Clinical manifestations and disease activity score of rheumatoid arthritis in southeast of Iran

Mahnaz Sandoughi 1 , Mahmoud Ali Kaykhaei 1 , Mahnaz Shahrakipoor 2 , Reza Darvishzadeh 1 , Masoumeh Nikbakht 1 , Sogol Shahbakhsh 3 and Zahra Zakeri 4 * Department of Internal Medicine, Ali Ebne Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran. Department of Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran. Medical Student, Iran University of Medical Sciences, Tehran, Iran. Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran


Introduction __________________________
Rheumatoid arthritis is a chronic systemic inflammatory disease with an unknown etiology.It is the most prevalent inflammatory arthritis.Different studies in developed countries have investigated its manifestations.QUEST-RA and an 8-year cohort study are two great studies in this field [1,2].Another study was conducted in 75 hospitals in France on both outpatients and inpatients [3].Still other studies have been conducted in developing countries, including Turkey,Brazil,Malaysia,.It seems that the clinical manifestations of rheumatoid arthritis in terms of DAS-28 and functional class differ between developing and developed countries, such that the functional class has remained at a satisfactory level despite a high DAS-28 in developed countries [6].However, extra-articular manifestations are less prevalent in Mediterranean countries [8].
There have been several registered studies in Iran concerning demographics and the clinical manifestations and activity of rheumatoid arthritis [9,10].This disease has a non-homogenous trend with different manifestations across the world, and there is little data about it in developing countries, including Iran.Therefore, this study was designed to assess its manifestations in the Sistan and Baloochestan province in southeastern Iran.The necessity of modifying treatment strategies and the need for biological medications can be assessed by investigating the specifications of this disease and promoting awareness of its activity in this region.

Materials and Methods _________________
This is a descriptive, cross-sectional study in which samples were selected by convenience sampling.All cases referred to the Rheumatology Clinic of Ali Ebn Abitaleb Hospital in the time period of one year (October 2012 to October 2013).This study was approved by the Zahedan University of Medical Science Ethics Committee.All patients who were diagnosed with rheumatoid arthritis and fulfilled the American College of Rheumatology (ACR) and European League Against Rheumatism (ULAR) classification criteria for rheumatoid arteritis were selected for participation in the study by two rheumatologists.Data was collected by a trained nurse with direct supervision by the rheumatologists.The data registered in the patients" charts included: demographic information, duration of morning stiffness (any kind of discomfort experienced in the morning), highlighted pain zones on pictures, therapy regimen, functional class, rheumatoid nodules (confirmed by a rheumatologist), associated diseases such as hypertension (over 140/90) or consumption of anti-hypertensive drugs, hyperlipidemia with triglycerides >200, total cholesterol ≥200, and LDL ≥130 or consumption of anti-lipidemic drugs, and diabetes (FBS ≥126) or consumption of anti-diabetic drugs.
DAS-28 values were investigated by a rheumatologist who recorded the number of swollen and tender joints.
Statistical analysis.All the information (raw data) collected from patients was saved in an Excel 2010 file (Microsoft Office, Microsoft, Washington D.C., USA).Data was presented as Mean ± SD or frequency (Relative Frequency %) for quantitative or qualitative variables, respectively.All statistical analyses were carried out using SPSS version 16 (SPSS Inc., IL, USA).

Results _______________________________
This study assessed 500 cases occurring within one year, 437 of whom were female (87.4%) and 63 were male (12.6%).Information regarding the cases and some clinical manifestations is shown in Tables 1 and 2, respectively.The mean age of subjects was 48.78 ± 13.97 years, and the mean duration of the disease was 7.28 ± 7.14 years.The mean DAS-28 value was investigated in 476 cases (24 cases were missed) and values ranged from 0.14 to 7.75 (average=3.54 ± 1.38) (Table 3).Among the cases, 287 (57.4%) and 154 (30.8%) suffered from joint tenderness and joint swelling, respectively.
The In this study, 87.45% of participants were female and 12.55% were male rheumatoid arthritis patients; the ratio of female to male was 7:1.This is similar to Latin American countries (5.2:1) and South Africa (6.9:1), but it is higher than European countries and the USA where the ratio is 3:1 [11].
In the current study, the equivalent DAS-28 was 3.54, which is lower than that of Dubai (5.2) [12], France (4.9) [3], Algeria (4.3) [13], and Malaysia (4.28) [6] and higher than that of Qatar (2.91) [7].The doses and timely consumption of drugs are important factors affecting .Biological medications were not used in this study because of the poor economic status of this region and the lack of insurance coverage for drugs.In studies conducted in France and Qatar, however, 29% of cases received biologics.Corticosteroids were used by 81%, 72%, 72.7%, and 51% of cases in Iran, France, Malaysia, and Qatar, respectively.Methotrexate was used by 62.4%, 45%, 51.3%, and 75% of cases in Iran, France, Malaysia, and Qatar, respectively.The lower DAS-28 of Qatar cases may originate from the higher consumption of methotrexate and other biologics.
In this study, 14.71% of cases had DAS-28 ≥5.1, which is lower than Turkey (52.1%) [4], while both countries selected cases from one center and a subspecialty clinic.In Turkey, 81% and 4% of cases consumed methotrexate and TNF blockers, respectively.According to Turkish authors, no access to timely treatment facilities is a cause for high DAS-28 values.This problem exists in the studied region too.Therefore, geographical and race differences should be taken into account in explaining differences in the results.
A part of disease activity assessment using DAS-28 is associated with the patients" perception of pain intensity.This is a subjective finding which depends on different factors, including education.In this study, 379 cases (75.8%) had a minimal education (<12 years).This result is consistent with Gladers" study where 77% of cases had a minimal education [15].In Malaysia, 55.6% of cases had a minimal or no formal education [6].Some studies have indicated the existence of a relationship between rheumatoid arthritis and a minimal education [16,17].It should be noted that the education level of the patients affects their perception expressed by the visual analogue scale.The frequency of rheumatoid nodules in this study was 2.6%.This is consistent with its frequency in Turkey (3.6%), Malaysia (4.5%), and Latin America (2.5%) but differs from its frequency in Brazil (12.5%).There is no justifiable explanation in the literature regarding this difference.Some authors have suggested that not paying accurate attention to the nodules may be considered a viable reason, but conducting more studies seems necessary.
The results of this study were extracted from one center, and this is a limitation of this study.This study was done in a referral center in the Sistan and Baloochestan province and covered a part of the southeast region of Iran, but patients with mild manifestations may not refer to this center and some patients referred to other nearby provinces.Therefore, the cases in this study may not represent all the patients of this province, and this necessitates the conducting of studies in multiple centers.

Conclusion ___________________________
This study found a lower mean age of patients, higher Disease activity score of rheumatoid arthritis 64 Rheum. Res., Vol. 2, No. 2, Apr. 2017 female to male ratio, and lower prevalence of nodules in rheumatoid arthritis patients in southeastern Iran than in European and North American countries.These results are consistent with findings of other studies in developing countries.Moreover, the mean value of DAS-28 was 3.54, implying the activity of this disease in most cases in southeastern Iran.This indicates the necessity of changing therapy regimens.

Table 1 .
Demographic data of patients with rheumatoid arthritis

Table 3 .
Disease activity score ESR DAS-28 in patients with rheumatoid arthritis