TREATMENT OF RHEUMATOID ARTHRITIS
Asgar Ali Kalla Professor of Rheumatology University of Cape Town
PREVALENCE OF RA IN SOUTH AFRICA
Urban Tswana Rural Tswana 0.9% 0.12%
Xhosa
0.68%
Clinical Course of RA
4 3.5
Severity of Arthritis
3 2.5 2 1.5 1 0.5 0 0 0.5 1 2 3 Type 2 4 Type 3 6 8 16
Years
Type 1
Type 1 = Self-limited—5% to 20% Type 2 = Minimally progressive—5% to 20% Type 3 = Progressive—60% to 90%
Adapted from: Pincus. Rheum Dis Clin North Am. 1995;21:619.
DETERMINATION OF COST OF ILLNESS
Direct costs Indirect costs Intangible costs
Direct Costs
Outpatients costs
Physician and Health professional Radiographs MRI, CT scans Endoscopies Other tests
Drug Costs
DMARDs
Biologics NSAIDs GI medications and Analgesics
Hospitalisation costs
INDIRECT COSTS
Loss of income from work Work disability in 60 - 70% after 5 years RA more likely to lose jobs or retire early than OA Reduction in household income 15% unable to get work 3 - 4 x higher than direct costs Underestimated because of predominance of women
INTANGIBLE COSTS
PAIN PSYCHOLOGICAL Depression, Coping, Anxiety, Cognitive changes LIMITED ACTIVITIES CHANGE IN APPEARANCE
ARTHRITIS IMPACT SURVEY (KEH, Durban)
35% Totally dependent on state support
Pensioners Disability grant 10% 25%
Two thirds of patients who stopped working did so because of their arthritis
Disability Legislation
In 1990 President Bush signed into law the Americans with Disabilities Act to extend the application of civil rights legislation to persons denied access to employment, housing, education, transportation or leisure pursuits due to chronic diseases
Factors influencing work disability in RA
Employment factors Nature of job, physical activity needed, degree of autonomy, work environment, transport to work Employee factors Age at onset of RA, marital status, education, motivation for work Disease factors Time since onset, level of disability, EMS, flare-ups
Other factors
Visits to GP, hospital clinic, surgery, rehabilitation
Vocational Rehabilitation A process whereby those disadvantaged by illness or disability can be enabled to access, maintain or return to employment, or other useful occupation
Vocational Rehabilitation
The best way to maintain work is to communicate quickly with employer at disease flare-up Encourage openness between patient and employer Current employer more likely to facilitate continued working than a new employer Return on costs between 2 – 10 fold
Remedies
Referral to Work Assessment Unit Health service ready to respond to worker’s urgent need Physician assessment of the risk of job loss Job modification Transport Self-employment Intensive rehabilitation
Cellular components in RA joints
Synovial membrane with synovial lining cells
Inflamed, thick synovial membrane Invading pannus Macrophage (type A synoviocyte)
Cartilage
Fibroblast-like synoviocyte
T and B lymphocyte
Plasma cell Chondrocyte
Joint capsule
Dendritic cell
Normal
RA
Buckley CD, Br Med J 315:236–238, 1997
Cells and cytokines in the arthritic joint
www.boneandjointdecade.org
Conclusions
Rheumatoid Arthritis causes severe disability Work assessment essential component of management Co-operation between employer, employee, physician Major advances in therapy in recent years