Objective The chronicity and severity of childhood onset Systemic Lupus Erythematosus (cSLE) necessitate effective transition from pediatric to adult providers. We studied transition outcomes in a cSLE cohort. Methods We identified patients at an adult Lupus clinic diagnosed with SLE ≤ 18 years who had been followed by a pediatric rheumatologist. Data extracted from the first 3 years in adult care (“post-transition period”) included: sociodemographics, depression, anxiety, SLE manifestations, SLE Disease Activity Index (SLEDAI) and Systemic Lupus International Collaborating Clinics/ACR Damage Index for SLE (SLICC) scores, non-adherence, and gaps in care (no appointments in the recommended time frame). Multivariable logistic regression analyses for predictors of: (1) time between pediatric and adult providers, (2) gaps in care, (3) unscheduled utilization (Emergency Department visits and admissions) (4) depression and/or anxiety were performed, as was a multivariable Poisson regression analysis for number of missed appointments. Results In 50 patients, SLEDAI scores were stable (mean 5.7 ± 5.0 at start vs. 4.7 ± 4.8 at year 3, p=0.2), but SLICC scores increased (0.46 ± 0.84, vs. 0.78 ± 1.25, p=0.01). Depression and anxiety increased significantly (10% vs. 26%, p=0.02). Mean time from last pediatric to first adult provider visit was almost 9 months (253 ± 392 days). Nearly 75% of patients had ≥1 gap in care. White race, low education level and non-adherence were significantly associated with missed appointments. Conclusion Despite moderate disease activity in this cSLE transition cohort, prolonged time between pediatric and adult providers and gaps in care in the post-transition period occurred. Anxiety and depression were frequently reported. Future work should identify methods to improve transition.

BackgroundDrug retention is considered an indicator of the overall effectiveness, safety and tolerability of a treatment. It is a useful guide to decide the best anti-TNF therapy in patients with R.A.ObjectivesTo determine which of the TNF inhibitors has the highest retention rate in patients with R.A and to analyze the different reasons for drug discontinuation.MethodsA search of MEDLINE, CENTRAL and EMBASE identified 201 randomized controlled trials (RCTs). We included those comparing a TNF inhibitor (standard dose) with a placebo group, plus concomitant use of conventional DMARDs. We excluded those allowing rescue therapy or not reporting the outcomes of interest. These outcomes were: drug discontinuation and reasons, adverse events, serious adverse events, infections, serious infections and acute infusion events or injection site reactions. A mixed-treatment comparisons analysis was constructed to indirectly compare each study group to one another. Calculation of the probability that each treatment is best was implemented using the Bayesian Markov chain Monte Carlo method.Results18 RCTs, including 6948 patients, were extracted. The mean length of study was 6.6 months. On average, patients were 52 years old with active R.A of 5.5 years duration, with 24 TJC, 15 SJC and CRP of 2.3 mg/dl at baseline.All TNF inhibitors were associated with relatively high rates of drug survival and no statistically significant differences were noted. By rank probability, Infliximab had the highest probability (52%) of retaining patients, and Golimumab (26%) and Certolizumab (29%) had the highest probabilities of being least likely to retain patients (see graphic). Regarding discontinuation due to lack/loss of efficacy, Certolizumab was the most likely and Infliximab the least likely drug to be discontinued. With respect to discontinuation due to adverse events, Infliximab had a 77% probability of being the most likely drug to be discontinued and Certolizumab (30%) was the least likely drug to be discontinued. Additionally, regarding adverse event-related outcomes, several observations were notable. Both Adalimumab and Golimumab were statistically significantly less likely than Infliximab to cause infections and, by rank probability, Infliximab had a 96% chance of being the drug most likely to cause infections. Regarding infusion/injection reactions, both Certolizumab and Infliximab were associated with very high probabilities (51% and 47%, respectively) relative to the other agents of being most likely to cause infusion reactions.ConclusionsInfliximab had the highest retention rate and was the least likely drug to be discontinued due to lack or loss of efficacy, but had the highest discontinuation rate due to adverse events. More data is needed with longer study periods to further reinforce these findings.ReferencesNeovius M, Arkema E V, Olsson H, et al. Drug survival on TNF inhibitors in patients with rheumatoid arthritis comparison of adalimumab, etanercept and infliximab. Ann Rheum Dis 2013; 0: 1–7AcknowledgementTo Helene Walco...