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Keywords:

  • ACCP;
  • Qatar;
  • RA ‘Biologic’ DMARDs;
  • rheumatoid arthritis

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

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.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Rheumatoid arthritis (RA) is a chronic inflammatory disorder affecting primarily cartilage and bone of small and middle-sized joints. In addition, larger joints and several organs such as lungs, blood vessels and the hematopoietic system may be involved.[1] The disease distribution involves all racial and ethnic groups. However, variations in the clinical expression, severity and outcome of the disease among different ethnic groups have been reported.

Few studies have reported prevalence and characteristics of the disease in an Arab population. Studies from Iraq,[2] Kingdom of Saudi Arabia,[3] Kuwait[4] and Lebanon[5] have suggested RA in Arab patients to be mild and nondestructive. These studies were descriptive and did not include disease activity score (DAS) measurement, However. a study from the United Arab of Emirates (UAE) shows that patients had very active disease with mean DAS28 (28 joints) scores of 5.2.[6]

Information about disease activity, treatment and outcomes will help for decision-making in health care. The characteristics of RA in Qatar have not been studied before; we aimed in this outpatient hospital-based study to gather information about RA clinical, radiological and serological characteristics and disease activity, and treatment in Qatar.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

This cross-sectional study was conducted at Hamad General Hospital (HGH), in Dohar, Qatar; HGH is a tertiary care referral center offering free health care services to Qatari patients and for non-Qatari expatriates at a significantly reduced cost with total exemption of payment for some of the costly drugs. Two-third of the 1.5 million population of Qatar are expatriate.

We enrolled 100 consecutive patients who met 1987 American College of Rheumatology classification criteria for the diagnosis of RA. These patients were followed up in a rheumatology outpatient clinic. Consent forms were signed by the patients. Demographic data (sex, nationality and age), number of swollen and tender joints, X-ray findings (which were reported electronically by a radiologist), current and past medications were recorded. DAS 28 was calculated and classified as follows: score of < 2.6 was defined as clinical remission, score from 2.6 to 3.2 corresponded to low disease activity and > 3.2 was consistent with active disease. The disease was considered as severe functional disability if the Health Assessment Questionnaires (HAQ) score was > 1.5.

Statistical analysis was performed using SPSS software (SPSS Inc, Chicago, IL, USA). Descriptive analysis was undertaken for all variables.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

In this study, 100 consecutive patients were collected from September 1, 2011 to March 31, 2012. Among these patients 23% were Qatari and 77% were non-Qatari (59% Asian, 16% African and 2% Western: Table 1). Most patients were female (67%). Mean age of the patients in the study was 47 ± 13.4 years. Rheumatoid factor (RF) was positive in 63%, anticyclic citrullinated peptide antibody (anti-CCP) in 71% and both of them were positive in 49% of cases.

Table 1. Comparison of demographics and clinical features between patients with RA of different ethnic groups
ParameterQatari (%)Asiain (%)African (%)Caucasian (%)
  1. RF, rheumatoid factor; anti-CCP, anti-cyclic citrullinated peptide antibodies; DAS28, disease activity score of 28 joints; ESR, erythrocyte sedimentation rate; DMARD, disease-modifying anti-rheumatic drug.

Female20 (91.3)31 (52.5)13 (81.3)2 (100)
Male3 (18.8)28 (47.5)3 (18.8)0
RF positive13 (56.5)38 (64.4)12 (75)0
Anti-CCP positive16 (69.6)41 (67.1)11 (68.8)2 (100)
Erosions1 (4.3)7 (11.9)2 (12.5)1 (50)
DAS28-ESR (mean)2.85 ± 1.252.86 ± 1.0473.07 ± 0.912.87 ± 0.88
One DMARD16 (69.6)39 (66.1)9 (56.3)2 (100)
Two DMARDs2 (8.7)19 (8.7)6 (37.5)0
Biologics15 (65.2)9 (15.3)4 (25)1 (50)

A very small group of patients had greater than six tender joints (6%) and swollen joints (9%); moreover there was no significant differences in number of tender and swollen joint counts across different populations. Mean DAS28 erythrocyte sedimentation rate (ESR) was 2.91 ± 1.02 and there were no statistically significant differences between the study groups. Almost half of the patients (49%) were in remission (DAS28 < 2.6) and one-third (36%) were in active disease (DAS28 > 3.2). However, a minority of patients (15%) were in low disease activity (DAS28 2.6–3.2).

The mean HAQ score was 1.02 (± 0.60). X-rays of hand and feet were performed on 65% of patients, of whom 11% were found to have erosions.

Sixty-six percent of our patients were on one synthetic DMARD in the last 2 months before being involved in the study, 27% were on two synthetic DMARDs and 7% were not on synthetic DMARDs. Synthetic DMARDs were mostly used in the Asian group (74.8%). Methotrexate was the most commonly used DMARD (75%). It was used alone in 31% or in combination with other synthetic or biologic DMARDs (44%).

Biologic DMARDs were used in 29%: 11% on rituximab, 8% on tocilizumab, 9% on anti-tumor necrosis factor and one patient was on abatacept. Use of biologics was more in the Qatari population (65.2%) and least in Asians (15.3%). Glucocorticoids were used in 51% of patients with dose range of 5–10 mg\day.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

In this cross-sectional study we described the characteristics of RA in Qatar managed on an outpatient base and analyzed the severity and activity of the disease.

Our study showed that the majority of patients was female (67%) and they were more frequently Qataris (91.3%) compared with Asians (52.5%) which reflects the pattern of the Qatar population (most Asians are male). Among all patients, RF was positive in 63%, anti-CCP in 71% and both were positive in 49% which is close to that reported from Kuwait 60%.[4] A comparative study of RA in British and Malaysian patients showed that RF was positive in 65% in each group of patients which is similar to our study.[7]

In our study 64% of patients were either in remission (49% with DAS28 < 2.6) or in low disease activity (15% with DAS28 < 3.2) while mean DAS28-ESR was 2.85 ± 1.047. This is in contrast to a UAE study which showed that only a few patients (15%) were in low disease activity and most of them had high disease activity with mean DAS of 5.2.[6] However, 36% of our patients had moderate to high disease activity with DAS28 > 3.2.

The majority of our patients (93%) were being treated with DMARDs over the last 2 months before enrolment in the study, 66% on one synthetic DMARD and 27% on two. The most common DMARDs prescribed was methotrexate: 31% methotrexate alone and 44% in combination with other DMARDs, which is better than in the UAE study (27%),[6] and is almost same as in a European and USA study (> 80%).[8]

Patients on biologic DMARDs, including anti-TNF (tumor necrosis factor), anti-interleukin-6 and rituximab account for 29% of all our RA patients; however, comparing group of patients, biologics were used in 65.2% in Qatari,15.3% in Asian, 25% in African and 50% in Caucasian patients. Biologics were used more in Qataris because it is free of charge but other nationalities still only pay 20%. In the USA 40% of RA patients are on biologics[8, 9] but in UAE only 5% are on biologic therapy.[6] Anti-TNF drugs have been proven to be more effective in combination with methotrexate in inducing remission and preventing radiological progression.

We found from our study the remission rate is better than reported in other Gulf countries which may be related to more use of anti-TNF in Qatar but is still lower when compared to USA and European studies.[8, 9]

Almost one-third of our RA patients are not well controlled. Some of these uncontrolled patients may have co-morbid conditions which limit the use of synthetic and biologic therapies and other patients may have joint damage due to long-standing diseases and their diseases were acquired in the pre-biologics era.

A limitation of our study is that the sample size was small because the population of Qatar is small and most of our patients were expatriates; moreover, we did not include extra-articular manifestations in our study.

More effort is needed to improve the management provided to our RA patients to tighten the control of their disease.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References