Ivanio Alves Pereira

Update on the brazilian consensus for the diagnosis and treatment of rheumatoid arthritis

Manoel Barros Bértolo(1), Claiton Viegas Brenol(2), Cláudia Goldenstein Schainberg(3), Fernando Neubarth(4), Francisco Aires Correa de Lima(5), Ieda Maria Laurindo(6), Inês Guimarães Silveira(7), Ivanio Alves Pereira(8), Marco Antonio Rocha Loures(9), Mario Newton de Azevedo(10), Max Victor Carioca de Freitas(11), Milton da Silveira Pedreira Neto(12), Ricardo Machado Xavier(13), Rina Dalva N. Giorgi(14), Sergio Candido Kowalski(15), Sonia Maria Alvarenga Anti(16)

Drug survival and causes of discontinuation of the first anti-TNF in ankylosing spondylitis compared with rheumatoid arthritis: analysis from BIOBADABRASIL

Treatment survival with biological therapy may be influenced by many factors, and it seems to be different among various rheumatic diseases and biological agents. The goal of the study was to compare the drug survival and the causes of discontinuation of anti-tumoral necrosis factor (anti-TNF) therapy in ankylosing spondylitis (AS) with rheumatoid arthritis (RA). Study participants were a cohort from the Brazilian Registry of Biological Therapies in Rheumatic Diseases (BIOBADABRASIL) between 2008 and 2012. The observation time was up to 4xa0years following the introduction of the first treatment. Gender, age, disease duration, disease activity, comorbidities, and concomitant therapies were assessed. A total of 1303 patients were included: 372 had AS and 931 had RA in which 38.7xa0% (nu2009=u2009504) used infliximab (IFX), 34.9xa0% (nu2009=u2009455) used adalimumab (ADA), and 26.4xa0% (nu2009=u2009344) used etanercept (ETA). The anti-TNF drug survival of patients with AS was 63.08xa0months (confidence interval (CI) 60.24, 65.92) and patients with RA was 47.5xa0months (CI 45.65, 49.36). It was significant higher in AS (log-rank; pu2009≤u20090.001). Patients with RA discontinued anti-TNF more than patients with AS when adjusted to gender and corticosteroid. The adjHR (95xa0% CI) was 1.6 (1.14, 2.31). Female patients who were also corticosteroid users, but not of advanced age, have shown lower survival for both diseases (log-rank, pu2009≤u20090.001). The discontinuation rate of IFX, but not of ADA or ETA, was significantly higher in RA than in SA; HR (95xa0% CI) was 2.49 (1.46, 4.24). The main causes of discontinuation were ineffectiveness and adverse event in both diseases. AS patients have better drug survival adjusted to gender, age, and corticosteroid. This results appear to be related to the disease mechanism.

Incapacitação e qualidade de vida não são influenciadas pela prevalência de autoanticorpos em pacientes com artrite reumatoide inicial - resultados da Coorte Brasília

INTRODUCTIONnAlthough many studies have suggested that the presence of autoantibodies, such as rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide (anti-CCP) in rheumatoid arthritis (RA) are predictors of joint damage, the association with disability and quality of life questionnaires are not known.nnnOBJECTIVESnTo evaluate the correlation between the Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) scores with serological markers, such as RF, anti-CCP, and anti-citrullinated vimentin (anti-Sa).nnnPATIENTS AND METHODSnSixty five patients with early RA (ERA) from the Brasília Cohort of ERA were evaluated. Serology tests (ELISA) for RF (IgM, IgG, and IgA), anti-CCP (CCP2, CCP3, and CCP3.1), and anti-Sa were performed, with the application of the HAQ and SF-36 questionnaires in the initial evaluation.nnnRESULTSnThe mean age was 45 years, with a female predominance (86%). At the initial evaluation, RF was positive in 32 individuals (49.23%), anti-CCP in 34 (52.3%), and anti-Sa in nine (13.8%). The initial HAQ score was 1.8. The SF-36 scores were as follow: role-emotional, 19.3; social functioning, 43.1; bodily pain, 25.43; general health, 57.6; mental health, 48.1; vitality, 49.5; role-physical, 4.6; and physical functioning, 24.7. The HAQ and SF-36 scores did not vary with autoantibody levels.nnnCONCLUSIONnIn many patients, ERA has a major impact on physical ability and health-related quality of life. Although RF and anti-CCP tests have been related with joint destruction and worse clinical prognosis, there is no correlation with the results of questionnaires of quality of life and disability.

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.