Max Victor Carioca Freitas

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.

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)

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.

Seropositivity to anti-phenolic glycolipid-I in leprosy cases, contacts and no known contacts of leprosy in an endemic and a non-endemic area in northeast Brazil

The seroprevalence rates of IgM anti-phenolic glycolipid-I (PGL-I) antibodies in four study groups with differing exposure to Mycobacterium leprae in Ceará, Brazil were investigated between March 2005 and August 2006. The first three groups in a high prevalence area included 144 cases of leprosy, their 380 contacts and 317 participants with no known leprosy contact. The fourth group in a low prevalence area consisted of 87 participants with no known leprosy contact living in an area in which no cases of leprosy had been reported in the previous 6 months. Seropositivity and levels of IgM antibodies to PGL-I were investigated using ELISA. The seropositivity levels of anti-PGL-I among the different clinical forms of leprosy cases were 61% for lepromatous, 25% for tuberculoid and 27% indeterminate. The levels of anti-PGL-I antibodies in the endemic area differentiated leprosy cases from non-cases. However, the seropositivity was similar among contact cases (15.8%) and no known leprosy contact cases from high (15.1%) and low (13.8%) prevalence areas. The seropositivity of both contacts and no known contacts was much higher than previously reported among no known contacts in other endemic areas. The study indicates that anti-PGL-I antibodies are not useful as immunological markers of household leprosy contacts and no known leprosy contacts in endemic areas.

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.

Impact of iron overload on interleukin-10 levels, biochemical parameters and oxidative stress in patients with sickle cell anemia

Objective The aim of this study was to evaluate the impact of iron overload on the profile of interleukin-10 levels, biochemical parameters and oxidative stress in sickle cell anemia patients. Methods A cross-sectional study was performed of 30 patients with molecular diagnosis of sickle cell anemia. Patients were stratified into two groups, according to the presence of iron overload: Iron overload (n = 15) and Non-iron overload (n = 15). Biochemical analyses were performed utilizing the Wiener CM 200 automatic analyzer. The interleukin-10 level was measured by capture ELISA using the BD OptEIAT commercial kit. Oxidative stress parameters were determined by spectrophotometry. Statistical analysis was performed using GraphPad Prism software (version 5.0) and statistical significance was established for p-values < 0.05 in all analyses. Results Biochemical analysis revealed significant elevations in the levels of uric acid, triglycerides, very low-density lipoprotein (VLDL), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), urea and creatinine in the Iron overload Group compared to the Non-iron overload Group and significant decreases in the high-density lipoprotein (HDL) and low-density lipoprotein (LDL). Ferritin levels correlated positively with uric acid concentrations (p-value < 0.05). The Iron overload Group showed lower interleukin-10 levels and catalase activity and higher nitrite and malondialdehyde levels compared with the Non-iron overload Group. Conclusion The results of this study are important to develop further consistent studies that evaluate the effect of iron overload on the inflammatory profile and oxidative stress of patients with sickle cell anemia.

Genotyping and drug resistance patterns of Mycobacterium tuberculosis strains observed in a tuberculosis high-burden municipality in Northeast, Brazil

OBJECTIVES This study has used a combination of clinical information, spoligotyping, and georeferencing system to elucidate the genetic diversity of the Mycobacterium tuberculosis isolates circulating in a TB-prevalent municipality of Northeast Brazil. METHODS A total of 115 M. tuberculosis strains were isolated from pulmonary tuberculosis patients from January 2007 to March 2008 in Fortaleza. Drug susceptibility and spoligotyping assays were performed and place of residence of the patients were georeferenced. RESULTS Of the M. tuberculosis strains studied, 51 (44.3%) isolates were resistant to at least one drug (R-TB) and 64 (55.7%) were sensitive to all the drugs tested (S-TB). A high frequency of resistance was found in previously treated cases (84%) and among new cases (16%; p<0.001). A total of 74 (64%) isolates were grouped into 22 spoligotyped lineages, while 41 (36%) isolates were identified as new. Among the predominant genotypes, 33% were Latim American Mediterranean (LAM), 12% Haarlem (H), and 5% U. There was no association of geographic distribution of RT-TB patients as compared to the controls and also the geographic location to the spoligotype patterns. The geospatial analysis revealed that 24 (23%) patients (hot spot zones) either shared the same residence or lived in a close neighborhood of a case. Among these concentration zones, the patients lived in the same residence and shared a common genotype pattern and resistance pattern. DISCUSSION It was observed that the spoligopatterns family distribution was similar to that reported for South America, prevailing the LAM and H lineages. A high rate-case among the resistant TB group occurs as a result of transmitted and acquired resistance. A more effective surveillance program is needed in order to succeed in reducing tuberculosis in Northeast Brazil.

Segurança do uso de terapias biológicas para o tratamento de artrite reumatoide e espondiloartrites

The treatment of autoimmune rheumatic diseases has gradually improved over the last half century, which has been expanded with the contribution of biological therapies or immunobiopharmaceuticals. However, we must be alert to the possibilities of undesirable effects from the use of this class of medications. The Brazilian Society of Rheumatology (Sociedade Brasileira de Reumatologia/SBR) produced a document based on a comprehensive literature review on the safety aspects of this class of drugs, specifically with regard to the treatment of rheumatoid arthritis (RA) and spondyloarthritides. The themes selected by the participating experts, on which considerations have been established as the safe use of biological drugs, were: occurrence of infections (bacterial, viral, tuberculosis), infusion reactions, hematological, neurological, gastrointestinal and cardiovascular reactions, neoplastic events (solid tumors and hematologic neoplasms), immunogenicity, other occurrences and vaccine response. For didactic reasons, we opted by elaborating a summary of safety assessment in accordance with the previous themes, by drug class/mechanism of action (tumor necrosis factor antagonists, T-cell co-stimulation blockers, B-cell depletors and interleukin-6 receptor blockers). Separately, general considerations on safety in the use of biologicals in pregnancy and lactation were proposed. This review seeks to provide a broad and balanced update of that clinical and experimental experience pooled over the last two decades of use of immunobiological drugs for RA and spondyloarthritides treatment.

Consenso 2012 da Sociedade Brasileira de Reumatologia sobre vacinação em pacientes com artrite reumatoide

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.

Serum levels of interleukin-6 in contacts of active pulmonary tuberculosis

INTRODUCTION: It is estimated that over two billion individuals are infected by Mycobacterium tuberculosis worldwide. Interleukin-6 (IL-6) is an important cytokine whose serum levels are commonly high in active pulmonary tuberculosis (TB). IL-6 screening in contacts of patients with TB may be useful to monitor the progress of the infectious process and to infer the risk of progression to active disease. OBJECTIVE: To evaluate the serum levels of interleukin-6 in contacts of patients with active pulmonary tuberculosis and to compare them with two other groups: a) patients affected by active pulmonary tuberculosis; b) non-contacts of tuberculosis. METHODS: Cross-sectional study with 15 contacts of patients with active pulmonary tuberculosis, selected according to the protocol recommended by the Ministry of Health. The serum levels of interleukin-6 were measured by Enzyme-linked immunosorbent assay (ELISA). The same test was also applied in the two comparison groups: 38 patients with active pulmonary tuberculosis (confirmed by clinical examination, X-rays of the chest and baciloscopy) and 63 non-contacts (healthy blood donors). RESULTS: In the contact group, the median IL-6 concentration was 1.7 pg/ml (0.96-4.8 pg/ml). For those affected by active pulmonary tuberculosis and non-contact individuals, these values corresponded to 4.3 pg/ml (0.5-24 pg/ml) and 0.5 pg/ml (0-2.8 pg/ml), respectively (p < 0.0001). CONCLUSION: Contacts of patients with active pulmonary tuberculosis had significantly higher IL-6 serum levels (3.4 times higher) in relation to non-contact individuals, but on a lower level (2.5 times lower) when compared to those affected by active disease.