2023 Management Recommendations of Bangladesh Rheumatology Society on Pharmacological Treatment of Rheumatoid Arthritis With Synthetic and Biologic Disease-Modifying Drugs.

Rheumatoid arthritis (RA) is the most common inflammatory polyarthritis in Bangladesh. Bangladesh Rheumatology Society (BRS) proposes these management recommendations to treat the considerable burden of RA in the resource-constrained situation based on the best current evidence combined with societal challenges and opportunities. BRS formed a task force (TF) comprising four rheumatologists. The TF searched for all available literature, including updated American College of Rheumatology (ACR), European Alliance of Associations for Rheumatology (EULAR), and Asia-Pacific League of Associations for Rheumatology (APLAR) and several other guidelines, and systematic literature reviews until October 2023, and then a steering committee was formed, which included rheumatologists and internists. We followed the EULAR standard operating procedures to categorize levels of evidence and grading of recommendations. This recommendation has two parts -- general (diagnosis of RA, nomenclature of disease-modifying anti-rheumatic drugs [DMARDs], disease activity indices) and management portion. The TF agreed on four overarching principles and 12 recommendations. Overarching principles deal with early diagnosis and disease activity monitoring. Recommendations 1-5 discuss using glucocorticoids, NSAIDs, and conventional synthetic DMARDs (csDMARD). Recommendations 6-9 stretch the use of targeted synthetic DMARDs (tsDMARDs) and biological DMARDs (bDMARDs). The suggested DMARD therapy includes initiation with methotrexate (MTX) or another csDMARD (in case of contraindication to MTX) in the first phase and the addition of a tsDMARD in the second phase, switching to an alternative tsDMARDs or bDMARDs in the subsequent phases. The TF included the Padua prediction score for the thromboembolism risk estimation. Recommendations 10-12 cover infection screening, vaccination, and DMARD tapering. Bangladesh has a higher prevalence of RA. This recommendation will serve as a tool to treat this high burden of patients with RA scientifically and more effectively.

Functional disability and health-related quality of life among systemic sclerosis patients in Bangladesh.

OBJECTIVE: To assess the relationship between functional disability and health-related quality of life (HRQoL) among systemic sclerosis (SSc) patients. METHODOLOGY: This cross-sectional study was carried out on 78 adults who met the classification criteria for SSc defined by the American College of Rheumatology/European League of Rheumatology (ACR/EULAR)-2013. The Bangla version of Short Form 36 (SF-36) and Health Assessment Questionnaire-Disability Index (HAQ-DI) were used to measure HRQoL and functional disability in SSc patients. RESULTS: The patients' median [IQR] HAQ-DI was 1.4 [0.6-2.1], with 37.2% having a mild functional disability, 33.3 percent having a moderate functional disability, and 29.5 percent having a severe functional disability. The hygiene and activity domains of the HAQ-DI obtained the highest scores, 2.0 [0.0-3.0] and 2.0 [1.0-3.0], respectively. The Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36 had median [IQR] values of 26.2 [15.0-58.1] and 42.0 [19.6-60.6]. The highest score was 50.0 [25.0-75.0] in social functioning. The PCS of the SF-36 was moderately correlated with the HAQ-DI (rs = - 0.629, P < 0.001) and the MCS of the SF-36 was weakly correlated with the HAQ-DI ((rs = - 0.344, P < 0.001). Age, female sex, and incomplete fist closure substantially influenced functional status. Calcinosis, Raynaud's Phenomenon, and flexion contracture significantly diminished the quality of life. CONCLUSIONS: Functional disability negatively affects health-related quality of life. Age, Musculoskeletal, and skin involvement are significantly associated with poor quality of life and functional disability. Therefore, treatment strategies should be aimed at reducing functional disability, which will enhance the HRQoL of SSc patients.

Risk factors of knee osteoarthritis in Bangladeshi adults: a national survey.

BACKGROUND: Knee osteoarthritis was reported as the second most prevalent condition in the national musculoskeletal survey. The purpose of this extended study was to identify risk factors for knee osteoarthritis in Bangladeshi adults. METHODS: This cross-sectional study was conducted in rural and urban areas of Bangladesh using stratified multistage cluster sample of 2000 adults aged 18 years or older recruited at their households. The Modified Community Oriented Program for Control of Rheumatic Disorders (COPCORD) questionnaire was used to collect data. The diagnosis of knee osteoarthritis was made using the decision tree clinical categorization criteria of the American College of Rheumatology. Univariate and multivariate logistic regression analyses were done to identify the risk factors for knee osteoarthritis. RESULTS: A total of 1843 individuals (892 men and 951 women) participated, and 134 had knee osteoarthritis yielding a prevalence of 7.3% (95% confidence interval (CI) 4.9 to 9.6%). The mean (standard deviation) age of the knee osteoarthritis patients was 51.7 (11.2) years. Multivariate logistic regression analysis found a significant association with increasing age (≥38 years OR 8.9, 95% CI 4.8-16.5; ≥58 years OR 13.9, 95% CI 6.9-28.0), low educational level (OR 1.7, 95% CI 1.0-2.7) and overweight (OR 1.9, 95% CI 1.2-2.9) with knee osteoarthritis. Knee osteoarthritis patients had a high likelihood of having work loss preceding 12 months (age and sex-adjusted OR 2.3; 95% CI 1.4-3.8; P < 0.01). CONCLUSIONS: Knee osteoarthritis is a commonly prevalent musculoskeletal problem among Bangladeshi adults having link to work loss. Increasing age, low education and overweight are significant risk factors of knee osteoarthritis.

Post-chikungunya arthritis: a longitudinal study in a tertiary care hospital in Bangladesh.

BACKGROUND AND OBJECTIVE: To identify the clinical patterns and consequences of post-chikungunya arthritis was the study's objective. METHODS: This longitudinal study was carried out among 143 Chikungunya virus (CHIKV) infected adult patients at the rheumatology department, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, during the outbreak of CHIKV infection in 2017. The disease was categorized into three phases: acute or febrile (lasting up to 10 days), subacute (11-90 days), and chronic (> 90 days). Patients who progressed towards the chronic phase were followed up to 1-year. Post-CHIKV de novo chronic inflammatory rheumatisms (CIRs) were characterized by persistent mono or oligoarthritis, undifferentiated polyarthritis, or meet the criteria rheumatoid arthritis (RA) or Spondyloarthritis (SpA). In addition, functional status was assessed by the validated Bangla version of the Health Assessment Questionnaire (HAQ). RESULTS: Mean age was 43.3 ± 11.5 years, and 51.0% were male. Within 1-year follow-up, 60 (41.9%) patients were suffering from arthralgia/ arthritis. Of them 52 patients did not have any pre-existing arthralgia/arthritis. 35 (65.3%) had undifferentiated arthritis, 10 (19.2%) had SpA, and 7 (13.5%) had RA. Patients with pre-existing rheumatological disorders, 6(4.2%) had SpA, 1(0.7%) had RA and 1(0.7%) had osteoarthritis. Polyarthralgia (n = 33, 55.0%) and polyarthritis (n = 20, 33.3%) were the main presentations. Female gender (OR: 0.45; CI: 0.21-0.96), positive IgG (OR: 0.30; CI: 0.12-0.76), and moderate to severe functional disability (OR: 3.46; CI: 1.62-7.40) were independent predictors of developing chronic post-CHIKV rheumatism. CONCLUSIONS: At 1-year follow-up, more than one-third of the patients remained symptomatic. Female gender, positive IgG, and moderate to severe functional disability contributed to the development of chronicity.

Low back pain in the Bangladeshi adult population: a cross-sectional national survey.

OBJECTIVE: Low back pain (LBP) is a common musculoskeletal disorder. This study aims to determine the residence-specific and sex-specific prevalence and the factors associated with LBP in Bangladesh. METHODS: The study subjects (aged ≥18 years) were identified from 20 primary sampling units of the national census following a cross-sectional multistage stratified sampling design. We considered the mechanical type of LBP for this study. A Bangla version of the modified Community Oriented Programme for Control of Rheumatic Disorders questionnaire was used. A team of trained field workers, rheumatology residents and rheumatologists collected the data. Analysis was done using weighted data. RESULTS: Two thousand subjects were approached, but 1843 could be screened. Among them, 561 had musculoskeletal disorders, and 343 were diagnosed with LBP. The weighted prevalence of LBP was 18.5% (95% CI: 11.8% to 25.2%) and age-standardised prevalence of LBP was 19.4% (95% CI: 14.0% to 24.8%), which was higher in women (27.2%, 19.3% to 35.1%) than men (14.0%, 8.7% to 19.3%). The prevalence persistently increased from age group 18-34 years (10.5%, 5.7 to 15.4) to ≥55 years (27.8%, 16.1% to 39.5%). People with no education had the highest prevalence (31.3%, 22.3% to 40.4%). The prevalence did not differ between urban and rural residential locations. Four factors were significantly associated with LBP: age (adjusted odds ratio: 2.4, 95% CI: 1.7 to 3.4), female sex (2.2, 1.5 to 3.3), absence of formal education (2.3, 1.6 to 3.3) and hypertension (1.7, 1.1 to 2.6). CONCLUSION: LBP is a common problem in Bangladeshi adults. The factors identified are age, female sex, no formal education and hypertension. These should be addressed adequately to prevent and treat LBP.

Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region.

BACKGROUND: Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a cross-sectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region. METHODS: RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission. FINDINGS: A total of 2010 RA patients was included in the study, the overall remission rates were 62•3% (DAS28-CRP), 35•5% (DAS28-ESR), 30•8% (CDAI), 26•5% (SDAI), 24•7% (Boolean), and 17•1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17•9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of GC usage. The favorable related factors were male sex, younger age, fewer comorbidities, fewer extra-articular manifestations (EAM), and use of b/tsDMARDs, while treatment with GC was negatively related to remission. INTERPRETATION: Remission rates were low and varied in the Asia-Pacific region. Treatment with b/tsDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region.

Development of a Bangla version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI).

AIM: Development of a Bangla version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI). METHODS: This biphasic observational study performed the translation and adaptation of the questionnaires carried out in 5 steps with pre-testing in 30 AS patients followed by the psychometric validation of the pre-final Bangla version utilizing content and construct validity in 115 AS patients. The reliability was examined through internal consistency and test-retest reliability involving 23 AS patients. RESULTS: After pre-testing of the pre-final Bangla version of both indices, the psychometric validation found that the convergent validity of Bangla version of BASDAI showed strong correlation with C-reactive protein (r = .75) and the Maastricht Ankylosing Spondylitis Enthesitis (r = .64), and moderate correlation with erythrocyte sedimentation rate (r = .49). Again, the Bangla BASFI showed significant correlation with occiput-to-wall distance (OWD) (r = .50), mentum-to-sternum distance (MSD) (r = .50), chest expansion (CE) (r = -.40), finger-to-floor (FFD) (r = .55), number of swollen joints (r = .69), and number of enthesitis (r = .68). The divergent validity demonstrated weak correlations between BASDAI and OWD (r = .43), MSD (r = .34), CE (r = -.44), FFD (r = .47). The divergent validity of BASFI could not be assessed due to lack of a suitable comparing parameter. The instruments revealed acceptable internal consistency as Cronbach's alpha was 0.86 for BASDAI and 0.93 for BASFI. A 7-day test-retest reliability measured by the intraclass correlation coefficient were 0.80 (CI at 95% = 0.58-0.90) for BASDAI and 0.83 (CI at 95% = 95% 0.64-0.92) for BASFI respectively. CONCLUSIONS: Bangla version of BASDAI and BASFI may be useful in disease activity and functional ability assessment in AS patients.

Translation, cross-cultural adaptation and validation of the English Lequesne Algofunctional index in to Bengali.

BACKGROUND: This study was focused on translation and cultural adaptation of the English Lequesne Algofunctional index (LAI) into Bengali for patients with primary knee osteoarthritis (OA) and testing reliability and validity of the Bengali version of the LAI. METHODS: This study was carried out in the Department of Rheumatology, BSM Medical University, Dhaka, Bangladesh. Using the forward-backward method the English LAI was translated into Bengali including cultural adaptation. For pretesting, A sample of 40 patients with primary knee osteoarthritis were screened using the Bengali version of LAI. Following the pretest, 130 consecutive patients with symptomatic knee OA completed the interviewer administered Bengali LAI, the validated Bengali version of SF-36, Visual Analogue Scale for Pain, Distance Walked and Activities of Daily Living. For the retest 60 randomly selected patients from the cohort were administered the Bengali LAI 7 days later. An item by item analysis was performed. Internal consistency was assessed by Cronbach's alpha, test-retest reliability by intraclass correlation coefficient (ICC) and Kappa coefficient, construct validity was measured using the Spearman rank correlation coefficient. RESULTS: It took 3.25 ± 0.71 min to complete the Bengali LAI and the mean score was 9.23 ± 4.58. For the Bengali LAI Cronbach's alpha score was 0.88, test-retest reliability assessed by ICC was 0.97. For construct validity, excellent convergent validity was achieved (ρ = 0.93) but the divergent validity was moderate (ρ = 0.43). CONCLUSIONS: The Bengali LAI showed excellent convergent validity, internal consistency and test-retest reliability, only the divergent validity was moderate. So, the Bengali LAI can be applied as a HRQoL assessment tool for primary knee OA patients.

Musculoskeletal symptoms and disorders among 350 garment workers in Bangladesh: A cross-sectional pilot study.

OBJECTIVE: To study the prevalence of musculoskeletal (MSK) symptoms and disorders among garment workers in Bangladesh, to look for possible relationships between pain location and type of work performed and to estimate the prevalence of rheumatological diagnoses. METHODS: A cross-sectional pilot study among 350 garment workers using the COPCORD (Community Oriented Program for Control of Rheumatic Disorders) methodology. Subjects with musculoskeletal pain were examined by rheumatologists for rheumatological diagnosis. The workers were classified into cutting, sewing, finishing and quality control operators. RESULTS: Most of the workers were aged below 35 years (88%) and females (82.9%) and the majority had only primary education (74.6%). The prevalence of MSK pain within 7 days of the interview was 77.1%, a much higher figure than in the general population. The most affected sites were: shoulder (17.9%), lower back (15.2%), neck (13.8%) and knee (10.8%). Multiple regional pain was the commonest finding in 173 of 350 workers. In this pilot study rheumatoid arthritis was diagnosed in 0.9%, undifferentiated arthritis in 1.1%, nonspecific low back pain in 4.6%, soft tissue rheumatism in 3.7%, osteoarthritis in 0.9% and lumbar spondylosis in 1.1%, figures comparable with those observed in the general population; spondyloarthropathy was seen more often, in 1.42%, possibly explained by the small numbers. CONCLUSIONS: Musculoskeletal pains are common among garment workers of Bangladesh and may cause morbidity, disability, and work loss. Our findings may be important to plan ergonomic measures preventing complaints and may be of interest for international companies ordering garments in Bangladesh.