Rheumatoid arthritis (RA)

Rheumatoid arthritis (RA) is a chronic, progressive and systemic autoimmune disease, characterized by fluctuating symptoms such as pain, fatigue and unpredictable flares of disease.1 It results in high individual, medical and societal costs.2  

Common risk factors for the development of RA include being older, being female, a member of your family having suffered from RA, smoking and obesity.3 

Research done in the last 20 years shows an increase in the number of people suffering from RA in Africa, particularly in urban areas.4 

​Heat map image of hand with RA

Early diagnosis and treatment are important to help minimise joint damage. Treatment aims to ensure that all patients have low disease activity or be in remission.2,4 Untreated RA results in severe disability and loss of QoL.4 

The advent of biological medications has drastically improved the treatment of RA.4  

In many countries the high cost of biological medicines may limit a patient’s access to these newer medications.2,4 The availability of biosimilars can help address this problem.2 

Juvenile Idiopathic Arthritis (JIA) 

Juvenile idiopathic arthritis (JIA) is defined as chronic arthritis lasting > six weeks in a child < 16 years with no identifiable cause.5,6 

As the most common cause of musculoskeletal disability in children, it affects one to four children per 1000.5 

JIA is an immune-related disorder:6 An interplay between environmental factors (e.g. an infection) and genetic factors leads to a disturbance in the balance between immune tolerance and inflammation.5 

Common symptoms include joint swelling, pain*, stiffness, limping, changes in physical activity or ability and recurrent sports injuries.6 

*not always present 

Heat map image of ankle

Approximately 19,000-75,000 children in South Africa suffer from JIA, the majority of whom are under diagnosed and receive inadequate treatment. Children are constantly growing and developing, and changing milestones, anatomy and physiology increase the difficulty of making the diagnosis of JIA.6 

Early recognition of JIA and referral to specialist and multidisciplinary services for management is important to achieve good outcomes.5 

The goal of treatment is complete disease remission and normal physical and social development.  Treatment includes non-pharmacological therapy (e.g. physiotherapy and occupational therapy), pharmacological therapy.5 

The advent of biologic agents has significantly enhanced the treatment options for children with JIA and made complete disease remission an achievable outcome.5 

Axial Spondyloarthritis (axSpA) 

Axial Spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease that causes back pain and stiffness, reduces mobility and decreases QoL.7,8  

It incurs high individual, medical and societal costs7 and is an often underdiagnosed cause of lower back pain.9 

axSpA typically presents with >three months of back pain (before age 40–45 years), waking up in the 2nd half of the night due to back pain, improvement with physical activity but not with rest, morning stiffness persisting for more than 30 minutes, and a good response to NSAIDs*.9 

*NSAIDs, non-steroidal anti-inflammatories 

Image of a persons back with the spine highlighted

Early treatment of axSpA is associated with improved symptoms, physical function and QoL.9 

Treatment goals include alleviating symptoms, optimising function and preventing structural damage to the spine.7,9 

Optimal management of patients requires a combination of non-pharmacological and pharmacological treatment.7 

Psoriatic Arthritis (PsA) 

PsA is a complex form of arthritis affecting the musculoskeletal system of people with active or underlying psoriasis (a skin disorder).12,13 It may also affect the patient’s skin, nails, gut and eyes.13 

Data is scarce but estimates suggest that 4–5% of urban South Africans suffer from PsA.12 It imposes a significant patient burden, with impact on QoL and functional ability.13,14 

Early recognition and treatment of PsA are likely to result in better long-term outcomes, yet almost 50% of cases in primary and secondary care clinics go unrecognised.14 

Picture of hand suffering from psoriatic arthritis

Treatment has changed substantially in recent years, 5 but the primary goals remain:13 

  • Improved QoL through symptom control 
  • Prevention of structural damage 
  • Normalisation of function and social participation  

Eliminating inflammation is an important component to achieve these goals.13 

Day-to-day management includes non-pharmacological and pharmacological interventions.13 Pharmacologically, various medications and a ‘step-up’ approach are often used.13,14 

References

  1. Flurey CA, Morris M, Richards P, et al. It's Like a Juggling Act: Rheumatoid Arthritis Patient Perspectives on Daily Life and Flare While on Current Treatment Regimes. Rheumatology (Oxford). 2014;53(4):696-703. doi: 10.1093/rheumatology/ket416  
  2. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-modifying Antirheumatic Drugs: 2019 update. Ann Rheum Dis. 2020;79(6):685-699. doi:10.1136/annrheumdis-2019-2166559 
  3. Rheumatoid Arthritis (RA) [Online]. CDC. Cited 11 Nov 2021. Available from: https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html  
  4. Bester FCJ, Bosch FJ, van Rensburg BJJ. The Specialist Physician’s Approach to Rheumatoid Arthritis in South Africa. Korean J Intern Med. 2016;31(2):219-236. doi:10.3904/kjim.2015.134 
  5. Scott C, Brice N. Juvenile Idiopathic Arthritis – An Update on its Diagnosis and Management. South African Medical Journal. 2015;105(12):1077. doi:10.7196/SAMJ.2015.v105i12.10223  
  6. The Doctor’s Guide to Juvenile Idiopathic Arthritis in South Africa [Online]. Arthritis Kids South Africa. Cited 11 Nov 2021. Available from: https://arthritiskids.co.za/library-doctors-guide-to-jia-in-sa/ 
  7. van der Heijde D, Ramiro S, Landewé R, et al. 2016 Update of the ASAS-EULAR Management Recommendations for Axial Spondyloarthritis. Annals of the Rheumatic Diseases. 2017;76(6):978-991. doi:10.1136/annrheumdis-2016-210770 
  8. Sieper J, Poddubnyy D. Axial Spondyloarthritis. Lancet. 2017;390(10089):73-84. doi:10.1016/S0140-6736(16)31591-4 
  9. Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing axial spondyloarthritis: a guide for primary care. Mayo Clinic Proceedings. 2020;95(11):2499-2508. doi:10.1016/j.mayocp.2020.02.007 
  10. Braun J, Baraliakos X, Heldmann F, et al. Tumor Necrosis Factor Alpha Antagonists in the Treatment of Axial Spondyloarthritis. Expert Opinion on Investigational Drugs. 2014;23(5):647-659. doi:10.1517/13543784.2014.899351  
  11. The South African Rheumatism and Arthritis Association (SARAA) Recommendations for the Use of Biologic Disease Modifying Anti-rheumatic Drugs [Online]. SARAA. Cited 11 Nov 2021. Available from: https://saraa.co.za/wp-content/uploads/2020/06/SARAA-recommendations-for-biologic-use-July-2019-Apr-2020-.pdf 
  12. Usenbo A, Kramer V, Young T, et al. Prevalence of Arthritis in Africa: A Systematic Review and Meta-Analysis. PLOS ONE. 2015;10(8):e0133858. doi:10.1371/journal.pone.0133858 
  13. Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR Recommendations for the Management of Psoriatic Arthritis with Pharmacological Therapies: 2019 Update. Annals of the Rheumatic Diseases. 2020;79(6):700-712. doi:10.1136/annrheumdis-2020-217159 
  14. Coates LC, Helliwell PS. Psoriatic Arthritis: State of the Art Review. Clin Med (Lond). 2017;17(1):65-70. doi:10.7861/clinmedicine.17-1-65