O FitzGerald

St Vincent's University Hospital, Dublin, Leinster, Ireland

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Publications (229)1200.05 Total impact

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    M. HAROON · A. B. RAFIQ CHAUDHRY · O. FITZGERALD

    Preview · Article · Feb 2016 · The Journal of Rheumatology
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    ABSTRACT: Guidelines for the prevention of glucocorticoid (GC) induced osteoporosis (GIOP) were implemented in a level 5 Irish Hospital with cross sectional audit of inpatient prescribing undertaken before and after. Prior to guideline implementation, elemental calcium (Ca) with Vitamin D (VitD) was prescribed for 11/66 (17%) of patients on GCs with 2/66 (3%) also receiving bisphosphonate (BP) therapy. Subsequent to guideline implementation, Ca with VitD was prescribed for 19/55 (35%) of patients on GCs with 11/55 (20%) also receiving BP therapy, representing a 2 and 6 fold respective increase. Internal promotion of guidelines is an effective strategy for healthcare improvement but needs refinement with or without repetition to achieve better patient outcomes.
    No preview · Article · Sep 2015 · Irish medical journal

  • No preview · Article · Jul 2015
  • M. Elmamoun · M. Haroon · P. Gallagher · O. FitzGerald
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    ABSTRACT: Background Psoriatic Arthritis (PsA) affects about 30% of individual with psoriasis after an average interval of 10 years (1,2). The most common classification of PsA by Moll and Wright still remains widely in use (3). The criteria include five clinical subgroups of PsA according to the pattern of joint involvement: oligoarthritis, polyarthritis, distal small joint arthritis, spondylarthritis, and Arthritis Mutilans (AM). AM is a rare type of PsA. In the literature the prevalence of AM has been estimated to range from zero or just 1% (4,5) up to 8% (6) of the PsA population. Objectives To determine the demographic and clinical characteristics of psoriatic AM in an Irish cohort attending a rheumatology unit. Methods Patients with a diagnosis of PsA, fulfilling the CASPAR criteria, who have AM, defined by digital shortening, erosion involving entire articular surfaces on both sides of the joint and/or pencil-in-cup change and/or osteolysis, aged >18 years were recruited. 23 patients were included after clinical and radiological examinations. Results The female to male ratio was close to 2:1. The mean age was 56.52. The mean age of skin disease onset was 24 years and the mean age of onset of joint disease was 30 years. At inclusion, the mean duration of arthritis was 25.8 years ±9.9 years. The only pattern of arthritis was that of polyarticular disease; with 48% of patients exhibiting concomitant axial disease. Enthesitis was found in 8 patients (35%), while 13 patients (57%) had dactylitis. 8 patients (35%) had sacroiliitis on plain films, 6 of these patients (75%) had asymmetrical sacroiliitis. 21 patients (91%) had nail disease. None of the patients in this cohort had uveitis. At the time of inclusion, 70% of patients were found to have clear or almost clear skin. 16 patients were on biologics (75%). The most frequent joints that showed AM were the MTP joints on the fourth toe on the left foot (n=10), followed by MTP joints on the fourth toe on the right (n=9). Further characteristics are outlined table 1. Conclusions The prevalence of AM in our psoriatic arthritis cohort is approximately 8%. The majority of patients present with nail disease, and mild skin disease. The average interval between skin and joint disease is approximately 6 years. AM occurs in the setting of poly articular disease and frequent axial involvement. The axial disease in these patients tends to be asymmetrical sacroiliitis. Many patients require biologics to control their disease. References Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background In 2013, the first patients were entered in to ASRI – the Ankylosing Spondylitis Registry of Ireland. The primary objectives of ASRI are to provide basic descriptive epidemiological data on the Ankylosing Spondylitis (AS) population in Ireland, and to establish a registry for potential future studies of genetics, aetiology and therapeutics. Objectives In this current study we were interested in exploring the issue of obesity in an AS cohort, and the effect this has on disease activity and functional impairment. Methods A standardised detailed clinical assessment of patients is performed on each patient and entered in a web-based database. Specific measures of disease activity (BASDAI), function (BASFI and HAQ), and quality of life (ASQoL) were obtained. Body Mass Index (BMI) was calculated. The cohort was divided in to those of normal weight (BMI <25), and those that were overweight or obese (BMI >25). The 2 cohorts were compared using a number of different clinical variable using standard t-test. Results As of Dec 2014, 267 patients have been entered in the database (212 males, 55 females). The average age of the cohort is 47.8 years. The average disease duration is 21.7 years. The average delay in diagnosis is 8.2 years. As regards extra-spinal manifestations, 15.8% have Psoriasis, 40.4% have uveitis, 13% have Crohns/IBD. Of the 267 patients, 183 were overweight or obese (68.5%). There is a significant difference in BASFI scores between normal weight AS patients versus those that are overweight/obese. There is also a trend towards higher BASDAI, HAQ and ASQoL in those that are overweight/obese also. See Table below. There were a higher percentage of patients with Hypertension (30% versus 13%), Hyperlipidaemia (15% versus 7%) and Diabetes (7% versus 4%) in those that were overweight/obese. The rate of current or past smokers was very similar between the 2 cohorts, 57% (normal weight cohort) and 60% (overweight/obese cohort). Conclusions The majority of AS patients in our cohort were overweight or obese. These patients have a greater burden of symptoms and more functional impairment. They also have a higher percentage of other cardiovascular risk factors. As our awareness of the increased risk of cardiovascular disease in AS patients improves this is important information in on going management. Acknowledgements I would like to acknowledge Abbvie and Pfizer for the unrestricted support of ASRI. I would also like to acknowledge all the effort from the rheumatology community in Ireland for their hard work, enthusiasm and support of ASRI. Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    O. FitzGerald · R. Fleischmann · B. Hoepken · L. Peterson · D. Gladman
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    ABSTRACT: Background Previous reports of RAPID-PsA (NCT01087788) have demonstrated the clinical efficacy of certolizumab pegol (CZP) in patients (pts) with psoriatic arthritis (PsA) over 96 weeks (wks), but have not yet investigated the long-term improvements in extra-articular manifestations (EAMs) of PsA.1 Objectives To report the efficacy of CZP for the treatment of EAMs in PsA including nail psoriasis, enthesitis, dactylitis, and psoriasis, over 96 wks of the RAPID-PsA trial. Methods RAPID-PsA1 was double-blind and placebo (PBO)-controlled to Wk24, dose-blind to Wk48 and open-label to Wk216. Pts had active PsA and had failed ≥1 DMARD. Pts were randomized 1:1:1 to either PBO or CZP 400mg loading dose at Wks 0, 2, 4 followed by 200mg Q2W or 400mg Q4W. We present efficacy data for all pts originally randomized to CZP. The primary clinical endpoint was Wk12 ACR20 response.2 EAMs were assessed in pts with baseline (BL) involvement and included nail psoriasis (modified nail psoriasis severity index [mNAPSI], BL involvement = BL mNAPSI >0; for some pts the nail analyzed was changed once or more to Wk96), enthesitis (Leeds enthesitis index [LEI], BL involvement = BL LEI >0), dactylitis (Leeds dactylitis index [LDI], BL involvement = at least 1 digit affected and with a difference in circumference ≥10%) and psoriasis (body surface area affected [BSA], BL involvement = BL BSA ≥3%). We also present data for pts with total resolution of each EAM, ie. the percentage of pts with BL involvement achieving complete clearance (a score of 0 for mNAPSI, LEI or LDI, or 0% BSA). Data shown are observed values. Results Of 409 pts randomized, 273 received CZP from Wk0. At BL, 197 of these pts had nail psoriasis, 172 enthesitis, 73 dactylitis and 166 psoriasis. Rapid reductions in scores were seen in all EAMs assessed and were maintained to Wk96 of the study. Improvements were observed in nail psoriasis, enthesitis, dactylitis and psoriasis, for pts with BL involvement (Table). These improvements were observed in pts treated with either CZP dose regimen. A large proportion of pts with BL EAM involvement went on to achieve total resolution. For pts with nail psoriasis at BL, 38.5% had achieved total resolution at Wk24 and 65.2% at Wk96. Similar results were seen for pts with enthesitis, dactylitis, or psoriasis at BL (pts with enthesitis at BL achieving total resolution: 65.2% at Wk24 and 71.0% at Wk96; pts with dactylitis at BL achieving total resolution: 73.8% at Wk24 and 89.5% at Wk96; pts with psoriasis at BL achieving total resolution: 26.8% at Wk24 and 48.5% at Wk96). Conclusions Improvements in EAMs of PsA were observed following CZP treatment and were maintained to Wk96 of RAPID-PsA. These improvements were seen in all EAMs measured, including nail psoriasis, enthesitis, dactylitis and psoriasis. Similar improvements were observed with both CZP dose regimens. References Acknowledgements The authors acknowledge Costello Medical Consulting for writing and editorial assistance, which was funded by UCB Pharma. Disclosure of Interest O. FitzGerald Grant/research support from: Abbvie, Roche, MSD, BMS, Speakers bureau: Janssen, Pfizer, Abbvie, UCB Pharma, Cellgene, R. Fleischmann: None declared, B. Hoepken Employee of: UCB Pharma, L. Peterson Employee of: UCB Pharma, D. Gladman Consultant for: Abbott, Bristol Myers Squibb, Celgene, Johnson & Johnson, MSD, Novartis, Pfizer, UCB Pharma
    Full-text · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background Abatacept is a fully human fusion protein which selectively inhibits T-cell activation via the CD80/CD86:CD28 co-stimulation pathway and decreases serum levels of inflammatory cytokines and proteins implicated in the pathogenesis of psoriatic arthritis (PsA). Improvement in skin psoriasis with greatest reduction in PASI using 3 mg/kg dose of abatacept and reduction of clinical symptoms of PsA on 10 mg/kg dose has been previously shown. Data is limited on the immunopathological effect of abatacept in PsA synovial tissue. Objectives (1) to study the change in immunohistochemical markers of synovial inflammation from baseline to 6 months after introducing abatacept treatment in patients with active PsA; (2) to evaluate the impact of a short period of abatacept 3 mg/kg treatment on both skin and joint-related clinical outcomes compared to placebo (PBO); (3) to investigate if cell markers of synovial inflammation correlate to disease activity measures and MRI synovitis scores. Methods Biological treatment-naïve PsA patients with active disease for ≥3 months with clinical synovitis of a knee and the presence of a psoriatic skin lesion were enrolled. Patients were randomised to receive abatacept 3mg/kg or PBO infusion on day 1, 15 and 29; thereafter abatacept 10mg/kg was administered every 28 days for 5 months. Clinical data were collected at each visit. Ga-enhanced MRI and arthroscopic synovial biopsy of the involved knee were obtained at 0, 2 and 6 months. Immunohistological staining for CD3, CD4, CD8, FoxP3 and CD31 was performed and expression was scored on a 5 point scale using a semi-quantitative method [1]. FoxP3 (%/300 cells) and CD31 expression (number of positive vessels/10 HPF) was evaluated. The PsAMRIS semi-quantitative method was used to score MRI scans by one consultant radiologist. A total synovitis score (MRS (0-12)) per knee was calculated [2]. Results 15 patients (8 female/7 male) with mean age of 45 (±14.6) years were recruited. 4 were on methotrexate, the remainder had not received any prior DMARDs. 73% and 80% of patients were EULAR responders at 2 and 6 months. Non responders had significantly higher CRP at basleline; ESR, CRP, DAS28 ESR and DAS28 CRP at 2 months and higher enthesitis scores at 6 months compared to responders. Preliminary synovial tissue analysis of the first 10 patients who completed the study revealed a reduction in expression for all cell markers as early as 2 months following treatment. There was a significant reduction in synovial CD4 expression at 6 months (p=0.038). Disease activity measures and cell markers did not show a significant difference between the treatment and PBO groups. MRS at baseline was lower (p=0.02) and change in DAS28 ESR 0 to 6 months was greater in the PBO group (p=0.08). Baseline DAS28 ESR significantly correlated with CD3, CD4 and FoxP3 expression at 6 months (rho=0.89 p=0.04). Conclusions Abatacept reduced synovial CD4 positive T-cell expression in psoriatic arthritis over 6 months. DAS28 ESR at baseline correlated with all observed T-cell markers in the synovium 6 months following treatment. References Disclosure of Interest A. Szentpetery: None declared, J. McCormack: None declared, L. Mellerick: None declared, E. Heffernan: None declared, A. Fabre: None declared, O. FitzGerald Grant/research support from: Pfizer, AbbVie, BMS, MSD, Roche, UCB, Consultant for: Pfizer, AbbVie, BMS, MSD, Janssen, Roche, Speakers bureau: Pfizer, AbbVie, Janssen, Roche, UCB
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Objective Previous reports of RAPID-PsA (NCT01087788) demonstrated efficacy and safety of certolizumab pegol (CZP) over 24 weeks in patients with psoriatic arthritis (PsA), including patients with prior antitumour necrosis factor (TNF) therapy. We report efficacy and safety data from a 96-week data cut of RAPID-PsA. Methods RAPID-PsA was placebo-controlled to week 24, dose-blind to week 48 and open-label to week 216. We present efficacy data including American College of Rheumatology (ACR)/Psoriasis Area and Severity Index (PASI) responses, HAQ-DI, pain, minimal disease activity (MDA), modified total Sharp score (mTSS) and ACR responses in patients with/without prior anti-TNF exposure, in addition to safety data. Results Of 409 patients randomised, 273 received CZP from week 0. 54 (19.8%) CZP patients had prior anti-TNF exposure. Of patients randomised to CZP, 91% completed week 24, 87% week 48 and 80% week 96. ACR responses were maintained to week 96: 60% of patients achieved ACR20 at week 24, and 64% at week 96. Improvements were observed with both CZP dose regimens. ACR20 responses were similar in patients with (week 24: 59%; week 96: 63%) and without (week 24: 60%; week 96: 64%) prior anti-TNF exposure. Placebo patients switching to CZP displayed rapid clinical improvements, maintained to week 96. In patients with ≥3% baseline skin involvement (60.8% week 0 CZP patients), PASI responses were maintained to week 96. No progression of structural damage was observed over the 96-week period. In the Safety Set (n=393), adverse events occurred in 345 patients (87.8%) and serious adverse events in 67 (17.0%), including 6 fatal events. Conclusions CZP efficacy was maintained to week 96 with both dose regimens and in patients with/without prior anti-TNF exposure. The safety profile was in line with that previously reported from RAPID-PsA, with no new safety signals observed with increased exposure. Trial registration number NCT01087788.
    Full-text · Article · Jun 2015
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    ABSTRACT: Background and objectives Despite RA and PsA share similar pathophysiological concepts, there are profound differences in the anatomical localisation of inflammatory lesions and in periarticular bone structure. Digital X-ray radiogrammetry (DXR) is a sensitive method for quantifying changes in periarticular bone mineral density (DXR-BMD) in the early phase of the disease. The aim of this study was to compare changes in hand BMD as measured by DXR in early, treatment-naïve RA to PsA patients prior to and 3, 12 months after introducing an anti-rheumatic drug. Methods Recent-onset (<12 months), active, treatment naïve PsA and RA patients were selected. Hand BMD was measured by DXR based on digitised hand radiographs (Sectra, Sweden) at baseline, 3 and 12 months. Mean DXR-BMD (mg/cm2) values of both hands and changes in DXR-BMD (mg/cm2/month) were compared between the two groups. Changes in hand BMD were further analysed by dividing PsA and RA into 3 subgroups based on cut-offs for the categories normal, elevated BMD loss (>-0.25 mg/cm2/month) and highly elevated BMD loss (>-2.5 mg/cm2/month). Results 64 patients (32 RA, 32 PsA) were included with median age 43 years. 95% of the patients were started on a DMARD at baseline and stayed on it at 12 months; 12.5% and 34.5% received TNFi in combination with a DMARD, respectively. 69% of RA and 68% of PsA patients were EULAR responders at 3 months, and 80% and 82% at 12 months, respectively. Mean hand DXR-BMD was lower in both diseases at 3 months compared to baseline. In RA DXR-BMD decreased further and was lower at 1 year compared to baseline (p = 0.004) and to 3 months (p = 0.002). In contrast mean DXR-BMD increased from 3 to 12 months in PsA (p = 0.07). Hand BMD was higher in PsA than in RA throughout the study. Patients started on a TNFi in combination with a DMARD had higher hand DXR-BMD at 3 and 12 months comparing with those who started on a DMARD monotherapy (p = 0.015 and p = 0.021, respectively). Among all patients with elevated BMD loss, change in DXR-BMD was less marked in the PsA group compared to RA from baseline to 3 (p = 0.018) and from 3 to 12 months (p = 0.011). Highly elevated bone loss was present only in the RA cohort at 1 year. Conclusions To our knowledge, this is the first prospective study comparing hand BMD changes in RA to PsA using DXR. Despite intervention of appropriate anti-rheumatic drug and improvement in disease activity measures, we found hand bone loss in RA, but bone gain in PsA after 12 months. Our observations support the hypothesis of different pathomechanisms being involved in hand bone remodelling in PsA.
    No preview · Article · Feb 2015 · Annals of the Rheumatic Diseases
  • A. -M. Tobin · R. Fitzgerald · O. FitzGerald · I. Graham · B. Kirby

    No preview · Conference Paper · Dec 2014
  • M O'rourke · M Haroon · P Ramasamy · O Fitzgerald · C Murphy
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    ABSTRACT: Purpose The association between anterior uveitis (AU) and spondyloarthritis (SpA) is well established. However, no algorithm exists to advise the ophthalmologist of which patients with AU should be referred to the rheumatolgist as a suspect SpA. Early diagnosis in SpA is key as disease severity and morbidity is related to disease duration. This study firstly establishes the incidence of SpA in an Irish cohort of patients attending eye casualty with previously unknown SpA. It also establishes a highly effective predictive algorithm to advise which patients should be referred to a rheumatologist as potential SpA.Methods 104 consecutive patients with non-infectious AU were recruited prospectively and subsequently screened by a rheumatologist for SpA. The most statically significant features were used to generate a predictive algorithm which was subsequently validated in a further cohort of 80 patients.Results The incidence of SpA is 41.5% with average duration of backache 9.36 years. Multiple regression analysis with detailed step wise post-hoc analysis identified that patients <45 years, with backache >3 months should have HLA-B27 checked. If positive, a referral is appropriate. If negative, a history of psoriasis should be ascertained and if present, the patient should be referred. This algorithm has sensitivity of 95% and specificity of 98%. Validation of this algorithm in a second cohort had comparable sensitivity and specificity.Conclusion The ophthalmologist has a necessary role in identifying SpA. Close collaboration between ophthalmologists and rheumatologists utilizing our algorithm will result in earlier treatment intervention to improve disease outcome.
    No preview · Article · Sep 2014 · Acta ophthalmologica
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    ABSTRACT: Background Abatacept, a soluble, fully human fusion protein which selectively inhibits T-cell activation via competitive binding to CD80/CD86, decreases serum levels of cytokines and inflammatory proteins implicated in the pathogenesis of psoriatic arthritis (PsA). It has been proposed that 10 mg/kg of abatacept, the approved dose for rheumatoid arthritis may be an effective treatment choice for PsA. [1] Objectives (1) To study both skin and joint-related clinical outcomes prior to and 6 months after introducing abatacept treatment in PsA; (2) To investigate MRI changes of an inflamed knee joint over time in PsA patients on abatacept. Methods 15 biological treatment-naïve PsA patients fulfilling the CASPAR criteria with active disease for ≥3 months (≥3 swollen and ≥3 tender joints) with clinical synovitis of a knee and the presence of a psoriatic skin lesion were enrolled in the study. Patients were randomised to receive abatacept 3mg/kg or placebo infusion on day 1, 15 and 29; thereafter abatacept 10mg/kg was administered to all patients every 28 days for 5 months. A stable dose of methotrexate (7.5-25 mgs/week) for >3 months prior to randomization was the only concomitant DMARD permitted. Gad-enhanced MRI of the same involved knee was performed at baseline, 2 and 6 months and scored using the PsAMRIS method by one consultant radiologist. For the semi-quantitative method each knee was divided into 4 anatomical regions; medial (MED) and lateral (LAT) parapateller recesses, intercondylar notch (ICN) and suprapatellar pouch (SPP). A synovitis score ranging from 0 to 3 was assigned to each region and then added to give a total MR synovitis score (MRS) ranging from 0 to 12. Results At the time of the analysis, the study is still blinded and so the results discussed are the overall results from 14 of the 15 patients. Patients (8 female/6 male) mean age was 44.6 (±15.2) years. Four patients were on methotrexate with the remainder not receiving any DMARDs during the study. At baseline patients' mean DAS28-ESR was 4.9 (±1) and DAS28-CRP 4.8 (±0.8). Median PASI, HAQ, PsAQol and DLQI were 3.6 (0-9.6), 1 (0-2.125), 10.5 (1-17) and 2.5 (0-27) respectively. Mean synovitis scores at MED, LAT, ICN and SPP regions were 2.07 (±0.9), 2.21 (±0.9), 1.4 (±0.8) and 1.85 (±1) respectively at baseline; mean MRS was 7.6 (±3.4). As per EULAR criteria 87.5% of the patients responded to the treatment at 6 months; 75% judged a good responder. 68 tender and 66 swollen joint counts, duration of morning stiffness, global health score, DAS28-ESR, DAS28-CRP, HAQ and PsAQol reduced significantly at 6 months compared to baseline. While there was no significant difference compared to baseline in the 4 anatomical region scores, the median MRS decreased over the study period and was significantly lower at 6 months compared to baseline (p=0.016). Conclusions These interim results show that 6 months of abatacept treatment reduced synovitis scores as assessed by MRI. Our results mirror the clinical improvements observed and support published data suggesting that 10 mg/kg of abatacept is a potent treatment option in PsA. References Acknowledgements This study received drug and financial support from Bristol Myers Squibb. Disclosure of Interest A. Szentpetery: None declared, E. Heffernan: None declared, M. Haroon: None declared, P. Gallagher: None declared, A.-M. Baker: None declared, M. Cooney: None declared, O. FitzGerald Grant/research support: Pfizer, Abbott, BMS, MSD, Roche, UCB, Consultant for: Pfizer, Abbott, BMS, MSD, Janssen, Roche, Speakers bureau: Pfizer, Abbott, Janssen, Roche, UCB DOI 10.1136/annrheumdis-2014-eular.5531
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background 68 tender (TJC) and 66 swollen joint counts (SJC) are recommended for disease activity assessment in psoriatic arthritis (PsA). However there are time constraints and these counts may not be performed. It has been shown in rheumatoid arthritis that patient's self-reported joint counts correlate well with functional disability, pain and global disease severity. Information concerning patients' self-assessed joint counts however is limited in PsA. Objectives The aim of this study is to evaluate the reliability of patient self-assessed joint counts versus joint counts obtained by a physician, a nurse and B-mode ultrasonography (US) in PsA. Methods PsA patients fulfilling the CASPAR criteria were recruited. Following a training session on the detection of tender and swollen joints by a nurse, each patient assessed their 68 joints using an electronic digital mannequin on touchscreen. A joint examination by a different nurse and a rheumatologist, both blinded to the patients' clinical data was completed. US evaluation was performed by a further consultant rheumatologist on 34 joints assessing wrists, MCPs and PIPs, ankles and MTPs, and all extensor/flexor tendons of the fingers and toes. Presence of joint effusion, synovial proliferation and tenosynovitis on grayscale (GS); and synovitis/tenosynovitis on power Doppler (PD) signal were evaluated. Results 43 patients (29 female and 14 male) were enrolled to the study with a mean age of 51 (±13.5) years. Focusing on the 34 joints also assessed by US, mean TJC assessed by the patients, physician and nurse was 9 (±8.3), 7 (±7.4) and 7 (±6.9), mean SJC was 4 (±5.6), 1 (±1.8) and 3 (±3.2) respectively. Mean number of affected (swollen or tender) joints as per patient, physician, nurse and US evaluation was 10 (±8.2), 7 (±7.1), 8 (±7) and 6 (±4.4), respectively. Patient and nurse-assessed SJC was significantly higher than physician-counts (p=0.0007; p=0.013, respectively). The number of affected joints was higher as evaluated by patients compared to physicians and US (p=0.019; p=0.012, respectively). Joint effusion was detected by US in 72%, synovitis in 79% on GS and 70% on PD and 30% of the patients had tenosynovitis. TJC and the number of affected joints did not correlate significantly with any of the US measurements irrespective of the assessors. Patients SJC significantly correlated with US-assessed joint effusion, and with synovitis (GS and PD). Physician and nurse-reported SJC correlated with US-derived synovitis scores only. Conclusions Patients scored their SJC and number of affected joints higher than physicians and US measurements. Patient-reported SJC correlated with both effusion and synovitis as detected by US suggesting that patients' self-evaluated SJC may be valid in routine clinical practice for monitoring disease activity in PsA. Disclosure of Interest A. Szentpetery: None declared, M. Haroon: None declared, E. O'Flynn: None declared, P. Gallagher: None declared, S. Alraqi: None declared, O. FitzGerald Grant/research support: Pfizer, Abbott, BMS, MSD, Roche, UCB, Consultant for: Pfizer, Abbott, BMS, MSD, Janssen, Roche, Speakers bureau: Pfizer, Abbott, Janssen, Roche, UCB DOI 10.1136/annrheumdis-2014-eular.5435
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases
  • E. O'Flynn · M. Haroon · M. O'Neill · A. Ahmad · O. FitzGerald
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    ABSTRACT: Background The evolution of Tumor Necrosing Factor inhibitor (TNFi) in the treatment and management of chronic inflammatory disease has revolutionised patients' disease and improved their quality of life substantially. However evidence shows there is an increased risk of infection, in particular mycobacterium infection and reactivation of a latent TB infection (LTBi)1, in patients receiving TNFi treatment. The screening of patients for LTBI is mandatory before initiating TNFi therapy; although TST is widely used in the diagnosis of LTBI, there is a lack of sensitivity and specificity2. Despite our initial TB screening policy, which included risk history assessment, chest X-ray (CXR), and TST, approximately 1% of patients over a 10 year period who screened negative subsequently developed active TB, frequently extra-pulmonary and treatment-resistant3. Data from our previous study revealed Quantiferon testing may identify additional patients with latent TB in Mantoux negative patients, indicating a potential benefit for Quantiferon testing as part of TB screening4. Objectives In this study, we sought to evaluate performance and benefits of incorporating Quantiferon in a TB screening protocol in our Rheumatology centre. Methods 109 patients were screened for LTBi. Their diagnoses including rheumatoid arthritis, psoriasic arthritis, ankylosing spondylitis, inflammatory arthritis and all patients were screened over a twelve month period (December 2011-December 2012). In the modified screening protocol, TST was replaced with Quantiferon blood test; however risk history assessment and CXR remain part of the screening protocol. Quantiferon positive patients were treated with isoniazid for LTBi. Results Mean age 50.5 years, 55% female. Diagnosis: 50.5%, 27% and 21% had RA, PsA and AS, respectively, 8% (9 patients) had positive Quantiferon, all received LTBi chemoprophylaxis. CXR suggestive of LTBi in 2.8% (3), all subsequently had normal CT- thorax. These 2.8% (3) had negative Quantiferon testing. 7% (8) had high TB risk history, only one patient tested Quantiferon positive. To date, no patient from this cohort has developed active TB after a mean follow-up of two years. Conclusions Replacing Mantoux testing with Quantiferon has proven a safe and effective strategy for LTBi screening. Quantiferon testing helpes improve TB testing compliance and eliminates false – positive results associated with BCG5. Quantiferon testing requires one clinic visit with substantial benefits for the patient and the rheumatology nurse specialist identified in terms of time and indirect costs. Mantoux testing can be inconvenient as it requires two patient visits. References Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.5717
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases
  • P. Helliwell · P. J. Mease · T. Nurminen · O. FitzGerald
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    ABSTRACT: Background Several new disease-specific composite disease activity measures have been developed for psoriatic arthritis (PsA). Objectives Using data from a randomized double-blind placebo-controlled trial of certolizumab pegol (CZP) in PsA (RAPID-PsA, NCT01087788) we aimed to compare the performance of the Psoriatic Arthritis Disease Activity Score (PASDAS), the Composite Psoriatic Disease Activity Index (CPDAI), and modifications of the CPDAI with the Disease Activity Score 28 (DAS28), which was developed for use in rheumatoid arthritis. Methods The CPDAI and PASDAS composite measures have been described previously.1,2 In RAPID-PsA not all components of CPDAI were collected, therefore psoriasis body surface area was substituted for Psoriasis Area Severity Index, and the Health Assessment Questionnaire was used as the function modifier for the axial component of this measure (CPDAIm). The CPDAI was further modified by the addition of a patient (pt)-completed outcome domain, based on the pt visual analogue scale scores for arthritis pain and global disease activity (CPDAIpro). The performance of these measures was assessed after 12 weeks of CZP treatment by calculating, for the change from baseline, the standardized response mean, the baseline-adjusted effect size compared to placebo (ESadj, based on analysis of covariance), and the required sample size based on the ESadj. Data are reported for those pts with all outcome components available. Only observed data were used, without imputation. Results The largest ESadj was found for PASDAS, followed by DAS28, CPDAIm and CPDAIpro (Table). These figures translated into differences in sample size estimation for further studies. Conclusions The PASDAS and CPDAI composite measures demonstrated good responsiveness and discriminative ability in this trial, supporting further exploration of their use in PsA clinical trials. Differences in the performance of these new PsA-specific composite measures were seen in this dataset. These results may help inform the selection of appropriate composite measures for PsA in future studies. Addition of a pt-completed outcome domain to the CPDAI did not appear to improve performance of the composite score. References Acknowledgements The authors acknowledge Costello Medical Consulting for editorial assistance which was funded by UCB Pharma Disclosure of Interest P. Helliwell Grant/research support: Abbvie, Celgene, Janssen, MSD, Pfizer, UCB Pharma, Novartis, Bristol-Myers Squibb, Roche, Speakers bureau: Abbvie, Celgene, Janssen, MSD, Pfizer, UCB Pharma, Novartis, Bristol-Myers Squibb, Roche, P. Mease Grant/research support: (Abbott) AbbVie, Amgen, BiogenIdec, Bristol-Myers Squibb, Celgene, Crescendo, Genentech, Janssen, Lilly, Merck, Novartis, Pfizer, UCB Pharma, Vertex, Consultant for: (Abbott) AbbVie, Amgen, BiogenIdec, Bristol-Myers Squibb, Celgene, Crescendo, Genentech, Janssen, Lilly, Merck, Novartis, Pfizer, UCB Pharma, Vertex, Speakers bureau: (Abbott) AbbVie, Amgen, BiogenIdec, Bristol-Myers Squibb, Crescendo, Genentech, Janssen, Lilly, Pfizer, UCB Pharma, T. Nurminen Employee of: UCB Pharma, O. FitzGerald Grant/research support: Pfizer, Abbvie, Roche, MSD, Bristol-Myers Squibb, Speakers bureau: Janssen, Pfizer, Abbvie, UCB Pharma, Cellgene DOI 10.1136/annrheumdis-2014-eular.1654
    No preview · Article · Jun 2014 · Annals of the Rheumatic Diseases
  • M. Fitzpatrick · P. Gallagher · C. Molloy · O. FitzGerald · F. O'Shea

    No preview · Article · Apr 2014 · Irish Journal of Medical Science
  • M. Haroon · B. Kirby · O. Fitzgerald
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    ABSTRACT: Background Delay in diagnosis of psoriatic arthritis (PsA) remains a significant contributor to poor patient outcome. Clinical predictors of the development of arthritis among patients with psoriasis (Ps) have been proposed and a number of screening questionnaires have been developed. Objectives The objectives of this study were: 1) to assess the prevalence of PsA among Ps patients attending dermatology clinics; 2) to identify clinical predictors of the development of PsA; and 3) to compare the performance of 3 PsA screening questionnaires [Psoriatic Arthritis Screening and Evaluation (PASE), Psoriasis Epidemiology Screening Tool (PEST), and the Toronto Psoriatic Arthritis Screening tool (ToPAS)]. Methods This study was carried out in general dermatology and rheumatology clinics. Patients were divided into two groups: group 1, consecutive patients with skin psoriasis attending dermatology clinics who have no known diagnosis of inflammatory arthritis; group 2, consecutive patients attending rheumatology clinics with a confirmed diagnosis of PsA. The diagnosis of PsA was made using the CASPAR criteria. In group 1, patients completed the screening questionnaires, which were followed by a thorough rheumatologic evaluation whether or not patients reported musculoskeletal symptoms. Results 200 patients were recruited; 100 in each group. 84% of patients in Group1 were using systemic therapy for their skin disease, and 99% of patients in Group 2 were on systemic immunosuppressives. In Group 1, 29% of patients were diagnosed with PsA after rheumatologic evaluation. Compared to Group 2, patients in Group1 had significantly higher PASIs (p=0.001), more scalp psoriasis at the time of assessment (p=0.0001) and less nail disease ever in the disease course (p=0.04). There was no significant difference in the presence of scalp disease ever in the disease course among Group 1, Group 2 and even in the subgroup of newly diagnosed patients with PsA. On univariate and multivariate analysis, the only significant positive association was noted between high PASIs and the new diagnosis of PsA (p=0.046), even after adjusting for confounders such as, age, gender, use of TNFi, duration of psoriasis and the presence of nail and scalp disease ever in the disease course. A strikingly different pattern of joint involvement was noted in patients with newly diagnosed PsA vs. patients with established PsA with fewer non-polyarticular disease (p=0.0001). In Group 1, the PEST, PASE and ToPAS had sensitivities of 27.5%, 24% and 41%, and specificities of 98%, 94% and 90%, respectively; however, in Group 2, the sensitivities were 86%, 62% and 83%, and specificities were 98%, 94% and 90%, respectively. Conclusions When patients with known PsA were excluded, 29% of Ps patients attending dermatology clinics had PsA diagnosed following rheumatologic assessment. Psoriasis severity as measured by PASI was associated with the diagnosis of PsA even after adjusting for the use of TNFi, duration of psoriasis, and the presence of nail or scalp disease. Nail disease ever in the disease course was commoner in patients with known PsA. Poor sensitivities for the screening questionnaires was noted among patients with psoriasis, perhaps due in part to inadequate recognition of patterns of arthritis other than that of polyarticular disease. Disclosure of Interest None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
  • M. Haroon · J. T. Giles · R. Winchester · O. FitzGerald
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    ABSTRACT: Background A rigorously ascertained psoriatic arthritis (PsA) cohort demonstrated considerable genetic heterogeneity and provided preliminary evidence that MHC genes determine quantitative traits within the PsA phenotype with different patterns of MHC effect. (Arth & Rheum 2012. 64: 1134). Objectives To investigate any potential association of clinical phenotypes with already well characterised and quantified genotypes of PsA patients belonging to a genetically relatively homogeneous population Methods A consecutive cohort of 283 PsA patients underwent detailed skin and rheumatologic assessments. We chose four traits to analyze - sacroiliitis, enthesitis, joint deformity and dactylitis. To examine their genotypic interaction, we assigned a score to each patient’s allele and haplotype. +1 if an allele or haplotype was associated with a high risk for the trait, and -1 if it conferred a low risk in univariate analysis. Alleles or haplotypes not significantly associated with a trait were assigned “0”, and the score summed assuming an additive risk model. Results A total of 283 PsA patients [mean age 55±12 years; 47% male; mean PsA duration=19±9 years; 25% with sacroiliitis; 44.5% with radiographic erosions; 34% with enthesitis; 53% with dactylitis, 60% of this PsA cohort requiring TNFi therapy] were studied. The figure shows the frequency of each trait as a function of the risk score for the alleles and haplotypes associated with high or low risk and the average change in the odds of having each trait per 1 unit increase in the genotype risk score, e.g. the OR of developing enthesitis with an alleles/haplotypes genotype score of +2 to +4 was 13.9, p<0.001. Conclusions HLA genotype importantly influences the clinical phenotype of psoriatic arthritis; and these phenotypes are likely the result of cis and trans interactions of multiple individual alleles. Disclosure of Interest None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background There is a growing interest in bone and cartilage biomarkers that could be used predicting and assessing changes in structural damage in inflammatory arthritis. Disease-related bone loss assessed by dual-energy X-ray absorptiometry (DXA) is a well known feature in RA and PsA, however data on bone loss during the first year of treatment in early disease are limited. Objectives (1) To study changes in serum levels of bone biomarkers and bone mineral density (BMD) measurements in early PsA and RA prior to and 12 months after introducing an anti-rheumatic drug; (2) To explore associations between disease-related variables, serum bone biomarkers and BMD measurements; (3) To investigate if serum bone biomarkers prior to treatment predict systemic bone loss over 1 year in patients with PsA and RA. Methods Recent-onset (<12 months), active, treatment naive PsA and RA patients were recruited. We measured serum bone-specific alkaline phosphatase (bone ALP), a marker of bone formation, and C-terminal cross-linking telopeptide (CTX-I), a degradation marker of type-I collagen reflecting systemic bone resorption at baseline, 3 and 12 months by immunoassay. We assessed bone remodelling balance by calculating bone ALP/CTX-1 ratios. BMD measurements were obtained at left total hip and lumbar spine at baseline and 12 month by DXA. Clinical parameters were correlated with bone biomarkers and BMD measurements. Results 64 patients (32 PsA, 32 RA) were included with median age 43 years. 95% of the patients were commenced on a DMARD therapy at baseline and 11.7 % (12.5% RA; 10.7% PsA) were also started on a TNF inhibitor. At 12 months 94.8% of the patients were on a DMARD and 34.5% on TNF inhibitor (33.3 % RA; 35.7% PsA). Bone ALP levels did not change significantly in either cohort during the study. CTX-I levels decreased after 3 months of treatment in RA (p=0.013) and in the entire group (p=0.043) remaining lower at 12 months (p= 0.042; p= 0.012 respectively) compared to baseline. Bone ALP/ CTX-I ratio was higher (p=0.05) at 1 year compared to baseline in the entire group reflecting improvement in bone remodelling balance. Hip BMD decreased in both diseases, significantly in RA (p=0.021), whilst spine BMD decreased in RA (p=0.056) but increased in PsA (p=0.017). CTX-I levels were correlated inversely with hip BMD in PsA at both baseline and 12 months (r = -0.38, p= 0.04; r = -0.51, p= 0.007) and similarly in the entire group (r = -0.29, p= 0.03; r = -0.3, p= 0.02). Baseline CTX-I levels correlated with the change in hip BMD over 12 month in the whole group (r = 0.31, p= 0.03). Stepwise multiple logistic regression analysis revealed significant associations of baseline CTX-I levels with change in BMD of the hip over 12 months in PsA (OR 2.8, p=0.009) and in the entire cohort (OR 2.5, p=0.014) with the model also including bone ALP, ESR, CRP, DAS28 CRP and HAQ. Conclusions The improvement in bone remodelling balance seen in early PsA and RA patients is most likely due to decrease in bone resorption after 1 year of appropriate anti-rheumatic therapy. High baseline levels of serum CTX-I may predict systemic bone loss at the hip over 1 year in patients with PsA. Disclosure of Interest A. Szentpetery: None Declared, M. Kilbane: None Declared, M. O’Keane: None Declared, M. Haroon: None Declared, P. Gallagher: None Declared, S. van der Kamp: None Declared, M. McKenna: None Declared, O. FitzGerald Grant/research support from: Abbott, BMS, Pfizer, MSD, Consultant for: Abbott, UCB, Pfizer, Speakers bureau: Abbott, Pfizer, MSD
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases
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    ABSTRACT: Background Therapeutic targets have been defined for diseases like diabetes, hypertension or rheumatoid arthritis and adhering to them has improved outcomes. Such recommendations are unavailable for spondyloarthritis. Objectives To define the treatment target for spondyloarthritis including ankylosing spondylitis (AS) and psoriatic arthritis (PsA) and develop recommendations for achieving the target, including a treat-to-target management strategy. Methods Based on results of a systematic literature review (performed by MS) and expert opinion, a task force of expert physicians and patients developed recommendations, which were broadly discussed and voted upon in a Delphi-like process. Level of evidence, grade of recommendation and strength of recommendation were derived by respective means. Results The literature review did not reveal trials comparing a treat-to-target approach with another or no strategy, but provided indirect evidence that facilitated the development of recommendations. The task force agreed on 5 overarching principles and 11 recommendations. Based on the current perception and classification of spondyloarthritis (including PsA, axial SpA (AS and non-radiographic axial SpA), peripheral SpA), only the last 2 recommendations are separate for axial spondyloarthritis, peripheral spondyloarthritis and PsA, while principles and 9 of the recommendations form a common trunk for all types of spondyloarthritis. The main treatment target, which should be based on a shared decision with the patient, was defined as remission, with an alternative target being low disease activity. Means to assess disease activity are discussed. Regular follow-up examinations should safeguard the evolution of disease activity toward the targeted goal. Additional items relate to extraarticular and extramusculoskeletal aspects and other factors, such as comorbidity. While the level of evidence was low for all items, the mean strength of recommendation was 9-10 (10: maximum agreement) for all recommendations. A research agenda was formulated. Conclusions The recommendations shall inform patients, rheumatologists, dermatologists and other experts as well as other stakeholders about expert opinion that allows reaching optimal outcomes of spondyloarthritis including AS and PsA. Acknowledgements This work was supported by an unrestricted educational grant from Abbott. Disclosure of Interest J. Smolen Grant/research support from: Abbott, Consultant for: Abbott, J. Braun: None Declared, M. Dougados: None Declared, P. Emery: None Declared, O. FitzGerald: None Declared, P. Helliwell: None Declared, A. Kavanaugh: None Declared, T. Kvien: None Declared, R. Landewé: None Declared, T. Luger: None Declared, P. Mease: None Declared, I. Olivieri: None Declared, J. Reveille: None Declared, C. Ritchlin: None Declared, M. Rudwaleit: None Declared, M. Schoels: None Declared, J. Sieper: None Declared, M. de Wit: None Declared, D. van der Heijde: None Declared
    No preview · Article · Jan 2014 · Annals of the Rheumatic Diseases

Publication Stats

5k Citations
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Institutions

  • 1999-2015
    • St Vincent's University Hospital
      Dublin, Leinster, Ireland
  • 1975-2015
    • University College Dublin
      • • School of Medicine & Medical Science
      • • School of Chemistry and Chemical Biology
      Dublin, Leinster, Ireland
  • 1992-2013
    • St. Vincents University Hospital
      • Department of Rheumatology
      Dublin, Leinster, Ireland
  • 1991-2008
    • St. Vincent Hospital
      Green Bay, Wisconsin, United States
  • 2004
    • Repatriation General Hospital
      Tarndarnya, South Australia, Australia
  • 1960-2002
    • St. Vincent's Private Hospital
      Dublin, Leinster, Ireland
  • 1998
    • Dublin City University
      Dublin, Leinster, Ireland
  • 1973-1995
    • St. Vincent’s Hospital, Fairview
      Dublin, Leinster, Ireland
  • 1989-1991
    • Beaumont Hospital
      Dublin, Leinster, Ireland
  • 1976
    • Port of Spain General Hospital
      City of Port-of-Spain, City of Port of Spain, Trinidad and Tobago