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Introduction The severity of lupus nephritis (LN) varies between different ethnicities. However, there are limited data regarding disease severity for LN in patients from the Arabian Gulf region; moreover, there are no treatment guidelines developed specifically for this population. The objective of this review was to characterise the incidence of LN, current treatment practices, the severity of LN, and the pathophysiology and biomarkers associated with LN in the Arabian Gulf region. Methods A literature search using EMBASE was conducted in October, 2021 to identify publications reporting on the incidence, treatment practices, severity, pathophysiology or biomarkers associated with LN, from countries in the Arabian Gulf region (including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates). Additional relevant publications were provided by collaborators. A manual review of the publications was conducted to determine their relevance and data on the outcomes of interest were extracted. Results Of 3705 publications, 54 publications were identified as relevant. LN is one of the most commonly diagnosed renal diseases within the Arabian Gulf and approximately 10%–36% of all renal biopsies are for LN. Treatment patterns within the region appear to vary and generally follow treatment guidelines recommended by the Asia Pacific League of Associations for Rheumatology (APLAR), the European Alliance of Associations for Rheumatology (EULAR) and Kidney Disease Improving Global Outcomes (KDIGO). The majority of patients receive cyclophosphamide for induction therapy, whilst others receive mycophenolate mofetil. Most studies showed that the most frequently diagnosed class of LN within the Arabian Gulf region was Class IV (up to 63% of patients with LN). Sustained or increased levels of serum creatinine and proteinuria; and depressed levels of complement C3/C4 were commonly seen among patients with LN from the Arabian Gulf region. Conclusions This review identified that LN may manifest more severely among patients from the Arabian Gulf region than in other populations, such as Caucasian populations. A greater understanding of LN and the treatment practices within the region, as well as the development of more specific treatment guidelines for this population may help improve outcomes for patients with LN in the Arabian Gulf region.

Psoriatic arthritis (PsA), a chronic inflammatory disease characterized by heterogeneous clinical manifestations, substantially impacts the quality of life of affected individuals. This article aims at developing consensus recommendations for the management of PsA and associated comorbidities and screening and monitoring requirements of PsA therapies in the United Arab Emirates (UAE) population.An extensive review of present international and regional guidelines and publications on the pharmacological management, monitoring of therapies in the context of PsA was performed. Key findings from guidelines and literature were reviewed by a panel of experts from the UAE at several meetings to align with current clinical practices. Consensus statements were formulated based on collective agreement of the experts and members of Emirates Society for Rheumatology.The consensus recommendations were developed to aid practitioners in clinical decision-making with respect to dosage recommendations for pharmacological therapies for PsA, including conventional drugs, non-biologic, and biologic therapies. Consensus recommendations for therapeutic options for the treatment of PsA domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease, were developed. The panel emphasized the importance of monitoring PsA therapies and arrived at a consensus on monitoring requirements for PsA therapies. The expert panel proposed recommendations for the management of common comorbidities associated with PsA.These consensus recommendations can guide physicians and healthcare professionals in the UAE in making proper treatment decisions, as well as efficiently managing comorbidities and monitoring therapies in patients with PsA.

Psoriatic arthritis (PsA), a chronic inflammatory arthropathy, is often underdiagnosed in Middle Eastern countries, substantially impacting the treatment of affected individuals. This article aims to highlight current unmet clinical needs and provide consensus recommendations for region-specific evaluation methods and nonpharmacological therapies in the United Arab Emirates (UAE).An extensive literature review was conducted, focusing especially on global and regional guidelines for the evaluation and treatment of PsA. These form the basis of the consensus statements formulated. Additionally, an expert panel of key opinion leaders from the UAE reviewed these guidelines and available literature at an advisory board meeting to identify unmet needs, bridge clinical gaps in the UAE, and develop consensus statements for the evaluation and treatment of PsA.The consensus statements were developed based on overarching principles for the management of PsA, evaluation of patients with PsA, and nonpharmacological approaches for the management of PsA. The overarching principles included adopting a targeted, multidisciplinary approach, along with collaboration between rheumatologists and dermatologists in cases of clinically significant skin involvement. The panel also highlighted the value of composite disease severity measures for characterizing clinical manifestations of PsA. In terms of nonpharmacological management approaches, lifestyle modification (comprising dietary change, exercise, and cessation of smoking) and psychotherapy were recommended.The consensus statements will aid healthcare professionals in clinical decision-making in the context of PsA.

Background: Demographic and clinical data of IgG4-related disease affecting solely the native population of the UAE, known as Emiratis, does not exist in the literature. Aim: To explore the demographic and clinical characteristics of IgG4-related disease in a well-defined population of Emirati patients attending Cleveland Clinic Abu Dhabi, a large tertiary center in the Middle East. Patients and Methods: The data presented is part of a retrospective cohort study, in which 15 Emirati patients with IgG4-related disease (IgG4-RD) were evaluated over 5 years from April 2015 to September 2020 at the rheumatology outpatient clinic at Cleveland Clinic Abu Dhabi. The demographic and clinical data were recorded. Descriptive statistics of the variables were applied. Results: Fifteen Emirati patients with an established diagnosis of IgG4-RD were assessed. There was a male predominance (53%) with a median age at the time of diagnosis of 47 ± 11.2 years. A 6-year lag period was noted from the initial presentation until a diagnosis of IgG4-RD was established. The most frequent comorbidities observed were hematological conditions (63%), hypertension (47%), diabetes mellitus (40%), and gastroesophageal reflux disease (40%). An elevated serum IgG4 was observed in the majority of patients at the initial presentation. Rheumatoid factor was detected in 13% and low titer of immunofluorescence antinuclear antibody in 7%. 86% of patients had a tissue biopsy with marked lymphocytic and plasmacytic infiltration being the most reported finding in 86%. Methotrexate, azathioprine, and rituximab were the most frequently prescribed disease-modifying agents. Conclusion: We report the first comprehensive analysis on a small cohort of Emirati patients with IgG4-RD. We describe disease features unique to UAE patients and demonstrate that IgG4-RD has a significant disease burden. Our results underscore the need for the IgG4-RD UAE-wide national registry to improve the quality of care of these patients.

Estimates of the global prevalence of rheumatoid arthritis (RA) range from 0.24 to 1%, but vary considerably around the globe. A variation in RA prevalence is also expected across Africa and the Middle East, due to ethnic, climate, and socioeconomic differences. To assess the prevalence of RA in Africa and the Middle East, we searched Medline (via PubMed) and databases of major rheumatology conferences. Seventeen journal articles and 0 abstracts met the inclusion criteria. Estimated prevalence ranged from 0.06 to 3.4%. Most studies reported values near or below 0.25%. Consistent with data from other regions, RA was more prevalent among urban than rural populations, and among women than men. The women:men prevalence ratio ranged from 1.3:1 to 12.5:1, which suggests notable differences from the global average of 2:1. Relative increases in prevalence were observed in North Africa and the Middle East (13% since 1990) and Western Sub-Saharan Africa (14%), whereas rates in Eastern, Central, and Southern Sub-Saharan Africa show decreases (4-12%). Low disease awareness, delays to visit rheumatologists, and socioeconomic factors appear to hinder early diagnosis and aggressive treatment. Few countries have developed RA-specific treatment guidelines, and many physicians and patients face limited access to even basic treatments. An improved understanding of the epidemiology and management of RA, and the related socioeconomic consequences is necessary, so that targeted attempts can be made to encourage early diagnosis and treatment.

This article aims to explore the Prophetic principles of developing sound rationality. The sunnah of the Prophet contains numerous pearls of wisdom. The human mind is a primary tool to understand lived reality with all its fluctuations and complexities. Moreover, it is the first door to understanding the revealed texts. The Prophet’s sunnah provides many principles and rules that can be adopted to inculcate sound rationality in the personality of a Muslim. If one understands these Prophetic principles correctly and follows them properly, they will lead one to succeed in life with distinction, leadership, and brilliance. Islam is not against reason nor does it prohibit its use. This article aims at deriving the principles of developing sound rationality from the Prophetic sunnah and explaining them with examples.

Systemic sclerosis is an autoimmune condition characterized by a wide range of clinical presentations. Registries may serve to expand understanding about systemic sclerosis and aid in patient care and follow-up. The objective of this study was to analyze the prevalence of systemic sclerosis in a large cohort from the United Arab Emirates Systemic Sclerosis Registry and find the significant similarities and differences between the different subsets. All scleroderma patients in the United Arab Emirates were included in this multicenter national retrospective analysis. Data on demographics, comorbidities, serological characteristics, clinical aspects, and treatment were collected and analyzed, highlighting the most common traits identified. A total of 167 systemic scleroderma patients from diverse ethnic backgrounds were enrolled. Overall, 54.5% (91/167) of the patients were diagnosed with diffuse cutaneous systemic sclerosis, and 45.5% (76/167) with limited cutaneous systemic sclerosis. The prevalence of systemic sclerosis was 1.66 per 100,000 for the total registry and 7.78 per 100,000 for United Arab Emirates patients. Almost all patients in the diffuse cutaneous systemic sclerosis and limited cutaneous systemic sclerosis groups tested positive for the immunofluorescence antinuclear antibody. Antibodies against Scl-70 were significantly more associated with diffuse cutaneous systemic sclerosis, whereas anticentromere antibodies were significantly more associated with the limited cutaneous systemic sclerosis group ( p

Psoriatic arthritis (PsA) is a chronic, inflammatory arthropathy occurring in up to 30% of patients with psoriasis, and is characterized by multiple manifestations including peripheral arthritis, enthesitis, dactylitis, spondylitis, and psoriatic skin and nail disease. This complex and heterogeneous disease is poorly understood and its diagnosis and treatment are suboptimal, particularly in Africa and the Middle East, where very few studies into the impact of PsA have been carried out. This article aims to highlight the disease burden of PsA in the region as well as to identify unmet clinical needs. A non-systematic review was carried out in the PubMed database and the most relevant publications were selected. Expert rheumatologists practicing in Africa and the Middle East provide an insight into the challenges of treating PsA in daily practice, along with recommendations for improvements.

Rheumatic and musculoskeletal diseases (RMDs) encompass a spectrum of degenerative, inflammatory conditions predominantly affecting the joints. They are a leading cause of disability worldwide and an enormous socioeconomic burden. However, worldwide deficiencies in adult and paediatric RMD knowledge among medical school graduates and primary care physicians (PCPs) persist. In October 2017, the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD), an international think tank of RMD and related experts, met to discuss key challenges and opportunities in undergraduate RMD education. Topics included needs analysis, curriculum content, interprofessional education, teaching and learning methods, implementation, assessment and course evaluation and professional formation/career development, which formed a framework for this white paper. We highlight a need for all medical graduates to attain a basic level of RMD knowledge and competency to enable them to confidently diagnose, treat/manage or refer patients. The importance of attracting more medical students to a career in rheumatology, and the indisputable value of integrated, multidisciplinary and multiprofessional care are also discussed. We conclude that RMD teaching for the future will need to address what is being taught, but also where, why and to whom, to ensure that healthcare providers deliver the best patient care possible in their local setting.

Objective: The aim of this study is to assess the level of knowledge and acceptance for biosimilars and nonmedical switching in Arab rheumatologists. Methods: A cross-sectional survey was conducted during the Arab League Against Rheumatism conference using a structured questionnaire consisting of 17 questions. Results: The participants were mainly females (50.7%), practicing in the Gulf region (65.7%) with a median [Interquartile Range (IQR)] age and years of practice as consultants of 44 (13) years and 10 (14) years, respectively. The median (IQR) self-perceived knowledge of biosimilars was 5.3 (4) out of 10. Most physicians agreed that the evidence published to grant biosimilars an approval for the studied indication was enough (40.6%), yet most of them believed it was not enough for extrapolation of indications (40.6%). The mean (standard deviation) likelihood to prescribe biosimilars in the future was 5.39 (2.6). The majority of rheumatologists (59.8%) believe that nonmedical switching could pose harm to patients. Most physicians agreed that nonmedical switching will lead to a significant saving in cost (58.5%) with the majority expecting a cost reduction between 30% and 50% to justify nonmedical switching. Conclusion: This is the first study to evaluate acceptance of biosimilars and nonmedical switching on a diverse population of rheumatologists in the Middle East. Future educational activities task forces should target these topics.

Background: Systemic lupus erythematosus is polygenic autoimmune rheumatic disease with heterogeneous manifestations. Lupus patients with nephritis signal represents management challenge. With current induction and maintenance therapy the risk of developing lupus nephritis related ESRD at five, ten and fifteen years remains 11,17 and 22% for the last decade Objectives: To study clinicopathological characteristics of lupus nephritis patients as well as short term renal outcome following induction of remission attempts. Methods: Retrospective, prospective observational study. We enrolled all patients with suspected active Lupus nephritis attending Dubai Hospital Rheumatology services. Data collected during outpatient, inpatient consultation using medical electronic system for all patients newly diagnosed to have lupus with renal involvement or patients who had nephritic or nephrotic flare from June 2016 till December 2018 Results: Of 71 patients included during the study period, mean age was 36.4 years, 93% were female while 7% were males.56 Out of 71 were Arab (78%) while the rest 15 out of 71 (22%) from non-Arab ethnicity. 84% (60/71) patients suspected to have active lupus nephritis underwent ultrasound guided kidney biopsy unless contra-indicated or the patient refused to sign the consent for the procedure. The commonest histopathological class according ISN/RPS 2003 Classification was class III. Induction of remission attempted with Mycophenolate Mofetil in 29% of patients (21/71). Around (8/71) received Rituximab regimen while more than 50% of the patients (39/71) received Cyclophosphamide Euro lupus protocol. At 6 months assessment following induction of remission 40/71 showed complete response and 26/71 responded partially, 5/71 required dialysis 2 of them required short term dialysis. On the other hand 3/71 (4%) progressed to end stage renal disease. Among patients who developed end stage renal disease there was signal of less favorable prognostic indicators such comorbid condition with possible glomerulopathy complications such as diabetes mellitus and hypertension. Moreover 2 of the 3 patients end with long term dialysis observed to have positive Antiphospholipid antibody status which may reflect co-existing thrombotic angiopathy. Among biopsy criteria predicting worse outcome was the presence of Cellular crescents on background of Class III or IV lupus nephritis. Conclusion: Our study is unique in the region, characterizing high risk group of SLE patients. The signal of co morbid conditions such as hypertension, diabetes mellitus and antiphospholipid antibody positivity as well as class III/IV Lupus nephritis with cellular crescents as predictor of worse renal outcome raise the unmet need for further study with large sample involving more than single center to determine clinical, serological and histopathological predictors of renal outcome in short term as well as long term with the available immune suppressive regimens. References [1] G K Bertsias, Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis, Ann Rheum Dis. 2012; 71(11): 1771–1782. [2] JAN J. WEENING, The Classification of Glomerulonephritis in Systemic Lupus Erythematosus Revisited, J Am Soc Nephrol 2004, 15: 241–250 Disclosure of Interests: None declared

Osteoporosis is the most common bone disease in humans. With its related fragility fracture, it represents a major public health problem in our region, with a significant medical and socio-economic burden. The high prevalence rate of vitamin D deficiency, the increase in life expectancy, the low socioeconomic level and the significant restriction to access to health care in some countries represent the major causes for the increasing prevalence of osteoporosis and incidence of fragility fractures in the Arabic countries. Bone mineral density (BMD) assessment is the gold standard to diagnose osteoporosis. However, a clinical diagnosis of osteoporosis may be made in the presence of a fragility fracture, without BMD measurement. Dual energy x-ray absorptiometry (DXA) is the preferred method for screening bone mineral density. For screening site of measurement, DXA of hip and spine is suggested. BMD assessment is recommended in all women 65 years of age and older and men 70 and older regardless of risk factors. Younger subjects with clinical risk factors and persons with clinical evidence of osteoporosis or diseases leading to osteoporosis should also be screened. These guidelines are aimed to provide to health care professionals in the region of an updated process for the diagnosis and treatment of osteoporosis. It includes risk factors for osteoporosis and the indications for screening, diagnosis of osteoporosis, treatment of osteoporosis in postmenopausal and premenopausal women, and men; in addition to prevention and treatment of glucocorticoid-induced osteoporosis.

Background:Fibromyalgia (FM) is a condition characterized by chronic widespread pain, tender points, fatigue and disturbed sleep rhythm. Some of these symptoms such as fatigue, tender points and diffuse pain seen in patients with spondylarthritis (SpA). Moreover, FM and SpA can coexist creating a diagnostic challenge, particularly in early disease course and influence clinical disease activity assessment.Objectives:With this cross-sectional study, we aim to estimate the prevalence of FM in SpA and to elaborate its effect on biological treatments.Methods:FM was identified according to the ACR 2010 diagnostic criteria. SpA patients identified according to rheumatologist using various SpA subsets criteria. A review of the electronic medical files for SpA patients attending the rheumatology outpatient clinic and infusion unit at a major tertiary hospital during the period from June to December 2018 were included. Patients’ demographics, socioeconomics, disease characteristics, activity, HLA status and abnormal MRI sacroiliac were explored. Regarding SpA medications, number, frequency and dose of DMARDs and biological agents were obtained.Continuous variables were reported by their mean and standard deviation (SD) and qualitative variables by frequency and percentage. Statistical significance was set at p Results:Of the 305 enrolled SpA patients, 43 (14.1%) had FM. Females represents 57.4% of the patients, mean age was 44.07 ± 11.85 years. Arab ethnicity represents most of our cohort 84.9%, the majority were Emirati 64.6%. Smokers were 8.2% and ex-smokers were 3.3%. Axial SpA represents 38.4% while peripheral SpA 61.6% of our cohort according to ASAS classification.HLA B27 tested in a sample of 180 patients; it was positive in only 17.8%. CRP found to be elevated in 20.3% of the patients at baseline. Abnormal MRI SIJ bone marrow edema changes were found in 10.8%, while other SIJ changes was seen in additional 20.6%. The prevalence of FM showed no statistically significant difference between axial and peripheral SpA. Patients SpA and FM have longer disease duration than SpA alone, P= 0.034. Table.1 show demographics, socioeconomics and clinical data of our cohort.Regarding medication, the use of biologics among SpA patients with FM is more frequent than SpA patients without FM (74.4% vs 51.5 % respectively), P= 0.005. Interestingly, the likelihood ratio testing showed that SpA patient with Fibromyalgia switch more frequently to another biologics than SpA without fibromyalgia, P= 0.015.Cramer’s V test showed that there is a high statistically significant (P= 0.002) and very strong association (> 0.25) between presence of Fibromyalgia and multiple switching of biologics in SpA.There was no difference in the exposure to prednisolone nor conventional DMARDs between SpA patients with or without FM, P= 0.64 & 1 respectively.Gender, Female, n (%)175 (57.4)Age, mean ± SD (min- max), years44.07 ± 11.85 (18- 78)Type of A, n (%)AxialPeripheral117 (38.4)188 (61.6)Fibromyalgia, n (%)FM in axial SpAFM in Peripheral SpA43 (14.1)18 (41.9)25 (58.1)SpA Disease duration (months)FM+, mean ±SDFM-, mean ±SD107.7± 50.486± 57.9Elevated CRP, n (%)62 (20.3)HLA B27 in180 patients, n (%)PositiveNegative32 (17.8)148 (82.2)Abnormal MRI SIJ, n (%)Bone marrow edemaSubchondral sclerosisFatty transformation of bone marrowErosion92 (30.2)33 (10.8)21 (6.9)5 (1.6)2 (0.7)Number of conventional DMARDs ever tired, n (%)NoneOneTwoThree81 (26.6)166 (54.4)46 (15.1)12 (3.9)Frequency of DMARDs usage, n, (%)Conventional DMARDsPrednisoloneBiologic DNARDs224 (73.4)56 (18.4)164 (53.8)Conclusion:FM coexistence with SpA might impact clinical evaluation of disease activity and possibly negatively affect self-measurement of treatment response. In our study, SPA patients exposed to more biologics if they have coexisting FM; Moreover, they are more frequent switchers among biologics including TNFi and IL17i.Acknowledgments:N Elsidig, A Al Marzooqi, N Zamani, A HossainiDisclosure of Interests: :None declared

This retrospective cohort study aimed to assess the demographic and clinical characteristics of rheumatoid arthritis (RA) in Emirati patients attending Cleveland Clinic Abu Dhabi, a large tertiary center in the Middle East. In this study, 414 Emirati patients with RA were evaluated over a 3-year period from April 2015 to April 2018. All patients fulfilled the 2010 RA ACR/EULAR criteria and were assessed for demographic and clinical characteristics. The estimated RA prevalence rate in our population cohort was 2.72%. Females showed predominance (80%) with a higher body mass index (31.4 ± 6.61, P=0.0001) compared to males (28.8 ± 6.03, P=0.0001). The most frequent comorbidity observed was dyslipidemia (43.5%) followed by hypertension (37.9%), diabetes mellitus (34.5%), and gastroesophageal reflux disease (33.1%). Xerophthalmia was the most frequent extra-articular manifestation. Rheumatoid factor and anti-citrullinated peptide were detected in 63.3% and 41.5% patients, respectively, while both were present in 33.3% of patients. Methotrexate, adalimumab, and rituximab were the most frequently prescribed disease modifying agents. In this study, we describe disease features that are unique to United Arab Emirates (UAE) patients and demonstrate that RA has a significant disease burden. Our findings highlight the need for a RA national registry to improve the quality of care of these patients in UAE.

Background Proteinuria is an important signal of Lupus nephritis. The standard method of proteinuria quantification is 24 hours urine collection. The ongoing practice of using spot urine sample to determine the ratio between protein and creatinine excretion as a convenient, alternative method of proteinuria estimation is not without limitation and criticism questioning its accuracy. Objectives Given the cumbersome expressed by some patients on collecting 24 hours urine for protein quantification, our aim was to determine the correlation between spot urine protein-to-creatinine ratio (PCR) and 24 hour urinary protein (UP) in patients with active Lupus nephritis. Methods The active patients included in the analysis was 53 attending Dubai Hospital shared Rheumatology/Nephrology clinic during the period of June 2016 till Dec 2017. All diagnosed to have systemic lupus erythematosus who either had flare with proteinuria or newly diagnosed as Lupus nephritis,. Suspicion of active Lupus nephritis was evidenced by active urine sediment and 24 hours UP quantification of more than 0.5 gm or more than 1.0 gm regardless to urine sediment. Paired baseline urine samples were obtained and results included in the final analysis. Most of the patients underwent ultrasound guided kidney biopsy to classify the nephritis according to ISN/RPS 2003 classification, unless contra-indicated or patient refused to give consent. We used Minitab 18.1 software to determine the Spearman’s correlation coefficient (r), and it is significance. P- Value Results Total of 54 patients evaluated, one patient excluded from the analysis as the patient nephritis was not related to lupus. 93% of the patients were females (49/53) while 7% were males (4/53). 42 patients underwent ultrasound guided kidney biopsy (79%) while 21% of the patients the histopathology class was not defined as no biopsy obtained either due to contra-indication to the procedure (i.e.: single kidney, flared during pregnancy) or the patient refusal to go for biopsy. 15 patients out of 53 (28%) had nephrotic range proteinuria (defined as urinary proteinuria level of more than 3.5 gm per 24 hours), on the other hand 72% (38/53) had sub nephrotic range. Linear regression Analysis revealed positive correlation between the two methods of estimation mainly at lower levels of proteinuria (less than 3.5 gm). We found a positive correlation between PCR and 24 hours UP quantification. The overall corrected correlation coefficient was r=0.46, with P value Conclusions PCR in spot urine specimens is an accurate and convenient method to estimate the protein excretion in urine only when proteinuria is at sub nephrotic range. Prospective study is required to explore the effect of disease activity, disease duration and co-morbidities on the correlation and predictive power of the model. References [1] G K Bertsias, Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis, Ann Rheum Dis. 2012;71(11):1771–1782. [2] JAN J. WEENING, The Classification of Glomerulonephritis in Systemic Lupus Erythematosus Revisited, J Am Soc Nephrol2004;15:241–250 Disclosure of Interest None declared

Aim The aim of this manuscript is to describe the development of the Asia Pacific Lupus Collaboration (APLC) cohort. Method The APLC cohort is an ongoing, prospective longitudinal cohort. Adult patients who meet either the American College of Rheumatology (ACR) Modified Classification Criteria for systemic lupus erythematosus (SLE), or the Systemic Lupus International Collaborating Clinics (SLICC) Classification Criteria, and provide informed consent are recruited into the cohort. Patients are routinely followed up at 3- to 6-monthly intervals. Information on demographics, clinical manifestations, treatment, pathology results, outcomes, and patient-reported quality of life (Short-form 36 version 2) are collected using a standardized case report form. Each site is responsible for obtaining local ethics and governance approval, patient recruitment, data collection, and data transfer into a centralized APLC database. Results The latest APLC cohort comprises 2160 patients with >12 000 visits from Australia, China, Hong Kong, Indonesia, Japan, Malaysia, Philippines, Singapore, Taiwan and Thailand. The APLC has proposed the Lupus Low Disease Activity State (LLDAS) as a treat-to-target (T2T) endpoint, and reported several retrospective and cross-sectional analyses consistent with the validity of LLDAS. Longitudinal validation of LLDAS as a T2T endpoint is currently underway. Conclusion The APLC cohort is one of the largest contemporary SLE patient cohorts in the world. It is the only cohort with substantial representation of Asian patients. This cohort represents a unique resource for future clinical research including evaluation of other endpoints and quality of care.

First described in 1983, antiphospholipid syndrome (APS) is an autoimmune condition characterized by the occurrence of recurrent arterial and/or venous thrombosis, and/or pregnancy morbidity, in the setting of persistent presence of antiphospholipid antibodies (aPL). While thrombosis is the most well-known pathogenic mechanism in this disorder, the relevance of some other mechanisms such as arterial stenosis is being increasingly recognized. Arterial stenosis has been first described in the renal arteries in patients with APS, however intracranial and coeliac arteries can also be involved with various and treatable clinical manifestations. The underlying pathophysiology of this stenotic arterial vasculopathy is not fully understood but some recent studies revealed new insights into the molecular mechanism behind this endothelial cell activation in APS. In this review, we discuss these newly discovered mechanisms and highlight the diagnostic and therapeutic modalities of the APS related arterial stenosis.

The World Health Organization (WHO) has ranked musculoskeletal diseases among the top ten leading causes of disability in the Middle East. The situation in the Middle East is unique as, although seventeen countries are geographical connected, there is considerable variability in the standard of rheumatology care and research between the countries. There are several factors contributing to this variability: allocated government resources to healthcare services, country demographics, the implemented healthcare system, the number of qualified rheumatologist, political stability, and the immigration to and from these countries.

Objectives A systematic review was conducted to explore the immunogenicity of biologic agents across inflammatory diseases and its potential impact on efficacy/safety. Methods Literature searches were conducted through November 2016 to identify controlled and observational studies of biologics/biosimilars administered for treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), ankylosing spondylitis (AS), non-radiographic axial spondyloarthritis (nr-axSpA), psoriasis (Ps), Crohn’s disease, and ulcerative colitis. Results Of >21,000 screened publications, 443 were included. Anti-drug antibody (ADAb) rates varied widely among biologics across diseases (and are not directly comparable because of immunoassay heterogeneity); the highest overall rates were reported with infliximab (0–83%), adalimumab (0–54%), and infliximab biosimilar CT-P13 (21–52%), and the lowest with secukinumab (0–1%), ustekinumab (1–11%), etanercept (0–13%), and golimumab (0–19%). Most ADAbs were neutralizing, except those to abatacept and etanercept. ADAb+ versus ADAb− patients had lower rates of clinical response to adalimumab (RA, PsA, JIA, AS, Ps), golimumab (RA), infliximab (RA, PsA, AS, Ps), rituximab (RA), ustekinumab (Ps), and CT-P13 (RA, AS). Higher rates of infusion-related reactions were reported in infliximab- and CT-P13-treated ADAb+ patients. Background immunosuppressives/anti-proliferatives reduced biologic immunogenicity across diseases. Conclusions Based on reviewed reports, biologic/biosimilar immunogenicity differs among agents, with the highest rates observed with infliximab and adalimumab. As ADAb formation in biologic-/biosimilar-treated patients may increase the risk of lost response, the immunogenicity of these agents is an important (albeit not the only) consideration in the treatment decision-making process. Electronic supplementary material The online version of this article (doi:10.1007/s40259-017-0231-8) contains supplementary material, which is available to authorized users.

Background Denosumab was introduce to the United Arab Emirates Market in 2013.Given the limited experience in using Denosumab in the region we have explored it efficacy and safety in daily practice. Objectives To assess the efficacy and safety of Denosumab in our practice. Methods Inclusion criteria: All patients received Denosumab in a dose of 60mg every six months. Underwent DEXA scan in Dubai Health Authority. Exclusion from analysis: Other Doses of Denosumab, who received less than 3 doses, and those with no follow up DEXA scan. Outcome measures: 1) Efficacy: Proposed Criteria for Assessing Clinical Response [1,2]. a) “inadequate”: incident fracture and significant BMD decrease. b) “possible inadequate”: incident fracture or significant BMD decrease. c) “appropriate”: no fracture and stability or increase in BMD. 2) Safety: Reviewing the medical records and conduct patients interview for occurrence of the following adverse events. Statistical analysis: Descriptive statistical analysis, Graphpad Prism 6 was used. Results 143 patient identified. Out 139 patients 86 were eligible for analysis (See table 1). At baseline 39% had normal vitamin D level, 57% had insufficiency and 4% had deficiency. 20 of 86 did not undergo repeated DEXA scan. 9% had osteopenia and 91% had osteoporosis before initiating Denosumab in comparison 8% had normal bone mineral density, 45% had osteopenia and 47% post four injections of Denosumab. Table 2 summarize the comparison between the responders and non-responders. There was a significant positive correlation in the increase in bone mineral density among the responders at the femoral neck and the lumbar spine, (r=0.56, 95% confidence interval: 0.31–0.74, P-value Conclusions Denosumab was effective and safe in our patients. Long-term follow up is required to verify these findings in our population. References Diez-Perez and Gonzalez-Macias. Inadequate responders to osteoporosis treatment: proposal for an operational definition. Osteoporos Int. 2008 Nov;19(11):1511–6. E. M. Lewiecki & N. B. Watts. Assessing response to osteoporosis therapy Osteoporos Int (2008) 19:1363–1368. Disclosure of Interest None declared

A recent editorial considered the management of rheumatoid arthritis (RA) in the Middle East and Africa [1]. Following review of the limited available evidence in the literature specifically that is from this region, it was suggested that management of RA is suboptimal for a variety of reasons [1]. The editorial authors met to determine whether the European League Against Rheumatism (EULAR) consensus recommendations published in 2010 [2] were applicable and appropriate for implementation in the MENA region and South Africa [1]. The group made recommendations on next steps to improve the management of RA in this region, including collection of epidemiological data to elucidate better the prevalence, severity and burden of RA in this region; educational initiatives to raise awareness of the disease and dispel misconceptions among health care professionals (HCPs) and patients; development of regional guidelines to increase implementation of an evidence-based approach and improve outcomes; and facilitation of access to treatments in line with the recommendations [1]. In addition, locally relevant issues not commonly seen in Europe such as high rates of hepatitis B and C, tuberculosis (TB) and parasitic infections as well as access and monitoring difficulties should be considered.

Background Hematopoietic stem cell transplantation (HSCT) has been proposed as a therapeutic option for patients with Systemic Lupus Erythematosus (SLE) refractory to standard therapy. This therapeutic approach has been applied to other severe autoimmune diseases refractory to standard therapy with promising results. Aim To systematically review the literature and analyze the available evidence on HSCT therapy in patients with SLE and antiphospholipid syndrome (APS), with a focus on therapy efficacy and occurrence of adverse events. Methods A detailed literature search, applied to Ovid MEDLINE, In-Process and Other Non-Indexed Citation and Ovid Medline 1986 to 2014, has been developed a priori to identify articles that reported findings from clinical and laboratory studies that investigated the effect of HCT in patients with SLE. Results Twenty-five studies met all inclusion criteria, including a total of 279 SLE patients; of those, 54 patients also fulfilled the classification criteria of APS. The majority of the studies reported an improvement after HSCT in terms of diseases activity control (assessed with SLEDAI, or time-free from diseases) or overall survival. However, one study reported no net benefit of HSCT when compared to immunosuppression alone. One retrospective study reported an overall survival at 5 years of 81% in 28 SLE patients. Of note, 5 cases (9.3%) of aPL negativization were reported after HSCT in the APS patients. When combining these studies and analyzing these patients with APS, 32 out of 44 (73%) were able to discontinue anticoagulation after HSCT. Our findings also demonstrate a total of 86 infections in the pool of patients (30.8%), 3 of which resulted in the death of the patient (1.3%). We observed an annual incidence of infection of 11.9% with a mean follow up of 36.2 months. Conclusion Preliminary results of HSCT as a therapeutic option for SLE appear promising. Further studies are warranted in order to assess the safety of the procedure for both the occurrence of secondary autoimmune disease and the rate of infection. However, the rate of adverse effects confines this option to very selected cases of SLE patients resistant or refractory to standard approaches.

Although the prevalence of RA in the Middle East and Africa is comparable with that in other parts of the world, evidence indicates that its management in this region is suboptimal for a variety of reasons, including misconceptions and misunderstandings about the disease's prevalence and severity in the region, compounded by the lack of local epidemiological and health-economic data around the disease; the perception that RA is a low priority compared with other more prevalent conditions; delayed diagnosis, referral and treatment; and a lack of a region-specific, evidence-based management approach. In the absence of such an approach, the EULAR treatment recommendations may provide a useful starting point for the creation of guidelines to suit local circumstances. However, although agreement with the EULAR recommendations is high, many barriers prevent their implementation in clinical practise, including lack of timely referral to rheumatologists; suboptimal use of synthetic DMARDs; poor access to biologics; lack of awareness of the burden of RA among healthcare professionals, patients and payers; and lack of appropriate staffing levels.To optimise the management of RA in the Middle East and Africa, will require a multi-pronged approach from a diverse group of stakeholders-including local, national and regional societies, such as the African League of Associations in Rheumatology and International League of Associations for Rheumatology, and service providers-to collect data on the epidemiology and burden of the disease; to increase awareness of RA and its burden among healthcare professionals, payers and patients through various educational programmes; to encourage early referral and optimise use of DMARDs by promoting the EULAR treatment recommendations; to encourage the development of locally applicable guidelines based on the EULAR treatment recommendations; and to facilitate access to drugs and the healthcare professionals who can prescribe and monitor them.

Rheumatic and musculoskeletal diseases (RMDs) represent a multitude of degenerative, inflammatory and auto-immune conditions affecting millions of people worldwide. Persons with these diseases may potentially experience severe chronic pain, joint damage, increasing disability and even death. With an increasingly ageing population, the prevalence and burden of RMDs are predicted to increase, placing greater demands on the global practice of rheumatology and related healthcare budgets. Effective treatment of RMDs currently faces a number of challenges in both the developed and developing world, and individual countries may face more specific local challenges. However, limited understanding of the burden of RMDs amongst public health professionals and policy-makers means that these diseases are often not considered a public health priority. The objective of this review is to increase awareness of the RMDs and to identify opportunities to address RMD challenges on both a local and global scale. On 26 September 2014, rheumatology experts from five different continents met at the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD) to discuss and identify some key challenges for the RMDs community today. The outcomes are presented in this review, focusing on access to rheumatology services, diagnostics and therapies, rheumatology education and training and on clinical trials, as well as investigator-initiated and epidemiological research. The long-term vision of the WFRMD is to increase perception of the RMDs as a major burden to society and to explore potential opportunities to improve global and local RMD care.

Symptomatic avascular necrosis (AVN) of the hip is a known complication of systemic lupus erythematosus (SLE). Data on the prevalence of bone avascular necrosis (AVN) in Arab SLE patients are limited. We conducted a cross-sectional and retrospective case-control study on 126 SLE patients from Dubai to determine prevalence and predictors of symptomatic hip AVN. 8.7% of our lupus cohort demonstrated evidence of symptomatic hip AVN and had longer disease duration, higher cumulative steroid dose, and received cyclophosphamide and mycophenolate mofetil more often than the SLE patients without AVN (controls). Skin manifestations, serositis, lupus nephritis, neuropsychiatric lupus, and sero-positivity for autoantibodies: anti-DNA, Anti-Sm, and antiphospholipid antibodies were higher in patients than controls. Administration of hydroxychloroquine prior to onset of AVN was less frequent in cases than controls. In conclusion, disease activity, steroids, cytotoxic drugs, and antiphospholipid antibodies are important predictors of symptomatic AVN in Emirati patients with SLE, Hydroxychloroquine may play a protective role against developing AVN in Emiratis with SLE. Controlled longitudinal studies are essential to validate these findings.

Background: Introduction Musculoskeletal symptoms are frequent complaints seen in primary health care[1]. Indeed, a considerable number of patients may have a long term sequel, including chronic pain and disabilities if the underlying cause of their complaints was not addressed. So far, there is no well designed study has looked on the occurrence of rheumatic diseases in the UAE. Objectives To estimate the prevalence of rheumatic diseases in Emirati’s living and attending government Primary Health Care (PHC) in Dubai. Methods As 95.6% of the Emirati’s living in Dubai are registered with Dubai government PHC clinics. The PRO- Dubai study, P revalence of R heumatic diseases and O steoporosis in Dubai; is a cross-sectional study, randomly invited Emiratis’ aged between 18years to 85 years attended 13 PHC clinics in Dubai in the period between January 2 nd , 2009 to December 31 st , 2009. The studied sample size was predetermined based on the reported Emirati’s population living in Dubai on June 1st 2008 using a sample size calculator. The PRO- Dubai study consisted of three parts. A) Completing a questionnaire that contained demographic data, GALS screening questions, questions on the quality of night sleep, shading corresponding area of pain in the last three months on a manikin, and past medical history of chronic diseases. B) Validating the positive answers in the questionnaire by a rheumatologist and performing a thorough locomotor examination. C) Referring and managing those who were found to have musculoskeletal diseases in the secondary care. Rheumatic diseases were classified according to ACR, EULAR, and task force criteria for the diagnosis of various diseases. Results The study included 3,985 individuals; 77.4% were female, and their mean age was 42.1 (SD 15.8) years. Of the 3,985 participants who satisfied the inclusion criteria, 33.8% were found to be a healthy individual, i.e. with no musculoskeletal complaints in the last three months. The prevalence of low backache was the highest in our population 32.9%. Knee osteoarthritis was the commonest type of arthritis seen in our cohort 25.8%. We detected tendinitis in 5.0% and bursitis in 2.0%. 2.8% fulfilled benign joint hypermobility classification criteria and 1.2% met the ACR classification criteria for fibromyalgia. Overall, the prevalence of inflammatory arthritis was 3.1% in our cohort, 0.9% rheumatoid arthritis and 2.2% seronegative spondyloarthritis. Conclusions: Conclusions Rheumatic diseases are quite common in our general population. Low backache and knee osteoarthritis were the commonest musculoskeletal diseases seen in our cohort. There is a need of more population-based studies in the Arab region to have better understanding of the epidemiology of rheumatic diseases in this region. References Pekka Mantyselka, Esko Kumpusalo, Riitta Ahonen, Anne Kumpusalo, Jussi Kauhanen, Heimo Viinamaki, Pirjo Halonen, Jorma Takala. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain, 2001; 89: 175-180 Disclosure of Interest J. Alsaleh Grant/research support from: Le Servier & Janssen Pharmaceuticals, M. El Sayed: None Declared, N. Monsef: None Declared, N. Salah: None Declared, N. Noureen Khan: None Declared, E. Darwish: None Declared, F. Elbadawi: None Declared, G. Harifi: None Declared, R. Babiker: None Declared, N. Zamani: None Declared