Treatment Management of

Rheumatoid
Arthritis



Findings and In Depth
Analysis
Patients load and monthly
work averages
Findings and In Depth Analysis
Rheumatologists Monthly Work Load
KSA
(n=30)
Monthly Work Load
(AV. Number of
Patients)
Split between new
and Repeated
Patients
Split According to
Disease Severity
(Percentage)
Rheumatoid
Arthritis
Ankylosing
Spondylitis
Psoriatic Arthritis
Juvenile
Rheumatoid
Arthritis
Others
In KSA, Rheumatologists see an average of 346 Patients per
month, out of which 75 are Rheumatoid Arthritis accounting
for 22% of the total , 57 repeated and 18 new cases, the
split of disease severity is 31% mild and 69% moderate to
severe cases of RA
75
12
6
15
238
48%
47%
38%
31%
46%
28%
32%
47%
23%
21%
15%
24%
24%
22%
26%
33%
67%
74%
78%
76%
Understanding RA
Findings and In Depth Analysis
Rating of Importance of Criteria used to classify Disease Severity
(Analysis Used top 2 boxes percentages - KSA)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Number of swelling and tender Joints
ACR (American College of Rheumatology) Criteria
Score
Impact on the patient's quality of life.
Response to current treatment DAS (Disease activity score)
HAQ Scores (Health Assessment Questionnaire)
CRP (Cell Reactive Protein) /ESR (Erythrocyte
Sedimentation Rate) /Anti CCP (Anti Cyclic Citrullinated
peptide)
(n=30)
The most preferred tool used for the Disease Evaluation
(KSA)
28%
22%
50%
ACR (American College of
Rheumatology) Criteria
Score
DAS (Disease activity score)
CRP (Cell Reactive Protein)
/ESR (Erythrocyte
Sedimentation Rate) /Anti
CCP (Anti Cyclic
Citrullinated peptide)
ACR criteria score is the most preferred diagnostic tool, followed by the
DAS and the blood tests respectively. These tools are described as
practical, accurate and of international use.
75%
100%
78%
44%
11%
Reasons for choosing each criteria as the
most suitable (KSA)
60%
80%
20%
Easy and practical Accurate and Objective Internationnally used
DAS, N=5
ACR, N=9
CPR/ESR/ Anti CCP, N=4
Objectives in the management of RA
patients (First mentioned KSA)
28%
22%
17%
11%
11%
6%
6%
0% 5% 10% 15% 20% 25% 30%
Improve patient's quality of life
Relief pain
Induce Remission
Improve Mobility
Relief oedema and swelling
Stop disease activity
Prevent Complication
Improving patients quality of life and reliving the pain are the main
objectives of the management of RA patients
Other mentioned objectives in the management
of RA patients (KSA)
33%
33%
17%
11%
11%
11%
11%
11%
6%
6%
0% 5% 10% 15% 20% 25% 30% 35% 40%
Improve patient's quality of life
Relief pain
Control the disease activity
Prevent deformity
Reduce Inflamation
Improve Mobility
Relief oedema and swelling
Prevent erosion
Normalize CRP and ESR
Prevent Complication
Again, Improving patients quality of life and reliving the pain are the
objectives of the management of RA patients mentioned by most of the
physicians
Factors that encourage the physicians to prescribe
biological treatment to RA patients (KSA)
40%
33%
16%
6%
5% 5%
Efficacy of the biologics Inadequate response to
DMARDs
Failure of second line
therapy
Immediate action Stops disease activity Efficacy sustained over a
long period of time
56% of the respondents would prescribe the biologics because of their
efficacy. 49% of the physicians use them as second or third line after failure
of the DMARDs
Barriers holding the doctors from prescribing
biologicals to their RA patients (KSA)
6% 6%
6%
11%
22%
89%
Cost Side effects Not Available History of T.B Contraindications Patient's refusal
All the respondents face the problem of the cost and/or availability of the biologics when they
want to prescribe them to their RA patients
Treatment Algorithm for the moderate to severe Rheumatoid
Arthritis
MTX
+
NSAIDs
First Line
In 12% of the cases,
physicians could switch
from one of the products,
mainly from NSAIDs for
the first line to
Hydroxychloroquine or
Steroids
MTX or NSAID
+
HQ or Steroid
In most of the cases,
physicians add
Hydroxychloroquine or
Steroids
to the products for the first
line
MTX + NSAIDs
+
HQ or Steroids
Second Line
Biologics
Biologics
+
MTX based
therapy
Sometimes, physicians
switch from the second
line therapy to the
biologics and they use
them as monotherapy in
third line

More often, the biologics
are added to the MTX
containing regimens and
they are used in
combination in third line
therapy

Third Line
Reasons for
switching to
another
medication are in
100% of the cases
the inadequate
response to the
previous one.
Adding another
medication is
always due to the
inadequate
response to the
previous one.
Physicians take
also into
consideration the
ability of the
patient to afford
the combination.
NSAIDs/Steroids are not used as a chronic therapy, they are stopped after stabilization of the patients' condition and they are reintroduced upon disease flares
Treatment Algorithm and
duration of therapy (KSA)
First Line Second Line Third Line
Number of
respondents
Duration of
therapy/mont
hs
Number of
respondents
Duration of
therapy/mont
hs
Number of
respondents
Duration of
therapy/mont
hs
NSAIDs 13 1 - 6 7 1 - 6 4 2 - 3
MTX 10 2 - 6 16 1 - 36 12 3 - 36
SS 1 1 4 3 - 6 2 2 - 6
HXQ 5 2 - 5 9 3 - 6 6 3 - 6
Steroids 4 2 - 5 2 2 3 2 3 - 4
Biologics 0 _ 5 6 36 12 2 - 24
(n=30)
Average Lapse of Time between RA Diagnosis and the
introduction of different therapeutic classes (KSA)
NSAIDs Steroids DMARDs Biologics
Less then 6
Months
56% 49% 61% 20%
6 months to one
year
20% 23% 9% 25%
1 2 Years 10% 16% 11% 9%
2 5 years 5% 3% 10% 21%
More then 5
years
8% 9% 9% 26%
100%
Some physicians in KSA have started to prescribe biologicals as first line therapy once the
diagnosis is confirmed. Others reserve it for third line therapy.
(n=30)
Treatment guidelines followed in the management of
moderate to severe RA patients (KSA)
73%
27%
Don't follow any guidelines Follow guidelines
The ACR guidelines are the only treatment protocol followed by the physicians.
Referral vs. diagnosis of RA (KSA)
62%
38%
24%
7%
3%
28%
Orthopedic
Internist
Surgeons
Family Medicine
Rheumatologists
General practitionner
76%
24%
Diagnosed Referred
Specialties of the referring doctors
Treatment Shares and Patterns
Findings and In Depth Analysis
Overall Prescription Shares of different therapeutic classes
used in the treatment of Rheumatoid Arthritis (KSA)
68%
87%
45%
21%
0% 20% 40% 60% 80% 100%
NSAIDs
DMARDs
Steroids
Biological
DMARDs are prescribed to almost 90%Patients
with RA, followed by NSAIDs
Biologics are prescribed to 21% of the RA
patients in KSA
(n=30)
Split of 100 biologics prescriptions according to
the previous therapy (KSA)
Classes Used before
Biological
Percentage of
Patients
1 NSAIDs with or without steroids
12%
Combination of NSAIDs with or
without Steroids
7%
1 DMARD with or without Steroids
15%
Combination of DMARDs with or
without Steroids
22%
NSAIDs + DMARDs with or
without Steroids
43%
Others
1%
100%
Out of each 100
prescriptions of
Biologics, 43 are given
to patients having
DMARDs + NSAIDs
(with or without
Steroids) and another
22% to patients having
1 DMARDs with or
without Steroids
(n=30)