COMBINATION THERAPY IN RA

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TREATMENT OF RHEUMATOID ARTHRITIS
Asgar Ali Kalla Professor of Rheumatology Universi
ty of Cape Town
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PREVALENCE OF RAIN SOUTH AFRICA

• Urban Tswana 0.9
• Rural Tswana 0.12
• Xhosa 0.68

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Clinical Course of RA
Severity of Arthritis
Years
Type 1 Self-limited5 to 20 Type 2
Minimally progressive5 to 20Type 3
Progressive60 to 90
Adapted from Pincus. Rheum Dis Clin North Am.
199521619.
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DETERMINATION OF COSTOF ILLNESS

• Direct costs
• Indirect costs
• Intangible costs

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Direct Costs

• Outpatients costs
• Physician and Health professional
• Radiographs
• MRI, CT scans
• Endoscopies
• Other tests
• Drug Costs
• DMARDs
• Biologics
• NSAIDs
• GI medications and Analgesics
• Hospitalisation costs

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INDIRECT COSTS

• Loss of income from work
• Work disability in 60 - 70 after
• 5 years
• RA more likely to lose jobs or retire early than
  OA
• Reduction in household income
• 15 unable to get work
• 3 - 4 x higher than direct costs
• Underestimated because of predominance of women

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INTANGIBLE COSTS

• PAIN
• PSYCHOLOGICAL
• Depression, Coping, Anxiety, Cognitive
  changes
• LIMITED ACTIVITIES
• CHANGE IN APPEARANCE

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ARTHRITIS IMPACT SURVEY(KEH, Durban)

• 35 Totally dependent on state support
• Pensioners 10
• Disability grant 25
• Two thirds of patients who stopped working did so
  because of their arthritis

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Disability Legislation

• In 1990 President Bush signed into law the
  Americans with Disabilities Act to extend the
  application of civil rights legislation to
  persons denied access to employment, housing,
  education, transportation or leisure pursuits due
  to chronic diseases

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Factors influencing work disability in RA

• Employment factors
• Nature of job, physical activity needed, degree
  of autonomy, work environment, transport to work
• Employee factors
• Age at onset of RA, marital status, education,
  motivation for work
• Disease factors
• Time since onset, level of disability, EMS,
  flare-ups
• Other factors
• Visits to GP, hospital clinic, surgery,
  rehabilitation

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Vocational Rehabilitation

• A process whereby those disadvantaged by
  illness or disability can be enabled to access,
  maintain or return to employment, or other useful
  occupation

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Vocational Rehabilitation

• The best way to maintain work is to communicate
  quickly with employer at disease flare-up
• Encourage openness between patient and employer
• Current employer more likely to facilitate
  continued working than a new employer
• Return on costs between 2 10 fold

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Remedies

• Referral to Work Assessment Unit
• Health service ready to respond to workers
  urgent need
• Physician assessment of the risk of job loss
• Job modification
• Transport
• Self-employment
• Intensive rehabilitation

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Cellular components in RA joints
Buckley CD, Br Med J 315 236238, 1997
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Cells and cytokines in the arthritic joint
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www.boneandjointdecade.org
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Conclusions

• Rheumatoid Arthritis causes severe disability
• Work assessment essential component of
  management
• Co-operation between employer, employee,
  physician
• Major advances in therapy in recent years

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