1. Treatment Management of Rheumatoid Arthritis

2. Findings and In Depth Analysis

3. Patients load and monthly work averages Findings and In Depth Analysis

4. Rheumatologists Monthly Work Load KSA (n=30) Monthly Work Load (AV. Number of Patients) Split between new and Repeated Patients Split According to Disease Severity (Percentage) Rheumatoid Arthritis Ankylosing Spondylitis Psoriatic Arthritis Juvenile Rheumatoid Arthritis Others In KSA, Rheumatologists see an average of 346 Patients per month, out of which 75 are Rheumatoid Arthritis accounting for 22% of the total, 57 repeated and 18 new cases, the split of disease severity is 31% mild and 69% moderate to severe cases of RA 75 12 6 15 238

5. Understanding RA Findings and In Depth Analysis

6. Rating of Importance of Criteria used to classify Disease Severity (Analysis Used top 2 boxes percentages - KSA) (n=30)

7. The most preferred tool used for the Disease Evaluation (KSA) ACR criteria score is the most preferred diagnostic tool, followed by the DAS and the blood tests respectively. These tools are described as practical, accurate and of international use.

8. Reasons for choosing each criteria as the most suitable (KSA) DAS, N=5 ACR, N=9 CPR/ESR/ Anti CCP, N=4

9. Objectives in the management of RA patients (First mentioned KSA) Improving patient’s quality of life and reliving the pain are the main objectives of the management of RA patients

10. Other mentioned objectives in the management of RA patients (KSA) Again, Improving patient’s quality of life and reliving the pain are the objectives of the management of RA patients mentioned by most of the physicians

11. Factors that encourage the physicians to prescribe biological treatment to RA patients (KSA) 56% of the respondents would prescribe the biologics because of their efficacy. 49% of the physicians use them as second or third line after failure of the DMARDs

12. Barriers holding the doctors from prescribing biologicals to their RA patients (KSA) All the respondents face the problem of the cost and/or availability of the biologics when they want to prescribe them to their RA patients

13. Treatment Algorithm for the moderate to severe Rheumatoid Arthritis MTX + NSAIDs First Line In 12% of the cases, physicians could switch from one of the products, mainly from NSAIDs for the first line to Hydroxychloroquine or Steroids MTX or NSAID + HQ or Steroid In most of the cases, physicians add Hydroxychloroquine or Steroids to the products for the first line MTX + NSAIDs + HQ or Steroids Second Line Biologics + MTX based therapy Sometimes, physicians switch from the second line therapy to the biologics and they use them as monotherapy in third line More often, the biologics are added to the MTX containing regimens and they are used in combination in third line therapy Third Line Reasons for switching to another medication are in 100% of the cases the inadequate response to the previous one. Adding another medication is always due to the inadequate response to the previous one. Physicians take also into consideration the ability of the patient to afford the combination. NSAIDs/Steroids are not used as a chronic therapy, they are stopped after stabilization of the patients' condition and they are reintroduced upon disease flares

14. Treatment Algorithm and duration of therapy (KSA) First LineSecond LineThird Line Number of respondents Duration of therapy/mont hs Number of respondents Duration of therapy/mont hs Number of respondents Duration of therapy/mont hs NSAIDs 131 - 67 42 - 3 MTX 102 - 6161 - 36123 - 36 SS 1143 - 622 - 6 HXQ 52 - 593 - 66 Steroids 42 - 522 – 323 - 4 Biologics 0_56 – 36122 - 24 (n=30)

15. Average Lapse of Time between RA Diagnosis and the introduction of different therapeutic classes (KSA)NSAIDsSteroidsDMARDsBiologics Less then 6 Months 56%49%61%20% 6 months to one year 20%23%9%25% 1 – 2 Years 10%16%11%9% 2 – 5 years 5%3%10%21% More then 5 years 8%9% 26% 100% Some physicians in KSA have started to prescribe biologicals as first line therapy once the diagnosis is confirmed. Others reserve it for third line therapy. (n=30)

16. Treatment guidelines followed in the management of moderate to severe RA patients (KSA) The ACR guidelines are the only treatment protocol followed by the physicians.

17. Referral vs. diagnosis of RA (KSA) Specialties of the referring doctors

18. Treatment Shares and Patterns Findings and In Depth Analysis

19. Overall Prescription Shares of different therapeutic classes used in the treatment of Rheumatoid Arthritis (KSA) DMARDs are prescribed to almost 90%Patients with RA, followed by NSAIDs Biologics are prescribed to 21% of the RA patients in KSA (n=30)

20. Split of 100 biologics prescriptions according to the previous therapy (KSA) Classes Used before Biological Percentage of Patients 1 NSAIDs with or without steroids12% Combination of NSAIDs with or without Steroids7% 1 DMARD with or without Steroids15% Combination of DMARDs with or without Steroids22% NSAIDs + DMARDs with or without Steroids43% Others1% 100% Out of each 100 prescriptions of Biologics, 43 are given to patients having DMARDs + NSAIDs (with or without Steroids) and another 22% to patients having 1 DMARDs with or without Steroids (n=30)