Ep 45: Immunology in the virtual biologics clinic

How do we approach a patient with rheumatic diseases who have cycled through multiple high cost drugs? In this pod, Dr Roz Benson, BSR Digital Learning Editor chats with Dr Arti Mahto, a consultant rheumatologist. They talk through some challenging cases discussed in the virtual biologics clinic and the role of the MDT in complex decision making.

Thanks for listening to Talking Rheumatology! Join the conversation on X using #TalkingRheum or tweet us @RheumatologyUK.

BSR is the UK's leading specialist medical society for rheumatology and MSK health professionals. To discover how we can support you in delivering the best care for your patients, visit our website.

Transcript

RB - Hi. I'm Roz Benson. I'm a rheumatology consultant in Liverpool, and I'm also one of the digital learning editors at the BSR. Thanks for tuning in to this spotlight pod. I'm going to be chatting with doctor Arti Mahto today. Aarti is a consultant rheumatologist at King's Hospital in London, and we're going to be talking about the virtual biologic clinic, also known as a VBC. Really, the VBC demonstrates immunology in action by choosing particular biologic drugs, we can target immunological pathways which help us treat diseases. So, hopefully, by the end of this pod, you'll have a better understanding of how the VBC is set up, but also, how to approach some of these treatment decisions for typical cases that we might see in our rheumatology clinic.So I'm going to hand over to you now, Arti, if that's okay. Can you tell us a bit about how you found yourself in the VBC? 

AH - Thanks, Roz. So yeah. So I've been a consultant now for six years and initially, my PhD and my initial research was all about synovial biopsies. So my interest in early inflammatory arthritis began from there and as time has gone on, I've also, become vasculitis lead at King’s. So I sort of have a hat and a foot in both camps, so to speak which is probably quite invaluable with the discussion around some of these more tricky patients.

RB - So I think we what we might do is start off, if that's okay, thinking about what is the virtual biologics clinic or as its oftenly called, the VBC

AM - We are very lucky at King's. So, so many years ago, Professor Galloway set up this virtual biologics clinic and really what it is, is actually a very in-depth, MDT. So on the clinic, we normally have at least three or four consultants, the trainees, nurse specialists, pharmacy, and then also, administrators then that will just help in case there's blood test missing, or there's anything specific that we need to get back to the patient for. The way it works at King's is that any patient starting a biologic, for whatever reason, and we also actually have the equivalent on the CTD side, gets referred into the, virtual biologics clinic. So we do this through Epic now. Before EPIC, the pharmacist used to have to compile a separate list, which was a little bit more difficult. And so everybody gets referred in and each patient is discussed, with input from all members of the team, to decide which biologics we're going to use. So, obviously, working in a specialist teaching hospital, there's probably more members of the team who might attend your VBC.

RB - And I suspect as we talk about some of the cases that you've brought for us to discuss today, they might be more complex and might be seen in, a different nonspecialist center. But, hopefully, some of the themes about what we're going to discuss and also similarities of the makeup of the VBC will be similar to what people experience locally. So I think that the footprint of, clinicians, specialist nurse, pharmacist, and administrator tends to often be the case, with a with a VBC. 

AM - Yeah. And I think the other important thing is that, it's actually, it's a really good place to document everything. So there's a few things. So, you know, sometimes the diagnosis is not a 100% clear. So you'll have the, patient who's got a low level rheumatoid factor but maybe has a bit of psoriasis. So it's a good time to go back and reflect on diagnosis if there's any, any sort of grey areas. And then also particularly for biologic switches, it's a really good time to discuss which switch, which biologic switch would be the most effective, what evidence there is, and what we think would be best for the patient. So in our VBC, we discuss, say rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis patients. Often also, because everyone's got a subspecialist interest, we'll often have, patients who've got IgG four disease, and some of the rarer conditions that you need to do blue text for, like, sarcoid. 

RB - Brilliant. So it's actually a very, a good learning experience for everybody attending, I imagine. Yeah.

AM - It's it is. It is. It's very good. 

RB - So, when people you said the process in your hospital is to EPR, your your, particular system. I suspect there's quite a bit of generic information that people give when they're referring a patient to VBC. So you've touched on diagnosis, and some of the disease manifestations. Are there any other bits of information which you need to have when you're referring a patient? 

AM - So we have, disease activity scores. So the DAS twenty eight ESR and CRP. We have a box for the BAS dye and the spinal BAS, and we also have a box for tender joint count for psoriasis. Also, previous biologics and previous disease modifying agents and then we have a box for making sure that the pre biologic screening has all been done and what year it was done in. There is also a box to say that vaccines have been discussed and that, as far as we know, there's no contraindication to the drug. So it's fairly it's very quick to do, but it just makes the whole process more streamlined then because also you're then not looking for the information during the meeting. 

RB - Because it's really quite comprehensive, the information you're given. And then when you do make a decision amongst the MDT about the drug that you're going to give, to the patient, do you, do you take into account, preferences given by the referrer to the VBC? And then, also, how do you communicate back your drug choice? 

AM - So most of us, if we have referred in, will try and make it to the VBC. If for any reason someone's not there, usually, you put in your preferred choice of drug. If you want it just to be a discussion, there is a box for us to tick for discussion only, and then that prompts a sort of discussion. And then, yeah. So it's may it's mainly referrer puts in their their preferred choice or the patient's preferred choice or for discussion, then we all sit down and make a decision. 

RB - Yeah. So I think it's probably really helpful, isn't it Because there's so many changing, it's a it's a really changing landscape, isn't it, with, originated drugs with biosimilars cost, procurement costs. Actually, it's quite difficult to keep on top of what's the best option drug to give in a case of rheumatoid arthritis in terms of cost particularly is in my head. And so actually having a pharmacist who can comment on that and help guide your decision is probably really useful. 

AM - Absolutely. And often, you know, we some of the some which is perfectly fine, but some members of the team might not know about whether there's any cost saving benefits at the moment or whether there's any sort of, you know, the the sort of cost of the incentives that some of the drug companies will run and it's always good to have that information. And I think the other really important thing also is that when you've been looking after patients for a really long time, actually, sometimes you just assume, don't you, that you might you might have made the best decision and actually just to have somebody challenge you, or not even challenge, but at least just to have an open discussion about, well, have you thought about this? Or have you thought about the shape of the pen? Or have you thought about the fact that this person travels a lot? And so often, you know, for example, the specialist nurses or allied health professionals will bring in other nuggets that I think sometimes as clinicians who are really busy, you might just not think about. 

RB - Yep. Yeah. And then that can shape your decision making, can't it, which is really important. So I think if we move on to three cases, we're going to cover a rheumatoid arthritis case, psoriatic arthritis case, and also somebody who's got ankylosing spondylitis. And in our discussion, hopefully, it will provide a bit of a framework as to the thinking when you're approaching these sort of quite complex patients that you've brought for our our chat. So, to any of the listeners, listening in who might feel slightly fearful about having to manage these patients, which was my my feeling, It's good to hear that the MDT approach has been helpful in creating a treatment pathway. 

AM - Yeah. I think the first thing I should say actually is we're quite lucky in Southeast London, in that we do we don't have the same constraints that I know a lot of our colleagues do, even in North London. And, you know, that's a whole different discussion, isn't it, about resources and what's available? But I mean, this the first case, about rheumatoid arthritis, again, it sort of it sort of spans over somebody who was quite difficult to treat. But also a really a really knowledgeable patient who himself, you know, sits on, a lot of committees, was really, really involved in his own care. And that's why I think actually having being able to say to him, it's not just me that's made this plan. There are some really amazing experts in this room that have made this plan with me, I think then also fills patients that might be difficult to treat or refractory, with a bit of confidence that it's not a one person decision. 

RB - Yeah. Absolutely. 

AM - So it does bring me on to the first case. I mean, who so so this gentleman actually, he'd had rheumatoid arthritis, since his twenties and also a type one diabetic, now in his forties. And unfortunately, I mean, he'd cycled through quite a lot of biologics. So methotrexate had caused a hemorrhagic cystitis, which meant that he had to stop the drug. And he'd been on adalimumab, which had worked quite well. Inflix, but then stopped working, so it was a secondary failure. Inflixmab worked well, but unfortunately, he developed anti drug antibodies. Had tried rituximab, tocilizumab, baricitinib, and abatacept, and was referred to us because, the, hospital that he'd come from would have had to do another individual funding request. And so it was interesting because we obviously was thinking to ourselves, well, what what do we use next? And so this is where it was really important to go back through the notes to work out which treatments had failed and why. And coming back to the immunology of things, so this gentleman, had a very, very high rheumatoid factor in CCP. So both were over 600, which is sort of almost at the top end of what our lab can measure. And so we we talked about it and we sort of thought, okay, what what, you know, what can we use? The other thing I should mention is that he'd had a he'd had a, knee replacement that had been complicated by an infection. And so there was all of this to take on board. 

RB - And actually, if we if I don't mean to interrupt you, but just to say, it's interesting looking at the choices of drugs that he's had in the past. So, and this is often the way that we manage these people and cycle through drugs, isn't it? That we so as you said, he'd had, obviously, methotrexate would be a starting drug. But then when he moved on to biologic therapy, he's had anti TNF, which targets one pathway, then he went on and then a second anti TNF, which sometimes can work, can't it, for people if the first has failed. But then another drug, rituximab, which is much more focused on b cell, immunology, and then he's had then another then he had was it tocilizumab next? Mhmm. And IL six, and then finally, JAK, and then even thinking about abatacept. So really, actually, in your approach to this patient, the the rheumatologist and the team looking after him have really tried to target all different, immunological mechanisms for of action. So sorry. I'll let you carry on, though. So we're at a really sticky point, aren't we, in patient? 

AM - So I think this this was the the the slight problem, and we were sort of thinking to ourselves, well, what are we going to add that is you know, he's he's had excellent care to this point but I suppose the con discussions that we had is okay. Well, do we go back very old school to the original rituximab trials where it was given with cyclophosphamide? Or do we try something different like tacrolimus, which has a bit of evidence, but again, a bit more difficult to take in terms of thinking about levels. And so the thought process was, well, actually, what happens if we just do a combination and he was very, very seropositive. So whilst rituximab on its own had not worked for him, we said, actually, why don't we just go back and try and get this level of antibody down, and see what happens? And so a little bit reluctantly at the start, he agreed, and we sort of made the argument that, look, we're going to give you sacrosanct with the rituximab and go back to that original the original trial. So that did require require a chair's action. And I think this is another aspect of where the MDT is really important. So if you then go to your chair and say, actually, this has been discussed in a VBC with pharmacy, with multiple consultants, with specialist nurse. And actually, that allows at least your trust director to say, well, clearly, this is a room full of experts and that's what they think is best. So this gentleman, we did we did cyclophosphamide and rituximab. And then he'd had a partial sort of response to baricitinib. So we thought, okay, we could maybe add in another JAK. With the obviously, the worry with this was always infection but we thought that it's relatively short acting. And if something happens and we want to give him something short acting that we can stop, in case of an infection, and fingers crossed it will all be okay. And actually, we're about a year and a half on now, and he's had three cycles of rituximab, which we gave fixed every six months. His antibody level has come right back down. So his CCP antibodies and we don't again, I don't normally routinely recheck them this was more of an academic exercise. He's come right down to sort of 80, and it's the first time in over ten years he's off steroids. 

RB - Which says a lot. That's pretty remarkable. 

AM - And his diabetes is is much, much better. The question obviously is that again, so the chair's action only goes for two years. And so, the conversation then to have is, well, how long do we keep going? And we don't want to risk him becoming hypogam. So it's all yeah. But it was a really good sort of in refractory patients having lots of heads around the room. As well as the patient involvement actually in this was really, like, really eye opening, and I think we're lucky it worked. Yeah. 

RB - Absolutely. Because this is actually not a treatment strategy that's without risk, is it? So in terms of, in the acute setting, risk of infection, by blocking multiple pathways, we increase the risk of infection, don't we. And we've reduced immunity. But then also, long term, as you mentioned, with this potential risk of hypogammagrobulinemia from recurrent rituximab infusions, this is difficult. But, actually, he was not in an easy situation before then, was he? That's what you've got to work with, isn't it? Yeah.

AM - And he was you know, he really wanted to come off the steroids. He just said, you know, his sugars I mean, they were he was on insulin. It was all controllable. You know, he had pumps, but still, just to try and stop these steroids is one of the most important things for him. And I think, again, I mean, highlighting different members of the VBC. So some of us do ultrasound scans. Some of us, you know, have a lot more kind of epidemiological, backgrounds. And so if there is a patient where we're sort of like, well, how are we going to monitor this? Are we going do imaging? Are we going to do blood tests? Are we just going to do DAS twenty eight? You often then also can cross refer at that point and say, well, could you just fit this person in for a scan? And that seems to work Yeah. Well as well.

RB - Really important to have the different modalities to assess disease response in these situations. And just interested in your choice in baricitinib?  So he's so he had I think he had a he had, we did try we did try, ubasistantib, but he didn't get on with that.

RB -  So I think, if we move on to the next scenario that you've got, which is of a patient with psoriatic arthritis, can you tell me a bit more about them?

AM - Yeah. So this lady, so initially actually, she's seen in about 2017, and she had skin psoriasis, and then had started to develop joint pain. And was started on methotrexate, but unfortunately, developed and she had a diagnosis of endometrial cancer, and ended up having surgery and then chemotherapy. Gave her some a short course of IL seventeen, so secukinumab, which unfortunately didn't really work for her skin. And this again is really important so what I was able to do was actually ask the experts in the room, well, well, you know, do we then at that point, IL twenty three inhibition was not, I think, freely available through rheumatology, but it was through dermatology. She's ended up on rizikizumab, and skin is fantastic, and her joints are doing very, very well. There's a there is a lot of sort of old damage there. But again, this just highlights what she you know, what the sort of different brains around the room can can bring in. Because we were really stuck because normally, we would maybe think about going on to a drug inhibitor, but given the DVTs and the cancer, that was also contraindicated.

RB - Yeah. Yeah. So your actually your choices are quite limited. And I guess it really illustrates how sometimes you need to think quite creatively. So you have an idea of the immunological pathway that you might want to target because you've looked at IL seventeen you've tried to block that with the secukinumab, and it's not successfully controlled disease. And then it's thinking, how can you block a different pathway if actually our prescribing guidance doesn't allow it. So the discussion with other members of multi specialties is sometimes our way to to do that, isn't it? 

AM - Yeah. Absolutely, again, I I feel very strongly in terms of with patients who've got several comorbidities, often the specialist nurses in our in in the team actually will will know them better, will have a bit more time to spend with them. And when they do the pre medication counseling, if they already know what all of the background is, actually, that that really helps to do the counseling. 

RB - Yeah. Absolutely. And do you find that it works, in other ways as well? So other specialties might contact rheumatology, from your experience to say, we would like to potentially give this drug. Is there a way to be able to access this through rheumatology? Yes. 

AM - Absolutely. So we often will get, sort of queries from gastro and from ophthalmology as well. So we've got we have quite a sort of complex uveitis clinic. And and, again, it's just just in trying to work out, well, are there any disease manifestations that we think need biologics? And then it comes through us, rather than coming through ophthalmology. 

RB - And I guess, actually, probably, we've been lucky in rheumatology because we've developed quite an experience, over time of giving biologics and their counseling and the risks that can go alongside that. And, I think probably biologics are a newer type of drug to some of our other colleagues in different specialties, aren't they? So I guess we're able to, not not ophthalmology and gastroenterology particularly, but in some of the other areas. And it we can share the learning then as well, can't we? 

AM - Absolutely. And I think sometimes it's nice just to invite people from outside the virtual biologics clinic. So sometimes if there is a gastro trainee that wants to come and present a case, I think the the floor is always open to whoever wants to to come. So I should have said at the beginning, actually, we do this all on Teams.  And so it makes it quite easy to Yep. 

RB - To have people drop in and and to share knowledge and learn as well. That sounds really good. So and how is this patient doing, now they're on rizikizumab? 

AM - Doing quite well, actually. I saw them last week. She's doing pretty she's doing well. Yeah. She's starting to get out and about. But, yeah. I mean, the the worry always, I suppose, is that if the joints get worse, where do we go next? Yeah. But touch wood at the moment, she's doing okay.

RB - And how often with these patients do you think of a second line option if that first one doesn't work, or would you often ask for the clinician that is, in charge of the patient to bring them back and then rediscuss? 

AM - Yeah. Yeah. So I think particularly for these difficult ones, it's always we bring them back and then rediscuss. And again, this is what, the way the biologics, MDT is really, really important because the documentation that's there then means that you don't always have to go back through every single sort of set of notes to work out why something failed. We try and document it right from the beginning of the patient's journey all the way to the end. So every every switch comes back, every dose increase comes back with clear documentation of why. And the same goes for injection site reactions clear documentation of what happens and that just makes it much easier for both commissioning, and then for anybody else. You know, if somebody leaves and somebody new takes over, it really helps. Yeah. 

RB - And and I guess, actually, it's very difficult for patients because they've often been on multiple drugs and, actually, to remember what reaction they had at one point to a drug they might have tried five, ten years ago, it's quite difficult if you're taking an up to date history. So, actually, if you got it all there, it makes it much easier, doesn't it, for forward forward planning as you said. So that sounds excellent. So a good another good outcome, which is great. So, now we've got we're going to move on to our third case actually, if that's alright, Arti. So this is, a patient who is ankylosing spondylitis so can you tell me a bit more about them, please? 

AM - Yeah. So, I mean, he I suppose he's a more of a sort of seronegative sort of spondyloarthritis. So King's is a is a complex liver center and so often, actually, we will have patients who have complex liver conditions. And so this gentleman, quite young actually, he's in his twenties. So he's got, an autoimmune hepatitis, ulcerative colitis, and primary biliary cirrhosis overlap, and with sort of active sacroiliitis and some peripheral joint disease as well. Now the difficulty with him is at some point he's going to require a liver transplant. But actually, at the moment, what's really troubling him is the pain. And so this was a very difficult one because most of the drugs that we could use are sort of contraindicated. So, his his liver function, sort of we the liver team weren't happy for us to use a TNF, with the worry that actually maybe for the autoimmune hepatitis, it's not the drug that's got the most evidence. And then we couldn't use an IL seventeen because of  colitis, with the evidence to suggest that that might become worse. And then and this is, again, it's a good example of the VBC. So we had a discussion about whether or not we use a JAK inhibitor, but liver sort of felt that, oh, well, maybe the LFT story wasn't quite explained just there as well. And so, again, they would rather that we use Ustekinumab.

So I know that on the new guidelines, it's it's not there. But I give I suppose the good thing is if you're going to use something that's off guidelines, again, you sat around the room, you had a discussion. And for often, again, these complex sick patients, it's good for them to know that it's not a unilateral decision. Yeah. Yeah.

RB - And absolutely because often guidelines are discussing a patient with with just that condition, aren't they? And actually, the reality is, we are dealing with comorbidity within our patients and often more than one autoimmune disease. So, it can be as a complication, and we can't always necessarily then use what we might be our top choice biologic in them. 

AM - Yeah. And I think particularly, actually, sometimes with, with, with ankylosing spondylosis in particular, if you're having sort of second line or third line treatment failures, often what we do in the VBC is go back to the original imaging, and then we look at all of the imaging sequentially and sometimes you will say to yourself, oh, well, actually, actually, those bone marrow lesions did get better with this and then got worse with this. Yes. And then often if there's a degree of sort of secondary pain overlay, again, going back to look at the last, MRI as a group, not only is a fantastic learning exercise for everybody that's there, but you then have four pairs of eyes looking at it and it just I think it just helps you scrutinize your own decisions.

RB - Yep. Yeah. Absolutely. Because actually when you're sitting in a room with a patient who is in pain and can be very symptomatic, it can be difficult sometimes objectively to say whether or not we think this is inflammation driven or whether there might be other factors which are driving their symptoms such as fibromyalgia overlay, which we know is very common in these, types of autoimmune diseases. And I guess then having that discussion, as you said, gives a bit more, confidence around if we are going to escalate or if we're second, third line treatment failures, where do we go?

AM - And often, actually, some of these people have not so we all we all assume, don't we, okay, physio is ongoing. But we also have a highly specialized physiotherapist who then will actually sometimes say, well, why don't I see the patient? And then we can see whether or not we can change things from a non drug point of view. Yeah. So it's just a much more holistic approach.

RB - Yeah. Which sounds that's brilliant, isn't it, actually? Because and do you find sometimes that can be the thing that actually makes a difference? Yeah. And I think I think sometimes, you know, we have to be careful not to be too quick. And, you know, and and personal questions just get asked, don't they? You know, somebody will just ask, oh, well, so they are doing physio, but how much exercise are they doing? And what are they doing? And where is the pain? And what is the pain like? And that then makes you go back to your own history and say, oh, well, actually, did I ask those questions? Yeah. So it's a continual learning exercise for everybody that's involved in the meeting. Yeah. Absolutely.

RB - And you mentioned that sometimes when you look back at scans, you see you might have seen that bone marrow edema improved. And so do you find that quite often in these discussions, sometimes you do go back to drugs that have been used in the past and perhaps reconsider or add in another agent to help with improve efficacy. 

AM - Yeah. And I think particularly with with AS where you've only got, you know, sort of three or four drugs that you can use, you do often have to go back and sometimes ask the patient, well, actually, do you remember what works best for you? And then go back to the imaging and just having to say, well, actually, we haven't really got anything else. So we'll trial back through to something maybe, you know, slightly different preparation of the drug as opposed to a different mechanism of action. So it's just being yeah and then thinking about things like whether it's adalimumab. Did we check the adalimumab levels? Could we have gone to weekly or thinking about infliximab. And did we do anti drug antibodies when it stops working? So it's just going back and asking yourself the question of have we looked at all the possibilities. 

RB - Yep. Which, when you and as you said, when there is a limited arsenal of medications available, that's crucial, isn't it, to really see what we've what we've potentially ruled out. So, I think there's a lot of learning points out there to take from this. So I think on principle, we can look and think these are some really tricky cases that if we were managing by ourselves, we would really struggle. And then I think even probably managing them as a very specialist team, they're not easy patients, are they? But there's some principles which I think you've elaborated on. 

AM - I think I just think it really highlights in rheumatology how lucky we are actually to have so many different members of the team and expertise. So I think if I was going to break it down, so the, you know, the first thing obviously is the treatment decision and all the factors that come into that. So, you know, which evidence have we got for what evidence have we got for each drug? What does the latest data say? What are the patient factors like infection, comorbidities? We also then go back and say, okay, you know, have we done lipids? Have we done so the so the comorbidities also get addressed. And then from a patient perspective, the counseling gets discussed. The nurses are there to, do the counseling from a trainee's learning perspective because we've been through the data and we've gone you know, it's a great learning experience. And actually, just from an admin perspective as well, so all of the prescriptions get screened and signed. So we know that from a safety aspect, all of the pre biologic screening has been checked off. The chest x-ray has been looked at. And it's not just one person doing all the prescriptions. We split up the prescriptions. And then for that week, they all get printed off together, and then the pharmacist then has the home care, scripts all done, ready to go. So even from a, I suppose, administration burden, actually, it's very it's very good and it's streamlined and and tidy.

RB - And probably quite efficient rather than sitting on somebody's desk waiting for them to sign it and when they get round to it. It's probably much, much better for all involved and and then the patient at the end of the day. So Yeah. So I think I guess one of the things that struck me is I think that if as a trainee or a specialist nurse or even as a consultant, this is not something that you've had an opportunity to observe or be part of, I would definitely, suggest trying to join one of these VBCs or virtual biologic clinics that were at a trust that you work at because I know when I did that, particularly as a trainee, I learned a lot about just the also having a better understanding of the trial evidence behind why a particular drug might be useful in a condition and that can also be particularly good at guiding your decision making when there's comorbidities. 

AM- Yeah. Absolutely. And we'd be more than happy to welcome people to join us. You can drop any of us an email at King's.

RB - That would be brilliant. And then I guess, also, it then gives ideas if you've not got a VBC running at your trust as to how to go about setting them up. And I suspect that there's some cost saving which, comes as a result of doing prescribing in this way. 

AM - Yes. Absolutely. And the best thing about it, it's all documented. So when your managers ask you, what have you done for cost saving and how do you do it? It's all there in sort of black and white as to why decisions were made, and who made them. And I suppose the one thing I didn't actually mention is that we have, our research team also comes to the VBC. And so if there are trials, for example, like, you know, biologic naive patients or trials available for patients with psoriatic arthritis that are switching, will they also get screened at that point and then we can offer clinical trials to patients without having to rely particularly just on one physician or somebody remembering to ask a question. 

RB - Yep. That's a really good point. And it just opens opportunities up then for patients, doesn't it? Particularly if they've cycled through multiple drugs and they are biologic and naive, and there might be a trial which they can go into as well on that front. And I guess from that also, it enables us to pick up patients that we should include on registries as well. Yeah. Because it's easy, isn't it, in clinical practice, in a busy clinic to forget to highlight these patients as with all the best will in the world for different registries, but it's another catching point, isn't it?

AM - Absolutely. And the other thing is  that all the blue techs that need to be done, if there are for any other conditions, not for inflammatory arthritis, but often for sarcoid, for example, they all get done at the same time Yeah.

RB - Brilliant. And so for any of our listeners who can't remember what or may not have heard of the phrase of blue tech, can you just briefly just explain what that is? Yeah. So this is where the, the, drug funding comes from NHS England and so there's criteria that you need to fill out. And so it's a fairly simple form if you can remember your login, which is literally the rate limiting step for the whole thing. But it's, again, it's just making sure that, it's been discussed often on that form there is actually a drop down box for this has been discussed at an MDT, and this patient will be put on a registry so it's useful to get that done at the same time as well it makes the pharmacist life so much easier. 

RB - Yeah. Absolutely. And probably much more meaningful to come back to meetings when they're not having to do lots and lots of admin on our behalf. So oh, that's brilliant, Arti. Well, thank you very much for going through the cases, illustrating, some of the pathways that we might target when we're thinking about treatment for patients and then the next drugs that we might choose. And just actually the overall running of a virtual biologics clinic and how if we don't have one, I think we all need to try and make sure that we do set one up within our trust. 

AM - I honestly can't remember doing it any other way.

RB - Well, there's clearly so much to be gained, so much benefit from it. So, well, thank you very much. 

AM - It's okay. Thanks for having me.