Christoph Kuhn

More efficient means of identifying patients with inflammatory rheumatic diseases (IRDs) could allow earlier diagnosis and treatment. The objective of this study was to evaluate the characteristics of a revised version of an online patient questionnaire-based self-referral tool, RhePort 1.3. This prospective study included adult patients with musculoskeletal complaints presenting for a first rheumatology visit at German RheumaDatenRhePort (RHADAR) rheumatology network centers. All patients completed the RhePort 1.3 questionnaire on patient characteristics and symptoms. Data from RhePort 1.3 were compared with historical data from previous versions. Of 614 patients, 225 (36.6%) were diagnosed with an IRD by a rheumatologist and 164/225 IRD patients (72.9%) had a RhePort 1.3 score > 1, the cut-off point used to determine the need for rheumatologic evaluation. A score > 1 was associated with an approximately two-fold higher IRD risk (odds ratio [95% confidence interval] of 1.98 [1.39, 2.83] vs ≤ 1) and had good sensitivity (73%) and moderate specificity (42%). Among patients referred through a standard referral pathway (n = 283), RhePort 1.3 scores > 1 in addition to physician referral were associated with increases in rheumatology-diagnosed IRD rates from 33.2% (physician referral only) to 45.7%. RhePort 1.3 had higher accuracy than earlier versions (54% vs 35%). We conclude that modest changes to the RhePort questionnaire resulted in increased accuracy. A score > 1 was associated with a doubled risk for an IRD and higher IRD rates in physician-referred patients. These data suggest that RhePort has the potential to streamline the rheumatologist’s workload and improve resource use. Further modifications are required to improve specificity.

Numerous biologic and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) have been approved for treating rheumatoid arthritis (RA), including Janus kinase inhibitors (JAKi), rituximab, abatacept, interleukin-6 inhibitors (IL-6i) and tumor necrosis factor inhibitors (TNFi). Real-world data regarding treatment persistence and drug survival in the time period following the approval of JAKI are limited. To investigate the persistence and drug survival of different (b/tsDMARDs) in patients with RA based on real-world data from German outpatients. We performed a retrospective analysis of RA patients in the German RHADAR database who received a newly prescribed therapy with a b/tsDMARD between January 15, 2015 and October 17, 2023. To compare drug survival, we used Cox regression analyses adjusted for age, sex and disease duration. We included 4678 patients (79.9% female, mean age 58.7 years, mean disease duration 11.7 years). TNFi (47.8%) and JAKi (29.4%) were most frequently prescribed. The five-year drug survival rate was highest for JAKi (68.3%), followed by TNFi (58.6%), IL-6i (58.6%), abatacept (55.0%), and rituximab (53.3%). Compared to JAKi, Cox regression showed a higher discontinuation risk for rituximab (HR 1.36, p = 0.015), abatacept (HR 1.46, p < 0.001), IL-6i (HR 1.20, p = 0.026), and TNFi (HR 1.29, p < 0.001). Rituximab had the highest two-year survival (70.3%) but a sharp decline afterward, with 60% of discontinuations occurring between March 2020 and July 2022. In a real-world setting in German outpatients with RA, JAKi was associated with longer drug survival than bDMARDS. There were no significant differences in treatment persistence among different bDMARDs.

In recent years Janus kinase inhibitors (JAKi) have joined tumor necrosis factor inhibitors (TNFi) and interleukin (IL)-17 inhibitors (IL-17i) as approved disease modifying anti-rheumatic drugs (DMARD) for moderate to severe forms of axial spondyloarthritis (axSpA). Drug survival in axSpA patients has not been well studied in a real-world outpatient scenario since the approval of JAKi. We aimed to analyze the three drug classes based on modes of actions (MoA) for their persistence rates among German axSpA outpatients. A retrospective analysis of the RHADAR database for axSpA patients with a new initiation of TNFi, IL-17i, or JAKi treatment between January 2015 and October 2023 was conducted. Analyses included Kaplan-Meier curves and adjusted Cox regressions for drug discontinuation. 1222 new biological DMARD (TNFi [n = 954], IL-17i [n = 190]) or JAKi (n = 78) treatments were reported. The median drug survival was 31 months for TNFi, 25 for IL-17i, and 18 for JAKi. The corresponding 2-year drug survival rate was 79.6%, 72.6%, and 62.8% for TNFi, IL-17i, and JAKi, respectively. The probability for discontinuation for JAKi was significantly higher compared with TNFi (HR 1.91 [95% CI 1.22–2.99]) as well as for IL-17i compared with TNFi (HR 1.43 [95% CI 1.02–2.01]), possibly related to more frequent use of TNFis as first-line therapy. IL-17i and JAKi discontinuation probabilities were similar. Primary non-response was the reason for drug discontinuation in most cases across all MoA. TNFi treatment might persist longer than JAKi and IL-17i in German axSpA outpatients, possibly related to more severe or refractory disease in patients with JAKi-treated or IL-17i-treated axSpA.

The categorization of axial spondyloarthritis (axSpA) into radiographic (r-axSpA) and non-radiographic (nr-axSpA) subtypes is important in clinical trials but may be of less value in clinical practice. This exploratory cross-sectional, multi-center study evaluated patients with axSpA under routine care at German clinical rheumatology sites (RHADAR real-world database), with a focus on imaging data used for diagnostic classifications. Our analyses included 371 patients with axSpA. The mean (standard deviation [SD]) age was 50.9 (14.0) years, disease duration was 16.4 (13.5) years, and 39.6% were female. Based on the rheumatologist’s final assessment, almost half of patients had definite r-axSpA (n = 179; 48.2%), 53 (14.3%) had suspected r-axSpA, 112 (30.2%) had non-radiographic-axSpA (nr-axSpA), and 27 (7.3%) had undefined axSpA. Patients assessed with definite or suspected r-axSpA were more likely to be treated with disease-modifying antirheumatic drugs (DMARDs) (62.0% and 64.2%, respectively) compared with nr-axSpA or undefined axSpA patients (37.5% and 48.1%, respectively). Almost all patients (348/371; 93.8%) had sacroiliac joint imaging data (radiographs or magnetic resonance imaging) documented in their charts, but only 216 (58.2%) had conventional radiographs required for formal diagnosis of r-axSpA by modified New York criteria. Follow-up radiographic imaging in nr-axSpA patients was uncommon (23/216 [25.0%]) but confirmed r-axSpA in 9/23 patients (39.1%). In conclusion, radiographs were available for slightly more than half of axSpA patients. Follow-up imaging was infrequent during rheumatology care in Germany but confirmed r-axSpA in ~ 40% of patients originally considered to have nr-axSpA. The distinction between r-axSpA and nr-axSpA may be ill-defined in routine clinical practice.

Real-world data are crucial to continuously improve the management of patients with rheumatic and musculoskeletal diseases (RMDs). The German RheumaDatenRhePort (RHADAR) registry encompasses a network of rheumatologists and researchers in Germany providing pseudonymized real-world patient data and allowing timely and continuous improvement in the care of RMD patients. The RHADAR modules allow automated anamnesis and adaptive coordination of appointments regarding individual urgency levels. Further modules focus on the collection and integration of electronic patient-reported outcomes in between consultations. The digital RHADAR modules ultimately allow a patient-centered adaptive approach to integrated medical care starting as early as possible in the disease course. Such a closed-loop system consisting of various modules along the whole patient pathway enables comprehensive and timely patient management in an unprecedented manner.

UNSTRUCTURED Real-world data are crucial to continuously improve the management of patients with rheumatic and musculoskeletal diseases (RMDs). The German RheumaDatenRhePort (RHADAR) registry encompasses a network of rheumatologists and researchers in Germany providing pseudonymized real-world patient data and allowing timely and continuous improvement in the care of RMD patients. The RHADAR modules allow automated anamnesis and adaptive coordination of appointments regarding individual urgency levels. Further modules focus on the collection and integration of electronic patient-reported outcomes in between consultations. The digital RHADAR modules ultimately allow a patient-centered adaptive approach to integrated medical care starting as early as possible in the disease course. Such a closed-loop system consisting of various modules along the whole patient pathway enables comprehensive and timely patient management in an unprecedented manner.