Cleandro Pires de Albuquerque

Preliminary guidelines of the Brazilian Society of Rheumatology for evaluation and treatment of tuberculosis latent infection in patients with rheumatoid arthritis, in face of unavailability of the tuberculin skin test

A detecção e o tratamento da tuberculose infecção latente (TBIL) nos indivíduos com maior risco de progressão para tuberculose doença (TB) são estratégias recomendadas pela Organização Mundial de Saúde para controle dessa enfermidade. O teste tuberculínico, que usa o PPD (do inglês purified protein derivative), é um meio amplamente incorporado à prática clínica para diagnóstico de TBIL. Pacientes com artrite reumatoide têm risco aumentado para desenvolvimento de TB ativa, sobretudo quando em tratamento com biológicos inibidores do TNF. O Consenso 2012 da Sociedade Brasileira de Reumatologia (SBR) para tratamento de artrite reumatoide recomenda rastreamento e, quando indicado, tratamento de TBIL em todo paciente candidato ao uso de qualquer agente biológico. O rastreamento inclui, além de avaliação do risco epidemiológico, radiografia do tórax e teste tuberculínico. O tratamento de TBIL, após exclusão de TB doença, consiste em isoniazida, na dose de 5-10 mg/kg/dia, máximo de 300 mg/dia, por seis meses. Está indicado nos pacientes com teste tuberculínico ≥ 5 mm, positividade ao Igra (do inglês interferonrelease assays), alterações radiográficas compatíveis com TB prévia ou contato próximo com caso de TB. O tratamento da TBIL (quimioprofilaxia) deve ser instituído pelo menos um mês antes do início do biológico, porém excepcionalmente ambos os medicamentos podem ser iniciados concomitantemente, quando a urgência sintomática da situação o exigir. Em setembro de 2014, o Ministério da Saúde, por meio da Coordenação Geral do Programa Nacional de Controle da Tuberculose, publicou nota (n◦ 8 / CGPNCT / DEVEP / SVS / MS, de 10/09/2014) em que informou dificuldades na aquisição do PPD, por indisponibilidade no mercado internacional, o que deve implicar desabastecimento do sistema de saúde brasileiro, ainda sem previsão de normalização. A indisponibilidade do teste tuberculínico já é efetivamente percebida na rede assistencial. Por considerar a situação em curso, a exigir um rápido posicionamento com vistas a orientar a prática clínica, a Comissão de Artrite Reumatoide da SBR decidiu por divulgar as seguintes orientações preliminares, que foram elaboradas por consenso de especialistas. A Comissão sugere consulta às referências selecionadas, que estendem as discussões aqui desenvolvidas.1-12

2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis

The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.

AB0417 Biological drugs in the treatment of rheumatoid arthritis: real life data in a brazilian multicentric study

Background Rheumatoid arthritis (RA) is a chronic disease, characterised by inflammatory involvement of the synovial joints. The ”treat to target” concept is well established in the rheumatologic community, however, in many patients, especially in developing countries, its implementation is not feasible. Considering the high costs of treatment com of RA and the limited national epidemiological data available on this disease, we sought to describe the profile of use of biological drugs in Brazilian patients with RA to help the decision-making process by public health managers. Objectives To describe the frequency and time of use of biological drugs in Brazilian patients with rheumatoid arthritis. Methods The REAL – RA in real life in Brazil – is a multicenter prospective cohort study, with twelve-month follow-up period. To be included in this study, consecutive patients from 11 tertiary rheumatology centres had to meet the 1987 ACR or the 2010 ACR/European League Against Rheumatism (EULAR) criteria. Data were collected during routine clinical care and previous medical records were used as secondary sources. The present study present data taken from the participants’ initial assessment. This research was approved by the Ethics Committees of each centre. Results A total of 1125 patients were analysed. 89% were women with a mean age of 56.6 years. The main clinic data were: DAS 28 (median)=3.52, HAQ (median)=0.87 and CDAI (median)=9. 1022 (90.84%) used synthetic DMARDs and 406 (36.09%) biologic therapy. The frequency of use of the biologic therapy was: abatacept (73 patients/6.49%), etanercept (66/5.87%), tocilizumab (60/5.33%), adalimumab (54/4.8%), infliximab (50/4.44%), rituximab (49/4.36%), golimumab (37/3.29%), certolizumab (17, 1.51%). The time of use of the biological drugs is presented in table 1.Abstract AB0417 – Table 1 Time (in years) of use of biological drugs in patients with rheumatoid arthritis DRUG MEAN MAXIMUM ABATACEPT 1.95 8 ADALIMUMAB 1.70 12 CERTOLIZUMAB 0.63 2.0 ETANERCEPT 1.49 9.0 GOLIMUMAB 0.65 2.0 INFLIXIMAB 1.56 9.0 RITUXIMAB 1.27 6.0 TOCILIZUMABE 2.0 6.0 Conclusions The therapeutic profile of this cohort of Brazilian RA patients shows some interesting results. The relatively high number of patients on biologics, compared to other studies, may be related to fact that the centres involved were reference centres, probably dealing with more difficult cases. References [1] Azevedo AB, Ferraz MB, Ciconelli RM. Indirect Costs of Rheumatoid Arthritis in Brazil. Value in Health2008;11(5):869–877. [2] Boonen A, Severens JL. The burden of illness of rheumatoid arthritis. Clin Rheumatol2011;30(Suppl 1):S3–S8. Disclosure of Interest None declared

Evolução da formação de reumatologistas no Brasil: a opção pela residência médica ☆

OBJECTIVE To describe the characteristics and progression of the supply of new rheumatologists in Brazil, from 2000 to 2015. METHODS Consultations to databases and official documents of institutions related to training and certification of rheumatologists in Brazil took place. The data were compared, summarized and presented descriptively. RESULTS From 2000 to 2015, Brazil qualified 1091 physicians as rheumatologists, of which 76.9% (n=839) completed a medical residency program in rheumatology (MRPR); the others (n=252) achieved this title without MRPR training. There was an expansion of MRPR positions. At the same time, there was a change in the profile of the newly qualified doctors. Early in the series, the fraction of new rheumatologists without MRPR, entering the market annually, was approaching 50%, dropping to about 15% in recent years. In 2015, Brazil offered 49 MRPR accredited programs, with 120 positions per year for access. There was an imbalance in the distribution of MRPR positions across the country, with a strong concentration in the southeast region, which in 2015 held 59.2% of the positions. Public institutions accounted for 94% (n=789) of graduates in MRPR during the study period, while still maintaining 93.3% (n=112) of seats for admission in 2015. CONCLUSIONS In the last sixteen years, in parallel with the expansion of places of access, MRPR has established itself as the preferred route for rheumatology training in Brazil, mainly supported by public funds. Regional inequalities in the provision of MRPR positions still persist, as challenges that must be faced.

Development of rheumatology training in Brazil: the option for a medical residency program.

OBJECTIVE To describe the characteristics and progression of the supply of new rheumatologists in Brazil, from 2000 to 2015. METHODS Consultations to databases and official documents of institutions related to training and certification of rheumatologists in Brazil took place. The data were compared, summarized and presented descriptively. RESULTS From 2000 to 2015, Brazil qualified 1091 physicians as rheumatologists, of which 76.9% (n=839) completed a medical residency program in rheumatology (MRPR); the others (n=252) achieved this title without MRPR training. There was an expansion of MRPR positions. At the same time, there was a change in the profile of the newly qualified doctors. Early in the series, the fraction of new rheumatologists without MRPR, entering the market annually, was approaching 50%, dropping to about 15% in recent years. In 2015, Brazil offered 49 MRPR accredited programs, with 120 positions per year for access. There was an imbalance in the distribution of MRPR positions across the country, with a strong concentration in the southeast region, which in 2015 held 59.2% of the positions. Public institutions accounted for 94% (n=789) of graduates in MRPR during the study period, while still maintaining 93.3% (n=112) of seats for admission in 2015. CONCLUSIONS In the last sixteen years, in parallel with the expansion of places of access, MRPR has established itself as the preferred route for rheumatology training in Brazil, mainly supported by public funds. Regional inequalities in the provision of MRPR positions still persist, as challenges that must be faced.

EGPA Associated to chCRR A Case Report Eosinophilic Granulomatosis with Polyangiitis Associated to Chromophobe Renal Cell Carcinoma: A Case Report

Sandra Maximiano de Oliveira1*, Cezar Kozak Simaan2, Leopoldo Luiz dos Santos Neto3, Cleandro Pires de Albuquerque1, Isadora Jochims4, Ana Paula Monteiro Gomides Reis2, Francisco Aires Côrrea Lima1, Daniel de Amorim Rondon1, Ana Carolina Emy Vicente Hidaka1, Ana Paula Faria Carvalho1, Talita Yokoy de Souza1 and Luciano Junqueira Guimarães1 1Rheumatology Department, Brasília University Hospital, Brazil 2Department of Rheumatology, Brasília University, Brazil 3Department of Internal Medicine, Brasília University, Brazil 4Brazilian Rheumatology Society, Brazil *Corresponding author: Sandra Maximiano de Oliveira, Rheumatology Department, Brasília University Hospital, Federal District, Brazil, Tel: +5561991776559; E-mail: sandramaximianoo@gmail.com