Background:Biologic interventions using highly specific immuno-modulatory biologic disease-modifying anti-rheumatic drugs (bDMARDs) represent a rapidly developing therapeutic approach to the treatment of Psoriatic Arthritis (PsA). However, despite high rates of response, adverse events, primary and secondary inefficacy are common, and multiple sequential lines of bDMARDs are often required. Data on drug persistence, as a surrogate for response, from national registries indicates switching has become accepted routine practice. One third of patients will fail or discontinue their first biologic with a significant proportion switching on to a 3rd biologic or higher.1-4 Due to a lack of evidence on the response to sequential therapies, individual patients may not have further lines routinely funded after three bDMARDs in the UK. While limiting lines of therapy remains a UK concern, many countries with rationed healthcare systems follow the UK model of drug usage.Objectives:To describe the response to sequential lines of bDMARD therapy prescribed in routine care in a UK single centre cohort.Methods:A retrospective sample of patients with PsA who fulfilled CASPAR criteria and had received at least one bDMARD were taken from the Bath longitudinal cohort for inclusion in the study. Clinical and laboratory variables that constitute physician and patient-reported outcome measures were collected at baseline and after a median (range) follow-up of 3 months (2-5) into their respective therapy line in accordance with the National Institute for Health and Care Excellence (NICE) rules. The mean change with a 95% confidence interval (CI) was used to report the difference between the baseline and follow-up measures. All patients provided consent to use their data collected during routine care, and ethical approval by the local committee was granted.Results:The patients mean age was 57.7 (SD 12.2) with a median (range) disease duration of 14.4 years (9.7 – 23.2). Data was available for 194 patients commencing 1st line bDMARD, 106 (2nd line), 93 (3rd line), 33 (4th line), 12 (5th line), and 9 (6th line and higher) from a total of 759 patients in the cohort. Mean tender and swollen joint count at baseline 1st bDMARD was 7 (SD 4.7) and 22 (SD 14.0), pain visual analogue scale 50 (SD 27.6) and PASI 1.3 (SD 2.2). Reasons for changing biological therapies include lack or loss of efficacy, intolerance, side effects, and comorbidities. Mean levels of joint disease at drug initiation did not diminish with subsequent lines of therapy. Clinical and patient reported outcomes by line of therapy are reported in Figure 1. Clinical responses were greatest to first line bDMARD, however clinically relevant DAPSA improvements were seen up to 5th line. Absolute levels of psoriasis in the cohort were low, however improvement in PASI was achieved across all lines of therapy. Patient and Physician Global Assessments (1-5 on Likert scale) and the Pain Visual analogue score (VAS on 1-10 Likert scale) showed a similar trend with greatest improvement to first line treatment across all lines of therapy.Conclusion:In this study we report the clinical response to sequential lines of bDMARD therapy for active PsA in routine clinical practice. Clinical response was greatest to the first line bDMARD but overall improvement in DAPSA, PASI or pain response did not appear to diminish up to 5th line. Further study in larger cohorts is required to confirm this finding and build on our understanding of clinical response to sequential lines of bDMARD therapy.References:[1]Hyrish et al 2006 Rheum 45, 1558-65[2]Kawabe A. 2020 Arth Res Ther 22, 136[3]Park DJ. 2017 Clin Rheum 36, 1013-22[4]Karlsson. 2007 JA Rheum 47,507-13Figure 1.Clinical and patient reported outcomes by line of therapyDisclosure of Interests:Abuelmagd Abdalla: None declared, Adwaye Rambojun: None declared, Laura C Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Gilead, Eli Lilly, Janssen, Medac, Novartis, Pfizer, and UCB., Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Pfizer, and Novartis, Eleanor Korendowych Consultant of: Abbvie, Celgene, Janssen, Lilly and Novartis., Neil McHugh: None declared, William Tillett Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc., and UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc., and UCB., Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc., and UCB.
Systematic collection of patient-reported outcomes in atrial fibrillation: feasibility and initial results of the Utah mEVAL AF programme