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PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010National Infl ammatory Arthritis Registry (NIAR)ii

Published by:Na onal Infl ammatory Arthri s Registry (NIAR)Clinical Research Centre, 4th fl oor Specialist offi ceSelayang Hospital, Selayang-Kepong Highway68100 Batu Caves, SelangorMalaysia

Direct line : (603) 6120233 ext 9111/4169Fax : (603) 61202761Website : h ps://app.acrm.org.my/NIAR

Disclaimer : Data reported here are supplied by the NIAR. Interpreta on and repor ng of these data are the responsibility of the editors and in no way should be seen as an offi cial policy or interpreta on of the NIAR. This report is copyright. However it can be freely reproduced without the permission of the NIAR. However, acknowledgement would be appreciated.

Suggested cita on : The suggested cita on for this report is as follows: Dr Azmillah Rosman, Dr Hasselynn Hussein, Dr Gun Suk Chyn, Dr Lau Ing Soo, Dr Mollyza Mohd. Zain, Dr Habiba @ Habibah Mohd Yusoof Dr Asmahan Mohamed Ismail, Dr Liza Mohd.Isa, Dr Nor Shuhaila Shahril, Dr Ramani Arumugam, Dr Ong Yew Chong

ISSN No :

PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010National Infl ammatory Arthritis Registry (NIAR) iii

CONTENTS

ACKNOWLEDGEMENTS

STEERING COMMITTEE MEMBERS

MEMBERS OF THE ADVISORY BOARD

LIST OF CONTRIBUTORS

ABOUT NIARObjec veInclusion CriteriaInstrumentData Flow ProcessProgress

1. DISTRIBUTION OF CASES ACCORDING TO HOSPITAL

2. DEMOGRAPHICS2.1 GENDER DISTRIBUTION2.2 AGE DISTRIBUTION2.3 ETHNIC GROUP2.4 SOCIOECONOMIC STATUS

2.4.1 PROFESSIONAL VS NON-PROFESSIONAL2.4.2 INCOME GROUP

2.4.3 PERSONAL MEDICAL INSURANCE 3. CHARACTERISTICS OF PATIENTS

3.1 NUMBER OF PATIENTS FULFILLING ACR CRITERIA3.2 DURATION OF DISEASE BEFORE DIAGNOSIS3.3 ASSOCIATED MEDICAL PROBLEMS

3.3.1 MEDICAL CO-MORBIDITIES3.3.2 MALIGNANCIES

3.4 EXTRAARTICULAR MANIFESTATIONS3.5 DISEASE STATUS AT 1ST NOTIFICATION

4. DISEASE BURDEN4.1 WORK STATUS4.2 DAYS OF SICK LEAVE TAKEN DUE TO ARTHRITIS IN THE PAST 3

MONTHS

5. STANDARD OF CARE5.1 TIME TO INITIATION OF DMARDS AFTER DIAGNOSIS5.2 TYPES OF DMARDS USED

1

2

2

3

566667

9

1112121314141515

1718192020212122

2526

26

272829

PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010National Infl ammatory Arthritis Registry (NIAR)iv

5.3 USE OF COMBINATION DMARDS 5.4 USE OF BIOLOGICS5.5 USE OF ORAL STEROIDS5.6 USE OF NSAIDS/COX2 INHIBITORS5.7 SURGERY

DISCUSSION

CONCLUSIONS AND RECOMMENDATIONS

REFERENCES

APPENDIX I : CASE REPORT FORMAPPENDIX II : INFORMATION ON PATIENT CONFIDENTIALITY

2930303030

31

33

35

PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010National Infl ammatory Arthritis Registry (NIAR) 1

ACKNOWLEDGMENTS

The Na onal Infl ammatory Arthri s Registry would like to express its sincere thanks and apprecia on to all who have supported and contributed to this report.

We thanks the following for their support:

• The Ministry of Health, Malaysia• Y.B. Tan Sri Dato’ Seri Dr Hj Mohd Ismail Merican, Director General of Health,

Malaysia• Dr Lim Teck Onn, Director, Network of Clinical Research Centre• Dr Goh Pik Pin, Co-Director, Network of Clinical Research Centre• Dr Jamaiyah Haniff , Head of Clinical Epidemiology Unit of CRC• Informa on technology personnelnamely MS Lim Jie Ying, database administrator,

Ms Teo Jau Shya, clinical data manager• Members of the “Steering Commi ee” for their contribu ons to the registry• Clinical Research Centre, Ministry of Health, Malaysia• Other sponsors and supporters from the professional bodies, industries and

ins tua ons as listed below:

Ka Consul ng Sdn. BhdSchering PloughStaff from Hospital Selayang, Hospital Tuanku Jaafar, Seremban andHospital Putrajaya

PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010National Infl ammatory Arthritis Registry (NIAR)2

STEERING COMMITTEE MEMBERS

Dr Azmillah Rosman (Principal Inves gator)Department of Medicine, Hospital Selayang

Dr Chow Sook KhuanSunway Medical Centre

Dr Amir Azlan ZainSunway Medical Centre

Dr Heselynn HusseinDepartment of Medicine, Hospital Putrajaya

Dr Gun Suk ChynDepartment of Medicine, Hospital Tuanku Abdul Jaafar, Seremban

Dr Lau Ing SooDepartment of Medicine, Hospital Selayang

Dr Mollyza Mohd ZainDepartment of Medicine, Hospital Selayang

MEMBERS OF THE ADVISORY BOARD

Dr Lim Teck Onn (Chairman)Clinical Research Centre, Ministry of Health Malaysia

Tan Sri Hari Narayanan (Co-chairman)Arthri s Founda on Malaysia

Ms Ding Mee HongArthri s Founda on Malaysia

Professor Florence WangUniversity Malaya Medical Centre


LIST OF CONTRIBUTORS

Hospital Selayang

Dr Azmillah RosmanDr Lau Ing SooDr Mollyza Mohd ZainDr Habibah Mohd YusoofDr Asmahan Mohamed IsmailDr Chong Hwee ChengDr Kuan Woon PangDr Ramani ArumugamDr Shereen Ch’ng SuyinDr Hilmi AbdullahDr Ong Yew ChongMdm Ramlah ShukorMdm Norlela Mohd Salleh

Hospital Tuanku Jaafar, Seremban

Dr Gun Suk ChynDr Beryl D’SauzaDr C GandhiDr Lim Ai LeeDr Nadia Mohd NoorMdm Ho Ah May

Hospital Putrajaya

Dr Heselynn HusseinDr Eashwary MageswarenDr Liza Mohd IsaDr Nor Shuhaila ShahrilDr Shamala RajalingamMdm Amnahliza Abu Rahman

ABOUT THE NATIONAL INFLAMMATORY ARTHRITIS

REGISTRY (NIAR)


ABOUT THE NATIONAL INFLAMMATORY ARTHRITIS REGISTRY (NIAR)

Introduc on

Rheumatoid Arthri s (RA), the most common form of infl ammatory arthri s is es mated to aff ect about 1% of the popula on. Of unknown ae ology, it typically aff ects many joints, causing acute infl amma on, in most cases leading to joint erosions and joint damage (1). The NIAR, ini ated in 2008, was set up with the aim of obtaining informa on about pa ents with Rheumatoid Arthri s. Informa on about pa ents with the other infl ammatory arthri des will be collected in the future.

Objec ves

1. To determine the incidence and prevalence of RA in Malaysia.2. To obtain demographic data.3. To determine the disease expression in terms of clinical manifesta ons.4. To study the management of pa ents.5. To assess pa ents’ outcome, studying pa ents’ disease ac vity, extent of disability,

economic impact and mortality rate.

Inclusion Criteria

Patients enrolled into the registry are patients with established Rheumatoid Arthritis, diagnosed by a rheumatologist.

Instrument

A structured Case Report Form (CRF) [Appendix I] is used for data collection. The CRF was designed and reviewed by a technical committee. Prior to the launch of the registry, copies of the CRFs were distributed to doctors from the various hospitals involved. A trial run was done and feedback given to the committee before the fi nal CRF was used for data collection. Training sessions were also conducted at the hospitals involved.Patients’ outcome is assessed three times - at months 0, 6 and 12.

Data Flow Process

The registry is coordinated centrally at the Clinical Research Centre (CRC) based at Hospital Selayang. Each hospital has an appointed clinic and registry nurse. The database is available online via password access.

Patients attending their regular clinic appointments were identifi ed. Verbal consent was obtained from patients using the Patient Confi dentiality Information form [Appendix II]. Demographic information was obtained from the patient or carer. Joint count assessments


were then performed by the assessing doctor while other information necessary to fi ll into the CRF was obtained from patients’ medical records. The registry nurse then entered the information into the online database. The next outcome date was then determined and this was coordinated with patients’ scheduled clinic visit.

Patient identifi ed byAppointed clinic

Nurse / Dr

Nurse / Dr obtains basic demographic

information

Doctor performs joint count and fi lls in

relevant information manually

Registry nurse enters data online

Registry nurse determines next visit date, informs clinic

nurse

Figure 1: Data Flow Process

Progress

The NIAR was launched offi cially on 18th December 2008. A er a trial run, the fi rst pa ent was enrolled into the registry on 21st April 2009. The online database was started on 22nd May 2009. As of 31st August 2010, 1000 pa ents have been enrolled into the registry.

DISTRIBUTION OF CASES ACCORDING TO HOSPITAL


1. DISTRIBUTION OF CASES ACCORDING TO HOSPITAL

Three hospitals were chosen for the pilot project, namely Hospital Selayang, Hospital Tuanku Jaafar, Seremban and Hospital Putrajaya. These hospitals were selected as they are the largest rheumatology centres in the MOH. The distribu on of cases are as follows:

Hospital Putrajaya202 (20.2%)

Hospital Tuanku Jaafar, Seremban

364 (36.4%)

Hospital Selayang 434 (43.4%)

N = 1000 pa ents

Figure 2: Distribu on of cases according to hospital

DEMOGRAPHICS


2. DEMOGRAPHICS

2.1 GENDER DISTRIBUTION

MaleFemale

12.6%

87.4%

Figure 3: Gender distribu on

The gender distribu on showed a female preponderance at 87.4% (n=874) compared to males 12.6% males (n=126). The male to female ra o was approximately 7:1.

2.2 AGE DISTRIBUTION

0

5

10

15

20

25

30

35

40

12 to 20

0.6

4.3

10.3

23.3

37.5

17.2

6.9

21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71>

Figure 4: Age Distribu on


Currently, data has only been collected for adult pa ents with Rheumatoid Arthri s, defi ned as those above 12 years old.

The mean age was 52.57 years with the youngest pa ent being 18 years and the oldest 87 years.

More than half of the pa ents were in the 41-60 age group categories.

2.3 ETHNIC GROUP

The Malays being the largest ethnic group in Malaysia made up 43.2% of the pa ents in the registry. The Indians who are the smallest of the 3 major ethnic groups in Malaysia made up 30.4% followed by the Chinese at 24.1%. The other ethnic groups and foreigners comprised 2.3% of the pa ents.

30.4%2.3%

43.2%

24.1%

Malay

Chinese

Indian

Other

Figure 5: Distribu on of ethnic groups

Comparing these fi gures with the 2004 Malaysian Census, the Indians are over-represented since they cons tute only 7.1% of the Malaysian popula on (2). The under-representa on of the other ethnic groups in the registry may be explained by the fact that none of the hospitals in Sabah or Sarawak were included in this pilot project.


Malaysian Census 2004 NIAR Malay 50.4% 43.2%

Chinese 23.7% 24.1% Indian 7.1% 30.4% Other 18.8% 2.3%

Table 1: Comparison of ethnic groups with Malaysian Census 2004

2.4 SOCIO-ECONOMIC STATUS

2.4.1 PROFESSIONAL VS NON-PROFESSIONAL

The majority of pa ents were from the lower socio-economic group. Nearly 90% were non-professionals.

Prfessional

Non-professional

10.2%

89.8%

Figure 6: Distribu on of professional and non-professional groups


2.4.2 INCOME GROUP

0 5 10 15 20 25 30 35 40

Unknown 9.3

4.1

5.8

12.8

37.7

30.3

>7000

5001-7000

3001-5000

1001-3000

<1000

Monthly Income (RM)

% of pa ents

Figure 7: Monthly income group

Two-thirds of pa ents had a monthly income of less than RM3000.

2.4.3 PERSONAL MEDICAL INSURANCE

Two-thirds of pa ents did not have any medical insurance.

Without

With

Unknown

77.01%

21.72%

1.27%

Figure 8: Distribu on of pa ents with and without medical insurance

CHARACTERISTICSOF PATIENTS


3. CHARACTERISTICS OF PATIENTS

3.1 NUMBER OF PATIENTS FULFILLING AMERICAN COLLEGE OF RHEUMATOLOGY (ACR) CRITERIA

The tradi onal defi ni on for Rheumatoid Arthri s has been defi ned as pa ents fulfi lling 4 or more of the 7 criteria listed in the 1987 ACR criteria (Table 2) (3). This criteria has been revised in the new ACR-EULAR criteria published in 2010 (4).

Morning s ff ness > 1 hour

≥ 3 joints arthri s

Arthri s in a wrist, MCP or PIP joint

Symmetrical arthri s

Factor

Posi ve rheumatoid factor

Erosions or osteopenia on hand or wrist radiograph

* symptoms present for at least 6 weeks

Table 2: 1987 ACR criteria for Rheumatoid Arthri s

The propor on of pa ents fulfi lling each criterion is shown in Table 3.

ACR criteria % of pa ents fulfi lling criteria

≥ 3 joints arthri s 94.4

Symmetrical arthri s 92.8

Arthri s in a wrist, MCP or PIP joint 70.5

Morning s ff ness > 1 hour 70.5

Posi ve rheumatoid factor 68.5

Erosions or osteopaenia on hand or wrist radiograph

41.0

Rheumatoid factor 6.1

Table 3: Percentage of pa ents fulfi lling each ACR criteria


The percentage of pa ents fulfi lling the 1987 ACR criteria is shown in Figure 9. 78.3% fulfi ll the ACR criteria defi ni on for Rheumatoid Arthri s however a signifi cant propor on fulfi ll less than 4 of the criteria.

0

5

10

15

20

25

30

35

4

22.5

34

1.8

20

5 6 7

21.7%

78.3%

≥ 4 ≥ 4

% o

f pa

ent

s

Number of ACRCriteria fulfi lled

Figure 9: Percentage of pa ents fulfi lling ACR criteria

3.2 DURATION OF DISEASE BEFORE DIAGNOSIS

Almost half of the pa ents were diagnosed late, that is more than a year a er the onset of symptoms. However, a signifi cant propor on of pa ents were diagnosed between 1 to 6 months from symptom onset.

0

10

20

30

40

50

37.3

< 6 months < 6 months < 12 months

14

48.7

Number of months from symptom onset to diagnosis

Figure 10: Distribu on of pa ents according to dura on of diseasebefore diagnosis


Comparing professionals and non-professionals, it would appear that more professionals are diagnosed earlier, that is less than 6 months from disease onset. However, even amongst the professionals, about 40% were diagnosed more than a year from the onset of symptoms.

> 12 months

6 to 12 months

< 6 months

0

20

40

60

80

100

120

N=102

40.2

15.59

44.11

49.67

13.81

36.52

Professional Non-Professional

N=898

Figure 11: Dura on of disease before diagnosis comparingprofessionals and non-professionals

3.3 ASSOCIATED MEDICAL PROBLEMS

3.3.1 MEDICAL CO-MORBIDITIES

Among the medical condi ons, hypertension was the commonest co-morbidity with a prevalence of 36.2%. This is slightly lower than the na onal prevalence of 42.6% of hypertension in adults above 30 years of age (5). Next was hyperlipidaemia at 25.5% followed by diabetes at 16.1%. The Na onal Health and Morbidity Survey in 2006 found that the prevalence of diabetes is 12% (6). 6.1% of pa ents had been diagnosed to have osteoporosis. Pep c ulcer disease and ischaemic heart disease were each reported in 3.9% of the pa ents.

The other medical condi ons with the reported fi gures are listed in Table 4.


0 5 10 15 20 25 30 35 40

3.9IHD

PUD

Osteoporosis

DM

Hyperlipidaemia

Hypertension

3.9

6.7

16.1

25.5

36.2

Figure 12: Associated co-morbidi es

Disease % of pa entsFa y liver 2.3%

Tuberculosis 1.2%Hepa s B 1.0%

Stroke 0.6%Renal impairment 0.5%

Hepa s C 0.2%Others 20.4%

Table 4: Associated co-morbidi es

3.3.2 MALIGNANCIES

16 cases of malignancies were reported. The highest malignancy reported was breast cancer. The other malignancies to fi nd out what the other malignancies are 4 other malignancies includes - kidney, brain, thyroid & colon cancer

3.4 EXTRAARTICULAR MANIFESTATIONS

There are a number of extraar cular manifesta ons associated with Rheumatoid Arthri s. The commonest one seen in this pa ent cohort was keratoconjunc vi s sicca followed by lung fi brosis and anaemia due to rheumatoid arthri s. 35


pa ents had rheumatoid nodules. The percentages of pa ents with each extraar cular manifesta ons are listed below.

Manifesta on Numbers Percentage %

Keratoconjunc vi s sicca 226 22.6

Inters al lung disease 61 6.1

Anaemia (due to RA disease ac vity) 37 3.7

Rheumatoid nodules 61 6.1

Eye infl amma on 8 0.8

Fever 5 0.5

Raynaud’s 4 0.4

Entrapment neuropathy 4 0.4

Atlanto-axial subluxa on 4 0.4

Cutaneous vasculi s 3 0.3

Mononeuropathy 2 0.2

Polyneuropathy 1 0.1

Felty’s syndrome 1 0.1

Cervical myelopathy 1 0.1

Pleural eff usion 0 0

Pericardi s/eff usion 0 0

Amyloidosis 0 0

Lymphadenopathy 0 0

Others 9 0.9

Table 5: Extraar cular manifesta ons

3.5 DISEASE STATUS AT 1ST NOTIFICATION

The DAS28 score is used to assess pa ent’s disease ac vity. The DAS28 score is calculated based on the number of swollen and tender joints (only 28 joints are assessed), general health assessment using a pa ent visual analogue scale and either ESR or CRP. Pa ents are then categorized into either having low (DAS28 2.6 to 3.2), moderate (DAS28 >3.2 to 5.1) or high (DAS28 >5.1) disease ac vity states or in remission (DAS29 <2.6). Those whose DAS28 scores cannot be obtained for various reasons were classifi ed as unknown. Nearly half of the pa ents in this cohort were in the moderate and high disease categories.


0

5

10

15

20

25

30

35

Remission

13.916.5

31.5

16

22.1

Unknown

Disease ac vity based onDAS28 ESR/CRP score

Figure 13: Disease status at 1st no fi ca on

DISEASE BURDEN


4. DISEASE BURDEN

4.1 WORK STATUS

Full me

Re red

Part- me

Home-maker

Unemployed due to disease

Unemployed due to family

Unemployed others

2%

26%

32%51.8%

due to disease

32%

8% unempliyed

Figure 14: Work status and reasons for unemployment

8% of pa ents were unemployed but signifi cantly, nearly 52% of those who were unemployed a ributed this to their disease. 32% of pa ents were home-makers.

4.2 DAYS OF SICK LEAVE TAKEN DUE TO ARTHRITIS IN THE PAST 3 MONTHS

10

8

6

4

2

0

8.1

1 to 14 15 to 3031 to 45

46 to 60 61 to 7576 to 90

00.3

00

0.1

Number of days

% of pa ents

Figure 15: Days of sick leave taken due to arthri s in the past 3 months

Out of the 338 pa ents who were employed, 81 pa ents took between 1 to 14 days of sick leave due to arthri s. 3 pa ents took between 15 to 30 days of sick leave and 1 pa ent took sick between 46 to 60 days. None took more than 60 days of sick leave.

STANDARD OF CARE


5. STANDARD OF CARE

5.1 TIME TO INITIATION OF DMARDS AFTER DIAGNOSIS

A large propor on of pa ents were started on Disease Modifying An -Rheuma c Drugs (DMARDS) soon a er the diagnosis was made. This is in accordance with current treatment recommenda ons.

69.780

60

40

20

0

11.6

< 1months1-6 months

6-12 months>12 months

Unknown

3.3 11.611.6

Figure 16: Time to ini a on of DMARDS a er diagnosis

Comparing professionals and non-professionals, there does not appear to be much diff erence in terms of when treatment was started.

100%90%

80%70%60%50%40%30%20%10%

0%

ProfessionalN=100

Non-ProfessionalN=862

55

15

75

11.723.25

12.88

72.12

> 12 months

6-12 months

1-6 months

< 1 months

Figure 17: Time to ini a on of DMARDS a er diagnosis comparing professionals and non-professionals


5.2 TYPES OF DMARDS USED

Methotrexate (MTX) being the anchor drug in the treatment of Rheumatoid Arthri s was used in 86.6% of pa ents. This was followed by sulphasalazine (SSZ) at 69.5% and hydroxychloroquine (HCQ) at 34.6%. The use of Lefl unomide was 24.1%. The other less commonly used drugs for example cyclosporine, penicillamine, azathioprine and cyclophosphamide were used in 2.7% of the pa ents.

100%86.6

69.5

24.134.6

2.7

MTX SSZ HCQ Others

90%

80%70%60%50%40%30%20%10%

0%

Figure 18: Types of DMARDS used

5.3 USE OF COMBINATION DMARDS

697 of pa ents were on combina on DMARDS. The distribu on of pa ents using the various combina on DMARDS are shown in the fi gure below.

MTX + SSZ

MTX + Lefl unomide

MTX + SSZ + HCQ

20.44%

24.6%

35.45%

Figure 19: Combina on DMARDS used


5.4 USE OF BIOLOGICS

The use of the TNF inhibitors comprising Infl iximab, Etanercept and Adalimumab was 3.9% in this pa ent cohort.

5.5 USE OF ORAL STEROIDS

Short courses of oral steroids is some mes used as bridging therapy. The use of steroids in this pa ent popula on was 38.2%.

5.6 USE OF NSAIDS/COX2 INHIBITORS

Non steroidal an -infl ammatory drugs (NSAIDS) is used as analgesic therapy. If NSAIDS are contraindicated, pa ents can be prescribed cyclo-oxygenase 2 inhibitors (COX2 INHIBITORS). About 62% of pa ents had been on NSAIDS/COX2 INHIBITORS.

5.7 SURGERY

4% of pa ents have undergone arthroplasty. Surgical interven ons such as arthrodesis, spinal surgery and synovectomy are not commonly performed. Surgeries not directly related to rheumatoid arthri s for example appendicectomy or caesearean sec ons are categorized into other.

25

20

15

10

5

0

4

Arthroplasty Arthrodesis Spinalsurgery

Synovectomy Other

0.4 0.4 0.8

23.3

Figure 20: Surgical interven ons

DISCUSSION


DISCUSSION

This is a pilot project involving only three hospitals from the Ministry of Health. In order to be er refl ect the demographics, characteris cs, standard of care and pa ent outcomes in the general popula on, there is a need to recruit pa ents from more centres including those from private and university hospitals.

There is over-representa on of Indians in this registry perhaps due to sampling bias because of the areas covered by the three hospitals. Not surprisingly, many of the pa ents are non-professionals and from the lower socio-economic group since the three hospitals are public hospitals. These pa ents do not have medical insurance cover and need fi nancial aid from the government.

A signifi cant propor on of pa ents do not fulfi ll the ACR criteria for rheumatoid arthri s. This confi rms the fact that the criteria should not be used as the sole criterion for diagnosis since many pa ents do not fulfi ll the criteria at disease onset especially those who present early in the course of the disease.

Alarmingly, many pa ents are s ll diagnosed late. This may result in increased disease burden. Nevertheless, the results from the registry show that there are a signifi cant propor on who are diagnosed less than six months from disease onset. It may be that pa ents who were diagnosed late were those who were diagnosed in the earlier years whereas there may be a trend now towards earlier diagnosis. However, this would require further study.

A signifi cant number of pa ents have medical co-morbidi es. The prevalence of the various diseases in this pa ent cohort are similar to the prevalence rates of the Malaysian adult popula on. Pa ents with rheumatoid arthri s are at risk of osteoporosis due to the disease itself as well as due to steroid use. The prevalence of osteoporosis in this cohort was reported as 6.7%. This is markedly below the reported prevalence of 22% (7). This might be due to under-repor ng or that pa ents have been not adequately screened. Pa ents with rheumatoid arthri s are also at increased risk of malignancies. Of the malignancies, the incidence of lymphoma has been reported to be two-fold higher than expected (8). However, there were no cases of lymphoma in this pa ent cohort.

In terms of pa ent outcome, many pa ents are s ll in the moderate to high disease ac vity categories. The reasons for this need to be ascertained. It may be that more aggressive treatment strategies need to be ins tuted. The cost-eff ec veness of biologics also need to be determined in rela on to this.

Among the unemployed pa ents, more than half of the pa ents claim that this is due to their disease. Of note, 32% of pa ents are home-makers. It would be interes ng to fi nd out whether the decision to be a home-maker was infl uenced by their disease.

The majority of pa ents were started on treatment soon a er the diagnosis was made. This is in accordance with current treatment guidelines (9).



Thus far, several interes ng results have been obtained from the registry. The data confi rm that rheumatoid arthri s has signifi cant socio-economic impact to the society. Therefore, policies need to be implemented to reduce the fi nancial burden to pa ents and to society as a whole. There is also a need to raise awareness among the general public regarding the disease and primary care physicians need to refer early so that pa ents can be treated appropriately. Clinicians also need to be aware that pa ents with rheumatoid arthri s have co-morbidi es and need to be treated holis cally.

The NIAR data off ers much poten al for research and hopefully, this will serve as an impetus for research and the implementa on of policies for the benefi t of pa ents.

REFERENCES


REFERENCES

(1) Kasper D. Braunwald E. et al. Harrisons’s Principles of Internal Medicine, 17th edi on. Chapter 14: Sec on 2.

(2) Malaysian census 2004

(3) Arne FC, Edworthy SM et al. The American Rheuma sm Associa on 1987 revised criteria for the classifi ca on of rheumatoid arthri s. Arthri s Rheum. 1988 Mar;31(3):315-24

(4) Aletaha D, Neogi T et al. 2010 Rheumatoid arthri s classifi ca on criteria: an American College of Rheumatology/European League Against Rheuma sm collabora ve ini a ve. Ann Rheum Dis 2010;69:1580-1588.

(5) The Third Na onal Health Morbidity Survey (NHMS III). Diabetes Group. Ministry of Health Malaysia, 2006.

(6) The Third Na onal Health Morbidity Survey (NHMS III). Hypertension Group. Ministry of Health Malaysia, 2006.

(7) Haugeberg G et al. Clinical decision rules in rheumatoid arthri s: do they iden fy pa ents at high risk for osteoporosis? Tes ng clinical criteria in a popula on based cohort of pa ents with rheumatoid arthri s recruited from the Oslo Rheumatoid Arthri s Register. Ann Rheum Dis 2002 Dec;61(12):1085-9)

(8) Franklin J, Lunt M et al. Incidence of lymphoma in a large primary care derived cohort of cases of infl ammatory polyarthri s. Ann Rheum Dis. 2006 May;65(5):617-22.

(9) Saag KG, Teng GG, Patkar NM et al. American College of Rheumatology 2008 recommenda ons for the use of nonbiologic and biologic disease-modifi ying an rheuma c drugs in rheumatoid arthri s. Arthri s Rheum 2008;59:762.

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