10Rheumatoid arthritis in the developing world
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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