Gabriel Medrano Ramírez

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.

Medicamentos biocomparables en México: la postura del Colegio Mexicano de Reumatología, 2012

Biotechnological drugs (BTDs) are complex molecules whose manufacturing process precludes the ability to identically reproduce the structure of the original product, and therefore there cannot be an absolute equivalence between the original (innovative) medication and its biosimilar counterpart. BTDs have been proven useful in the treatment of several rheumatic diseases, however their high cost has prevented their use in many patients. Several BTD patents have expired or are close to expire, triggering the development of structurally similar drugs with efficacy and safety profiles comparable to the innovative compound; however, these must be evaluated through evidence based medicine. The Mexican General Health Law contemplates the registry of these biosimilar drugs for their use in our country. This document is a forethought from members of the Mexican College of Rheumatology, pharmacologists, and epidemiologists, in accordance with Mexican health authorities regarding the necessary scientific evidence required to evaluate the efficacy and safety of biosimilar drugs before and after their arrival to the Mexican market.

Hand function in rheumatic diseases: patient and physician evaluations

Rheumatic diseases have repercussions in hand function. The m‐SACRAH (modified Score for the Assessment and quantification of Chronic Rheumatoid Affections of the Hands) questionnaire evaluates hand function according to the patients opinion. Our aim was to look for the clinical and para‐clinical variables that correlate with m‐SACRAH in rheumatic diseases.

Relapsing Polychondritis: An Analysis of 11 Patients

Results: We described 8 female patients and 4 males, with a mean age of 40.8 years. The delay time in diagnosis was from 4 months to 4 years. The main manifestations were: auricular chondritis in 8 patients (72.7%), hearing loss in 4 (36.3%), and dysphonia in 4 (36.3%). The complications included subglotic stenosis in 4 patients (36.3%), episcleritis in 2 (18.1%), 1 retinal and corneal detachment with macular lesion (9%), conductive and sensorial hearing loss in 2 (18.1%), glomerulonephritis in 2 (18.1%), and mitral and tricuspid insufficiency in 1 patient (9.0%). All of them received prednisone. Cyclophosphamide, methotrexate, and azathioprine were the most common immunosuppressants used. Conclusions: This is the largest cohort reported in our country, sharing clinical and outcome patterns reported in other series and in the literature. Response to steroids is good; however, we need to consider other therapeutic options because the disease continues progressing and relapsing.

Desempeño del examen clínico objetivo estructurado como instrumento de evaluación en la certificación nacional como reumatólogo

OBJECTIVE To assess reliability and validity of the objectively-structured clinical examination (OSCE) applied in postgraduate certification processes by the Mexican Board of Rheumatology. METHOD Thirty-two (2013) and 38 (2014) Rheumatology trainees (RTs) underwent an OSCE consisting of 12 and 15 stations respectively, scored according to a validated check-list, as well as 300-multiple-choice 300 question examination (MCQ). Previously, 3 certified rheumatologists underwent a pilot-OSCE. A composite OSCE score was obtained for each participant and its performance examined. RESULTS In 2013, OSCE mean score was 7.1±0.6 with none RT receiving a failing score while the MCQ score was 6.5±0.6 and 7 (21.9%) RTs receiving a failing (< 6) score. In 2014, the OSCE score was 6.7±0.6, with 3 (7.9%) RTs receiving a failing score (2 of them also failed MCQ) while the MCQ score was 6.4±0.5 and 7 (18.5%) RTs were disqualified (2 of them also failed OSCE). A significant correlation between the MCQ and the OSCE scores was observed in the 2013 (r=0.44; P=0.006). Certified rheumatologists performed better than RTs at both OSCE. Overall, 86% of RTs obtaining an OSCE passing score also obtained a MCQ passing score, while this was only 67% (P=.02) among those who obtained an OSCE failing score. Nine stations were applied at both consecutive years. Their performance was similar in both certification processes, with correlation coefficients ranging from 0.81 to 0.95 (P≤0.01). CONCLUSION The OSCE is a valid and reliable tool to assess the Rheumatology clinical skills in RTs.

Autoimmune/inflammatory syndrome induced by mineral oil: a health problem

Autoimmune/inflammatory syndrome induced by adjuvant (ASIA) includes the following conditions: siliconosis, Gulf War syndrome, macrophagic myofasciitis syndrome, and post-vaccination phenomena. Afterward, other syndromes have been recognized, such as in ASIA by mineral oil (ASIA-MO). These conditions are triggered by adjuvants and they are the result of the interplay of genetic and environmental factors. ASIA-MO is defined as the infiltration of oily type modeling substances for cosmetic purposes. It has been reported in many countries and used surreptitiously. Pathogenesis of ASIA-MO is not clear, but is characterized by chronic granulomatous inflammation, like the pristane model in mice, with increase of proinflammatory cytokines: type I interferons (IFNα and IFNß), systemic lupus erythematosus (SLE), and erosive arthritis. In humans, an increase of interleukin 1 (IL-1) has been found. Clinical spectrum of ASIA-MO is heterogeneous, varying from mild to severe and being local and systemic. The systemic manifestations can be non-specific and specific, meeting criteria for any autoimmune disease (AID), i.e., SLE, rheumatoid arthritis, and systemic sclerosis, among others. The areas of the body where the mineral oil is mostly applied include the following: buttocks (38–72%), breasts (12–16%), lower extremities (18–22%), and face (6–10%). The penis augmentation is also common. Treatment is focused on local and systemic manifestations and requires medical and surgical management representing a challenge for the physician.

Tratamiento de la esclerosis sistémica

Resumen El tratamiento de la esclerosis sistemica se basa en 3 tipos de medicamentos modificadores de la enfermedad: farmacos que previenen el dano vascular, agents antifibroticos e inmunomoduladores e inmunodepresores. Los farmacos que previenen el dano vascular son: los antagonistas del calcio, los analogos de las prostaglandinas, los bloqueadores de los receptores de endotelina (bosentan), los inhibidores de la enzima de conversion de la angiotensina, los antagonistas de los receptores de la angiotensina y los inhibidores de la 5’-fosfodiesterasa, y han demostrado eficacia en el fenomeno de Raynaud, la crisis renal y la hipertension arterial pulmonar. En contraste, los resultados del tratamiento de la fibrosis son poco alentadores y la D-penicilamina continua siendo motivo de controversia. La terapia inmunodepresora con ciclofosfamida y el trasplante de celulas hematopoyeticas pueden ser beneficiosos. El conocimiento de la patogenia molecular de la esclerosis sistemica conducira a nuevas estrategias de tratamiento.

Microquimerismo fetal en enfermedades reumáticas

El microquimerismo fetal es la presencia de celulas fetales en tejidos maternos y viceversa, es decir, la coexistencia de 2 poblaciones celulares diferentes, originadas en individuos geneticamente distintos, presentes en un solo individuo. La causa mas frecuente es el microquimerismo asociado al embarazo debido a un intercambio bidireccional de celulas feto-madre, lo cual sucede durante el embarazo y el parto. Las celulas fetales se han demostrado en los tejidos de pacientes con enfermedades reumatologicas, endocrinas o infecciosas, asi como en sujetos sanos. La enfermedad en la que mejor se ha demostrado el papel del microquimerismo es la esclerosis sistemica. Se sugiere que, durante el embarazo, las celulas fetales o maternas alogenas atraviesan la placenta de forma bidireccional y persisten en la circulacion y tejidos de ambos, posteriormente son activadas e inician una reaccion injerto contra huesped, relacionada con el inicio de las manifestaciones clinicas. Tambien se ha demostrado algun papel del microquimerismo en otras enfermedades del tejido conectivo.Fetal microchimerism is the presence of fetal cells inmaternal tissues and vice versa, i.e., the coexistence of2 different cellular populations from genetically differentindividuals within a single person. The most frequentcause of microchimerism is pregnancy, in which there is abi-directional fetal-maternal interchange of cells duringpregnancy and delivery. Fetal cells have been demonstrated in the tissues ofpatients with rheumatic, endocrine or infectious diseases,as well as in those of healthy individuals. Microchimerism has been most extensively studied insystemic sclerosis. It seems that during pregnancyallogenic fetal or maternal cells cross the placenta bidirectionallyand persist in the systemic circulation andtissues of both mother and child. Subsequently, they areactivated, resulting in is a graft-against-host reactionassociated with the onset of clinical manifestations.Microchimerism has been also studied in otherconnective tissue diseases.Fetal microchimerism is the presence of fetal cells inmaternal tissues and vice versa, i.e., the coexistence of2 different cellular populations from genetically differentindividuals within a single person. The most frequentcause of microchimerism is pregnancy, in which there is abi-directional fetal-maternal interchange of cells duringpregnancy and delivery. Fetal cells have been demonstrated in the tissues ofpatients with rheumatic, endocrine or infectious diseases,as well as in those of healthy individuals. Microchimerism has been most extensively studied insystemic sclerosis. It seems that during pregnancyallogenic fetal or maternal cells cross the placenta bidirectionallyand persist in the systemic circulation andtissues of both mother and child. Subsequently, they areactivated, resulting in is a graft-against-host reactionassociated with the onset of clinical manifestations.Microchimerism has been also studied in otherconnective tissue diseases.