P031 Adherence to liver monitoring guidelines in rheumatology patients on methotrexate

Abstract Background/Aims Methotrexate (MTX) has historically been associated with liver fibrosis (LF), although recent evidence suggests that this risk is lower than previously thought. Current Guy’s and St Thomas’ NHS Foundation Trust (GSTT) pan-specialty guidelines recommend baseline Alanine Aminotransferase (ALT), Gamma-Glutamyl Transferase (GGT), viral screening and Fibroscan prior to commencing MTX, followed by annual Fibroscans. These recommendations are more intensive than those of both National Institute for Health and Care Excellence (NICE) and British Society for Rheumatology (BSR) guidance, which is due to be updated. This audit evaluated adherence to, and the sustainability of, the existing GSTT guidelines. Methods All patients scheduled to attend GSTT Rheumatology clinics over one week were audited. Data was extracted from electronic patient records, including rheumatology diagnosis, MTX dose, risk factors for liver disease and liver biomarkers. Missing investigations were ordered where screening was incomplete. Additionally, case notes of seven rheumatology patients who developed liver cirrhosis while on MTX were reviewed to identify other contributory risk factors. Results Of 440 patients, 77 (17.5%) were MTX users. Of these, only 43% had GGT measured and 11.7% had a Fibroscan performed or ordered. Twenty (25.9%) MTX users had abnormal LFTs at some point during treatment. Of these, 60% had a Hepatitis B/C screen, 10% a complete liver autoantibody screen, 55% a liver ultrasound, and 25% a Fibroscan performed or ordered. Fibroscans were ordered for the 77 MTX users, of which 56 were attended. All showed mean liver stiffness (MLS) <7.8kPa, below threshold for hepatology referral. All seven cirrhotic patients had significant metabolic risk factors for liver pathology. 5/7 had Type 2 diabetes mellitus (T2DM), and 7/7 had T2DM and/or BMI>30. Conclusion Adherence to the trust’s pan-specialty guideline, particularly for baseline and annual Fibroscans, was poor, likely reflecting limitations on scanning capacity and differences from national rheumatology guidelines. Emerging evidence suggests that the link between MTX and LF has been overstated previously, with metabolic risk factors playing a more substantial role. This is reflected in the seven cirrhotic patients who had significant metabolic comorbidities. We propose updating the guideline to include risk stratification of LF based on metabolic risk factors and calculation of FIB-4. MTX users with FIB-4 > 1.3 (<65 yrs old) or > 2 (>65 years old), would undergo Fibroscan assessment. Applying this approach to the audited cohort, 25% of MTX users would require Fibroscan, none of whom would have met hepatology referral thresholds. In contrast, current guidelines mandate Fibroscan for all MTX users, despite zero referrals required. Trust-wide pan-specialty guidelines have limitations due to differing specialty guidance. We propose a sustainable guideline update to include metabolic risk factor assessment and FIB-4 calculations, reducing unnecessary Fibroscans whilst maintaining patient safety. Disclosure Y. Charavanamuttu: None. K. Biddle: None. N. Ng: None.