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Musings on Sri Lankan Rheumatology

Musings on Sri Lankan Rheumatology

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 I was fortunate to be in Colombo on the weekend to talk to the Sri Lankan rheumatology association.

The brief was to share the experience of biologic use for rheumatoid arthritis (RA) in Australia and to give a practical perspective as a clinician in private practice. It was a difficult talk to prepare as we have very different health systems so I hoped to share some thoughts while opening up the floor to discussion.

Sri Lankans are reserved and very polite. As they warmed up, there were thankfully questions and a shared conversation.

Here’s some of what I learned:

Sri Lankan rheumatologists are up to date. Many have trained in Western countries and been exposed to alternative health systems. They speak the same rheumatoid lingo, believing in the window of opportunity and wanting to practice a treat-to-target strategy.

But the situation they work in makes the above very hard.

Access issues abound. Consider that Australia and Sri Lanka have a roughly equivalent population, 20+ million. There are around 22 practising rheumatologists in Sri Lanka vs my guess of 280 practising Australian rheumatologists.

Health is basically government-funded. Private hospitals with clinics do exist but that caters to much smaller numbers. Waiting lists are very long. Clinics are jam-packed with patients who may have travelled hours to then wait a further few hours for a few minutes of the doctor’s time. The rheumatologists are perpetually pushed for time.

Sri Lankan rheumatologists work much harder than yours truly. They have full time jobs (5 and a half days) in a government hospital. Many then leave to work a few hours after their public hospital shift in a private hospital. Most work a full day Saturday.

Cost containment is a major issue. They have full access to conventional DMARDs such as Methotrexate, Sulphasalazine, Hydroxychloroquine and Leflunomide.

Access to biologic medications is understandably restricted in this much poorer country. I audited our own clinic’s use of biologics and we would very likely have more patients on biologic medications than in the whole of Sri Lanka.

I was very surprised to hear that the most used TNF-inhibitors for RA worldwide, Adalimumab and Etanercept, are not available.

Instead they have access to Infliximab, Rituximab and Tocilizumab (compared to the 9 biologic medications we have available in Australia as well as the new targetted-DMARD, Tofacitinib).

One rheumatologist told me that they could also access Golimumab but it is not really used as there is a very clear preference for intravenous medication in Sri Lanka. This seems to be due to the hospital system, the assumed better compliance, and the fact the medications are not used continuously. Instead, biologics are prescribed for short courses due to costs, for eg, 6 months of Tocilizumab only.

With the high rates of tuberculosis, the preference is to use Tocilizumab and Rituximab.

I also learned of the use of “copies” of biologic medication being used. These are termed non-comparable biotherapeutic products. They originate from India and China from what I was told. Unlike biosimilars, they seem to have less robust actual clinical trial data for efficacy and safety. I had not heard the term before so I googled. You can read more here.

I always find it fascinating to find out about rheumatology in other countries. Australia is the lucky country, and that’s for both rheumatologists and our patients.

Putting our complaints into perspective is a useful exercise.

 

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