Background: Digital ulceration in systemic sclerosis is a severe and disabling aspect of this complex, multi-system disease. Traditionally, intravenous (IV) iloprost has been prescribed to treat the problem. Alternative oral medications including sildenafil and bosentan are now readily available, although NHS clinical commissioning policy is yet to be updated to reflect changes in drug costs. Use of IV iloprost across Wessex was audited to review current practice across the region.

Objectives: To compare use of IV iloprost across 7 different hospital rheumatology departments

Methods: Data was collected across 7 different NHS hospital sites using rheumatology specific pharmacy records for high cost drug prescribing and a single uniform data collection proforma, which was then analysed by 1 person to ensure uniformity of results. Case notes were reviewed retrospectively to determine diagnosis, frequency and duration of iloprost treatment, if patients had been considered for sildenafil treatment (including if sildenafil was prescribed, any cautions or contra-indications to treatment, dose and any reason for discontinuation of treatment) and if patients had been considered for bosentan treatment and if it was prescribed.

Results: 45 patients were identified currently receiving IV iloprost. 32/45 (71%) had a diagnosis of systemic sclerosis, mixed connective tissue disease (CTD) or undifferentiated CTD (to be called scleroderma group). 13/45 had other miscellaneous diagnoses which had resulted in digital ulceration. These 13 patients were excluded from further analysis relating to sildenafil or bosentan prescribing as these medications were not indicated for other causes of digital ulceration. In the scleroderma group, 27/32 (84%) had been considered for sildenafil treatment. Of these, 8/27 started and discontinued due to intolerance and 17/27 remained on sildenafil. In the scleroderma group, 9/32 had been considered for bosentan treatment, and of these 7/9 remained on bosentan.

Conclusion: The authors have identified that IV iloprost is still widely used for management of digital ulceration in rheumatology departments across seven different hospitals in Wessex. Most of this group of patients would likely be eligible for treatment with sildenafil or bosentan. Sildenafil intolerance is a challenge to management. Consideration of bosentan as a treatment option was limited in this group, and may be a cost-effective alternative to IV iloprost which would also eliminate the risk of infection associated with IV access in a potentially immunosuppressed group of patients.

Disclosure of Interests: None declared