1. Revised ARA criteria (1987) the diagnosis of RA requires presence of at least 4 of the following 7 features: 1) morning stiffness> 1 hour 2) swelling of 2 or more joints (of 6 weeks duration) 3) symmetrical joint involvement 4) arthritis of more than 1 hand joints (of at least 6 weeks duration) 5) positive rheumatoid factor, 6) presence of rheumatoid nodule 7) X-ray changes. 2. Use of DMARD should start early, along with pain control by non steroidal anti inflammatory drugs (NSAID) 3. Early referral to rheumatologists is the current recommendation 4. Indications for early referral include: i. Early morning stiffness (EMS) of 30 mins ;- ii. Metatarsophalangeal (MTP) / metacarpophalageal (Mep) involvement. iii. 2 or more swollen joints.
Background: In the ageing population, osteoporosis (OP) is becoming an increasingly common medical condition. Effective interventions are available that should enable clinicians to limit the magnitude of the burden but this will require the proper knowledge of OP and its management. Objective: To explore family physicians' perceptions of OP and to identify their educational needs in this area.
Method: Self administered questionnaires about OP knowledge and management were distributed to attendees of Rheumatology Workshops for primary care physicians between March and November 2005, in Malaysia.
Results: A total of 134 primary care physicians participated in this survey comprising 53% private practitioners, 44% government doctors, 2.2% from academic institutions and 0.7% not stated. The majority 73 (54.4%) had practiced for more than 10 years, 29 (21.6%) under 5 years and 32 (23.9%) between 5 and 10 years. 127 (94.4%) of them saw patients with osteoporosis. Those who had qualified for over 10 years were more likely to treat OP (p = 0.012). 82% felt that osteoporosis was under-diagnosed whereas 14.9% thought it was over diagnosed. This was not related to specialty or years qualified. Regarding the reasons for under-diagnosis of osteoporosis, 71% stated that they had no access to DXA screening, 74% had no access to heel ultrasound, 66% felt the disease was asymptomatic, 37% felt that investigations were costly and only 11% perceived the problem as a lack of referral for specialist opinion. Majority of respondents recognized the risk factors for OP such as increasing age (93%), post menopausal state (90%), positive family history (70%) and a previous low trauma fracture (65%). 7% were not sure how to further investigate a case of OP. For all categories of bone density, under 50% would advise changes in life-style measures. For osteopenia, 65.7% recommended calcium, 54.5% activated vitamin D products. For OP, 79.1% would use bisphosphonates, 50% calcium. In established OP, 80.6% would use bisphosphonates, 44% calcium. Usage of HRT and SERMs ranged between 20% and 30% in all categories. 63% were aware of the Malaysian Clinical Practice Guidelines on Osteoporosis. 22% would not refer to a specialist, whereas 50.4% would refer severe cases only. Almost all (98%) requested for further continuing medical education on OP.
Conclusions: In this study, the majority of primary care physicians had a reasonable working knowledge of the management of OP. However, 71% had no access to DXA. Therefore, awareness needs to be supplemented by adequate facilities to further improve the management of OP in the community.
Objective: To determine the epidemiological, clinical and laboratory features of the patients with gout, on follow up in Rheumatology Outpatient Clinic, Hospital Seremban.
Methods: This was a retrospective study. Case notes of all our existing gout patients were reviewed, and data on demography, clinical features, associated conditions, and laboratory findings were noted.
Results: 54 patients were studied, 48 (89%) were male and 6 (11%) were female at the ratio of M : F = 8:1, 30 (57%) of them had the onset of symptoms at their 3rd and 4th decades of life. The majority were the Malays 39 (72%), followed by the Indians 11 (20%) and the Chinese 4 (8%). Commonly associated conditions were hypertension in 37 (68.5%), obesity (BMI of 30 and above) in 36 (66.7%) and hyperlipidaemia in 36 (66.7%) of them. Mixed hyperlipidaemia (High TG and LDL cholesterol) were found in 19 (53%). Underlying history of diabetes mellitus 7 (13%), alcohol consumption 8 (15%), smoking habits 22 (40%) and family history of gout 18 (33%). Half of our patients 27 (50%) had at least 2 or more joints involvement. 28 (52%) of them had tophaceous gout. Among those with tophaceous gout, 18 (64%) had renal impairment with serum creatinine of .150mmol/l. 6 (31.5%) of the patients with renal impairment found to have renal calculi on ultrasonography.
Conclusion: There was male predominance in our group of patients which was consistent with other reported epidemiological studies. Hypertension, mixed hyperlipidaemia and obesity were common associated conditions while diabetes mellitus, smoking and family history of gout were not. The majority of gout patients in our clinic were Malays and due to religious reasons, alcohol was not a common associated factor. Half of our patients had multiple joints involvement and more than half also had tophaceous gout. There was high incidence of renal impairment seen in patients with tophaceous gout. These could be due to delay in seeking medical treatment, present of renal calculi and possibly contributed by associated hypertension and diabetes mellitus.
Objective: To determine the number of RA cases and to evaluate the demographic patterns in all 4 Rheumatology Referral Centers under the Ministry of Health Malaysia. Materials and methods: One thousand and eighty-four rheumatoid arthritis patients from all 4 centers i.e. Hospital Selayang, Putra Jaya, Seremban and Taiping which are situated in the west coast of West Malaysia, using rheumatoid arthritis database comprising of basic clinical and patient questionnaire, until the end of year 2004 were analysed. Results: At the time of documentation, 88.6% were female at all range of ages especially between age of 25 and 54 years (77.6%) with female to male ratio 8 :1. 52.1% were housewives. Mean age of onset of RA was 49.6 ± 11.8 SD with female 49.3 ± 11.7 SD and male 52.0 ± 12.0 SD (p < 0.05). Indian was the predominant ethnic group (54.5%), followed by Malay (31.4%), Chinese (11.6%) and others (27%). Majority had their education up to secondary level (50.8%), followed by primary (32.6%), and tertiary (6.3%) levels while 10.3% of cases had not received any formal education in their lives. 74.4% were seropositive and 87.3% fulfilled at least 4 out of 7 American College of Rheumatology (ACR) revised criteria for rheumatoid arthritis. 74% were diagnosed RA within 2 years after the onset of arthritis. Seropositivity was not significantly related to gender. Positive rheumatoid factor was dominated by Indian followed by Malay and Chinese. 83.3% were married. 23.3% female and 33.9% male between age group 25-54 were employed. 7.4% had achieved their retirement at time of entry whilst 8.9% were unemployed. Employment status was statistically significant across gender (p < 0.001). The cases differed between rheumatology centers as well as individual practices. Conclusion: There are increasing numbers of RA cases in Malaysia. Results from this study did not reflect the true prevalence of RA in Malaysia. Hence, a larger and more comprehensive database on RA with collaboration of all Government and Private Hospitals in the whole nation will provide better information about the patient case mix in different healthcare settings, treatment practice as well as disease complications. The implementation of rheumatology centers with better regional cooperation, will lead to better treatment and outcome in terms of identification of early as well as established RA cases. Early referral to the centers will be made possible for proper treatment institution and rehabilitation. Hence, improve quality of life including socio-economic status especially among those within the productive age.
Background: Rheumatoid arthritis (RA) is an inflammatory disease. Predictors of disease activity include presence of joint inflammation, blood investigations such as erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP). ESR is said to be imprecise as it is affected by aging, female sex, obesity, pregnancy, anaemia and polycythaemia. But it is inexpensive and easy to perform. CRP is produced as an acute phase reactant by the liver in response to interleukin 6 and other cytokines. CRP is more specific but costs more than ESR. Both tests are done in the rheumatology clinic of Hospital Seremban. Objective: To compare the usefulness of ESR and CRP as a predictor of disease activity in rheumatoid arthritis (RA) patients. Method: This was a retrospective study. The medical records of 248 RA patients who attended the rheumatology clinic, Hospital Seremban between 1 January 2004 and 31 Dec 2004 were reviewed. The following data were obtained: joint swelling and tenderness, other clinical features which indicate inflammation secondary to infection or trauma and inflammation of soft tissue, ESR, CRP, FBC and UFEME. Results: Data was analysed and the results showed that a total number of 248 patients were seen. There were 13 defaulters. Of the 248 patients there were 929 patients' visits. Of the total number of patients' visits where patients clinically had active disease, 80.2% had raised ESR while 88.8% had raised CRP. As for visits where patients had quiescent disease clinically, 57.3% had normal ESR and 36.5% had normal CRP. Conclusion: CRP is more sensitive but less specific than ESR. This suggests that we still should use both tests as they complement each other. ESR can serve as a countercheck for CRP and vice versa.
In this study, three single nucleotide polymorphisms (SNPs) located within the promoter of the human interleukin (IL)-10 gene [rs1800896 (position: -1087G>A), rs1800871 (position: -824C>T) and rs1800872 (position: -597C>A)] were investigated in 84 rheumatoid arthritis (RA) patients and 95 age- and sex-matched healthy subjects using polymerase chain reaction-restriction fragment length polymorphism method. Production of IL-10 by peripheral blood lymphocytes from the RA patients and healthy subjects cultured in the presence of Concanavalin A (Con A) was determined by using enzyme-linked immunosorbent assay. The results show that the distribution of the IL-10 genotypes did not differ significantly between RA patients and healthy subjects (P>0.05). However, a significant difference was observed in allele frequencies of -824CT, -824TT, -597CA, and -597AA between the RA patients and healthy volunteers (P=0.04). The -1087A/-824T/-597A (ATA) haplotype, which comprises all mutant alleles, was associated with lower IL-10 production when compared with the other haplotypes. In contrast, the RA patients who did not display the ATA haplotype produced significantly higher levels of IL-10 when compared with those carrying either one (P=0.012) or two (P=0.005) ATA haplotypes. Our findings suggest that there is an association between SNPs in the promoter of the human IL-10 gene and susceptibility to RA.
Study site: Hospital Tuanku Ja’afar, (Hospital Seremban), Seremban, Negeri Sembilan, Malaysia
Aim: This is a rheumatoid arthritis (RA) descriptive study, the first of its kind carried out in Malaysia.
Methods: This descriptive study involved 1084 RA patients' epidemiological and clinical data taken from Selayang, Putrajaya, Taiping and Seremban hospitals from June 2004 to December 2005.
Results: One thousand and eighty-four RA patients'data were analysed; 960 (88.6%) patients were female and 124 (11.4%) were male, approximately 8 : 1 M : F ratio. The majority of the patients were Indian (591; 54.5%), followed by the Malays (340; 31.4%), Chinese (126; 11.6%), indigenous (13; 1.2%) and others (14; 1.3%). Mean age was 49.6 ± 11.8 years with the youngest being 15 years and the oldest 88 years of age. Mean age for males was 52.0 ± 12.0 and females 49.3 ± 11.7 years (P =; 0.017). Most of these patients were housewives (565; 52.1%), followed by paid workers (266; 24.5%), retired patients (80; 7.4%), unemployed (76; 7.0%) and others (97; 8.9%). Mean duration of illness was 8.4 ± 6.7 years; 805 (74.3%) patients were relatively new patients (≤ 2 years illness duration) and 279 (25.7%) patients had illness duration > 2 years. Eight hundred and six (74.4%) were seropositive RA patients and 385 (35.5%) had presence of deformity. The majority of patients were treated with methotrexate (178; 16.4%), followed by combination of methotrexate, sulfasalazine and hydroxychloroquine (143; 13.2%), leflunomide (140; 12.9%), sulfasalazine (133; 12.3%) and combination of methotrexate and sulfasalazine (108; 10%).
Conclusion: In the above study, the majority of patients were female (960; 88.6%), Indian (591; 54.5%), had a mean age of 49.6 ± 11.8 years, most were housewives with a mean duration of illness of 8.4 ± 6.7 years and were treated with methotrexate (178; 16.4%). The results of the study may help Malaysian rheumaologists to understand their patients better and treat RA holistically.
Comment in: Yeap SS. Comment on: Multicentre survey of rheumatoid arthritis patients from Ministry of Health rheumatology centres in Malaysia. Int J Rheum Dis. 2009 Jul;12(2):177-8; author reply 179. doi: 10.1111/j.1756-185X.2009.01403.x. PubMed PMID: 20374340.
AIM: The aim of this study was to ascertain the management of gout by doctors in Malaysia.
METHODS: A cross-sectional questionnaire survey was carried out among doctors attending rheumatology post-graduate courses, where gout was not a lecture topic.
RESULTS: A total of 128 questionnaires were analyzed, of which the majority (67: 52.3%) were general practitioners. In the treatment of acute gout, 68.0% use non-selective non-steroidal anti-inflammatory drugs (NSAIDs), 53.9% use selective COX-2 inhibitors (coxibs), 66.4% use colchicine and 10.2% use allopurinol (ALLO). In the treatment of chronic gout, 36.7% use NSAIDs, 44.5% use coxibs, 19.5% use colchicine and 93% use ALLO. In both acute and chronic gout, corticosteroids (CS) are not used by over 90% of respondents. Fifty percent would stop ALLO during an acute attack. 95.3% do not start ALLO during an acute attack; 87.5% would start ALLO after the attack, with a median of 14 days afterwards. Once ALLO was started, 54.7% would continue indefinitely. Regarding target urate levels while on treatment, 10.9% would be satisfied with a high normal range, 21.9% middle of the range, 18.0% low normal range and 45.3% anywhere within the normal range. Fifteen percent would treat asymptomatic hyperuricemia.
CONCLUSIONS: In Malaysia, anti-inflammatory agents are most commonly used for the treatment of acute and chronic gout, with corticosteroid usage at a low level. However, there are areas of concern regarding the diagnosis of gout and the usage of ALLO which are not consistent with current guidelines
BACKGROUND: In Malaysia, patients have a choice of attending a public (fully subsidised bygovernment) hospital (PUBH) or a private (fee-paying) hospital (PRIH) for their healthcare.The aim of this study was to, firstly, provide an overview of the characteristics of MalaysianSLE patients attending rheumatology clinics, and secondly, to ascertain if there were any dif-ferences between patients attending PUBH and PRIH.
METHODS:A standardised questionnaire was administered to all SLE patients attendingrheumatology clinics in a PRIH in Selangor state and a PUBH in Negeri Sembilan state dur-ing the months of September to December 2009.
RESULTS:One hundred and thirty patients were included in the study. There were 55(42.3%) patients from PRIH and 75 (57.7%) from PUBH. 93.8% were female. 61.5% wereChinese, 29.2% Malay and 7.7% Indians. The majority of patients completed secondaryschooling (46.9%) with significantly less PUBH patients going onto higher education(P = 0.001). 53.8% were in fulltime employment with 37.7% housewives/unemployed.There were significantly more unemployed patients in PUBH (45.3%) versus PRIH (27.2%)(P = 0.05). 33.8% of patients were single, 60.8% married and 3.8% divorced. Average ageat SLE diagnosis was 29.8510.17 years. At diagnosis, the most common presenting symp-tom was related to the mucocutaneous system 70.8%, followed by joints 55.3%, haemato-logical 46.9% and renal 23.1%. Significantly more patients had renal involvement atdiagnosis in PUBH (33.3%) versus PRIH (9.1%) (P = 0.001). At the time of survey, therewere 12 (9.2%) patients in remission. Of those still symptomatic, 48.5% related to themucocutaneous system, 32.3% joints, 27.7% haematological, 22.3% renal, with significantlymore current renal disease in PUBH (30.7%) versus PRIH (10.9%) (P = 0.008). The mostfrequently prescribed drug was prednisolone in 83.1% of patients, followed by hydroxychlo-roquine 68.5% and azathioprine 23.1%. Only 64.8% of patients on prednisolone were onbone protective agents. More patients in PRIH were on prednisolone (90.9%) versus PUBH(77.3%) (P = 0.04), but more patients were on activated vitamin D in PUBH (72%) versusPRIH (29.1%) (P < 0.001).
CONCLUSION:The demographics and clinical characteristics of SLE patients attending PUBHand PRIH are significantly different. This has important implications when considering edu-cational and treatment strategies
AIM: The purpose of this study is to compare the prevalence of rheumatoid factor (RF) isotypes and second generation anti-cyclic citrullinated peptides (anti-CCP) in Malaysian rheumatoid arthritis (RA) patients.
METHODS: In this cross-sectional study, 147 established RA patients from three ethnic groups were recruited from a major rheumatology clinic in Malaysia. Enzyme-linked immunosorbent assays (ELISA) for serum RF isotypes IgA, IgG and IgM as well as second-generation anti-CCP were performed and the prevalence of each auto-antibody was compared in the three ethnic groups.
RESULTS: The anti-CCP was the most prevalent auto-antibody in each of the ethnic groups, followed closely by RF IgM and RF IgG. Rheumatoid factor IgA was the least prevalent across all three ethnic groups. The anti-CCP-RF IgM combination provided the best test sensitivity. Seroprevalence of anti-CCP was strongly associated with the presence of each of the RF isotypes. The seroprevalence of RF and anti-CCP did not increase or decrease with advancing age, age at onset and disease duration.
CONCLUSION: When used alone, anti-CCP provides a diagnostic advantage over RF IgM on the basis of test sensitivity. Considering the high cost of the anti-CCP assay, step-wise serum testing with IgM RF followed by anti-CCP may provide a more economically sensible option to optimize test sensitivity for RA.
Study site: Rheumatology clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
INTRODUCTION: Gout is an increasingly common medical problem. The traditional risk factors of male sex and high red meat or alcohol consumption have been joined with newer risks such as increased life expectancy, and the metabolic syndrome (hypertension, diabetes, dyslipidaemia, truncal obesity).
METHODS: This was a retrospective study to determine the epidemiology, clinical features, associated conditions as well as renal related conditions in existing gout patients followed-up in Rheumatology outpatient clinic, Hospital Tuanku Ja'afar, Seremban.
RESULTS: Over a three month period, we identified 54 gouty patients on our follow-up, the majority being male, Malay ethnicity, with the age of onset in the third and fourth decades of life. Commonly associated risk factors were hypertension, hyperlipidaemia and obesity. However, underlying history of diabetes mellitus, alcohol consumption, and family history were not commonly associated with gout in our group of patients. Half of our patients had at least two or more joints involvement. About half of the patients with tophaceous gout had renal impairment.
CONCLUSION: Our series of gout patients highlight the high prevalence of cardiovascular risk factors. The high prevalence of tophi and renal impairment is a cause for concern.
Study site: Rheumatology outpatient clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia.
OBJECTIVES: The prognostic significance of rheumatoid factor (RF) and anticyclic citrullinated peptide antibody (anti-CCP) in rheumatoid arthritis (RA) remains contentious due to the conflicting lines of evidence. This study aims to determine the association between RF isotypes and anti-CCP with disease severity in RA patients from three ethnic groups.
METHODS: A total of 147 RA patients from three different ethnic groups (Malays, Chinese, and Indians) who fulfilled the 1987 American College of Rheumatology (ACR) revised criteria for RA were recruited into this study. The seroprevalence of RF isotypes immunoglobulin (Ig)A, IgG, and IgM, as well as anti-CCP was determined using commercial enzyme-linked immunosorbent assay (ELISA) kits. Multinomial regression analysis was performed to assess the independent effects of autoantibody status on the development of deforming and erosive RA and the presence of extra-articular manifestations (EAM).
RESULTS: In Chinese patients, we found a significant association (p < 0.05) between IgG RF and anti-CCP and the presence of erosive disease, as well as IgM RF and IgG RF with the presence of joint deformities. In Indian patients, IgM RF was associated with deforming disease, whereas none of the antibodies were associated with disease severity in Malay patients. Multinomial regression analysis revealed that IgG RF was the most important predictor variable for erosive disease in Chinese patients, and IgM RF the only predictor variable associated with deforming disease in both Chinese and Indian RA patients.
CONCLUSIONS: There is variability in the phenotypic association of RF isotypes and anti-CCP in relation to disease severity of RA in the three ethnic groups. RF, in particular, IgG and IgM, may be better prognosticators of severe disease in Chinese and Indian patients.
Pseudo-pseudo Meigs' syndrome (PPMS) has been reported to be a rare presentation of patients with systemic lupus erythematosus (SLE). However, such a presentation is not common in other forms of connective tissue disease. We presented a case of gross ascites, pleural effusion, and marked elevation of CA-125 level (PPMS-like features) that led to a diagnosis of MCTD. The patient responded to systemic steroid therapy.
The objective of this study was to compare the tolerability of methotrexate in two different regimes of folic acid (FA) supplementation in rheumatoid arthritis (RA). We performed a multicenter, cross-sectional observational cohort study on 240 RA patients with 120 patients each in 5 mg of FA weekly and 30 mg of FA weekly supplementation. There were no significant differences for side effects (14.2 versus 22.5%, P=0.523) and discontinuation of methotrexate (3.6 versus 13.3%, P=0.085). RA patients given 5 mg of FA weekly supplementation had a lower disease activity score 28 compared to 30 mg of FA weekly supplementation [3.44 (1.10) versus 3.85 (1.40), P=0.014]. FA supplementation of 5 mg per week and 30 mg per week was associated with similar tolerability of methotrexate in RA patients.
A total of 951 Southeast Asia Malays from Peninsular Malaysia were genotyped for HLA-A, -B, -C -DRB1, and -DQB1 loci using polymerase chain reaction sequence-specific oligonucleotide probe hybridization methods. In this report, there were significant deviation from Hardy-Weinberg proportions for the HLA-A (p<0.0001), -B (p<0.0001), -DRB1 (p<0.0001) and -DQB1 (p<0.01) loci. Minor deviations from HWEP were detected for HLA-C (p=0.01). This genotype data was available in Allele Frequencies Network Database (AFND) Gonzalez-Galarza et al. (2015).
The effect of biologic disease modifying anti-rheumatic drugs (bDMARDs) in treating rheumatoid arthritis (RA) in real-world clinical practice remains unknown in Southeast Asia. We aimed to assess the efficacy and safety of bDMARDs among Malaysian RA patients treated in routine clinical practice. A retrospective medical chart review of RA patients from 11 government hospitals were conducted from January 2003 to January 2014. A standardized questionnaire was used to abstract patient's demographic, clinical and treatment data. Level of disease activity was measured by DAS28 collected at baseline, 3, 6 and 12 months. Three hundred and one patients were available for analysis, mean age 41 (SD, 10.8) years, mean RA duration 12.3 (SD, 6.9) years and 98% had history of two or more conventional-synthetic DMARDs. There were 467 bDMARD courses prescribed with mean bDMARDs duration use of 12.9 months (SD 14.7). Tumour necrosis factor alpha inhibitors were the most common prescribed bDMARDs (77.1%), followed by Tocilizumab (14.6%) and Rituximab (8.4%). We observed significant improvement in mean DAS28 values from baseline to 3, 6 and 12 months (p
AIM: The main objective of this study is to elucidate the clinical significance of the SLC2A9/GLUT9 rs11722228 polymorphism among male gout patients.
METHOD: We consecutively recruited all newly diagnosed male gout patients who were treatment-naive from the rheumatology outpatient clinics of two Malaysian hospitals. Age-matched healthy male adults were employed as controls. All subjects were tested for the SLC2A9/GLUT9 rs11722228 genotypes, serum uric acid (SUA), urine uric acid and creatinine levels. All gout subjects were examined for the presence of tophi and sonographically screened for renal calculi.
RESULTS: A total of 73 male gout patients and 73 age-matched healthy male adults were recruited in this study. The genotypic frequencies of SLC2A9/GLUT9 rs1172228 did not differ significantly between the gout cases and the healthy controls. The gout subjects with the CC genotype had significantly higher SUA levels (P = 0.002), family history of gout (P < 0.050) and the occurrence of renal calculi (P = 0.026). The SUA-adjusted odds ratios (OR) of the occurrence of renal calculi in the CC genotype (OR = 1 [reference]) was significantly higher than the CT genotype (OR = 0.338, 95%CI: 0.141-0.813) and the TT genotype (OR = 0.271, 95%CI: 0.086-0.854).
CONCLUSIONS: The genotypic distribution of SLC2A9/GLUT9 rs1172228 in male gout patients did not differ significantly from that of healthy male controls. However, the CC genotype in gout had significant associations with higher levels of SUA, renal calculi and a positive family history of gout.
Study site: Rheumatology clinic, Tuanku Jaafar Hospital, Malaysia and Putrajaya Hospital, Malaysia