The Treatment Modalities Of Rheumatoid Arthritis In Dalian(People’s Republic Of China) And Mauritius

Objective:Disease modifying anti-rheumatic drugs (DMARDs) are used worldwide in the management of rheumatoid arthritis (RA). However, the prescribing trends of these drugs differ across countries. The aim of this study is to evaluate the treatment patterns of rheumatoid arthritis in Dalian (People’s Republic of China) and Mauritius, and also determine the demographic and laboratory characteristics of RA patients for both countries.Patients and Methods:This is a retrospective study. Hospital records of110patients, who presented at the Rheumatology/Immunology Department of the First Affiliated Hospital of Dalian Medical University (Dalian, People’s Republic of China), between February2010and December2011and who fulfilled the2010ACR/EULAR criteria for RA were reviewed. All the patients had active disease (DAS28≥2.6) when they attended hospital. For each patient, the following details were recorded:age, gender, age at onset of disease, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, rheumatoid factor (RF) value, anti-cyclic citrullinated protein (anti-CCP) result at last attendance and current RA medications.Case notes of110patients, attending the Rheumatology Clinic of Dr A.G. Jeetoo Hospital (Mauritius), from September to November2010and fulfilling the2010ACR/EULAR criteria for RA, were obtained. All the patients had active disease (DAS28≥2.6) when they attended the clinic. For each patient, the following parameters were noted:age, gender, age at onset of disease, ESR, RF positivity at last follow-up and current RA medications. Mauritian patients were not tested for CRP and anti CCP.SPSS11.5software package was used for statistical analysis. Results of normally distributed continuous variables are expressed as mean±SD. Continuous variables with a non-normal distribution are presented as median (interquartile range). Categorical variables are presented as frequencies and percentages. For comparison of rates, the chi-square test was used. Independent-samples T test was used to compare mean values. Results were considered significant at a P value of<0.05.Results:The mean age of the Chinese patients was60.0±13.4years, with the youngest being20years old and the oldest being86years old; the mean age of the Mauritian patients was56.1±10.0years, with the youngest being32years old and the oldest being83years old (P=0.012). In both populations, RA was more prevalent in the50-59years age group. The mean age at disease onset of the Chinese patients was found to be53.0±14.8years and that of the Mauritian patients was48.0±10.9years (P=0.001). The average disease duration was7.3±7.7years for the Chinese patients and7.6±5.6years for the Mauritian patients (P=0.000). Females were the predominant gender in both groups and constituted78.2%(86/110) of the Chinese and88.2%(97/110) of the Mauritian patients. The male to female ratio was1:3.6in the Chinese group and1:7.5in the Mauritian group (P=0.047).The mean ESR was44.1±26.0mm/hr in the Chinese group and55.7±26.6mm/hr in the Mauritian group (P=0.865). Median CRP levels were17.3mg/1(interquartile range13.1-35.6) in the Chinese group.89.1%of the Chinese patients and77.3%of the Mauritian patients were positive for RF (P=0.019).81%of the Chinese patients had positive anti CCP.In the Chinese study group,43patients (39.1%) were prescribed a single DMARD (monotherapy) and67patients (60.9%) were given two or more DMARDs (combination therapy). In the monotherapy group, methotrexate was used in58.1%of the patients (25/43), leflunomide in23.3%(10/43), and thunder god vine (TwHF) in18.6%(8/43).The combination therapy group with two DMARDs consisted of methotrexate plus leflunomide in28.4%of the patients (19/67), TwHF plus glucocorticoid (GC) in14.9%(10/67), methotrexate plus GC in11.9%(8/67), methotrexate plus TwHF in9.0%(6/67), leflunomide plus GC in6.0%(4/67), methotrexate plus hydroxychloroquine in4.5%(3/67), leflunomide plus TwHF in3.0%(2/67), hydroxychloroquine plus sulfasalazine in1.5%(1/67), methotrexate plus sulfasalazine in1.5%(1/67), hydroxychloroquine plus TwHF in1.5%(1/67) and hydroxychloroquine plus GC in1.5%(1/67).Combination therapy with three DMARDs consisted of methotrexate plus leflunomide plus GC in6.0%of the patients (6/67), methotrexate plus hydroxychloroquine plus GC in3.0%(2/67), methotrexate plus TwHF plus GC in3.0%(2/67) and leflunomide plus TwHF plus GC in1.5%(1/67).Methotrexate was the most commonly used single DMARD (58.1%). Methotrexate plus leflunomide was the most frequently used combination (28.4%).In the Mauritian study group,11patients (10%) were on DMARD monotherapy and99patients (90%) were on combination therapy. In the monotherapy group, hydroxychloroquine was used in63.6%of the patients (7/11), sulfasalazine in27.3%(3/11), methotrexate in9.1%(1/11).The combination therapy group with two DMARDs consisted of hydroxychloroquine plus GC in21.2%of the patients (21/99), sulfasalazine plus GC in12.1%(12/99), methotrexate plus GC in9.1%(9/99), hydroxychloroquine plus sulfasalazine in3.0%(3/99), methotrexate plus sulfasalazine in2.2%(2/99) and azathioprine plus GC in1.0%(1/99).Combination therapy with three DMARDs consisted of hydroxychloroquine plus sulfasalazine plus GC in30.3%of the patients (30/99), methotrexate plus sulfasalazine plus GC in6.1%(6/99), methotrexate plus hydroxychloroquine plus GC in5.1%(5/99) and azathioprine plus sulfasalazine plus GC in2.0%(2/99).8.1%(8/99) of patients in the combination group were prescribed methotrexate plus hydroxychloroquine plus sulfasalazine plus GC.Hydroxychloroquine was the most commonly used single DMARD (63.6%). Hydroxychloroquine plus sulfasalazine plus GC was the most frequently used combination (30.3%).85.5%(94/110) of the Mauritian patients were on long term (≥6months) daily low dose glucocorticoid (5mg prednisone equivalent). None of the Chinese patients were prescribed glucocorticoids for long term use.Conclusions:In both populations, RA was more prevalent in the50-59years age group. Females were the predominant gender in both groups and constituted78.2%of the Chinese and88.2%of the Mauritian patients.Inflammatory markers (ESR, CRP) were raised in the RA patients.The sensitivity of RF was89.1%in the Chinese group and77.3%in the Mauritian group. The sensitivity of anti CCP was81%in the Chinese group.DMARDs remain the mainstay of treatment in RA.In Dalian, methotrexate was the most commonly used single DMARD (58.1%). Methotrexate plus leflunomide was the most frequently used combination (28.4%).In Mauritius, hydroxychloroquine was the most commonly used single DMARD (63.6%). Hydroxychloroquine plus sulfasalazine plus GC was the most frequently used combination (30.3%). Also, most of the Mauritian patients (85.5%) were prescribed long term daily low dose glucocorticoid whereas the Chinese patients were not prescribed glucocorticoid for long term use.