RESUMEN
OBJECTIVE: To establish agreement on systemic lupus erythematosus (SLE) treatment. METHODS: SLE experts (n = 69) were e-mailed scenarios and indicated preferred treatments. Algorithms were constructed and agreement determined (≥50% respondents indicating ≥70% agreement). RESULTS: Initially, 54% (n = 37) responded suggesting treatment for scenarios; 13 experts rated agreement with scenarios. Fourteen of 16 scenarios had agreement as follows: discoid lupus: first-line therapy was topical agents and hydroxychloroquine and/or glucocorticoids then azathioprine and subsequently mycophenolate (mofetil); uncomplicated cutaneous vasculitis: initial treatment was glucocorticoids ± hydroxychloroquine ± methotrexate, followed by azathioprine or mycophenolate and then cyclophosphamide; arthritis: initial therapy was hydroxychloroquine and/or glucocorticoids, then methotrexate and subsequently rituximab; pericarditis: first-line therapy was nonsteroidal antiinflammatory drugs, then glucocorticoids with/without hydroxychloroquine, then azathioprine, mycophenolate, or methotrexate and finally belimumab or rituximab, and/or a pericardial window; interstitial lung disease/alveolitis: induction was glucocorticoids and mycophenolate or cyclophosphamide, then rituximab or intravenous gamma globulin (IVIG), and maintenance followed with azathioprine or mycophenolate; pulmonary hypertension: glucocorticoids and mycophenolate or cyclophosphamide and an endothelin receptor antagonist were initial therapies, subsequent treatments were phosphodiesterase-5 inhibitors and then prostanoids and rituximab; antiphospholipid antibody syndrome: standard anticoagulation with/without hydroxychloroquine, then a thrombin inhibitor for venous thrombosis, versus adding aspirin or platelet inhibition drugs for arterial events; mononeuritis multiplex and central nervous system vasculitis: first-line therapy was glucocorticoids and cyclophosphamide followed by maintenance with azathioprine or mycophenolate, and then rituximab, IVIG, or plasmapheresis; and serious lupus nephritis: first-line therapy was glucocorticoids and mycophenolate, then cyclophosphamide then rituximab. CONCLUSION: We established variable agreement on treatment approaches. For some treatment decisions there was good agreement between experts even if no randomized controlled trial data were available.
Asunto(s)
Lupus Eritematoso Sistémico/terapia , Guías de Práctica Clínica como Asunto , Anciano , Algoritmos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y CuestionariosAsunto(s)
Conservadores de la Densidad Ósea/uso terapéutico , Difosfonatos/uso terapéutico , Fracturas Óseas/prevención & control , Osteoporosis/tratamiento farmacológico , Pautas de la Práctica en Medicina , Densidad Ósea , Conservadores de la Densidad Ósea/economía , Calcio/uso terapéutico , Difosfonatos/economía , Humanos , Osteoporosis/diagnóstico , Vitamina D/uso terapéuticoRESUMEN
OBJECTIVE: To explore use of bone densitometry in Australia and to identify any sex and geographic differences, as a marker of osteoporosis diagnosis and care. DESIGN AND SETTING: Analysis of claims data from Medicare Australia in patients aged over 45 years during the period 2001-2005. MAIN OUTCOME MEASURES: Age-standardised rates of bone densitometry use, by sex and by metropolitan, rural or remote classification. RESULTS: Bone densitometry use increased by 26% over the 5 years. Rates were lower for rural and remote populations, with people in capital cities about three times as likely to undergo the investigation as those in remote areas. The sex ratio for the rate of bone densitometry use (women to men) decreased from more than 6 : 1 in 2001 to 4 : 1 in 2005. CONCLUSION: Although the sex ratio for osteoporotic fracture is close to 2 : 1 (women to men), the sex ratio for testing is much higher, suggesting underuse of bone densitometry in men. Sex and rural inequities in use of the investigation need to be addressed as part of a national approach to reducing minimal trauma fracture.
Asunto(s)
Densidad Ósea , Densitometría/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Bases de Datos Factuales , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Osteoporosis/diagnóstico , Osteoporosis/epidemiología , Osteoporosis/prevención & control , Prevalencia , Población Rural/tendencias , Factores Sexuales , Población Urbana/tendenciasRESUMEN
The cytokine, tumour necrosis factor-alpha (TNF-alpha) plays a key role in the pathogenesis of many chronic inflammatory and rheumatic diseases, in particular, Crohn's disease, rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Controlled trials have shown that the TNF inhibitors (etanercept, infliximab and adalimumab) significantly reduce symptoms and signs, improve function and quality of life, and reduce radiologically evident damage in patients with rheumatoid diseases. For reasons that are not entirely clear, etanercept does not work in Crohn's disease. Injection site and intravenous reactions and increased risk of infection (in particular, reactivation of tuberculosis) are associated with the use of these agents. Increased risk of lymphoproliferative disease, the development of lupus-like syndromes and demyelination, including optic neuritis and reactivation of multiple sclerosis, are under evaluation in long-term follow-up studies. The TNF inhibitors are expensive (about $18 000 per year), and in some patients need to be given continuously to maintain benefit, even in the presence of other immunosuppressive therapy.