The advent of biological therapies has been a major therapeutic advance in rheumatology. Many patients now enjoy improved quality of life through better disease control. The number of therapies continues to grow both within drug class (including biosimilar drugs) and via new mechanisms. For the first time, nonbiological drugs such as small-molecule inhibitors (Janus kinase inhibitors) have shown clinical equivalence. However, clinical unmet need remains with up to a third of patients commenced on a biologic therapy having minimal or no response: (a) Generally, the first biologic used secures the best response, with likelihood of remission falling thereafter with successive therapies; (b) the success of strategy trials using biological therapies can be difficult to replicate in clinical practice due to a combination of patient factors and service limitations. Accordingly, ensuring optimization of initial treatment is an important consideration before switching to alternatives. Therapeutic drug monitoring (TDM) is the measurement of serum levels of a biologic drug with the aim of improving patient care. It is usually combined with detection of any antidrug antibodies that could neutralize the effect of the therapy. This technology has the potential to be a form of ‘personalized medicine’ by individualizing therapy, in particular, dosing and likelihood of sustained treatment response. It requires a clear relationship between drug dose, blood concentration and therapeutic effect. This paper will outline the technology behind TDM and unpack what we can learn from our colleagues in gastroenterology, where the adoption of TDM is at a more advanced stage than in rheumatology. It will explore and set out a number of clinical scenarios where rheumatologists might find TDM helpful in day-to-day practice. Finally, an outline is given of international developments, including regulatory body appraisals and guideline development.

Background: What is the quantitative relationship between repeated surgical intervention and unemployment in the spine surgery population? And, does the literature pay sufficient attention to this important aspect of spine surgery outcome? Methods: This was a retrospective review of 905 patients of working age undergoing one of three types of spine surgery. The index surgery at the time of the study was either on the cervical or lumbar spine. We retrospectively collected data on patients’ employment status and history of prior spine surgery. In this study, history of prior spine surgery was coded using two nominal (categorical) variables: The number of previous spine surgeries (0, 1, 2, ≥3) and the variability of location of previous spine surgeries (cervical, lumbar). We also looked into scientific publications related to spine surgery and probed “employment” and “reoperation” awareness in randomized controlled trials (RCTs). In addition, we queried some common factors that are known to play an important role in exacerbating the unemployment problem, such as opioid (ab)use and depression. Results: The unemployment rate was 19.4% among males and 34.8% among females. Unemployment rate correlated with the number of previous spine surgery (r = 0.077, p = 0.020), opioid use (r = 0.080, p = 0.017) and being on antidepressants (r = 0.119, p = 0.000). The unemployment rate was sta-tistically different (χ2 = 10.656, p = 0.014) among patients with different numbers of previous spine surgeries: 25.6% of de novo patients versus 28.1% of patients with one previous spine surgery, 32.7% of patients with two previous spine surgeries and 48.7% of patients with three or more previous spine surgeries. Females had significantly higher unemployment rate if they had three or more previous spine surgeries in their past (31.4%, 34.4%, 46.2% versus 83.3%, χ2 = 21.841, p = 0.000). Unemployment rate was as high as 90% in female patients with ≥3 surgeries on different regions of the spine and receiving antidepressants. Among randomized controlled trials addressing spine surgery in humans and published in English, 10.4% of reported studies mentioned opioids in their text, 4.1% (23/566) mentioned reoperation, 1.4% (8/566) mentioned employment, and none mentioned antidepressants. Conclusion: Females’ employment status is more sensitive to repeated surgical intervention, regardless of the part of the spine being targeted, reaching close to ten times the general population’s unemployment rate (83.3% versus 8%). On the other hand, a small percentage of randomized controlled trials pertaining to spine surgery deals with employment issues and reoperation rate in their outcome analysis

A 62 year-old gentleman with underlying ANCA vasculitis was admitted to hospital for severe musculoskeletal pain involving both shoulders, hips and hands. There was a history of long term usage of anti-fungal medication-voriconazole for his Aspergillus fumigatus lung infection as treatment and prophylaxis. Clinically the range of movement of both shoulders and hips was restricted with the presence of digital swelling of both hands. His imaging findings noted the presence of periosteal reaction involving shoulders and hips in addition to increased radiotracer uptake on his bone scan. A diagnosis of voriconazole induced periostitis was made and discontinuation of therapy led to rapid clinical improvement.