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

Clinical Characteristics, Medication Use, and Short-Term Outcomes in Patients With Rheumatoid Arthritis: A Prospective Observational Study at a Tertiary Care Centre in Central India

Background Rheumatoid arthritis (RA) is a chronic inflammatory arthritis associated with articular and extraarticular manifestations. Clinical profile, treatment patterns, and treatment outcome of RA patients vary based on geographic location, both globally and among certain ethnic groups within a country. Objectives We aim in this study to describe the demographic and clinical characteristics, treatment patterns, and short-term treatment outcomes by DAS-28 CRP score (disease activity score) in patients with RA in Central India. Methods This prospective observational study was conducted from September 2023 to September 2024 at a tertiary care hospital in central India. A total of 121 RA patients aged over 18 years, diagnosed as per the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria or already receiving treatment for RA, were enrolled. Data on demographics, clinical profiles, drug usage patterns, comorbidities, and treatment outcomes were collected using a structured case record form over a follow-up period of three months. Results Out of 121 total participants, 101 (83.5%) were females. The female-to-male ratio was 5:1. The participants' mean age was 46.99±12.84 years. Of the 121 patients, 75 (61.9%) were previously diagnosed with RA, with 32 (42.7%) of them having disease duration between 1 and 5 years (mean duration: 4.1 years). Common symptoms included arthralgia (118 [97.5%]), early morning stiffness (102 [84.3%]), and weight loss (45 [37.2%]). Polyarticular involvement was seen in 105 (86.8%) of patients, most commonly affecting the hand joints. Boutonniere and Swan neck deformities were present in 18 (14.9%) and 16 (13.2%) of cases, respectively. Anemia (65 [53.7%]) was the most frequent extra-articular manifestation. Common comorbidities included obesity in 38 (31.4%), hypertension in 27 (22.3%), and ILD/COPD in 18 (14.9%) of the patients. Methotrexate and folic acid were each used in 103 (85.1%) patients, with hydroxychloroquine in 86 (71.1%); while 75 (61.9%) received steroids. Conclusions RA is predominant among the middle-aged population and females. Arthralgia and early morning stiffness in hand joints were the most common articular symptoms, while anemia was the most common extraarticular feature. Obesity followed by hypertension was the most common comorbidity reported in our study. Dual DMARDs (disease-modifying antirheumatic drugs) therapy, particularly the methotrexate-hydroxychloroquine combination, was most preferred. Treatment with DMARDs led to a significant reduction in disease activity over three months. These findings highlight RA characteristics and treatment patterns in Central India.

Clinical Characteristics, Comorbidities, and Sex-related Differences Among Smoking and Non-smoking Patients with Rheumatoid Arthritis: A Matched Case-control Study

Background

Smoking may increase levels of pro-inflammatory cytokines, which is an important contributor to rheumatoid arthritis (RA) pathogenesis.

Objectives

The aim of this study was to describe the characteristics of RA patients who were smokers compared with non-smokers.

Methods

A total of 849 RA patients who were smokers out of a large RA cohort of 10,364 patients (8.2%) were compared to 924 age-, sex-, and body mass index-matched RA patients who were non-smokers. Patients were subjected to full history-taking and clinical examination. Laboratory tests such as rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) were measured. The disease activity score 28 (DAS28) and the health assessment questionnaire (HAQ) score were assessed.

Results

The mean age among smokers was 46.4 ± 11.3 years, the male-female ratio was 3:1, and the mean disease duration was 6.4 ± 6.2 years. There was a significantly higher frequency of diabetes mellitus, hypertension, and metabolic syndrome in smokers compared to non-smokers (13.7%, 17.1%, and 9.2% vs. 8.4%, 12.9%, and 3.5%; P < 0.0001, P = 0.01, P < 0.0001, respectively), while hypothyroidism was more common in non-smokers (P = 0.03). Rheumatoid nodules (P = 0.03), oral ulcers (P = 0.002), keratoconjunctivitis sicca (P = 0.043), and neurological manifestations (P = 0.002) were significantly more common in smokers, but the DAS28 was lower (4.2 ± 1.5 vs. 4.8 ± 2.5; P < 0.0001). RA-related changes were significantly more common in female smokers than in males. On regression analysis, none of the differences found in the comparison between smokers and non-smokers remained significant.

Conclusions

Smoking in RA patients was found to be associated with a higher frequency of traditional comorbidities, rheumatoid nodules, oral ulcers, sicca complex, and neurological manifestations, but a lower disease activity. There is an obvious sex-driven pattern, with clinical alterations occurring more frequently in female smokers. Higher RF, anti-CCP, and double seropositivity are more observable in males and positive antinuclear antibody in females.

Patient perspectives on rheumatic and musculoskeletal diseases: insights from a large-scale survey

INTRODUCTION/OBJECTIVES

Rheumatic and musculoskeletal diseases (RMD) are prevalent among Arabic-speaking patients in the Middle East and North Africa (MENA), yet their perspectives remain underexplored. This study examines patient experiences and perspectives.

METHOD

A cross-sectional survey was developed using pilot testing with clinimetric sensibility assessment to ensure clarity and relevance, and the Open-Source Metric for Measuring Arabic Narratives (OSMAN) to assess readability. The Checklist for Reporting Internet E-Surveys (CHERRIES) was used to enhance the quality of the survey. The survey was distributed via social media to Arabic-speaking patients with self-reported RMDs. Collected data included demographics, disease characteristics, medication use, treatment satisfaction factors, perceived causes, and patient concerns.

RESULTS

Of the 1050 responses received, 456 were complete and included in the analysis. Most respondents were female (81.4%) and between the ages of 25 and 44 (63.4%). The most frequently reported diseases were systemic lupus erythematosus, rheumatoid arthritis, and ankylosing spondylitis. Nearly all (97.1%) used medications within the previous three months, primarily hydroxychloroquine, glucocorticoids, and biologics. Key factors influencing treatment satisfaction were pain relief, laboratory result discussions, sleep quality, and mood improvement. Patients perceived immune system abnormalities (76.5%), psychological factors (54.8%), and genetics (41.7%) as primary disease causes. Main concerns included fear of disease complications, adverse drug reactions, and being a burden to others. Rheumatologists and internet search engines were the primary sources of information for patients. Most avoided alternative medicine, while 33.3% used it.

CONCLUSION

This survey is the first and largest in the MENA region, providing valuable insights into patient perspectives on RMD. It highlights the need for holistic management, enhanced education, and supportive services to improve quality of life. Key Points • The most commonly perceived causes of rheumatic and musculoskeletal diseases among patients with RMD were immune system abnormalities, psychological factors, genetic/hereditary influences, and envy. • Patients' top concerns included fear of future complications, adverse drug reactions, becoming a burden to others, physical disability, and issues related to marriage and childbirth. • Key factors influencing treatment satisfaction included pain relief, discussions of laboratory results, sleep quality, and mood improvement. • Approximately one-third of patients had consulted practitioners of complementary and alternative medicine.

Global RA treatment recommendations: An update from the various international societies

Rheumatoid arthritis is a chronic inflammatory arthritis with many extra-articular manifestations and is associated with an increased risk of morbidity and mortality. This review attempts to provide an update on the treatment recommendations from various global societies and discuss some of the challenges and solutions to caring for people with rheumatoid arthritis across the world. A search was conducted on PubMed, Google Scholar, and EMBASE from 2000 to 2024 using rheumatoid arthritis, treatment, recommendations, guidelines, management, disparities, and access as the search terms. Emphasis was placed on pertinent recommendations published in the last five years. Recent available recommendations of the American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), Asia-Pacific League of Associations for Rheumatology (APLAR), Pan-American League of Rheumatology (PANLAR) and African League of Associations for Rheumatology (AFLAR) were concentrated on. The latest recommendations from various societies are discussed.

Prevention of rheumatoid arthritis using a familial predictive medicine approach

Most of the chronic-degenerative diseases deserve a very early recognition of symptoms and signs for the earliest secondary prevention, which could be also very useful in many cases for the most precocious clinical approach. The periodic monitoring of a subject at risk of a specific disease, because of genomic predisposition by predictive medicine approach, may help to earlier detection of onset and/or the progression of the pathology itself, through intra-individual monitoring. This is particularly the case of rheumatoid arthritis (RA) for which an early diagnosis is undoubtedly the first step to ensure the most proper therapy for the patient. Thus, the earlier identification of individuals at high risk of RA could lead to ultra-preventive strategies to start for the best lifestyle performances and/or for any other effective therapeutic interventions to contrast the onset, and/or the evolution of the putative RA. This will also optimize both costs and medical resources, according to the health care policies of many countries.

Predictive factors of methotrexate monotherapy success in patients with rheumatoid arthritis in a national referral center: a cohort study

BACKGROUND

Methotrexate (MTX) remains the recommended first-line treatment for rheumatoid arthritis (RA); however, its response varies and is influenced by various factors. This study aimed to identify predictors of MTX monotherapy treatment success in an Indonesian cohort.

METHODS

This retrospective cohort study included newly diagnosed RA patients receiving MTX monotherapy. Treatment success was defined as achieving remission or low disease activity according to Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR) after 12 months of MTX therapy. The association between demographic, clinical, and laboratory factors and achieving therapy targets was evaluated using multivariate logistic regression analysis.

RESULTS

Among 254 subjects, 59.4% achieved treatment success with MTX monotherapy, with remission attained in 33% and low disease activity in 26.4%. Most subjects were female (95.7%) with a mean age of 48 ± 11 years. Multivariate analysis revealed that lower disease activity (OR 1.97; 95% CI [1.04-3.72]), normal ESR (OR 2.58; 95% CI [1.05-6.34]), normoweight (OR 2.55, 95% CI [1.45-4.49]), and tender joint count ≤ 5 (OR 2.45, 95% CI [1.31-4.58]) were significant predictors of treatment success.

CONCLUSION

The rate of MTX monotherapy success in our study was 59.4%. Lower disease activity, normal ESR, normoweight, and fewer tender joints at baseline were significant predictors of treatment success.

Rheumatoid arthritis study of the Egyptian College of Rheumatology (ECR): nationwide presentation and worldwide stance

To depict the spectrum of rheumatoid arthritis (RA) in Egypt in relation to other universal studies to provide broad-based characteristics to this particular population. This work included 10,364 adult RA patients from 26 specialized Egyptian rheumatology centers representing 22 major cities all over the country. The demographic and clinical features as well as therapeutic data were assessed. The mean age of the patients was 44.8 ± 11.7 years, disease duration 6.4 ± 6 years, and age at onset 38.4 ± 11.6 years; 209 (2%) were juvenile-onset. They were 8750 females and 1614 males (F:M 5.4:1). 8% were diabetic and 11.5% hypertensive. Their disease activity score (DAS28) was 4.4 ± 1.4 and health assessment questionnaire (HAQ) 0.95 ± 0.64. The rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) were positive in 73.7% and 66.7% respectively. Methotrexate was the most used treatment (78%) followed by hydroxychloroquine (73.7%) and steroids (71.3%). Biologic therapy was received by 11.6% with a significantly higher frequency by males vs females (15.7% vs 10.9%, p = 0.001). The least age at onset, F:M, RF and anti-CCP positivity were present in Upper Egypt (p < 0.0001), while the highest DAS28 was reported in Canal cities and Sinai (p < 0.0001). The HAQ was significantly increased in Upper Egypt with the least disability in Canal cities and Sinai (p = 0.001). Biologic therapy intake was higher in Lower Egypt followed by the Capital (p < 0.0001). The spectrum of RA phenotype in Egypt is variable across the country with an increasing shift in the F:M ratio. The age at onset was lower than in other countries.

Social, political, and economic determinants of access to biologics: A scoping review of structural determinants in the clinical disparities literature

BACKGROUND

The number of biologics among new medication approvals is increasing. Social, political, and economic factors influence access to these expensive medications. Disparities in access to new medications can exacerbate health disparities. The notion of "structural determinants" provides a theoretical framework for broadly evaluating the integration of upstream social, political, and economic determinants in the clinical study of access.

OBJECTIVE

To review the literature on access to FDA approved biologic medications with particular focus on the integration of social, political, and economic determinants into study design and interpretation.

METHODS

We used PRISMA guidelines to review studies on racial and socioeconomic disparities in biologic access through August 2020. We assessed whether the design or interpretation of studies considered key economic determinants of access: the biologics supply chain, trade agreements, patents, drug research and development, insurance reimbursement, and non-insurance drug policies.

RESULTS

100 studies met our inclusion criteria. Sixty-six studies considered insurance reimbursement, but trade law, patents, and other key economic determinants were rarely considered. The literature focuses on a small number of older biologics.

CONCLUSIONS

A small number of studies model the integration of structural determinants into clinical research on access to biologics, but overall this literature has many limitations and lacks integration of structural determinants. Increased interdisciplinary collaboration, availability of manufacturer data, and use of disease registries can help create structurally grounded understandings of the relationship between the political economy of expensive medications and clinical disparities.

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.

Lebanese Hospital-Based Rheumatoid Arthritis Registry: Characteristics of Patients and Comparison with Other Populations

Objectives

The aim of the Lebanese hospital-based Rheumatoid Arthritis (RA) registry, initiated in 2011, is to evaluate the safety and efficacy of biologic agents among patients seeking care at the American University of Beirut Medical Center (AUBMC). We aimed to characterize the demographic and clinical profile of RA patients included in the Lebanese registry. We compared our results with those issued from Middle Eastern and non-Middle Eastern registries.

Methods

195 Patients enrolled in the RA registry from 2011 to 2018 were considered in this study. Patients enrolled in the registry were eligible to be treated with biologics, but 56 patients remained biologics naïve. Patients were reassessed every six months.

Results

The highest proportion of patients were female (81%). The mean age was 55.53±15 years, and the disease duration was 11.38±7.7 years. RA was diagnosed at a mean age of 44.13±16 years. Almost one-third of RA patients were smokers (29.2%) and 15% consumed alcohol. Comorbidities included cardiac diseases (30.8%), hypertension (24.6%), hyperlipidemia (11.8%), diabetes mellitus (9.2%), and Hypothyroidism (6.2%). Three cases of cancer and seven cases of tuberculosis were reported. The mean of the Disease Activity Score (DAS28) was 3.75 ± 2.28 with no difference according to gender; the mean of the Health Assessment Questionnaire (HAQ) score showed a significant difference between females and males (1.02 ± 0.84 and 0.61 ± 0.7 respectively). Methotrexate was the most commonly used medication. There was non-significant difference in taking biologics according to gender.

Conclusion

Our findings are similar to other studies in terms of gender distribution. The higher mean age at diagnosis compared to other populations could indicate a delay in seeking appropriate care. The Lebanese RA registry provides valuable data on pharmacological interventions used and an opportunity to follow up to examine the effectiveness of different therapeutics and to monitor their side effects.

The Safety and Effectiveness of Infliximab Biosimilar in Managing Rheumatoid Arthritis: A Real-Life Experience from Jordan

BACKGROUND

Infliximab (IFX) biosimilar was the first biosimilar approved in Jordan in 2014, with limited evidence of its safety and effectiveness from the Middle East and North Africa (MENA) region. Thus, this study aimed to evaluate the safety and effectiveness of IFX biosimilar in active rheumatoid arthritis (RA) patients over 34 weeks by investigating (1) the adverse events (AEs), serious adverse events (SAEs), and therapy discontinuation and (2) the score changes of the 28-Joint Disease Activity Score (DAS28) and the Health Assessment Questionnaire Disability Index (HAQ-DI).

METHODS

This multicenter prospective cohort study collected clinical parameters within hospital settings every four weeks. The numbers and percentages of observed AEs and SAEs were informed. The DAS28 utilizing Erythrocyte Sedimentation Rate (ESR), HAQ-DI, and ESR were reported at baseline and 14th and 30th weeks; thus, they were reported as means (SD).

RESULTS

A total of 22 RA patients were enrolled and initiated IFX biosimilar, of which nine (41.0%) discontinued the study, but their data were analyzed up to the point of withdrawal. A total of 35 AEs were reported in 14 patients, including two (5.7%) SAEs. None of the participants discontinued treatment due to AEs. The mean (SD) score of DAS28-ESR significantly decreased from 6.55 (1.16) at baseline to 4.59 (1.45) at week 14 (p < 0.0001) and to 4.77 (1.09) at week 30 (p < 0.0001). Similarly, the mean (SD) HAQ-DI score significantly decreased from 0.95 (0.74) at baseline to 0.48 (0.62) at week 14 (p=0.008) and to 0.71 (0.78) at week 30 (p=0.483). The mean (SD) value of ESR decreased from 58.75 (26.94) at baseline to 47.92 (33.89) at week 14 (p=0.082) and to 39.83 (17.38) at week 30 (p=0.005).

CONCLUSION

IFX biosimilar demonstrated safety and effectiveness in managing RA patients bringing real-world clinical support for biosimilars' role in rheumatology.

Patterns of Response to Different Treatment Strategies in Seropositive Rheumatoid Arthritis Patients in a Tertiary Hospital in South-Western Saudi Arabia: A Retrospective Study

Purpose

To study the pattern of response to different treatment strategies in seropositive rheumatoid arthritis (RA) patients and to describe our clinical practice in RA management.

Patients and Methods

Over a period of two years from April 2018 to April 2020, we conducted a retrospective analysis of data for 288 consecutive seropositive RA patients attending rheumatology clinics and the daycare unit at Aseer Central Hospital. Data were collected on patient demographics, disease duration, extraarticular manifestations, comorbidities and treatment. Disease activity was assessed using the clinical disease activity index (CDAI).

Results

Out of the total 288 patients, 42% (120) are on csDMRADs, while 54% (162) are on bDMRADs and 4% (6) are on tsDMARDs. Of the patients on csDMARDS, 51%, 43% and 7% of them were on remission, low and moderate disease activity, respectively. However, of the patients on non-csDMARDS, 36.3%, 49.4% and 14.3% of them were on remission, low and moderate disease activity, respectively. Failure of csDMARDs was affected by the presence of high disease activity at baseline, extraarticular lung manifestations and coexistent fibromyalgia, with a significant effect of the latter on remission rate. Among patients on non-csDMARDs, 42 (25%) showed one or more therapy changes. Tumor necrosis factor inhibitors were the predominant first-line agents in biologically naive patients (65%) followed by abatacept (18%). Abatacept was the most frequently prescribed second biologic in 52% of cases followed by tocilizumab in 19%.

Conclusion

The current clinical practice in our hospital is consistent with the latest American College of Rheumatology (ACR)/The European League Against Rheumatism (EULAR) guidelines. Treat-to-target strategy was achieved in the vast majority of our patients, while remission was observed in almost half of the patients.

Single nucleotide polymorphism rs5029937 in TNFAIP3 gene is correlated with risk of rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is a progressive and common autoimmune disease with multifactorial etiology. Several pieces of research show that genetic factors play a major role in the incidence of RA. Several genome-wide association studies (GWAS) have identified the tumor necrosis factor alpha inducible protein 3 (TNFAIP3) genes as one of the candidate loci. The TNFAIP3 gene encoding ubiquitin-editing protein A20 witch restricts B cell survival and prevents autoimmunity. Previous studies have indicated that single nucleotide polymorphisms (SNPs) in the TNFAIP3 gene are correlated with several autoimmune disorders. In the present study, we assessed the possible association between SNP rs5029937 (intronic variant) in the TNFAIP3 gene with RA risk in the Iranian population.

Methods: A case-control study using 50 RA patients and 50 control subjects was undertaken to evaluate rs5029937 (G>T) genotypes using real-time PCR high resolution melting method (HRM). The SPSS22 was used for statistical analyses and the significance level was set at P<0.05.

Results: Logistic regression analysis demonstrates that homozygous TT + heterozygous TG genotypes compared with GG genotype increase the risk of RA (TT+TG vs GG; P= 0.004, OR= 3.46; 95%CI [1.492-8.075]). Also, individuals with allele T were more frequently affected with RA than subjects with G allele (T vs G; P= 0.004, OR= 2.61; 95%CI [1.382-4.919]).

Conclusion: Our findings propose a substantial correlation between rs5029937 (G>T) polymorphism and RA risk in Iranian population.

Saudi cultural adaptation of the "compliance questionnaire of Rheumatology" for Rheumatoid arthritis patients on disease modifying anti-rheumatic drugs (DMARDs)

Purpose

This study aims to develop a valid and reliable Arabic version of the Compliance Questionnaire on Rheumatology (CQR-A) and to explore the impact of demographic factors on compliance.

Methods

This is a descriptive cross-sectional study carried out at the outpatient clinics of rheumatology in King Fahad hospital (KFH) in Madinah, Saudi Arabia, from May 2019 to October 2019. Initially, the original version was culturally adapted to an Arabic version by forward translation, backward translation, committee review of both the Arabic and the original versions, and lastly, pre-testing. Then, seventy-two rheumatoid arthritis patients were recruited to evaluate the reliability and validity of the CQR-A. Reliability was assessed by the test–retest method with a two-week interval through the intraclass correlation coefficient (ICC). The criterion validity of the CQR-A was assessed through Pearson correlation of pharmacy refill and CQR-A. The content validity index (CVI) was used to determine content validity. Multiple regression analysis was done to evaluate the effect of demographic factors on compliance.

Results

The CQR-A has adequate reliability and validity. The ICC = 0.757 with a 95% CI ranging from 0.579 to 0.860, p < 0.001, Cronbach’s alpha coefficient = 0.788. Pearson correlation coefficient was found to be (r = 0.338, p = 0.013). The individual content validity index (I-CVI) ranged from 0.67 to 1.00, and the average scale content validity index (S-CVI/Ave) = 0.91. Education was the only significant predictor of compliance amongst the demographic factors with R2 of 0.158.

Conclusion

The Arabic version of the Compliance Questionnaire on Rheumatology (CQR-A) is a reliable and valid clinical tool to assess compliance in Arabic speaking patients.

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.

U.S. FDA Approved Drugs from 2015-June 2020: A Perspective

In the present work, we report compilation and analysis of 245 drugs, including small and macromolecules approved by the U.S. FDA from 2015 until June 2020. Nearly 29% of the drugs were approved for the treatment of various types of cancers. Other major therapeutic areas of focus were infectious diseases (14%); neurological conditions (12%); and genetic, metabolic, and cardiovascular disorders (7-8% each). Itemization of the approved drugs according to the year of approval, sponsor, target, chemical class, major drug-metabolizing enzyme(s), route of administration/elimination, and drug-drug interaction liability (perpetrator or/and victim) is presented and discussed. An effort has been made to analyze the pharmacophores to identify the structural (e.g., aromatic, heterocycle, and aliphatic), elemental (e.g., boron, sulfur, fluorine, phosphorus, and deuterium), and functional group (e.g., nitro drugs) diversity among the approved drugs. Further, descriptor-based chemical space analysis of FDA approved drugs and several strategies utilized for optimizing metabolism leading to their discoveries have been emphasized. Finally, an analysis of drug-likeness for the approved drugs is presented.

The Use of Infliximab (Remicade®) for the Treatment of Rheumatic Diseases at a Tertiary Center in Lebanon: A 17-Year Retrospective Chart Review

Objectives:

Infliximab (Remicade®) was the first tumour necrosis factor-α (TNF) inhibitor to receive its initial marketing approval from the US Food and Drug Administration (FDA) for the treatment of Crohn’s disease. Following that, infliximab became approved for several immune-mediated inflammatory diseases. No evidence exists in the Middle East and North Africa region on the experience with infliximab use over an extended period in terms of efficacy and safety.

Methods:

The Rheumatology division at the American University of Beirut Medical Centre (AUBMC), one of the largest tertiary centres in the Middle East and North Africa region, has been using infliximab infusions for the treatment of certain rheumatic diseases for around two decades. By reviewing retrospectively medical charts at AUBMC, we investigate indications, safety and efficacy, rate of withdrawals, rate of switching to another biologic, and financial coverage of the drug to present data for practitioners and patients in the region considering infliximab for treatment of immune-mediated inflammatory diseases.

Results:

A total of 198 patients were identified in the past 17 years to have taken infliximab. The largest proportion of treated patients had RA. Fourteen percent of the total cohort experienced serious adverse events, with 96.4% of those events being mild hypersensitivity reactions. Five patients withdrew the medication because of infectious complications, 4 of which were cases of tuberculosis reactivation. Despite that, around half of the patients were switched to another biologic agent such anti-TNF-α, anti-CD20, and anti-IL-6 due to partial response, and less than half were receiving add-on disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, 70% of patients who used infliximab only or were switched achieved complete remission at their last hospital information. Around 98% of infliximab users were financially covered.

Conclusion:

According to our experience, infliximab has made remission and prevention of long-term disability realistic goals of therapy in the Middle East region.

Clinicodemographic Profiles of Rheumatoid Arthritis Patients from a Single Center in Saudi Arabia

Purpose

Rheumatoid arthritis (RA), if left untreated, can lead to joint damage and deformity, disability, and even death. Hence, early diagnosis and management are essential to improve clinical and functional outcomes. This study aimed to identify the most common variables and risk factors related to RA activity among patients living in the Kingdom of Saudi Arabia (KSA).

Patients and Methods

This study was conducted between January 2018 and March 2019 on consecutive patients diagnosed with RA at a tertiary care hospital in KSA. Adult patients (≥18 years old) diagnosed with RA based on the American College of Rheumatology 2010 criteria were recruited. The Disease Activity Score-28 for Rheumatoid Arthritis with CRP (DAS28-CRP) and health assessment questionnaire disability index (HAQ-DI) were calculated for 75 patients attending the rheumatology clinic during the study period to evaluate the rate of remission and functional capacity, and to compare findings with other local studies after assessing the relationship of these factors with medication use and existing comorbidities.

Results

The majority of the 75 patients were female (n=64), with a mean age of 49.7 years and average disease duration of 130 days. The median HAQ-DI was less than 0.5 (range 0–1.95). The DAS28-CRP scores revealed moderate disease activity in 45.3% and low disease or remission in 38.6% of the patients. Many patients (45.3%) were treated with methotrexate, and the most commonly used biological treatment was adalimumab in 14.6%. Comorbidities included hypertension (26.7%) and diabetes mellitus (18.7%). There was a strong association between cardiovascular diseases and a high DAS28-CRP score (p < 0.001).

Conclusion

A higher RA activity rate was observed. This may be related to difficultly accessing rheumatology clinics in our facility and financial difficulties accessing biological treatments.

The role of radiation treatment in the management of inflammatory musculoskeletal conditions: a revisit

Inflammatory musculoskeletal conditions are a common group of diseases among the elderly, worldwide. They are characterized by articular degenerative changes accompanied with often debilitating pain. Treatments often involve life-long analgesic therapy or joint replacement in extreme cases. The aim of this current review is to look at the role of radiation treatment with the hope of further study into the effectiveness of radiation treatment in reducing pain, eliminate or reduce the need for life-long analgesic therapy and thereby avoiding the analgesics’ side effects. Extensive literature search was done on PubMed and other available data base and the findings are presented and discussed. Literature showed that many countries in Europe, especially Germany use radiation routinely for the treatment of many degenerative disorders including osteoarthritis with good results and few side effects. A pilot study is therefore recommended with a view to establish the effectiveness or otherwise of this treatment method in patients.

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.

Dissecting the Role of NF-κb Protein Family and Its Regulators in Rheumatoid Arthritis Using Weighted Gene Co-Expression Network

Rheumatoid arthritis (RA) is a chronic synovial autoinflammatory disease that destructs the cartilage and bone, leading to disability. The functional regulation of major immunity-related pathways like nuclear factor kappa B (NF-κB), which is involved in the chronic inflammatory reactions underlying the development of RA, remains to be explored. Therefore, this study has adopted statistical and knowledge-based systemic investigations (like gene correlation, semantic similarity, and topological parameters based on graph theory) to study the gene expression status of NF-κB protein family (NK^PF) and its regulators in synovial tissues to trace the molecular pathways through which these regulators contribute to RA. A complex protein–protein interaction map (PPIM) of 2,742 genes and 37,032 interactions was constructed from differentially expressed genes (p ≤ 0.05). PPIM was further decomposed into a Regulator Allied Protein Interaction Network (RA^PIN) based on the interaction between genes (5 NK^PF, 31 seeds, 131 hubs, and 652 bottlenecks). Pathway network analysis has shown the RA-specific disturbances in the functional connectivity between seed genes (RIPK1, ATG7, TLR4, TNFRSF1A, KPNA1, CFLAR, SNW1, FOSB, PARVA, CX3CL1, and TRPC6) and NK^PF members (RELA, RELB, NFKB2, and REL). Interestingly, these genes are known for their involvement in inflammation and immune system (signaling by interleukins, cytokine signaling in immune system, NOD-like receptor signaling, MAPK signaling, Toll-like receptor signaling, and TNF signaling) pathways connected to RA. This study, for the first time, reports that SNW1, along with other NK regulatory genes, plays an important role in RA pathogenesis and might act as potential biomarker for RA. Additionally, these genes might play important roles in RA pathogenesis, as well as facilitate the development of effective targeted therapies. Our integrative data analysis and network-based methods could accelerate the identification of novel drug targets for RA from high-throughput genomic data.

Skeletal phenotype/genotype in progressive pseudorheumatoid chondrodysplasia

BACKGROUND

Axial and extra-axial deceleration in function and progressive joint pain with subsequent development of antalgic gait associated with swellings, and stiffness of the joints with loss of the physiological spine biomechanics were the natural history in this group of patients. Clinical and radiological phenotypes have been analysed carefully to further understand the aetiology behind.

METHODS

Seven patients (three children around the age of 9-11 and one child of 17 years old). Three adults aging 25, 30, 33 and 40 years old were seen and examined. The paediatric group of patients were initially diagnosed with myopathy followed later by juvenile rheumatoid arthritis in other institutions. Clinical and imaging documentation were collected in our departments, followed by mutation screening, was carried out by bidirectional sequencing of the WISP3 gene.

RESULTS

Clinical and radiological phenotypic studies confirmed the diagnosis of progressive pseudorheumatoid chondrodysplasia. A constellation of abnormalities such as early senile hyperostosis of the spine (Forestier disease), osteoarthritis of the hips showed progressive diminution and irregularities of the hip joint spaces associated with progressive capital femoral epiphyseal dysplasia and coxa vara have been encountered. Loss-of-function homozygous mutations (c.667T>G, p.Cys223Gly) and (c.170C>A, p.Ser57*) in the WISP3 gene were identified in our patients.

CONCLUSION

The definite diagnosis was not defined via vigorous myopathic and rheumatologic investigations. Detailed clinical examination and skeletal survey, followed by genotypic confirmation, were our fundamental pointers to rule out the false diagnosis of juvenile rheumatoid arthritis and rheumatoid polyarthritis in the adult group of patients. We wish to stress that the clinical/radiological phenotype is the baseline tool to establish a definite diagnosis and to guide the geneticist toward proper genotype.Key Points•Joint pain and difficulties in walking/climbing the stairs are characteristic features encountered in early childhood. False diagnosis of juvenile rheumatoid arthritis can be made at this point.•False positive-like muscular wasting resembling myopathy results in ensuing vigorous troublesome investigations.•Flattened vertebral bodies associated with defective ossification of the anterior end plates are characteristic features of progressive pseudorheumatoid chondrodysplasia.•Joint expansions, which are usually accompanied by narrowing of the articular ends of the appendicular skeletal system, show a clear radiological phenotype of pseudorheumatoid chondrodysplasia.