By Joseph Kabia
The Arthrheuma Society of Kenya has published clinical guidelines aimed at improving healthcare delivery for those suffering from rheumatoid arthritis. The guidelines titled; “Kenya Recommendations for the Management of rheumatoid Arthritis: An algorithm for the standard of care,” is developed by a multi-disciplinary team comprising of Rheumatologists, Physicians, Medical Officers, Physiotherapists, Nurses and Patients based in Kenya, with valuable inputs from consultant professionals.
Rheumatoid arthritis is the commonest inflammatory Polyarthritis seen in clinical practice. The guidelines state that RA is an autoimmune disorder of unknown etiology characterized by symmetrical, erosive synovitis and in some cases, extra-articular involvement. Most RA patients experience a chronic fluctuating course of disease that, despite therapy, may result in progressive joint destruction, deformity, disability and even premature death.
“RA results in more than 9 million physician visits and more than 250,000 hospitalizations per year in the United States of America,” notes the guideline, adding that the prevalence of RA worldwide is one percent of the adult population.
The guidelines state RA is one of the leading causes of morbidity in the developed world but little is known in Africa. “RA is often seen as a minor health problem and has been neglected in research and resource allocation throughout Africa despite emerging experience of severe morbidity and potentially fatal systemic manifestations in Africa as well as the rest of the world,” reads the document in part.
For a long period, Kenya has not had an organized rheumatic service both in hospitals and in the community. The country has not been having adequate resources to effectively diagnose and manage rheumatic disorders. It points out that with the increase in non-communicable diseases (NCDs) in developing countries, an increase in RA occurrence could stress medical services that are already struggling with a high burden of acute infectious illnesses to an extent that they may be unable to cope with the fast-changing patterns of disease distribution seen in Africa today.
“Not only does RA contribute significantly to this burden, but it also contributes by increasing the rate of cardiovascular diseases, certain cancers, and possibly diabetes, RA is also a cause of gender inequality as it predominantly affects women,” says the guidelines. It explores the diagnostic approach to Polyarticular joint pain stating that it poses a diagnostic challenge because of the many differential diagnosis. The guidelines state that many rheumatological laboratory tests lack the desired specificity and so the result should be interpreted in the clinical context and with caution.
“Tests with low specificity, such as those in arthritis panels, are frequently positive in the general population, for example rheumatoid factor, thus some of these tests are misleading,” adding that, “In the absence of definitive rheumatologic laboratory tests, the history and physical examination are key to the early diagnosis and treatment of conditions that cause polyarticular joint pains.”
It recommends that the differential diagnosis can be narrowed through investigation of six clinical factors; disease chronology, inflammation, distribution, extra-articular manifestations, disease course, and patient demographics. In RA diagnosis, the guidelines state, the common symptoms include joint pain and stiffness and when prolonged the disease is associated with psychological problems such as depression. The causes of RA are currently unknown but the guidelines suspect that genetic susceptibility to an environmental trigger could be the most plausible aetiology.
“Various bacteria and virus have been suggested as the initial trigger, with a form of molecular mimicry imitating human antigens activating an immune response against the host’s own cells,” the guidelines state. There are other effects of RA analysed in the document that include extra articular manifestations and mortality, saying that extraarticular manifestations affect the skin, respiratory, cardiac and visual systems.
Specific manifestations may include: Lymphadenopathy, pleural and pericardial effusions, fibrosing alveolitis obliterative bronchiolitis, splenomegaly, vasculitis and Raynaud’s phenomena. In the treatment of RA, the guidelines state that MTX (methotrexate) should be part of the first treatment strategy in patients with RA and if oral MTX (methotrexate) is not tolerated, subcutaneous should be considered.
And in case of MTX contradiction (or early intolerance), Sulfasalazine or leflunomide should be considered as part of the (first) treatment strategy. “In DEMARD (diseasemodifying anti-rheumatic drug), naïve patients irrespective of the addition of glucocorticoids, csDEMARD monotherapy or combination therapy of csDEMARDs should be used,” indicate the guidelines.
The document lists the conventional DMARDS used in the treatment of RA starting with MTX, HCQ SSZ with indications, dosage, side effects, monitoring and contra-indications. It also indicates the Biologic DMARDS in RA which it cautions should be handled at the physician or rheumatologist level, like the newer TNF-Inhibitors that include Certolizub, Golimumab and B-cell agent like Rituximab and T-cell action, Abatacept and IL-6 Inhibitor, Tocilizumab.
The issues of complications and safety are well documented saying that all RA patients are at risk of TB and the risk is increased by drugs used to treat RA that include GCs, MTX and biologic drugs, particularly anti-TNF therapy. There are other effects like bacterial infections and challenges in the management of RA patients who are HIV –positive among others like cardiovascular risk factors.
However, the document stipulates recommendations on every complication and safety concerns in the drug management of RA. The guidelines recommend future research areas to provide answers to optimal RA management in Kenya.