¿Cómo hacer buen uso del metotrexato en artritis reumatoide?

Methotrexate (MTX) is the first choice disease modifying anti-rheumatic drugs for rheumatoid arthritis. In spite of its generalized use by rheumatologists worldwide, there is a general lack of agreement regarding the route of administration, the start-up dose and the way to increase the same. In this article we propose a simplified outline for the use of the drug that should be individualized, based on it's pharmacological aspects, guidelines and recommendations published in high impact factor journals during the past few years. Adverse reactions and side effects, as well as their follow up are also reviewed.     

Aspectos prácticos de la medición de los niveles de fármacos biológicos y de anticuerpos antifármaco en artritis reumatoide y espondiloartritis

ObjectivesIssue recommendations on practical aspects of the monitoring of levels of biological drugs that may be useful for rheumatologists.MethodsWe conducted a systematic review of studies in which drug and anti-drug antibody levels were determined in patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) to study whether they could predict different outcomes. In light of the results of the review, a group of experts discussed under what circumstances testing biological drug levels and their antibodies could be useful. The discussion resulted in a series of clinical questions that were answered with the scientific evidence collected, and in algorithms that facilitate decision making.ResultsIt was established that the determination of drug levels can be especially useful in two clinical situations, on treatment failure (primary or secondary) and on sustained remission. It is also reviewed which laboratory technique and timing for sample drawing are the most suitable for the measurement. Recommendations are issued on the interpretation of drug levels and on factors to be taken into account (for example, body mass index and disease modifying drugs).ConclusionsEvidence-based algorithms and guidelines have been established to test drug levels and anti-drug antibodies in patients with RA and SpA, which can help clinical decision making.     

¿Se puede suspender la medicación en los pacientes con artritis reumatoide en remisión?

Rheumatoid arthritis is a chronic systemic inflammatory disease that causes significant morbidity and mortality. The combined use of methotrexate and biological agents directed against tumor necrosis factor (TNF) has achieved significant improvement in clinical, radiographic and functional parameters not seen previously and has revolutionized the therapeutic goal of achieving remission in clinical, structural and functional parameters. The next goal should be to achieve remission without the use of biological drugs and later without medication. Although there is evidence about the efficacy and safety of TNF inhibitors, there is none on remission without the use of biological agents or disease modifying drugs.     

Qué, cómo,cuándo y hasta cuándo tratar una artritis indiferenciada

With the establishment of early arthritis clinics, patients can now be increasingly attended early in the course of their disease. This means that a significant proportion of these patients cannot be classified into a specific diagnosis using the traditional American College of Rheumatology (ACR) classification criteria. In these patients with undifferentiated arthritis (UA), even more important than assigning a diagnosis is the need to distinguish between patients who will develop a persistent and/or erosive disease and will be candidates for prompt treatment with disease-modifying antirheumatic drugs (DMARD), and patients in whom the disease is self limiting. Serologic markers in combination with clinical features at presentation, integrated into predictive models, are the tools currently available to the clinician for identifying these patients. Several studies have demonstrated the advantages of early treatment in UA.     

?Cómo son los pacientes con artritis reumatoide de reciente comienzo en Espa?a? Descripción de la cohorte PROAR

ObjectiveTo identify factors present in recent onset arthritis that may help to predict rheumatoid arthritis (RA), and to describe a cohort of recent onset RA.Patients and methodA 5 year prospective cohort of patients with early oligo and polyarthritis (< 1 year of evolution) from 34 rheumatology units, was studied. Sociodemographic, clinical features and RA risk factors were recorded. Rheumatoid factor (RF), anti-CCP determinations and radiographs of hands and feet were analyzed too. After three years, a diagnosis of certainty and the variables that determined the evolution to RA, were evaluated.ResultsOne hundred and seventy one patients were included; 161 (94.2%) fulfilled RA diagnostic criteria; most of them (157; 97.5%) in the first visit. Factors associated with RA diagnosis were: positive RF, anti-CCP and DAS-28; 65% of the patients had radiological erosions in the first visit.ConclusionsPositive RF, anti-CCP and the disease activity are predictive factors of RA. Radiological damage exists very early in most of patients, that's why it is more important to treat the disease aggressively instead than achieving an RA diagnosis of certainty.     

¿Cómo se evalúa una respuesta inadecuada en un paciente con artritis reumatoide en la práctica clínica?

Rheumatoid arthritis (RA) is a chronic disease that particularly affects the joints, causing their destruction, changes in its functional capacity and considerably compromising the quality of life. It is known that early treatment can reduce structural damage and improve the disability in the long term, but the optimal therapeutic strategies are still not universally accepted. As with diabetes and hypertension, strict control of the disease is required, with the objective of achieving no disease activity, which may be seen as a remission, or if this is not possible, to keep the inflammatory activity as low as possible so that the unfavourable consequences, such as the articular damage process and the risks that the patients assume deriving from treatment, do not occur. The improvement criteria of the American College of Rheumatology (ACR) are useful for comparing the efficacy of treatment in clinical trials, but they must not be used as a therapeutic objective, since they do not evaluate the final activity, which can be as important as having an improvement. To evaluate the response, the most logical and convenient for the doctor is to use the same tools that are used to evaluate the activity of the disease in clinical practice, such as the DAS and SDAI activity scores. Some limits which separate the different levels of activity have been proposed to improve their interpretation and establish therapeutic objectives. The categorisation into classes according to activity is important for starting or changing treatment (when it is moderate or high) and to define stages of conceptually different activity (activity or remission). The cut-off points that separate these categories were proposed years ago when the therapeutic possibilities of RA were limited and their long term consequences were not known. The therapeutic objective of remission or lower activity is much easier to achieve these days, therefore the therapeutic categories need to be reconsidered and the definition of lower activity levels as a potential objective. Nowadays, to assume moderate or high activity as a result of treatment is unacceptable, particularly when our therapeutic arsenal is already considerable and strategies and therapeutic combinations have been proposed which have demonstrated higher efficacy with tolerable risks. Although changes happen gradually in all aspects of life, there is no reason not to accept remission of RA as not only a desirable objective, but also an achievable one.     

¿Qué papel juega la actividad de la enfermedad en el riesgo cardiovascular de la artritis reumatoide?

Rheumatoid arthritis (RA) is associated with a 1.3 to 3-fold increase in mortality, being the major cause of death from cardiovascular complications (40%-50%). Therefore, the initial approach should include cardiovascular risk (CVR) assessment using algorithms adapted for this population. Although, SCOREM is an important advance, there are data indicating that subclinical atherosclerosis may be underdiagnosed.

Desarrollo y viabilidad de cuatro checklists para la evaluación de la comorbilidad en pacientes con artritis reumatoide,espondiloartritis axial y artritis psoriásica: Proyecto GECOAI

ObjectiveTo develop and assess the feasibility in daily practice of four comorbidity checklists, for common use in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA).MethodsA multidisciplinary panel of experts on comorbidity was established. Data from the GECOAR, GECOAX and GECOAP projects were analysed and a narrative literature review in Medline on RA, axSpA and PsA comorbidity was performed in order to select the most relevant and common comorbidities across the three diseases. With these results and those obtained from a focus group of patients, in a nominal group meeting, the experts generated preliminary checklists. These were afterwards modified by an external evaluation by two associations, a patients’ association and an association of health professionals related to rheumatology. As a result, the final checklists were generated. A cross-sectional study was conducted to test the feasibility of three of the checklists in daily practice, in which eight health professionals evaluated the checklists in five patients with RA, five with axSpA and five with SpA.ResultsFour comorbidity checklists were designed, three for health professionals (one to assess current comorbidity, one on prevention/health promotion and one with the referral criteria to other health professionals), and another for patients. The feasibility study showed them to be simple, clear, and useful for use in routine clinical practice.ConclusionsThe use of specific and common checklists for patients with RA, axSpA and PsA is feasible and might contribute favorably to their prognosis as well as in daily practice.     

Cambio de CLSI a EUCAST en la interpretación de la sensibilidad a antimicrobianos: ¿cómo influye en nuestro medio?

Introduction

Implementation of the breakpoints established in the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines in comparison with those of the Clinical and Laboratory Standards Institute (CLSI) means that the criteria for interpreting the susceptibility of some antimicrobials have been modified, resulting in changes in the reports of accumulated antibiotic susceptibility.

¿Cómo elaborar un proyecto de investigación en ciencias de la salud?

Knowing how to properly prepare a research proposal is a real challenge — and being able to prepare an excellent research proposal is increasingly a requirement to compete for funding with assurances of success. With this in mind, we aim to share with the reader our experience (in many cases, unsuccessful) as applicants on the most important aspects of preparing a research proposal and securing its approval and funding. This article aims not only to list theoretical recommendations but also to share some personal and eminently practical suggestions on the following elements of a research proposal: the title, the abstract, the introduction, the objectives, the methodology, the work plan or schedule, the proposal's consistency and coherence, its viability, its applicability, the importance of the principal investigator and the research team, the proposal's limitations and alternatives, its budget, its references, and, finally, the research proposal's form or wording. In summary, a research proposal is a carefully written plan that includes all the scientific, ethical and logistical aspects of the study to be conducted. Writing a good research proposal requires considerable effort and a great deal of time, but it's worth it.     

Osteoporosis premenopáusica: ¿cómo tratarla?

There is no agreement in defining osteoporosis in premenopausal women and diagnosis must be done carefully and not based on densitometric parameters. One must take into account the presence of other risk factors and history of fragility fractures, diseases or drugs that cause bone loss. Over 50% of premenopausal women with osteoporosis will have a secondary cause, with the remainder diagnosed with idiopathic osteoporosis. Therapeutic considerations are limited by a few studies in this group of patients, especially in regard to the risk of fractures. On the other hand, the FRAX index cannot be applied to premenopausal women. This article will review the measures to apply depending on the type of premenopausal osteoporosis, based on current scientific evidence.