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ORIGINAL ARTICLE

Characteristics of patients with rheumatoid arthritis

in Qatar: a cross-sectional studyAbdo LUTF, Abdul R. POIL and Mohammed HAMMOUDEH

Rheumatology Division, Department of Medicine, Hamad General Hospital, Doha, Qatar

Abstract

Objective:To describe the clinical characteristics, serologic, radiological and clinical disease activity, and modal-

ity of therapy in patients with rheumatoid arthritis (RA) at tertiary outpatient care in Qatar.

Methods:The study design was cross-sectional where 100 consecutive cases who met 1987 American College of

Rheumatology criteria for diagnosis of RA were enrolled in this study. Demographic data (sex, nationality and

age) numbers of swollen and tender joints, X-rays and current medications were collected during outpatients

visits to Hamad General Hospital. Disease Activity Score of 28 joints (DAS28) and Health Assessment Question-

naires (HAQ) scores were calculated. All patients with RA who were seen as rheumatology outpatients were

invited to participate in the study.

Results: One hundred patients were seen and examined during their follow-up at the outpatient clinic; data

were collected and analyzed. Females represented 67% of all patients, 6% had more than six swollen joints, 9%

had more than six tender joints. DAS28 and erythrocyte sedimentation rate (DAS28) calculation revealed 49%

of patients were in remission (DAS28 < 2.6), 15% had low disease activity (DAS28 2.63.2) and 36% had

DAS28 > 3.2.Mean HAQ score was 1.02. Rheumatoid factor (RF) was positive in 63%, while anti-cyclic citrulli-

nated protein antibody (anti-CCP) was positive in 71%, and 49% were positive for both. Radiography of hands

and feet during the previous year was done in 65% of patients: 11% of them had erosions. Sixty-six percent were

on one synthetic disease-modifying anti-rheumatic drug (DMARD) and 27% where on more than one synthetic

DMARD and 7% where on no DMRD. Glucocorticoids were used in 51% and 29% were on biologics.

Conclusion: Sixty-four percent of rheumatoid arthritis patients in Qatar were in remission or had low disease

activity while the remaining 36% had active disease and among these patients 29% were on biologics.

Key words: ACCP, Qatar, RA Biologic DMARDs, rheumatoid arthritis.

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory

disorder affecting primarily cartilage and bone of small

and middle-sized joints. In addition, larger joints and

several organs such as lungs, blood vessels and the

hematopoietic system may be involved.1

The diseasedistribution involves all racial and ethnic groups.

However, variations in the clinical expression, severity

and outcome of the disease among different ethnic

groups have been reported.

Few studies have reported prevalence and character-

istics of the disease in an Arab population. Studies

from Iraq,2 Kingdom of Saudi Arabia,3 Kuwait4 and

Lebanon5 have suggested RA in Arab patients to be

mild and nondestructive. These studies were descrip-

tive and did not include disease activity score (DAS)

measurement, However. a study from the United

Arab of Emirates (UAE) shows that patients had very

active disease with mean DAS28 (28 joints) scores

of 5.2.6

Correspondence: Dr Abdo Lutf, Rheumatology Division,Department of Medicine, Hamad General Hospital, Doha,Qatar.Email: alotf1970@gmail.com

2013 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd

International Journal of Rheumatic Diseases 2014; 17: 6365

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Information about disease activity, treatment and

outcomes will help for decision-making in health care.

The characteristics of RA in Qatar have not been studied

before; we aimed in this outpatient hospital-based

study to gather information about RA clinical, radiolog-

ical and serological characteristics and disease activity,

and treatment in Qatar.

METHODS

This cross-sectional study was conducted at Hamad

General Hospital (HGH), in Dohar, Qatar; HGH is a

tertiary care referral center offering free health care ser-

vices to Qatari patients and for non-Qatari expatriates

at a significantly reduced cost with total exemption of

payment for some of the costly drugs. Two-third of the

1.5 million population of Qatar are expatriate.

We enrolled 100 consecutive patients who met 1987

American College of Rheumatology classification crite-

ria for the diagnosis of RA. These patients were followedup in a rheumatology outpatient clinic. Consent forms

were signed by the patients. Demographic data (sex,

nationality and age), number of swollen and tender

joints, X-ray findings (which were reported electroni-

cally by a radiologist), current and past medications

were recorded. DAS 28 was calculated and classified as

follows: score of< 2.6 was defined as clinical remission,

score from 2.6 to 3.2 corresponded to low disease activ-

ity and > 3.2 was consistent with active disease. The

disease was considered as severe functional disability if

the Health Assessment Questionnaires (HAQ) score

was > 1.5.Statistical analysis was performed using SPSS software

(SPSS Inc, Chicago, IL, USA). Descriptive analysis was

undertaken for all variables.

RESULTS

In this study, 100 consecutive patients were collected

from September 1, 2011 to March 31, 2012. Among

these patients 23% were Qatari and 77% were non-

Qatari (59% Asian, 16% African and 2% Western:

Table 1). Most patients were female (67%). Mean ageof the patients in the study was 47 13.4 years. Rheu-

matoid factor (RF) was positive in 63%, anticyclic

citrullinated peptide antibody (anti-CCP) in 71% and

both of them were positive in 49% of cases.

A very small group of patients had greater than six

tender joints (6%) and swollen joints (9%); moreover

there was no significant differences in number of tender

and swollen joint counts across different populations.

Mean DAS28 erythrocyte sedimentation rate (ESR) was

2.91 1.02 and there were no statistically significant

differences between the study groups. Almost half of

the patients (49%) were in remission (DAS28 < 2.6)

and one-third (36%) were in active disease (DAS28> 3.2). However, a minority of patients (15%) were in

low disease activity (DAS28 2.63.2).

The mean HAQ score was 1.02 ( 0.60). X-rays of

hand and feet were performed on 65% of patients, of

whom 11% were found to have erosions.

Sixty-six percent of our patients were on one synthetic

DMARD in the last 2 months before being involved in

the study, 27% were on two synthetic DMARDs and 7%

were not on synthetic DMARDs. Synthetic DMARDs

were mostly used in the Asian group (74.8%). Metho-

trexate was the most commonly used DMARD (75%).

It was used alone in 31% or in combination with othersynthetic or biologic DMARDs (44%).

Biologic DMARDs were used in 29%: 11% on ritux-

imab, 8% on tocilizumab, 9% on anti-tumor necrosis

Table 1 Comparison of demographics and clinical features between patients with RA of different ethnic groups

Parameter Qatari (%) Asiain (%) African (%) Caucasian (%)

Female 20 (91.3) 31 (52.5) 13 (81.3) 2 (100)

Male 3 (18.8) 28 (47.5) 3 (18.8) 0

RF positive 13 (56.5) 38 (64.4) 12 (75) 0

Anti-CCP positive 16 (69.6) 41 (67.1) 11 (68.8) 2 (100)Erosions 1 (4.3) 7 (11.9) 2 (12.5) 1 (50)

DAS28-ESR (mean) 2.85 1.25 2.86 1.047 3.07 0.91 2.87 0.88

One DMARD 16 (69.6) 39 (66.1) 9 (56.3) 2 (100)

Two DMARDs 2 (8.7) 19 (8.7) 6 (37.5) 0

Biologics 15 (65.2) 9 (15.3) 4 (25) 1 (50)

RF, rheumatoid factor; anti-CCP, anti-cyclic citrullinated peptide antibodies; DAS28, disease activity score of 28 joints; ESR, erythrocyte sedimenta-tion rate; DMARD, disease-modifying anti-rheumatic drug.

64 International Journal of Rheumatic Diseases 2014; 17: 6365

A. Lutfet al.

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factor and one patient was on abatacept. Use of biolo-

gics was more in the Qatari population (65.2%) and

least in Asians (15.3%). Glucocorticoids were used in

51% of patients with dose range of 510 mg\day.

DISCUSSION

In this cross-sectional study we described the character-

istics of RA in Qatar managed on an outpatient base

and analyzed the severity and activity of the disease.

Our study showed that the majority of patients was

female (67%) and they were more frequently Qataris

(91.3%) compared with Asians (52.5%) which reflects

the pattern of the Qatar population (most Asians are

male). Among all patients, RF was positive in 63%,

anti-CCP in 71% and both were positive in 49% which

is close to that reported from Kuwait 60%.4 A compara-

tive study of RA in British and Malaysian patients

showed that RF was positive in 65% in each group of

patients which is similar to our study.7

In our study 64% of patients were either in remission

(49% with DAS28 < 2.6) or in low disease activity

(15% with DAS28 < 3.2) while mean DAS28-ESR was

2.85 1.047. This is in contrast to a UAE study which

showed that only a few patients (15%) were in low dis-

ease activity and most of them had high disease activity

with mean DAS of 5.2.6 However, 36% of our patients

had moderate to high disease activity with DAS28

> 3.2.

The majority of our patients (93%) were being trea-

ted with DMARDs over the last 2 months before enrol-

ment in the study, 66% on one synthetic DMARD and27% on two. The most common DMARDs prescribed

was methotrexate: 31% methotrexate alone and 44% in

combination with other DMARDs, which is better than

in the UAE study (27%),6 and is almost same as in a

European and USA study (>80%).8

Patients on biologic DMARDs, including anti-TNF

(tumor necrosis factor), anti-interleukin-6 and ritux-

imab account for 29% of all our RA patients; however,

comparing group of patients, biologics were used in

65.2% in Qatari,15.3% in Asian, 25% in African and

50% in Caucasian patients. Biologics were used more

in Qataris because it is free of charge but other nation-

alities still only pay 20%. In the USA 40% of RA

patients are on biologics8,9 but in UAE only 5% are on

biologic therapy.6 Anti-TNF drugs have been proven to

be more effective in combination with methotrexate in

inducing remission and preventing radiological pro-

gression.

We found from our study the remission rate is better

than reported in other Gulf countries which may be

related to more use of anti-TNF in Qatar but is still

lower when compared to USA and European studies.8,9

Almost one-third of our RA patients are not well con-trolled. Some of these uncontrolled patients may have

co-morbid conditions which limit the use of synthetic

and biologic therapies and other patients may have

joint damage due to long-standing diseases and their

diseases were acquired in the pre-biologics era.

A limitation of our study is that the sample size was

small because the population of Qatar is small and

most of our patients were expatriates; moreover, we did

not include extra-articular manifestations in our study.

More effort is needed to improve the management

provided to our RA patients to tighten the control of

their disease.

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