David F. L. Liew

Immune checkpoint inhibitor-associated inflammatory arthritis (ICI-IA) represents the most common rheumatic immune-related adverse event, characterized by a distinct clonal expansion of CD8⁺ T cells that often mirrors the immune pathways driving antitumour responses. Clinically, ICI-IA presents with diverse phenotypes, including polyarticular and oligoarticular patterns, and is notably persistent, often continuing as a chronic condition long after the cessation of immunotherapy. Unlike traditional autoimmune arthritis, ICI-IA is predominantly seronegative, making diagnosis reliant on clinical recognition and the exclusion of mimics such as metastatic cancer and other immune-related adverse events. Management strategies prioritize symptom optimization to maintain patient quality of life and facilitate the continuation of life-saving cancer therapy. Treatment includes glucocorticoids and increasing use of conventional and biologic DMARDs. This approach is aimed at minimizing glucocorticoid toxicity while preserving the efficacy of the checkpoint inhibitor therapy, highlighting the need for a balanced, multidisciplinary approach to care.

Aim: To describe Australian trends in JAKi uptake, where there are no restrictions on the sequence of their use in clinical practice. Methods: We included all people aged 18 years and over initiating a JAKi between 1 October 2015 and 31 August 2022. We used national dispensing claims data for a random 10% sample of Australians to: describe the number of people initiating JAKi per quarter; the characteristics of new JAKi users including demographics, use of other medicines to manage cardiovascular comorbid disease; and use of prior targeted therapy (biologics or small molecule inhibitors). We used Kaplan–Meier analysis to estimate the proportion of initiators who were persistent on their initial JAKi to 365 days. Results: We identified 2904 people initiating JAKi treatment between 1 October 2015 and 31 August 2022; new use increased consistently during the study period. 45% of initiators had not been dispensed a prior subsidised targeted therapy in 365 days prior to JAKi initiation; 72% of new users were female and 62% were aged 55 years or older. Almost half of people initiating JAKi had at least one marker of higher cardiovascular risk, with 30% dispensed medicines to treat or prevent cardiovascular disease in the year prior to initiation; and 34% being aged 65 years or older. 60% of people persisted on their initial JAKi therapy to 365 days. Of those who stopped, 51% switched to a biologic and 15% switched to a different JAKi. Conclusion: In a setting where JAKi are permitted to be used in any line of therapy, 45% of new users of JAKi were naïve to targeted therapy and half had at least one marker of cardiovascular risk. Continued monitoring is required to understand the risk profile of JAKi, particularly in those with high baseline cardiovascular disease risk.

Background: Polymyalgia rheumatica is the commonest inflammatory condition affecting adults over 50 years of age, however it has been under‐researched and management varies in everyday clinical practice. Aim: This national survey of rheumatologists and trainees managing polymyalgia rheumatica (PMR) in Australia sought to determine current diagnostic and management approaches and establish a baseline for future development of a disease‐specific clinical care standard. Methods: Following ethics approval, an online survey was circulated to the membership of the Australian Rheumatology Association. Relevant demographic information about respondents was collected, along with answers to multiple‐choice questions on the clinical presentation, diagnosis, management and prognosis of PMR. Free‐text responses were also permitted at the end of each section. The survey remained open between 25 March 2022 and 11 November 2022. Data analysis involved descriptive statistics for multiple‐choice questions and thematic analysis for free‐text responses. Results: Seventy‐nine clinicians completed the survey, of whom the majority were qualified rheumatologists who regularly managed patients with PMR. Most respondents relied upon clinical diagnosis, but some did not recognise peripheral joint involvement or normal inflammatory markers as possible features of PMR. Access to imaging investigations like ¹⁸ F‐fluorodeoxyglucose positron emission tomography combined with computed tomography was limited but desirable in circumstances of diagnostic uncertainty. Management predominantly involved glucocorticoid monotherapy; however, long‐term outcomes were diverse and almost every clinician had prescribed a conventional synthetic DMARD for steroid‐sparing purposes. The use of adjunctive physical therapy was inconsistent. Conclusion: Variability remains in the diagnosis and management of PMR among Australian clinicians, with gaps in recognition of atypical presentations, imaging access and incorporation of physical therapy, ultimately supporting the need for standardised, evidence‐based clinical care guidelines.

Introduction: High‐risk medications are medications associated with significant patient harm or death if misused or used in error. This study aimed to develop a national consensus high‐risk medication list for use in Australian residential aged care. Methods: A 3‐round modified Delphi study involving Australian healthcare professionals was conducted. In Round 1, participants indicated their level of agreement, on a 9‐point Likert scale, whether 60 medications/medication classes were considered high‐risk and should be included in a high‐risk medication list for Australian residential aged care. Round 2 included medications/medication classes that did not reach consensus and new medications identified by participants. Consensus was defined as 70% or more of participants responding at 7 or higher on the Likert scale. In Round 3, participants were asked to prioritise medications/medication classes that reached consensus in Round 1 or 2. Results: In total, 42 participants completed Round 1, and 35 (83%) completed all three rounds. Participants included pharmacists ( n = 21), prescribers ( n = 15), nurses ( n = 5) and a paramedic ( n = 1), with representation from all Australian states and mainland territories. Overall, 26 medications reached consensus (21 in Round 1, five in Round 2) and were categorised into 15 medications/medication classes for prioritisation in Round 3. The final prioritisation list was opioids, insulin, benzodiazepines, anticoagulants, z‐drugs, antipsychotics, lithium, sulfonylureas with high risk of hypoglycaemia, chemotherapeutic agents, methotrexate, digoxin, narrow therapeutic range antiepileptics, tricyclic antidepressants, immunosuppressants for transplant and sedating antihistamines. Discussion: This is the first, national consensus list of high‐risk medications developed specifically for Australian residential aged care. It can be used to implement targeted strategies to minimise medication‐related harm.

Introduction: Giant cell arteritis (GCA) is the most common vasculitis of the elderly. Delayed diagnosis or inadequate treatment can lead to severe and irreversible consequences. There are limited data on diagnosis and management practices of rheumatologists and rheumatology trainees in Australia. This study aimed to determine practices and views of Australian rheumatologists/rheumatology trainees in the diagnosis and management of GCA. Methods: An online survey was completed by Australian rheumatologists/trainees. The survey gathered data on the respondent demographics and a range of topics related to the diagnosis and management of GCA, including the use of temporal artery biopsy (TAB) and imaging, confidence in ultrasound, use of steroid‐sparing medication, and approaches to aortic aneurysm screening and referral back to primary care. Results: There were 58 respondents (52 rheumatologists, six trainees). On average, respondents used TAB alone (56% of respondents), imaging alone (19%), both (15%) or neither (10%). The majority of respondents (79%) rarely or never made a diagnosis of GCA without TAB. Only 40% expressed confidence in GCA diagnosis by temporal artery ultrasound from their preferred radiology provider. Management approaches following the end of government‐funded tocilizumab varied. Only 12% of respondents reported that >50% of their GCA patients were able to cease prednisolone by 12 months. Conclusions: Australian rheumatologists and trainees have low confidence in ultrasound and rarely make a diagnosis of GCA without a TAB. Variable practice would support the need to develop Australian clinical care standards for GCA.

Purpose The utility of ¹⁸F-fluorodeoxyglucose positron emission tomography with low-dose computed tomography (¹⁸F-FDG PET/CT) to diagnose patients with atypical features but clinically confirmed PMR is unknown. This study explored ¹⁸F-FDG PET/CT findings among atypical PMR cases and contrasted results with a typical PMR population. The performance of an AI model for PMR diagnosis was also tested. Methods Natural language processing searched the electronic data warehouse at our institution for ¹⁸F-FDG PET/CT reports with PMR findings. Medical record review confirmed the clinical diagnosis for potential cases. Required entry Criteria of the 2012 EULAR/ACR Classification for PMR (age ≥50 years, bilateral shoulder aching and abnormal CRP and/or ESR) stratified patients as “typical” or“atypical”. Qualitative and semi-quantitative (SUV_max) scoring of ¹⁸F-FDG uptake at characteristic musculoskeletal sites was undertaken for steroid-naïve, atypical PMR patients and compared with results for steroid-naïve, typical cases from an earlier study. A ResNet50 AI model was tested on the atypical cohort’s images, with GradCam maps generated and cross-checked by an experienced clinician. Results 225 ¹⁸F-FDG PET/CT reports were retrieved from >38,000 scans; 121 patients had a clinical PMR diagnosis. Seventeen steroid-naïve, atypical cases were compared with 35 steroid-naïve, typical patients. The frequency of abnormalities at key musculoskeletal sites was similar between groups, however mean SUV_maxwas significantly higher in the typical cohort. The AI model identified a PMR diagnosis in 16/17 (94.1%) atypical patients. Conclusion Characteristic findings of PMR are appreciated on ¹⁸F-FDG PET/CT among atypical patients, but avidity is reduced. AI technology can reliably detect this imaging pattern. Words: 249 _{(max. 250)}.

Background: Anti-interleukin-1 (IL-1) biologic disease-modifying anti-rheumatic drugs are the mainstay for several childhood rheumatic and autoinflammatory diseases. Long-term medication safety is a key consideration for chronic disease management. Aim: The objective was to synthesise evidence on the long-term safety of anti-IL-1 medications in children and young people with rheumatic diseases, including autoinflammatory diseases. Methods: The study protocol was registered prospectively (PROSPERO CRD420251000272). Original full text studies of at least ten patients presenting safety data on anti-IL-1 medications in children with rheumatic diseases were eligible for inclusion. Medline, Embase and Web of Science were searched from inception to 27 February 2025. The methodological index for non-randomized studies (MINORS) tool was used to assess risk of bias. All relevant safety outcomes were presented and synthesised. Meta-analysis was not performed owing to study heterogeneity. Results: A total of 1660 unique records were screened, and 57 unique studies (3690 patients) were included. In total, 31 were retrospective cohort studies, and 10 were prospective interventional trials. Most studies were of moderate ( n = 31) or high ( n = 25) risk of bias. Rates of adverse events varied significantly between studies. Injection site reactions (particularly with anakinra) and minor infections were common. Infections were the most common type of serious adverse event. Drug reaction with eosinophilia and systemic symptoms ( n = 3) and interstitial lung disease (including related conditions) ( n = 9) were reported in patients with systemic onset juvenile arthritis only. Deaths ( n = 16) and malignancies ( n = 7) were uncommon, often occurring long after anti-IL-1 medication discontinuation and were often deemed to be unrelated to the anti-IL-1 medication. Conclusions: Our results are consistent with the known safety profile of anti-IL-1 medications and show that they are generally safe for use in the context of childhood rheumatic and autoinflammatory diseases. This review of clinical trial and real-world data will help inform clinical decision-making and family counselling when initiating anti-IL-1 medications in children.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating pain and inflammation across a wide range of conditions. Choosing an NSAID requires an understanding of their different risk profiles in the context of individual patients.

Introduction: The efficacy and safety of SMS text message-delivered interventions for providing pain self-management education and improving clinical pain outcomes have been demonstrated in several randomised controlled trials. However, little is known about the feasibility and effectiveness of these interventions within Australian hospital settings. The current protocol describes a trial designed to evaluate the effectiveness and implementation of an SMS text message-delivered intervention designed to support patients’ engagement with pain self-management strategies and improve clinical pain outcomes after total knee replacement surgery. Methods and analysis: A hybrid, type 1 effectiveness-implementation trial will be conducted at a private hospital in Australia. Participants (n=130) will be randomised to either the intervention group (receiving a pain self-management educational video prior to surgery, plus daily SMS text message reminders for 3 weeks after surgery) or an active control group (receiving the pre-surgery video alone, without text message reminders) in addition to usual care. Effectiveness outcomes will be pain intensity (primary), opioid dose, knee function and pain-related distress and will be recorded at baseline, 3 days, 3 weeks, 6 weeks, 3 months and 6 months after surgery using self-reported surveys. Pain self-efficacy and health-related quality of life will be measured at 6 weeks, 3 months and 6 months post-surgery. Implementation outcomes (Reach, Experience, Adoption, Implementation, Maintenance) will be evaluated using mixed (qualitative and quantitative) methods. This trial represents a first step towards the translation of digitally delivered postoperative support for engaging with pain self-management in the Australian healthcare system. Ethics and dissemination: The study protocol was reviewed and approved by the Austin Health Human Ethics Research Committee (Australia, HREC/110142/Austin-2024). Study results will be published in a peer-reviewed journal and presented at scientific and professional meetings. Trial registration number: ACTRN12624001060538