BackgroundAtypical femoral fractures (AFFs) are rare events associated with increased duration of bisphosphonate exposure. Recommended management of AFFs include cessation of bisphosphonates and imaging of the contralateral femur. The aims of this study were to identify the local incidence of AFFs in bisphosphonate users and to audit the medical management of AFFs against published recommendations.MethodsA retrospective analysis of the admissions database for a major trauma centre identified all femoral fractures (3150) in a five-year period (July 2009 to June 2014). Electronic health records and radiographs were reviewed using the 2013 American Society for Bone and Mineral Research (ASBMR) diagnostic criteria for AFF to establish the number of cases. To estimate incidence, the total number of bisphosphonate users was derived from primary care prescription and secondary care day-case records. Medical management of cases with AFF on bisphosphonates was audited against guidance from ASBMR and Medicines & Healthcare Products Regulatory Agency.Results10 out of 3150 femoral fractures met criteria for AFF; 7 of these patients had a history of exposure to bisphosphonates (6 oral, 1 intravenous). There were 19.1 AFFs per 100,000 years of bisphosphonate use in our region. Bisphosphonates were stopped and the contralateral femur imaged in only 2 of the 7 patients treated with bisphosphonates.ConclusionOur local incidence is in line with published figures; however, this is the first published evidence suggesting that medical management and identification of AFF may be suboptimal. Managing these patients remains challenging due to their rarity and possible lack of awareness.

BackgroundRheumatoid arthritis is a well-known inflammatory condition with a prevalence around 1% in females and 0.5% in males in UK (as per NOAR study). In the past decade use of biologic therapy has helped clinicians to treat rheumatoid arthritis more effectively. Rituximab is one of the biologics which is used commonly for treating rheumatoid arthritis. Rituximab is chimeric monoclonal antibody targeting CD20 molecule of B cells. First trial of rituximab in treating rheumatoid arthritis was published in 2004 and since then it has shown promising results in trials. In order to guide clinicians British society of rheumatology proposed recommendations in March 2010. An audit is required to ensure adherence to clinical guidelines at Haywood hospital.ObjectivesTo assess whether patients receiving Rituximab are appropriately monitored with pretherapy evaluation of immunoglobulin levelsTo assess the effects of rituximab on immunoglobulin levels and incidence of infection among patients on rituximabMethodsData was collected of all (N=105) patients who received Rituximab between May 2014 until April 2015 at the Haywood Hospital where patients attend for Rituximab injections.Data was collected retrospectively from the Diamond System, Medisec system and Clinical Information System and entered onto an excel spread sheet which included following details Start date of RituximabIgG levels prior to Rituximab and current IgG levelsTotal doses of rituximab and frequency of IgG monitoringIntermittent infections and type of infections. ResultsWe observed that 82 out of 105 patients were started on rituximab after February 2011 when the BSR guidance was published and 53 out of 105 patients had their immunoglobulin levels checked prior to commencing rituximab35/76 (46%) patients had 1 or more episodes of infections whilst on Rituximab which required treatment. Of these, 16 (46%) had recurrent infections.39 patients had dropped their IgG levels after starting rituximab 18 (46%) of these suffered from infections.17 patients had a drop in IgG ≥20% and 6 of these (36%) had recurrent infections and 1 patient had 1 episode of infection.None of the patients had dropped their IgG levels below 5ConclusionsA significant number of patients (35/76 =46%) had 1 or more episodes of infections despite IgG levels being above lower normal limitAmong patients who dropped their IgG levels had increased number infections. Also they had more than 1 episodes of infectionPatients who dropped IgG levels ≥20% suffered with recurrent infectionsReferences BSR and BHPR guidelines on the use of rituximab in rheumatoid arthritis doi:10.1093/rheumatology/ker106b. Disclosure of InterestNone declared

Background:Secukinumab was approved by NICE for patients with active Ankylosing Spondylitis and Psoriatic Arthritis in 2017. Clinical trial data suggests secukinumab is a useful treatment option in both conditions, but often real world experience differs greatly from clinical trial results. In addition, patients with more refractory disease are often excluded from clinical trials.Objectives:To assess the response to secukinumab in patients with seronegative spondyloarthropathy receiving treatment at University Hospital Coventry and WarwickshireMethods:Patients starting secukinumab at UHCW were identified from the Blueteq funding database. Medical notes were reviewed retrospectively to assess response rates using BASDAI responses in Ankylosing spondylitis and PsARC responses in PsA. Patients who had previously had inadequate response to TNF inhibitors (PsA only) and severe psoriasis received 300mg secukinumab monthly; the remainder were prescribed 150mg monthly.Results:146 patients commenced secukinumab between June 2017 and January 2020 and had outcome data recorded. 73 patients (50%) had received previous biologic agents prior to secukinumab exposure. Patients with Ankylosing spondylitis had high BASDAI (6.8±1.4) and spinal pain (7.5±1.4). 48 patients had an initial response to treatment as per outcome measures done before and after Secukinumab inception. Secukinumab was effective in 89 patients (94%), and 87 (91%) continued treatment.In psoriatic arthritis, despite high levels of activity at baseline (mean tender joint count 10±8; swollen joint count 6±3) and 65% prior biologic exposure; high rates of response were seen. The majority of patients have continued treatment. Secukinumab was well tolerated in both patient groups with low rates of discontinuation due to adverse events (8 patients, 5%). Adverse events included recurrent infection (3), rash (1), mouth ulcers (1), vertigo (1), new onset cancer (1) and new onset Crohn’s (1) although rates were low overall. Patients with pre-existing uveitis did not develop exacerbations but low numbers of patients with prior uveitis were treated.PsA (n=51)AS (n=95)Age in years, mean (SD)53 (13)49(12)Male sex, n (%)21 (41)62 (65)Disease duration in years, mean (SD)8 (8)10.9 (9.2)Previous biologic exposure, n (%)30 (65)43 (48)Number of prior biologics, median (range)1 (1-4)1 (1-4)Responder, n (%)37 (72)*89 (93)Discontinuation, n(%)12 (24)8 (8.5)Adverse events62Lack of efficacy64Other02*Response could not be assessed in 3/51 PsA patients due to insufficient clinical data; these patients have been recorded as non respondersConclusion:Secukinumab demonstrates high levels of efficacy even in a cohort of patients with longstanding PSA and AS with high rates of inadequate responses to other biologics.Secukinumab is well tolerated with low rates of discontinuation due to adverse events.References:Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs Technology appraisal guidance [TA445]Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors Technology appraisal guidance [TA407]Disclosure of Interests:None declared

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