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Rheumatoid arthritis in the developing world

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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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