South African recommendations for the management of rheumatoid arthritis: An algorithm for the standard of care in 2013

Rheumatoid arthritis in the Middle East and Africa: are we any closer to optimising its management?

“…Infections were a common theme among the many abstracts at the AFLAR/ SARAA 2013 meeting [12], which ties in with our previous finding that physicians can be wary of using immunosuppressive agents in a population already at risk of endemic infections such as TB [1]. Indeed, Hammoudeh et al confirmed that the risk for active TB and other infections in patients with RA from Asia, Africa and the Middle East is increased in patients receiving TNF inhibitors and higher in those receiving monoclonal antibodies versus the soluble TNF receptor etanercept [21], which is also highlighted by the South African recommendations [11]. Pettipher et al reported that infections were a major reason for discontinuation in South Africans and concluded that biologics with alternative modes of action are needed for patients with moderate to severe RA in South Africa [22].…”

“…This is reflected in the updated treatment recommendations from South Africa, which advocate early diagnosis, prompt initiation of DMARDs and an intense treatment strategy. This includes assessment of disease activity with composite scores such as the Simplified Disease Activity Index (SDAI), frequent assessments and escalation of therapy until low disease activity or remission and the use of synthetic DMARDs alone (in combination with concomitant corticosteroids if necessary) and biologic DMARDs in refractory disease [11].…”

Tuberculosis and biologics in rheumatology: A special situation

“…The optimal interval between the initiation of LTBI therapy and the start of biologic therapy is an area of uncertainty. Perspectives on the optimal time interval and loading dose of biologic therapy varies among the guidelines from different countries . Further evidence needs to be generated in the Indian context for consolidating and recommending an approach to practicing physicians.…”

Infections in the management of rheumatic diseases: An update

“…Patients should have a chest radiograph and, if suggestive of active TB, a sputum examination should be done to test for the presence of active TB. In a high-prevalence TB setting such as SA, these screening tests are not always reliable and there is little consensus on the most appropriate test, [22] but a TST and/or an IGRA (if deemed appropriate by the clinician) may be performed. If both tests are used, they should be done at the same time, as TST could boost IGRA responses, which may confound the interpretation of the results.…”