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      The specialist physician’s approach to rheumatoid arthritis in South Africa

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          Abstract

          Rheumatoid arthritis (RA) is expected to increase in Africa and South Africa. Due to the low numbers of rheumatologists in South Africa, specialist physicians also have to care for patients with RA. Furthermore several new developments have taken place in recent years which improved the management and outcome of RA. Classification criteria were updated, assessment follow-up tools were refined and above all, several new biological disease-modifying anti-rheumatic drugs were developed. Therefore it is imperative for specialist physicians to update themselves with the newest developments in the management of RA. This article provides an overview of the newest developments in the management of RA in the South African context. This approach may well apply to countries with similar specialist to patient ratios and disease profiles.

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          The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.

          D McShane, D. Bloch, Emma Healey … (1988)
          The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a "classification tree" schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91-94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.
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            EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs

            Josef S. Smolen, Robert Landewé, Ferdinand C Breedveld … (2010)
            Treatment of rheumatoid arthritis (RA) may differ among rheumatologists and currently, clear and consensual international recommendations on RA treatment are not available. In this paper recommendations for the treatment of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs) that also account for strategic algorithms and deal with economic aspects, are described. The recommendations are based on evidence from five systematic literature reviews (SLRs) performed for synthetic DMARDs, biological DMARDs, GCs, treatment strategies and economic issues. The SLR-derived evidence was discussed and summarised as an expert opinion in the course of a Delphi-like process. Levels of evidence, strength of recommendations and levels of agreement were derived. Fifteen recommendations were developed covering an area from general aspects such as remission/low disease activity as treatment aim via the preference for methotrexate monotherapy with or without GCs vis-à-vis combination of synthetic DMARDs to the use of biological agents mainly in patients for whom synthetic DMARDs and tumour necrosis factor inhibitors had failed. Cost effectiveness of the treatments was additionally examined. These recommendations are intended to inform rheumatologists, patients and other stakeholders about a European consensus on the management of RA with DMARDs and GCs as well as strategies to reach optimal outcomes of RA, based on evidence and expert opinion.
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              American College of Rheumatology. Preliminary definition of improvement in rheumatoid arthritis.

              D Felson, J J Anderson, M. Boers … (1995)
              Trials of rheumatoid arthritis (RA) treatments report the average response in multiple outcome measures for treated patients. It is more clinically relevant to test whether individual patients improve with treatment, and this identifies a single primary efficacy measure. Multiple definitions of improvement are currently in use in different trials. The goal of this study was to promulgate a single definition for use in RA trials. Using the American College of Rheumatology (ACR) core set of outcome measures for RA trials, we tested 40 different definitions of improvement, using a 3-step process. First, we performed a survey of rheumatologists, using actual patient cases from trials, to evaluate which definitions corresponded best to rheumatologists' impressions of improvement, eliminating most candidate definitions of improvement. Second, we tested 20 remaining definitions to determine which maximally discriminated effective treatment from placebo treatment and also minimized placebo response rates. With 8 candidate definitions of improvement remaining, we tested to see which were easiest to use and were best in accord with rheumatologists' impressions of improvement. The following definition of improvement was selected: 20% improvement in tender and swollen joint counts and 20% improvement in 3 of the 5 remaining ACR core set measures: patient and physician global assessments, pain, disability, and an acute-phase reactant. Additional validation of this definition was carried out in a comparative trial, and the results suggest that the definition is statistically powerful and does not identify a large percentage of placebo-treated patients as being improved. We present a definition of improvement which we hope will be used widely in RA trials.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Intern Med
                Journal ID (iso-abbrev): Korean J. Intern. Med
                Journal ID (publisher-id): KJIM
                Title: The Korean Journal of Internal Medicine
                Publisher: The Korean Association of Internal Medicine
                ISSN (Print): 1226-3303
                ISSN (Electronic): 2005-6648
                Publication date (Print): March 2016
                Publication date (Electronic): 26 February 2016
                Volume: 31
                Issue: 2
                Pages: 219-236
                Affiliations
                [1 ]Department of Internal Medicine, Rosepark Life Health Care Hospital, Bloemfontein, South Africa
                [2 ]Department of Internal Medicine, University of Free State Medical School, Bloemfontein, South Africa
                Author notes
                Correspondence to Frederik C. J. Bester, MBChB Department of Internal Medicine, Rosepark Life Health Care Hospital, Fichmed Suite G5, 53 Gustav Crescent, Fichardt Park, Bloemfontein 9322, South Africa Tel: +27-51-522-1907 Fax: +27-51-522-6951 E-mail: fcjbester@ 123456drbester.co.za
                Article
                Publisher ID: kjim-2015-134
                DOI: 10.3904/kjim.2015.134
                PMC ID: 4773728
                PubMed ID: 26932399
                SO-VID: cff9111a-6a61-4e5c-a3a7-8bd46774ba92
                Copyright © Copyright © 2016 The Korean Association of Internal Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 8 May 2015
                Date accepted : 8 May 2015
                Categories
                Subject: Review

                ScienceOpen disciplines: Internal medicine
                Keywords: rheumatoid arthritis management,biological disease-modifying anti-rheumatic drug,rheumatoid arthritis criteria,south africa
                Data availability:
                ScienceOpen disciplines: Internal medicine
                Keywords: rheumatoid arthritis management, biological disease-modifying anti-rheumatic drug, rheumatoid arthritis criteria, south africa

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