Benzodiazepines are approved for and used in the treatment of anxiety, insomnia, seizures, and alcohol withdrawal. However, benzodiazepine prescriptions often do not align with regulatory approved (i.e. “on-label”) indications, or duration, which can result in serious adverse drug events, especially among older people. Benzodiazepine labels universally warn against long-term use due to known adverse effects, dependence, and withdrawal symptoms. It is therefore important to understand factors associated with durations longer than regulators approved (i.e. “off-label” duration). This can be challenging due to a lack of data on prescribed duration of treatment and treatment indication. The aim of this study is to identify risk factors for long-term benzodiazepine use. Data from the MOXXI (Medical Office of the XXIst century) electronic health record system in Quebec Canada was used to collect benzodiazepine prescription indication and duration, which was then integrated with the public pharmacare system to determine dispensation in the period between December 17th, 2002 and December 31st, 2023. The entire dataset was used. Each drug indication and duration was retrospectively classified as either on-label or off-label, and short-duration (≤30 days) or long-duration (>30 days) according to the Health Canada drug database. To assess determinants of long-term use, a multi-level approach was used, with the patient-drug indication pair as the unit of analysis. Duration of prescription was evaluated as the outcome. 69.2

Objectives Sleep disturbances are reported in up to 80% of persons with inflammatory arthritis (IA) and are poorly addressed. Cognitive-behavioral therapy for insomnia (CBTi) is the first-line insomnia treatment in the general population, but access is limited. Internet-delivered CBT for insomnia (ICBTi) overcomes accessibility barriers. A randomized waitlist-controlled pilot trial was conducted to determine the acceptability and preliminary efficacy of ICBTi for individuals with inflammatory arthritis and insomnia symptoms. Methods Participants with IA and symptoms of insomnia were recruited through social media and patient-partner organizations and randomly assigned to the ICBTi treatment group (n= 24; 6 modules over 8 weeks) or the waitlist-control group (n= 26). Participants completed surveys at baseline, 8 weeks (post-treatment), and 3 months later. Treatment group participants completed questions about treatment perceptions. The Insomnia Severity Index (ISI) (maximum score of 28) assessed insomnia symptoms at each time point. Paired sample t-tests were used to analyze changes in ISI scores over time for each group. Results The sample included 50 participants with IA and insomnia symptoms (Table 1). Post treatment completion, most participants in the treatment group rated the ICBTi modules as moderately or extremely useful (84%) and were moderately or extremely satisfied (89%) with the program. Seventy-three percent of treatment group participants self-reported moderate or extreme improvements in sleep. However, only 52% of the treatment group completed the entire program. Feedback included wanting more relevance to arthritis and chronic pain, and a guide alongside the intervention. The mean baseline ISI score was 16.7 in the treatment group and 14.9 in the control group. Twenty treatment groups and 24 control group participants completed the 8-week survey. The mean (95% CI) change in ISI scores pre- to post-treatment in the treatment group was −4.95 (−6.77, −3.13), p<.001, and −0.94 (−.38, 2.26) in the control group, a non-significant difference. Eighteen treatment group and 21 control group participants completed the 3-month survey. The mean (95% CI) change in ISI scores from pre-treatment to the 3-month follow-up was −5.28 (−7.62, −2.93, p<.001) in the treatment group and −0.83 (−1.53, 3.20) in the control group, a non-significant difference. Table 1 Characteristics of the Sample Conclusion The Internet-delivered CBTi program was acceptable and perceived as useful by most participants but could benefit from further adaptation to arthritis-specific needs. The results suggest efficacy of ICBTi among individuals with arthritis. A larger randomized-controlled trial with a larger, more diverse sample is needed to determine the effectiveness of using ICBTi to help people manage the double-burden of insomnia and arthritis. Supported by a CIORA grant

Background Early cardiovascular disease risk detection opportunities are limited in men, whereas gestational diabetes, gestational hypertension and preeclampsia are risk indicators in women. We hypothesised adverse pregnancy outcomes also signal risk in fathers, due to shared environments and behaviours. Methods Our retrospective cohort study included fathers whose female partners had at least two singleton deliveries between April 1990 and December 2012. We examined population-based data up to April 2019 from Quebec province, Canada (health administrative databases, birth, stillbirth and death registries). The primary exposure was cumulative gestational diabetes, gestational hypertension and preeclampsia occurrences across two pregnancies. Outcomes were new diagnoses of diabetes, hypertension and cardiovascular disease in fathers, analysed using Cox proportional hazards models. Results Among 415 730 fathers, 17 065 developed diabetes, 44 315 developed hypertension and 9695 experienced a cardiovascular disease event over more than a decade. Compared with no gestational diabetes or gestational hypertension/preeclampsia occurrences in partners, the hazards of diabetes in fathers increased by 21% with a single occurrence (HR 1.21, 95% CI 1.16 to 1.26), 40% with two (HR 1.40, 95% CI 1.30 to 1.50) and 84% with three or more (HR 1.84, 95% CI 1.54 to 2.21). Corresponding increases in hypertension hazards were 11% (HR 1.11, 95% CI 1.08 to 1.14), 17% (HR 1.17, 95% CI 1.12 to 1.23) and 39% (HR 1.39, 95% CI 1.22 to 1.58), respectively. Cardiovascular disease hazards increased by 15% with two or more occurrences (HR 1.15, 95% CI 1.04 to 1.27). Conclusion More maternal adverse pregnancy outcomes lead to greater paternal cardiometabolic disease hazards. Partner pregnancy history may help identify at-risk men to support early prevention.

Introduction: Medical cannabis use in Canadians with arthritis may have increased up to threefold since its use was legalized in 2018. However, evidence for its effectiveness in arthritis is sparse and inconsistent. Our objectives were to compare HRQL in people with arthritis between cannabis users and nonusers and to evaluate factors associated with being a cannabis user. Methods: Data were drawn from a Canada-wide cross-sectional survey of health-seeking behaviors in people with arthritis experiencing sleep disturbance. Respondents (n = 283) were recruited through advertisements on Arthritis Research Canada and Arthritis Consumer Experts platforms. Respondents provided sociodemographic and arthritis characteristics, as well as cannabis use in the past year and reasons for use. They also completed the PHQ-2, GAD-2, Perceived Stress Scale-4, Insomnia Severity Index, 11-point numeric rating scales for pain and fatigue, and a question on Self-Rated Health. t tests and chi-square tests were used to compare groups. Multivariable regression characterized factors associated with use, adjusting for age and sex. Results: The 283 respondents had a mean (SD) age of 62 (13) years and were mostly female (84%); 27% used cannabis in the past 3 months, mostly for medical purposes only (81%). Between-group comparisons showed that proportionately more users reported high pain, high stress, and poorer self-rated health (p’s < 0.05). However, the logistic regression results indicated that having poorer patient-reported outcomes was not associated with greater odds of being a cannabis user. Discussion: Although medical cannabis use was common, users and nonusers reported similar patient-reported outcomes. It is possible that users were not experiencing much benefit, but also possible that cannabis was boosting users' outcomes such that they appeared similar to nonusers. More research is needed to understand how using cannabis affects arthritis symptoms, and why outcomes in users and nonusers may appear similar.

Objective Sleep disturbances, including difficulty initiating sleep, maintaining sleep or early morning awakenings, are prevalent in arthritis, contributing to fatigue, pain, and reducing quality of life. Cognitive‐behavioral therapy for insomnia (CBTi) is the first‐line treatment. Accessibility remains challenging. Internet‐delivered CBTi (ICBTi) increases accessibility. To tailor ICBTi to arthritis, a needs assessment survey was conducted. Methods Individuals with arthritis, recruited through social media and patient organizations, completed an online survey assessing insomnia, help‐seeking behaviors or barriers, management strategies, and treatment preferences. Results Of the 248 participants, 55% discussed sleep with health care providers, and 35% did not in the past year despite perceiving the need. Common barriers to seeking treatment despite the need were having their own ways of coping (54% in inflammatory arthritis [IA] and 46% in osteoarthritis [OA]), and believing sleep problems are normal stress responses (53% in IA and 38% in OA). In IA, 54% and in OA, 43% used relaxation techniques for sleep, and 37% in IA and OA used over‐the‐counter medication at least once. In IA, 44%, and in OA, 39% rated medication as somewhat or very acceptable, 74% with IA and 66% in OA were willing to see health care providers for insomnia regularly, and 91% with IA and 86% with OA were likely or very likely to try an online arthritis‐specific approach. Conclusion Given the prevalence, chronicity, and consequences of insomnia, better insomnia management is needed for individuals with arthritis. ICBTi is an acceptable approach for this population. These findings will guide the evaluation of an arthritis‐specific ICBTi.

Objectives The use of cannabis among individuals with rheumatologic conditions has gained increasing attention due to potential effects on pain, mood, and overall quality of life. However, data on its frequency of use, motivations, and patient-reported outcomes remain limited. We compared cannabis users and non-users by sociodemographic and arthritis characteristics and HRQL, and explored motivations for use, and assessed differences in HRQL among people with rheumatic diseases. Methods Data is from the baseline visit of a pilot study of people with inflammatory rheumatic diseases who volunteered for an internet-based intervention to improve sleep. Participants self-reported cannabis use, reasons for consumption, and completed the PROMIS-29 questionnaire (physical function, anxiety, depression, fatigue, sleep disturbance, pain interference, and social participation). Characteristics were compared between cannabis users and non-users using t-test and chi-square. Associations between cannabis use, demographics, and clinical characteristics were examined using multivariable regression. Results Our sample had a mean (SD) age of 54 (14) and all were female. Most had RA or PsA, with a mean disease duration of 10 (11) years; many also had OA (30%) (Table 1). One-third reported have used cannabis in the past year, and 24% in the past 3 months (of which 38% used weekly and 31% daily/almost daily). All participations indicated they were using for medicinal reasons only (100%), with primary motivations being to improve pain (19%), sleep (17%), fatigue (<5%) or anxiety (<5%). Nearly half (46%) reported a little improvement in arthritis symptoms with use, 15% reported a lot of improvement, 31% no change, and 8% were unsure. Users reported similar levels of physical function, pain, fatigue, sleep disturbance, and social participation, but significantly higher anxiety (p=.046) and depression (p=.014) than non-users. Table 1. Sociodemographics, arthritis characteristics, and mean PROMIS-29 scores by cannabis use in the past three months Conclusion One in 3 participants in an online intervention to improve sleep reported using cannabis in the past year to improve their arthritis symptoms, with nearly a quarter using cannabis regularly to improve pain, sleep, fatigue and anxiety. Users did not report different PROMIS-29 outcomes, although 61% reported a little to a lot of symptom improvement. Understanding the motivations and health impact of cannabis use can help guide patient counseling and future research on alternative management strategies for pain and mood disorders. Supported by a CIORA grant

Importance: Disease-modifying anti-rheumatic drugs (DMARDs) are the standard first-line therapy for psoriatic arthritis (PsA). Observational studies suggest earlier initiation is associated with superior achievement of minimal disease activity (MDA) and improved patient-reported outcomes, yet the long-term economic and health implications of treatment timing remain uncertain. We evaluated the cost-effectiveness of early versus delayed DMARD initiation in DMARD-naïve adults with PsA. Methods: This cost-utility analysis from a U.S. payer perspective was conducted using a state-transition (Markov) model with monthly cycles over a 15-year horizon and was informed by studies published from 2000 to 2025, identified through a targeted literature review. Adult DMARD-naïve PsA patients initiating conventional synthetic DMARDs (methotrexate), targeted synthetic DMARDs (tofacitinib or apremilast), or a biologic DMARD were modelled under two strategies: early initiation (≤1 year after diagnosis) and delayed initiation (>1 year). Patients transitioned among four health states: complete response (achieved sustained MDA), partial response (non-sustained MDA), non-response (did not meet MDA), and death. Primary outcomes included the incremental cost-effectiveness ratio (ICER) and incremental net monetary benefit (INMB). Uncertainty intervals (UIs) were derived from probabilistic sensitivity analyses. Findings: The simulated cohort included 1000 adults with a mean (SD) age of 53 (13) years at DMARD initiation. Early DMARD initiation provided an additional 0.56 (95% UI, 0.32 to 0.83) QALYs at an incremental cost of –USD$43,902.94 (95% UI, –USD$147,096.29 to USD$61,615.86) per patient relative to delayed initiation, yielding a favorable ICER of –USD$78,398.11/QALY. At a willing-to-pay threshold of USD$50,000/QALY, mean INMB was USD$71,902.94 (95% UI, –USD$36,663.51 to USD$176,658.91), with early initiation preferred in 90.6% simulations. Interpretation: Early DMARD initiation in DMARD-naive PsA adults was associated with improved long-term health outcomes at reduced costs. These findings support timely therapeutic intervention and reconsideration of reimbursement policies that may delay access to DMARDs.

BACKGROUND:Pregnancy guidelines recommend moderate to vigorous physical activity of ≥150 min/week (7000 steps/day) and weight gain specific to prepregnancy weight category. We aimed to assess step and weight changes, with tracking to achieve individualized targets and with coaching conversations on physical activity and eating. The overarching goal was to identify interventions warranting integration and evaluation through a larger trial assessing perinatal outcomes. METHODS:In this feasibility trial, we randomized 227 participants (GDM clinics, 5 Canadian cities) to 'track & target,' 'coaching,' 'both,' or 'neither' arms. 'Track & target' participants monitored steps/day (counter) and weight (scale). We delivered weekly targets, applying algorithms that incorporated step and weight data and nudged towards recommendations. Coaching participants conversed weekly with a coach, who applied motivational communication methods. We examined changes in steps/day and weight, between trial entry and 37 weeks' gestation. FINDINGS:Weight change was guideline-concordant across arms. Steps/day averaged 6385 (SD 3406) at baselinue and were stable in the 'track & target' arm (change -59, 95 %CI -749 to 630). The other arms declined (coaching: -915, 95 %CI -1605 to -225; both -1183, 95 %CI -1979 to -386; neither -1456, 95 %CI -2193 to -718). INTERPRETATION:Our algorithm-driven step target strategy prevents step count decline, meriting study for perinatal impact.