Aims
The field of axial spondyloarthritis (axSpA) has undergone significant changes recently in particular with disease classification, assessment of disease activity and increased treatment options ...for biologics. In order to reflect these developments, we aimed to update the local consensus recommendations for subsidization of biologics.
Methods
A modified Delphi approach was used. Six published guidelines from major rheumatology societies and healthcare authorities on axSpA were reviewed. Findings were synthesized and used in formulating updated recommendation statements. Recommendations were rated by 10 practicing rheumatologists in Singapore. Consensus was reached if there was more than 70% agreement or disagreement.
Results
Ten statements achieved consensus. Patients may be considered for subsidization of biologic therapy if they fulfill the Assessment of Spondyloarthritis International Society or modified New York criteria, with persistently active disease (defined either by Ankylosing Spondylitis Disease Activity Score ≥ 2.1 or Bath Spondylitis Disease Activity Index ≥ 4), despite 4 weeks of full‐dose non‐steroidal anti‐inflammatory drugs and regular exercise. Either tumor necrosis factor inhibitors or interleukin 17 inhibitors may be used as first‐line therapy, and should be continued if adequate response is achieved at 6 months.
Conclusion
Recommendation statements were formulated through a formal consensus process by local experts with a view to assist relevant authorities in funding considerations and for use in clinical practice.
BackgroundHospital in-patient laboratory testing is steadily rising, contributing to increasing healthcare costs, errors, and unnecessary treatments. Strategies to reduce over-utilization of ...laboratory tests have been tried with mixed results.ObjectivesTo reduce the volume of the most frequently ordered laboratory tests by 10% over 6 months.MethodsThe most commonly ordered tests in medical wards were determined and a survey was conducted among residents and faculty to determine the perceived causes of over-testing. A resident-led multilevel collaborative campaign was launched. This comprised of education sessions (intern and resident teaching), cost awareness information (mini cards, computer screensavers), publicity (reminders to on-call teams), regular audits and feedback. The focus was on changing test ordering behavior and culture. Monthly average test numbers were compared with those in the preceding year.ResultsThe campaign was launched in 8 medical wards from the period of September 2014 to February 2015. The top 6 laboratory tests/panels (full blood count, renal panel, calcium panel, liver panel, C-reactive protein and acute coronary screen) were selected based on order-volume. There was a 9.4% reduction in tests ordered during the study period, resulting in costs savings estimated at $34,235 per month. Results were sustained over the 6-month study period. Reduced testing had no effect on in-hospital mortality (3.17% post-intervention vs. 3.02% pre-intervention, p=0.47).ConclusionsThe development of a multilevel collaborative initiative resulted in reduction in test-ordering and significant and sustained costs savings. Approaches targeting culture change may be a feasible method of maintaining a lean health care system.Figure 1 Run chart.Figure 2Overview of tests per patient day.Figure 3Overview of tests per patient.
Introduction
Approximately 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional‐synthetic disease‐modifying anti‐rheumatic drugs (csDMARDs). However, widespread use of ...biologic DMARDs (bDMARDs) and targeted‐synthetic (tsDMARDs) is limited by cost. We formulated updated recommendations for eligibility criteria for government‐assisted funding of bDMARDs/tsDMARDs for RA patients in Singapore.
Materials and Methods
Published guidelines regarding use of bDMARD and tsDMARDs were reviewed. We excluded those without a systematic literature review, formal consensus process or evidence grading. Separately, unpublished national reimbursement guidelines were included.
Results
Eleven recommendations regarding choice of disease activity measure, initiation, order of selection and continuation of bDMARD/tsDMARDs were formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least moderately active RA with a Disease Activity Score in 28 joints/erythrocyte sedimentation rate (DAS28‐ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 1 of which must be a combination; (c) received an adequate dose regimen of ≥3 months for each strategy. For the first‐line bDMARD/tsDMARD, either tumor necrosis factor inhibitors (TNFi), non‐TNFi (abatacept, tocilizumab, rituximab), or tsDMARDs, may be considered. If a first‐line TNFi fails, options include another TNFi, non‐TNFi biologic or tsDMARDs. If a first‐line non‐TNFi biologic or tsDMARD fails, options include TNFi or another non‐TNF biologic or tsDMARD. For continued bDMARD/tsDMARD subsidization, a patient must have a documented DAS28‐ESR every 3 months and at least a moderate European League Against Rheumatism response by 6 months.
Conclusion
These recommendations are useful for guiding funding decisions, making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail csDMARDs.
Aim
There have been major advances in biologic treatment options for psoriatic arthritis (PsA) since the publication of the 2015 consensus recommendations by the Chapter of Rheumatologists, College ...of Physicians, Academy of Medicine, Singapore, for government‐assisted funding, thus warranting a revision of this guideline.
Methods
Recent trials and nine published guidelines on the use of biologic therapy for PsA were reviewed. Based on the synthesized evidence, a task force panel (TFP), consisting of 10 practicing rheumatologists in Singapore, rated the statements pertaining to the use of biologic therapy, using a modified Delphi approach. Consensus was obtained if >70% agreed on a statement.
Results
The TFP agreed on 10 recommendations pertaining to the initiation, choice and continuation of biologic therapy. A biologic is indicated in patients with PsA: (a) with at least three swollen and tender joints, digits or entheses; and (b) who have failed at least two conventional synthetic disease‐modifying anti‐rheumatic drug (csDMARD) strategies for a minimum of 3 months each. Any approved drug class including tumor necrosis factor inhibitors, interleukin‐17 inhibitors (IL‐17i), IL‐12/23i or targeted synthetic DMARDs may be considered as first‐line treatment, and continued only if a response is achieved by 6 months.
Conclusion
These recommendations developed through a formal consensus method may be useful to guide funding considerations for appropriate and equitable use of biologic therapy for eligible patients with PsA.
There is an increasing interest in the role of traditional Chinese medicine (TCM) in rheumatoid arthritis (RA), as evidenced by recent trials comparing their efficacy against established ...disease-modifying antirheumatic drugs. While the TCM in these trials seem to support a favorable cost-benefit ratio, many products are marketed under the guise of TCM, potentially exposing the user to unpredicted adverse events. We present the case of a patient with RA, who developed side effects from treatment with adulterated TCM. While TCM may be of value in the treatment of rheumatic diseases, their application in routine care continues to warrant careful consideration of safety and reliability.
Heparin has been widely used for intradialytic anticoagulation since the 1940s. Heparin induced anaphylaxis can be life threatening, mandating early recognition and intervention. However, due to its ...relative rarity many physicians remain unaware. We report the case of a 70-year-old woman requiring dialysis, who developed recurrent anaphylaxis to intradialytic heparin. We describe a systematic approach to confirm the suspected heparin allergy, which must include an evaluation of predisposing factors, the dialysis equipment and concomitant medications. Further workup for safe alternatives employing skin prick and intradermal tests, as well as provocation tests are discussed.
BACKGROUNDPrimary Sjögren syndrome (PSS) is a systemic autoimmune condition with an estimated prevalence of 0.6%. The frequency of neurologic manifestations in PSS varies widely from 0% to 60%.
...METHODSWe report the characteristics of PSS patients with neurologic involvement seen at a single tertiary hospital in Singapore. Eight consecutive women (median age, 51 years range, 38–67 years) with neurologic manifestations of PSS seen between March 2009 to June 2011 were followed up for a mean duration of 19 months from the onset of neurologic manifestations.
RESULTSSix of 8 patients with neurosjögren had their neurologic manifestation at time of PSS diagnosis. The lag times of neurologic manifestations from PSS diagnosis for the remaining 2 patients were 9 and 30 years, respectively. Sicca symptoms were not readily volunteered as a presenting complaint in the majority of patients. All our patients received early aggressive therapy with pulse corticosteroids and intravenously administered cyclophosphamide. The mean duration from initial presentation to initiation of treatment was 11 days (1–26 days). All achieved good recovery regardless of the type or site of neurologic involvement, initial erythrocyte sedimentation rate, immunoglobulin and complement levels.
CONCLUSIONSNeurologic disease, when present, is a strong contributor to disease activity and damage. Confirmatory tests should be conducted early regardless of the presence of sicca symptoms. Vigilance for the development of new neurologic symptoms is imperative even in chronic, apparently stable patients. It is likely that early initiation of treatment contributed to good recovery in our patients.
Background/Objective
Molecular‐based allergy diagnostics are gaining popularity in clinical practice. Our aim was to evaluate their role in the tropics, given the inherent genetic and environmental ...differences.
Methods
We recruited subjects with history of atopy and collected data on demographics and atopic symptoms using validated questionnaires. Subjects underwent a series of skin prick tests (SPT). Serum total and specific IgE levels were measured using ImmunoCAP FEIA and ImmunoCAP ISAC®, respectively. We describe their pattern of sensitization and agreement between test methods.
Results
A total of 135 subjects were recruited; mean ± SD age of 31.18 ± 12.72 years, 52.7% female. Allergic rhinitis (AR) was the most prevalent clinical manifestation of atopy (70.7%), followed by atopic dermatitis (AD) (50.5%) and asthma (26.2%). Polysensitization was seen in 51.1% of subjects by both SPT and ISAC. House dust mites (HDM) were the dominant allergen, with sensitization in 67.8% and 62% of subjects on SPT and ISAC, respectively. A group of subjects with monosensitization to B. tropicalis was identified. HDM sensitization was strongly associated with AR, while AD and asthma were not associated with sensitization to any allergen. Agreement between SPT and ISAC was mostly suboptimal. Greatest agreement was documented for the measurement of HDM sensitization with both methods (κ = 0.64). Sensitization to the bulk of the remaining allergens in the ISAC panel was infrequent.
Conclusion
Multiplex methods should not be used as a screening tool, especially in a population with lower rates of polysensitization and a dominant sensitizing allergen. There may be a role in adjusting the antigen spectrum in the ISAC panel to regional differences.
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