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Clin Rheumatol (2008) 27:739-742DOI 10.1007/s10067-007-0782-z Rheumatoid arthritis in the United Arab Emirates Humeira Badsha & Kok Ooi Kong & Paul P. Tak Received: 12 September 2007 / Revised: 10 October 2007 / Accepted: 14 October 2007 / Published online: 1 November 2007 Abstract Studies have shown that patients with rheuma- were not on DMARD, only 28.1% had disease duration less toid arthritis (RA) in the Middle East have delayed than 1 year (p=<0.01). Erosions were present in 55.2% of diagnosis and low disease-modifying anti-rheumatic drug patients with available X-rays, and deformities in 26% of (DMARD) utilization. We describe the characteristics and patients. There were no racial differences in disease treatments of consecutive RA patients presenting to a new characteristics. The UAE has a unique population with musculoskeletal clinic in Dubai, United Arab Emirates many races residing in the country. Among the first 100 (UAE). Demographic and clinical data were collected over consecutive patients seen at our clinic, there were no a 10-month period at the first visit to our clinic for patients significant differences in disease characteristics with the meeting the American College of Rheumatology (ACR) majority of the patients having very active disease, delayed criteria for RA. A total of 100 patients were seen: (average± diagnosis, and not being treated with DMARDs.
SD) age 42.2±12.3 years; female 87%; Arabs 38%, Indian36%, Caucasian and others 26%; 73% rheumatoid-factor Keywords Arab. Disease activity. Gulf. Indian.
positive; years since diagnosis: 3.9±5.7; lag time between Middle East. Rheumatoid arthritis. Treatment symptom onset to diagnosis 1.2±1.3 years and lag time tofirst DMARD was 1.6±2.0 years. Mean tender joint countwas 8.9± 7.9, mean swollen joint count 9.0±7.6, mean pa- tient's global assessment of disease activity 57.4±25.0 mm,mean ESR 33±25 mm/h, mean DAS28 5.2±1.6, physician Information on rheumatoid arthritis (RA) among Arab global assessment 55.0±23.8. Only 43% were on DMARDs populations in the Middle East is very scarce. Studies have (25% MTX, 5% TNF blockers). Among the patients who suggested that patients with RA living in Arab countrieshave similar clinical features but less extraarticular manifes-tations, compared to Western countries ]. These studies were mainly descriptive and noted a general lack of extra- articular features and a trend towards being less destructive and erosive compared to disease patterns observed in the Level 50, Emirates Towers, P.O. Box 118855, west. However, there is a paucity of information regarding Dubai, United Arab Emiratese-mail: humeira.badsha@dbaj.ae disease activity, treatment, and outcomes. Obviously, suchinformation is critical for decision making in health care. Our Center has had preliminary data showing that patients with Department of Rheumatology, Allergy and Immunology, RA in the United Arab Emirates (UAE) have active disease, Tan Tock Seng Hospital,Singapore, Singapore delayed diagnosis, and low DMARD utilization [There-fore, the aim of our study was to prospectively gather data on patients with arthritis meeting American College of Division of Clinical Immunology & Rheumatology, Rheumatology (ACR) criteria for the diagnosis of RA Academic Medical Center, University of Amsterdam,Amsterdam, The Netherlands and confirm and extend our previous findings.
formed using the Intercooled STATA 8.2 for Macintosh(Stata Corporation, College Station, TX, USA).
Data were collected in the Dubai Bone and Joint Center(Dubai, UAE), a new multi-disciplinary musculoskeletalcenter in the Middle East, over a 10-month period onconsecutive patients over the age of 16 who fulfilled at their first visit to our clinic the ACR classification criteria forRA. Demographics features such as age, sex and ethnicity, Patient characteristics and disease activity insurance, employment, and clinical data including lag timefrom symptom onset to diagnosis, disease duration and A total of 100 consecutive RA patients were seen from disease-modifying anti-rheumatic drugs (DMARDs) use, February 2006 to December 2006. The patients were seen and date of first use were recorded for all patients. Patients at a newly established private musculoskeletal practice in had a 28 joint count, patient's and physician's global assess- Dubai, UAE. The patients were predominantly Arab (38%), ment of disease activity, erythrocyte sedimentation rate with 20% being UAE nationals, with others being from other (ESR), clinical disease activity index for RA (CDAI) ], Middle Eastern countries. Other ethnic groups were Indians and disease activity score (DAS28) ] at their first visit.
(36%), Caucasians (19%), Black (5%), and Hispanic (2%).
Data on deformities and erosions were collected as well.
Comparing the Arab, Indian, Caucasian, and other ethnic Erosions were noted on hand and/or feet X-rays, if available groups, there were no significant differences in the lag time at the first visit. Deformities were defined as ankylosed to diagnosis, disease activities, or deformities (Table ).
joints, or joints with standard deformities such as swan neck, Patients were mainly female (87%) and the average age boutonniere or cock-up joints. In addition, extraarticular was 42.2± 12.3 years. Fifty-four patients were working manifestations such as sicca symptoms, rheumatoid nodules, outside the home, and 50% of patients were covered for their eye complications, and anemia (defined as a hemoglobin less medical expenses by health insurance. Seventy-three percent than 11 g/dl) were recorded. Since the data collected were of patients were sero-positive for rheumatoid factor (RF).
part of standard clinical review, ethics approval was not Only 44% of patients had an anti-CCP (cyclic citrullinated required by UAE Ethics Boards and law. For the same peptide) antibody checked and 50% of these were positive.
reason, informed consent was not obtained.
The average disease duration since symptom onset was 5.1±5.9 years, and lag time between symptom onsets to Statistical analysis Continuous data are presented in this diagnosis was 1.2±1.3 years. Only 19% of the patients had report as mean ±standard deviation (SD). Categorical data early onset RA with symptom duration <1 year at pre- are presented as percentage with/without absolute count.
sentation to us. In this cohort, the mean tender joint count at Nonparametric chi-square and Kruskal-Wallis tests were first presentation to our clinic was 8.9±7.9, mean swollen performed for univariate comparisons where appropriate.
joint count was 9.0±7.6, mean ESR 33±25 mm/h, DAS28 Spearman's correlation was done to assess the relationship 5.2±1.6, patient's global assessment of disease activity 57.4± between the lag time from symptom onset to diagnosis and 25.0 mm, physician's global assessment 55.0±23.8, and disease activity. A p-value of <0.05 was considered to be CDAI 29.2±18.0. Only a small minority (12%) of patients statistically significant. All statistical analyses were per- had low disease activity (DAS 28 <3.2).
Table 1 compares the demographics and clinical features between patients with RA of different ethnic groups; none of the variables issignificantly different (p>0.05) DAS28, disease activity score; CDAI, clinical disease activity index; DMARD, disease-modifying anti-rheumatic drug Erosions were present in 55.2% and deformities in 26% which had high disease activity and delays in starting of the patients. However, it must be noted that only 67% of DMARD, the use of methotrexate was much higher at more patients have hands X-rays at the first visit. The main than 68% Recent evidence supports early aggressive deformities seen were found in the wrists, fingers, and treatment of RA with DMARDs and methotrexate [ elbows. Rheumatoid nodules were present only in 4%, sicca Anti-TNF use locally is still also not widespread locally symptoms in 28%, and anemia (hemoglobin <11 g/dl) in 22%.
(5% in contrast to 40% in the USA and up to 54% in We found that there was a positive relationship between France) , ]. Anti-TNF drugs have been proven to be increased lag time to diagnosis from symptom onsets and more effective in combination with methotrexate in higher DAS28 scores (ρ=0.22, p=0.03). However, the inducing remission, preventing radiological progression disease duration since diagnosis did not show any significant and even in reducing mortality due to RA -Our relationship with DAS28. There was also a positive cor- study also showed a statistically significant difference in the relation between RF seropositivity and the presence of DAS28 scores between patients taking DMARDs versus deformity (p=0.04) but not with the presence of erosions (p>0.1). Those with deformity had significantly longer We also found a significant lag time between symptom disease duration (11.0±7.7 vs 3.0±3.2 years, p<0.01).
onsets to diagnosis as well as lag to first DMARD beinginitiated. There is now evidence that the best predictor of response to therapy in RA is symptom duration. Andersonet al. [showed that patients with disease duration less Importantly, only 43% of the patients were on DMARDs than 12 months had a 53% response rate to treatment at presentation (among patients who had symptoms for whereas those with longer disease duration had a diminish- 1 year or longer (n=81) only 50% were on DMARDs): ing response. In the QUEST RA study delay to start 25% were on methotrexate (an additional 11% had received DMARDs from symptom onset was 9 months with some MTX in the past), 18% on sulfasalazine, 13% on hydroxy- countries such as Netherlands having a mean delay of only chloroquine, 7% on leflunomide, and 5% on anti-TNF 5 months []. Our mean lag time to first DMARD was blockers, 1 patient each on gold, azathioprine, and cyclo- phosphamide. Among patients not currently on DMARD We are a private clinic and the majority of our patients (n=57), only 28.1% had early RA with symptoms less than are referred from primary care physicians or orthopedic 1 year (p=< 0.01). The patients currently on DMARD had doctors, in addition to self-referrals. Patients do not require lower DAS28 scores (4.8±1.6) than those not on DMARD referrals to see specialists but lack of awareness of the need (5.6±1.5, p=0.03). Lag time to first DMARD was 1.6± to see rheumatologists limits early diagnosis. The majority 2.0 years. Steroids were used at any point in 51% of pa- of our patients who had delayed diagnosis had in fact tients. Data on cumulative steroid doses was not collected.
sought medical attention but did not usually see a Data on DMARD combinations was not collected.
rheumatologist initially. There were no significant racialdifferences in disease activity or delay in diagnosis. Thereare about 15 rheumatologists in the UAE, caring for a population of 4 million. Although there is some reason tobelieve that Asians may have a lower prevalence of RA, we Previous reports have suggested RA in Arab patients to be have assumed a prevalence of RA of about 0.75-1% as mild and nondestructive. However, the present study suggested in studies in neighboring countries clearly shows that patients had very active disease with This would imply a shortage of rheumatologists in the mean DAS28 scores of 5.2, compared to 3.2 in USA, and UAE. Care by a rheumatologist increases the possibility of 3.0 in the Netherlands []. In the QUEST RA study, only 3 countries out of 15 had similarly high DAS28 scores There are many different types of healthcare options in (Poland, Serbia, and Argentina) Despite having active the UAE. The Government hospitals provide free health disease, the majority of patients were not being treated with care at Government hospitals to the citizens of the UAE, DMARDs; only a small minority was receiving methotrex- who are, however, a minority (20% of total UAE popula- ate. Even among patients who had symptoms for 1 year or tion). In addition, there are private hospitals and clinics that longer (n=81), only 50% were on DMARDs. This is in provide rheumatology care. Mandatory health insurance contrast to trends in the USA and Europe which now puts coverage is not widespread yet, with less than 50% of the DMARD use over 80%, with methotrexate being the most population having access to insurance coverage. We are not commonly prescribed of the DMARDs (52-85% in the sure how the lack of insurance coverage or a third party USA vs 27% in our study) Even in the countries payer in 50% of patients in the UAE influences their mentioned above such as Poland, Argentina, and Serbia, decisions to seek specialist care. It is unclear how cultural beliefs and use of complementary and alternative treatments 4. Alballa SR (1995) The expression of rheumatoid arthritis in Saudi are influencing the delayed diagnosis and lower DMARD Arabia. Clin Rheumatol 14(6):641-645, Nov 1995 5. Badsha H, Kong KO, Tak PP (2007) Rheumatoid arthritis in use among our predominantly Asian and Arab cohort.
Dubai-delayed diagnosis and low usage of disease modifying Although there are data suggesting that a majority of Indian antirheumatic drugs. Ann Rheum Dis 66(6):835, Jun 2007 patients use complementary and alternative treatments, no 6. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, data are available for the Middle East ].
Cooper NS et al (1988) The American Rheumatism Association1987 revised criteria for the classification of rheumatoid arthritis.
It is known that the occurrence and manifestations of RA Arthritis Rheum 31(3):315-324, Mar 1988 are temporally and geographically variable, but in our study, 7. Smolen JS, Breedveld FC, Schiff MH, Kalden JR, Emery P, Eberl G we have not found major racial differences. ] Our cohort et al (2003) A simplified disease activity index for rheumatoid reflects the ethnic background of the UAE, where 40% are arthritis for use in clinical practice. Rheumatology (Oxford) 42(2):244-257, Feb 2003 expatriates from India, Pakistan and Bangladesh, 20% are 8. Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Arabs from the UAE, 15% are Arabs from other countries, Putte LB, van Riel PL (1995) Modified disease activity scores that and 15% are Caucasians, blacks and others. ( include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoidarthritis. Arthritis Rheum 38(1):44-48, 1995 Jan ). However, our numbers are limited, and while our 9. Sokka T, Kautiainen H, Toloza S, Makinen H, Verstappen SM, study may reflect a trend in disease activity and treatment Hetland ML et al (2007) QUEST-RA: Quantitative clinical assess- patterns in the UAE, it cannot be considered representative ment of patients with rheumatoid arthritis seen in standard rheuma- of the entire UAE population. On the other hand, this is one tology care in 15 countries. Ann Rheum Dis 66:1491-1496, Apr 2007 10. Michaud K, Wolfe F (2006) Trends in mEdication Use by 10,982 of the more comprehensive studies with disease activity Rheumatoid Arthritis patients in the United States from 1998-2005: scores and DMARD utilization from the Arab States.
Biological Use now at 40%. Ann Rheum Dis 65(Suppl II):311 We wish to acknowledge some important limitations of 11. Nurmohamed MT, Dijkmans BA (2005) Efficacy, tolerability and our study. HAQ scores have not been collected as there was cost effectiveness of disease-modifying antirheumatic drugs andbiologic agents in rheumatoid arthritis. Drug 65(5):661-694 a need to have validated/translated questionnaires in the 12. Verstappen SM, Jacobs JW, Bijlsma JW, Heurkens AH, van Booma- multiple languages spoken in the UAE. Almost one third of Frankfort C, Borg EJ et al (2003) Five-year followup of rheumatoid patients have not had X-rays at their first visit, and this was arthritis patients after early treatment with disease-modifying anti- mainly because the majority of our patients are either self- rheumatic drugs versus treatment according to the pyramid approachin the first year. Arthritis Rheum 48(7):1797-1807, Jul 2003 paying or have to pay and get reimbursed through their 13. Breedveld FC, Weisman MH, Kavanaugh AF, Cohen SB, Pavelka insurance. Many of our patients went on to have X-rays at K, van Vollenhoven R et al (2006) The PREMIER study: A later stages but this was not reflective of their condition at multicenter, randomized, double-blind clinical trial of combination the time of the first visit to us. We do not have data on therapy with adalimumab plus methotrexate versus methotrexatealone or adalimumab alone in patients with early, aggressive cumulative prednisolone use, and this was mainly due to rheumatoid arthritis who had not had previous methotrexate treat- difficulty in obtaining past records on the majority of our ment. Arthritis Rheum 54(1):26-37, Jan 2006 patients who are expatriates and have had some of their 14. Michaud K, Wolfe F (2005) Reduced Mortality among RA care in other countries. Sicca symptoms were not further Patients Treated with Anti-TNF Therapy and Methotrexate. AnnRheum Dis 64(Suppl III):87, 2006 verified, and this was again an issue of affordability.
15. St Clair EW, Van der Heijde DM, Smolen JS, Maini RN, Bathon JM, It is interesting to note that the various races had no Emery P et al (2004) Combination of infliximab and methotrexate difference in disease severity or DMARD use. Although we therapy for early rheumatoid arthritis: a randomized, controlled trial.
cannot make assumptions on rheumatological care in the Arthritis Rheum 50(11):3432-3443, Nov 2004 16. Anderson JJ, Wells G, Verhoeven AC, Felson DT (2000) Factors UAE, our impression is that our patients had been predicting response to treatment in rheumatoid arthritis: the impor- inadequately treated, and this could have consequences for tance of disease duration. Arthritis Rheum 43(1):22-29, Jan 2000 their joint and general health in the future.
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