Cost-Effective Treatment Algorithm for Autoimmune Diseases

Abstract:
This article outlines a cost-effective treatment algorithm for autoimmune rheumatic diseases in resource-constrained settings. By integrating current ACR/EULAR treatment guidelines with locally available, affordable options, our approach emphasizes individualized therapy for conditions such as SLE, RA, Sjögren’s syndrome, systemic sclerosis, inflammatory myopathies, and MCTD. A detailed flowchart (Figure 1) visually summarizes the treatment pathways, supporting clinicians in optimizing therapy while considering cost-effectiveness.

Introduction
Autoimmune rheumatic diseases—including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjögren’s syndrome (SjS), systemic sclerosis (SSc), inflammatory myopathies (IM), and mixed connective tissue disease (MCTD)—present significant treatment challenges, particularly in resource-constrained settings. Balancing efficacy with affordability is critical, as many patients in countries like India face economic constraints that limit access to high-cost therapies. This article presents a systematic, evidence-based treatment algorithm that leverages cost-effective, commonly available medications while adhering to established ACR/EULAR treatment guidelines.

Methodology
Our treatment algorithm was developed by reviewing current rheumatology guidelines and analyzing treatment regimens used in low-resource settings. The algorithm prioritizes:

• Initial Treatment: Utilizing conventional disease-modifying antirheumatic drugs (DMARDs) and corticosteroids.
• Adjunct Therapy: Incorporating symptomatic treatments and low-cost immunosuppressants.
• Dose Optimization: Standardized dosing regimens (e.g., methotrexate with folinic acid) to maximize efficacy while minimizing side effects.

A treatment flowchart (Figure 1) is provided below to visually represent the decision-making process.

This flowchart graphically summarizes the stepwise treatment approach from diagnosis to the selection of cost-effective treatment modalities. It serves as a quick reference guide for clinicians to tailor therapy based on disease severity and patient-specific factor

Treatment Algorithm

1. SLE:
   • Mild/Moderate: Hydroxychloroquine 200 mg twice daily (BD) combined with low-dose Prednisolone 10 mg once daily (OD) for 2–4 weeks, then gradually taper over 3 months.
   • Severe: Hydroxychloroquine 200 mg BD plus Prednisolone 40 mg OD (or 1 mg/kg) for 4–6 weeks, then taper; add Azathioprine 50 mg BD or Methotrexate 10–15 mg once weekly (with folinic acid 5 mg next day) for 6–12 months.
2. RA:
   • Initiate treatment with conventional DMARDs such as Methotrexate (7.5–15 mg once weekly with folinic acid 5 mg next day), Hydroxychloroquine 200 mg BD, and Sulfasalazine 500 mg BD or TDS.
   • NSAIDs (e.g., Diclofenac 50 mg BD) are used for symptomatic relief.
   • If DMARDs fail, consider low-cost biosimilar biologics.
3. Sjögren’s Syndrome:
   • Emphasize symptomatic management with artificial tears and saliva substitutes.
   • For systemic involvement, a low-dose Prednisolone regimen (5–10 mg OD for 4–6 weeks, then taper) is recommended.
4. Systemic Sclerosis:
   • For Raynaud’s phenomenon, use calcium channel blockers (e.g., Nifedipine 10 mg BD, titrating up to 20 mg BD as needed).
   • Manage gastrointestinal reflux with proton pump inhibitors (e.g., Omeprazole 20 mg OD).
   • For skin involvement, low-dose Methotrexate 10 mg once weekly (with folinic acid) for 3–6 months, coupled with supportive care and physical therapy, is advised.
5. Inflammatory Myopathies:
   • Start with high-dose Prednisolone at 1 mg/kg/day (e.g., approximately 60 mg OD) for 4–6 weeks.
   • Add a low-cost immunosuppressant (Methotrexate 10–15 mg once weekly with folinic acid or Azathioprine 50 mg BD) if needed, followed by physiotherapy and supportive care.
6. MCTD:
   • A regimen of low-dose Prednisolone 10 mg OD combined with Hydroxychloroquine 200 mg BD is recommended.
   • In severe cases, add an immunosuppressant (e.g., Azathioprine 50 mg BD).

Conclusion
A cost-effective treatment algorithm that incorporates conventional therapies and tailored dosing strategies can optimize care for autoimmune rheumatic diseases in resource-constrained settings. By following evidence-based guidelines and utilizing available medications efficiently, clinicians can improve patient outcomes while managing costs. The accompanying flowchart (Figure 1) serves as a practical visual guide to this approach.

Click Here to Read: Diagnostic Algorithm for Autoimmune rheumatic diseases in low resource.