laporan tahunan hospital selayang.indd - CRC

ii 

PRELIMINARY REPORT: APRIL 2009 - AUGUST 2010 

National Infl ammatory Arthritis Registry (NIAR) 

Published by: 

Na onal Infl ammatory Arthri s Registry (NIAR) 

Clinical Research Centre, 4th fl oor Specialist offi ce 

Selayang Hospital, Selayang-Kepong Highway 

68100 Batu Caves, Selangor 

Malaysia 

Direct line : (603) 6120233 ext 9111/4169 

Fax : (603) 61202761 

Website : h ps://app.acrm.org.my/NIAR 

Disclaimer : Data reported here are supplied by the NIAR. Interpreta on and 

repor ng of these data are the responsibility of the editors and in 

no way should be seen as an offi cial policy or interpreta on of the 

NIAR. This report is copyright. However it can be freely reproduced 

without the permission of the NIAR. However, acknowledgement 

would be appreciated. 

Suggested cita on : The suggested cita on for this report is as follows: 

Dr Azmillah Rosman, Dr Hasselynn Hussein, 

Dr Gun Suk Chyn, Dr Lau Ing Soo, 

Dr Mollyza Mohd. Zain, Dr Habiba @ Habibah Mohd Yusoof 

Dr Asmahan Mohamed Ismail, Dr Liza Mohd.Isa, 

Dr Nor Shuhaila Shahril, Dr Ramani Arumugam, 

Dr Ong Yew Chong 

ISSN No :

CONTENTS 

ACKNOWLEDGEMENTS 

STEERING COMMITTEE MEMBERS 

MEMBERS OF THE ADVISORY BOARD 

LIST OF CONTRIBUTORS 

ABOUT NIAR 

Objec ve 

Inclusion Criteria 

Instrument 

Data Flow Process 

Progress 

1. DISTRIBUTION OF CASES ACCORDING TO HOSPITAL 

2. DEMOGRAPHICS 

2.1 GENDER DISTRIBUTION 

2.2 AGE DISTRIBUTION 

2.3 ETHNIC GROUP 

2.4 SOCIOECONOMIC STATUS 

2.4.1 PROFESSIONAL VS NON-PROFESSIONAL 

2.4.2 INCOME GROUP 

2.4.3 PERSONAL MEDICAL INSURANCE 

3. CHARACTERISTICS OF PATIENTS 

3.1 NUMBER OF PATIENTS FULFILLING ACR CRITERIA 

3.2 DURATION OF DISEASE BEFORE DIAGNOSIS 

3.3 ASSOCIATED MEDICAL PROBLEMS 

3.3.1 MEDICAL CO-MORBIDITIES 

3.3.2 MALIGNANCIES 

3.4 EXTRAARTICULAR MANIFESTATIONS 

3.5 DISEASE STATUS AT 1ST NOTIFICATION 



4. DISEASE BURDEN 

4.1 WORK STATUS 

4.2 DAYS OF SICK LEAVE TAKEN DUE TO ARTHRITIS IN THE PAST 3 

MONTHS 

5. STANDARD OF CARE 

5.1 TIME TO INITIATION OF DMARDS AFTER DIAGNOSIS 

5.2 TYPES OF DMARDS USED 

1 

2 

2 

3 

5 

6 

6 

6 

6 

7 

9 

11 

12 

12 

13 

14 

14 

15 

15 

17 

18 

19 

20 

20 

21 

21 

22 

25 

26 

26 

27 

28 

29 

iii

iv 



5.3 USE OF COMBINATION DMARDS 

5.4 USE OF BIOLOGICS 

5.5 USE OF ORAL STEROIDS 

5.6 USE OF NSAIDS/COX2 INHIBITORS 

5.7 SURGERY 

DISCUSSION 

CONCLUSIONS AND RECOMMENDATIONS 

REFERENCES 

APPENDIX I : CASE REPORT FORM 

APPENDIX II : INFORMATION ON PATIENT CONFIDENTIALITY 

29 

30 

30 

30 

30 

31 

33 

35

ACKNOWLEDGMENTS 



The Na onal Infl ammatory Arthri s Registry would like to express its sincere thanks and 

apprecia on to all who have supported and contributed to this report. 

We thanks the following for their support: 

• The Ministry of Health, Malaysia 

• Y.B. Tan Sri Dato’ Seri Dr Hj Mohd Ismail Merican, Director General of Health, 

Malaysia 

• Dr Lim Teck Onn, Director, Network of Clinical Research Centre 

• Dr Goh Pik Pin, Co-Director, Network of Clinical Research Centre 

• Dr Jamaiyah Haniff , Head of Clinical Epidemiology Unit of CRC 

• Informa on technology personnelnamely MS Lim Jie Ying, database administrator, 

Ms Teo Jau Shya, clinical data manager 

• Members of the “Steering Commi ee” for their contribu ons to the registry 

• Clinical Research Centre, Ministry of Health, Malaysia 

• Other sponsors and supporters from the professional bodies, industries and 

ins tua ons as listed below: 

Ka Consul ng Sdn. Bhd 

Schering Plough 

Staff from Hospital Selayang, Hospital Tuanku Jaafar, Seremban and 

Hospital Putrajaya 

1

2 



STEERING COMMITTEE MEMBERS 

Dr Azmillah Rosman (Principal Inves gator) 

Department of Medicine, Hospital Selayang 

Dr Chow Sook Khuan 

Sunway Medical Centre 

Dr Amir Azlan Zain 

Sunway Medical Centre 

Dr Heselynn Hussein 

Department of Medicine, Hospital Putrajaya 

Dr Gun Suk Chyn 

Department of Medicine, Hospital Tuanku Abdul Jaafar, Seremban 

Dr Lau Ing Soo 


Dr Mollyza Mohd Zain 


MEMBERS OF THE ADVISORY BOARD 

Dr Lim Teck Onn (Chairman) 

Clinical Research Centre, Ministry of Health Malaysia 

Tan Sri Hari Narayanan (Co-chairman) 

Arthri s Founda on Malaysia 

Ms Ding Mee Hong 

Arthri s Founda on Malaysia 

Professor Florence Wang 

University Malaya Medical Centre

LIST OF CONTRIBUTORS 

Hospital Selayang 

Dr Azmillah Rosman 

Dr Lau Ing Soo 

Dr Mollyza Mohd Zain 

Dr Habibah Mohd Yusoof 

Dr Asmahan Mohamed Ismail 

Dr Chong Hwee Cheng 

Dr Kuan Woon Pang 

Dr Ramani Arumugam 

Dr Shereen Ch’ng Suyin 

Dr Hilmi Abdullah 

Dr Ong Yew Chong 

Mdm Ramlah Shukor 

Mdm Norlela Mohd Salleh 

Hospital Tuanku Jaafar, Seremban 

Dr Gun Suk Chyn 

Dr Beryl D’Sauza 

Dr C Gandhi 

Dr Lim Ai Lee 

Dr Nadia Mohd Noor 

Mdm Ho Ah May 


Dr Heselynn Hussein 

Dr Eashwary Mageswaren 

Dr Liza Mohd Isa 

Dr Nor Shuhaila Shahril 

Dr Shamala Rajalingam 

Mdm Amnahliza Abu Rahman 



3

ABOUT THE NATIONAL 

INFLAMMATORY ARTHRITIS 

REGISTRY (NIAR)

6 



ABOUT THE NATIONAL INFLAMMATORY ARTHRITIS REGISTRY (NIAR) 

Introduc on 

Rheumatoid Arthri s (RA), the most common form of infl ammatory arthri s is es mated 

to aff ect about 1% of the popula on. Of unknown ae ology, it typically aff ects many joints, 

causing acute infl amma on, in most cases leading to joint erosions and joint damage (1). 

The NIAR, ini ated in 2008, was set up with the aim of obtaining informa on about pa ents 

with Rheumatoid Arthri s. Informa on about pa ents with the other infl ammatory 

arthri des will be collected in the future. 

Objec ves 

1. To determine the incidence and prevalence of RA in Malaysia. 

2. To obtain demographic data. 

3. To determine the disease expression in terms of clinical manifesta ons. 

4. To study the management of pa ents. 

5. To assess pa ents’ outcome, studying pa ents’ disease ac vity, extent of disability, 

economic impact and mortality rate. 

Inclusion Criteria 

Patients enrolled into the registry are patients with established Rheumatoid Arthritis, 

diagnosed by a rheumatologist. 

Instrument 

A structured Case Report Form (CRF) [Appendix I] is used for data collection. The CRF 

was designed and reviewed by a technical committee. Prior to the launch of the registry, 

copies of the CRFs were distributed to doctors from the various hospitals involved. A trial 

run was done and feedback given to the committee before the fi nal CRF was used for data 

collection. Training sessions were also conducted at the hospitals involved. 

Patients’ outcome is assessed three times - at months 0, 6 and 12. 

Data Flow Process 

The registry is coordinated centrally at the Clinical Research Centre (CRC) based at 

Hospital Selayang. Each hospital has an appointed clinic and registry nurse. The database 

is available online via password access. 

Patients attending their regular clinic appointments were identifi ed. Verbal consent was 

obtained from patients using the Patient Confi dentiality Information form [Appendix II]. 

Demographic information was obtained from the patient or carer. Joint count assessments



were then performed by the assessing doctor while other information necessary to fi ll into 

the CRF was obtained from patients’ medical records. The registry nurse then entered the 

information into the online database. The next outcome date was then determined and this 

was coordinated with patients’ scheduled clinic visit. 

Patient identifi ed by 

Appointed clinic 

Nurse / Dr 

Progress 

Nurse / Dr obtains 

basic demographic 

information 

Registry nurse 

determines next visit 

date, informs clinic 

nurse 

Figure 1: Data Flow Process 

Doctor performs joint 

count and fi lls in 

relevant information 

manually 

Registry nurse enters 

data online 

The NIAR was launched offi cially on 18th December 2008. A er a trial run, the fi rst pa ent 

was enrolled into the registry on 21st April 2009. The online database was started on 22nd 

May 2009. As of 31st August 2010, 1000 pa ents have been enrolled into the registry. 

7

DISTRIBUTION OF CASES 

ACCORDING TO HOSPITAL

10 



1. DISTRIBUTION OF CASES ACCORDING TO HOSPITAL 

Three hospitals were chosen for the pilot project, namely Hospital Selayang, Hospital 

Tuanku Jaafar, Seremban and Hospital Putrajaya. These hospitals were selected as 

they are the largest rheumatology centres in the MOH. The distribu on of cases are 

as follows: 

Hospital Tuanku 

Jaafar, Seremban 

364 (36.4%) 


202 (20.2%) 

Figure 2: Distribu on of cases according to hospital 

Hospital Selayang 

434 (43.4%) 

N = 1000 pa ents

DEMOGRAPHICS

12 



2. DEMOGRAPHICS 

2.1 GENDER DISTRIBUTION 

87.4% 

12.6% 

Figure 3: Gender distribu on 

Male 

Female 

The gender distribu on showed a female preponderance at 87.4% (n=874) 

compared to males 12.6% males (n=126). The male to female ra o was 

approximately 7:1. 

2.2 AGE DISTRIBUTION 

40 

35 

30 

25 

20 

15 

10 

5 

0 

0.6 

12 to 20 

4.3 

10.3 

23.3 

37.5 

17.2 

6.9 

21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 > 71 

Figure 4: Age Distribu on



Currently, data has only been collected for adult pa ents with Rheumatoid 

Arthri s, defi ned as those above 12 years old. 

The mean age was 52.57 years with the youngest pa ent being 18 years and 

the oldest 87 years. 

More than half of the pa ents were in the 41-60 age group categories. 

2.3 ETHNIC GROUP 

The Malays being the largest ethnic group in Malaysia made up 43.2% of the 

pa ents in the registry. The Indians who are the smallest of the 3 major ethnic 

groups in Malaysia made up 30.4% followed by the Chinese at 24.1%. The other 

ethnic groups and foreigners comprised 2.3% of the pa ents. 

30.4% 

24.1% 

2.3% 

43.2% 

Figure 5: Distribu on of ethnic groups 

Malay 

Chinese 

Indian 

Other 

Comparing these fi gures with the 2004 Malaysian Census, the Indians are overrepresented 

since they cons tute only 7.1% of the Malaysian popula on (2). 

The under-representa on of the other ethnic groups in the registry may be 

explained by the fact that none of the hospitals in Sabah or Sarawak were 

included in this pilot project. 

13

14 



Malaysian Census 2004 NIAR 

Malay 50.4% 43.2% 

Chinese 23.7% 24.1% 

Indian 7.1% 30.4% 

Other 18.8% 2.3% 

Table 1: Comparison of ethnic groups with Malaysian Census 2004 

2.4 SOCIO-ECONOMIC STATUS 

2.4.1 PROFESSIONAL VS NON-PROFESSIONAL 

The majority of pa ents were from the lower socio-economic group. 

Nearly 90% were non-professionals. 

89.8% 

10.2% 

Prfessional 

Non-professional 

Figure 6: Distribu on of professional and non-professional groups

2.4.2 INCOME GROUP 

Monthly Income (RM) 

Unknown 9.3 

>7000 

5001-7000 

3001-5000 

1001-3000 

CHARACTERISTICS 

OF PATIENTS

18 



3. CHARACTERISTICS OF PATIENTS 

3.1 NUMBER OF PATIENTS FULFILLING AMERICAN COLLEGE OF RHEUMATOLOGY 

(ACR) CRITERIA 

The tradi onal defi ni on for Rheumatoid Arthri s has been defi ned as pa ents 

fulfi lling 4 or more of the 7 criteria listed in the 1987 ACR criteria (Table 2) (3). 

This criteria has been revised in the new ACR-EULAR criteria published in 2010 

(4). 

Morning s ff ness > 1 hour 

≥ 3 joints arthri s 

Arthri s in a wrist, MCP or PIP joint 

Symmetrical arthri s 

Factor 

Posi ve rheumatoid factor 

Erosions or osteopenia on hand or wrist radiograph 

* symptoms present for at least 6 weeks 

Table 2: 1987 ACR criteria for Rheumatoid Arthri s 

The propor on of pa ents fulfi lling each criterion is shown in Table 3. 

ACR criteria % of pa ents fulfi lling criteria 

≥ 3 joints arthri s 94.4 

Symmetrical arthri s 92.8 

Arthri s in a wrist, MCP or PIP joint 70.5 

Morning s ff ness > 1 hour 70.5 

Posi ve rheumatoid factor 68.5 

Erosions or osteopaenia on hand or 

wrist radiograph 

41.0 

Rheumatoid factor 6.1 

Table 3: Percentage of pa ents fulfi lling each ACR criteria



The percentage of pa ents fulfi lling the 1987 ACR criteria is shown in Figure 

9. 78.3% fulfi ll the ACR criteria defi ni on for Rheumatoid Arthri s however a 

signifi cant propor on fulfi ll less than 4 of the criteria. 

21.7% 

≥ 4 ≥ 4 

78.3% 

% of pa ents 

35 

30 

25 

20 

15 

10 

5 

0 

22.5 

4 

34 

20 

1.8 

5 6 7 

Figure 9: Percentage of pa ents fulfi lling ACR criteria 

3.2 DURATION OF DISEASE BEFORE DIAGNOSIS 

Number of ACR 

Criteria fulfi lled 

Almost half of the pa ents were diagnosed late, that is more than a year a er 

the onset of symptoms. However, a signifi cant propor on of pa ents were 

diagnosed between 1 to 6 months from symptom onset. 

50 

40 

30 

20 

10 

0 

37.3 

14 

48.7 

< 6 months < 6 months < 12 months 

Number of months from symptom onset to diagnosis 

Figure 10: Distribu on of pa ents according to dura on of disease 

before diagnosis 

19

20 



Comparing professionals and non-professionals, it would appear that more 

professionals are diagnosed earlier, that is less than 6 months from disease 

onset. However, even amongst the professionals, about 40% were diagnosed 

more than a year from the onset of symptoms. 

120 

100 

80 

60 

40 

20 

0 

N=102 

40.2 

15.59 

44.11 

N=898 

49.67 

13.81 

36.52 

Professional Non-Professional 

Figure 11: Dura on of disease before diagnosis comparing 

professionals and non-professionals 

3.3 ASSOCIATED MEDICAL PROBLEMS 

3.3.1 MEDICAL CO-MORBIDITIES 

> 12 months 

6 to 12 months 

< 6 months 

Among the medical condi ons, hypertension was the commonest comorbidity 

with a prevalence of 36.2%. This is slightly lower than the 

na onal prevalence of 42.6% of hypertension in adults above 30 years 

of age (5). Next was hyperlipidaemia at 25.5% followed by diabetes at 

16.1%. The Na onal Health and Morbidity Survey in 2006 found that the 

prevalence of diabetes is 12% (6). 6.1% of pa ents had been diagnosed 

to have osteoporosis. Pep c ulcer disease and ischaemic heart disease 

were each reported in 3.9% of the pa ents. 

The other medical condi ons with the reported fi gures are listed in 

Table 4.

IHD 

PUD 

Osteoporosis 

DM 

Hyperlipidaemia 

Hypertension 

3.3.2 MALIGNANCIES 

3.9 

3.9 



6.7 

16.1 

25.5 

36.2 

0 5 10 15 20 25 30 35 40 

Figure 12: Associated co-morbidi es 

Disease % of pa ents 

Fa y liver 2.3% 

Tuberculosis 1.2% 

Hepa s B 1.0% 

Stroke 0.6% 

Renal impairment 0.5% 

Hepa s C 0.2% 

Others 20.4% 

Table 4: Associated co-morbidi es 

16 cases of malignancies were reported. The highest malignancy 

reported was breast cancer. The other malignancies to fi nd out what 

the other malignancies are 4 other malignancies includes - kidney, 

brain, thyroid & colon cancer 

3.4 EXTRAARTICULAR MANIFESTATIONS 

There are a number of extraar cular manifesta ons associated with Rheumatoid 

Arthri s. The commonest one seen in this pa ent cohort was keratoconjunc vi s 

sicca followed by lung fi brosis and anaemia due to rheumatoid arthri s. 35 

21

22 



pa ents had rheumatoid nodules. The percentages of pa ents with each 

extraar cular manifesta ons are listed below. 

Manifesta on Numbers Percentage % 

Keratoconjunc vi s sicca 226 22.6 

Inters al lung disease 61 6.1 

Anaemia (due to RA disease ac vity) 37 3.7 

Rheumatoid nodules 61 6.1 

Eye infl amma on 8 0.8 

Fever 5 0.5 

Raynaud’s 4 0.4 

Entrapment neuropathy 4 0.4 

Atlanto-axial subluxa on 4 0.4 

Cutaneous vasculi s 3 0.3 

Mononeuropathy 2 0.2 

Polyneuropathy 1 0.1 

Felty’s syndrome 1 0.1 

Cervical myelopathy 1 0.1 

Pleural eff usion 0 0 

Pericardi s/eff usion 0 0 

Amyloidosis 0 0 

Lymphadenopathy 0 0 

Others 9 0.9 

3.5 DISEASE STATUS AT 1ST NOTIFICATION 

Table 5: Extraar cular manifesta ons 

The DAS28 score is used to assess pa ent’s disease ac vity. The DAS28 score 

is calculated based on the number of swollen and tender joints (only 28 joints 

are assessed), general health assessment using a pa ent visual analogue scale 

and either ESR or CRP. Pa ents are then categorized into either having low 

(DAS28 2.6 to 3.2), moderate (DAS28 >3.2 to 5.1) or high (DAS28 >5.1) disease 

ac vity states or in remission (DAS29

35 

30 

25 

20 

15 

10 

5 

0 

13.9 

Remission 

16.5 



31.5 

Disease ac vity based on 

DAS28 ESR/CRP score 

16 

Figure 13: Disease status at 1st no fi ca on 

22.1 

Unknown 

23

DISEASE BURDEN

26 



4. DISEASE BURDEN 

4.1 WORK STATUS 

2% 

26% 

32% 

32% 

8% unempliyed 

51.8% 

due to disease 

Full me 

Re red 

Part- me 

Home-maker 

Unemployed due to disease 

Unemployed due to family 

Unemployed others 

Figure 14: Work status and reasons for unemployment 

8% of pa ents were unemployed but signifi cantly, nearly 52% of those 

who were unemployed a ributed this to their disease. 32% of pa ents 

were home-makers. 

4.2 DAYS OF SICK LEAVE TAKEN DUE TO ARTHRITIS IN THE PAST 3 MONTHS 

10 

8 

6 

4 

2 

0 

% of pa ents 

1 to 14 

8.1 

0.3 

15 to 30 

0 

31 to 45 

0.1 

46 to 60 

Number of days 

0 

61 to 75 

0 

76 to 90 

Figure 15: Days of sick leave taken due to arthri s in the past 3 months 

Out of the 338 pa ents who were employed, 81 pa ents took between 1 to 14 

days of sick leave due to arthri s. 3 pa ents took between 15 to 30 days of sick 

leave and 1 pa ent took sick between 46 to 60 days. None took more than 60 

days of sick leave.

STANDARD OF CARE

28 



5. STANDARD OF CARE 

5.1 TIME TO INITIATION OF DMARDS AFTER DIAGNOSIS 

A large propor on of pa ents were started on Disease Modifying An -Rheuma c 

Drugs (DMARDS) soon a er the diagnosis was made. This is in accordance with 

current treatment recommenda ons. 

80 

60 

40 

20 

0 

69.7 

< 1months 

11.6 

1-6 months 

3.3 

6-12 months 

11.6 

>12 months 

Figure 16: Time to ini a on of DMARDS a er diagnosis 

11.6 

Unknown 

Comparing professionals and non-professionals, there does not appear to be 

much diff erence in terms of when treatment was started. 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

5 

5 

15 

75 

Professional 

N=100 

12.88 

3.25 

11.72 

72.12 

Non-Professional 

N=862 

> 12 months 

6-12 months 

1-6 months 

< 1 months 

Figure 17: Time to ini a on of DMARDS a er diagnosis comparing 

professionals and non-professionals

5.2 TYPES OF DMARDS USED 



Methotrexate (MTX) being the anchor drug in the treatment of Rheumatoid 

Arthri s was used in 86.6% of pa ents. This was followed by sulphasalazine 

(SSZ) at 69.5% and hydroxychloroquine (HCQ) at 34.6%. The use of Lefl unomide 

was 24.1%. The other less commonly used drugs for example cyclosporine, 

penicillamine, azathioprine and cyclophosphamide were used in 2.7% of the 

pa ents. 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

86.6 

69.5 

5.3 USE OF COMBINATION DMARDS 

24.1 

34.6 

2.7 

MTX SSZ HCQ Others 

Figure 18: Types of DMARDS used 

697 of pa ents were on combina on DMARDS. The distribu on of pa ents 

using the various combina on DMARDS are shown in the fi gure below. 

20.44% 

24.6% 

35.45% 

Figure 19: Combina on DMARDS used 

MTX + SSZ 

MTX + Lefl unomide 

MTX + SSZ + HCQ 

29

30 



5.4 USE OF BIOLOGICS 

The use of the TNF inhibitors comprising Infl iximab, Etanercept and Adalimumab 

was 3.9% in this pa ent cohort. 

5.5 USE OF ORAL STEROIDS 

Short courses of oral steroids is some mes used as bridging therapy. The use of 

steroids in this pa ent popula on was 38.2%. 

5.6 USE OF NSAIDS/COX2 INHIBITORS 

Non steroidal an -infl ammatory drugs (NSAIDS) is used as analgesic therapy. 

If NSAIDS are contraindicated, pa ents can be prescribed cyclo-oxygenase 2 

inhibitors (COX2 INHIBITORS). About 62% of pa ents had been on NSAIDS/ 

COX2 INHIBITORS. 

5.7 SURGERY 

4% of pa ents have undergone arthroplasty. Surgical interven ons such as 

arthrodesis, spinal surgery and synovectomy are not commonly performed. 

Surgeries not directly related to rheumatoid arthri s for example appendicectomy 

or caesearean sec ons are categorized into other. 

25 

20 

15 

10 

5 

0 

4 

0.4 0.4 0.8 

Arthroplasty Arthrodesis Spinal 

surgery 

Figure 20: Surgical interven ons 

23.3 

Synovectomy Other

DISCUSSION

32 



DISCUSSION 

This is a pilot project involving only three hospitals from the Ministry of Health. In order 

to be er refl ect the demographics, characteris cs, standard of care and pa ent outcomes 

in the general popula on, there is a need to recruit pa ents from more centres including 

those from private and university hospitals. 

There is over-representa on of Indians in this registry perhaps due to sampling bias 

because of the areas covered by the three hospitals. Not surprisingly, many of the pa ents 

are non-professionals and from the lower socio-economic group since the three hospitals 

are public hospitals. These pa ents do not have medical insurance cover and need fi nancial 

aid from the government. 

A signifi cant propor on of pa ents do not fulfi ll the ACR criteria for rheumatoid arthri s. 

This confi rms the fact that the criteria should not be used as the sole criterion for diagnosis 

since many pa ents do not fulfi ll the criteria at disease onset especially those who present 

early in the course of the disease. 

Alarmingly, many pa ents are s ll diagnosed late. This may result in increased disease 

burden. Nevertheless, the results from the registry show that there are a signifi cant 

propor on who are diagnosed less than six months from disease onset. It may be that 

pa ents who were diagnosed late were those who were diagnosed in the earlier years 

whereas there may be a trend now towards earlier diagnosis. However, this would require 

further study. 

A signifi cant number of pa ents have medical co-morbidi es. The prevalence of the 

various diseases in this pa ent cohort are similar to the prevalence rates of the Malaysian 

adult popula on. Pa ents with rheumatoid arthri s are at risk of osteoporosis due to the 

disease itself as well as due to steroid use. The prevalence of osteoporosis in this cohort was 

reported as 6.7%. This is markedly below the reported prevalence of 22% (7). This might 

be due to under-repor ng or that pa ents have been not adequately screened. Pa ents 

with rheumatoid arthri s are also at increased risk of malignancies. Of the malignancies, 

the incidence of lymphoma has been reported to be two-fold higher than expected (8). 

However, there were no cases of lymphoma in this pa ent cohort. 

In terms of pa ent outcome, many pa ents are s ll in the moderate to high disease ac vity 

categories. The reasons for this need to be ascertained. It may be that more aggressive 

treatment strategies need to be ins tuted. The cost-eff ec veness of biologics also need to 

be determined in rela on to this. 

Among the unemployed pa ents, more than half of the pa ents claim that this is due to 

their disease. Of note, 32% of pa ents are home-makers. It would be interes ng to fi nd 

out whether the decision to be a home-maker was infl uenced by their disease. 

The majority of pa ents were started on treatment soon a er the diagnosis was made. 

This is in accordance with current treatment guidelines (9).

CONCLUSIONS AND 

RECOMMENDATIONS

34 



CONCLUSIONS AND RECOMMENDATIONS 

Thus far, several interes ng results have been obtained from the registry. The data confi rm 

that rheumatoid arthri s has signifi cant socio-economic impact to the society. Therefore, 

policies need to be implemented to reduce the fi nancial burden to pa ents and to society 

as a whole. There is also a need to raise awareness among the general public regarding 

the disease and primary care physicians need to refer early so that pa ents can be treated 

appropriately. Clinicians also need to be aware that pa ents with rheumatoid arthri s 

have co-morbidi es and need to be treated holis cally. 

The NIAR data off ers much poten al for research and hopefully, this will serve as an 

impetus for research and the implementa on of policies for the benefi t of pa ents.

REFERENCES

36 



REFERENCES 

(1) Kasper D. Braunwald E. et al. Harrisons’s Principles of Internal Medicine, 17th edi on. 

Chapter 14: Sec on 2. 

(2) Malaysian census 2004 

(3) Arne FC, Edworthy SM et al. The American Rheuma sm Associa on 1987 

revised criteria for the classifi ca on of rheumatoid arthri s. Arthri s Rheum. 1988 

Mar;31(3):315-24 

(4) Aletaha D, Neogi T et al. 2010 Rheumatoid arthri s classifi ca on criteria: an American 

College of Rheumatology/European League Against Rheuma sm collabora ve 

ini a ve. Ann Rheum Dis 2010;69:1580-1588. 

(5) The Third Na onal Health Morbidity Survey (NHMS III). Diabetes Group. Ministry of 

Health Malaysia, 2006. 

(6) The Third Na onal Health Morbidity Survey (NHMS III). Hypertension Group. Ministry 

of Health Malaysia, 2006. 

(7) Haugeberg G et al. Clinical decision rules in rheumatoid arthri s: do they iden fy 

pa ents at high risk for osteoporosis? Tes ng clinical criteria in a popula on based 

cohort of pa ents with rheumatoid arthri s recruited from the Oslo Rheumatoid 

Arthri s Register. Ann Rheum Dis 2002 Dec;61(12):1085-9) 

(8) Franklin J, Lunt M et al. Incidence of lymphoma in a large primary care derived cohort 

of cases of infl ammatory polyarthri s. Ann Rheum Dis. 2006 May;65(5):617-22. 

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laporan tahunan hospital selayang.indd - CRC

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