Diagnostic Delay in Chronic Inflammatory Rheumatic Diseases Presented to the Tertiary Care Rheumatology Unit in PIMS
DOI:
https://doi.org/10.51985/JBUMDC2025755Keywords:
Ankylosing Spondylitis, Diagnostic Delay, Psoriatic Arthritis, Rheumatoid Arthritis, and TherapeuticAbstract
Objective: To quantify the therapeutic and diagnostic delays among patients with CIRDs in Pakistan.
Study Design and Setting: Cross sectional study. PIMS Hospital Islamabad Rheumatology OPD. Duration 8th June 2025
to 8th September 2025.
Methodology: This cross-sectional study comprised 220 patients. Informed consent was obtained; demographic details
like age and sex were noted. All Patients previously diagnosed with conditions such as rheumatoid arthritis, ankylosing
spondylitis, psoriatic arthritis, or similar diseases were selected from various rheumatology clinics and departments over
six months. Data collection was done using a structured face-to-face interview which included data on demographic
information, age of symptom onset, consultation times, and treatment commencement, dividing delays into diagnostic and
therapeutic categories. For the analysis in SPSS v21, Shapiro–Wilk, Chi-square, and Fisher’s Exact Test were performed,
and the results were presented as the median for continuous variables and percentages for categorical data. A p-value =
0.05 was taken as statistically significant.
Results: A total of 220 participants were included in this study. Among the 220 patients, 40.5% had diagnostic delay
exceeded 18 months with only 6.4% diagnosed within 6 months. Patients who visited homeopaths had the highest delay
rate (56.1%). Psoriatic arthritis (71.4%) and ankylosing spondylitis (53.8%) had longest delays. Joint pain led to early
referral in 54.6%, whereas atypical symptoms caused prolonged delays.
Conclusions: The findings of this study revealed that both diagnostic and therapeutic delays are common in CIRDs in
Pakistan, often caused by multiple reasons before reaching a rheumatologist and referral system inefficiencies.
References
1. Arida A, Protogerou AD, Kitas GD, Sfikakis PP. Systemic
inflammatory response and atherosclerosis: The paradigm of
chronic inflammatory rheumatic diseases. Int J Mol Sci. 2018
Jun 27;19(7):1890. https://doi.org/10.3390/ijms19071890
2. Glynn LE. The chronicity of inflammation and its significance
in rheumatoid arthritis. Ann Rheum Dis. 1968 Mar; 27(2):
105. https://pmc.ncbi.nlm.nih.gov/articles/PMC1031077/
3. Combe B, Landewe R, Daien CI, Hua C, Aletaha D, ÁlvaroGracia JM, et al. 2016 update of the EULAR recommendations
for the management of early arthritis. Annals of the rheumatic
diseases. 2017 Jun 1;76(6):948-59. https://doi.org/10.1136/
annrheumdis-2016-210602
4. Naqvi AA, Hassali MA, Naqvi SB, Aftab MT. Impact of
pharmacist educational intervention on disease knowledge,
rehabilitation and medication adherence, treatment-induced
direct cost, health-related quality of life and satisfaction in
patients with rheumatoid arthritis: study protocol for a
randomized controlled trial. Trials. 2019 Aug 9;20(1):488.
https://doi.org/10.1186/s13063-019-3540-z
5. Petruzzi M, Della Vella F, Squicciarini N, Lilli D, Campus
G, Piazzolla G, et al. Diagnostic delay in autoimmune oral
diseases. Oral Dis. 2023 Oct;29(7):2614-23. https://doi.org/
10.1111/odi.14480
6. Stack RJ, Nightingale P, Jinks C, Shaw K, Herron-Marx S,
Horne R, et al. Delays between the onset of symptoms and
first rheumatology consultation in patients with rheumatoid
arthritis in the UK: an observational study. BMJ open. 2019
Mar 1;9(3):e024361. https://doi.org/10.1136/bmjopen-2018-
024361
7. Triantifyllou C, Fonseca VR, Breda J. Strengthening Health
Systems’ Quality in the World Health Organization European
Region. World Med J. 2024 Mar 1;70(1). https://www.
researchgate.net/publication/382463024
8. Handa R, Rao UR, Lewis JF, Rambhad G, Shiff S, Ghia CJ.
Literature review of rheumatoid arthritis in India. Int J Rheum
Dis. 2016 May;19(5):440-51. https://doi.org/10.1111/1756-
185X.12621
9. Dincer U, Cakar E, Kiralp MZ, Dursun H. Diagnosis delay
in patients with ankylosing spondylitis: possible reasons and
proposals for new diagnostic criteria. Clin Rheumatol. 2008
10. Ranganathan V, Gracey E, Brown MA, Inman RD, Haroon
N. Pathogenesis of ankylosing spondylitis—recent advances
and future directions. Nat Rev Rheumatol. 2017;13(6):
359–367. https://doi.org/10.1038/nrrheum.2017.56
11. Mohsin Z, Asghar AA, Faiq A, Khalid I, Ul-Haque I, Rehman
S, et al. Prevalence of rheumatic diseases in a tertiary care
hospital of Karachi. Cureus. 2018 Jun 22;10(6). https://doi.org/
10.7759/cureus.2858
12. Safiri S, Kolahi AA, Hoy D, Smith E, Bettampadi D,
Mansournia MA, Almasi-Hashiani A, Ashrafi-Asgarabad A,
Moradi-Lakeh M, Qorbani M, Collins G. Global, regional
and national burden of rheumatoid arthritis 1990–2017: a
systematic analysis of the Global Burden of Disease study
2017. Annals of the rheumatic diseases. 2019 Nov
1;78(11):1463-71. https://doi.org/10.1136/annrheumdis-2019-
215920
13. Klavdianou K, Lazarini A, Fanouriakis A. Targeted biologic
therapy for systemic lupus erythematosus: emerging pathways
and drug pipeline. BioDrugs. 2020 Apr 1;34(2):133-47. https://
doi.org/10.1007/s40259-020-00405-2
14. Bittar M, Yong WC, Magrey M, Khan MA. Worldwide
differences in clinical phenotype of axial spondyloarthritis.
Current Rheumatology Reports. 2021 Oct;23(10):76 https://
doi.org/10.1007/s11926-021-01043-5 .
15. Son MT, Biloa YJ, Gouttefarde P, Franck T, Cizeron G, Oriol
M, Maccari F, Cinotti E, Trombert-Paviot B, Bongue B, Perrot
JL. Unravelling the Major Cardiovascular Risks of Systemic
Psoriasis Medications: A Literature Systematic Review.
JEADV Clinical Practice. 2025 Sep 8. https://doi.org/10.1002/
jvc2.70134
16. Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca
M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter
T, Harwood C. ECCO guidelines on extraintestinal
manifestations in inflammatory bowel disease. Journal of
Crohn's and Colitis. 2024 Jan 1;18(1):1-37. https://doi.org/
10.1093/ecco-jcc/jjad108
17. Ferrara CA, La Rocca G, Ielo G, Libra A, Sambataro G.
Towards early diagnosis of mixed connective tissue disease:
updated perspectives. ImmunoTargets and therapy. 2023 Dec
31:79-89. https://doi.org/10.2147/ITT.S390023
18. Perez-Garcia C, Aguilar JR, Mateo L, Gómez-Puerta JA, Roc
MV, Alarcon GS, et al. AB0310 STUDY “AR-CAT INICI”:
management of early rheumatoid arthritis in catalonia. Ann
Rheum Dis. 2022 Jun 1;81:1280-1. https://doi.org/10.1136/
annrheumdis-2022-eular.3910
19. Xu H, Wang Z, Xu L, Su Y. Refractory psoriatic arthritis:
emerging concepts in whole process management. Clinical
Rheumatology. 2025 Feb;44(2):583-90. https://doi.org/10.1007/
s10067-024-07267-x
20. Sherbini AA, Gwinnutt JM, Hyrich KL, Verstappen SM. Rates
and predictors of methotrexate-related adverse events in
patients with early rheumatoid arthritis: results from a
nationwide UK study. Rheumatology. 2022 Oct 1;61(10):3930-
8. https://doi.org/10.1093/rheumatology/keab917
21. Roberts JH, Gunn C, Mackinnon JE, Parlee S, Bakowsky V,
Taylor T, Barber CE, Hanly JG. Feasibility of physiotherapistled rheumatology triage: a randomized study. The Journal of
Rheumatology. 2024 Jul 1;51(7):715-20. https://doi.org/
10.3899/jrheum.2023-1071
22. Majumder MS, Hasan AT, Choudhury MR, Ahmed S, Miah
MT, Amin MR, et al. 2023 Management Recommendations
of Bangladesh Rheumatology Society on Pharmacological
Treatment of Rheumatoid Arthritis with Synthetic and Biologic
Disease-Modifying Drugs. Cureus. 2024 Apr 30;16(4).
https://doi.org/10.7759/cureus.59395
23. Perez-Alamino R, Maldonado-Ficco H, Moltó A, Waimann
C, Maldonado-Cocco J, Dougados M, et al. Trends to shorter
diagnostic delay in spondyloarthritis patients during the last
decades and association with clinical presentation: data from
ASAS-COMOSPA study. RMD Open. 2025 Jan 1;11(1):
e004756. https://doi.org/10.1136/rmdopen-2024-004756
24. Zhao SS, Pittam B, Harrison NL, Ahmed AE, Goodson NJ,
Hughes DM. Diagnostic delay in axial spondyloarthritis: a
systematic review and meta-analysis. Rheumatology. 2021
Apr 1;60(4):1620-8. https://doi.org/10.1093/ rheumatology/
keaa807
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Alina Fakhar, Shazia Zammurrad, Uzma Rasheed, Muhammad Sufyan Khan (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Journal of Bahria University Medical & Dental College is an open access journal and is licensed under CC BY-NC 4.0. which permits unrestricted non commercial use, distribution and reproduction in any medium, provided the original work is properly cited. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc/4.0
