Correlation of Disease Activity Scores and Routine Assessment of Patient Index Data (RAPID3) on a Multidimensional Health Assessment Questionnaire in Patients With Rheumatoid Arthritis: A Saudi Experience

Introduction This study aimed to analyze the correlation between Routine Assessment of Patient Index Data (RAPID3) and disease activity scores using the Disease Activity Score 28 (DAS28 erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP)), Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI) in patients with rheumatoid arthritis (RA) attending a single rheumatology center in Jeddah. Methods A cross-sectional study of patients with RA who fulfilled the 2010 American College of Rheumatology criteria for the diagnosis of RA between June 2018 and November 2019 was conducted. The validated Arabic version of the multidimensional health assessment questionnaire (MDHAQ) was used. The data collected included demographic information, comorbid illnesses, concomitant medications, laboratory results, and disease activity measured using the DAS 28 ESR/CRP, CDAI, SDAI, and RAPID3. Results A total of 137 patients with RA were included in the analysis; the mean age was 53.1 (± 12) years, there were 122 (89%) females, and the mean disease duration was 8 (± 4) years. Forty-nine (44.5%) patients were treated with anti-tumor necrosis factor (anti-TNF), 53 (48.2%) with non-anti-TNF, 8 (7.3%) with Janus kinase (JAK) inhibitors, and 27 (20%) with synthetic disease-modifying drugs (sDMARD). The mean RAPID3 (0-10) score was 3.6 (± 2) for low disease activity. The mean DAS28 ESR was 4.16 (± 4) for moderate disease activity. The mean DAS CRP was 3.39 (± 1.2) for moderate disease activity. The mean CDAI was 13.4 (± 10.7) for moderate disease activity. The mean SDAI was 15.34 (± 11.8) for moderate disease activity. Pearson's correlations showed a strong correlation with DAS28 CRP (r=0.773, p < 0.001), SDAI (r=0.764,p < 0.001), CDAI (r=0.710, p < 0.001), and DAS28 ESR (r=0.283, p < 0.002). Conclusion RAPID3 significantly correlated with DAS28-CRP, SDAI, and CDAI scores in our patients. It is a simple, inexpensive, and patient-centered practical tool for assessing disease activity that can reflect the health-related quality of life and be easily implemented in clinical practice.

Recommendations for the treatment of rheumatoid arthritis in Saudi Arabia: adolopment of the 2021 American College of Rheumatology guidelines

BACKGROUND

The 2021 American College of Rheumatology (ACR) rheumatoid arthritis (RA) guideline considers the specific context of the United States which differs from that of Saudi Arabia in many aspects that may impact recommendations. The objective of this project was to adapt a set of prioritized recommendations from the 2021 ACR guideline for the treatment of rheumatoid arthritis RA for the context of Saudi Arabia, by the Saudi Society for Rheumatology (SSR).

METHODS

The process followed the GRADE-ADOLOPMENT methodology, and the reporting adhered to the RIGHT-Ad@pt checklist. Working groups included a coordination group and a 19-member panel representing different stakeholder groups. The Evidence to Decision (EtD) tables included evidence on health effects from the source guideline and contextual information from the Saudi setting.

RESULTS

The panel prioritized and adapted five recommendations from the source guideline. The process led to modifying two out of the five prioritized recommendations, all listed here. In naive patients with low disease activity, methotrexate (MTX) is conditionally recommended over sulfasalazine (SSZ) (modified direction); hydroxychloroquine (HCQ) is conditionally recommended over SSZ (unmodified). Initiation of csDMARDs with short-term glucocorticoids is conditionally recommended over csDMARDs alone in naive patients with moderate to high disease activity (modified direction). Switch to subcutaneous MTX is conditionally recommended over addition/switch to alternative DMARD(s) in patients taking oral MTX who are not at target (unmodified). Discontinuation of MTX is conditionally recommended over gradual discontinuation of the bDMARD or tsDMARD for patients taking MTX plus a bDMARD or tsDMARD who wish to discontinue a DMARD (unmodified).

CONCLUSION

Rheumatologists practicing in Saudi Arabia can use the adoloped recommendations generated by this project while adopting the rest of the recommendations from the 2021 ACR guidelines.

From Symptoms to Diagnosis: An Observational Study of the Journey of SLE Patients in Saudi Arabia

Background and Objectives

Early diagnosis and treatment is associated with improved outcomes in patients with systemic lupus erythematosus (SLE). Studying the journey of SLE patients in Saudi Arabia is essential to direct future health-care plans.

Patients and Methods

This is a cross-sectional, multicenter study. Eligibility criteria included a diagnosis of SLE that was confirmed by a rheumatologist. Patients younger than 18 at the time of interview were excluded. Primary objectives were to determine time from first symptoms to initial physician visit (Lag 1), time from initial physician visit to encounter with rheumatologist (Lag 2), time from first visit to a rheumatologist to diagnosis of SLE (Lag 3), and time from diagnosis to start of treatment (Lag 4). Secondary objectives were to determine the number and specialty of physicians seen by patients, the speciality type that confirmed the diagnosis, first symptoms experienced, and age at first diagnosis of SLE.

Results

Three hundred patients (92.3% women) with SLE were evaluated. Mean age at diagnosis was 29.92 years. Mean disease duration was 8.1 years. The majority were college educated (43.0%). The most common initial symptom was joint pain (68%), followed by skin rash (23%), and fever (3.7%). Lag 1 was less than one month in 68.2% of patients. Lag 2 was less than one month in 33.4% of patients and exceeded one year in 25.8%. Lag 3 was less than 1 month in 68.7% of patients. Lag 4 was less than one month in 94.4% of patients. The diagnosis of SLE was made most frequently by rheumatologists (80%). Evaluation by primary care, orthopedic and dermatology physicians were associated with delays in diagnosis.

Conclusion

Delay was marked in Lag 2. Causes of delay included evaluation by non-specialists and visiting higher numbers of physicians before diagnosis confirmation.

Adverse Impact of Rheumatoid Arthritis on Pregnancy Outcomes: A Saudi Arabia Prospective Multicenter Study

Background

Rheumatoid arthritis (RA) is associated with adverse pregnancy outcomes and postpartum complications, especially with severe disease activity.

Objective

The current study aimed to compare the pregnancy outcomes in patients with RA and healthy controls as well as to assess the impact of disease-related variables, medications and disease activity on pregnancy and neonatal-related outcomes in the Saudi population.

Methods

This prospective multicenter study included pregnant female patients with RA from three tertiary centers in Saudi Arabia. The demographics, disease activity scoring (DAS28-CRP), medication before and during pregnancy, pregnancy-related outcomes, and complications in comparison to age-matched healthy female controls were noted.

Results

A total of 77 pregnant patients with RA and 250 healthy age-matched pregnant controls were included in the study. A total of 67.53% were in remission before conception (DAS28CRP ≤2.6), and 81.8% of pregnancies were planned. Age of conception, preterm labor, neonatal intensive care unit (NICU) admission and low birth weight were statistically significant (p <0.05) and higher in RA patients than in healthy controls. Longer disease duration (p <0.001), and high C-reactive protein and erythrocyte sedimentation rate levels before conception (p ≤0.001) were statistically associated with preterm NICU admission. There was statistically significant association between mild (p = 0.015) or moderate to severe DAS28-CRP (p = 0.001) and RA patients regarding pregnancy outcomes. The classification table obtained from the logistic model showed patients with mild and moderate-severe DAS28-CRP have significantly high chances of having an adverse pregnancy outcome.

Conclusion

RA has a negative impact on pregnancy-related outcomes. Higher disease activity is considered a major risk; thus, tight disease control should be aimed. Planned pregnancy follow-up is associated with better pregnancy outcomes.

AB0366 DIFFUSE ALVEOLAR HEMORRHAGE IN LUPUS NEPHRITIS PATIENTS: MULTICENTER RECTROSPECTIVE STUDY

Background:

Diffuse alveolar hemorrhage (DAH) is a rare and potentially lethal complication of systemic lupus erythematosus (SLE) with a high mortality rate. It occurs more frequently in patients with lupus nephritis (LN).

Objectives:

The aim of our study is to explore the characteristics of patients that develop DAH with lupus nephritis, risk factors that predispose DAH, treatment response and outcomes.

Methods:

Multicenter retrospective cohort study was undertaken including 6 centers in Saudi Arabia from 2002 to 2018. Systemic lupus erythematosus patients meeting the SLICC criteria with lupus nephritis (biopsy proven or proteinuria or renal impairment due to lupus) presenting with diffuse alveolar hemorrhage (fulfilling a predefined criteria) were included in the study. An identical number of control group with lupus nephritis was also studied. Data was obtained from medical records by using a data sheet: demographics including age, gender, diagnosis, date of diagnosis of lupus, date of presentation of alveolar hemorrhage, clinical presentation, detection of alveolar hemorrhage proved by radiology, lavage or biopsy and laboratory parameters: including level of hemoglobin before and during DAH, sign of activity, treatment and outcome of DAH. Identification of risk factors predisposing to DAH in lupus nephritis patients was analyzed.

Results:

We identified 23 cases of DAH with lupus nephritis, all fulfilling the criteria. Mean age at presentation of DAH was 31.09 ± 12.6 years ranging from 14-57 years, of which 87 % were females. 13 patients 56.5% had Class 4 LN and 21.7% had Class 4 and 5 LN on renal pathology. DAH occurred at a mean of 6.5 years ±3.8 in 13/23 patients with LN. Shortness of breath 95%, new chest x ray finding 95.7% and mean drop of haemoglobin of 2.72 gm/dl ±0.97 were more frequent at presentation of DAH with LN patients. High SLE disease activity - SELENA SLEDAI 2K was 38.56 ±19.3 was present at the onset of DAH. All were treated with methyprednisone,15/23 (65.2%) underwent mechanical ventilation and plasmapheresis was done in 21/23 patients (91.3%). Cyclophosphamide was given in 14/21 patients (60.9%), Intravenous immunoglobulins were given in 14/23 patients (65.2%) and dialysis was done in 12/23 patients (52.2%). Mortality occurred 8 patients 34.8 %. In comparison with the LN group, a mean haemoglobin of 7.56 ± 1.3, CNS involvement, vasculitis and fever>38% were of statistically significance P value: <0.001,0.02,0.03 and 0.03 respectively.

Conclusion:

In this multicenter cohort series with DAH in LN patients CNS involvement, vasculitis and fever>38 were associated in the occurrence of DAH. Mortality was low in our cohort in comparison to previous series which may be explained by early diagnosis and use of aggressive management.Well designed prospective studies are required to identify high risk patients for preventing this serious complication.

References:

[1]Eagen JW, Memoli VA, Roberts JL, et al. Pulmonary hemorrhage in systemic lupus erythematosus. Medicine (Baltimore) 1978; 57:545.

[2]Badsha H, Teh CL, Kong KO, et al. Pulmonary hemorrhage in systemic lupus erythematosus. Semin Arthritis Rheum 2004; 33:414.

[3]Zamora MR, Warner ML, Tuder R, Schwarz MI. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome. Medicine (Baltimore) 1997; 76:192.

[4]Hsu BY, Edwards DK 3rd, Trambert MA. Pulmonary hemorrhage complicating systemic lupus erythematosus: role of MR imaging in diagnosis. AJR Am J Roentgenol 1992; 158:519.

Disclosure of Interests:

None declared

Biological therapy in arthritis patients with hepatitis B or C infection: a multicenter retrospective case series

Objective

Reactivation of viral hepatitis B (HBV) and C (HCV) has been reported in various case reports of patients with arthritis on biological therapy. The objective of this study was to describe the clinical characteristics and outcomes of arthritis patients with HBV or HCV treated with biological therapy.

Material and Methods

This is a retrospective case series including all patients above 13 years of age with arthritis patients from four centers in Saudi Arabia with concurrent chronic viral hepatitis infection (HBV or HCV) who received biological agents in the rheumatology clinics during their course of their disease from duration of the disease onset until last outpatient visit up to November 2015. Demographic information, full details about the hepatitis status of each patient, rheumatic disease diagnosis and different therapies used were reviewed.

Results

We identified 10 cases each with HBV and HCV on biological therapy. The mean age in the HBV group was 51 (34-85) years and 80% were females. Eight patients had rheumatoid arthritis (RA), one patient had RA/systemic lupus erythematosus, and one had human immunodeficiency virus related-arthritis. Seven were chronic inactive HBsAg carriers and three had chronic active HBV. Nine HBV patients received prophylactic antiviral therapy. Two cases with chronic HBV had reactivation with no elevation of the transaminases.The mean age in the HCV group was 54 (23-79) years and all were female RA patients. Three had detectable hepatitis C virus-ribonuecleic acid (HCV-RNA) before the start of biological therapy. Nine HCV patients received antiviral treatment and seven had a sustained virologic response (SVR) before start of biological treatment. Three patients had detectable HCV-RNA during the course of biological therapy. One of the three was a non-responder and two were relapsers. One of the patients with HCV relapse was started on sofosbuvir plus ribavirin and achieved SVR on follow-up.

Conclusion

We report the successful use of biological therapy in arthritis patients with hepatitis B infection with antiviral therapy with no detoriation of their viral status. Due to the lack of sufficient prospective studies demonstrating the rate of HCV flare on biological therapy, caution should be exercised and careful monitoring with liver enzymes and viral load is mandated in vulnerable HCV RNA patients. Treatment should be individualized by the rheumatologist in collaboration with the hepatologist to minimize complications.

Clinical characteristics and outcomes of cancer patients with post-chemotherapy arthritis: a retrospective case series report

OBJECTIVE

The objective of this report was to describe the demographics, clinical characteristics and outcomes of patients with cancer presenting with arthritis following chemotherapy in Jeddah, Saudi Arabia.

PATIENTS AND METHODS

This is a retrospective case series report. We included any patient ≥18 years of age with an established diagnosis of cancer who had received standard therapeutic intervention and was subsequently diagnosed with arthritis after developing rheumatic symptoms either during or after treatment. Patients with clinical evidence of arthritis at the time of their cancer diagnosis were excluded.

RESULTS

Seven cases from different centers were identified. Breast cancer was the most common type of cancer reported. The diagnosis of arthritis was established by a rheumatologist. Bilateral involvement of the metacarpophalangeal and proximal interphalangeal joints was the most common presentation. The knee, back, shoulder and wrist joints were less affected. Following treatment, one patient experienced complete resolution of symptoms, four patients symptomatically improved and one patient had no improvement.

CONCLUSION

Arthritis can develop both during and after treatment of a malignancy. Solid tumors seem to be more commonly associated with this phenomenon. In this case series, the prognosis was poor as the majority of patients developed persistent arthritis.

Challenges of diagnosis and management of axial spondyloarthritis in North Africa and the Middle East: An expert consensus

Axial spondyloarthritis (SpA) is a spectrum of inflammatory disease with stages characterized by both nonradiographic and radiographic sacroiliitis. Nonradiographic axial SpA is associated with health-related quality-of-life impairment and may progress to ankylosing spondylitis. Axial SpA has a low prevalence in some countries in North Africa and the Middle East, and pooling of data and resources is needed to increase understanding of the regional picture. Early diagnosis and effective treatment are required to reduce disease burden and prevent progression. Anti-TNF therapy is recommended for patients with persistently high disease activity despite conventional treatment, and has been shown to be effective in patients without radiographic damage. Diagnostic delays can be an obstacle to early treatment and appropriate referral strategies are needed. In some countries, restricted access to magnetic resonance imaging and anti-TNF agents presents a challenge. In this article, a group of experts from North Africa and the Middle East evaluated the diagnosis and management of axial SpA with particular reference to this region.