E085 Advanced therapy use in rheumatoid arthritis patients with moderate disease activity in a large NHS Foundation Trust in South London, UK

Background/Aims Moderate disease severity in rheumatoid arthritis (RA) is defined as a 28-joint disease activity score (DAS28) of 3.2-5.1 (MDAS). The National Institute for Healthcare Excellence (NICE) guidelines recommend that patients with moderate RA, failing treatment with ≥ 2 conventional disease-modifying anti-rheumatic drugs (cDMARDs) should be assessed for eligibility for treatment with a TNF-inhibitor, upadacitinib, filgotinib or tofacitinib. This audit aimed to assess compliance with NICE guidance on escalation to advanced therapies in moderate RA across four NHS Trust hospital sites in South London. Methods All patients with a confirmed diagnosis of RA (EULAR/ACR 2010 criteria) seen in rheumatology clinic in the past 24 months were extracted from King’s College Healthcare NHS Trust’s electronic health record system (Epic). Patients were stratified into two groups: i) Patients established on an advanced therapy via a moderate RA pathway; ii) Patients not established on an advanced therapy. All patients in group i were automatically eligible for inclusion. Patients in group ii were included if they had confirmed MDAS at their most recent clinical review and met criteria for escalation to an advanced therapy. If MDAS was present, the reason for non-initiation of advanced therapy was extracted from Epic. Other data extracted included demographics, DAS28, comorbidities and treatment history. The standards specified in NICE technology appraisals (TA715, TA676, TA744) were used to assess compliance with NICE guidance. Results In total, 87 patients were commenced on advanced therapies via a moderate RA pathway (mean age [SD]: 53 [14.7]; 55% female), most commonly adalimumab (n = 70). Of the 1000 patients not established on an advanced therapy, 23% (n = 232) had no DAS recorded or inadequate information to calculate a DAS score, most commonly due to absence of patient global health assessment or up-to-date erythrocyte sedimentation rate or C-reactive protein. 4% (n = 41) only had telephone encounters during the audit period. 17% (n = 169) of patients not established on advanced therapies had MDAS recorded at their most recent clinic visit. 30% (n = 51) of these patients were deemed eligible for escalation to an advanced therapy. No offer of or discussion of escalation to an advanced therapy was documented for 55% (n = 28) of eligible patients. When escalation to advanced therapies had been discussed, medication hesitancy was the most common reason for declining treatment (30% [n = 7]). Conclusion Our results show partial compliance with NICE guidance on escalation to advanced therapies in moderate RA. Missing DAS scores—mainly from absent recent blood tests—and increased telehealth use limited eligibility assessments. A cyber-attack within this NHS Trust may have contributed to reduced blood test access. Clinicians may be more reluctant to commence advanced therapies in patients who have expressed medication hesitancy. Utilisation of self-assessment tools, appropriate telehealth triage, and shared decision-making may facilitate escalation to advanced therapies.