RESUMEN
OBJECTIVES: To study the characteristics of B-cell non-Hodgkin's lymphoma (NHL) or Hodgkin lymphoma complicating rheumatoid arthritis (RA) and to identify RA-related factors associated with their occurrence. METHODS: A multicentre case-control study was performed in France. Cases were patients with RA fulfilling ACR-EULAR 2010 criteria in whom B-cell NHL or Hodgkin lymphoma developed after the diagnosis of RA. For each case, 2 controls were assigned at random from the ESPOIR cohort and were matched on age at lymphoma diagnosis (cases)/age at the 10-year follow-up visit in the cohort (controls). Case and control characteristics were compared to identify parameters associated with the occurrence of lymphoma. RESULTS: 54 cases were included and matched to 108 controls. Lymphomas were mostly diffuse large B-cell lymphoma (DLBCL, n=27, 50.0%). On immunochemistry, 4 of 27 (14.8%) lymphoma cases were positive for Epstein-Barr virus. On univariate analysis, factors associated with the occurrence of lymphoma were male sex (OR 3.3, 95% CI 1.7 to 6.7), positivity for ACPA (OR 5.1, 95% CI 2.0 to 15.7) and rheumatoid factor (OR 3.9, 95% CI 1.6 to 12.2), and erosions on radiographs (OR 3.8, 95% CI 1.7 to 8.3) and DAS28 (OR 2.0, 95% CI 1.5 to 2.7), both at the time of matching. Methotrexate, TNF blockers and a number of previous biologics were not associated with the occurrence of lymphoma. On multivariable analysis, erosions and DAS28 remained significantly associated with increased risk of lymphoma. CONCLUSION: Lymphomas complicating RA are mostly DLBCL. Risk of lymphoma in patients with RA was increased with markers of disease activity and severity, which supports the paradigm of a continuum between autoimmunity and lymphomagenesis in RA.
Asunto(s)
Artritis Reumatoide , Infecciones por Virus de Epstein-Barr , Linfoma , Artritis Reumatoide/complicaciones , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/tratamiento farmacológico , Estudios de Casos y Controles , Herpesvirus Humano 4 , Humanos , MasculinoRESUMEN
Herpes zoster can be serious or incapacitating, particularly in patients whose immune system is compromised by a disease or treatment. Immunomodulating drugs can increase the risk of infection. Well-established risk factors include advanced age and glucocorticoid therapy. The data are somewhat conflicting for medications such as methotrexate, tofacitinib, TNFα antagonists (infliximab, adalimumab, etanercept, certolizumab, and golimumab), abatacept, tocilizumab, and rituximab. Nevertheless, the risk of herpes zoster is increased in patients taking biological agents, because of the underlying diseases and/or effects of the drugs. A live attenuated herpes zoster vaccine has been proven effective and safe in immunocompetent individuals. At present, however, it is not recommended for patients with immunodeficiencies, including those taking biological drugs, as no studies have assessed its risk/benefit ratio in this population. This situation may change in the near future, as recent data support the effectiveness and safety of the herpes zoster vaccine in patients who take biotherapies or have other causes of immunodeficiency. Alternative approaches designed to protect these patients from herpes zoster and its complications are also under evaluation. There is a need to define the indications of the herpes zoster vaccine in terms of the target population, timing, modalities, and frequency, according to the underlying chronic systemic disease, age group, varicella-zoster virus status, and exposure to therapeutic agents.
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Productos Biológicos/efectos adversos , Vacuna contra el Herpes Zóster/administración & dosificación , Herpes Zóster/prevención & control , Inmunomodulación , Enfermedades Reumáticas/tratamiento farmacológico , Productos Biológicos/uso terapéutico , Femenino , Estudios de Seguimiento , Herpes Zóster/inmunología , Humanos , Inmunización/métodos , Masculino , Enfermedades Reumáticas/inmunología , Medición de Riesgo , Resultado del TratamientoRESUMEN
Hepatitis B virus (HBV) reactivation can occur in chronic carriers of the HBV surface antigen (HBsAg) and constitutes a well-known complication of immunosuppressive therapy. HBV reactivation has also been reported after contact with the HBV. The increasing use of biological agents (TNFα antagonists, rituximab, abatacept, and tocilizumab) to treat systemic diseases has resulted in numerous publications about the risk of HBV reactivation. The relevant scientific societies have issued recommendations designed to prevent HBV reactivation. The main measures consist of screening for markers indicating chronic HBV infection (HBsAg) or HBV infection in the distant past (antibodies to the HBV core antigen) before initiating biological therapies, vaccinating marker-negative patients, and considering close follow-up or antiviral treatment before immunosuppressive treatment initiation or in the event of HBV reactivation. Here, we discuss the pathophysiological mechanisms underlying HBV reactivation during biological treatments, most notably in patients with occult HBV infection or markers for remote HBV infection, whose hepatocyte nuclei may contain a resistance form of HBV DNA known as covalently closed circular DNA (cccDNA). Assessment of the risk of reactivation relies on the HBV status, drugs used, and data from the literature. Finally, we discuss the various recommendations and modalities for HBV vaccination, preemptive treatment, and patient management, according to the level of risk and to the circumstances in which reactivation occurs.
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Terapia Biológica , Hepatitis B Crónica/terapia , Activación Viral/inmunología , Antivirales/uso terapéutico , Vacunas contra Hepatitis B/uso terapéutico , Hepatitis B Crónica/inmunología , Hepatitis B Crónica/fisiopatología , Hepatitis B Crónica/prevención & control , Humanos , Riesgo , Factor de Necrosis Tumoral alfa/inmunología , VacunaciónRESUMEN
OBJECTIVES: To develop and/or update fact sheets about abatacept treatment, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS: 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable 2. identification and review of publications relevant to each topic 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields (dermatologist, cardiologist, pediatric rheumatologist, endocrinologist, hematologist, immunologist, infectiologist), and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid arthritis (RA). They were members of the CRI (Club Rhumatismes et Inflammation), a section of the French Rheumatology Society (Societe Francaise de Rhumatologie). Each fact sheet was revised by several experts and the overall process was coordinated by three experts. RESULTS: Several topics of major interest were selected: contraindications of abatacept treatment; management of adverse effects and concomitant diseases that may develop during abatacept treatment; and management of common situations such as pregnancy, surgery, patient older than 75 years of age, and patients with co-morbidities (such as dialysis, hemoglobinopathy, or splenectomy). After a review of the literature and discussion among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA, initiation and monitoring of the abatacept treatment, management of patients with specific past histories, and specific clinical situations such as pregnancy 2. diseases other than RA, such as juvenile idiopathic arthritis, spondylarthropathies, or autoimmune diseases (systemic lupus erythematosus and other systemic autoimmune diseases) 3. models of letters for informing the rheumatologist and general practitioner 4. patient information about the use of abatacept in RA 5. and data on the new abatacept formulation for subcutaneous administration (approved by the FDA in August 2011 for patients with moderate-to-severe RA). CONCLUSION: These fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on abatacept. They will be available continuously on www.cri-net.com and will be updated at appropriate intervals.
Asunto(s)
Inmunoconjugados/efectos adversos , Inmunoconjugados/uso terapéutico , Enfermedades Reumáticas/tratamiento farmacológico , Abatacept , Antirreumáticos/efectos adversos , Antirreumáticos/uso terapéutico , Comorbilidad , Manejo de la Enfermedad , Medicina Basada en la Evidencia , Humanos , Guías de Práctica Clínica como Asunto , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
Giant cell arteritis (GCA) affects middle-sized or large arteries in individuals over 50 years of age. GCA is characterized by a combination of focal inflammation responsible for arterial stenosis or occlusion and of systemic inflammation manifesting as polymyalgia rheumatica, a decline in general health, and inflammatory anemia. In addition to the typical involvement of the branches of the external carotid arteries, relatively common sites of involvement include the aorta, most notably in its thoracic segment, and the subclavian, axillary, brachial, vertebral, and femoral arteries. The treatment of GCA rests on daily glucocorticoid administration, which should be started on an emergency basis in patients with incipient visual impairments (diplopia or amaurosis fugax). The duration of glucocorticoid therapy is unpredictable and side effects are common. Initial megadose glucocorticoid therapy does not decrease subsequent glucocorticoid requirements. Glucocorticoid therapy regulates the Th17 pathway, which is involved in the prominent vascular and systemic manifestations; but not the Th1 pathway, which may underlie the chronic course of the disease (whereas aspirin, in addition to decreasing platelet aggregation, blocks the Th1 mediator interferon-gamma). Although GCA is classically described as resolving within 1 to 3 years, clinical practice often teaches otherwise. Many patients experience rebound abnormalities in laboratory tests and/or relapses, and some of them have recurrences after an apparently full recovery. Histological documentation is useful to confirm the diagnosis. The effect of methotrexate and TNFα antagonists is modest at best. A few patients have responded to tocilizumab, which suppresses IL-6, a key cytokine in GCA. Life expectancy in GCA patients is similar to that in same-age controls except for a slight excess in vascular mortality shortly after the diagnosis.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Arteritis de Células Gigantes/tratamiento farmacológico , Glucocorticoides/uso terapéutico , Inmunosupresores/uso terapéutico , Arteritis de Células Gigantes/diagnóstico , Arteritis de Células Gigantes/inmunología , Humanos , Interleucina-6/antagonistas & inhibidores , Interleucina-6/inmunologíaRESUMEN
OBJECTIVES: To develop and/or update fact sheets about TNFα antagonists treatments, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS: 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several experts and the overall process was coordinated by three experts. RESULTS: Several topics of major interest were selected: contraindications of TNFα antagonists treatments, the management of adverse effects and concomitant diseases that may develop during these therapies, and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA and SpA, initiation and monitoring of TNFα antagonists treatments, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION: These TNFα antagonists treatments fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on these therapies. They will be available continuously at www.cri-net.com and updated at appropriate intervals.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Espondilitis Anquilosante/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adalimumab , Adulto , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales Humanizados , Etanercept , Medicina Basada en la Evidencia , Femenino , Humanos , Inmunoglobulina G/efectos adversos , Inmunoglobulina G/uso terapéutico , Infliximab , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Embarazo , Ensayos Clínicos Controlados Aleatorios como Asunto , Receptores del Factor de Necrosis Tumoral/uso terapéuticoRESUMEN
Rheumatoid anemia is a typical example of anemia of chronic disease. It differs from other forms of anemia, such as iron deficiency anemia or iatrogenic anemia. Rheumatoid anemia is normochromic, normocytic or, less often, microcytic, aregenerative, and accompanied with thrombocytosis. Serum transferrin levels are normal or low, transferrin saturation is decreased, serum ferritin levels are normal or high, the soluble transferrin receptor (sTfR) is not increased (a distinguishing feature with iron deficiency anemia), and the sTfR/log ferritin ratio is lower than 1. This review discusses the prevalence and impact of rheumatoid anemia based on a review of the literature. Iron metabolism, absorption, diffusion, storage, and use by the bone marrow are described using published data on transferrin, ferritin, and hepcidin. Hepcidin is now recognized as a key factor in rheumatoid anemia, in conjunction with the cytokine interleukin-6 (IL-6). Hepcidin is a hormone that lowers serum iron levels and regulates iron transport across membranes, preventing iron from exiting the enterocytes, macrophages, and hepatocytes. In addition, hepcidin inhibits intestinal iron absorption and iron release from macrophages and hepatocytes. The action of hepcidin is mediated by binding to the iron exporter ferroportin. Hepcidin expression in the liver is dependent on the protein hemojuvelin. Inflammation leads to increased hepcidin production via IL-6, whereas iron deficiency and factors associated with increased erythropoiesis (hypoxia, bleeding, hemolysis, dyserythropoiesis) suppress the production of hepcidin. Data from oncology studies and the effects of recombinant human IL-6 support a causal link between IL-6 production and the development of anemia in patients with chronic disease. IL-6 diminishes the proportion of nucleated erythroid cells in the bone marrow and lowers the serum iron level, and these abnormalities can be corrected by administering an IL-6 antagonist. IL-6 stimulates hepcidin gene transcription, most notably in the hepatocytes. Studies involving human hepatocyte exposure to a panel of cytokines showed that IL-6, but not TNFα or IL-1, induced the production of hepcidin mRNA. Recent data on hepcidin level variations in patients with rheumatoid arthritis are reviewed. Rheumatoid anemia is best corrected by ensuring optimal control of systemic disease activity. The role for iron supplementation (per os or intravenously) and erythropoietin in the treatment of rheumatoid anemia is discussed. Given the cascade of interactions linking IL-6, hepcidin, and anemia, IL-6 antagonists hold considerable promise for the management of rheumatoid anemia.
Asunto(s)
Anemia/etiología , Anemia/fisiopatología , Artritis Reumatoide/complicaciones , Anemia/epidemiología , Péptidos Catiónicos Antimicrobianos/fisiología , Hepcidinas , Humanos , Interleucina-6/fisiología , Hierro/sangre , Prevalencia , Transferrina/fisiologíaRESUMEN
Stickler syndrome is a group of rare genetic conditions (incidence, 1/7500 births) related to mutations in the collagen genes. Both the mutations and the clinical features vary widely across affected patients. The main manifestations are craniofacial birth defects, bone and joint symptoms, ocular abnormalities, and hearing loss. Stickler syndrome may be revealed at birth (25% of cases) by a combination of cleft palate, retrognathism, and micrognathism known as Pierre Robin sequence, which may cause neonatal respiratory problems. The ocular abnormalities include severe myopia, abnormalities of the vitreous, and a high risk of retinal detachment (60% of cases), which may cause blindness (4% of cases). Severe hearing loss with onset in early childhood may impair performance at school. Osteoarthritis (75% of patients) with onset before 30 years of age is a severe manifestation that causes chronic hip and low back pain and functional impairments. Joint replacement surgery is often required. The risk associated with multiple anesthesias is highest in patients with craniofacial defects. The bone status may deserve to be evaluated, as the combination of genetic abnormalities and physical impairments may promote bone loss. Clinicians should be cognizant of Stickler syndrome so that they can detect the disease in patients and their family members, prevent functional impairments, organize a multidisciplinary management strategy, and arrange for genetic counseling.
Asunto(s)
Osteoartritis/epidemiología , Síndrome de Pierre Robin/epidemiología , Edad de Inicio , Artritis/diagnóstico por imagen , Artritis/epidemiología , Artritis/genética , Enfermedades del Tejido Conjuntivo/diagnóstico por imagen , Enfermedades del Tejido Conjuntivo/epidemiología , Enfermedades del Tejido Conjuntivo/genética , Pérdida Auditiva Sensorineural/diagnóstico por imagen , Pérdida Auditiva Sensorineural/epidemiología , Pérdida Auditiva Sensorineural/genética , Humanos , Incidencia , Osteoartritis/diagnóstico por imagen , Osteoartritis/genética , Síndrome de Pierre Robin/diagnóstico por imagen , Síndrome de Pierre Robin/genética , Radiografía , Desprendimiento de Retina/diagnóstico por imagen , Desprendimiento de Retina/epidemiología , Desprendimiento de Retina/genética , Factores de RiesgoRESUMEN
OBJECTIVES: To develop fact sheets about tocilizumab, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS: 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The 20 experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of RA. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several. experts and the overall process was coordinated by three experts. RESULTS: Several topics of major interest were selected: contraindications of tocilizumab; the management of adverse effects and concomitant diseases that may develop during tocilizumab therapy; and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: Several topics of major interest were selected: contraindications of tocilizumab; the management of adverse effects and concomitant diseases that may develop during tocilizumab therapy; and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA, initiation and monitoring of tocilizumab therapy, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION: These tocilizumab fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on tocilizumab therapy. They will be available continuously at www.cri-net.com and updated at appropriate intervals.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales Humanizados , Contraindicaciones , Medicina Basada en la Evidencia , Humanos , Educación del Paciente como Asunto , Factores de Riesgo , Administración de la SeguridadRESUMEN
Breast and prostate cancers are specially metastasizing to bone. Metastases from breast cancer usually exhibit a mixed osteolytic/osteosclerotic aspect, with osteolysis predominating. Osteosclerosis is a common finding in prostatic cancer although osteolysis occurs within the sclerotic lesions. B-cell malignancies (lymphoma, myeloma) are also associated with marked osteolysis. Histopathological examination of bone biopsies was used for the diagnosis of malignancies and, prior to embedding, microcomputed tomography (microCT) was done on the bone specimens. Patients (247) who presented either a bone metastasis, an overt myeloma, a lymphoma or a monoclonal gammopathy of undetermined significance were studied. All patients had a bone biopsy studied by 2D histomorphometry for the histopathology. During the fixation time, the bone cores were analyzed by microCT. On the 3D reconstructed models provided by microCT, signs of osteolysis/osteosclerosis were searched: excess of bone resorption, focal disorganization of microarchitecture, bone metaplasia, osteosclerosis. A strong agreement was obtained between histomorphometry and microCT results using Cohen's kappa test (kappa = 0.713). MicroCT identified excess bone resorption on trabecular surfaces when eroded surfaces were >10.5% by histomorphometry. MicroCT failed to identify some patients with smoldering myeloma or some lymphomas with microresorption. MicroCT data are obtained within 4 hr and suggest the malignant invasion of bone marrow when excess of bone resorption/formation is obtained. MicroCT can be used in the immediate postbiopsy period making possible a fast identification of malignancy. However these signs are not specific and must be confirmed by histopathological analysis.
Asunto(s)
Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/secundario , Huesos/diagnóstico por imagen , Microtomografía por Rayos X , Neoplasias Óseas/patología , Resorción Ósea/diagnóstico por imagen , Huesos/patología , Neoplasias de la Mama/patología , Femenino , Humanos , Masculino , Osteólisis/diagnóstico por imagen , Osteosclerosis/diagnóstico por imagen , Osteosclerosis/patología , Neoplasias de la Próstata/patologíaRESUMEN
OBJECTIVES: Increased susceptibility to infections is among the main safety concerns raised by biological agents. We describe five cases of Whipple's disease diagnosed during treatment with biological agents. METHODS: We retrospectively identified five cases of Whipple's disease diagnosed between 2003 and 2009 in patients treated with TNFalpha antagonists in five French hospitals. RESULTS: Five patients (four male; mean age: 50.4 years; range: 38-67) underwent biological therapy according to prior diagnoses of rheumatoid arthritis (n=2), ankylosing spondylitis (n=2), or spondyloarthropathy (n=1). Biological therapy failed to control the disease, which responded to appropriate antibiotics for Whipple's disease. Retrospectively, clinical symptoms before biological therapy were consistent with Whipple's disease. All five patients had favorable outcomes (mean follow-up, 29 months [13-71]). CONCLUSIONS: Biological therapy probably worsened preexisting Whipple's disease, triggering the visceral disorders. Whipple's disease must be ruled out in patients with joint disease, as patients with this spontaneously fatal condition should not receive immunosuppressive agents.
Asunto(s)
Artritis Reumatoide/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Espondiloartropatías/tratamiento farmacológico , Espondilitis Anquilosante/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Enfermedad de Whipple/diagnóstico , Adalimumab , Adulto , Anciano , Antibacterianos/uso terapéutico , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados , Doxiciclina/efectos adversos , Doxiciclina/uso terapéutico , Etanercept , Femenino , Humanos , Hidroxicloroquina/uso terapéutico , Inmunoglobulina G/efectos adversos , Inmunoglobulina G/uso terapéutico , Inmunosupresores/efectos adversos , Infliximab , Masculino , Persona de Mediana Edad , Receptores del Factor de Necrosis Tumoral/uso terapéutico , Estudios Retrospectivos , Enfermedad de Whipple/tratamiento farmacológicoRESUMEN
OBJECTIVES: To elaborate a how-to-use abatacept material intended to help physicians in the management of patients with inflammatory diseases treated with this drug in routine practice. METHODS: 1) Selection of the relevant domains by a rheumatologists' panel; 2) Search for published evidence in each domain; 3) Elaboration of the clinical tool guide with a 3-level gradation of evidence (evidence-based medicine EBM, official recommendations and expert's opinion). The experts were 11 academic rheumatologists with a large experience in prescribing abatacept and in managing rheumatoid arthritis. They were all members of the CRI (Club Rhumatismes et Inflammation), a section of the French Rheumatology Society dedicated to the inflammatory rheumatic diseases. Each fact sheet was reviewed by two other experts; 4) Regular updating based on medical literature and postmarketing surveillance data. RESULTS: Four domains were considered relevant: abatacept contraindications, management of side effects or associated diseases appearing during abatacept treatment, management of "practical situations" such as surgery or pregnancy, physician and patient information. After the literature analysis and discussion during an experts' meeting, a consensus was reached on: a pre-treatment checklist aimed at searching abatacept contraindications; a what-to-do document when facing side effects or associated diseases (autoimmune pathology, bacterial or viral infections, cardiovascular diseases, intolerance to abatacept, solid or haematological malignancy) or "practical situations" (surgery, pregnancy, vaccination, travel, drug-drug interactions); an example of standard information letter to be addressed to the attending physician (rheumatologist and general practitioner); an example of standard information letter to be addressed to the patient. CONCLUSION: Based on both an EBM approach and an expert's opinion approach, this abatacept clinical tool guide should provide assistance to all physicians attending patients treated with abatacept. For a better implementation in clinical practice, this tool guide will be available online at www.cri-net.com and regularly updated.
Asunto(s)
Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Inmunoconjugados/uso terapéutico , Administración de la Seguridad/métodos , Abatacept , Antirreumáticos/efectos adversos , Humanos , Inmunoconjugados/efectos adversos , Resultado del TratamientoAsunto(s)
Artritis Reumatoide/tratamiento farmacológico , Glucosamina/análogos & derivados , Meningitis Aséptica/inducido químicamente , Sulfasalazina/efectos adversos , Amoxicilina/uso terapéutico , Antibacterianos/uso terapéutico , Artritis Reumatoide/patología , Artritis Reumatoide/fisiopatología , Ceftriaxona/uso terapéutico , Combinación de Medicamentos , Femenino , Fiebre de Origen Desconocido/inducido químicamente , Fiebre de Origen Desconocido/diagnóstico , Glucosamina/efectos adversos , Humanos , Meningitis Aséptica/diagnóstico , Persona de Mediana Edad , Resultado del Tratamiento , Privación de TratamientoAsunto(s)
Vértebras Cervicales/irrigación sanguínea , Glucocorticoides/efectos adversos , Infarto/inducido químicamente , Inyecciones Epidurales/efectos adversos , Traumatismos de la Médula Espinal/etiología , Médula Espinal/irrigación sanguínea , Arterias/anomalías , Humanos , Infarto/fisiopatología , Paraplejía/inducido químicamente , Paraplejía/fisiopatología , Médula Espinal/fisiopatología , Traumatismos de la Médula Espinal/fisiopatologíaAsunto(s)
Anticuerpos Monoclonales/uso terapéutico , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Reumatología/métodos , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales de Origen Murino , Antirreumáticos/efectos adversos , Artritis Reumatoide/diagnóstico , Relación Dosis-Respuesta a Droga , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/inducido químicamente , Femenino , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Embarazo , Práctica Profesional , Rituximab , Administración de la Seguridad , Vasculitis/tratamiento farmacológicoRESUMEN
Radiculopathy is a common condition, characterized by a spontaneous regression: in 95 percent of patients, it resolves without surgery, within 1 to 12 months. To shorten the course of this disease, enable patients to resume social and professional activities and avoid chronicity, several therapeutic solutions have been assessed. Based on scientific evidence supporting effectiveness, physicians may prescribe analgesics, NSAID and epidural infiltrations, which probably relieve the pain and improve the quality of life without really modifying the mid-term prognosis. Following a specialized physical, social and professional assessment, surgery may be offered to patients who keep experiencing radicular (and not lumbar) pain. The complication rate is approximately 1 to 3 percent. The effectiveness of surgery is well established, especially with an improved recovery time (50 percent as compared to medical treatment). However, the superiority of a particular surgical technique has not been demonstrated. To date, we are still lacking evidence to demonstrate the effectiveness of percutaneous techniques in good methodological conditions. Finally, confinement to bed, cortisone administered per os or IV, localized spinal manipulations, corsets, vertebral tractions and physiotherapy have no demonstrated impact on the course of sciatica.
Asunto(s)
Desplazamiento del Disco Intervertebral/complicaciones , Ciática/etiología , Ciática/terapia , Humanos , Ciática/diagnósticoRESUMEN
OBJECTIVE: To update French Society for Rheumatology guidelines regarding the use of tumor necrosis factor alpha (TNFalpha) antagonists for treating patients with ankylosing spondylitis (AS) or psoriatic arthritis (PsA). METHODS: We used the method recommended by Shekelle et al. to update the original recommendations: a limited group of experts selected the items that required updating, the relevant literature was critically appraised, and the experts developed new wording for the recommendations, which was then subjected to internal and external validation. As with the original recommendations, three topics were addressed, namely, indications of TNFalpha antagonist therapy, treatment initiation, and treatment adjustment and follow-up. RESULTS: Four criteria should be used to evaluate the indication of TNFalpha antagonist therapy. First, the patient must have a definitive diagnosis of AS or PsA. Thus, patients with AS must meet modified New York criteria or exhibit characteristic involvement of the sacroiliac joints, spine, or peripheral sites documented by radiographs or computed tomography (structural damage) or by magnetic resonance imaging (inflammation). Patients with PsA must meet validated criteria such as the Moll and Wright or CASPAR criteria. The second criterion is active disease for more than 1month, with a BASDAI >or=4 in patients with predominantly axial disease or a tender/swollen joint count >or=3, and with a physician assessment of disease activity of >or=4/10. The third criterion is failure of at least three non-steroidal anti-inflammatory drugs in patients with axial disease or of disease-modifying antirheumatic drug (DMARD) therapy (methotrexate, salazopyrine, or leflunomide) in patients with peripheral disease. Fourth, the patient must be free of contraindications to TNFalpha antagonist therapy. Four recommendations pertain to the initiation of TNFalpha antagonist therapy: a workup should be performed prior to treatment initiation; there is no evidence that one TNFalpha antagonist is more effective than the others, so decisions about drug selection should be shared with the patient and guided by available safety data and the patient's profile; there is no proof that greater effectiveness can be achieved by routinely combining a conventional DMARD; and patients should receive regular standardized follow-up. The last four recommendations deal with adjusting TNFalpha antagonist therapy: the treatment objective is a 2-point or greater improvement in the BASDAI in patients with axial disease and a 30% or greater improvement in the tender/swollen joint counts in patients with peripheral disease; there is no evidence to support the introduction of DMARD therapy in non-responders, who can be switched to another TNFalpha antagonist or, when on infliximab, given higher dosages or more closely spaced injections; patients who fail to tolerate one TNFalpha antagonist can be switched to another TNFalpha antagonist if allowed by the nature of the adverse event; and when a remission is achieved, reduction or discontinuation of concomitant anti-inflammatory therapy should be considered, followed in the event of a prolonged remission by a reduction in the dosage of the TNFalpha antagonist.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Antirreumáticos/uso terapéutico , Artritis Psoriásica/tratamiento farmacológico , Reumatología/normas , Sociedades Médicas , Espondilitis Anquilosante/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Artritis Psoriásica/diagnóstico , Artritis Psoriásica/metabolismo , Francia , Estado de Salud , Humanos , Guías de Práctica Clínica como Asunto , Práctica Profesional , Índice de Severidad de la Enfermedad , Espondilitis Anquilosante/diagnóstico , Espondilitis Anquilosante/metabolismo , Factor de Necrosis Tumoral alfa/metabolismoAsunto(s)
Artritis Reumatoide/inmunología , Autoanticuerpos/análisis , Proteínas de Filamentos Intermediarios/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/análisis , Femenino , Proteínas Filagrina , Técnica del Anticuerpo Fluorescente Indirecta/métodos , Humanos , Masculino , Persona de Mediana Edad , Péptidos Cíclicos/inmunología , Sensibilidad y EspecificidadRESUMEN
Psoriatic arthritis in HIV-positive patients is not only severe, but also raises specific treatment challenges, as immunosuppressant and immunomodulating agents may adversely affect both the course of the HIV infection and the risk of opportunistic infections. TNFalpha antagonists have not been evaluated in patients with HIV infection, which is therefore considered to contraindicate their use. Two HIV-positive patients with psoriatic arthritis unresponsive to methotrexate alone were treated with infliximab (5 and 2 mg/kg, respectively), methotrexate, and antiretroviral drugs. Dramatic improvements in the skin and joint manifestations occurred in both patients. Tolerance was good, after follow-ups of 24 and 50 months, respectively. No opportunistic infections occurred. Viral load remained well controlled and CD4+T-cell counts stable, although both patients required adjustments in their antiretroviral regimens based on close monitoring of these two parameters. HIV infection classically contraindicates the use of TNFalpha antagonists to treat refractory inflammatory joint disease. However, exceptions to this rule can be made in carefully selected patients who have exhausted all other treatment options for their joint disease and who respond well to antiretroviral therapy. Potential long-term effects such as opportunistic infections, malignancies, and loss of HIV control need to be evaluated.