Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Background: Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a crosssectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region. Methods: RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized casereport form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission. Findings: A total of 2010 RA patients was included in the study, the overall remission rates were 62 • 3% (DAS28-CRP), 35 • 5% (DAS28-ESR), 30 • 8% (CDAI), 26 • 5% (SDAI), 24 • 7% (Boolean), and 17 • 1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17 • 9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of

Introduction: Rheumatoid arthritis (RA) is an autoimmune rheumatic disease which often found in daily practice and requires certain considerations in recognizing clinical appearance also managing the disease as it often causes permanent joint damage, disability, even premature death. This recommendation is expected to become the latest reference for diagnosis and management of RA in Indonesia. Methods: The steering committee was formed by the Indonesian Rheumatology Association (IRA) to formulate key questions; conduct literature search, selection, and review; then formulate recommendation statements for diagnosis, therapy, and monitoring of RA. Furthermore, the steering committee determined the level of evidence and grades of the recommendations. After that, the level of agreement (LOA) was determined for each item by panelists including rheumatology consultants who have been appointed by IRA to represent Indonesia regions. Results: The steering committee established 30 recommendations including diagnosis, the role of laboratory and radiology tests, general treatment, the use of glucocorticoids, sDMARD, bDMARD, and tsDMARD. This recommendation also discusses guidelines on monotherapy, combination therapy, treatment strategies (treat-to-target), tapering, and continuous clinical remission. Treatment on co-morbidities and complications are also included in brief. Conclusion: IRA recommendations regarding the diagnosis and management of RA was made by considering various aspects such as the availability of drugs and supporting facilities, socioeconomic and cultural conditions in Indonesia, as well as the latest research that can be applied to Indonesian population.

Background : In recent years, rheumatoid arthritis (RA) uses a “treat to target”  treatment strategy. This strategy requires a valid and accurate tool for assessing disease activity. The most widely used tool is DAS28, which was developed from DAS with the omission of ankle and foot joints. There has been many critization aboutthe accuracy of DAS28 in classifying the state of RA disease. Most importantly, when an active disease state was misclassified as an inactive state (false negative)which lead to under treat and subsequently to disability. The difference between DAS28 and DAS lies mainly in the exclusion of ankle and foot joints, thus DAS28-squeeze, a new and simple tool has been proposed. It comprises the same 28 joints in DAS28 added with a sqeeze test on both metatarsophalangeal joints. However, this new tool has never been validated with any imaging techniques.Objective : To assess the diagnostic values of DAS28 and DAS28-squeeze.Methods : This study comprised a cross-sectional diagnostic study, using Power Doppler sonography as a standard reference in evaluating the diagnostic value ofDAS28 and DAS28-squeeze. This study uses the most sringent sonography criteria of active disease which is an active Doppler signal with a moderate synovial hypertrophy on B-mode. Results : Over the study period, 56 subjects underwent diagnostic tests using DAS28, DAS28-squeeze and Power Doppler sonography. There were 4 false negativecases in DAS28 and 1 case in DAS28-squeeze. The sensitivities of DAS28 and DAS28-squeeze to identify active disease using Power Doppler sonography as reference standard were 73.3% (95%CI ± 11.59) and 93.3% (95%CI ± 6.55), respectively. While the specificities of DAS28 and DAS28-squeeze were 36.6% (95%CI ± 12.62) and 34.1% (95%CI ± 12.42), respectively. Furthermore the negative likelihood ratioof DAS28 and DAS28-squeeze were 0.73 and 0.19, respectively.Conclusion : This study is the first to validate DAS28- squeeze using imaging techniques. From this study the false negative rate of DAS28-squeeze is lower thanDAS28. DAS28-squeeze has a better sensitivity and negative likelihood ratio than DAS28 in identifying RA disease state.Keywords : Rheumatoid Arthritis, DAS28, DAS28-squeeze, treat to target, Power Doppler, squeeze test

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Background: The development of Systemic Lupus Erythematosus (SLE) treatment has led the increased of patients survival. Quality of life has became a value based medicine component that should be evaluated in treating SLE. One standardized questionnaire to asses the quality of life in SLE patients is Lupus Quality of Life (Lupus QoL). Currently, in Indonesia, there has not been any spesific questionnaire to asses the quality of life in SLE patients. This study aims to prove that Lupus QoL is valid and reliable to asses the quality of life in SLEpatients in Indonesia.Methods: This study used cross sectional study method. Firstly, we translated the Lupus QoL into Indonesian language, then we tested to 10 respondents. Then, we continued the study with larger sample size. We analyzed the reliability of the test and the re-test result using the interclass coefficient correlation and the internal consistency of the tests using cronbach alpha. Construct validity was evaluated using multi trait scaling analysis and the extrenal validity was evaluated using correlation between domains in short form 36 (SF 36)with Lupus QoL and with disease activity.Results: Data collection was done to 65 SLE patients between October – November 2015 in RSCM. The test has good external validity SF 36 (r=0.38-0.66, p<0.05) and good construct validity (r >0.4; range: 0.44-0.93). The ICC value in one week >0.7 and Cronbach α was>0.7 in each domain. The correlation between lupus QoL and the disease activity was weak and consistentwith other studies.Conclusion: Lupus QoL questionnaire is valid and reliable to asses the quality of life in SLE patients inIndonesia.Key words: Quality of Life, Systemic Lupus Erythematosus, Lupus QoL, Validity, Reliability

Background:The mortality of Rheumatoid Arthritis (RA) is quite high, which is largely due to cardiovascular complications caused by endothelial dysfunction. One of the important inflammatory mediators that contribute to RA joints arthritis of TNF-α, also proven to play a role in endothelial dysfunction and play a role in increasing intracellular lipolysis, thus increasing circulating FFA levels.Objectives:To determine the correlation between TNF-α levels with VCAM-1 levels, correlation of TNF-α levels with FFA levels, and correlation of FFA levels with VCAM-1 levels.Methods:Cross sectional and retrospective design studies of adult RA patients treated at Cipto Mangunkusumo Hospital (RSCM), without metabolic disturbances, acute infection, cardiovascular disorders, or other autoimmune diseases. The cross-sectional data was collected from October to November 2017, while retrospective samples were collected since August 2016. TNF-α, VCAM-1, and FFA levels were assessed by serum blood test by ELISA method. Correlation analysis is done by Pearson analysis when the data distribution is normal and with Spearman analysis when the data distribution is not normal.Results:A total of 35 subjects were enrolled in the study. Most (97.1%) were women with an average age of 45.29 years, median disease duration of 48 months, and most had moderate disease activity (65.7%). No significant correlation was found between TNF-α levels and VCAM-1 levels (p = 0.677; r = +0.073). as well betwen TNF-α levels and FFA levels (p = 0.227; r = -0.21). The correlation between FFA and VCAM-1 levels showed significant correlation with negative correlation and weak correlation (p = 0.036; r = -0.355).Conclusions:(1) There was no correlation between TNF-α levels and VCAM-1 levels in RA patients; (2) There was no correlation between TNF-α levels and FFA levels in RA patients; (3) There was a negative correlation between FFA levels and VCAM-1 levels in RA patients.

These recommendations serve to guide rheumatologists and other stakeholders on the assessment and management of morning stiffness, and help implement the treat-to-target principle in the management of RA.