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Male Female
< 5 years
5-10 years
11-20 years
>20 years
Multi-specialty hospital
Clinic/ nursing home
Government hospital/ medical college
Mixed
Tier 1 city
Tier 2 city
Tier 3 city
Rural area
Mild to moderate RA is most prevalent
Moderate to severe RA is most prevalent
RA more common in young population
RA more common in old age population
Majority of patients respond to conventional synthetic DMARDs
Majority of patients do not respond to conventional synthetic DMARDs and require targeted synthetic DMARDs to achieve remission
Majority of patients do not respond to conventional synthetic DMARDs and require biological DMARDs to achieve remission
1-10
11-20
21-40
Any other
1-10%
11-20%
21-40%
Musculoskeletal examination (Tender and Swollen Joint Count)
C-Reactive Protein
Erythrocyte Sedimentation Rate
Antinuclear Antibody (ANA)
Rheumatoid Factor
Anti-cyclic citrullinated peptide (Anti-CCP)
X ray
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT) scan
Synovial fluid examination
Clinical examination to assess joint pain & swollen joint and morning stiffness
Clinical Disease Activity Index > 2.8
High acute phase reactant levels (ESR > 28 mm/h & CRP > 8 mg/L)
Presence of RF and/or ACPA especially at high levels
Failure of two or more conventional synthetic DMARDs
Presence of early bony erosions
Cardiac diseases
Gastrointestinal diseases
Pulmonary diseases
Skin manifestations
Ocular manifestations
American College of Rheumatology (ACR) Guidelines
European League Against Rheumatism (EULAR) Guidelines
National Institute of Health and Care Excellence (NICE) Guidelines
10-20%
21-30%
31-40%
First line therapy
After inadequate response to conventional synthetic DMARDs
After inadequate response to infliximab
After inadequate response to etanercept
Subcutaneous route of administration
Hospitalization is not required
Efficacy has been proved in multiple clinical trials
Favourable safety
No any specific preferable parameters
Adalimumab monotherapy
Adalimumab with methotrexate combination therapy
Adalimumab with other conventional synthetic DMARDs except methotrexate
Biological DMARDs
Targeted synthetic DMARDs
< 6 months
1-2 years
> 2 years
3-6 months
6-12 months
2-3 years
>3 years
Life long
1-3 months
>1 year
< 10%
>40%
Poor patient compliance
Patients do not take the treatment as prescribed due to higher cost of therapy
Development of anti-adalimumab antibodies
Incorrect administration by the patients
Insufficient blockade of TNF due to development of anti-drug antibodies leading to low serum concentration
Primary failure of adalimumab
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
Comparable efficacy
Less efficacy than low concentration adalimumab
More efficacy than low concentration adalimumab
Not able to comment as I did not differentiate between two formulations
Symptom resolution
Improvement of functionality and activities of daily living
Improvement of quality of life
Delay in the development of extra-articular manifestations
Prevention of bony erosions
Do not monitor ADA if loss of clinical response occurs and assess clinically
Development of ADA is not evaluated
Development of ADA is seen rarely
Development of ADA is seen infrequently
Development of ADA is seen frequently
Development of ADA is seen in ___% of patients
Restart Adalimumab with same dose and same dosing interval (alternate week)
Adalimumab with higher dose and same dosing interval (alternate week) gets started
Adalimumab with same dose with reduced dosing interval (weekly) gets started
Adalimumab with higher dose with reduced dosing interval (weekly) gets started
Another TNF blocker gets started.
Patients are screened for latent and active tuberculosis before giving adalimumab and during treatment
Patients are treated with anti-tubercular drugs if latent or active tuberculosis is detected before giving adalimumab
Adalimumab is not prescribed to patient with history/suspicion of tuberculosis
Consultation with physician with expertise in the treatment of tuberculosis to decide whether initiating anti-tuberculosis therapy is appropriate for an individual patient
Chest radiograph
T-cell interferon-gamma release assay (IGRA)
Tuberculin skin test (TST)
TST in parallel with IGRA
TST in parallel with QuantiFERON TB Gold
Chest radiograph and TST in parallel with IGRA
QuantiFERON TB Gold
Patients are closely monitored before and during adalimumab therapy for various infections
Concomitant use of adalimumab and other biologicals is avoided to treat RA
Treatment with adalimumab is not initiated in patient with active infection
Adalimumab is avoided in patients 65 years of age and older
Adalimumab is avoided in patients with co-morbid conditions
Continue adalimumab and start treatment for the infection simultaneously
Infection is treated, adalimumab is stopped and other TNF blocker is started once infections is subsided
Treatment for infection is started and adalimumab is resumed once infection is subsided
Treatment for infection is started and therapy with drug other than TNF blockers is started once infection is subsided
Adalimumab is not prescribed in patients with prior history of any malignancy
Adalimumab is not prescribed if patient is already taking immunosuppressant for other illnesses
Adalimumab is avoided in patients with family history of malignancy
Adalimumab along with specific cardiac treatment
Infliximab along with specific cardiac treatment
Etanercept along with specific cardiac treatment
Tofacitinib along with specific cardiac treatment
Any other biological with specific cardiac treatment (Please mention name of biological)
Adalimumab along with specific disease treatment
Infliximab along with specific disease treatment
Etanercept along with specific disease treatment
Tofacitinib along with specific disease treatment
Refer to pulmonologist for further treatment for pulmonary disease
Adalimumab along with specific skin disease treatment
Infliximab along with specific skin disease treatment
Etanercept along with specific skin disease treatment
Tofacitinib along with specific skin disease treatment
Refer to dermatologist for further treatment for skin disease
Adalimumab along with specific ocular disease treatment
Infliximab along with specific ocular disease treatment
Etanercept along with specific ocular disease treatment
Tofacitinib along with specific ocular disease treatment
Refer to ophthalmologist for further treatment for ocular disease