Rheumatoid Arthritis: Patient Characteristics and Disease Activities at Tertiary Hospital in Saudi Arabia

The body's defense mechanism against disease and pathogenic microorganisms is the immune system, which is made up of a wide range of chemicals and cells [1]. All autoimmune diseases (AD) are rooted in a failure to distinguish self from non-self, which is a breach of tolerance [2]. Genetic and environmental factors and their interactions all contribute to the development of ADs, even if their pathophysiology and etiology are uncertain [3]. Chronic synovial joint inflammation is a hallmark of rheumatoid arthritis (RA), a systemic inflammatory disease [4]. It also has extra-articular characteristics [5], which include cutaneous, cardiac, pulmonary and renal diseases [6]. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are autoantibodies that are essential for RA diagnosis and estimation of disease activity [7].

The prevalence of RA has been increasing worldwide, a meta-analysis done between 1980 and 2019 estimated the newly diagnosed cases at 460 per 100,000 people [8]. Treat-to-target (T2T) principles stress the importance of achieving remission or reduced disease activity [9]. Several practical and safe drugs can reduce inflammation and lead to low disease activity or remission. Among them are oral conventional synthetic disease-modifying anti-rheumatic medicines (DMARDs as methotrexate), injectable biologic DMARDs and oral targeted synthetic DMARDs [9]. However, this therapeutic model did not consider the patient characteristics that could influence a patient's likelihood of returning to minimal disease activity or remission regardless of treatment. Moreover, depending on patient’s demographics characteristics and the history of fluctuations in the disease’s activity, physicians can predict the future illness behavior [10].

RA imposes a significant socioeconomic burden on patients and healthcare systems in Saudi Arabia. A study at King Saud University Medical City estimated the average annual direct medical cost per RA patient to be 38,596 SAR (±3,055). Costs increased to 75,097 SAR for patients undergoing knee replacement procedures. The primary cost driver was biologic disease-modifying antirheumatic drugs (DMARDs), accounting for 84% of expenses [11]. Research comparing tocilizumab to adalimumab and etanercept among RA patients in Saudi Arabia highlighted the need for cost-effectiveness analyses to inform treatment decisions, given the high costs associated with biologic DMARDs [12]. RA treatment in Saudi Arabia presents a substantial economic burden, mainly due to the high costs of biologic therapies. Addressing these challenges requires strategies to improve insurance coverage, enhance cost-effectiveness of treatments and support patients financially to ensure access to necessary care.

Recent advancements in RA management have revolutionized treatment approaches, leading to improved disease control, reduced joint damage and better patient outcomes. Key innovations include early aggressive treatment strategies, targeted biologic therapies and personalized medicine. Modern RA management emphasizes early diagnosis and aggressive pharmacological intervention to prevent disease progression [13]. The "treat-to-target" strategy focuses on tight disease control using composite disease activity measures [14]. Advances in biologics include TNF inhibitors (etanercept, infliximab), IL-6 inhibitors (sarilumab, tocilizumab) and B-cell therapies (rituximab), which provide targeted suppression of inflammatory pathways. Janus kinase (JAK) inhibitors such as tofacitinib and filgotinib offer an oral alternative to biologics with promising efficacy [4]. The past decade has seen a shift from traditional DMARD monotherapy toward targeted biologics, JAK inhibitors and personalized combination therapies. These advancements have significantly improved patient outcomes, though cost, safety and accessibility remain challenges. Future research aims to refine treatment strategies for higher remission rates and fewer side effects [15].

According to research done in Ecuador in 2019, women are more likely than males to have the disease, which results in greater impairment and more severe symptoms [16]. A 2020 study conducted in Mexico revealed a strong positive correlation between having a high body mass index (BMI) and number of swollen joints [17]. Additionally, a study conducted in Mexico in 2022 revealed that individuals with positive antibody tests have higher joint damage based on their ACPA and RF status, especially in the metacarpophalangeal (MCP) joints [18]. Leflunomide therapy at prescribed dosages enhances clinical improvement, according to a 2019 Polish study [19]. In addition, a study done in Germany in 2015 concluded that patients with chronically high disease activity have a higher mortality risk that reduced by efficient management of disease activity [20]. Additionally, a Japanese study has shown that increased use of biological DMARDs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) improved the disease activity and functional impairment measures of RA patients over ten years [21].

There are few studies done in Saudi Arabia to assess the disease activity with other factors. This study aimed to evaluate comparison between RA patients' demographics, medication use and the disease activity at a tertiary hospital in Jeddah, Saudi Arabia.

Study Design and Settings

This retrospective study was conducted at King Abdulaziz University Hospital (KAUH), a tertiary care facility in Jeddah, Saudi Arabia.

Study Participants and Ethical Considerations

The study included 259 patients diagnosed with RA by a rheumatologist and met the ACR/EULAR 2010 categorization criteria for RA diagnoses aged ≥18 years during the study period [22]. Excluded from the study were patients did not meet the ACR/EULAR 2010 categorization criteria for RA diagnoses and those under 18. Data was collected from the internal medicine department's electronic medical records (EMR) at KAUH during period from December 2021 to December 2023. The study received approval from the Institutional Review Board (IRB) of KAUH (Reference Number 744-23).

Data Collection

Demographic data, including gender, marital status, whether they have children, education and occupation, were recorded. Clinical characteristics, including the disease duration and BMI, were collected. Data was also gathered regarding past and current medications including Non-steroidal Anti-inflammatory Drugs (NSAIDs), corticosteroids, DMARDs and other medications. RF, anti-nuclear antibody (ANA) and ACPA levels were obtained by accessing laboratory data from the patient's file. Two methods were used to measure disease activity: the disease activity score in 28 joints (DAS28) or the clinical disease activity index (CDAI) [23,24].

Total Joint Count (TJC), Swollen Joint Count (SJC), provider global assessment and patient global assessment were used to calculate CDAI. Remission (CDAI < 2.8), mild disease activity (CDAI >2.8 and <10), moderate disease activity (CDAI >10 and <22) and severe disease activity (CDAI >22) were the four categories of disease activity according to the CDAI [23]. TJC, SJC, an Erythrocyte Sedimentation Rate (ESR) and a visual analog scale were used to determine DAS28. A patient is in remission if their DAS28-ESR score is less than 2.6; low activity is suggested by a score higher than or equal to 2.6 and less than 3.1; moderate activity is indicated by a score greater than or equal to 3.1 and less than 5.1; and high activity is indicated by a score of 5.1 or more [24].

Data Analysis

Data were collected and stored throughout Microsoft Spreadsheet Version 20 and Statistical analysis was done using Statistical Package of Social Science (SPSS) version 21. A p-value less than 0.05 was considered significant. Categorical data has been stated according to the drug class and disease activity. Pearson Chi-Square (χ²) Test used to assess comparison between disease activity and different drug classes. Quantitative and demographic variables have been visualized in compound bar charts.

In this retrospective record study 259 RA patients were included, most of them were females (N = 230), married (N = 205) and had children (n = 206). Also, most subjects who participated in the study were college students (N = 116) and were unemployed (N = 238). ANA, RF and anti-CCP were positive in 90, 109 and 103 patients, respectively. There were 232 patients on treatment and 27 did not receive treatment. There were insignificant different between treated and untreated patients regarding gender (p = 0.998), marital status (p = 0.809), having children (p = 0.780), education (p = 0.977), job (p = 0.672) as well as status of ANA (p = 0.587), RF (p = 0.998) and Anti-CCP (p = 0.748) (Table 1). The distribution of the illness duration is represented in Figure 1.

Table 1: Subject’s demographic characteristics and laboratory data according to treatment status

Figure 1: The distribution chart shows the duration of illness according to treatment status

Regarding the disease activity, patients on treatment are categorized achieve remission (N = 30, 12.9%), low disease activity (N = 104, 44.8%) moderate disease activity (N = 93, 40.1%) and high disease activity (N = 5, 2.1%) (Figure 2).