Challenges and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East

Prevalence and Predictors of Remission and Sustained Remission in Patients with Rheumatoid Arthritis from the United Arab Emirates: A Two-Year Prospective Study

Aim

To estimate the prevalence of remission and sustained remission for more than 12 months in a cohort of patients with rheumatoid arthritis in the United Arab Emirates and explore predictors of remission and sustained remission in these patients.

Methods

A two-year prospective study conducted in Dubai Hospital (January 1, 2018-December 31, 2019) included all consecutive patients with rheumatoid arthritis attending the rheumatology clinic. Patients with a Simplified Disease Activity Index ≤3.3 and/or Clinical Disease Activity Index ≤2.8 in December 2018 were considered in remission and followed until December 2019. Those who maintained remission through 2019 were considered in sustained remission.

Results

In this study, a total of 444 patients were followed for a 12-months period. The percentage of remission achieved in RA patients was 30.4% according to the Clinical Disease Activity Index, 31.1% according to Simplified Disease Activity Index, and 50.9% according to the Value of Disease Activity Score 28 (DAS28) remission criteria. The 12-months sustained remission rates ranged from 38.3% for the ACR-EULAR to 69.3% for the DAS28. Male gender, shorter disease duration, better functioning as evaluated by the Health Assessment Questionnaire Disability Index (lower HAQ scores), and higher compliance rates are among sustained remission predictors.

Conclusion

Establishing "real-world" data and understanding local predictors to sustained remission is principal for implementing timely and appropriate patient-tailored strategies. These strategies include early detection, close monitoring, and enhancing treatment adherence among UAE patients.

Prevalence of rheumatoid arthritis and diagnostic validity of a prediction score, in patients visiting orthropedic clinics in the Madinah region of Saudi Arabia: a retrospective cross-sectional study

Introduction

In Saudi Arabia, the epidemiology of rheumatoid arthritis (RA) is not well studied and is marked by inconsistencies in clinical diagnosis. Therefore, in this study, we explored the prevalence, clinical characteristics, and diagnostic validity of a prediction score based upon disease markers in orthropedic clinics' patients in the Madinah region of Saudi Arabia.

Method

The clinical data for this retrospective cross-sectional study were retrieved from the database registry of orthopedic clinics in selected hospitals of the Medinah province of Saudi Arabia. Sociodemographic features, disease markers and the clinical characteristics were collected for a period of 6 months, from December 1, 2020, to May 31, 2021. The prediction score was generated from the sum of disease markers, coded as dichotomous variables.

Results

The total sample size of our study was 401. The prevalence of RA in the study subjects (n = 401) was 14.46% (n = 58). Among RA patients, the majority were females (60.3%). Painful joints (69%) and swollen joints (51.7%) were the most common clinical complaints among RA patients. RA patients suffered from arthritis (51.7%) and experienced fatigue (46.6%), weight loss (44.8%), and loss of appetite (41.4%). Diabetes (55.2%) was the most common comorbidity in the RA patients. The sensitivity and specificity of the prediction score at the criterion score of 2.5 were 67.3% and 63.0%, respectively. The area under the curve was 0.69 (95% CI [0.62-0.76]).

Conclusion

There was a moderately high prevalence of RA in patients visiting the orthropedic clinics of the selected hospitals of Madinah region of Saudi Arabia. The diagnostic validity of the prediction score, though promising, was slightly lower than the acceptable range.

Global epidemiology of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune disease that predominantly affects the joints. The prevalence of RA varies globally, with generally a higher prevalence in industrialized countries, which may be explained by exposures to environmental risk factors, but also by genetic factors, differing demographics and under-reporting in other parts of the world. Over the past three decades, strong trends of the declining severity of RA probably reflect changes in treatment paradigms and overall better management of the disease. Other trends include increasing RA prevalence. Common risk factors for RA include both modifiable lifestyle-associated variables and non-modifiable features, such as genetics and sex. A better understanding of the natural history of RA, and of the factors that contribute to the development of RA in specific populations, might lead to the introduction of specific prevention strategies for this debilitating disease.

Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses

Objectives:

The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges.

Methods:

Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified.

Results:

Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix.

Conclusion:

Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.

A Review of the Prevalence and Unmet Needs in the Management of Rheumatoid Arthritis in Africa and the Middle East

Estimates of the global prevalence of rheumatoid arthritis (RA) range from 0.24 to 1%, but vary considerably around the globe. A variation in RA prevalence is also expected across Africa and the Middle East, due to ethnic, climate, and socioeconomic differences. To assess the prevalence of RA in Africa and the Middle East, we searched Medline (via PubMed) and databases of major rheumatology conferences. Seventeen journal articles and 0 abstracts met the inclusion criteria. Estimated prevalence ranged from 0.06 to 3.4%. Most studies reported values near or below 0.25%. Consistent with data from other regions, RA was more prevalent among urban than rural populations, and among women than men. The women:men prevalence ratio ranged from 1.3:1 to 12.5:1, which suggests notable differences from the global average of 2:1. Relative increases in prevalence were observed in North Africa and the Middle East (13% since 1990) and Western Sub-Saharan Africa (14%), whereas rates in Eastern, Central, and Southern Sub-Saharan Africa show decreases (4-12%). Low disease awareness, delays to visit rheumatologists, and socioeconomic factors appear to hinder early diagnosis and aggressive treatment. Few countries have developed RA-specific treatment guidelines, and many physicians and patients face limited access to even basic treatments. An improved understanding of the epidemiology and management of RA, and the related socioeconomic consequences is necessary, so that targeted attempts can be made to encourage early diagnosis and treatment.

Nurse-led care for the management of rheumatoid arthritis: a review of the global literature and proposed strategies for implementation in Africa and the Middle East

Globally, increasing demand for rheumatology services has led to a greater reliance on non-physician healthcare professionals (HCPs), such as rheumatology nurse specialists, to deliver care as part of a multidisciplinary team. Across Africa and the Middle East (AfME), there remains a shortage of rheumatology HCPs, including rheumatology nurses, which presents a major challenge to the delivery of rheumatology services, and subsequently the treatment and management of conditions such as rheumatoid arthritis (RA). To further explore the importance of nurse-led care (NLC) for patients with RA and create a set of proposed strategies for the implementation of NLC in the AfME region, we used a modified Delphi technique. A review of the global literature was conducted using the PubMed search engine, with the most relevant publications selected. The findings were summarized and presented to the author group, which was composed of representatives from different countries and HCP disciplines. The authors also drew on their knowledge of the wider literature to provide context. Overall, results suggest that NLC is associated with improved patient perceptions of RA care, and equivalent or superior clinical and cost outcomes versus physician-led care in RA disease management. Expert commentary provided by the authors gives insights into the challenges of implementing nurse-led RA care. We further report practical proposed strategies for the development and implementation of NLC for patients with RA, specifically in the AfME region. These proposed strategies aim to act as a foundation for the introduction and development of NLC programs across the AfME region.

Household air pollution and arthritis in low-and middle-income countries: Cross-sectional evidence from the World Health Organization's study on Global Ageing and Adult Health

Background

Evidence points to a clear link between air pollution exposure and several chronic diseases though investigations regarding arthritis are still lacking. Emerging evidence suggests an association between ambient air pollution and rheumatoid arthritis. Household air pollution exposure, conversely, is largely unstudied but may be an important consideration for arthritis, particularly in low- and middle-income countries (LMICs), where cooking and heating activities can generate high indoor air pollutant levels.

Methods

We investigated the association of household air pollution (electricity vs. gas; kerosene/paraffin; coal/charcoal; wood; or agriculture/crop/animal dung/shrubs/grass as the main fuel used for cooking) and arthritis in six LMICs (China, Ghana, India, Mexico, the Russian Federation, South Africa) using data from Wave I of the World Health Organization Study on Global AGEing and Adult Health (SAGE) (2007–2010). Multivariable analyses were adjusted for sociodemographic, household and lifestyle characteristics and several comorbidities.

Results

The use of gas (aOR = 1.76, 95%CI: 1.40–2.21); coal (aOR = 1.74, 95%CI: 1.22–2.47); wood (aOR = 1.69, 95%CI: 1.30–2.19); or agriculture/crop/animal dung/shrubs/grass: aOR = 1.95 (1.46–2.61) fuels for cooking were strongly associated with an increased odds of arthritis, compared to electricity in cluster and stratified adjusted analyses. Gender (female), age (≥50 years), overweight (25.0 ≤BMI<30.0 kg/m²), obesity (BMI ≥30.0 kg/m²), former and current alcohol consumption, and the comorbidities angina pectoris, diabetes, chronic lung disease, depression and hypertension were also associated with a higher odds of arthritis. Underweight (BMI<18.5 kg/m²) and higher education levels (college/university completed/post-graduate studies) were associated with a lower odds of arthritis.

Conclusions

These findings suggest that exposure to household air pollution from cook fuels is associated with an increased odds of arthritis in these regions, which warrants further investigation.

Ultrasound versus magnetic resonance imaging in the evaluation of shoulder joint pathologies in a cohort of rheumatoid arthritis patients

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune disease that has a great impact on different joints, may result in their destruction and loss of function. Although the shoulder is affected in a large portion of patients with RA, it does not receive much attention during the follow up of RA. The precise diagnosis of shoulder pain in RA is a clinical challenge and benefits from a reliable imaging modality to detect its exact origin.

AIM

To determine the diagnostic accuracy of ultrasound (US) in detecting shoulder joint pathologies in RA, considering magnetic resonance imaging (MRI) as the gold standard.

MATERIALS AND METHODS

This cross-sectional, observational study was carried out on 30 RA patients complaining of unilateral or bilateral shoulder pain. Patients were subjected to history taking, clinical shoulder examination, plain X-ray, US examination following a standardized protocol, and MRI. The results were correlated with each other.

RESULTS

In comparison with the MRI findings, US showed high accuracy in terms of sensitivity (Sn) and specificity (Sp) in supraspinatus tendinopathy (Sn 96.6%; Sp 93.3%), biceps tenosynovitis (Sn 87.5%; Sp 97.6%), subacromial-subdeltoid bursitis (Sn 72.7%; Sp 95.7%), humeral erosions (Sn 90.5%; Sp 97.3%), and acromioclavicular osteoarthritis (Sn 85.7%; Sp 95.7%). In terms of reliability, the agreement between US and MRI was almost perfect (κ = .9, P < .001).

CONCLUSION

US may have a role as the initial imaging modality in RA patients with shoulder pain, as it is highly sensitive and specific in detecting different pathological abnormalities of the shoulder.

Treatment destinations and visit frequencies for patients seeking medical treatment overseas from the United Arab Emirates: results from Dubai Health Authority reporting during 2009-2016

BACKGROUND

Each year, the Dubai Health Authority (DHA) spends millions of dollars to cover the costs of United Arab Emirates (UAE) nationals seeking healthcare overseas. Patients may travel overseas to seek an array of treatments. It is important to analyze the number of trips and treatment destinations for patients travelling overseas to provide baseline information for the DHA to improve polices and strategies related to overseas treatment for UAE nationals.

METHODS

Administrative data were obtained from the DHA for UAE nationals who sought medical treatment overseas during 2009-2016. We examined the number of trips and treatment destinations by medical specialty, age, gender, years of travel and travel seasons. Multinomial logistic and negative binomial regression models were used to assess the relationships of the treatment destinations and number of trips, respectively, with the key variables of interest.

RESULTS

The study included data from 6557 UAE nationals. The top three treatment destinations were Germany (46%), the UK (19%) and Thailand (14%). The most common medical specialties were orthopedic surgery (13%), oncology (13%) and neurosurgery (10%). Oncology had the highest expected number of trips adjusted for a number of covariates (IRR 1.34, 95% CI: 1.24-1.44). Regarding destination variation, patients had a lower relative risk ratio of seeking healthcare in Germany in the winter (RRR 0.68, 95% CI: 0.57-0.80). Endocrinology was the most common medical specialty sought in the UK (RRR 3.36, 95% CI: 2.01-5.60).

CONCLUSIONS

This is the first study to systematically examine the current practice of medical treatment overseas among UAE nationals. The results demonstrate that treatment destinations, medical specialties for which treatment was sought, age, gender and travel season are significant factors in understanding overseas travel for medical care. The study can guide the DHA in collecting more data for further research that may lead to policy-relevant information about sending patients to the best-quality treatment choices at an optimal cost.

Biosimilars in Rheumatic Diseases: Regulatory Guidelines, Efficacy and Safety Implications in Saudi Arabia

Background:

Treatment with biologic drugs has enabled many patients with inflammatory rheumatic disease to achieve disease control. In some areas of the world, limited access to biologic therapies has created a demand for lower cost options such as biosimilars, which are highly similar, but not identical to originator biologics. The safe use of biosimilars requires a scientifically rigorous review process for their approval, and guidelines that aid rheumatologists in their use.

Discussion:

In Saudi Arabia, there are no national or regional guidelines to assist rheumatologists in the proper use of biosimilars in clinical practice, and this may potentially affect the quality of patient care. In this review, we discuss the importance of developing a guidance and the need for healthcare professionals and patients to receive education about biosimilars. We discuss the unique requirements for biosimilar approval, and the differences between biosimilars, originator biologics, and generics. We review important considerations related to biosimilar use, such as switching from originator biologics to biosimilars, switching between different biosimilars, interchangeability, automatic substitution, naming, and pharmacovigilance. We also provide recommendations based on the authors’ expert opinions as rheumatologists to help ensure the appropriate use of biosimilars in Saudi Arabia.

Conclusion:

The approval and use of biosimilars must be supported by scientifically sound evidence. Guidelines for the use of biosimilars are needed in Saudi Arabia to aid rheumatologists in making clinical decisions. Additionally, educational resources should be provided to healthcare professionals and patients.

Epidemiology and treatment patterns of rheumatoid arthritis in a large cohort of Arab patients

OBJECTIVES

There is limited information on the epidemiology and treatment patterns of rheumatoid arthritis (RA) across the Arab region. We aim in this study to describe the demographic characteristics, clinical profile, and treatment patterns of patients of Arab ancestry with RA.

METHODS

This is a cross sectional study of 895 patients with established rheumatoid arthritis enrolled from five sites (Jordan, Lebanon, Qatar, Kingdom of Saudi Arabia (KSA), and United Arab Emirates). Demographic characteristics, clinical profile, and treatment patterns are compared between the five countries.

RESULTS

The majority of our patients are women, have an average disease duration of 10 years, are married and non-smokers, with completed secondary education. We report a high (>80%) ever-use of methotrexate (MTX) and steroids among our RA population, while the ever-use of disease modifying anti-rheumatic drugs (DMARDs) and TNF-inhibitors average around 67% and 33%, respectively. There are variations in RA treatment use between the five country sites. Highest utilization of steroids is identified in Jordan and KSA (p-value < 0.001), while the highest ever-use of TNF-inhibitors is reported in KSA (p-value < 0.001).

CONCLUSION

Disparities in usage of RA treatments among Arab patients are noted across the five countries. National gross domestic product (GDP), as well as some other unique features in each country likely affect these. Developing treatment guidelines specific to this region could contribute in delivering standardized therapies to RA patients.

Maintenance of low disease activity and remission with etanercept-disease-modifying antirheumatic drug (DMARD) combination therapy compared with treatment with DMARDs alone in Latin American patients with active rheumatoid arthritis: Subset analysis of a randomized trial

BACKGROUND

Current guidelines on the treatment of rheumatoid arthritis (RA) recommend early therapy targeting the achievement of low disease activity (LDA) or clinical remission. Little published information is available on the success of this treatment strategy in Latin America. In a subset analysis of patients from Latin America, we compared efficacy maintenance with etanercept 50 mg once weekly (ETN50) versus placebo (PBO), on a background of methotrexate (MTX) ± other non-biologic, disease-modifying antirheumatic drugs, in patients with moderate-to-severe RA who had achieved LDA with ETN50.

METHODS

In the Treat-to-Target trial, adult patients with active RA nonresponsive to MTX were treated with ETN50 for 24 weeks (Period 1). Patients achieving LDA were randomized to receive ETN50 or PBO for 28 additional weeks (Period 2). The proportion of patients maintaining LDA at week 52 and other efficacy and quality-of-life measures were assessed. Descriptive statistics are presented using last observation carried forward imputation of data.

RESULTS

Of the 64 patients from Latin America treated in Period 1, 61 (95.3%) achieved LDA. Among patients receiving ETN50, 13/34 remained in LDA and 6/14 maintained remission at week 52 versus 6/27 and 4/10 patients receiving PBO. The median time to flare was 113 days and 33 days for the ETN50 and PBO groups, respectively. In the overall population, adverse events were reported in 37% and 43%, serious adverse events in 1% and 4%, and serious infections in 0% and 2% of patients in the ETN50 and PBO groups, respectively.

CONCLUSIONS

In patients with RA from Latin America, continuing treatment with ETN50 after achieving LDA appears to result in a higher proportion of patients maintaining LDA and remission compared with switching to PBO. CLINICALTRIALS.

GOV REGISTRATION

NCT01578850.

Maintenance of Remission with Etanercept-DMARD Combination Therapy Compared with DMARDs Alone in African and Middle Eastern Patients with Active Rheumatoid Arthritis

INTRODUCTION

To compare etanercept (ETN) and placebo (PBO) for maintaining low disease activity (LDA) achieved with ETN in patients with rheumatoid arthritis (RA) from Africa and the Middle East.

METHODS

In this subset analysis of the Treat-to-Target trial (ClinicalTrials.gov identifier NCT01981473), 53 adult patients with moderate-to-severe RA nonresponsive to methotrexate were treated with 50 mg ETN/week for 24 weeks (Period 1). Patients achieving LDA were randomized to continue ETN treatment or switched to PBO for an additional 28 weeks (Period 2). The proportion of patients maintaining LDA or remission in each arm at the end of Period 2 was determined. Additional efficacy and patient-reported outcomes (PROs) were also evaluated.

RESULTS

During Period 1, 51 patients achieved LDA according to the disease activity score-28 joints-erythrocyte sedimentation rate (DAS28-ESR LDA) and 30 achieved remission. At week 52, nine of 22 and eight of 29 in the ETN and PBO groups, respectively, remained in DAS28-ESR LDA without experiencing a flare. Additionally, six of 14 and five of 16 in the ETN and PBO groups, respectively, remained in remission. Among patients experiencing a flare during Period 2, 13 of 22 and 21 of 29 received ETN or PBO, respectively. The median time to flare was 193 and 87 days in the ETN and PBO groups, respectively. At week 52, consistently more patients in the ETN group than in the PBO group achieved predetermined efficacy and PRO endpoints.

CONCLUSIONS

These data suggest continuing ETN maintenance therapy is beneficial to patients after they have achieved their treatment target. However, this subset analysis is limited by the small patient population and must be interpreted with caution.

FUNDING

Pfizer.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT0198147.

Gambogic acid suppresses inflammation in rheumatoid arthritis rats via PI3K/Akt/mTOR signaling pathway

Gamboge is the dried resin secreted by the Garcinia maingayi gambogic tree and is a substance that may be used to treat a variety of diseases, exhibits anti‑tumor and detoxification effects and prevents bleeding. The primary active constituent is gambogic acid. The present study aimed to investigate the anti‑inflammatory effects of gambogic acid in rheumatoid arthritis (RA) rats and to elucidate the mechanisms by which these effects occur. The swelling degree, the clinical arthritic scoring and pain threshold measurements were used to evaluate the effects of gambogic acid on RA. ELISA kits and western blot analysis were used to investigate inflammatory processes and the expression of RA‑associated proteins, respectively. The present results demonstrated that gambogic acid significantly inhibited the degree of right foot swelling, increased pain thresholds and reduced clinical arthritic scores of RA rats. Treatment with gambogic acid suppressed the activities of interleukin (IL)‑1β and IL‑6, promoted the protein expression of phosphorylated (p)‑Akt serine/threonine kinase (Akt), p‑mammalian target protein of rapamycin (mTOR) and inhibited hypoxia‑inducible factor‑1α and vascular endothelial growth factor expression in RA rats. The results of the present study therefore suggest that the anti‑inflammatory effects of gambogic acid in RA rats occur via regulation of the phosphoinositide 3‑kinase/Akt/mTOR signaling pathway.

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.

The treatment of rheumatoid arthritis using Chinese medicinal plants: From pharmacology to potential molecular mechanisms

ETHNOPHARMACOLOGICAL RELEVANCE

Rheumatoid arthritis (RA) is a common worldwide public health problem. Traditional Chinese Medicine (TCM) achieved some results to some extent in the treatment of rheumatoid arthritis (RA). Especially in China, TCM formulas are used in the clinic because of their advantages. Some of these TCM formulas have been used for thousands of years in ancient China, they pays much attention to strengthening healthy qi, cleaning heat, and wet, activating blood, etc. So TCM in anti-RA drug is considered as a simple and effective method. In addition, TCM are also traditionally used as extracts and many Chinese herbs which are considered to be effective for RA. With the advancement of technologies and research methods, researchers have devoted themselves to exploring new therapeutic materials from troves of TCM. The components of TCM are identified and purified, which include alkaloids, coumarins, flavonoids, saponins and so on. However, little or no review works are found in the research literature on the anti-RA drugs from TCM. The present review aims to provide systematically reorganized information on the ethnopharmacology, phytochemistry and pharmacology of TCM used traditionally against RA. The information recorded in this review will provide new directions for researchers in the future.

MATERIALS AND METHODS

Relevant scientific literatures were collected from Chinese traditional books and Chinese Pharmacopoeia. Several important pharmacology data, clinical observations, animal experiments on effects of anti-RA drugs from TCM and their mechanisms were extracted from a library and electric search (Pubmed, PubChem Compound, Science Direct, Spring Link, Elsevier, Web of Science, CNKI, Wan Fang, Bai du, The Plant List, etc.). We collected information published between 2002 and 2015 on Chinese medicine in the treatment of RA. Information was also acquired from local classic herbal literature, conference papers, government reports, and PhD and MSc dissertations.

RESULTS

This review mainly introduces the current research on anti-RA TCM formulas, extracts and compounds from TCM, pharmacological data and potential mechanisms (inhibit osteoclast proliferation, suppress fibroblast-like synoviocytes (FLSs) growth, decrease the expression of inflammatory cytokines, blocking signal pathways, etc.).

CONCLUSIONS

TCM, as a multi-component and multi-target approach, which is a perfect match with the holistic concept of systems biology, is applicable in the treatment of RA. The synergistic connections of Chinese herbs and mechanisms of related active compounds on RA increase the trust for TCM. TCM as alternative remedies for RA not only has an important position in the world market, but also has an irreplaceable role in the treatment of RA in future.

Survey on management strategies of rheumatoid arthritis in Saudi Arabia: a Saudi Society for Rheumatology Initiative

AIM

Currently there are no national recommendation guidelines for the management of rheumatoid arthritis (RA) in Saudi Arabia, which has led to a lack of standard of care. The aim of this study is to explore RA management strategies in practicing rheumatologists in Saudi Arabia.

METHODS

A 38 questions survey was designed using an electronic website. The survey was distributed through the official email of the Saudi Society for Rheumatology. Rheumatologists with at least 1 year of experience were included. Descriptive analysis was used to report demographics and participants' answers. Chi-square and Fischer's exact test were used to evaluate the relation between the characteristics of participants and their answers.

RESULTS

Out of 120 registered practicing adult rheumatologists, 54 (45%) completed the survey. The majority were male 31 (57.4%) and Saudis 36 (66.7%). Forty-two participants (77.8%) use clinical outcome measures in daily clinical practice to guide treatment decisions with the majority using the Disease Activity Score of 28 joints (61.1%). Quality of life measures were used by 22 (40.7%) participants with statistically significant male predominance (P = 0.043). Time consumption was the most important cause for not using any outcome measures. Thirteen (24.1%) and 17 (31.5%) participants do not use parenteral methotrexate and leflunomide, respectively, because of unavailability in the hospital formulary. Nine (16.7%) and 38 (70.37%) participants do not see a role for tofacitinib and biosimilars, respectively, in the management of RA.

CONCLUSION

This survey has highlighted many areas of improvement in the practice of rheumatologists in Saudi Arabia and should be the focus of future educational activities.

Prevalence of rheumatoid arthritis in low- and middle-income countries: A systematic review and analysis

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disorder that affects the small joints of the body. It is one of the leading causes of chronic morbidity in high-income countries, but little is known about the burden of this disease in low- and middle-income countries (LMIC).

METHODS

The aim of this study was to estimate the prevalence of RA in six of the World Health Organization's (WHO) regions that harbour LMIC by identifying all relevant studies in those regions. To accomplish this aim various bibliographic databases were searched: PubMed, EMBASE, Global Health, LILACS and the Chinese databases CNKI and WanFang. Studies were selected based on pre-defined inclusion criteria, including a definition of RA based on the 1987 revision of the American College of Rheumatology (ACR) definition.

RESULTS

Meta-estimates of regional RA prevalence rates for countries of low or middle income were 0.40% (95% CI: 0.23-0.57%) for Southeast Asian, 0.37% (95% CI: 0.23-0.51%) for Eastern Mediterranean, 0.62% (95% CI: 0.47-0.77%) for European, 1.25% (95% CI: 0.64-1.86%) for American and 0.42% (95% CI: 0.30-0.53%) for Western Pacific regions. A formal meta-analysis could not be performed for the sub-Saharan African region due to limited data. Male prevalence of RA in LMIC was 0.16% (95% CI: 0.11-0.20%) while the prevalence in women reached 0.75% (95% CI: 0.60-0.90%). This difference between males and females was statistically significant (P < 0.0001). The prevalence of RA did not differ significantly between urban and rural settings (P = 0.353). These prevalence estimates represent 2.60 (95% CI: 1.85-3.34%) million male sufferers and 12.21 (95% CI: 9.78-14.67%) million female sufferers in LMIC in the year 2000, and 3.16 (95% CI: 2.25-4.05%) million affected males and 14.87 (95% CI: 11.91-17.86%) million affected females in LMIC in the year 2010.

CONCLUSION

Given that majority of the world's population resides in LMIC, the number of affected people is substantial, with a projection to increase in the coming years. Therefore, policy makers and health-care providers need to plan to address a significant disease burden both socially and economically.