Rheumatologic and musculoskeletal diseases are among the most common disorders and causes of disability worldwide. Many of these require advanced therapeutics and subspecialty health care. In most of the countries, there is a shortage of trained specialists to treat patients with these diseases. The lack of subspecialty care, especially in low-resource countries, is largely attributable to a lack of or insufficient training opportunities for the rheumatology workforce. Addressing these issues will require expanding training programs, improving opportunities for fulfillment in rheumatology academic careers, and using technologies for training and as platforms to increase access to specialist care in remote areas.

BACKGROUND:The rheumatological management of older people with inflammatory rheumatic diseases (iRMD) is becoming increasingly more important. The 2026 annual report from the National Database (NDB) of the Collaborative Arthritis Centers focusses on characteristics of older patients with iRMD as well as on developments in drug therapy. METHODS:Within the NDB, patients under routine outpatient rheumatology care and the treating rheumatologists document disease outcomes, progression and treatment once a year. Data from 2010-2024 were included and analyzed by age groups. RESULTS:In 2024 a total of 13,416 patients from 14 rheumatology centers were included; 52% were ≥ 60 years old. The most common iRMD in patients aged ≥ 60 years were rheumatoid arthritis (RA 57%), psoriatic arthritis (PsA 12%), axial spondyloarthritis (axSpA 7%), polymyalgia rheumatica (PMR 6%) and giant cell arteritis (GCA 5%). The mean number of comorbidities increased with age, from 1.3 (18-39 years) to 4.4 (≥ 80 years). Women experienced more functional limitations and more pain in higher age groups. Older patients more frequently received glucocorticoids and analgesics but received biologics less frequently than younger adults. For example, RA patients ≥ 80 years, as compared to patients aged 18-39 years, received 25% (≥80 years) vs. 47% (18-39 years) biologics and 37% vs. 13% glucocorticoids. Nevertheless, changes still followed the general trend. Since 2010, the use of biologic disease-modifying antirheumatic drugs (bDMARD) increased from 7% to 25% among RA patients aged ≥ 80 years, while glucocorticoids decreased from 63% to 37%. CONCLUSION:Despite overall lower use of biologics in older age groups, long-term data from the NDB show that biologics are being prescribed more frequently also to older patients compared to previous calendar years.

Objectives The number of adults living with inflammatory rheumatic diseases (iRMDs) in a country is key for calculating the demand for rheumatologists. Our aim was to estimate the incidence and prevalence of iRMD in Germany by compiling current epidemiologic German and other European data. Methods A systematic review included original studies on prevalence and incidence of iRMDs in Germany and other European countries, covering study data from 2013 to the present. Considering heterogeneous methodology, we qualitatively estimated the prevalence and incidence for 11 iRMDs and extrapolated the results to the German population. Results A total of 20 German and 72 studies from other European countries were considered. All German studies used claims data with moderate to high risk of bias. Studies relying solely on International Classification of Diseases codes as case definition reported higher rates than those applying diagnostic criteria or multistage population-based methods. Prevalence ranges (with estimates for Germany in parentheses) per 100,000 are: rheumatoid arthritis 410 to 1380 (1000), polymyalgia rheumatica 100 to 937 (600 aged >50 years), axial spondyloarthritis 75 to 500 (300), psoriatic arthritis 20 to 580 (300), giant cell arteritis 76 to 250 (146 aged >50 years), primary Sjögren's disease 32 to 250 (70), systemic lupus erythematosus 35 to 210 (56), systemic sclerosis 17 to 50 (35), idiopathic inflammatory myopathies 17 to 25 (17), anti-neutrophil cytoplasmic antibody-associated vasculitides 14 to 43 (26), and Behçet’s disease 0.3 to 15 (4.7). Overall, we estimate the prevalence of iRMD in Germany to be 2.6% (1.8 million adults) and an annual incidence of 0.2% (130,000 adults). Conclusions This study compiles European epidemiological data on 11 iRMDs to calculate the number of people affected. The methodology could be a blueprint for studies in other regions.

OBJECTIVES:To describe inequalities in health indicators relevant for quality of care to people with rheumatic and musculoskeletal diseases (RMDs) across Europe by comparing RMD health system indicators across European Alliance of Associations for Rheumatology (EULAR) member countries. METHODS:RheumaFacts is an EULAR initiative to improve the quality of care across Europe by monitoring access to and outcomes of care for people living with RMDs. In this study, we present the first edition of this longitudinal mixed-sources study initiated in 2024. A standardised form including indicators on RMD health resources and organisation, national workforce, and access to care was sent to the 40 National Scientific Rheumatology Societies who were EULAR members in 2024 was sent to the EULAR-member National Scientific Rheumatology Societies of 40 countries. Complementary data on the demographic and economic status of the various countries were extracted from open-source databases such as the WHO and World Bank datasets. Analyses were descriptive. RESULTS:Standardised report forms were returned by 36 of 40 countries (90%). The density of rheumatologists ranged from 0.8 to 6.6 per 100,000 inhabitants (median, 2.9; IQR, 2.1-3.5) across the different countries. The reimbursement of nonpharmacological care on a chronic basis was limited: physiotherapy was reimbursed in 26 of 36 countries (72%), whereas psychological support was reimbursed in only 14 of 36 countries (39%). In 94% of the countries, all conventional synthetic disease-modifying antirheumatic drugs (DMARDs) were available. Despite all countries indicating the availability of at least 1 biologic DMARD, only 12 countries (34%) had access to all biologic DMARDs, and only 18 of 35 (51%) had access to all targeted synthetic DMARDs. CONCLUSIONS:Wide cross-national inequalities exist in workforce capacity and reimbursed care for people with RMDs. RheumaFacts delivers the first harmonised basis for monitoring these gaps, enabling EULAR and national societies to track progress and inform health policy makers to advocate for improving the quality of life of people with RMDs.

Die Versorgung älterer Menschen mit entzündlich-rheumatischen Erkrankungen (ERE) gewinnt immer mehr an Bedeutung. Im Jahresbericht 2026 aus der Kerndokumentation werden Charakteristika von Patienten mit ERE im höheren Lebensalter sowie Entwicklungen in der medikamentösen Therapie dargestellt. Patienten aus der ambulanten rheumatologischen Routineversorgung und ihre behandelnden Rheumatologen dokumentieren einmal jährlich Krankheitsverlauf, Therapien und Krankheitsfolgen. Es wurden Daten von 2010 bis 2024 berücksichtigt und nach Altersgruppen ausgewertet. Im Jahr 2024 wurden 13.416 Patienten aus 14 rheumatologischen Einrichtungen eingeschlossen, 52

To investigate associations with incident heart failure (HF) in patients with rheumatoid arthritis (RA) in relation to sex, traditional risk factors, and RA-specific factors, with analyses stratified by sex. Patients without prevalent HF enrolled between January 2007 and June 2022 in the biologics register RABBIT were included and followed up to 10 years until December 2022. Patients were observed from the time of enrollment until the diagnosis of HF (outcome of interest), death, dropout, or end of study, whichever occurred first. The association of sex with HF and the association of traditional and RA-specific variables with HF, stratified by sex, were analyzed using multiple logistic regression. The study sample consisted of 4022 men (3.9

OBJECTIVES:This study aims to provide an update of the European Alliance of Associations for Rheumatology (EULAR) rheumatoid arthritis (RA) management recommendations addressing the most recent insights. METHODS:An International Task Force was formed with a wide expertise and solicited 2 systemic literature research activities on the safety and efficacy of disease-modifying antirheumatic drugs (DMARDs). New evidence was discussed, considering the update from 2022. A voting process was applied to each item. Levels of evidence and strengths of recommendation were assigned, and participants voted on the levels of agreement. RESULTS:The task force agreed on 5 overarching principles and reduced the number of recommendations to 9 concerning use of conventional synthetic DMARDs (methotrexate [MTX], leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b)DMARDs (tumour necrosis factor inhibitors [adalimumab, certolizumab pegol, etanercept, golimumab, infliximab], abatacept, rituximab, tocilizumab, sarilumab, including biosimilars) and targeted synthetic [ts]DMARDs (namely the Janus kinase inhibitors [JAKi] tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target), and tapering following clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were considered. Initially, MTX ideally in combination with short-term GCs is recommended; upon insufficient response after 3 to 6 months, a bDMARD should be added; after careful consideration of risks, including MACEs, malignancies and/or thrombo-embolic events, JAKi may also be considered. If the first bDMARD (or JAKi) fails, any other bDMARD (from another or the same class) or JAKi (considering risks) is recommended. With sustained remission, DMARDs may be tapered, but caution is required as stopping often leads to a flare. Levels of evidence and levels of agreement were high for most recommendations. CONCLUSIONS:These updated EULAR recommendations provide consensus on RA management based on currently available evidence regarding efficacy, safety, and cost.

Background: Treating rheumatic musculoskeletal diseases (RMDs) during pregnancy and breastfeeding presents significant complexities, mainly due to inconsistencies between the clinical guidance documents and the reference safety information, including the summary of product characteristics (SmPC) and the patient information leaflets (PIL). Objectives: To assess healthcare professionals’ (HCPs) prescribing behaviors, comfort levels, and challenges when advising patients, focusing on discrepancies between clinical guidance documents and SmPC/PIL. Design: Online survey entitled PRAISE (Perception of healthcare providers Regarding Antirheumatics in pregnancy and breastfeeding: advice, Information and patient perSpEctives) and disseminated through HCPs groups and social media. Methods: A cross-sectional survey was conducted among 414 HCPs globally. Respondents were divided into prescribers ( n = 336) and non-prescribers ( n = 78) based on their self-reported role in prescribing antirheumatic medications to pregnant or breastfeeding patients with RMDs. The survey covered demographics, clinical experience, confidence in prescribing, use of clinical guidelines, and experiences managing conflicting information between guidelines and SmPC/PIL. Results: Prescribers were more likely than non-prescribers to feel comfortable discussing medication safety during pregnancy. Most prescribers found clinical guidance documents useful, with 48% rating them as “very useful” and 38% as “extremely useful.” In case of conflicting information between clinical guidance documents and SmPC/PIL, 58% of HCPs reported that it caused confusion and tension in patient–doctor relationships, and almost 20% of them are “likely” or “very likely” to discontinue ongoing treatment. Clear communication and shared decision-making were the most common strategies used to address patient concerns. Conclusion: HCPs often face significant challenges when advising patients with RMDs on the use of medications during pregnancy and breastfeeding. Conflicting information between clinical guidance documents and SmPC/PIL can disrupt patient–doctor relationship and lead to treatment discontinuation, with potential consequences on maternal disease control. Improved alignment between clinical guidance documents and the SmPC/PIL could enhance patient care and prevent confusion among HCPs and patients.

OBJECTIVES:To estimate the effects of Janus kinase inhibitors (JAKis) vs biologic disease-modifying antirheumatic drugs (bDMARDs) on the risk of incident malignancies (excluding nonmelanoma skin cancer) in patients and patient subgroups with rheumatoid arthritis. METHODS:Episodes of disease-modifying antirheumatic drug (DMARD) treatment initiated between January 2017 and December 2020 and followed up to June 2024 in RABBIT, the German register for the long-term observation of therapy with biologics and targeted disease-modifying antirheumatic drugs in adult patients with rheumatoid arthritis, were analysed. Incidence rates (IRs) per 1000 patient-years with 95% CIs were calculated, and incident malignancy risk was estimated as hazard ratios (HRs) by inverse probability weighted adjusted Cox models. RESULTS:Among 2285 JAKi and 4259 bDMARD treatment episodes, 88 and 135 malignancies occurred, respectively. JAKi treatments were dominated by baricitinib and tofacitinib, while most bDMARD treatments comprised tumour necrosis factor inhibitors. IRs were 11.6 (95% CI: 9.3, 14.3) in JAKi- and 8.9 (95% CI: 7.4, 10.5) in bDMARD-treated groups. The adjusted HR comparing JAKis with bDMARDs was 1.40 (95% CI: 1.09, 1.80). An increase in the malignancy risk for JAKi vs bDMARD treatment could only be observed in treatment episodes lasting longer than 16 months. The risk appeared higher in some subgroups of patients, including those who started treatment aged ≥60 years, patients with ≥3 prior conventional synthetic DMARD treatments, and patients with high disease activity. CONCLUSIONS:In this German observational cohort study, an overall small increase in malignancy risk for JAKi vs bDMARD treatment was observed, with more pronounced risks in some subgroups of patients. The observed risk should be carefully counterbalanced to the known malignancy risk associated with insufficient disease control.

OBJECTIVE:Our objective was to assess the incidence of major adverse cardiovascular events (MACEs) in patients with rheumatoid arthritis (RA) treated with JAK inhibitors (JAKi), tumor necrosis factor inhibitors (TNFi), or biologic disease-modifying antirheumatic drugs with other modes of action (bDMARD-OMA) in a multicountry, real-world population. METHODS:Patients with RA from 15 registries in the JAK-pot collaboration were included. MACE incidence was analyzed using two approaches: a within-registry analysis aggregating country-specific estimates from registers with >25 incident MACEs through meta-analysis and an individual-level data combined analysis. We used adjusted linear mixed Poisson regression to obtain incidence rate ratios (IRRs) of MACEs between treatment groups, accounting for multiple treatment courses. RESULTS:The study included 73,008 treatment courses (16,417 JAKi, 35,373 TNFi, and 21,218 bDMARD-OMA) and 828 incident MACEs among 51,233 patients. Median follow-up time was 1.3 years, with most of the follow-up concentrated in the first two years of treatment. Incidence rates were 7.0, 7.6, and 11.8 per 1,000 person-years for JAKi, TNFi, and bDMARD-OMA, respectively. Compared to TNFi, JAKi (within-registry adjusted IRR 0.89, 95% confidence interval [CI] 0.63-1.25) had similar incidence rates of MACEs and bDMARD-OMA had higher rates (within-registry adjusted IRR 1.35, 95% CI 1.10-1.66). Combined analysis showed similar results. CONCLUSION:Observational data from the JAK-pot collaboration show no evidence of an increase in cardiovascular events during the first two years of use with JAKi compared to TNFi in the general RA population.

BACKGROUND:The number and scope of work of rheumatology specialists are crucial for the care of patients with inflammatory rheumatic diseases. We report on current developments in numbers of rheumatologists up to 2024. METHODS:The number of internal medicine specialists in rheumatology is reported by age group, gender, field of activity, and scope of activity based on medical statistics from the German Medical Association (BÄK), the Federal Register of Physicians of the National Association of Statutory Health Insurance Physicians (KBV), basic data from hospitals, and extrapolated to the population figures of the Federal Statistical Office. RESULTS:As of 31 December 2024, there were 1161 practicing rheumatology specialists, of whom 531 (46%) were female and 386 (33%) were aged 60 or older. The number and proportion of rheumatologists under the age of 60 fell from 806 (73%) in 2020 to 775 (67%) in 2024. A total of 725 rheumatologists were accredited to work in outpatient practices for national health insurance patients. Of these, 301 (42%) were employed, an increase compared with 2020 (148 [30%]). In contrast, the number of licensed rheumatologists fell from 392 (57%) to 365 (50%). For every 100,000 adults in Germany, there were 1.7 practicing rheumatologists, 1.0 of whom was accredited to outpatient contracted care, with regional variations ranging from 0.8 in Saarland to 1.6 in Brandenburg and Hamburg (persons, not full-time employees). Since 2018, the number of rheumatologists in hospitals has risen from 360 to 386 in 2023; part-time employment increased from 25% to 39%. The annual average number of full-time inpatient staff has fallen from 340 to 312. Between 2020 and 2024, a total of 303 new rheumatology specialists were recognized, corresponding to an average of 61 specialists per year. CONCLUSION:The decline in the number of younger rheumatology specialists, coupled with an increase in part-time work, is leading to a decrease in rheumatology capacity in Germany. The current rate of further training is not sufficient to compensate for the age-related retirement of rheumatologists, let alone the loss of full-time positions.

BACKGROUND:Data of patients with inflammatory rheumatic diseases are annually recorded within the National Database of the German Collaborative Rheumatology Centers. METHODS:For rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondylarthritis (axSpA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), Sjögren's syndrome (SjS), idiopathic inflammatory myositis (IIM), polymyalgia rheumatica (PMR), giant cell arteritis (GCA), ANCA-associated vasculitis (AAV), Behçet's disease (BD), adult onset Still's disease (AOSD) and autoinflammatory diseases (AID) data are reported from 2023. Information includes physician-reported disease activity on a numeric rating scale (NRS) of 0-10, treatment and patient-reported outcomes. For selected diagnoses, developments from 2010 to 2023 are presented regarding physicians' assessments of disease activity and treatment. RESULTS:A total of 13,884 patients were documented from 14 rheumatology centers, most frequently with RA (5734), PsA (1741) and axSpA (1494). The mean age ranged from 45 years (BD) to 73 years (GCA) and the median disease duration ranged from 3 years (PMR) to 16 years (axSpA). Disease activity was predominantly low, with 6% (BD) to 15% (axSpA) rated moderate to high (> 4 on the NMR) by rheumatologists. Biological disease-modifying antirheumatic drugs (bDMARD) were most frequently prescribed for axSpA (65%), AOSD (58%), PsA (53%) and GCA (41%). Tumor necrosis factor (TNF) inhibitors were frequently used in axSpA (53%), BD (30%) and PsA (28%), interleukin (IL)-1 inhibitors in AOSD (51%) and AID (50%), IL-6Ri in GCA (38%), IL17i in PsA (17%) and rituximab in AAV (29%). Higher levels of pain, fatigue, sleep disturbances and reduced well-being were reported by patients with IIM, SSc, axSpA and AID. Among those younger than 65 years, 58% (SSc) to 77% (axSpA) were employed. The percentage of early retirement due to rheumatic diseases was 5% (AOSD) to 18% (AAV). Since 2010 the development in the proportion of patients in remission or with very low disease activity (NRS 0-1) has increased across all diagnoses. In terms of treatment there has been an increase in b/tsDMARDs and a decrease in glucocorticoids for various diagnoses. CONCLUSION:The results show the diversity of inflammatory rheumatic diagnoses and the continuously growing range of treatment in rheumatology along with good disease control in many patients.

The European biologics registers are a new generation of observational studies that provide robust real-world data on the long-term safety and effectiveness of new therapies. The safety results so far are reassuring: while all new therapies carry an increased risk of serious infections because of their potent immunosuppression, this can be offset by successful control of disease activity and glucocorticoid tapering. Joint register analyses have convincingly shown that tumour necrosis factor inhibitors do not increase the risk of solid malignancies or lymphoproliferative disorders. Tight control of disease activity with the new therapies has a protective effect against myocardial infarction, stroke and all-cause mortality. Overall, the risks of uncontrolled disease activity have been shown to far outweigh those of the new therapies. Drug-specific risks have been identified for lower gastrointestinal perforations, interstitial lung disease and skin cancer.

A scoping review was conducted to compile evidence on sex-specific differences in systemic lupus erythematosus (SLE) with focus on autoantibodies, organ manifestation, damage, treatment and patient-reported outcomes (PROs). Systematic searches in PubMed and Cochrane were performed including meta-analyses, observational studies and clinical trials from 01/2015 to 11/2024. Studies of adults with SLE reporting outcomes by sex were eligible. The research protocol is registered in the Registry for Scoping Reviews (OSF, https://osf.io/gfbs9 ). From 373 screened articles, 81 publications were included. Studies comprised differences in autoantibodies (n = 13), damage (n = 40), organ involvement (n = 27), treatment (n = 14), and PROs (n = 6). Twenty studies compared proportions of outcomes by sex with patient numbers ranging from 98 to 11,943. The female/male ratio was between 4:1 and 11:1. The review found a higher age at onset in men and a higher proportion of positive lupus anticoagulant, nephritis, serositis, antiphospholipid syndrome, greater renal and cardiovascular damage and severe infections. SLE in women more often presented with Ro/SSA autoantibodies, alopecia, photosensitivity, Raynaud, and osteoporosis. Some studies showed more frequent cyclophosphamide and less frequent antimalarials in men. Little evidence indicated more frequent non-adherence with azathioprine and mycophenolate in women. Limited evidence was available for PROs. This review confirms significant sex differences in SLE, with men showing later onset, more severe organ damage, and distinct autoantibody and treatment patterns, while women more often present with Ro/SSA autoantibodies, photosensitivity, and osteoporosis. Evidence on patient-reported outcomes remains limited, highlighting the need for further research to guide sex-specific management.

Musculoskeletal disorders are a significant public health burden concern, projected to increase in the coming decades, and will substantially contribute to the rising prevalence of functional impairment, frailty and disability in a growing global population. Since persons with musculoskeletal disorders tend to have immune dysfunction, inflammation or be taking immunosuppressive medication, prevention of vaccine-preventable diseases (VPDs) in this group is particularly important. The European Interdisciplinary Council for Aging (EICA) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) jointly convened a 2-day in-person and virtual meeting on 26–27 September 2023, to review the state of the evidence on the link between musculoskeletal diseases, infections and vaccines. We present here the Executive Summary of the proceedings of this meeting. We review the importance of physical activity in preventing or mitigating both musculoskeletal diseases and risk of infection. We summarize current knowledge of the impact of common VPDs on the development and progression of musculoskeletal diseases, and the role of selected vaccines in preventing onset and worsening of frailty and disability in these individuals. This report summarizes the evidence presented at the two-day meeting, highlighting the need to raise awareness among scientists, healthcare professionals, decision-makers, civil society and the general public about the long-term sequelae of VPDs, with focus on the health status of older patients with musculoskeletal diseases.

Background: The main goals of the disease registry RABBIT-SpA for axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) are to analyse the long-term effectiveness and safety of the antirheumatic drugs used for these chronic conditions. While the registry focuses on documenting antirheumatic drugs, the recording of co-medication has been inadequate, despite growing awareness of the importance of comorbidities in the outcomes of rheumatic and musculoskeletal diseases. Research question and objective: The primary objective is the data protection-compliant integration of a medication reminder app into the registry’s existing online documentation system, providing a technically simple solution for participating rheumatologists. Secondary objectives include the direct documentation of medication by patients using the integrated app and the more frequent capture of patient-reported outcome (PRO) parameters. The main research question of this preliminary analysis is the concordance between the anti-rheumatic medication documented by the patient via the app and by the rheumatologist via the registry. Methods: RABBIT-SpA is a disease registry for axSpA and PsA. A study version of the MyTherapy app was developed by expanding the generic app, which primarily records medication and provides medication reminders, to include questions from the RABBIT-SpA patient questionnaire (covering pain, health status, global disease activity, sleep disorders, and skin involvement). Patients use their own Android or iOS smartphones and provide informed consent for participation. Results: The integration process was successfully implemented. Personalized QR codes were generated from the registry documentation system, enabling patients to download the study version of the MyTherapy app and link their data using a second pseudonym. As of now, 367 patients have been invited to participate, with 139 consenting and 76 successfully using the app. App users are generally younger and more often male compared to the overall registry cohorts. On average, 4.7 medications were recorded per patient (range 1–42), with a high concordance (94%) between the medications documented in the app and those in the registry. The proportion of patients with polypharmacy (defined as the simultaneous documentation of five or more medications) is 25%. Discussion: The integration of the medication reminder app into the RABBIT-SpA registry was successfully achieved in a data protection-compliant manner. The antirheumatic drugs documented in the app were concordant to the registry data. The integration of an app to an ongoing disease registry offers the possibility of supplementing data from the registry with patient generated data.