The expression of rheumatoid arthritis in Malaysian and British patients: a comparative study

Decline in Incidence of Extra-Articular Manifestations of Rheumatoid Arthritis: A Population-Based Cohort Study

OBJECTIVE

The focus of this study was to assess changes in the cumulative incidence of extra-articular manifestations of rheumatoid arthritis (ExRAs) and associated mortality risk.

METHODS

This study evaluated trends in occurrence of ExRAs using a population-based inception cohort that included all adult patients with incident rheumatoid arthritis (RA) from 1985 through 2014 meeting the 1987 American College of Rheumatology criteria. Patients were divided into two cohorts based on the incidence date of RA, 1985 to 1999 and 2000 to 2014. The occurrence of ExRAs was determined by manual chart review, and the 10-year cumulative incidence was estimated for each ExRA in both cohorts. Cox proportional hazard models were used to determine associations between specific demographic and RA disease characteristics and ExRAs and between ExRAs and mortality.

RESULTS

There were 907 patients included, 296 in the 1985 to 1999 cohort and 611 in the 2000 to 2014 cohort. The 10-year cumulative incidence of any ExRA decreased significantly between the earlier and later cohorts (45.1% vs 31.6%, P < 0.001). This was largely driven by significant declines in subcutaneous rheumatoid nodules (30.9% vs 15.8%, P < 0.001) and nonsevere ExRAs (41.4% vs 28.8%, P = 0.001). Identified risk factors for the development of any ExRAs include rheumatoid factor positivity (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.43-2.86) and current smoking (HR 1.61, 95% CI 1.10-2.34). Mortality was increased in patients with either nonsevere (HR 1.83, 95% CI 1.18-2.85) or severe ExRAs (HR 3.05, 95% CI 1.44-6.49).

CONCLUSIONS

The incidence of ExRAs has decreased over time. Mortality remains increased in patients with ExRAs.

ZIF-8 nanoparticles coated with macrophage-derived microvesicles for sustained, targeted delivery of dexamethasone to arthritic joints

Dexamethasone sodium phosphate (Dex) is widely used in the clinic for the treatment of rheumatoid arthritis. However, it circulates in blood for a short time and it is linked to high risk of severe side effects caused by repeated dosing. Here, we encapsulated Dex onto zeolitic imidazolate framework-8 (ZIF-8) to prepare metal-organic framework nanoparticles with high drug loading efficiency. To prevent clearance by the mononuclear phagocyte system and extend time in circulation, the nanoparticles were also camouflaged with macrophage-derived microvesicles (MV) to obtain the biomimetic drug delivery system MV/Dex/ZIF-8. In vitro and in vivo experiments showed that the nanosystem had high drug loading and encapsulation efficiency, high stability, and long circulation time, and it permitted sustained drug release longer in inflamed joint tissues. Our study provides new insights into designing camouflaged drug carriers to prevent their phagocytosis and prolong their time in circulation.

A not-to-miss Cause of Severe Cervical Spine Pain in a Patient with Rheumatoid Arthritis: A Case-Based Review

Background:

Rheumatoid arthritis (RA) may affect any diarthrodial joint with a predilection on the peripheral skeleton in a symmetrical manner. When the axial skeleton is affected, it is the cervical spine (CS) that gets involved with potentially detrimental effects, if not treated promptly.

Case:

A 60-year-old female suffering from RA presented with severe neck pain and stiffness, difficulty of standing and walking with brisk tendon reflexes, Babinski sign positive, and clonus. Despite the high inflammatory markers and high titres of autoantibodies (rheumatoid factor and anticitrullinated protein antibodies), she never received proper treatment. She was using only paracetamol and non-steroidal anti-inflammatory drugs. Conventional radiography (CR) of CS showed extensive degenerative changes affecting the C3–C5 vertebral level. Magnetic Resonance Imaging of the neck showed sub-axial subluxation (SAS) and spinal cord compression at C3 level, and to a lesser extent, in other levels. A multi-level cervical laminectomy and spinal cord decompression were deployed with good results. To this end, literature review was performed until September 2020 and showed that the frequency of radiological findings varies substantially, ranging between 0,7–95% in different studies. The most common radiological feature is the atlanto-axial subluxation (AAS) followed by SAS. Because CS involvement can often be clinically asymptomatic, its assessment should not be forgotten by physicians and should be assessed using CR, which is an easy-to-perform technique and gives important information as a screening tool. On the other hand, RA patients need to be treated in a prompt and efficient manner in order to avoid any potentially fatal complications.

Work disability in rheumatic diseases: Baseline results from an inception cohort

AIM

We aimed to characterize work disability in patients with newly diagnosed rheumatic diseases and compare work characteristics between patients with rheumatic diseases and controls without rheumatic diseases at diagnosis.

METHODS

Patients with inflammatory arthritis (IA) and osteoarthritis (OA), surrogates for autoimmune and non-autoimmune rheumatic diseases, respectively, and controls of working age were surveyed at diagnosis. Patients with rheumatic diseases who were employed before symptom onset were characterized as having work disability if they reported reduced work ability and productivity while remaining in the same job as before symptom onset, changed to a less demanding job or stopped working/retired. Work characteristics at diagnosis were compared between rheumatic diseases patients and controls.

RESULTS

The unemployment rate before symptom onset was lower in patients with IA (20%) compared to patients with OA (32%). Among patients with IA and OA who were employed before symptom onset, 59% and 43% reported work disability, respectively (P = .04). The unemployment rate at diagnosis was comparable in patients with IA (26%) and higher in patients with OA (38%) compared to controls (29%). Employed patients with IA and OA, when compared with controls, reported poorer work ability (score: 37 vs 39 vs 41, P < .01; proportion with poor/moderate work ability: 48% vs 33% vs 21%, P < .01) and greater work productivity loss (score: 32 vs 29 vs 17, P < .01) at diagnosis.

CONCLUSION

Rheumatic diseases impose significant work disability at diagnosis, highlighting the need for identification and interventions targeting work disability early in the course of disease.

Rheumatology in Malaysia

Malaysia is a developing country in the South-East Asian region with a significant burden of disability from musculoskeletal disease. Rheumatology in Malaysia is a relatively young speciality. Currently, there is approximately 1 rheumatologist per 390,000 population, mostly concentrated in the urban areas. This article aims to give a brief overview of the research in rheumatology, the healthcare system, and rheumatology training and education in Malaysia. From 1950 until mid-2019, there were 547 publications about rheumatological conditions from Malaysia, with a 27-fold increase in the numbers from the period before 1980 compared to 2010-2019. Although there is universal access to healthcare through the public (government funded) hospitals and clinics, as well as a system of private healthcare, funding for expensive biological therapies remain patchy and scarce, leading to significant under-utilization of such treatments in rheumatology patients. Training in rheumatology in Malaysia is well established with a formalised training curriculum introduced in 2004, followed by the introduction of training in musculoskeletal ultrasound in 2006. To improve care for patients with musculoskeletal conditions, there has been regular continuing educational meetings and courses, not just for rheumatologists, but also for other medical professionals, as not all areas in Malaysia have easy access to rheumatology services. Thus overall, despite the small number of rheumatologists, rheumatology in Malaysia has made encouraging progress over the past 2 decades, but improvements in patient care, training, education and research need to continue in the future.

Real-world clinical experience of biological disease modifying anti-rheumatic drugs in Malaysia rheumatoid arthritis patients

The effect of biologic disease modifying anti-rheumatic drugs (bDMARDs) in treating rheumatoid arthritis (RA) in real-world clinical practice remains unknown in Southeast Asia. We aimed to assess the efficacy and safety of bDMARDs among Malaysian RA patients treated in routine clinical practice. A retrospective medical chart review of RA patients from 11 government hospitals were conducted from January 2003 to January 2014. A standardized questionnaire was used to abstract patient's demographic, clinical and treatment data. Level of disease activity was measured by DAS28 collected at baseline, 3, 6 and 12 months. Three hundred and one patients were available for analysis, mean age 41 (SD, 10.8) years, mean RA duration 12.3 (SD, 6.9) years and 98% had history of two or more conventional-synthetic DMARDs. There were 467 bDMARD courses prescribed with mean bDMARDs duration use of 12.9 months (SD 14.7). Tumour necrosis factor alpha inhibitors were the most common prescribed bDMARDs (77.1%), followed by Tocilizumab (14.6%) and Rituximab (8.4%). We observed significant improvement in mean DAS28 values from baseline to 3, 6 and 12 months (p < 0.001). Overall, 16.9% achieved DAS28 remission at 6 months. A third (35.6%) of patients reported adverse events, three commonest being infections (46.5%), allergy (22.9%) and laboratory abnormalities (12.9%). 3.7% of our patients had tuberculosis. Biologic DMARDs were effective in treating RA in real-world practice in Malaysia, despite a lower remission rate compared to developed countries. Except for higher rates of tuberculosis, the AEs were similar to the published reports.

Prevalence of foot problems in people with inflammatory arthritis in Singapore

Background

Foot problems are highly prevalent in people with inflammatory arthritis reported from studies in the UK, Europe and New Zealand, but there is limited evidence from Southeast Asia. The study aim was to evaluate the prevalence of foot problems in people with inflammatory arthritis in Singapore.

Methods

People with inflammatory arthritis were recruited from the rheumatology outpatient clinic of a tertiary hospital in Singapore. Disease and clinical characteristics included age, sex, disease duration, current blood tests and medications. The Leeds Foot Impact Scale was used to evaluate foot impairment/disability and the Modified Health Assessment Questionnaire was used to assess global function.

Results

We recruited 101 people with inflammatory arthritis, of which 50 % were female. The majority of participants were Chinese (70 %). The mean (SD) age was 52 (15) years, and the mean (SD) disease duration was 9.3 (0.3) years. The most commonly reported inflammatory arthritic conditions were rheumatoid arthritis (46), gout (31) and spondyloarthritis (15 %). The mean (SD) of the total Leeds Foot Impact Scale was 17 (13) indicating moderate to severe levels of foot impairment and activity limitation. Over 80 of participants reported foot pain during the course of their condition, and 48 % reported current foot pain. Despite the high prevalence of foot pain, only 21 participants (21 %) had been referred to a podiatrist.

Conclusion

This is the first study to investigate the prevalence of foot problems in people with inflammatory arthritis from Singapore. The majority of the participants reported foot problems, but had not been referred to a podiatry service.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0169-y) contains supplementary material, which is available to authorized users.

Cervical spine involvement in rheumatoid arthritis over time: results from a meta-analysis

Introduction

Complications in rheumatoid arthritis (RA) seem less common than they were years ago. The prevalence and progression of anterior atlantoaxial subluxations (aAASs), vertical subluxations (VSs), subaxial subluxations (SASs), and associated cervical myelopathy in RA over the past 50 years were determined.

Methods

A literature search was performed by using Medline-OVID/EMBASE, PubMed, and Scopus (from 1960 to June 21, 2014). Prevalence studies were included if the sample size was at least 100 or the prevalence/progression of cervical subluxations was reported. Study quality was assessed by using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Prevalence of cervical subluxations was calculated for each study. Student’s t test and meta-regression were used to evaluate for significance.

Results

In total, 12,249 citations were identified and 59 studies were included. The prevalence of aAAS decreased from 36% (95% confidence interval (CI) 30% to 42%) before the 1980s to 24% (95% CI 13% to 36%) in the 2000s (P = 0.04). The overall prevalence rates were 11% (95% CI 10% to 19%) for VS, 13% (95% CI 12% to 20%) for SAS, and 5% (95% CI 3% to 9%) for cervical myelopathy, and there were no significant temporal changes. Rates of progression of aAAS, VS, and SAS were 4, 6, and 3 lesions per 100 patients per year, respectively. The incidence of new or progressive cervical myelopathy was 2 cases per 100 patients with known cervical subluxations per year.

Conclusions

Since the 1960s, only aAAS has decreased dramatically. It is still more than twice as common as VS or SAS. No temporal changes in the development of cervical myelopathy in affected patients with RA were noted. The progression rates of cervical subluxations and myelopathy were unchanged over time.

[Demographic and clinical features of patients with rheumatoid arthritis in Piauí, Brazil--evaluation of 98 patients]

INTRODUCTION

Brazilian epidemiological studies on rheumatoid arthritis are scarce, mainly in the northeast; thus many data currently available originate from the international literature.

OBJECTIVES

To describe demographic, clinical and serological characteristics of patients with rheumatoid arthritis (RA) followed-up by the same physician, in state of Piauí, Brazil.

PATIENTS AND METHODS

Data were collected between August 2010 and March 2013, in three health services of Piauí that provided health care in Rheumatology: a university-affiliated hospital, a public outpatient clinic and a private clinic.

RESULTS

The numbers represent mean ± SD or percentage: 47.5±11.03 years-old non-Caucasian woman, non-smoker (59.2%), low educational level, mean disease duration of 7.7 years ± 7.6, and major extra-articular manifestations were rheumatoid nodules (19.4%) and sicca syndrome (46.9%).

CONCLUSION

Features of rheumatoid arthritis obtained in this study are similar to those found in some national and international studies, but we observed higher female preponderance and illiteracy rate, in addition to a moderately severe erosive disease on average, with frequent sicca and other extra-articular manifestations.

Characteristics of patients with rheumatoid arthritis in Qatar: a cross-sectional study

OBJECTIVE

To describe the clinical characteristics, serologic, radiological and clinical disease activity, and modality of therapy in patients with rheumatoid arthritis (RA) at tertiary outpatient care in Qatar.

METHODS

The study design was cross-sectional where 100 consecutive cases who met 1987 American College of Rheumatology criteria for diagnosis of RA were enrolled in this study. Demographic data (sex, nationality and age) numbers of swollen and tender joints, X-rays and current medications were collected during outpatients visits to Hamad General Hospital. Disease Activity Score of 28 joints (DAS28) and Health Assessment Questionnaires (HAQ) scores were calculated. All patients with RA who were seen as rheumatology outpatients were invited to participate in the study.

RESULTS

One hundred patients were seen and examined during their follow-up at the outpatient clinic; data were collected and analyzed. Females represented 67% of all patients, 6% had more than six swollen joints, 9% had more than six tender joints. DAS28 and erythrocyte sedimentation rate (DAS28) calculation revealed 49% of patients were in remission (DAS28 < 2.6), 15% had low disease activity (DAS28 2.6-3.2) and 36% had DAS28 > 3.2.Mean HAQ score was 1.02. Rheumatoid factor (RF) was positive in 63%, while anti-cyclic citrullinated protein antibody (anti-CCP) was positive in 71%, and 49% were positive for both. Radiography of hands and feet during the previous year was done in 65% of patients: 11% of them had erosions. Sixty-six percent were on one synthetic disease-modifying anti-rheumatic drug (DMARD) and 27% where on more than one synthetic DMARD and 7% where on no DMRD. Glucocorticoids were used in 51% and 29% were on biologics.

CONCLUSION

Sixty-four percent of rheumatoid arthritis patients in Qatar were in remission or had low disease activity while the remaining 36% had active disease and among these patients 29% were on biologics.

Major trends in the manifestations and treatment of rheumatoid arthritis in a multiethnic cohort in Singapore

We analyzed the epidemiological changes of rheumatoid arthritis (RA) over three decades using patients from a single center in Singapore. All patients who fulfill the 1987 American College of Rheumatology criteria for RA were invited to enroll in a prospective disease registry. We analyzed the patient demographics, disease manifestation, management and patient-reported outcomes, including quality of life (QoL), in the three categories according to the year of disease onset: before 1989 (group I), 1990-1999 (group II) and after 2000 (group III). There were 1,153 patients with 231, 532 and 390 in groups I, II and III, respectively. The mean disease durations were 25, 12 and 4.8 years, respectively. The majority was female (84.1 %) and Chinese (76.6 %) with no socio-demographic differences across the three periods. The age of onset rises and the prevalence of rheumatoid factor falls with the proximity of disease onset. Patients with most recent disease onset had the earliest access to the rheumatologist. They also had the highest tender and swollen joint counts, lowest deformed joint count and highest remission rate. Patients in group I report better mental and emotional QoL though many developed marked disability. We have documented changes of the manifestations of RA that are dependent and independent of improved treatment. Significant differences in accessibility to the rheumatologist, RA activity, functional capacity, quality of life and comorbidities were seen in subsequent cohorts due to treatment evolution and more efficient healthcare delivery.

Advanced glycation end-products inhibition improves endothelial dysfunction in rheumatoid arthritis

AIM

Chronic inflammation in rheumatoid arthritis is associated with vascular endothelial dysfunction. The objective was to study the efficacy and safety of advanced glycation end products (AGEs) inhibitor (benfotiamine 50 mg + pyridoxamine 50 mg + methylcobalamin 500 μg, Vonder(®) (ACME Lifescience, Baddi, Himachal Pradesh, India)) on endothelial function in rheumatoid arthritis (RA).

METHODS

Twenty-four patients with established active RA with high disease activity (Disease Activity Score of 28 joints [DAS28 score] > 5.1) despite treatment with stable doses of conventional disease-modifying antirheumatic drugs were investigated. Inflammatory disease activity (DAS28 and Health Assessment Questionnaire-Disability Index [HAQ-DI] scores, erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]), markers of endothelial dysfunction, serum nitrite concentration and endothelium-dependent and -independent vasodilation of the brachial artery were measured before and after 12 weeks therapy with twice a day oral AGEs inhibitor.

RESULTS

After treatment, flow-mediated vasodilation improved from 9.64 ± 0.65% to 15.82 ± 1.02% (P < 0.01), whereas there was no significant change in endothelium-independent vasodilation with nitroglycerin and baseline diameter; serum nitrite concentration significantly reduced from 5.6 ± 0.13 to 5.1 ± 0.14 μmol/L (P = 0.004), ESR from 63.00 ± 3.5 to 28.08 ± 1.5 mm in the first h (P < 0.01) and CRP levels from 16.7 ± 4.1 to 10.74 ± 2.9 mg/dL (P < 0.01). DAS28 and HAQ-DI scores were significantly reduced, from 5.9 ± 0.17 to 3.9 ± 0.17 (P < 0.01) and 4.6 ± 0.17 to 1.7 ± 0.22 (P < 0.01), respectively.

CONCLUSIONS

Advanced glycation end products inhibitor improves endothelial dysfunction and inflammatory disease activity in RA. In RA, endothelial dysfunction is part of the disease process and is mediated by AGEs-induced inflammation.

The efficacy of disease modifying anti-rheumatic drugs in rheumatoid arthritis in local patients of Karachi

The primary objective of the study is to assess the efficacy of the 'Disease Modifying AntiRheumatic Drugs (DMARDs) on the disease activity in Rheumatoid Arthritis (RA) in the local patients of Karachi. The secondary objective is to evaluate whether the combination of two concurrent DMARDs (Combination Therapy) is superior to a single DMARD (Mono-therapy). This is an open labeled retrospective case series. One hundred and five consecutive patients fulfilling 1987 ACR criteria for the diagnosis of RA were initially selected from the case notes of out patients department. Sixty nine patients fulfilled the inclusion criteria and were finally recruited for analysis. Details of the Tender Joint Count (TJC), Swolen Joint Count (SJC), Patient Global Assessment (PGA) and ESR were obtained at six weeks, three months, six months and one year. Out of the 69 patients studied 48 were in the mono-therapy group and 21 in the combination therapy group. Methotrexate (MTX) was the most commonly used single DMARD (75%) as well as the most frequent component of the combination groups (85%). The TJC, SJC and PGA analyses of all patients show that DMARDs are effective agents for clinically controlling RA activity. The speed of their beneficial effect is slow and unlike analgesics and NSAIDS, may take up to six weeks to start working. The 6 week responses showed 32.49% improvement in TJC, 33.19% improvement in SJC and 59% better responses in PGA. This response continued to show further improvement and at six months when TJC improved by 63.41%, SJC by 53.21% and PGA with 81% better responses. After 6 months the response reached a plateau but nevertheless maintained until 1 year with improvements in TJC by 66.23%, SJC by 56.48% and PGA with 88.23% better responses. The changes in ESR did not go parallel with the other three outcome measures. The mean baseline ESR of 56 reduced to 44 at 6 weeks but rose again gradually to 54 at 1 year. The sub-group analysis did not show the overall superiority of combination therapy over mono-therapy. DMARDs are effective in controlling disease activity in RA. Their effect starts slowly over 6 week and may take up to 6 months to show full benefits. The beneficial effect was maintained for at least 1 year. Sub-group analysis did not show any advantage of combination therapy over mono-therapy in this series of patients. Methotrexote being the most frequently used DMARDs in both groups and being most cost effective agent seems to be the most useful drug in RA in the developing world.

The pattern and clinical manifestations of rheumatoid arthritis in Sarawak General Hospital

The aim of our study is to describe the pattern, clinical features, treatment regimes, and disease activity among the patients treated for rheumatoid arthritis (RA) in the Sarawak General Hospital. We performed a cross-sectional study of all patients with a diagnosis of RA who received treatment at the General Medical Clinic and the Rheumatology Clinic in Sarawak General Hospital over a 1-year period from 1st June 2006 to 31st May 2007. Demographic data, clinical features, and disease activity of all 154 patients were collected for statistical analysis. Rheumatoid arthritis afflicts all the major racial groups in Sarawak including the native population. Our patients have a mean disease duration of 5.4 years (SD 5.69) and a mean duration of delay in diagnosis RA and initiation of disease-modifying antirheumatic drug (DMARD) treatment of 42.9 months (SD 60.1). They have a low rate of interstitial lung disease (6.5%) and rheumatoid nodules (4.5%). Rheumatoid factor was positive in 65.5% of our patients. They have a mean Disease Activity Score (DAS) 28 score of 4.28 (SD 1.33). Only 12.5% of our patients are in remission with DAS 28 < 2.6 and 30.9% of our patients are having high disease activity with DAS 28 > 5.1. Despite the high usage of DMARDs in Sarawak (>80%), our patients have severe disease with high disease activity indices. This is most likely due to delay in diagnosis and initiating DMARDs in RA patients in Sarawak.

Rheumatoid arthritis in the developing world

The general impression is that rheumatoid arthritis (RA) has a lower prevalence and a milder course in developing countries. Epidemiological studies from different regions show that varying prevalence is possibly related to urbanization. The data suggest that where severe disability does occur, it presents a significant health challenge because of scarce medical and social resources. Disease-modifying anti-rheumatic drugs (DMARDs) remain the mainstay of therapy to alter the natural history of the disease. New therapies are unlikely to be of general benefit in the developing world because of financial constraints and increased risk of infections, particularly tuberculosis, associated with the use of tumour necrosis factor-alpha blockers. Instead, future research in poorer communities should be directed at assessing the burden of disease, the role of early aggressive therapy with DMARDs in combination with glucocorticoids for the majority of patients with RA, and finally, sourcing targeted biological therapies through clinical trials and grants for compassionate use in patients with refractory disease.

Disease activity and health status in rheumatoid arthritis: a case-control comparison between Norway and Lithuania

OBJECTIVE

To compare disease characteristics and health status in patients with rheumatoid arthritis (RA) from two countries, Norway and Lithuania.

METHODS

Patients were recruited from the RA registers in Vilnius (Lithuania) and Oslo (Norway). For each patient from Vilnius, a patient matched for age and sex from the Oslo register was selected. Sociodemographic characteristics, disease process, and health status were compared between the patient groups.

RESULTS

201 Lithuanian patients and 201 Norwegian patients were included. Mean (SD) age in both groups was 55.9 (10.0) years, and 83% were women. Patients from Lithuania were less often employed (27% v 42%; p=0.001), had higher disease activity expressed by the disease activity score (DAS28; mean (SD) 5.3 (1.0) v 4.4 (1.4); p<0.001), had worse physical function by the modified Health Assessment Questionnaire (MHAQ; mean (SD) 2.3 (0.8) v 1.6 (0.5); p<0.001), had more often comorbidity (73% v 53%; p<0.001) and they reported worse general health measured by Short Form-36 Health Survey (SF-36; mean (SD) 23.2 (13.5) v 44.5 (21.3); p<0.001). The proportions of patients who had used disease modifying drugs were similar, but the pattern of use differed.

CONCLUSION

Important differences in employment, disease activity, physical function, and self reported health status were observed in patients with RA from two northern European countries. Socioeconomic inequalities, differences in disease management, and access to specialised health care, as well as methodological issues regarding instruments and data collection are likely explanations. These data support the view that management of RA should be adapted to country-specific needs.

Racial origin and its effect on disease expression and HLA-DRB1 types in patients with rheumatoid arthritis: a matched cross-sectional study

OBJECTIVE

There are a significant number of patients with rheumatoid arthritis (RA) of North Indian or Pakistani origin (Asian) now living in the UK. RA has been poorly studied in this racial group. The aim of this study was to compare RA in this Asian group with RA in the indigenous northern European (European) population. It was hypothesized that these two racial groups would have different disease expressions and immunogenetics that could be relevant to pathogenesis, prognosis and therapy.

METHODS

One hundred and seven Asian RA patients, who fulfilled the 1987 American College of Rheumatology criteria, were stringently matched for age, sex and disease duration with 107 European RA patients, and were fully assessed.

RESULTS

The Asian RA patients had significantly fewer bony erosions [median Larsen score 58.5 (interquartile range 45.5-77.8) vs 68 (52-93) for European patients; P: = 0.0066, Mann-Whitney U:-test] and rarely had nodules (5.7 vs 20%, P: = 0. 0019, Fisher's exact test). The two groups had the same prevalence of rheumatoid factor positivity, number of swollen joints and level of inflammation (C-reactive protein). The Asian RA patients had a reduced prevalence of the conserved third allelic hypervariable region (3AHVR) (45 vs 82%, P: < 0.0001, Fisher's exact test), particularly DRB1*0401 (4.5 vs 55%). However, the prevalence of the conserved 3AHVR was significantly increased in the Asian RA patients compared with Asian controls. By contrast, the Asian patients had more tender joints [13.5 (7-22) vs 5.5 (2-11.8); P: < 0.0001 Mann-Whitney U:-test]. The Health Assessment Questionnaire score was also significantly worse in the Asians compared with the Europeans [median 2.0 (1.13-2.63) vs 1.25 (0.5-2.13), P: = 0.0001).

CONCLUSIONS

The Asian patients had similar levels of inflammation and less damage but more pain and disability than the matched European RA patients. Of the known prognostic factors for erosions (rheumatoid factor, conserved 3AHVR, swollen joints and C-reactive protein), only the conserved 3AHVR was reduced in the Asian RA patients, and this was consistent with their less erosive disease. These data also indicate the importance of pain as well as erosive damage in determining disability in Asian patients and stress the importance of adequate pain relief, in addition to disease suppression, when treating Asian RA patients.

Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis

OBJECTIVE

To review epidemiological studies dealing with the temporal and geographic variability in the occurrence of rheumatoid arthritis (RA) and clinical studies that address the variability of severity and manifestations among populations.

METHODS

An extensive search of the literature, including a Medline search, was completed. Studies addressing the origin, history, and trends in the occurrence of RA were reviewed first. Next, studies of the prevalence and incidence of RA in different populations were reviewed, and occurrence rates compared. Standardization was attempted by tabulating adult prevalence rates of studies using equivalent sets of criteria. Studies comparing RA patients from two populations were sought next. Finally, studies dealing with explanations of the presumed variability were reviewed.

RESULTS

Temporal variability is indicated by paleopathological evidence that RA has existed in the New World since 4000 BC, whereas there is no evidence that it occurred in Europe before the 17th century, or in Africa before the 20th century. Epidemiological studies show a possible trend of decreasing incidence of RA in the United States and Western Europe, whereas reports from Africa note a rising incidence. In white populations of Europe and America, prevalence is approximately 1%, and incidence is 0.03%. Significantly higher rates are found in some North American Indians, and significantly lower rates in some Asian and African populations, even when the different population structures are taken into account. In the latter populations, different patterns of occurrence from those observed in whites emerge, such as greater female preponderance and a much younger peak age at onset. Direct standardized comparisons of two diverse populations of RA patients showed some differences in expression, severity, or manifestations of RA between populations.

CONCLUSION

The occurrence and manifestations of RA are temporally and geographically variable.

The expression of rheumatoid arthritis in Saudi Arabia

This retrospective study describes the characteristics of rheumatoid arthritis patients seen at the King Khalid University Hospital, Riyadh over a period of 5 years. One hundred and ninety-five patients with rheumatoid arthritis seen during this period were reviewed. There were 155 females and 40 males (F:M ratio 4:1). Females had a younger age at onset than males (38.6 +/- 13.4 vs 42.9 +/- 13.3 year for male - p = 0.037). The majority of patients (76.4%) described an insidious onset. 45.1% used one or more forms of local medicine. Constitutional symptoms were reported in 78 (40%). Rheumatoid factor was positive in 79.5%. The most frequently involved joints were the proximal interphalangeal (PIP) joints, knees and metacarpophalangeal (MCP) joints. Rheumatoid nodules were observed in 15.9% and keratoconjunctivitis sicca in 14.4%. Most patients used second line drugs. The majority of patients (57.4%) were in functional class 1 and 2. The disease pattern and joint distribution resemble more the pattern reported in developed countries.

Rheumatoid arthritis and connective tissue disorders: India and South-East Asia

With a few exceptions, there remains a paucity of good epidemiological studies from India and South-East Asia. The overall impression is that the prevalence of rheumatoid arthritis (RA) is slightly less compared with the West and follows a milder course. There may be differences in the articular expression of the disease with the wrist and forefoot less commonly affected than in Caucasian studies. Extra-articular manifestations and erosive change are less frequent and severe. HLA DR4 does not correlate with seropositivity and severity of RA. The prevalence of SLE may be less in the Indian subcontinent than in the West. However, recent indications are that in South-East Asia and the Pacific region the prevalence morbidity and mortality are higher than in developed countries. An improvement in socio-economic conditions may be accompanied by an improvement in the survival of patients with SLE.