Rheumatoid arthritis in the Kingdom of Saudi Arabia

We read with interest the comprehensive review on rheumatoid arthritis (RA) in the kingdom of Saudi Arabia (KSA) by Almoallim and Alharbi.1 We would like to make a few comments. The best predictors for the development of RA, are anti-citrullinated protein antibodies (ACPA) and rheumatoid factors (RF), which can appear more than 10 years before clinical arthritis.2 Screening using ACPA and RF are a cost effective method for identifying the population susceptible to RA. Though susceptibility to RA is clearly defined by a pattern of inherited genes, the overall contribution of genetics to the development of the disease is very small at around 15%.3 The best defined environmental factor is smoking. Its interaction with genes increases susceptibility to RA 20to 40fold.4 Smoking increases citrullination in alveolar macrophages. However, citrullination of peptides in the lung is not specific for RA. In the United Kingdom (UK), the introduction of the gait, arms, legs, and spine (GALS) screening examination represents a major advance for undergraduate education by enabling medical students to perform a validated, straightforward musculoskeletal examination. The video and the details of this simple screening test is available free from Arthritis Research, UK on http://www.arthritisresearchuk.org/healthprofessionals-and-students/video-resources/rems/galsscreening-examination.aspx.5 The GALS is an objective and a quick screen for both locomotor abnormality and functional disability.6 Our final point, there are many excellent international guidelines for the treatment of RA, but more importantly is whether practicing clinicians adhere to them. Maintaining a high standard of care for our patients with RA, requires a national or regional audit.