David Vega-Morales

Actualización de la Guía Mexicana para el Tratamiento Farmacológico de la Artritis Reumatoide del Colegio Mexicano de Reumatología

BACKGROUND The pharmacologic management of rheumatoid arthritis has progressed substantially over the past years. It is therefore desirable that existing information be periodically updated. There are several published international guidelines for the treatment of rheumatoid arthritis that hardly adapt to the Mexican health system because of its limited healthcare resources. Hence, it is imperative to unify the existing recommendations and to incorporate them to a set of clinical, updated recommendations; the Mexican College of Rheumatology developed these recommendations in order to offer an integral management approach of rheumatoid arthritis according to the resources of the Mexican health system. OBJECTIVE To review, update and improve the available evidence within clinical practice guidelines on the pharmacological management of rheumatoid arthritis and produce a set of recommendations adapted to the Mexican health system, according to evidence available through December 2012. METHODS The working group was composed of 30 trained and experienced rheumatologists with a high quality of clinical knowledge and judgment. Recommendations were based on the highest quality evidence from the previously established treatment guidelines, meta-analysis and controlled clinical trials for the adult population with rheumatoid arthritis. RESULTS During the conformation of this document, each working group settled the existing evidence from the different topics according to their experience. Finally, all the evidence and decisions were unified into a single document, treatment algorithm and drug standardization tables. CONCLUSIONS This update of the Mexican Guidelines for the Pharmacologic Treatment of Rheumatoid Arthritis provides the highest quality information available at the time the working group undertook this review and contextualizes its use for the complex Mexican health system.

Factors associated with mortality and infections in patients with systemic lupus erythematosus with diffuse alveolar hemorrhage.

Objective. To evaluate factors associated with mortality and infections in patients with systemic lupus erythematosus (SLE) and diffuse alveolar hemorrhage (DAH). Methods. A retrospective chart review was carried out for medical admissions of patients with a diagnosis of SLE and DAH in 9 hospitals. Clinical and laboratory data were recorded for each patient at DAH diagnosis. Results. We included 57 episodes of DAH of 50 patients (7 recurrences), 49 women (86%), 14 juvenile SLE (24.6%); 24 had died (42.1%). In the chart review we detected infection in 22 episodes (38.6%): 8 invasive fungal infections, 16 bacterial infections, and 2 patients had both types. In the bivariate analysis, factors associated with mortality were high Acute Physiology and Chronic Health Evaluation II scores, requirement of mechanical ventilation (OR 15.0, 95% CI 1.9 to 662.2), infections (fungal or bacterial; OR 3.2, CI 0.9 to 11.1), renal failure (OR 4.9, CI 1.4 to 18.0), and thrombocytopenia (OR 4.3, CI 1.2 to 15.6). We found similar mortality between children and adults. Infections were associated with treatment for SLE, requirement of mechanical ventilation, hypocomplementemia, and high levels of C-reactive protein. Conclusion. Infection is a frequent finding in patients with DAH and SLE; we found similar mortality between adult SLE and juvenile SLE. Factors that we describe associated with infections may influence the therapeutic selection for these patients.

Hormona anti-mülleriana en mujeres en edad reproductiva con lupus eritematoso sistémico

UNLABELLED Systemic lupus erythematosus (SLE) is an inflammatory autoimmune systemic and chronic disease. Fertility in SLE patients is considered normal; factors that have been associated in these patients with ovarian failure are: disease activity, autoantibodies, and the use of cytotoxic agents. The anti-Müllerian hormone (AMH) is a marker that helps to determine the follicular reserve. OBJECTIVE Determinate the objective was to determine AMH levels in women of reproductive age with SLE. MATERIAL AND METHODS We included 65 women with SLE classified according to the 1997 ACR criteria, 18- to 40-years old. We obtained demographic, clinical, obstetric, and gynecological characteristics as well as serum levels of AMH. We performed a bivariate analysis among patients with low ovarian reserve and those with normal ovarian reserve. We also performed a correlation analysis between activity and damage index and between the cumulative cyclophosphamide dose and AMH levels. RESULTS We found a median of serum AMH in SLE patients of .61 ng/mL. The prevalence of low ovarian reserve in our study was 3.07%. We found a median MEX-SLEDAI score of 1 point and the median SLICC score was 2 points. Twenty-five patients (38.4%) had used cyclophosphamide and their cumulative average dose was 7.5 grams. CONCLUSIONS We found a median of AMH of .61 ng/mL in our population. The prevalence of low ovarian reserve in SLE patients was 3.07%. We did not find a correlation between AMH levels, the use of cyclophosphamide, and disease activity.

Factors associated with treatment of osteoarthritis: Analysis of a COPCORD study in Nuevo León, México

INTRODUCTION Osteoarthritis (OA) is the most prevalent rheumatic disease in Mexico. Treatment involves pharmacological and non-pharmacological strategies. OBJECTIVE To describe the factors associated with treatment of osteoarthritis in the urban and rural population of Nuevo León. METHODS Analysis of a cross-sectional study of patients with OA from a COPCORD study database. Univariate and multivariate analyses of the variables associated with treatment of OA. RESULTS We included 696 patients with OA with an average age of 58 years (SD 14.1), 484 (69.5%) women. Pain with a visual analog scale (VAS) ≥4 was present in 507 (72.8%) patients. Functional disability was present in 133 (19%) patients and a mean HAQ of 0.37 (IQR 0.75) was found. The most frequent place of OA was knee in 356 (51.1%) patients; 259 (37%) patients already knew their diagnosis. The most employed treatments were non-steroidal anti-inflammatory drugs (289 patients, 58.5%). The variables associated with treatment were age >58 years (OR 1.3, 95% CI 1.0-1.5), female gender (OR 1.17, 95% CI 1.0-1.3), VAS pain ≥4 (OR 1.3, 95% CI 1.1-1.4), functional disability (OR 2.6, 95% CI 1.6-4.1), HAQ >0.375 (OR 1.9, 95% CI 1.5-2.4), and past diagnosis of OA (OR 5.1, 95% CI 3.3-8.0). In the multivariate analysis, VAS pain ≥4 (OR 1.9, 95% CI 1.2-2.8), kneeling disability (OR 3.15, 95% CI 1.3-7.4) and previous diagnosis of OA (OR 7.6, 95% CI 4.5-12.9) had statistical significance. CONCLUSION factors associated with treatment of OA are VAS pain ≥4, kneeling disability and previous diagnosis of OA.

Aplicación de un modelo de predicción de progresión de artritis reumatoide en pacientes con artritis indiferenciada

INTRODUCTION Different prediction rules have been applied to patients with undifferentiated arthritis (UA) to identify those that progress to rheumatoid arthritis (RA). The Leiden Prediction Rule (LPR) has proven useful in different UA cohorts. OBJECTIVE To apply the LPR to a cohort of patients with UA of northeastern Mexico. METHODS We included 47 patients with UA, LPR was applied at baseline. They were evaluated and then classified after one year of follow-up into two groups: those who progressed to RA (according to ACR 1987) and those who did not. RESULTS 43% of the AI patients developed RA. In the RA group, 56% of patients obtained a score ≤ 6 and only 15% ≥ 8. 70% who did not progress to RA had a score between 6 and ≤ 8. There was no difference in median score of LPR between groups, p=0.940. CONCLUSION Most patients who progressed to RA scored less than 6 points in the LPR. Unlike what was observed in other cohorts, the model in our population did not allow us to predict the progression of the disease.

Age and Comorbidities Influence Initial Treatment of Patients with Early Rheumatoid Arthritis

To the Editor: We are quite interested in the study recently published by Dr. Helga Radner, et al 1, in which they compared treatment profiles between multimorbid established rheumatoid arthritis (RA) patients and patients with RA only. They found a decrease in biologic disease-modifying antirheumatic drugs used for each additional chronic comorbidity1. We, too, have observed the influence of comorbidities on decision making in the initial treatment of patients with early RA. The aim of our study was to evaluate such influences. Our retrospective and observational study was done between March 2014 and March 2015. We included all medical records of patients with RA according to 2010 American College … Address correspondence to Dr. D. Vega-Morales, Hospital Universitario, Rheumatology, Francisco I. Madero S/N, Mitras Centro, Monterrey, Mexico. E-mail: drdavidvega{at}yahoo.com.mx

Time Delay to Rheumatology Consultation Rheumatoid Arthritis Diagnostic Concordance Between Primary Care Physician and Rheumatologist

To the Editor: Rheumatology referral of patients with suspected arthritis impacts in the prognosis of rheumatoid arthritis (RA) because of earlier diagnosis and treatment initiation. An assessment in <12 weeks of symptom onset is associated with less joint destruction and a greater chance of achieving disease-modifying antirheumatic drugs (DMARD)–free remission as compared with a longer delay to assessment. The aim of the study was to evaluate the time to evaluation by the rheumatologist from the primary care provider (PCP) and their diagnosis concordance. We conducted a retrospective observational study from January to December 2013 in a Northern Mexico second-level public hospital. We evaluated the time to evaluation between rheumatologists and the referring PCP diagnosis and their concordance. We made a descriptive analysis and used κ coefficient to assess the level of concordance. We classified the patients’ main complaints at rheumatology consultation as follows: any pain in the upper extremities (hand, elbow, and shoulder), hip, lower extremities (knees and feet), and complaint of morning stiffness. The study was approved by the Institutional Review Board (Registry No. R-2014-1906-29). We evaluated 206 referrals; the most common cause of referral was RA. We found a mean time of 112.8 weeks (SD 187.6) (28.2 months [SD 46.9]) from onset of symptoms to evaluation by the rheumatologist, and a mean wait time of 9.5 weeks (SD 5.6) from PCP referral to the rheumatologist consultation, corresponding to 7.8% of latency of the disease. RA diagnosis concordance between PCP and rheumatologist was 0.131 (P = .041). Previously, Corominas et al delineated 4 steps to describe the delay from diagnosis to commencing treatment for RA: time from symptom onset to the first visit with the rheumatologist, time from referral to the first visit to rheumatology, time between symptom onset and final diagnosis, and time between first symptom to initiation of the first DMARD. In our study, the median time delay between symptom onset and rheumatologist evaluation was 28 months, in contrast with other authors who reported a median delay of 10 months. Even though 82% of patients were treated at a rheumatology clinic before 12 weeks, the wait time between seeing a PCP and seeing a rheumatologist was 9.5 weeks on average. Although diagnostic concordance was low between physicians, we observed that the presence of pain in the upper limbs (including hands, elbows, and shoulders) and morning stiffness were associated with a final diagnosis of RA (odds ratio = 10.5, 95% confidence interval = 1.3–81.4; and odds ratio = 3.04, 95% confidence interval = 1.69–5.45, respectively). This is consistent with other reports and triage strategies. In conclusion, we found a sizable delay in time to rheumatology consultation with low diagnostic concordance. We consider that the continuous education of not only doctors but also patients will improve early referral and therefore modify the time to diagnosis, treatment, and prognosis of rheumatic diseases.

Comorbidities in a Mexican mestizo cohort with established rheumatoid arthritis

In the study recently published in the Annals of Rheumatic Diseases , Dougados et al 1 evaluated the prevalence of comorbidities and compared their management in rheumatoid arthritis (RA) patients from different countries. We know that RA is a chronic autoimmune disease characterised by chronic inflammation, progressive deterioration of joint function, increased comorbidity and mortality; RA patients have about a 50% increased risk of premature mortality.2 A comorbid condition may represent an active, past or transient illness and may be linked to RA process itself and/or its treatment or it may be completely independent of them3; the average RA patient has approximately 1.6 comorbidities.4 We conducted an observational, cross-sectional, non-comparative study to describe the presence of comorbidities in RA Mexican mestizo …

Causes of Hospital Mortality in Patients with Rheumatoid Arthritis and Systemic Lupus Erythematosus in a University Hospital: 1998–2015 Analysis

With great interest we read the article entitled “Hospitalizations in Patients with Systemic Lupus Erythematosus in an Academic Health Science Center” by Gu, et al 1. They described the hospitalization of patients with systemic lupus erythematosus (SLE) in an academic hospital over 2- and 3-year periods. They found that incidental causes were … Address correspondence to Dr. D. Vega-Morales, Hospital Universitario, Rheumatology, Francisco I. Madero S/N, Mitras Centro, Monterrey, Nuevo Leon 64460, Mexico. E-mail: drdavidvega{at}yahoo.com.mx

Inequity in access to bDMARD care and how it influences disease outcomes across countries worldwide: results from the METEOR-registry

Objective To establish in a global setting the relationships between countries’ socioeconomic status (SES), measured biological disease modifying antirheumatic drug (bDMARD)-usage and disease outcomes. To assess if prescription and reimbursement rules and generic access to medication relates to a countries’ bDMARD-usage. Methods Data on disease activity and drug use from countries that had contributed at least 100 patients were extracted from the METEOR database. Mean disease outcomes of all available patients at the final visit were calculated on a per-country basis. A questionnaire was sent to at least two rheumatologists per country inquiring about DMARD-prices, access to treatment and valid regulations for prescription and reimbursement. Results Data from 20 379 patients living in 12 different countries showed that countries’ SES was positively associated with measured disease activity (meanDAS28), but not always with physical functioning (HAQ-score). A lower country’s SES, stricter rules for prescription and reimbursement of bDMARDs as well as worse affordability of bDMARDs were associated with lower bDMARD-usage. bDMARD-usage was negatively associated with disease activity (although not with physical functioning), but the association was moderate at best. Conclusions Disease activity in patients with rheumatoid arthritis as well as bDMARD-usage varies across countries worldwide. The (negative) relationship between countries’ bDMARD-usage and level of disease activity is complex and under the influence of many factors, including—but not limited to—countries’ SES, affordability of bDMARDs and valid prescription and reimbursement rules for bDMARDs.