Irish Society for Rheumatology (ISR) Spring Meeting

Hotel Kilkenny, 23 March 2018

Timing of vaccination vital for rheumatology patients

Rheumatologists need to consider what disease-modifying antirheumatic drugs (DMARDs) a patient is on when determining the appropriate time for vaccination, the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny heard.

In a talk titled ‘Vaccinations: Timing and Targets for the Rheumatologist’, US-based infectious disease specialist Dr Kevin Winthrop said that while some DMARDs do not interact adversely with vaccines, others cause negative reactions.

“Rituximab, of course, ruins all vaccine response, so really it is about trying to pay attention to vaccine before rituximab, or at least six months after being on it, no matter what vaccine you are talking about,” Dr Winthrop told the Medical Independent (MI).

Dr Winthrop also spoke about how tofacitinib diminishes vaccine responses, in a similar manner to methotrexate.

This is especially significant for the influenza vaccine and pneumococcal vaccine.

“The big issue with JAK [Janus kinase] inhibitors is that there is this JAK-wide increase in zoster risk,” he said.

“It is a fairly big deal; it is a fairly large increase. It is a two- or three-fold higher risk than most of the other drugs. And so we are talking about using zostavax prior to using these drugs.”

Dr Winthrop, who is based at the Division of Infectious Diseases, Department of Medicine at Oregon Health and Science University, US,  referred to research he was involved in that showed better responses are achieved for patients if methotrexate is stopped temporarily for two weeks prior to vaccination.

“That is a simple strategy that probably everybody here could use for flu vaccine, for pneumococcal vaccine and a lot of these patients are on methotrexate here,” he advised.

“This is a very clinically-relevant strategy that I think we should talk about.”

Dr Winthrop pointed out that rheumatologists rather than GPs are in the best position to vaccinate these patients as a result of their training and expertise.

“One problem we have, and I think you have it too, is that the GPs don’t really know what drugs these people are on, and they don’t know what their mechanisms are, and they don’t know how they would interfere with the vaccine,” he stated.

“And they don’t know if it is safe to give the vaccine to these people, usually. The best person to make that decision is usually the rheumatologist. They should know when it is safe, and they should know when the optimal time to vaccinate is. I think they are well-equipped to do that. And I think that is why this topic is so important, because it is important for the patient that this is done right.”

Need to avoid treatment target confusion for axial spondyloarthritis

There are a number of problems with the 2016 Assessment of SpondyloArthritis International Society/European League Against Rheumatism (ASAS/EULAR) recommendations for the management of the condition, according to Prof Nemanja Damjanov, Head of Clinical Department, Institute of Rheumatology, Belgrade, Serbia.

Speaking at the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny, Prof Damjanov said that the guidelines, as currently configured, often result in “treatment target confusion”.

He argued that part of the confusion lies in the fact the guidelines state that disease activity can be measured by either the Ankylosing Spondylitis Disease Activity Score (ASDAS) or Bath Ankylosing Spondylitis Activity Disease Activity Index (BASDAI).

While ASDAS is a combination of patient-reported outcomes and C-reactive protein (CRP) levels, BASDAI is a fully patient-reported outcome.

“Increased ASDAS may lead to syndesmophyte formation, while this has not been proven for BASDAI alone,” Prof Damjanov said, citing research in the area.

“High BASDAI appeared to be a predictor for stopping TNF therapy, while a high ASDAS was a predictor for continuation of TNF, which can be seen as a surrogate outcome for efficacy.”

He also stated that frequently, there is a concordance between a BASDAI  ≥4 and ASDAS  ≥2.1, but in discordant cases, an elevated ASDAS was more predictive of a good response than an elevated BASDAI.

“ASDAS cut-offs for disease activity states and response activity criteria were based on a thorough validation process, while BASDAI cut-offs were arbitrarily chosen.”

Prof Damjanov also asked what is considered a “sufficient response” in phase 1 of treatment.

According to the guidelines, a decision should be based on continuous use of non-steroidal anti-inflammatory drugs (NSAIDs) to the symptoms of the patient rather than on a possible protective effect regarding structural progression.

The guidelines go on to state that if symptoms recur after stopping or dose reduction of an NSAID, continuous use should be advised.

“To avoid mistakes, we should use one best known way of disease management measurement,” Prof Damjanov said in conclusion.

“We should avoid using just change (delta) and define that a certain level of decrease of ASDAS is considered treatment success. We should define a preferred target (or targets) and use them as criteria for the treatment success or failure.”

Targeting autoantibodies could help RA patients

Recent evidence has shown that immune interventions targeting autoantibodies, in addition to inflammation, may provide additional therapeutic value in some rheumatoid arthritis (RA) patients.

At the Irish Society for Rheumatology (ISR) Spring Meeting, Prof Georg Schett, Head of the Department of Internal Medicine, Rheumatology and Immunology, Friedrich-Alexander University, Erlangen, Germany, spoke about the role of autoantibodies in the treatment of RA.

Prof Schett pointed out that bone erosion with no adequate bone response is a hallmark of RA and that “periarticular” osteoporosis is based on loss of intra-articular cortical and trabecular bone.

A key message of the presentation was how autoimmunity precedes RA.

Prof Schett explained that anti-citrullinated protein antibodies(ACPAs) and rheumatoid factors (RFs) in patients appear many years prior to RA onset.

IgA Rfs also appear in patients years prior to clinical symptoms.

He also explained how cytokines promote the differentiation of bone-resorbing osteoclasts.

“Autoantibodies stimulate osteoclast differentiation and trigger bone loss very early in the course of RA,” according to Prof Schett.

He was involved in recent research that showed disease-modifying antirheumatic drugs (DMARDs) targeting the adaptive immune response, such as abatacept and rituximab, significantly lowered anti-CCP2 IgG levels, while cytokine inhibitors and methotrexate had no significant effects on anti-CCP2 IgG levels. Rituximab is the only DMARD that also lowers total IgG level.

The purpose of the study was to show whether stable treatment with DMARDs affects anti-CCP2 antibody levels in patients with RA.

Difficulty filling rheumatology vacancies in the NHS

The NHS had difficulty filling rheumatology consultant posts last year, a UK-based consultant rheumatologist has said.

Prof Ashok Rai, who works in Worcestershire Acute Hospital, stated that some 30 per cent of consultant rheumatologist posts were not filled in 2017 and there is an ongoing supply and demand mismatch.

“At the moment, we have reached the situation whereby the number of posts we are trying to fill is greater than the number of suitable applicants,” Prof Rai told the Irish Society for Rheumatology (ISR) Spring Meeting in Kilkenny.

In relation to retirements, Prof Rai showed how 29 per cent of consultant rheumatologists in the UK are reaching the age of 65, while about 48 per cent will reach the age of 60 over the next decade.

Currently, there are approximately 870 consultant rheumatologists working in the NHS.

“We have a projected trend that approaches 1,000 to 2021, so we already have some issues about where we want to be,” he stated.

Prof Rai highlighted the importance of detailed workforce planning to adequately deliver future rheumatology services.

“The only way to do that planning is to have a database,” he told delegates.

“We do have a database of sorts in the UK, and that is the Royal College of Physicians dataset on workforce planning.”

The current salary for consultant rheumatologists in the UK for a basic 40-hour week is between £76,761 and £103,490, which is the equivalent to 10 sessions of four hours’ programmed activities (PAs).

There are also further payments for additional duties beyond 10 PAs/40 hours and through Clinical Excellence Awards.

Prof Rai said it is important to make posts as attractive as possible in order to recruit the best candidates.

At crisis point — delving into physician burnout

The topic of doctor burnout was the focus of a special presentation at the Irish Society for Rheumatology (ISR) Spring Meeting. Paul Mulholland reports

n the US alone, 400 physicians die by suicide each year. One of the main reasons behind these tragic events is burnout. In a wide-ranging and fascinating talk on the subject at the Irish Society for Rheumatology (ISR) Spring Meeting, which took place in Hotel Kilkenny on Friday, 23 March, Dr Paddy Barrett, Consultant Cardiologist in St Vincent’s University Hospital, Dublin, pointed out to delegates that this number is the equivalent of an entire graduating class taking their own lives annually. Those involved in healthcare are at substantially higher risk of suicide compared to the general population: Males are up to 2.5 times more likely to die by suicide, while females are four times as likely.

“When we think of suicide, people in healthcare don’t attempt suicide; compared to the general population people in healthcare ‘commit suicide’,” said Dr Barrett.

The severity of the issue was made plain to Dr Barrett when two physicians at the US hospital he was working in killed themselves over the course of a week. Since then, he has sought to understand the complex factors behind physician burnout and develop interventions to tackle the problem, which is endemic across the healthcare sector.

What is burnout?

Dr Barrett said that a strict definition of burnout is difficult to reach.

“When I thought of burnout, I thought of something where somebody collapsed at home, stayed in bed and really didn’t do anything, and who wasn’t a participant in actual medical practice, and doing their job on a day-to-day basis,” he said.

“But the reality is, the majority of people who are suffering from burnout are your colleagues, who are at work every single day. It is that angry person who is walking down the corridors and who is sometimes difficult to deal with and maybe that is the manifestation of them struggling with their job and maybe they are asking for help.”

Burnout was first described by the psychologist Herbert Freudenberger, but it is the work of Christina Maslach that has brought the term into the mainstream. Maslach, who is a social psychologist from the US, listed three core features of burnout: Emotional exhaustion; depersonalisation; and lack of efficacy.

Dr Barrett distinguished emotional exhaustion from normal fatigue. The latter could involve straightforward tiredness after a night on-call and needing to go to sleep.

“[Abnormal fatigue] is that you are depleted of all your energy levels, physical, emotional, spiritual levels, and that you really just have nothing left to give. Ultimately, that work takes more than you could ever hope to get back. So this is not regular fatigue.  These are the descriptions you hear from people: ‘It is not that I don’t want to help, but it is that I can’t.’ And the analogy has been made to a bucket with large holes at the bottom, insofar as no matter how much you fill it, it still continues to drain. That is why when you take a day off, a weekend off, or even a week sometimes, it is not enough to address that problem.”

Depersonalisation often arises as result of physicians trying to protect themselves from the pressures of their job, stated Dr Barrett.

“We hear lines that you change, that you become tough, hard and cynical in order to survive,” he said.

“And sometimes without realising it, you act that way all the time, even with your wife and kids. And this is a feature that I think is worth stating, that just because you are having challenges at work doesn’t mean that these things can’t translate into challenges at home. It is an important feature to identify.”

On lack of efficacy, Dr Barrett said that someone who is burned-out comes to believe that nothing changes, no matter how hard they try.

“That was certainly an issue for me: You are doing procedures, you are putting in stents, but patients aren’t taking their medication, they are having in-stent thrombosis and you wonder, ‘why should I do this at all?’ But I think that is when you begin to lose sight of the reasons why you do what you do.”

He considered that the “acid test” for whether someone is burned-out is their attitude to going to work.

“It is the front door of your hospital,” said Dr Barrett. “It is the front door of your clinic, it is the front door of the place that you work. If you walk up to the front door of the place that you work and all you want to do is walk straight back out that door, then there is the likelihood that you are at risk of burning out, and that if everything and everyone who asks you to do anything is seemingly in your way, there is the likelihood you are burned-out.”

Causes

Dr Barrett stressed that the causes for burnout are complex and vary from country-to-country, institution-to-institution and from hospital department to hospital department. As extremely conscientious individuals who hold themselves to high standards, Dr Barrett said doctors tend to blame themselves rather than their environment when they begin to feel stressed or burned-out. However, environmental or organisational factors are the chief reasons behind the problem. While Dr Barrett said workload is an important factor, it is not the chief predictor of burnout.

 “It is the biggest problem for those who are burned-out, but not the strongest predictor,” according to Dr Barrett.

“Therefore when we start addressing this by reducing hours, it is unlikely to make the biggest difference.”

Other contributors are a lack of rewards, a perception of unfairness in the workplace and no alignment between the values of the person and that of the hospital.

“But the number-one factor is a lack of control,” Dr Barrett told ISR delegates.

“This is control over our time, how we structure our schedules, how we are able to bring resources to bear over certain clinical scenarios, over the environment that we actually work in, and most importantly, our futures. Again, it is that state of weary indifference.”

What can be done?

Dr Barrett said that it is important to recognise that burnout cannot be treated in and of itself.

“The reason you can’t treat burnout is because burnout is a symptom of a problem that is driven largely by the ecosystem that we work in.”

Similarly, he explained that interventions focusing on the individual will not lead to lasting results, and that organisational change was required.

Shining a spotlight on burnout is the first part of addressing the problem, according to Dr Barrett, who added there is already evidence this is working. New figures in the US from Medscape show that the upward trend in physician burnout has stopped and the numbers are now going down.

“Although these figures are still way too high, it does demonstrate that the attention being brought on this area is making a difference and that meaningful reductions have been achieved,” he argued.

Also, Dr Barrett said there was a need for clinicians and healthcare managers to come together and start making the type of organisational changes that can make a difference for employees.

“Certainly, in the US, there’s the perception that this is an ‘us versus them’ problem,” he stated.

“It can feel that way, no matter where people are. But we are all part of the same system. We all have to work collaboratively and collectively together to make a difference. For anyone who runs an organisation, the first thing you can do is take the temperature… whatever survey tool you use, find out if it is a problem. After that, you can do a root cause analysis.

“There are a variety of different tools that you can use and they will give you an idea of where the true drivers are coming from. Now, you have something to aim for. When you have something to aim for, you have got a test that will take the temperature, you can find out the root cause, you can design an intervention, and then you can ‘rinse, wash and repeat’. And this requires organisational change.”

While Dr Barrett said there was no ‘silver bullet’ to reducing burnout, strong leadership and building communities were absolutely vital to improving the working lives of medical and healthcare professionals. A hospital’s occupational health department is also a good and under-utilised resource, he feels, for physicians who are burned-out.

“Their role is to provide the emotional wellbeing and support and actually have safe working environments for people who work within their organisations… they are very much attuned to dealing with this problem. So for anybody struggling in the immediate sense, this is an under-utilised resource that most people have an incredibly positive experience with.”

Reducing hours can be helpful but Dr Barrett does not believe this is the most important issue.

“If you decrease hours from 100 to 80 a week, it is not going to make a difference. But if you look at this idea of people working less than 70 hours a week, there is a difference. You need to recognise it is not simply about hours. Hours are a big problem for people who feel burned-out, but if people feel engaged and motivated and passionate about being in their work, the hours are less of a problem, so I feel we should focus less on them.”

Dr Barrett said career breaks can be a good thing, but stressed something has to change when the doctor returns to work.

Funding is required to make the necessary organisational changes to prevent burnout and make workplaces better for employees, Dr Barrett argued. Some hospitals, however, are reluctant to invest sufficiently to address the issue. Dr Barrett, who throughout his talk repeated that burnout was a quality and safety issue that affected patients as well as staff, said there were many benefits for those who put the necessary resources in place.

“It is not cheap, but it is worth it,” he said.