Objectives:The assessment of axial spondyloarthritis international society (ASAS) has published recommendations on information to include when requesting and reporting MRIs for suspected or known axSpA. In a service improvement evaluation, we aimed to audit our current practice against the newly published recommendations. Methods:MRIs of the spine and sacroiliac joints performed under the inflammatory back pain protocol at The Leeds Teaching Hospitals NHS Trust between September and December 2023 were identified. Information included in the MRI request and radiology reports was extracted from the electronic health records. Results:Overall, 158 MRIs were evaluated. Of the MRI requests, age was included in 11.8% (n = 18), sex in 3.8% (n = 6); HLA-B27 in 22.2% (n = 35), back pain symptom duration in 18.9% (n = 30) and location in 45.6% (n = 72) and presence of inflammatory features in 62.7% (n = 99). For MRI report data: osteitis/bone marrow oedema was mentioned in 81.0% (n = 128), erosions in 58.8% (n = 93) and fat metaplasia in 6.3% (n = 10); active inflammation was mentioned in 77.8% (n = 123) and structural changes in 51.2% reports (n = 82). Over half (62.0%; n = 98) included a statement as to "whether the MRI was overall indicative of spondyloarthritis or not". Conclusion:Despite the retrospective nature of this audit performed against newly published guidance, these results provide awareness, identifying key areas in need of improvement at our centre. Further, this exercise has strengthened the collaboration between rheumatologists and radiology colleagues, illustrating the value of the recent ASAS recommendations as a benchmark to guide further training and education for rheumatologists and radiologists, and improve clinical care provision in axSpA.

OBJECTIVES:Dual blockade of IL-4 and IL-13 in atopic dermatitis (AD) has been associated with activation of the IL-23/IL-17 axis, potentially leading to paradoxical psoriasis and PsA-like presentation. However, the specific cytokine responsible for these reactions remains unclear. We report a case series of PsA-like presentation following treatment with tralokinumab, an anti-IL-13 monoclonal antibody used for AD. METHODS:We identified four patients who developed a PsA-like presentation affecting the joints, entheses, and, in some instances, the skin, following tralokinumab initiation for AD. Clinical features, laboratory findings, imaging results and treatment outcomes were assessed. RESULTS:Among 139 patients treated with tralokinumab across two large UK referral centres, four developed new-onset PsA-like presentation with inflammatory arthritis and enthesitis that emerged after tralokinumab initiation. All four had previously failed dupilumab therapy. Skin biopsies and joint imaging confirmed PsA-like features. Symptoms began weeks to months after starting tralokinumab and resolved following treatment withdrawal or modification. CONCLUSION:To our knowledge, this is the first case series documenting arthritis and enthesitis associated with anti-IL-13 therapy, suggesting a potential pathogenetic role of IL-13 inhibition in the development of PsA-like presentation. These findings warrant further investigation.

Introduction The role of MRI of the spine/sacroiliac joints to aid the diagnosis of axial spondyloarthritis (axSpA) is well established. Limited data, however, exist on the use of MRI to assess disease activity, resulting in current Assessment of SpondyloArthritis International Society (ASAS)/European Alliance of Associations for Rheumatology (EULAR) guidelines not recommending the use of MRI for this purpose. We aimed to assess the current use of MRI to assess disease activity and its impact on clinical decision making.Methods As part of a service evaluation, we identified patients with a prior diagnosis of axSpA, who had an MRI of the spine/sacroiliac joints requested between May 2020 and December 2023 at The Leeds Teaching Hospitals Trust (Leeds) and Northwick Park Hospital (London). Clinical and demographic data were extracted from the medical notes. Data on MRI findings were extracted from the radiologist’s report.Results Overall, 346 scans were performed in 335 patients. 301 patients had axSpA (170 radiographic axSpA, 131 non-radiographic axSpA) and 31 axial psoriatic arthritis. Patients were predominantly male (60.0%) and HLA-B27 positive (60.6%). 140/172 (80.1%) of patients had evidence of inflammation on a pre-treatment MRI scan. 224 scans (64.7%) were performed in patients on biologic/targeted synthetic disease-modifying antirheumatic drugs. Of the 346 MRIs performed during the audit period, 179 (54.7%) had evidence of active inflammation and those with active inflammation were more likely to have their treatment escalated (59.3% vs 23.2%).Conclusions MRI is of utility in assessing disease activity with results of MRI scans directly influencing treatment decision making at the bedside. Further research exploring the relationship between MRI findings and clinical outcomes is warranted.

Objectives:To describe the findings from a dedicated psoriatic disease (PsD) triage clinic, including new PsA diagnosis rates, the characteristics of psoriasis (PsO) patients referred by general practitioners (GPs) vs dermatologists and the utility of the Psoriasis Epidemiology Screening Tool (PEST). Methods:A single-centre, cross-sectional study of consecutive PsO patients with arthralgia referred by either GPs or dermatologists to the PsD Triage Clinic underwent clinical, laboratory and imaging evaluations as appropriate. Patient characteristics were compared by referral route and by PEST scores using a Wilcoxon signed-rank test for continuous variables and a chi-squared test for categorical variables. Results:Of 158 patients [mean age 49 years (s.d. 14), 63% female], 28% were diagnosed with PsA, with similar rates across referral sources. Dermatology-referred patients had more metabolic comorbidities and more DMARD exposure (P < 0.05), whereas GP-referred patients were more often female and had a family history of PsA (P < 0.05). Overall, PEST demonstrated limited sensitivity (56.8%) and specificity (41.4%) for PsA. Patients with a PEST score ≥3 were older, had higher BMI and more entheseal tenderness than those with a PEST score <3. Conclusions:A PsD triage clinic facilitated early PsA diagnosis in nearly one-third of referred patients, irrespective of GP or dermatology clinic referral routes.

Abstract Background Assessing disease activity in axial spondyloarthritis (axSpA) is challenging, with heavy reliance on patient reported outcome measures. These measures are subjective and can be influenced by non-inflammatory causes of symptoms, potentially resulting in inappropriate changes to therapy. Despite its unanimous use in the diagnosis of axSpA, the most recent EULAR/ASAS guidelines do not support the use of MRI to assess disease activity due to the lack of evidence and cost implications. However, it is often a pragmatic approach taken in clinical practice. Aims To assess current usage of MRI to assess disease activity in axSpA at Leeds Teaching Hospitals NHS Trust (LTHT), particularly in patients experiencing treatment non-response and how findings influence treatment decision making at the bedside. Methods As part of a larger service evaluations, MRIs of the whole spine and SIJ requested at LTHT between May 2020 and December 2023 to assess disease activity in patients with previously diagnosed axSpA nr-axSpA, r-axSpA or axial psoriatic spondyloarthritis [axPsA]) were identified. Clinical data was extracted from electronic health records and clinic letters. Results In total 237 MRI scans were performed on 231 patients. The average age was 47, 131 (55.3%) were male and 145 (60.3%) were HLA-B27 positive. 109 had a diagnosis of radiographic axSpA, 95 non-radiographic and 27 axial PsA. 167 were on a b/ts-dmard at time of MRI. Overall, 116 (48.9%) had inflammation in spine or SIJ and 137 (57.8%) had non-axSpA related pathology on MRI. Patients with active inflammation were more likely to have their treatment switched or escalated than those without (48% vs 18%). 12 patients were referred to spinal surgical services, 6 to the pain team and 1 to oncology services, based on the results of the MRI scan. Conclusions Findings on MRI to assess disease activity influences treatment decisions in a large proportion of patients. Further research into the utility and health economics of MRI to assess disease activity in routine clinical practice, particularly in those experiencing treatment non-response is urgently required.

Abstract Background and aims The mean average time to diagnosis (TTD) in the UK for axial SpA is currently 8.29 yearsi. However, it should be possible to ensure diagnosis within 12 months of symptom onset to optimise clinical outcomesii. Current evidence suggests significant variability in the patient journey, particularly within primary care, where patients have repeat consultations for axial SpA related symptoms before being referred onward to rheumatologyiii. The National Axial Spondyloarthritis Society (NASS) TTD patient survey assesses where in the pathway patients experience most delays and the factors that may be driving these pinch points. Methods We developed a patient self-administered post-diagnosis axial SpA online survey form, and analysed the results along the pathway. Data were collected from 534 patients diagnosed since January 2021. Results The average time from first GP appointment to rheumatology referral was the longest wait, at 4.33 years (53% of the total delay). Other elements of the pathway were (mean): • 2.49 years (31%) from experiencing symptoms to seeking help from a GP, • 0.39 years (5%) waiting for a first rheumatology appointment following referral, • 0.88 years (11%) for the time from first appointment in rheumatology to formal diagnosis. Patients also reported seeing healthcare practitioners multiple times pre diagnosis. Physiotherapists (66%, n = 353) and GPs (63%, n = 337) were seen most frequently, with chiropractors (19%, n = 103) and osteopaths (17%, n = 93) seeing around a fifth of patients repeatedly. P001 Figure 1.Proportional split of average (mean) time to diagnosis by pathway. P001 Figure 2.Number of visits to other Health Care Professionals (HCPs) before receiving a formal diagnosis. Whilst specialist clinics are not possible everywhere, patients in these settings get a swifter diagnosis due to increased expertise, greater access to co-located MSK radiology services and expedited triage out of general rheumatology pools. References 1. Eddison J, et al. www.actonaxialspa.com; Webb D, et al. Act on axial SpA: A Gold Standard time for the diagnosis of axial SpA (2021); Al-Attar M, et al. Ann Rheum Dis 2021;80(Suppl 1):757.

Objective:The aim was to assess the use and drug survival of IL-17Ai in a real-world cohort of axial SpA (axSpA) and PsA patients. Methods:Patients ever commenced on an IL-17Ai (secukinumab or ixekizumab) for axSpA or PsA at the Leeds Specialist Spondyloarthritis Service were identified. Demographics, IL-17Ai treatment length and reason for cessation were collected. Drug survival data were plotted as a Kaplan-Meier curve, with log rank test of median survival compared between axSpA and PsA. Cox regression analysis was performed to investigate the relationship between diagnosis and length of drug survival. Results:In total, 228 patients (91 axSpA and 137 PsA) were exposed to IL-17Ai. Drug survival for all patients at 12 months was 69% (95% Confidence Interval (CI) 63, 75%) and at 24 months 60% (95% CI 54, 67%). In axSpA and PsA, drug survival at 12 months was 63% (CI 54, 74%) and 73% (CI 66, 81%), respectively, and at 24 months it was 53% (CI 44, 65%) and 65% (CI 57, 75%), respectively. Median survival did not differ significantly between both diseases (log rank test 0.65). There was no association between diagnosis and survival (hazard ratio 0.92, 95% CI 0.63, 1.33), including when adjusting for age, previous biologic DMARD usage and sex (hazard ratio 0.89, 95% CI 0.61, 1.13). Conclusion:This is the first study, to our knowledge, to analyse and compare real-world IL-17Ai drug survival in patients with axSpA and PsA from a single centre. We demonstrate that there is no difference in IL-17Ai survival rates and no relationship between diagnosis and drug survival. These results contribute to the body of real-world evidence confirming the role of IL-17Ai in the management of axSpA and PsA.

Abstract Background Therapy non-response (NR) can be seen in 30% of axial spondyloarthritis (axSpA) with some patients requiring multiple therapies. We wanted to assess in our axSpA population those with difficult to treat (D2T) disease as defined in two ways: (ever) failure of any 2 b/ts-DMARDs which we called “standard definition” or (ever) failure ≥2 b/ts-DMARDs with differing mechanisms of action (MoA), “strict definition”. Aims To describe the clinical, laboratory and imaging characteristics of axSpA patients meeting varying definitions of D2T disease and to compare differences between those responding to their current b/tsDMARD (BASDAI <4) and those who are not (BASDAI ≥4). Methods A cross-sectional analysis of b/ts-DMARD prescribing in the Leeds Specialist Spondyloarthritis Service identified patients with axSpA treated with a b/ts-DMARD between October 2023 and May 2024. Demographics and clinical characteristics including BASDAI, CRP and imaging were assessed. Patients were classified as NR at the time of assessment based if BASDAI ≥4, as a marker of ongoing disease activity. Results Overall, 680 patients on b/ts-DMARDs were identified, of which 109 (16.0%) had (ever) failed any 2 b/ts-DMARDs and 58 (8.5%) ≥2 b/ts-DMARDs with differing MoA. The demographics were similar between groups with mean age (49.2 [SD12.4] vs 49.5 [SD12.3]), predominant male sex (62% vs 65%), HLA-B27 (77% vs 81%), and prevalence of radiographic disease (59% vs 56%) in those meeting standard and strict definitions respectively. At last clinical review, 99 (91%) patients meeting standard definition and 51 (88%) meeting strict definition remained on a b/ts-DMARD. Of the patients reviewed during 2023/2024, 40/55 (73%) meeting the standard definition and 18/25 (72%) meeting the strict definition had NR. In patients experiencing NR, 17/35 (49%) had CRP >5 mg/L in the standard definition compared to 7/15 (47%) in the strict definition. Active inflammation on MRI was found on 1/4 patients meeting the standard criteria and 0/2 patients meeting the strict criteria. All patients had non-axSpA related pathology on MRI. Conclusions In this cross-sectional assessment a small proportion of axSpA patients appear to have D2T disease according to above definitions. Objective evidence of inflammation was seen in less than 50% either by CRP, MRI or both, suggesting a mix of non-inflammatory and true refractory disease. Further characterization of these populations in this and larger cohorts may identify predictors of non-response to b/tsDMARD therapy in axSpA.

Background/Aims Rapid access to magnetic resonance imaging (MRI) of the spine and sacroiliac joints is essential for the timely diagnosis of axial spondyloarthritis (axSpA). A recent NASS/BRITSpA national FOI survey highlighted deteriorating waiting times to access MRI for the assessment of inflammatory back pain in the UK, with only 73% of Trusts reporting access within 8 weeks, compared to 90% in 2017. In addition, NHS England and the Royal College of Radiologists have recently published a target of 28 days for turn-around time (TAT) for a verified report to be provided after image acquisition in any circumstance. Aims: To evaluate the usage of MRI performed under the "inflammatory back pain protocol" at a large tertiary centre, including the time from MRI request to scan being performed, TAT for reporting and whether this has changed over time. Methods A service evaluation audit was conducted at Leeds Teaching Hospitals Trust (LTHT). MRIs of the spine and sacroiliac joints requested between December 2021 and May 2023 under the local "inflammatory back pain protocol" were identified by the radiology department. Data extracted from medical records included: indication for MRI request, time elapsed from request to scan, and from scan to verified report. Results A total of 668 MRI requests were identified. The commonest reason for MRI request was to aid the diagnosis of axSpA 75% (n = 501); followed by disease activity monitoring in established axSpA (16.7%, n = 111) and assessment of axial involvement in peripheral psoriatic arthritis, i.e. diagnosis of axPsA (8.5% n = 57 scans). The majority (92%) had a request to scan time of 8 weeks, with a TAT to report of 4 weeks (77%). However, a greater delay in TAT to verified report was seen from December 2022 to May 2023 with <45% of reports issued within 28 days, despite no change in scanning time. Causes identified were related to local workforce issues including delays in appointing new radiographers and radiology consultants. Conclusion The main reason for request of an MRI under the inflammatory back pain protocol at LTHT is to support making a diagnosis of axSpA. A significant number of patients were scanned for treatment monitoring and to diagnose axial psoriatic arthritis, although data on the utility of MRI for these indications are limited. Whilst nearly all patients were scanned within 2 months at all time periods, the TAT to report has significantly deteriorated since December 2022 in our region, due to workforce issues. Further understanding of the impact of workforce factors on service delivery in rheumatology is required. Disclosure J. Weddell: None. R. Shah: None. P. Robinson: None. A. Barr: None. C. Vandevelde: None. J. Freeston: None. D. McGonagle: None. H. Marzo-Ortega: None.

BACKGROUND:Musculoskeletal problems are reported in the literature as a common problem for people with cystic fibrosis, with a range of aetiologies including an inflammatory arthritis. However, accurate data on the presentations and prevalence are lacking. The aim of this cohort study was to describe the scale and impact of musculoskeletal symptoms in CF. METHODS:A collaboratively designed questionnaire was administered to adults attending two large UK CF centres. Data collected evaluated scale and impact of musculoskeletal symptoms. RESULTS:Results were obtained from 489 patients (response rate 59%). Of these, 49% reported that musculoskeletal symptoms impacted their activities of daily living in the previous year. Back pain was common, occurring in 44% of participants in the preceding week. The knee was the most commonly affected painful peripheral joint, with 26% of participants reporting knee pain within the last week rising to 50% within the last year. Early morning stiffness and joint swelling were markedly less common, suggesting that the majority of musculoskeletal pain in CF is not due to an inflammatory arthritis but is due to other factors. CONCLUSION:Musculoskeletal problems are common in CF and frequently affect activities of daily living. Symptoms of inflammatory arthritis occurred in only a small minority of individuals. A focused approach to characterising and clarifying the aetiology of musculoskeletal symptoms is needed to inform the management of these disabling symptoms.

Background/Aims The role of MRI of the spine and sacroiliac joints to aid the diagnosis of axial spondyloarthritis (axSpA) is now well established. However, its utility in disease monitoring, in particular assessment of treatment non-response is unclear with limited and conflicting data on the relationship between inflammatory changes suggestive of disease activity on MRI and outcome measures such as ASDAS-CRP and BASDAI. Although the most recent ASAS/EULAR guidelines recommend against routine use of MRI in the assessment of treatment response in axSpA, this is a pragmatic approach often undertaken in NHS clinics with substantial cost implications. We aimed to explore the current use of MRI to assess disease activity in axSpA in a large tertiary centre, in particular its utility in exploring treatment non-response and its impact on treatment switching decision. Methods As part of a service evaluation audit, MRIs performed under the "inflammatory back pain protocol" at Leeds Teaching Hospitals Trust between December 2021 and May 2023 were identified from radiology request data. Patients with axial spondyloarthritis (nr-axSpA, r-axSpA or axial psoriatic spondyloarthritis [axPsA]), were identified. Demographic data, baseline MRI findings, current medications, repeat MRI findings for ongoing axial symptoms, outcome measures and inflammatory markers were extracted from the clinical notes. Data on MRI findings consistent with inflammatory or structural changes related to axSpA or alternative findings, were extracted from the radiologist's report. Results Overall, 111 patients had an MRI to assess disease activity, 93 had axSpA (49 r-axSpA, 44 nr-axSpA) and 18 axPsA. Patients were predominantly male (58.5%) and HLA-B27 positive (65.8%), 25.2% and 27.9% current smokers and ex-smokers respectively. A history of psoriasis was documented in 25.2% and peripheral arthritis in 42.3%. Baseline MRI was available on 76 patients (68.9%), of which 61 (80.3%) had spinal or sacroiliac inflammation as per the radiologist report. In total, 79 patients were on bDMARD therapy, with TNFi the commonest class (n = 59, 52.7%). Repeat MRI demonstrated active inflammation in the spine or sacroiliac joints in 58.6% (n = 65) as per the radiologist report. Patients with active inflammation in the repeat scan were more likely to have their bDMARD switched or treatment escalated (54% vs 36%). Other important findings included spinal stenosis (n = 4), disc disease (n = 15), vertebral fractures (n = 2) and potential malignancy (n = 1). Conclusion In our practice, MRI is of utility in the monitoring and assessment of non-response in axSpA in two-thirds of cases, aiding treatment decision making by leading to a switch of bDMARD in half of patients and excluding alternative pathologies, such as vertebral fractures and disc disease which may also affect components of disease activity scores. Further research exploring association of MR findings with clinical outcomes, including economic evaluation of routine MRI to assess disease activity in axSpA is warranted. Disclosure J. Weddell: None. R. Shah: None. P. Robinson: None. A. Barr: None. C. Vandevelde: None. J. Freeston: None. D. McGonagle: None. H. Marzo-Ortega: None.

Objectives This study aimed to develop a novel whole-body MRI protocol capable of assessing inflammatory arthritis at an early stage in multiple joints in one examination. Materials and methods Forty-six patients with inflammatory joint symptoms and 9 healthy volunteers underwent whole-body MR imaging on a 3.0 T MRI scanner in this prospective study. Image quality and pathology in each joint, bursae, entheses and tendons were scored by two of three radiologists and compared to clinical joint scores. Participants were divided into three groups based on diagnosis at 1-year follow-up (healthy volunteers, rheumatoid arthritis and all other types of arthritis). Radiology scores were compared between the three groups using a Kruskal-Wallis test. The clinical utility of radiology scoring was compared to clinical scoring using ROC analysis. Results A protocol capable of whole-body MR imaging of the joints with an image acquisition time under 20 min was developed with excellent image quality. Synovitis scores were significantly higher in patients who were diagnosed with rheumatoid arthritis at 12 months (p < 0.05). Radiology scoring of bursitis showed statistically significant differences between each of the three groups-healthy control, rheumatoid arthritis and non-rheumatoid arthritis (p < 0.05). There was no statistically significant difference in ROC analysis between MRI and clinical scores. Conclusion This study has developed a whole-body MRI joint imaging protocol that is clinically feasible and shows good differentiation of joint pathology between healthy controls, patients with rheumatoid arthritis and patients with other forms of arthritis.

Abstract Background/Aims People with Spondyloarthritis (SpA), especially those with psoriatic disease (PsD) [psoriasis (PsO) and psoriatic arthritis (PsA)], are at higher risk of non-alcoholic fatty liver disease (NAFLD) due to increased prevalence of metabolic syndrome, obesity, hypertension, dyslipidaemia and disease-specific factors such as duration/ severity of psoriasis. There is significant concern that both synthetic and biological DMARDs (including methotrexate) may worsen liver function in PsD patients with NAFLD. The Leeds Teaching Hospitals Trust (LTHT) NAFLD pathway uses three screening tools (ELF, FIB-4 and fibroscanning) to identify those needing further investigation/ treatment by hepatology. However, the pathway is not validated in PsD. Our aim was to survey the prevalence of liver disease in our PsD population and explore the performance of our hepatology referral pathway. Methods We audited consecutive patients referred from the Leeds Specialist SpA service at LTHT with persistently abnormal ALT, whom the consultant Rheumatologist felt required Hepatology referral for suspected NAFLD. Data collected were: age, sex, BMI, history of diabetes, ALT, AST, platelets, albumin, hepatitis B and C, ELF score, FIB-4 score, fibroscan score, abdominal ultrasound, liver biopsy result and final hepatology diagnosis (NAFLD, fibrosis/cirrhosis or other). Results 72 patients were included; 84.2% had PsD (61/72), and 15.8% (11/62) had ‘Other’ forms of SpA (including axial spondyloarthritis, enteropathic arthritis, etc). Baseline characteristics, drug treatment and liver biochemistry/virology were similar between PsD and Other arthritis groups (Table 1) except for age which was lower in the Other. The average ELF scores were similar between PsD and Other, however FIB-4 scores were higher in PsD, and was associated with higher rates of fibrosis/cirrhosis (Table 1). FIB-4 >1.3, but not ELF>9.5, was statistically significantly associated with a high fibroscan score (p = 0.038 and p = 0.443 respectively). Conclusion PsD patients had higher rates of significant fibrosis/cirrhosis compared with patients with Other SpAs. FIB-4 was better than ELF for identifying which PsD patients required fibroscan and further investigation to exclude significant fibrosis/ cirrhosis. These findings will now be validated in a larger prospective study. Disclosure S.R. Harrison: None. U. Nandasoma: None. R. Parker: None. C. Chimakurthi: None. P. Laws: None. A. Barr: None. C. Vandevelde: None. H. Marzo-Ortega: None. J. Freeston: None.

Counselling services embedded within rheumatology clinics could help bridge the gap in mental health care provision for adults with rheumatic diseases Georgia Hayward, Rachel Mandela, Andrew Barr , Jane Freeston , Claire Vandevelde, Helena Marzo-Ortega * Rheumatology Department, Leeds Teaching Hospitals Trust, Leeds, UK Clinical Psychology Department, Leeds Teaching Hospitals Trust, Leeds, UK NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK *Correspondence to: Helena Marzo-Ortega, LIRMM, Second Floor, Chapel Allerton Hospital, Leeds LS7 4SA, UK. E-mail: h.marzo-ortega@leeds.ac.uk

Objectives. Dupilumab blocks the IL-4 receptor (IL-4R) and thus signalling of the 'Th2' cytokines IL-4 and IL-13. It has a license to treat atopic eczema and was recently linked to emergent enthesitis and psoriasis. We investigated the cellular and functional basis for how IL-4/IL-13 regulates the IL-23-IL-17 axis in entheseal stromal, myeloid and lymphocyte cells. Methods. Immunohistochemistry was performed on healthy enthesis samples from patients undergoing elective spinal surgery to investigate entheseal tissue IL-4R expression and cytokine expression by intracellular flow cytometry for IL-4 and IL-13. Digested human enthesis samples were stimulated with lipopolysaccharide (LPS) for IL-23 induction, either alone or with IL-4 or IL-13. Enthesis fibroblasts were stimulated with TNF and IL-17 with and without IL-4 or IL-13 to assess the effect on CCL20 secretion. Synovial fluid samples from PsA patients were also analysed by ELISA for levels of IL-4 and IL-13. Results. The IL-4/IL-13 receptor was present in both the peri-entheseal bone and enthesis soft tissue, and entheseal-derived T cells produced basal levels of IL-4, but not IL-13. Both IL-4 and IL-13 attenuated LPS-induced entheseal IL-23 production. IL-4 also downregulated secretion of TNF/IL-17A-induced CCL20 from entheseal fibroblasts. Both IL-13 and IL-4 were also detectable in the synovial fluid of PsA patients. We also noted a seronegative inflammatory oligoarthritis whilst under dupilumab therapy. Conclusion. Our findings suggest a previously unknown protective role for IL-4/IL-13 in entheseal induction of the IL-23-IL-17 axis. These findings point towards a novel explanation for IL-13 pathway single nucleotide polymorphisms in PsA and also a molecular explanation for why anti-IL-4/IL-13 therapy may induce musculoskeletal entheseal pathology as recently reported.

NICE guidance (NG65) endorses the need for a multi-specialist approach in spondyloarthritis. The Leeds Combined Psoriatic Service has been running rheumatology and dermatology clinics in parallel since 2011, where patients with psoriatic arthritis (PsA) and psoriasis from both services are reviewed on request by both teams. Prospective survey to assess the potential benefits of the current combined review over a 17-month period (May 2018-September 2019). In addition, a patient satisfaction survey was performed in the rheumatology setup. In a standard month, 120 patients with PsA and 180 with psoriasis are reviewed in each clinic. A total of 136 combined consultations took place during this study period with dermatologists reviewing rheumatology patients on 87 occasions and rheumatology reviewing dermatology patients on 49 occasions. Overall, the combined review had a direct impact on the other specialty’s clinical treatment plan in 32% (44/136). This included altering csDMARDs (16%; 7/44), switching or starting a TNF inhibitor (20%; 9/44), new IL-17 inhibition (41%; 18/44); IL-23 inhibition (19%; 8/44), apremilast (5%; 2/44). Furthermore, 12 Rheumatology patients with PsA were able to access a biological medication for which they didn't fulfil NICE criteria or which is not yet approved for use in PsA, based on their skin involvement (1 secukinumab, 2 ixekizumab, 3 adalimumab, 1 rizankizumab, 5 guselkumab); 2 dermatology patients were able to access biological medication prescribed by rheumatology (1 adalimumab, 1 apremilast). Objectively, combined reviews avoided a separate out-patient appointment on 82 occasions averaging a saving of £21,080 to the CCG. A new rheumatological diagnosis was given to 18 people attending the dermatology clinic (4 spondyloarthritis; osteoarthritis, gout, fibromyalgia or mechanical joint pains) and 34 people were given a new skin diagnosis (3 new psoriasis, 9 fungal rash or possible psoriasis, 2 vasculitis, 17 eczema, rosacea or other). During the past year, 196 patients were recruited to clinical trials in rheumatology and 170 in dermatology conducted studies. The patient satisfaction survey was returned by 108 rheumatology patients. In total, 24% (26 of 108) reported benefitting from a dermatologist’s review whilst attending a rheumatology appointment. 70% of rheumatology patients with psoriasis, who were not already under dermatology, had either seen or would like to have seen a dermatologist whilst attending rheumatology clinic. Combined clinics give clear patient benefits, with improved clinical decision making, enhanced diagnosis and access to therapies. In addition, they carry substantial savings for the CCGs and lead to high patient satisfaction. These specialised services support pioneering clinical practice and deliver cutting-edge care acting as hubs for translational research within the NHS, and as such should be eligible for high tariff commissioning to allow for fine tuning on the delivery of quality of care and cost control. C. Vandevelde: None. K. Harnden: None. J. Freeston: None. A. Barr: None. K. Shams: None. P. Laws: None. H. Marzo-Ortega: None.

OBJECTIVES The TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) study was the first strategy trial in psoriatic arthritis using an early treat-to-target strategy to improve clinical outcomes. The current study aimed to review a cohort of patients who had completed TICOPA to judge if the clinical advantage gained by participants in the tight control (TC) arm was sustained, and to explore subsequent therapy. METHODS A case note review was conducted for a cohort of patients who had participated in TICOPA. Current drug use and clinical status were obtained, with low disease activity judged as no tender or swollen joints, no dactylitis and enthesitis, and no change in treatment required. RESULTS Approximately five years after completion of the TICOPA study, notes were reviewed for 110 patients [TC, n = 54; standard care (StdC), n = 56]. Disease activity was found to be similar in both groups (current low disease activity: TC 69%, StdC 76%). Biologic use at the end of the study was higher in the TC arm (TC 33%, StdC 9%), but at review a similar percentage in both groups were taking biologic drugs (TC 54%, StdC 52%), whereas MTX use diminished. CONCLUSION After several years, clinical outcomes and therapeutic drug use were similarly good for patients in both arms of the TICOPA study, with no obvious clinical advantage after TC ended. Notably, TC did not result in greater biological use long term, and MTX use decreased in both arms of the study.