic pain. The users reported significant improvement in pain compared to non-users (p=0.002). On comparing the perception of cannabinoids between GPs and patients, there was a statistically significant difference regarding awareness and effectiveness (p<0.001). Conclusion With the paucity of data and research about the use of cannabinoids in rheumatology, the patient self-reported responses provided an estimate as to their efficacy. This was significantly different from the GP perception. Disease and drug-focused research is need of the hour. To our knowledge, this is the First Single Centre study in the UK evaluating GP and rheumatology patient perception on cannabinoids.

Promising Treatment Options for Axial Spondyloarthritis: An Overview of Experimental Pharmacological Agents.

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition that predominantly affects the axial skeleton. All patients receive conservative management measures which include physiotherapy, patient education and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Those with significant active disease will require escalation of their treatment with the use of biologics. Currently, there are five approved TNF inhibitors and two approved IL-17 inhibitors for use in axSpA. However, despite this up to 40% of patients do not respond or are intolerant to current available treatment. This leaves a significant number of patients with uncontrolled disease and unmet need for additional therapies. Though many drug classes have been trialed for axSpA they show poor efficacy; however, over the last few years there are three which demonstrate much greater promise as novel therapies for axSpA, these include dual neutralization of IL-17A and IL-17F, Janus kinase (JAK) inhibitors, and granulocyte-macrophage colony-stimulating factor (GM-CSF) inhibitors. This article reviews the evidence for these novel emerging therapeutic options for axSpA.

Are There Any Ethnic Differences in the Response to Baricitinib for the Treatment of Rheumatoid Arthritis?

Introduction Baricitinib is an oral synthetic Janus Kinase inhibitor that inhibits JAK1 and JAK2, and the new kid on the block in the treatment of rheumatoid arthritis (RA). To date, there are no studies comparing the clinical benefit of baricitinib in RA between different ethnicities. Ethnicity plays a role in the effectiveness of therapeutic agents. Given the large multi-ethnic population of Leicestershire in the United Kingdom and the range of new therapeutics in RA, we reviewed our cohort of patients with RA to see whether there is any difference in baricitinib Disease Activity Score 28 (DAS28) response between the Asian and White cohorts. Methods This was a retrospective study. The patients included were those under the care of rheumatology at University Hospitals of Leicester (UHL) with a diagnosis of RA and either receiving baricitinib or had received it in the past. Data was collected using the UHL information technology systems, clinic letters and pharmacy records. In addition to ethnicity, we reviewed patient age, gender, concurrent disease-modifying anti-rheumatic drugs (DMARDs) used, previous biologics used, baseline and post-treatment DAS28, dropout from therapy, baseline biochemical assays (anti-cyclic citrullinated peptide (anti-CCP) and rheumatoid factor (RF) status) and radiographic findings. An independent t-test was used to compare continuous data, and Pearson's chi-squared test was used to compare categorical data. Results A total of 120 patients were included in the analysis, and data were analysed with Portable Format for Analytics (PFA). There was no statistically significant difference in the mean DAS28 at baseline (Asian: 5.17 versus White: 4.65; p-value = 0.107) and post-treatment (Asian: 2.8 versus White: 3.3; p-value = 0.404). Comparing both ethnicities, there was no statistically significant difference in previous biologics used, anti-CCP and RF titres, and radiographic findings of erosions. Conclusion This is the first study of its kind, and it found no significant difference in baricitinib response between the Asian and White cohorts. Our study had certain limitations, and future studies will be needed to evaluate this subject further. Such data is important as it can contribute to a body of evidence that may in the future help inform clinical decision-making.