Nilzio Antônio da Silva

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.

Consenso de lúpus eritematoso sistêmico

DESCRICAO DO METODO DE COLETA DE EVIDENCIAS Dez reumatologistas que trabalham em servicos que atendem grande numero de pacientes com lupus eritematoso sistemico, alguns dos quais tem pesquisa e publicacoes cientificas nesta area, foram convidados a participar do grupo de trabalho. Todos se reuniram para discutir o tratamento das diferentes manifestacoes da doenca, subdivididos em grupos de trabalho, cada qual ficando responsavel por buscar a melhor evidencia para o tratamento de um ou mais comprometimentos da doenca. A ultima edicao de Dubois’s Lupus Erythematosus, editado por Wallace D e Hahn B, em 2007 (Lippincott Williams & Wilkins), foi utilizada como base da discussao. Trabalhos publicados nos ultimos cinco anos foram pesquisados no MedLine. Em virtude da frequencia e da heterogeneidade de manifestacoes da doenca, a maioria dos trabalhos terapeuticos nao contempla grande casuistica, nem sao randomicos e controlados. Como as manifestacoes e a gravidade da doenca variam em diferentes grupos populacionais, devem ser avaliados com cuidado os estudos realizados em grupos populacionais distintos.

Acute rheumatic fever. Still a challenge.

At the end of the 20th century, after an apparent decline, acute rheumatic fever (ARF) now constitutes a great challenge for developed and developing countries. It is caused by a group A beta-hemolytic Streptococcus upper airways infection, but the exact pathogenetic mechanisms are not yet clear. The role of the immune system in the pathogenesis of ARF is understood better than genetic host factors. ARF can mimic many other diseases, and the diagnosis is based on clinical criteria. It is still overdiagnosed and underdiagnosed in different settings. Penicillin has greatly contributed to the reduction in the incidence and recurrence of this disease. Current schemes of prophylaxis, however, present many problems, and failures are common. Future efforts to reduce the burden of this disease should induce public health measures the vaccine strategies.

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.

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.

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.

Leptina e adiponectina no lúpus eritematoso sistêmico: correlações clínicas e laboratoriais

OBJECTIVE To evaluate the serum levels of leptin and adiponectin in patients with systemic lupus erythematosus (SLE) and correlate their levels with disease activity, presence of autoantibodies and clinical manifestations. METHODS 52 women with SLE and 33 healthy women were evaluated. The patients were divided into two groups, the first with active SLE and the second with inactive SLE. Patients with SLEDAI ≥3 were considered active. Serum levels of leptin (ng/ml) and adiponectin (μg/ml) were measured by enzyme immunoassay. RESULTS There was a significant difference in leptin levels between SLE and controls (20.7 ± 17.1 vs. 8.0 ± 5.0 ng/mL, P <0.001), but no significant difference in adiponectin levels (87.5 ± 69.7 vs. 118.1 ± 70.6 pg/ml, P = 0.053). No significant difference in levels of leptin and adiponectin was noted between inactive and active SLE groups. There was a significant association between low levels of leptin and positivity for anticardiolipin (aCL) (P = 0.025) and lupus anticoagulant (LA) (p = 0.003) and a significant association between high levels of leptin and the presence of renal disease (p <0.001). However, there was no association between adiponectin levels with autoantibodies and clinical features in SLE patients. CONCLUSION Patients with SLE had elevated leptin levels, with association with renal involvement. Leptin and adiponectin were not correlated with disease activity. Low levels of leptin have been associated with the presence of LA and aCL.

I Consenso Nacional para Padronização dos Laudos de FAN HEp-2

A analise da presenca de auto-anticorpos feita por imunofluorescencia indireta em celulas HEp-2 constitui-se em um metodo de triagem escolhido na maioria dos laboratorios clinicos. A ausencia de uma nomenclatura definida para a descricao dos laudos tem trazido problemas na utilizacao clinica do teste, pelas dificuldades no controle de qualidade e na padronizacao dos resultados, que, por sua vez, embora similares, recebiam denominacoes diferentes. O I Consenso Brasileiro para Padronizacao dos Laudos de FAN HEp-2 reuniu em agosto de 2000, em Goiânia, diversos especialistas de todo o Brasil. Esses emitiram pareceres em consenso para os distintos padroes: nucleares, nucleolares, citoplasmaticos e aparelho mitotico. Foram feitas recomendacoes sobre os criterios para a leitura de uma lâmina, bem como para relacao entre a diluicao de triagem e o sistema optico utilizado.