Rheumatoid arthritis in the developing world

doi:10.1016/S1521-6942(03)00047-0

Best Practice & Research Clinical Rheumatology

Volume 17, Issue 5, October 2003, Pages 863-875

https://doi.org/10.1016/S1521-6942(03)00047-0 Get rights and content

Abstract

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-α 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.

Section snippets

Epidemiology

With the exception of Jamaica—with a prevalence of 2%—RA is less common in developing countries (<0.5% prevalence), such as South Africa, Nigeria, Indonesia, Pakistan, China, the Philippines and Argentina, compared to Western populations (1%). In South Africa, there is evidence of an urban–rural gradient, with virtually no cases reported in some rural areas and a 0.9% prevalence in an urban Black South African population. In Indonesia, the prevalence in rural areas is 0.2% compared with 0.3% in

Natural history and burden of disease

Little is known about the natural history of RA in the developing world due to the paucity of longitudinal outcome studies. Many earlier cross-sectional studies emphasized the mildness of RA, with few extra-articular manifestations, but more recent surveys indicate that the occurrence of severe disease is not uncommon.22., 23. In a hospital-based outpatient report of Mapuche aborigines and Chilean natives, 46.9% were found to be severely disabled, with a functional classification of class III

Current approaches

The experience with conventional DMARDs in developing countries is not significantly different from that in the industrialized world.20., 22., 23. Drugs such as gold preparations, D-penicillamine, chloroquine (CQ), sulphasalazine (SSZ) and methotrexate (MTX) have been used extensively in the treatment of RA, even in the developing world. However, most patients either do not have access to DMARDs or are treated sub-optimally for a variety of reasons. The concept of ‘shared-care’ of RA between

New therapies

The introduction of biological agents targeted specifically against TNF-α (infliximab, etanercept, adalimumab) and, to a lesser extent, IL-1 receptor antagonist (anakinra) has revolutionized the practice of rheumatology in many industrialized countries.¹ These highly effective agents have been shown to improve quality of life and disease progression in both patients with refractory RA and those with early disease. While they are very effective in controlling symptoms and progression, they do

Future research and proposed solutions

The research agenda for the treatment of RA in developing countries needs to focus on the evaluation of additional drugs with DMARD potential, studying and documenting the risks of using biologicals in these regions, elucidating possible aetiological mechanisms for disease in developing countries, quantifying the health burden of RA with respect to the direct, indirect and intangible costs of the disease and looking at innovative combination approaches to the treatment of RA.

There is an urgent

Summary

The challenges that face rheumatologists managing RA in the developing world are in many respects very different from those in the industrialized world. Developing countries face several difficulties with respect to the use of the newer biological therapies for the treatment of RA. These difficulties relate to the exorbitant cost of the drugs, as well as the potential for exacerbation and dissemination of infections such as TB. The use of traditional DMARDs is similarly influenced by

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Implications of a diagnosis of rheumatoid arthritis in resource-poor countries
2022, Best Practice and Research: Clinical Rheumatology
Citation Excerpt :
The use of biologic and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) in the developing world is often hampered by their prohibitive cost. Patients in low-income countries often pay for healthcare themselves, with the resultant inability of many patients in need to access biologics [6]. This review discusses the implication of a diagnosis of RA in terms of early diagnosis, treatment, screening for infections, and other comorbidities in resource-poor countries.
Rheumatoid arthritis (RA) is a multisystemic autoimmune disease that predominantly affects synovial joints. It causes marked disability, reduces health-related quality of life, and leads to high mortality. The diagnosis of RA is often made by standard criteria, and the management of this condition is usually undertaken according to the established guidelines. In resource-poor settings, the diagnosis and management of RA are hampered by diverse factors such as late presentation, inadequate trained personnel, poor healthcare infrastructure, low socioeconomic status, poor access to both conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics, and a high burden of infectious diseases such as tuberculosis, hepatitis, and human immunodeficiency virus. There is a need to establish registries in these settings to provide adequate information on the pattern, medication, and long-term outcome of RA in resource-poor countries in order to provide a practical and evidence-based management guide for rheumatologists, which is appropriate for these settings.
Health Disparities in Rheumatic Diseases: Understanding Global Challenges in Africa, Europe, Latin America, and Asia and Proposing Strategies for Improvement
2021, Rheumatic Disease Clinics of North America
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There is limited availability of epidemiologic information on rheumatic conditions in Africa and SLE, for example, is thought to be rare22 compared with infectious diseases such as human immunodeficiency virus, malaria, and tuberculosis. Therefore, chronic rheumatic diseases have been relegated to the background and given low priority with no support at the country level.23 Safe and standardized management of these diseases requires trained practitioners, and yet the shortage to nonexistence of rheumatologists is a problem.
Management of Rheumatoid Arthritis and the Pharmacist's Role
2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy: Volumes 1-3
Rheumatoid arthritis (RA) is an autoimmune rheumatic disorder resulting in systemic inflammation by targeting the joints of the wrist and/or feet, making them painful, warm, and swollen. The deleterious effects of RA are not restricted to joints or connective tissues, but the heart, eyes, and lungs may also be affected. The expression of the disease is dependent on genetic predisposition and exposure to some undetermined environmental chemicals. The American College of Rheumatology/European League Against Rheumatism have developed criteria for RA classification. The major therapeutic classes of drugs used in RA patients are nonsteroidal anti-inflammatory agents, corticosteroids, biologic and nonbiologic disease-modifying antirheumatic drugs. A multidisciplinary team comprising physicians, nurses, and pharmacists is helpful in managing RA. The pharmacist can play an integral role in medication management, pharmaceutical care provision, as well as the distribution and control of antirheumatic drugs.
Management of rheumatoid arthritis and the pharmacist’s role
2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy
Rheumatoid arthritis (RA) is an autoimmune rheumatic disorder resulting in systemic inflammation by targeting the joints of the wrist and/or feet, making them painful, warm, and swollen. The deleterious effects of RA are not restricted to joints or connective tissues, but the heart, eyes, and lungs may also be affected. The expression of the disease is dependent on genetic predisposition and exposure to some undetermined environmental chemicals. The American College of Rheumatology/European League Against Rheumatism have developed criteria for RA classification. The major therapeutic classes of drugs used in RA patients are nonsteroidal anti-inflammatory agents, corticosteroids, biologic and nonbiologic disease-modifying antirheumatic drugs. A multidisciplinary team comprising physicians, nurses, and pharmacists is helpful in managing RA. The pharmacist can play an integral role in medication management, pharmaceutical care provision, as well as the distribution and control of antirheumatic drugs.
Structural insights into pH-responsive drug release of self-assembling human serum albumin-silk fibroin nanocapsules
2018, European Journal of Pharmaceutics and Biopharmaceutics
Inflammation processes are associated with significant decreases in tissue or lysosomal pH from 7.4 to 4, a fact that argues for the application of pH-responsive drug delivery systems. However, for their design and optimization a full understanding of the release mechanism is crucial.
In this study we investigated the pH-depending drug release mechanism and the influence of silk fibroin (SF) concentration and SF degradation degree of human serum albumin (HSA)-SF nanocapsules. Sonochemically produced nanocapsules were investigated regarding particle size, colloidal stability, protein encapsulation, thermal stability and drug loading properties. Particles of the monodisperse phase showed average hydrodynamic radii between 438 and 888 nm as measured by DLS and AFM and a zeta potential of −11.12 ± 3.27 mV. Together with DSC results this indicated the successful production of stable nanocapsules. ATR-FTIR analysis demonstrated that SF had a positive effect on particle formation and stability due to induced beta-sheet formation and enhanced crosslinking.
The pH-responsive release was found to depend on the SF concentration. In in-vitro release studies, HSA-SF nanocapsules composed of 50% SF showed an increased pH-responsive release for all tested model substances (Rhodamine B, Crystal Violet and Evans Blue) and methotrexate at the lowered pH of 4.5 to pH 5.4, while HSA capsules without SF did not show any pH-responsive drug release.
Mechanistic studies using confocal laser scanning microscopy (CLSM) and small angle X-ray scattering (SAXS) analyses showed that increases in particle porosity and decreases in particle densities are directly linked to pH-responsive release properties. Therefore, the pH-responsive release mechanism was identified as diffusion controlled in a novel and unique approach by linking scattering results with in-vitro studies. Finally, cytotoxicity studies using the human monocytic THP-1 cell line indicated non-toxic behavior of the drug loaded nanocapsules when applied in a concentration of 62.5 µg mL⁻¹.
Based on the obtained release properties of HSA-SF nanocapsules formulations and the results of in-vitro MTT assays, formulations containing 50% SF showed the highest requirements arguing for future in vivo experiments and application in the treatment of inflammatory diseases.
Do out-of-pocket costs affect medication adherence in adults with rheumatoid arthritis? A systematic review
2018, Seminars in Arthritis and Rheumatism
For individuals with a chronic condition, long-term management of their medication can be difficult and as a result non-adherence is common among this cohort. In patients with rheumatoid arthritis (RA), the introduction of biologic agents was a revolutionary treatment but the high costs of this medication might limit their utilisation.
This systematic review aimed to determine whether out-of-pocket (OOP) costs affect adherence to RA medications in adults with a diagnosis of RA.
Twelve databases were searched to identify primary peer-reviewed articles, written in English from inception to April 2016 that referred to the relationship between adherence to RA medication and OOP costs. The CASP check list was used to assess the quality rating of the included studies.
Six articles were identified in the review and all were considered as high quality studies. Among them, three directly considered the association between OOP costs and medication adherence as their main objective. Although the population and the methods of the studies varied widely, there was an inverse relationship between OOP costs and medication adherence in patients with RA.
The findings of this review suggest that OOP costs can contribute to non-adherence to RA medication in patients with RA. Therefore, health policy makers globally should identify the appropriate OOP amount so these costs do not affect adherence whilst simultaneously ensuring that costs are not an intolerable burden for governments, providers and insurers.

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10Rheumatoid arthritis in the developing world

Abstract

Section snippets

Epidemiology

Natural history and burden of disease

Current approaches

New therapies

Future research and proposed solutions

Summary

Baillière's Clinical Rheumatology

The Lancet

The Lancet

American College of Rheumatology subcommittee on rheumatoid arthritis guidelines

Arthritis and Rheumatism

Epidemiology and genetics of rheumatoid arthritis

Arthritis Research

Absence of rheumatoid arthritis in a Nigerian population

Journal of Rheumatology

The prevalence of rheumatic diseases in a Filipino urban population: a WHO-ILAR COPCORD Study. World Health Organisation. International League of Associations for Rheumatology. Community oriented programme for the control of the rheumatic diseases

Journal of Rheumatology

The prevalence of rheumatoid arthritis in affluent and poor urban communities of Pakistan

British Journal of Rheumatology

Rheumatoid arthritis in blacks in South Africa

Annals of the Rheumatic Diseases

The epidemiology of rheumatoid arthritis in Indonesia

British Journal of Rheumatology

Epidemiology and semiology of rheumatoid arthritis in Third World Countries

Review Rheumatologica (English edition)

Low prevalence of rheumatoid arthritis in Chinese

Journal of Rheumatology

Rheumatoid arthritis among Mapuche Aborigines. A 16 years experiment in the IX region of the Chile

Review of Medicine in Chile

Prevalence of rheumatoid arthritis in Tucuman, Argentina

Journal of Rheumatology

10-year epidemiological study on rheumatic diseases in Shantou area

Zhonghua Nei Ke Za Zhi

Rheumatoid arthritis in a rural South African Negro population

Annals of the Rheumatic Diseases

Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis

Seminars in Arthritis and Rheumatism

Responsiveness of Keitel functional index compared with laboratory measures of disease activity in rheumatoid arthritis

British Journal of Rheumatology

A longitudinal study of rheumatoid arthritis in South Africans

Medscape General Medicine

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Journal of Rheumatology

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Tissue Antigens

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Scandinavian Journal of Rheumatology

The pattern of rheumatoid arthritis in West Africa and comparison with a cohort of British patients

Quarterly Journal of Medicine

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Rheumatoid arthritis in the developing world