The efficacy of disease modifying anti-rheumatic drugs in rheumatoid arthritis in local patients of Karachi.

The primary objective of the study is to assess the efficacy of the 'Disease Modifying AntiRheumatic Drugs (DMARDs) on the disease activity in Rheumatoid Arthritis (RA) in the local patients of Karachi. The secondary objective is to evaluate whether the combination of two concurrent DMARDs (Combination Therapy) is superior to a single DMARD (Mono-therapy). This is an open labeled retrospective case series. One hundred and five consecutive patients fulfilling 1987 ACR criteria for the diagnosis of RA were initially selected from the case notes of out patients department. Sixty nine patients fulfilled the inclusion criteria and were finally recruited for analysis. Details of the Tender Joint Count (TJC), Swolen Joint Count (SJC), Patient Global Assessment (PGA) and ESR were obtained at six weeks, three months, six months and one year. Out of the 69 patients studied 48 were in the mono-therapy group and 21 in the combination therapy group. Methotrexate (MTX) was the most commonly used single DMARD (75%) as well as the most frequent component of the combination groups (85%). The TJC, SJC and PGA analyses of all patients show that DMARDs are effective agents for clinically controlling RA activity. The speed of their beneficial effect is slow and unlike analgesics and NSAIDS, may take up to six weeks to start working. The 6 week responses showed 32.49% improvement in TJC, 33.19% improvement in SJC and 59% better responses in PGA. This response continued to show further improvement and at six months when TJC improved by 63.41%, SJC by 53.21% and PGA with 81% better responses. After 6 months the response reached a plateau but nevertheless maintained until 1 year with improvements in TJC by 66.23%, SJC by 56.48% and PGA with 88.23% better responses. The changes in ESR did not go parallel with the other three outcome measures. The mean baseline ESR of 56 reduced to 44 at 6 weeks but rose again gradually to 54 at 1 year. The sub-group analysis did not show the overall superiority of combination therapy over mono-therapy. DMARDs are effective in controlling disease activity in RA. Their effect starts slowly over 6 week and may take up to 6 months to show full benefits. The beneficial effect was maintained for at least 1 year. Sub-group analysis did not show any advantage of combination therapy over mono-therapy in this series of patients. Methotrexote being the most frequently used DMARDs in both groups and being most cost effective agent seems to be the most useful drug in RA in the developing world.

The personal cost of diabetic foot disease in the developing world--a study from Pakistan.

AIMS: The aim of the present study was to estimate the direct cost of treatment of diabetic foot ulcer at a tertiary care hospital in Karachi, Pakistan in order to assess the extent of the economic burden which it imposes. METHODS: Out of 383 patients seen at Foot clinic of Baqai Institute of Diabetology and Endocrinology (BIDE), records of 214 patients were analyzed while 169 patients left against medical advice (LAMA). The UT system was used to classify ulcer types. Information was retrieved on resource consumption (physician services, chiropody, investigations, medicines, hospital care and surgical procedures). Interventions were summed and multiplied by the unit price of each resource, using charges levied at BIDE in the year 2005, in order to calculate the total cost of treatment. RESULTS: 64% were male, with mean age 52.7 +/- 10.2 years. Mean duration of diabetes was 16.2 +/- 6.6 years. Majority (62.1%) were Grade 2 ulcer. The estimated direct cost of management increased from 2700 +/- 250 rupees (21 +/- 2 pounds) for a UT grade 1, stage B ulcer to 37,415 +/- 24,125 rupees (288 +/- 186 pounds) for UT grade 2, stage D and 49,058 +/- 30,144 rupees (378 +/- 232 pounds) for UT grade 3, stage D ulcers, respectively. The mean direct cost of major amputation (transtibial or transfemoral) was 46,182 +/- 30,742 ( 356 +/- 237 pounds) whilst the cost of a minor amputation was 50,494 +/- 30,488 rupees (389 +/- 235 pounds). CONCLUSIONS: This retrospective study, despite having limitations, is important for a developing world country with limited data on health economics. Further larger scale prospective studies are needed to address this issue in more detail.