Session Information
Session Type: ACR Poster Session A
Session Time: 9:00AM-11:00AM
Background/Purpose: Methotrexate (MTX) is standard therapy for rheumatoid arthritis (RA) and also used to treat other rheumatic diseases. Existing guidelines for RA treatment/ MTX use did not contemplate the realities of resource limited countries. We aimed to understand MTX use patterns and barriers in African countries to inform the development of culturally appropriate guidelines.
Methods: We identified African physicians (MDs) from countries classified as low Human Development Index (LHDI) and medium/high HDI (MHDI) by the United Nations Development Programme and who self-identified as MTX prescribers. Each MD participated in a 45 minute semi-structured interview by phone in either English or French regarding their MTX practices.
Results: 29 MDs (23 rheumatologists; 6 internists) from 29 African countries were interviewed (17 LHDI; 12 MHDI) representing a population of 1,000.4 million; (LHDI 673.8 million; MHDI 326.6 million). The median (range) of rheumatologists/ million population in these countries was only 0.17 (0-9.4). LHDI countries had significantly fewer rheumatologists/ million population than MHDI (0.1 (0-0.66) vs 1.1(0-9.43) p=0.004). MTX was prescribed by non-rheumatologists in 93% LHDI and 67% MHDI countries. Most MDs practised in capital cities and served adult patients. 88% LHDI and 67% MHDI MDs also provided pediatric care. The main indication for MTX use was RA with connective tissue diseases and psoriatic arthritis as secondary indications. Prior to prescribing MTX, most MDs (97%) evaluated patients for pulmonary, hepatic and renal dysfunction and excluded cytopenias. Screening was performed for TB (with CXR) by 62%, HIV by 55% and Hepatitis B/C by 52%. Pregnancy screening was usually by patient self-report (86%). Discussing alcohol consumption was considered pertinent to the local consumption by 42% of MDs. MTX dosing was similar between LDHI and MDHI countries, and usually given with folate (83%). Only 55% of countries had parenteral MTX. 55% of MDs reported barriers to MTX use due to drug availability or costs. Compared to MHDI countries, LHDI countries were more likely to have an inconsistent MTX supply throughout the year (82% LHDI vs 42% MHDI (p=0.05) and less likely to have MTX available in the hospital pharmacy (35% LHDI vs 83% MHDI; p=0.02). Major contributors to MTX non-adherence included drug cost or availability (85%), lack of prescribers (15%) and patients’ beliefs/education/tolerance (37%).
Conclusion: The challenges of treating RA patients in African countries with low HDIs are unique. Costs of medical care and drugs, limited subspecialist availability, patient specific beliefs, and lack of MTX are significant challenges faced by MDs treating patients with rheumatic disease. Understanding the African LHDIs reality is critical for the development of guidelines to improve care quality and outcomes. Table: Patterns of MTX prescription in Africa. All values are % or median (range)
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Total n=29 |
LHDI n=17 |
MHDI n=12 |
P value |
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Population (2015) Rheumatologists/million |
1,000,446,000 0.17 (0-9.4) |
673,839,000 0.8 (0-0.66) |
326,607,000 1.1 (0-9.4) |
P=0.47 P=0.004 |
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Rheumatologic indications for methotrexate |
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Main reason RA (% reporting) Second reasons CTD/ PsA/ JIA |
100 43/43/14 |
100 44/38/19 |
100 42/50/8 |
P=1 P=0.7 |
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Pre-methotrexate evaluation |
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Lung, liver, kidney, hematology Xray done TB screen CXR done HIV done Hepatitis B/C done Pregnancy screen by self-report only |
97% 58% 62% 55% 52% 86% |
94% 65% 71% 59% 41% 88% |
100% 50% 50% 50% 67% 83% |
P=1 P=0.4 P=0.3 P=0.6 P=0.3 P=1 |
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Methotrexate prescription |
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Starting dose (mg/wk) Maximum dose (mg/wk) Folate prescribed |
10( 2.5-15) 25(12.5-30) 83% |
10(7.5-15) 25(15-25) 82% |
10(2.5-15) 22.5(12.5-30) 83% |
P=0.5 P=0.5 P=1 |
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Prescribing challenges |
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Cost for 1 month (10-15 mg/wk) USD Injectable formulation available Inconsistent MTX supply MTX in hospital pharmacy |
17( 0.5-27) 55% 66% 55% |
17.25 (1-27) 52% 82% 35% |
10(0.5-27) 58% 42% 83% |
P=0.7 P=0.8 P=0.05 P=0.02 |
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Adherence challenges |
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Cost/drug availability Lack of prescribers Patient belief/education/intolerance |
85% 15% 37% |
94% 13% 44% |
73% 18% 27% |
P=0.3 P=1 P=0.4 |
To cite this abstract in AMA style:
Hitchon CA, Liu Y, Shi S, Mody GM, Feldman CH, Weinblatt M, Colmegna I. Patterns of Methotrexate Use in African Countries with Low Versus Medium/High Human Development Index: Preliminary Results of Semi-Structured Interviews [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/patterns-of-methotrexate-use-in-african-countries-with-low-versus-mediumhigh-human-development-index-preliminary-results-of-semi-structured-interviews/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/patterns-of-methotrexate-use-in-african-countries-with-low-versus-mediumhigh-human-development-index-preliminary-results-of-semi-structured-interviews/