INTRODUCTION:Data on Tocilizumab (TCZ) efficacy and safety among RA patients in the Middle East in clinical practice remains limited. We aimed to evaluate the safety and efficacy of TCZ, as monotherapy or in combination with disease-modifying antirheumatic drug (DMARDs), in patients with moderate to severe active RA. METHODS:A regional, multicenter, descriptive, and prospective study conducted among 62 adults with moderate to severe active RA (DAS-28 ≥3.2) initiating treatment with TCZ after inadequate response to ≥1 conventional DMARD. TCZ treatment was for 24 weeks with a follow-up period of 6 months after the last injection. RESULTS:Clinical improvement, as measured by the DAS-28 score, was observed in 83.0% at Week 12 compared to 96.3% at Week 48. Low disease activity was achieved in 61.9% of patients at Week 12 and 81.50% at Week 48. Remission was reported in 42.9% at Week 12 compared to 55.6% at Week 48. During the 24-week treatment, 24/62 (38.7%) patients experienced 47 adverse events (AEs), infections being the most common, with 11 serious AEs. DISCUSSION:Our results were similar to those reported from developed countries. The significant drop in mean DAS-28 score in RA patients treated with TCZ comes in line with data from the U-Act-Early and CAMERA-II trials. No specific safety concern was reported with an AE rate of 42%, similar to another open-label phase-4 study done in the Middle East. CONCLUSION:Short-course treatment with TCZ was effective and safe for patients with moderate to severe active RA with inadequate response to DMARDs.

Abstract Lebanon is one of the Arab countries historically known for its multiple regional referral hospital centers. With several principal investigators leading international randomized clinical trials, several Lebanese researchers have been devoted to advancing the quality of practice in the Arab world, ultimately improving patients’ quality of life. Rheumatology is not a stranger to these descriptions. Since the 1950s, the number of rheumatology providers has been substantially increasing. The Lebanese Society of Rheumatology was established in 1961 to attract ideas and organize collaborations. The prevalence of rare autoimmune/autoinflammatory diseases, such as Behcet’s disease and familial Mediterranean fever, partly shapes Lebanon’s research and clinical practice. Despite having no dedicated basic science autoimmune facilities, many groups work on the genetic and immunological aspects of systemic autoimmune rheumatic diseases. From a clinical research perspective, Lebanese rheumatologists collaborate on regional and international projects. Regarding clinical practice, the availability of serological and imaging facilities is an asset for rheumatologists. One of the significant challenges is the cost of novel antirheumatic therapies, such as biological agents. While national and private services try to aid dependent patients, the burden is still significant. Future challenges lie in attracting more expertise, making research funding available to investigators, and establishing dedicated centers of excellence, which frequently incorporate patient-reported outcomes.

To evaluate the drug persistence in patients with rheumatic and musculoskeletal diseases (RMDs) during the current economic crisis in Lebanon and to estimate predictors of persistence. A nationwide multicentric cross-sectional study using an online questionnaire was conducted in Lebanon with patients with chronic inflammatory rheumatic diseases (CIRDs) and non-inflammatory RMDs controls between July and October 2022. Disease-modifying antirheumatic drugs (DMARDs) were categorized as conventional synthetic (cs), biological (b), subcutaneous (SC) or intravenous (IV), and targeted synthetic (ts). Persistence was defined as “number of tablets or injections taken during the past month versus prescribed”. The percentage of patients who discontinued or changed treatment due to cost or non-availability was reported. Factors associated with persistence were identified using multivariable linear regression. The study included 317 patients with RMDs (286 CIRDs); mean age 49.5 years, 68% females, 58% reporting currently low economic level. Persistence at one month was low for tsDMARDs (36%) and bDMARDs (SC55%, IV63%), and acceptable for csDMARDs (88%). A persistence ≥80% was found in 23.3% of patients on tsDMARDs, 42.9% on SC bDMARDs, 45.0% on IV bDMARDs, and 74.7% on csDMARDs. During the past 6 months, 55.8% of CIRD patients discontinued or changed treatment due to non-availability (45.3%) or cost (21.2%). Persistence was positively associated with finding alternative sources such as buying abroad (36%), depending on friends or families abroad (20%), charities (10%), and negatively associated with unemployment and low financial status. Persistence was significantly compromised for essential antirheumatic drugs and was mostly driven by treatment unavailability and cost.

OBJECTIVES:The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges.METHODS:Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified.RESULTS:Twenty-three rheumatologists from MEAC identified unmet needs in patients' education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician's visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix.CONCLUSION:Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

Increased risk of comorbidities has been reported in Rheumatic and Musculoskeletal Diseases (RMD). We aimed to evaluate the prevalence and pattern of comorbidities in RMD patients nationwide, to identify multimorbidity clusters and to evaluate the gap between recommendations and real screening. Cross-sectional, multicentric nationwide study. Prevalence of comorbidities was calculated according to six EULAR axes. Latent Class Analysis identified multimorbidity clusters. Comorbidities' screening was compared to international and local recommendations. In 769 patients (307 RA, 213 OA, 63 SLE, 103 axSpA, and 83 pSA), the most frequent comorbidities were cardiovascular risk factors and diseases (CVRFD) (hypertension 36.5%, hypercholesterolemia 30.7%, obesity 22.7%, smoking 22.1%, diabetes 10.4%, myocardial infarction 6.6%), osteoporosis (20.7%) and depression (18.1%). Three clusters of multimorbidity were identified: OA, RA and axSpA. The most optimal screening was found for CVRF (> = 93%) and osteoporosis (53%). For malignancies, mammograms were the most optimally prescribed (56%) followed by pap smears (32%) and colonoscopy (21%). Optimal influenza and pneumococcus vaccination were found in 22% and 17%, respectively. Comorbidities were prevalent in RMD and followed specific multimorbidity patterns. Optimal screening was adequate for CVRFD but suboptimal for malignant neoplasms, osteoporosis, and vaccination. The current study identified health priorities, serving as a framework for the implementation of future comorbidity management standardized programs, led by the rheumatologist and coordinated by specialized health care professionals.

Background: Involving patients with rheumatoid arthritis (RA) in the assessment of their disease may increase adherence to treatment, improve disease outcomes and reduce consultation time. Objectives: To evaluate the concordance between physician and patient assessment of disease activity in RA using Disease Activity Score (DAS-28). Methods: During the routine consultation, patients were briefed about DAS-28 by their rheumatologist. Using a standard DAS-28 mannequin, physicians, patients and nurses reported the number of tender and swollen joint, inflammatory markers and global health on a 0-10 Likert scale. DAS-28, Clinical Disease Activity Index (CDAI) and Simple Disease Activity Index (SDAI) were calculated blindly by each participant. Agreement between physician- and patient-DAS categories was calculated using weighted kappa (WK) for category comparison. Concordance between physician- and patient-DAS was estimated using the Bland-Altman method. Predictive factors of positive concordance between physician and patient-DAS were identified using logistic regression. Results: Four hundred and twenty patients from 7 Middle-Eastern countries were included, with a mean age of 49 years (SD 12), 84% of females, disease duration of 11 years (SD 8). Mean physician-DAS-28 was 4.03 (SD 1.51). 65% had positive rheumatoid factor, 56% had positive ACPA, 30% had erosive disease and 34% were on biotherapy. Agreement between physician- and patient-DAS categories was 89%, WK was 0.84. WK were 0.80 for DAS physician-nurse, 0.79 for DAS patient-nurse, 0.83 for CDAI physician-patient and 0.88 for SDAI physician-patient agreements respectively. All activity measures were higher in patients compared to physicians, except for the swollen joints count. The mean difference between physician- and patient-DAS was -0.09 [95% CI -0.14; -0.04] and was smaller in patients in remission (Figure 1: Bland Altman plot). Concordance was statistically associated with CRP and patient SDAI. Conclusion: Concordance between patient and physician assessment of disease activity in RA was excellent and was higher using SDAI followed closely by DAS-28 and CDAI. Self-assessment of disease activity should be decided according to the physician’s clinical judgment. References: [1] Gossec L, et al. Arthritis Rheumatol 2016; 68 (suppl 10). [2] Smolen J, et al. Arthritis Research & Therapy (2016) 18:114. [3] Studenic Pet al. Arthritis Rheumatol. 2012;64(9):2814–23. The physician-patient DAS-mean is plotted on the X-axis. The physician-patient DAS-difference is plotted on the Y-Axis. The horizontal black line corresponds to the mean DAS difference (-0.09 [95% CI -0.14; -0.04]). The horizontal blue lines correspond to +/-1.96 SD. The vertical red line corresponds to the DAS-28 cut-off for remission (2.6). Disclosure of Interests: None declared

AIM:To calculate the prevalence of human leukocyte antigen (HLA)-B27 in axial spondyloarthritis patients (axSpA) compared to blood donors (BD) in Lebanon, to identify the clinical and radiological findings associated with HLA-B27 and to estimate the proportion of patients fulfilling the clinical arm of the Assessment of the Spondyloarthritis International Association (ASAS) criteria.METHOD:Consecutive Lebanese adult axSpA patients fulfilling the ASAS classification criteria were included from 12 rheumatology clinics across Lebanon. BD served as controls. A binary logistic regression was used to study the association between HLA-B27 and the disease features.RESULTS:A total of 247 individuals were included (141 axSpA patients and 106 BD). The prevalence of HLA-B27 was 3.8% in BD and 41.1% in axSpA. Overall, 39.7% of the axSpA patients fulfilled the clinical arm of the ASAS classification criteria. Sensitivity of HLA-B27 for axSpA was 41.1%, specificity was 96.2%, positive predictive value was 93.6%, and negative predictive value was 55.13%. Positive likelihood ratio (LR) was 10.9 and negative LR was 1.63. We found a positive association of HLA-B27 with family history of SpA and psoriasis.CONCLUSION:Our study confirmed a low prevalence of HLA-B27 in axSpA patients and BD in this Lebanese population, However, we found a high specificity and positive LR, as well as the same number of axSpA patients fulfilling the clinical arm of the ASAS criteria as in European studies. HLA-B27 is therefore valuable for identification of axSpA in Lebanese patients despite the overall low prevalence in this population. Our results may guide future evaluations the role of HLA-B27 in planning local referral strategies.

Introduction: To investigate the treatment preferences of patients with rheumatoid arthritis (RA) and determine whether these preferences are related to specific disease characteristics. Method: A national survey was designed to collect demographic, disease, treatment, and preference data on RA patients enrolled in 7 private and university hospital clinics in Lebanon. Associations between patient factors and treatment preferences for RA were analyzed by chi(2) or Mann-Whitney U test. Results: A total of 693 patients (83% female; 67% aged 41-70 years) consulting 7 trained rheumatologists completed the survey. Most patients (80%) had established RA >24 months, and approximately one-third (34%) were in remission according to the disease activity score in 28 joints (DAS28). Most (87%) were receiving oral agents (60% oral only). Almost twothirds of patients (64%) expressed a preference for oral treatments, and more than half (53%) ranked doctor's advice as the most influential factor when choosing treatment. In univariable analysis, health coverage, radiographic damage, disease duration, current therapy, and previous side effects were significantly associated with treatment preference. In multivariable analyses, only radiographic damage and current route of administration were independently associated with preference (both P<0.001), with patients with no radiographic damage and those on oral-only therapy being more likely to prefer oral agents. Conclusion: RA patients expressed a preference for oral rather than subcutaneous/intravenous-administered drugs. Understanding patients' preferences may help to inform policymaker decisions.

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