Ahmed Laatar

Suboptimal management of rheumatoid arthritis in the Middle East and Africa: could the EULAR recommendations be the start of a solution?

Although the prevalence of RA in the Middle East and Africa is comparable with that in other parts of the world, evidence indicates that its management in this region is suboptimal for a variety of reasons, including misconceptions and misunderstandings about the diseases prevalence and severity in the region, compounded by the lack of local epidemiological and health-economic data around the disease; the perception that RA is a low priority compared with other more prevalent conditions; delayed diagnosis, referral and treatment; and a lack of a region-specific, evidence-based management approach. In the absence of such an approach, the EULAR treatment recommendations may provide a useful starting point for the creation of guidelines to suit local circumstances. However, although agreement with the EULAR recommendations is high, many barriers prevent their implementation in clinical practise, including lack of timely referral to rheumatologists; suboptimal use of synthetic DMARDs; poor access to biologics; lack of awareness of the burden of RA among healthcare professionals, patients and payers; and lack of appropriate staffing levels.To optimise the management of RA in the Middle East and Africa, will require a multi-pronged approach from a diverse group of stakeholders-including local, national and regional societies, such as the African League of Associations in Rheumatology and International League of Associations for Rheumatology, and service providers-to collect data on the epidemiology and burden of the disease; to increase awareness of RA and its burden among healthcare professionals, payers and patients through various educational programmes; to encourage early referral and optimise use of DMARDs by promoting the EULAR treatment recommendations; to encourage the development of locally applicable guidelines based on the EULAR treatment recommendations; and to facilitate access to drugs and the healthcare professionals who can prescribe and monitor them.

Challenges and opportunities in the early diagnosis and optimal management of rheumatoid arthritis in Africa and the Middle East

Early diagnosis and early initiation of disease‐modifying antirheumatic drug (DMARD) therapy slow the progression of joint damage and decrease the morbidity and mortality associated with rheumatoid arthritis (RA). According to the European League Against Rheumatism (EULAR) guidelines, treatment should be initiated with methotrexate and addition of biological DMARDs such as tumour necrosis factor (TNF) inhibitors should be considered for RA patients who respond insufficiently to methotrexate and/or other synthetic DMARDs and have poor prognostic factors. Africa and the Middle East is a large geographical region with varying treatment practices and standards of care in RA. Existing data show that patients with RA in the region are often diagnosed late, present with active disease and often do not receive DMARDs early in the course of the disease. In this review, we discuss the value of early diagnosis and remission‐targeted treatment for limiting joint damage and improving disease outcomes in RA, and the challenges in adopting these strategies in Africa and the Middle East. In addition, we propose an action plan to improve the overall long‐term outlook for RA patients in the region.

The level of interleukin-17 in serum is linked to synovial hypervascularisation in rheumatoid arthritis.

Joint Bone Spine - In Press.Proof corrected by the author Available online since vendredi 4 juillet 2014

Collagenous colitis and spondylarthropathy.

Collagenous colitis is a recent cause of chronic diarrhea. Cooccurrence with spondylarthropathy is rare. We describe two cases: one man and one woman of 33 and 20 years old were suffering from spondylarthropathy. They then developed collagenous colitis, 4 and 14 years after the onset of spondylarthropathy. The diagnosis was based on histological features. A sicca syndrome and vitiligo were observed with the female case. The presence of colitis leads to therapeutic problems. This association suggests a systemic kind of rheumatic disease of collagenous colitis.

Vasculitis Associated with Connective Tissue Disease

Vasculitis secondary to connective tissue disorders most commonly arises in the context of preexisting rheumatoid arthritis, systemic lupus erythematosus, or primary Sjogren’s syndrome. In patients with established connective tissue disorders, vasculitis may involve vessels of any size, but small vessel involvement predominates. The presence of vasculitis is usually correlated with disease activity. The clinical presentation ranges from isolated cutaneous involvement to life-threatening internal organ involvement. Tissue biopsy is the gold standard for diagnosis. Vasculitis secondary to systemic lupus erythematosus is common (11–50%). Cutaneous involvement is the most frequent form. Pulmonary involvement is manifested by diffuse alveolar hemorrhage. Chest radiographs shows alveolar infiltrates and CT shows diffuse ill-defined centrilobular nodules or small ground-glass centrilobular opacities. MRI in neurological involvement shows white matter lesions that are not specific and brain infarction. Other organ involvements that can be diagnosed by imaging are uncommon: gastrointestinal tract, coronary arteries, and the aorta. Vasculitis secondary to rheumatoid arthritis is common; autopsy data have reported systemic vasculitis ranging from 15 to 31%. Cardiac involvement includes pericarditis and coronary vasculitis. MRI in neurological vasculitis shows leptomeningitis and parenchymal ischemia. Abdominal vasculitis including ischemic bowel, intra-abdominal hemorrhage, and pancreatitis is rare. Imaging is not specific of vasculitis in these cases. Pulmonary artery involvement is uncommon.