Geraldo da Rocha Castelar Pinheiro

Women, men, and rheumatoid arthritis: Analyses of disease activity, disease characteristics, and treatments in the QUEST-RA Study

IntroductionGender as a predictor of outcomes of rheumatoid arthritis (RA) has evoked considerable interest over the decades. Historically, there is no consensus whether RA is worse in females or males. Recent reports suggest that females are less likely than males to achieve remission. Therefore, we aimed to study possible associations of gender and disease activity, disease characteristics, and treatments of RA in a large multinational cross-sectional cohort of patients with RA called Quantitative Standard Monitoring of Patients with RA (QUEST-RA).MethodsThe cohort includes clinical and questionnaire data from patients who were seen in usual care, including 6,004 patients at 70 sites in 25 countries as of April 2008. Gender differences were analyzed for American College of Rheumatology Core Data Set measures of disease activity, DAS28 (disease activity score using 28 joint counts), fatigue, the presence of rheumatoid factor, nodules and erosions, and the current use of prednisone, methotrexate, and biologic agents.ResultsWomen had poorer scores than men in all Core Data Set measures. The mean values for females and males were swollen joint count-28 (SJC28) of 4.5 versus 3.8, tender joint count-28 of 6.9 versus 5.4, erythrocyte sedimentation rate of 30 versus 26, Health Assessment Questionnaire of 1.1 versus 0.8, visual analog scales for physician global estimate of 3.0 versus 2.5, pain of 4.3 versus 3.6, patient global status of 4.2 versus 3.7, DAS28 of 4.3 versus 3.8, and fatigue of 4.6 versus 3.7 (P < 0.001). However, effect sizes were small-medium and smallest (0.13) for SJC28. Among patients who had no or minimal disease activity (0 to 1) on SJC28, women had statistically significantly higher mean values compared with men in all other disease activity measures (P < 0.001) and met DAS28 remission less often than men. Rheumatoid factor was equally prevalent among genders. Men had nodules more often than women. Women had erosions more often than men, but the statistical significance was marginal. Similar proportions of females and males were taking different therapies.ConclusionsIn this large multinational cohort, RA disease activity measures appear to be worse in women than in men. However, most of the gender differences in RA disease activity may originate from the measures of disease activity rather than from RA disease activity itself.

Consenso da Sociedade Brasileira de Reumatologia 2011 para o diagnóstico e avaliação inicial da artrite reumatoide

OBJETIVO: Elaborar recomendacoes para o manejo da artrite reumatoide (AR) no Brasil, com enfoque no diagnostico e na avaliacao inicial da doenca. METODO: Revisao da literatura e opiniao de especialistas membros da Comissao de AR da Sociedade Brasileira de Reumatologia. RESULTADOS E CONCLUSOES: Foram estabelecidas 10 recomendacoes: 1) O diagnostico da AR deve ser estabelecido considerando-se achados clinicos e exames complementares; 2) Deve-se dedicar especial atencao ao diagnostico diferencial dos casos de artrite; 3) O fator reumatoide (FR) e um teste diagnostico importante, porem com sensibilidade e especificidade limitadas, sobretudo na AR inicial; 4) O anti-CCP (teste para anticorpos antipeptideos citrulinados ciclicos) e um marcador com sensibilidade semelhante a do FR, mas com especificidade superior, sobretudo na fase inicial da doenca; 5) Embora inespecificas, provas de atividade inflamatoria devem ser solicitadas a pacientes com suspeita clinica de AR; 6) A radiografia convencional deve ser empregada para avaliacao de diagnostico e prognostico da doenca. Quando necessario e disponivel, a ultrassonografia e a ressonância magnetica podem ser utilizadas; 7) Podem-se utilizar criterios de classificacao de AR (ACR/EULAR 2010), embora ainda nao validados, como um guia para auxiliar no diagnostico de pacientes com artrite inicial; 8) Deve-se utilizar um dos indices compostos para avaliacao de atividade de doenca; 9) Recomenda-se a utilizacao regular de ao menos um instrumento de avaliacao da capacidade funcional; 10) Deve-se verificar, na avaliacao inicial da doenca, a presenca ou nao de fatores de pior prognostico, como o acometimento poliarticular, FR e/ou anti-CCP em titulos elevados e erosao articular precoce.

Registro brasileiro de biológicos: processo de implementação e resultados preliminares do BiobadaBrasil

OBJETIVOS: O presente estudo teve por objetivo descrever o processo de implementacao de um registro nacional em um pais em desenvolvimento (Brasil) e relatar os principais resultados preliminares do registro BiobadaBrasil. MATERAL E METODOS: Atraves de um acordo com a PANLAR, o protocolo Biobadaser foi utilizado como modelo para a implementacao de um novo registro no nosso pais. Durante os dois primeiros anos desse esforco, o protocolo original foi adaptado, traduzido e apresentado a todos os reumatologistas brasileiros. Durante dez meses, dados de 1.037 pacientes (750 tratados com biologicos e 287 controles) de 15 centros foram coletados. RESULTADOS: A maioria dos pacientes tinha artrite reumatoide (AR) (n = 723). Infliximabe foi o agente anti-TNF mais usado, e a exposicao total a biologicos foi 2.101 pacientes-ano. A razao mais comum para suspensao da droga foi ineficiencia ou perda de efetividade (50%), e 30% dos pacientes interromperam o tratamento devido a eventos adversos. Tres casos de tuberculose foram observados no grupo biologico, representando maior incidencia do que aquela da populacao brasileira geral. Infeccoes foram observadas em 23% dos pacientes do grupo biologico, sendo o trato respiratorio superior o local mais comumente afetado. Apenas um caso de hanseniase tuberculoide foi observado. Nenhuma morte nem malignidade atribuivel ao efeito dos medicamentos foi observada ate fevereiro de 2010. CONCLUSOES: A implementacao do registro foi bem sucedida. Embora recente, o registro BiobadaBrasil ja forneceu importantes dados.

Consenso 2012 da Sociedade Brasileira de Reumatologia sobre o manejo de comorbidades em pacientes com artrite reumatoide

OBJECTIVE To elaborate recommendations of the Rheumatoid Arthritis Committee of the Brazilian Society of Rheumatology (SBR) to manage comorbidities in rheumatoid arthritis (RA). METHODS To review the literature and the opinions of the SBR RA Committee experts. RESULTS AND CONCLUSIONS RECOMMENDATIONS 1) Early diagnosis and proper treatment of comorbidities are recommended; 2) The specific treatment of RA should be adapted to the presence of comorbidities; 3) Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers are preferred to treat systemic arterial hypertension; 4) In patients diagnosed with rheumatoid arthritis and diabetes mellitus, the continuous use of a high cumulative dose of corticoids should be avoided; 5) Statins should be used to maintain LDL cholesterol levels under 100 mg/dL and the atherosclerotic index lower than 3.5 in patients with RA who have other comorbidities; 6) Metabolic syndrome should be treated; 7) Performing non-invasive tests to investigate subclinical atherosclerosis is recommended; 8) Greater surveillance for the early diagnosis of occult malignancy is recommended; 9) Preventive measures of venous thrombosis are suggested; 10) Bone densitometry is recommended in RA patients over the age of 50 years and in younger patients on corticoid therapy at a dose greater than 7.5 mg for over three months; 11) Patients with RA and osteoporosis should be instructed to avoid falls, to increase their dietary calcium intake and sun exposure, and to exercise; 12) Calcium and vitamin D supplementation is suggested. Bisphosphonates are suggested for patients with T score < -2.5 on bone densitometry; 13) A multidisciplinary team, with the active participation of a rheumatologist, is recommended to treat comorbidities.OBJECTIVE: To elaborate recommendations of the Rheumatoid Arthritis Committee of the Brazilian Society of Rheumatology (SBR) to manage comorbidities in rheumatoid arthritis (RA). METHODS: To review the literature and the opinions of the SBR RA Committee experts. RESULTS AND CONCLUSIONS: Recommendations: 1) Early diagnosis and proper treatment of comorbidities are recommended; 2) The specific treatment of RA should be adapted to the presence of comorbidities; 3) Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers are preferred to treat systemic arterial hypertension; 4) In patients diagnosed with rheumatoid arthritis and diabetes mellitus, the continuous use of a high cumulative dose of corticoids should be avoided; 5) Statins should be used to maintain LDL cholesterol levels under 100 mg/dL and the atherosclerotic index lower than 3.5 in patients with RA who have other comorbidities; 6) Metabolic syndrome should be treated; 7) Performing non-invasive tests to investigate subclinical atherosclerosis is recommended; 8) Greater surveillance for the early diagnosis of occult malignancy is recommended; 9) Preventive measures of venous thrombosis are suggested; 10) Bone densitometry is recommended in RA patients over the age of 50 years and in younger patients on corticoid therapy at a dose greater than 7.5 mg for over three months; 11) Patients with RA and osteoporosis should be instructed to avoid falls, to increase their dietary calcium intake and sun exposure, and to exercise; 12) Calcium and vitamin D supplementation is suggested. Bisphosphonates are suggested for patients with T score < -2.5 on bone densitometry; 13) A multidisciplinary team, with the active participation of a rheumatologist, is recommended to treat comorbidities.

Guidelines for the drug treatment of rheumatoid arthritis.

Description of evidence collection method A literature review of the scientific articles referenced in these guidelines was conducted with the MEDLINE database. The evidence search was based on real clinical scenarios, and the following keywords (MeSH terms) were used: Arthritis, Rheumatoid, Therapy (early OR late OR later OR time factors OR delay), Prognosis, Remission, Steroids, Anti-Inflammatory Agents, Non-Steroidal, NSAIDs, Diclofenac, Ibuprofen, Indomethacin, Piroxicam, COX-2, Celecoxib, Etoricoxib, Disease-modifying antirheumatic drug OR DMARD, Methotrexate, Gold sodium, Leflunomide, Sulfasalazine, Hydroxychloroquine, Tumor Necrosis Factor-alpha, Adalimumab, Certolizumab, Etanercept, Infliximab, Golimumab, Rituximab, Tocilizumab and Abatacept. Grades of recommendation and strength of evidence A: Most consistent experimental and observational studies. B: Less consistent experimental and observational studies. C: Case reports (uncontrolled studies). D. Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models. Objective These guidelines aim to provide recommendations for the treatment of rheumatoid arthritis in Brazil. Although North American and European guidelines for the treatment of rheumatoid arthritis have been recently published, it is important to review the subject with regard to specific aspects of Brazilian reality. Thus, the ultimate purpose of the establishment of consensus guidelines for the treatment of rheumatoid arthritis in Brazil is to provide an orientation and foundation for Brazilian rheumatologists with evidence from scientific studies and the experience of a committee of experts on the subject. Thus, therapeutic approaches to rheumatoid arthritis within the Brazilian socioeconomic context will be standardized, while physician autonomy will be maintained with regard to the indication/ selection of available treatment options. As knowledge in this scientific field progresses rapidly, we suggest biannual updates to these guidelines.

Diretrizes para o tratamento da artrite reumatoide

Descricao do metodo de coleta de evidencia A revisao bibliografica de artigos cientificos dessa diretriz foi realizada na base de dados MEDLINE. A busca de evidencia partiu de cenarios clinicos reais, e utilizou palavras-chaves ( MeSH terms ) : Arthritis, Rheumatoid, Therapy ( early OR late OR later OR time factors OR delay), Prognosis, Remission, Steroids, Anti-Inflammatory Agents, Non-Steroidal, NSAIDs, Diclofenac, Ibuprofen, Indomethacin, Piroxicam, COX-2, Celecoxib, Etoricoxib, Disease-modifying antirheumatic drug OR DMARD, Methotrexate, Gold sodium, Leflunomide, Sulfasalazine, Hydroxychloroquine, Tumor Necrosis Factor-alpha, Adalimumab, Certolizumab, Etanercept, Infliximab, Golimumab, Rituximab, Tocilizumab, Abatacept. Graus de recomendacao e forca de evidencia A: Estudos experimentais e observacionais de melhor consistencia. B: Estudos experimentais e observacionais de menor consistencia. C: Relatos de casos (estudos nao controlados). D: Opiniao desprovida de avaliacao critica, baseada em consensos, estudos fisiologicos ou modelos animais Objetivo Esta diretriz tem o objetivo de fazer recomendacoes sobre o tratamento da artrite reumatoide no Brasil. Embora recentes diretrizes norte-americanas e europeias para o tratamento da artrite reumatoide tenham sido publicadas, e importante rever o assunto, considerando aspectos especificos da realidade brasileira. Desta forma, o proposito final em estabelecer diretrizes consensuais para o tratamento da artrite reumatoide no Brasil e definir e embasar os reumatologistas brasileiros, utilizando evidencias obtidas em estudos cientificos e a experiencia de uma comissao de especialistas no assunto, a fim de homogeneizar a abordagem terapeutica da artrite reumatoide, dentro do contexto socioeconomico brasileiro, mantendo a autonomia do medico na indicacao/escolha das alternativas terapeuticas disponiveis. Como ha rapida evolucao do conhecimento nesse campo da ciencia, sugerimos a atualizacao dessas diretrizes a cada dois anos.

Interleukin 6 Inhibition and Coronary Artery Disease in a High‐Risk Population: A Prospective Community‐Based Clinical Study

Background Atherosclerosis is a chronic inflammatory disease, with interleukin 6 (IL‐6) as a major player in inflammation cascade. IL‐6 blockade may reduce cardiovascular risk, but current treatments to block IL‐6 also induce dyslipidemia, a finding with an uncertain prognosis. Methods and Results We aimed to determine the endothelial function responses to the IL‐6–blocking agent tocilizumab, anti–tumor necrosis factor α, and synthetic disease‐modifying antirheumatic drug therapies in patients with rheumatoid arthritis in a 16‐week prospective study. Sixty consecutive patients with rheumatoid arthritis were enrolled. Tocilizumab and anti–tumor necrosis factor α therapy were started in 18 patients each while 24 patients were treated with synthetic disease‐modifying antirheumatic drugs. Forty patients completed the 16‐week follow‐up period. The main outcome was flow‐mediated dilation percentage variation before and after therapy. In the tocilizumab group, flow‐mediated dilation percentage variation increased statistically significantly from a pre‐treatment mean of (3.43% [95% CI, 1.28–5.58] to 5.96% [95% CI, 3.95–7.97]; P=0.03). Corresponding changes were 4.78% (95% CI, 2.13–7.42) to 6.75% (95% CI, 4.10–9.39) (P=0.09) and 2.87% (95% CI, −2.17 to 7.91) to 4.84% (95% CI, 2.61–7.07) (P=0.21) in the anti–tumor necrosis factor α and the synthetic disease‐modifying antirheumatic drug groups, respectively (both not statistically significant). Total cholesterol increased significantly in the tocilizumab group from 197.5 (95% CI, 177.59–217.36) to 232.3 (201.62–263.09) (P=0.003) and in the synthetic disease‐modifying antirheumatic drug group from 185.8 (95% CI, 169.76–201.81) to 202.8 (95% CI, 176.81–228.76) (P=0.04), but not in the anti–tumor necrosis factor α group. High‐density lipoprotein did not change significantly in any group. Conclusions Endothelial function is improved by tocilizumab in a high‐risk population, even as it increases total cholesterol and low‐density lipoprotein levels.

Guidelines for the diagnosis of rheumatoid arthritis

Description of the evidence collection method A review of the scientific literature was performed with the Medline database. The search for evidence was based on actual clinical scenarios and used the following Medical Subject Headings (MeSH) terms: Arthritis, Rheumatoid, Diagnosis (Delayed Diagnosis OR Delay OR Early Rheumatoid Arthritis OR VERA), Prognosis, Criteria (American College of Rheumatology/European League Against Rheumatism OR ACR/EULAR OR classification), Comparative Study, Smoking (OR tobacco use disorder), Rheumatoid Factor, Anti-cyclic Citrullinated Peptide (or anti-CCP), HLA-DRB1 OR PTPN22 OR EPITOPE, extra-articular OR extraarticular OR systemic OR ExRA, Disease Progression, Radiography OR X RAY, ULTRASONOGRAPHY, and MAGNETIC RESONANCE Grades of recommendation and strength of evidence A: A Most consistent experimental and observational studies. B: B Less consistent experimental and observational studies. C: C Case reports (uncontrolled studies). D: D Opinion that is not substantiated by critical evaluation, based on consensus, physiological studies or animal models. Objective To formulate guidelines for the management of rheumatoid arthritis (RA) in Brazil, with a focus on diagnosis. The aim of the present document is to summarise the current position of the Brazilian Society of Rheumatology on this topic to orient Brazilian doctors, particularly rheumatologists, to RA diagnosis in our country.

Development of Preliminary Remission Criteria for Gout Using Delphi and 1000Minds Consensus Exercises

To establish consensus for potential remission criteria to use in clinical trials of gout.

2012 Brazilian Society of Rheumatology Consensus on vaccination of patients with rheumatoid arthritis

OBJECTIVE To elaborate recommendations to the vaccination of patients with rheumatoid arthritis (RA) in Brazil. METHOD Literature review and opinion of expert members of the Brazilian Society of Rheumatology Committee of Rheumatoid Arthritis and of an invited pediatric rheumatologist. RESULTS AND CONCLUSIONS The following 12 recommendations were established: 1) Before starting disease-modifying anti-rheumatic drugs, the vaccine card should be reviewed and updated; 2) Vaccines against seasonal influenza and against H1N1 are indicated annually for patients with RA; 3) The pneumococcal vaccine should be indicated for all patients with RA; 4) The vaccine against varicella should be indicated for patients with RA and a negative or dubious history for that disease; 5) The HPV vaccine should be considered for adolescent and young females with RA; 6) The meningococcal vaccine is indicated for patients with RA only in the presence of asplenia or complement deficiency; 7) Asplenic adults with RA should be immunized against Haemophilus influenzae type B; 8) An additional BCG vaccine is not indicated for patients diagnosed with RA; 9) Hepatitis B vaccine is indicated for patients with RA who are negative for antibodies against HBsAg; the combined hepatitis A and B vaccine should be considered; 10) Patients with RA and at high risk for tetanus, who received rituximab in the preceding 24 weeks, should undergo passive immunization with tetanus immunoglobulin in case of exposure; 11) The YF vaccine is contraindicated to patients with RA on immunosuppressive drugs; 12) The above described recommendations should be reviewed over the course of RA.