AB0714 DELAY IN THE INITIATION OF DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND FACTORS RESPONSIBLE FOR THE DELAY
Authors: M. Z. Amin, S. Ahmed, F. Shumy, A. Kamruzzaman, A. T. M. T. Hasan, I. H. Bandhan, M. R. Choudhury
Journal: Annals of the Rheumatic Diseases (2024)

<h3>Background:</h3> Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by joint inflammation, leading to substantial morbidity and disability. Timely initiation of Disease-Modifying Anti-Rheumatic Drugs (DMARD) is imperative for effective management, yet delays in initiation persist. This research investigates the factors contributing to delays in DMARD initiation among RA patients, aiming to enhance our understanding of barriers and propose strategies for improvement. <h3>Objectives:</h3> To determine the delay (lag time) between the onset of symptoms and the initiation of DMARDs in patients with RA and to assess the factors responsible for the delay. <h3>Methods:</h3> This cross-sectional study was conducted in the outpatient department of rheumatology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh. A mixed-methods approach was employed, involving retrospective analysis of medical records, cross-sectional surveys, and interviews. For generating factors that may be responsible for the delay, group discussions were done. The group included seven members (three rheumatologists and four residents). A preliminary questionnaire was served to 10 patients to refine the questionnaire and add factors. A total of 187 patients aged ≥18 years who met 2010 ACR/EULAR criteria for RA were enrolled after having written informed consent. Patients who failed to reproduce medical records and were unable to give an adequate history were excluded from the study. Associations between the lag time and the factors affecting the lag time were analyzed by multiple linear regression analysis. <h3>Results:</h3> A total of 154 patients were included. The average disease duration was 61.3±55.7 months. 22% of patients had deforming disease. The first physician visit occurred approximately 8.1 months after the onset of the symptoms, whereas the mean duration of the initial physician visit to the start of DMARD was around 20.5 months. The mean lag time between the onset of symptoms and the start of DMARD therapy was 28.6±36.1 months. Only 29.9% of our patients initially attended with a qualified medical graduate. Of them, only 11% attended to a rheumatologist. Whereas 38.3% attended to a general practitioner at the onset of their disease, followed by orthopedic surgeons (19.5%), physical medicine specialists (14.3%), internal medicine specialists (4.5%), nephrologists (3.2%), neurologists (3.9%), neurosurgeons (0.6%), and cardiologists (1.9%). The majority of the patients (70.1%) took initial remedies from non-qualified practitioners like medicine shopkeepers (27.3%), rural practitioners (16.2%), homeopathic practitioners (15.6%), kobiraj or ayurvedic practitioners (7.1%), unani (1.9%), and herbal medicine (1.3%) practitioners at the onset of their symptoms. A total of 64.3% of our study subjects believed that indigenous medicine was effective. The mean distance from the nearest rheumatology services for our patients was 48.7±59.7 kilometers, whereas the mean distance from the nearest healthcare facility was 4.4±3.8 kilometers. Only 29.2% of our study patients could start DMARD treatment within 3 months of disease onset. Most of our patients got methotrexate as their starting DMARD (89.6%). Referral to the right specialty, like rheumatologist or a trained internal medicine specialist, was not done by primary care physicians for the majority of our patients (59.7%). Primary care physicians started DMARD treatment for only 30% of RA patients. Several factors were found to be significant in the regression model, like the predominant pattern of initial joint involvement, distance from the residence to the nearest rheumatology service provider, inappropriate referral by a primary care physician, year of RA symptom onset, and lack of correct information on the availability of physicians with expertise in RA treatment. <h3>Conclusion:</h3> Minimizing the delays in the diagnosis of RA and starting DMARD at an early stage will prevent complications related to the disease. Measures like increasing the number of rheumatologists, establishing a referral system, and creating awareness among patients, caregivers, and policymakers are required. <h3>REFERENCES:</h3> <b>NIL.</b> <h3>Acknowledgements:</h3> <b>NIL.</b> <h3>Disclosure of Interests:</h3> <b>None declared.</b>