Rheumatoid arthritis in a population sample in the Gulf: clinical observations

An assessment of the current treatment landscape for rheumatology patients in Qatar: Recognising unmet needs and moving towards solutions

Objective This study assessed the mode of application (oral, intravenous or subcutaneous (SC)) currently employed in the treatment of rheumatoid arthritis (RA) in patients from Qatar in comparison with patients' individual preferences for the mode of application of their treatment. Methods This study included 294 RA patients visiting three clinics at the main referral hospital in Qatar who were interviewed using a standard questionnaire to determine their preference of mode of application for their disease-modifying antirheumatic drug (DMARD) treatment in relation to their currently employed mode of application. Results The majority of patients were female (76%), and 93% of male patients and 61% of female patients in the study clinics were of a nationality other than Qatari. The highest patient preference recorded was for an oral therapy (69%), compared with injection (23%) and intravenous (8%) therapy. In total, 85% of patients expressed a preference to remain on oral therapy compared with 63% and 58% of intravenous and SC injection patients indicating a preference to remain on their current method of administration. Conclusions This high preference for oral therapies highlights the considerable need for incorporation of new oral targeted synthetic DMARD therapies into clinical practice within the region.

Safety, Tolerability, and Efficacy of Tocilizumab in Rheumatoid Arthritis: An Open-Label Phase 4 Study in Patients from the Middle East

This open-label study investigated the safety and efficacy of tocilizumab in Middle Eastern patients with rheumatoid arthritis (RA). Patients whose Disease Activity Score based on 28 joints (DAS28) was >3.2 received tocilizumab 8 mg/kg intravenously every 4 weeks for 24 weeks. Patients receiving aTNF ± nonbiologic disease-modifying antirheumatic drug(s) (DMARD(s)) switched to tocilizumab; patients receiving nonbiologic DMARD monotherapy added tocilizumab. Primary end points were adverse events (AEs), serious AEs (SAEs), and laboratory parameters; secondary end points were DAS28, Health Assessment Questionnaire-Disability Index, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Eighty-eight of 95 patients completed 24 weeks. Overall, 125 AEs were reported in 43 (45%) patients; the most common were increased hepatic enzymes (16%) and cholesterol (11%). Eight patients experienced SAEs. Significant changes from baseline to week 24 occurred for hemoglobin, neutrophils, platelets, total cholesterol, and liver enzymes (P < 0.05). DAS28, CRP, and ESR decreased significantly from baseline at each visit (P < 0.0001). At week 24, the proportions of patients reporting DAS28 clinically meaningful improvement (decrease ≥1.2), low disease activity (DAS28 ≥2.6 to ≤3.2), and remission (DAS28 <2.6) were 92%, 23%, and 64%, respectively. Safety and efficacy of tocilizumab were consistent with values reported in Western patients.

Validation of the Arabic version of the early inflammatory arthritis detection tool

OBJECTIVE

To evaluate the reliability and validity of the Arabic version of the Early Inflammatory Arthritis Questionnaire (EIAQ-A), a detection tool for screening for early inflammatory arthritis (EIA) in Arabic-speaking populations.

SUBJECTS AND METHODS

A cross-sectional study was conducted among 30 consecutive participants (21 female and 9 male) attending the Internal Medicine Outpatient Clinic at Mubarak Al-Kabeer Hospital. They completed the self-administered EIAQ-A twice within a 2-week period. Their disease activity was evaluated during the visits based on clinical and laboratory variables. Cross-cultural adaptation was performed using forward and backward translations of the original questionnaire. Test-retest reliability of the EIAQ-A was evaluated using the measure of agreement, kappa (κ), between the response of participants in the two interviews. Internal consistency of the EIAQ-A was measured using the Kudar-Richardson-20 coefficient (KR-20), a binary response equivalent to Cronbach's α. External construct validity was assessed by Spearman's rank correlation coefficient (rs) between the score of EIAQ-A and both clinical and laboratory variables of disease activity.

RESULTS

The test-retest reliability for EIAQ-A was good (κ = 0.558) for the overall score and between 0.841 and 0.368 for the subscale scores. Internal consistency had an acceptable value of KR-20 = 0.869. The construct validity for EIAQ-A was high for all disease activity variables tested, rs was between 0.727 (swollen joint count) and 0.896 (visual analog scale pain score).

CONCLUSION

The EIAQ-A was a reliable and valid tool for population screening for EIA. Its use may accelerate the early detection of EIA in Arabic-speaking communities.

Anti-CCP2 is an adjunct to, not a surrogate for, rheumatoid factor in the diagnosis of rheumatoid arthritis: diagnostic utility of anti-CCP2 antibodies in Egyptian patients with rheumatoid arthritis

OBJECTIVES

To examine the diagnostic utility of the second generation of anti-cyclic citrullinated peptide (anti-CCP2) antibodies versus rheumatoid factor (RF) in rheumatoid arthritis (RA), and to study the association between anti-CCP2 and RA disease parameters.

METHODS

Fifty consecutive Egyptian patients with RA, 37 patients with other rheumatic diseases, and 10 healthy controls were recruited for testing for anti-CCP2 and immunoglobulin M (IgM) rheumatoid factor (RF). Assessment measures included the Disease Activity Score (DAS28) for disease activity, the Health Assessment Questionnaire - Disability Index (HAQ-DI) for disability and the Short Erosion Narrowing Score (SENS) for radiological damage.

RESULTS

The sensitivities of anti-CCP2 and IgM-RF in RA patients were 70% and 52%, with specificities of 91.5% and 89.4%, respectively. There was 73.2% agreement between anti-CCP2 and RF for all groups tested (kappa = 0.42, p<0.001) but agreement was only 66% for RA patients (kappa = 0.31, p<0.05). Anti-CCP2 had superior diagnostic properties [sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)] than RF, but using both RF and anti-CCP2 enhanced the sensitivity to 78%, when either test was positive, and the specificity to 100%, with a PPV of 1, when both tests were positive. Anti-CCP2 titre was significantly correlated with disease severity [rheumatoid nodules, rheumatoid factor (RF), and radiological damage] and HAQ-DI (p<0.05) but not with parameters of disease activity.

CONCLUSION

Anti-CCP2 has superior diagnostic and prognostic properties in RA compared with RF. It should not replace RF as a serological test; however, since using both tests modestly increases sensitivity and markedly enhances specificity, so that diagnosis of RA is highly probable when both tests are positive.

Rheumatoid arthritis in the United Arab Emirates

Studies have shown that patients with rheumatoid arthritis (RA) in the Middle East have delayed diagnosis and low disease-modifying anti-rheumatic drug (DMARD) utilization. We describe the characteristics and treatments of consecutive RA patients presenting to a new musculoskeletal clinic in Dubai, United Arab Emirates (UAE). Demographic and clinical data were collected over a 10-month period at the first visit to our clinic for patients meeting the American College of Rheumatology (ACR) criteria for RA. A total of 100 patients were seen: (average +/- SD) age 42.2 +/- 12.3 years; female 87%; Arabs 38%, Indian 36%, Caucasian and others 26%; 73% rheumatoid-factor positive; years since diagnosis: 3.9 +/- 5.7; lag time between symptom onset to diagnosis 1.2 +/- 1.3 years and lag time to first DMARD was 1.6 +/- 2.0 years. Mean tender joint count was 8.9 +/- 7.9, mean swollen joint count 9.0 +/- 7.6, mean patient's global assessment of disease activity 57.4 +/- 25.0 mm, mean ESR 33 +/- 25 mm/h, mean DAS28 5.2 +/- 1.6, physician global assessment 55.0 +/- 23.8. Only 43% were on DMARDs (25% MTX, 5% TNF blockers). Among the patients who were not on DMARD, only 28.1% had disease duration less than 1 year (p = <0.01). Erosions were present in 55.2% of patients with available X-rays, and deformities in 26% of patients. There were no racial differences in disease characteristics. The UAE has a unique population with many races residing in the country. Among the first 100 consecutive patients seen at our clinic, there were no significant differences in disease characteristics with the majority of the patients having very active disease, delayed diagnosis, and not being treated with DMARDs.

Characterization of systemic lupus erythematosus in patients in U.A.E

Twenty-eight SLE patients (Arabs and Asians) in the UAE were studied in this report. The F:M ratio was markedly high; 27:1 in the group as a whole and 21:1 among Arabs. Local patients (Emirians) developed the disease at an earlier age compared to their expatriate Arab compatriots. Arthropathy occurred in 86% and nephropathy in 43% of cases. Next in frequency were leucopenia, mucocutaneous manifestations and serositis. Apart from lupus headache, the other neuro-psychiatric LE were uncommon or not encountered. Anti-cardiolipin syndrome, Sneddon's syndrome, shrunken lung syndrome, sicca complex, thyrotoxicosis and myasthenia gravis were also present in this small group of patients. Their presence reflects the marked heterogeneity displayed by the disease irrespective of the number of cases involved. An unusually high prevalence of anti ds (DNA) antibodies (92.5%) as compared to ANF (82.5%) was detected (P = NS). Anti-Sm antibody occurred in 30% of cases particularly in those patients with lymphadenopathy and fever. There was a relative paucity in the prevalence of anti RNP, Ro and La antibodies in this group. Differences with and similarities to previous reports concerning other populations are also presented.