Rheumatoid Arthritis: What You Need to Know

At a Glance

About Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune inflammatory disease in which the immune system attacks the body's own joints, causing persistent inflammation, pain, swelling, and — if untreated — progressive joint destruction and disability. Unlike osteoarthritis (wear-and-tear), RA is driven by immune dysregulation, not mechanical damage.

RA most commonly begins in the small joints of the hands and feet, typically symmetrically (both hands at the same time). It can also involve extra-articular organs: lungs, eyes, heart, and blood vessels. Three times more common in women than men; peak onset 40–60 years.

The goal of modern RA management is treat-to-target: achieving low disease activity or remission and maintaining it. The 2024 SARAA (South African Rheumatism and Arthritis Association) guidelines confirm this as the standard for South African practice.

Disease Activity Assessment

RA management is guided by standardised disease activity scores assessed at every visit:

• DAS28 (Disease Activity Score — 28 joints): Combines tender joint count, swollen joint count, ESR/CRP, and patient global assessment
• Target: DAS28 < 2.6 (remission) or < 3.2 (low disease activity)
• If the target is not achieved at 3 months, the treatment strategy is escalated — this is the treat-to-target principle

Treatment Pathway

First Line — Conventional Synthetic DMARDs (csDMARDs)

Methotrexate (MTX) is the anchor drug. Started at a low dose (7.5mg weekly) and titrated to 15–25mg weekly. Takes 6–12 weeks for full effect. Always co-prescribed with folic acid to reduce toxicity.

Additional csDMARDs added in combination if MTX monotherapy is insufficient: - Hydroxychloroquine (HCQ) 200–400mg daily — antimalarial, well-tolerated - Sulfasalazine (SSZ) 500–1000mg twice daily - Leflunomide 20mg daily — alternative to MTX for patients who cannot tolerate it

Monthly monitoring initially: full blood count + liver function tests (MTX toxicity screen).

Second Line — Biologic DMARDs (bDMARDs)

When ≥ 2 adequate csDMARD trials fail (typically 3+ months each), biologic therapy is indicated. SARAA Biologics Advisory Peer Review Panel (BAPRP) approval is required before initiation — this is a South Africa-specific gatekeeping mechanism involving specialist peer review.

TNF inhibitors (most commonly used first biologic class): - Adalimumab (Humira — originator; AMGEVITA — biosimilar). Subcutaneous injection every 2 weeks. Originator: ~R9,000/month. Biosimilar (AMGEVITA, launched SA 2020): ~R5,000/month. - Etanercept (Enbrel — originator; biosimilars available). Subcutaneous weekly. ~R6,000-6,500/month. - Infliximab IV infusion every 8 weeks after loading.

Other biologic classes: - Tocilizumab (Actemra) — IL-6 receptor inhibitor. SC or IV. - Rituximab (MabThera) — CD20 B-cell depleter. IV infusion courses. - Abatacept (Orencia) — CTLA4-Ig co-stimulation blocker. SC or IV.

Third Line — Targeted Synthetic DMARDs (tsDMARDs / JAK inhibitors)

Oral alternatives to injectables. Used as second-line alongside or instead of bDMARDs: - Tofacitinib (Xeljanz) 5mg twice daily or 11mg extended-release — JAK1/3 inhibitor. ~R4,500/month. - Baricitinib (Olumiant) 2–4mg daily — JAK1/2 inhibitor. ~R5,000/month.

Also require SARAA BAPRP authorisation.

Annual Cost Estimates (Private Sector)

The R48,000/year biosimilar–originator gap is the central RA financial decision point.

The PMB and CDL Position

All schemes must fund csDMARDs (MTX, HCQ, SSZ, leflunomide) and associated monitoring as CDL benefits.

Biologic and JAK inhibitor funding: NOT in the standard CDL formulary. Requires: 1. Two documented failed adequate csDMARD trials 2. SARAA BAPRP review and approval 3. Scheme exceptional needs committee authorisation

This two-step approval (SARAA + scheme) is SA-specific and takes weeks to months. Initiating biologics urgently is difficult — factor this into disease management planning.

Ophthalmology screening for HCQ: Hydroxychloroquine requires annual retinal toxicity screening (fundoscopy or OCT). Funding is scheme-dependent — typically d2d benefits.

Gap Cover Relevance

The Talk to Eldon Angle

csDMARDs cost R150–500/month and are fully CDL-funded. The financial escalation point is biologic therapy. Scheme formulary policy on biosimilar-vs-originator adalimumab determines whether biologic escalation costs R60,000/year or R108,000/year — a R48,000/year difference for the same clinical effect.

Joint replacement surgery is the most common planned hospitalisation in RA with significant disease. An orthopaedic surgeon billing above scheme rate for a total knee replacement adds R15,000–R40,000 in shortfall. Gap cover closes this.

Sources

1. SARAA 2024 updated guidelines for RA management. SAMJ, October 2024.
2. SARAA 2024 guidelines for biologic and targeted synthetic DMARDs in RA. SAMJ, October 2024.
3. Amgen launches AMGEVITA in South Africa. MedPharm, 2020.
4. CMS PMB Regulations — CDL: Rheumatoid Arthritis.

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