ObjectivesTo compare 1-year clinical efficacy of (1) initial triple disease-modifying antirheumatic drug therapy (iTDT) with initial methotrexate (MTX) monotherapy (iMM) and (2) different glucocorticoid (GC) bridging therapies: oral versus a single intramuscular injection in early rheumatoid arthritis.MethodsIn a single-blinded randomised clinical trial patients were randomised into three arms: (A) iTDT (methotrexate+sulfasalazine+hydroxychloroquine) with GCs intramuscularly; (B) iTDT with an oral GC tapering scheme and (C) MTX with oral GCs similar to B. Primary outcomes were (1) area under the curve (AUC) of Health Assessment Questionnaire (HAQ) and Disease Activity Score (DAS) and (2) the proportion of patients with radiographic progression.Results281 patients were randomly assigned to arms A (n=91), B (n=93) or C (n=97). The AUC DAS and HAQ were respectively −2.39 (95% CI −4.77 to −0.00) and −1.67 (95% CI −3.35 to 0.02) lower in patients receiving iTDT than in those receiving iMM. After 3 months, treatment failure occurred less often in the iTDT group, resulting in 40% fewer treatment intensifications. The difference in treatment intensifications between the arms required to maintain the predefined treatment goal remained over time. No differences were seen between the two GC bridging therapies. Respectively 21%, 24% and 23% of patients in arms A, B and C had radiographic progression after 1 year. Patients receiving iTDT had more adjustments of their medication owing to adverse events than those receiving iMM.ConclusionsTreatment goals are attained more quickly and maintained with fewer treatment intensifications with iTDT than with iMM. However, no difference in radiographic progression is seen. Both GC bridging therapies are equally effective and, therefore, both can be used.Trial registration numberISRCTN26791028.

Objective: This paper describes the baseline demographics, clinical characteristics, and patient-reported outcomes (PROs) according to clinical phenotype of patients with early psoriatic arthritis (PsA) for the purpose of creating a decision support system for daily clinical practice. Method: Patients with newly diagnosed PsA were included in the Dutch south west Early Psoriatic ARthritis (DEPAR) study. No classification criteria were applied, to ensure collection of real-world data on demographics, medication, clinical characteristics, and PROs. An IT infrastructure facilitated data collection. Results: We described 527 patients, categorized according to the clinical phenotype stated by the rheumatologist at the time of diagnosis, namely monoarthritis (15%), oligoarthritis (40%), polyarthritis (23%), enthesitis (10%), axial disease (2%), and dactylitis (10%). Overall psoriasis severity was mild and 83 patients (16%) had no psoriasis. Short-term sick leave (> 1 day per 4 weeks) was 17% and long-term sick leave (> 4 weeks) was 4%. The group with phenotype enthesitis reported the longest duration of complaints, had the highest fatigue scores, and contained the highest percentage of patients with a Hospital Anxiety and Depression Scale (HADS) anxiety score ≥ 8 and depression score ≥ 8. Conclusion: PsA patients presenting at outpatient clinics in the Netherlands had a mild degree of psoriasis, with impairment of quality of life and work productivity. Most patients presented with phenotype oligoarthritis. Those presenting with phenotype enthesitis more often reported scores suggestive of an anxiety or depression disorder and fatigue. It is important for attending rheumatologists to be aware of these differences when assessing patients with PsA.

BackgroundPsoriasis patients with enthesitis can classify as psoriatic arthritis since the introduction of the CASPAR classification criteria in 2006. However, clinical assessment of the entheses could be challenging. In addition, the presence of a tender enthesis is not necessarily indicative for underlying inflammatory disease as it could be related to overuse, metabolic disease or ageing. Therefore, we need a better way to identify the inflammatory component of entheseal involvement in psoriasis. To detect these inflammatory components in the entheses, ultrasound (US) examination can be used to identify inflammatory disease at the entheses.ObjectivesOur aims were to determine the prevalence of US abnormalities among psoriasis patients in primary care and to determine the concordance of clinical and US information at individual entheseal sites.MethodsAdult patients with psoriasis were invited to participate in the SENSOR study. Patients who reported pain in joints, entheses or the lower back were eligible for clinical evaluation. If physical examination indicated a painful enthesis on the LEI/MASES or if arthritis was present, US examination of the entheses was performed. The six entheses of the Madrid Sonographic Enthesis Index (MASEI) and the lateral epicondyle tendon insertion (elbow) were evaluated according to the MASEI scoring system. Enthesitis was defined as US inflammation (positive power Doppler (PD) signal or a thickened enthesis of the plantar fascia) in combination with one clinical feature at the same enthesis. Structural changes detected by ultrasound were calcifications, increased thickness, irregular fibre structure and erosions.ResultsOf 524 patients who participated in the SENSOR study, 111 patients were assessed both by physical examination and by US. In 106 (95%) patients we detected US abnormalities. In 56 (50%) patients we found structural changes without indication for inflammatory disease. In 50 (45%) patients we found US abnormalities indicating inflammatory disease at the enthesis (positive PD: n=35; thickened plantar fascia: n=15). When we combined the US data with the clinical information, 36% of US inflammatory disease were confirmed [Figure 1].ConclusionsWe found US abnormalities in 95% of the primary care psoriasis patients with musculoskeletal complaints, which is a combination of both structural and inflammatory US components. In 45% of primary care psoriasis patients we observed US inflammatory disease, which was confirmed in 36% of the patients by clinical information.AcknowledgementsThis study was financially funded by an investigator-initiated grant from Pfizer bv.Disclosure of InterestNone declared

Background The POEET (Potential Optimalisation of Expediency of TNFi) study is an ongoing study investigating TNFi cessation in RA patients on TNFi and conventional DMARD. Part of this study is the POET-US, investigating whether ultrasonography (US) can predict flare.(1) Objectives To present preliminary data of the POET-US study in which prediction of flare, defined as DAS28>3.2 and at least > 0.6 increase compared to baseline DAS28, by US at baseline is investigated. Methods The POETUS study is a multicenter (n=14) randomized prospective cohort study in the Netherlands. Participating patients have RA according to ACR 1987 criteria, DAS28 low disease activity low disease activity (<3.2) > 6 months and have been treated with stable dose TNF-i and conventional DMARD > 1 year. Patients are randomized to continue or stop TNFi; of those who stop US is performed at baseline (MCP 1-5 dorsal & volar, wrists and MTP 2-5 dorsal, all bilaterally). All US-scans are performed with an Esaote MyLab 60 machine and high-frequency, linear transducer. A semi-quantitative synovitis scoring system is used for Grey Scale (GS) and Power Doppler (PD). Grey scale: Grade 0: normal; Grade 1: elevated capsule, below the joint boundaries; Grade 2: elevated capsule above the joint boundaries, <50% convex; Grade 3: elevated capsule above the joint boundaries, > 50% convex. Power Doppler: Grade 0: no PD signal; Grade 1: few single PD signals; Grade 2: merging PD signals, < 50% of the synovial space; Grade 3: PD signal in > 50% of the synovial space. GS and PD scores of individual joints were summed; as grade 1 GS occured very frequently this was recoded to grade 0. Also baseline laboratory parameters and RA characteristics are recorded. The presented data are preliminary data from 2 centers (Utrecht, Nijmegen). Results 53 patients were included, 9 (17%) flared. Mean (sd) follow-up of all patients was 106 (79) days; mean (sd) time until flare was 77 (46) days. Conclusions Our preliminary results with limited data show that PD US and CRP, both assessed at cessation of TNFi in low disease activity RA, may predict future flare. Analysis of all data at completion of the study is necessary to corroborate these results. References   Disclosure of Interest F. Lamers-Karnebeek Grant/research support from: Abbott, H. Jacobs: None Declared, J. Fransen: None Declared, J. Luime: None Declared, P. Riel: None Declared, T. Jansen: None Declared

BackgroundSeveral referral strategies for axial spondyloarthritis (axSpA) have been proposed. The goal of these strategies is to overcome the delay between the first symptoms and the final diagnosis of axSpA by supporting primary care physicians in recognizing potential axSpA patients. All referral strategies are tested in their original study population, however no direct comparison of the performance of different strategies in one study population is performed.ObjectivesTo evaluated six different referral strategies for axSpA in unselected young primary care patients with chronic low back pain (CLBP) and secondly to find the optimal referral strategy for daily practice.MethodsThe referral strategies were evaluated in a large Dutch primary care population of unselected CLBP patients (18-45 years, CLBP ≥3 months, back pain onset <45 years). Patients already diagnosed with ankylosing spondylitis were not invited. Patients underwent a diagnostic work-up including, a standardized history, physical examination, HLA-B27 and CRP testing. A conventional radiograph and MRI of the sacroiliac joints were obtained. Definite axSpA was defined by the ASAS criteria. The following referral strategies were tested, listed by year of publication; the Brandt strategy1, MASTER2, RADAR3, the 2-step strategy4, the CaFaSpA strategy5, and the new ASAS recommendations6. For a description of the different strategies see Figure 1. The performance of the different referral models was assessed by sensitivity, specificity, area under the curve (AUC) and positive predictive value (PPV).ResultsIn total 941 primary care CLBP patients participated (58% female, mean age 36.0 years), of those were 181 (19%) identified as axSpA, 54 of the 181 (30%) were newly diagnosed with ankylosing spondylitis. Almost all referral strategies had a good discriminative performance (AUC >0.7). (Table 1) The MASTER referral strategy had the most balanced sensitivity and specificity. The new ASAS proposal has the lowest AUC, lowest specificity and the lowest PPV.Table 1.Performance of several referral strategies for axial spondyloarthritis tested in primary care patients (18–45 years) with chronic low back painStrategyAUC (95% CI)SensitivitySpecificityPPVBrandt10.80 (0.78–0.82)1.00.600.63Master20.88 (0.78–0.91)0.960.820.55RADAR30.87 (0.85–0.89)0.960.780.512-step40.64 (0.60–0.68)0.540.750.34CaFaSpA50.71 (0.67–0.75)0.750.580.30ASAS recommendation 60.61 (0.60–0.63)1.00.220.23ConclusionsAlmost all referral strategies had a good performance in this primary care cohort of CLBP patients. Strategies including imaging, HLA-B27 and inflammatory back pain (IBP) had the highest AUC and PPV. However imaging and blood tests are not always accessible in primary care, mainly due to high costs. The optimal strategy for primary care should include non-invasive referral parameters without additional costs such as IBP, good response to NSAIDs and family history.ReferencesBrandt et al, 2007.Poddubnyy et al, 2011.Sieper et al, 2013.Braun et al, 2013.van Hoeven et al, 2014.Poddubnyy et al, 2...