Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023.

OBJECTIVE: To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA). METHODS: A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process. RESULTS: The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others. CONCLUSIONS: This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.

Impact of obesity and overweight on C-reactive protein concentrations and disease activity in rheumatoid arthritis: A systematic review and meta-analysis.

AIM: This study aims to assess the association of obesity and CRP concentrations in adult patients with rheumatoid arthritis (RA), and its influence on measures of disease activity. METHODS: A comprehensive search was performed using Scopus, Web of Science, MEDLINE, and EMBASE, from the time of their inception to November 2021. Observational studies that evaluated the association between CRP concentrations and obesity or overweight in patients with RA were considered eligible. Correlation coefficients were pooled using the inverse variance method, while effect sizes were pre-calculated for adjusted standardized regression coefficients (ß). RESULTS: A total of 10 studies, which comprised 4024 patients, were included in this systematic review. Individually, most studies report a significant association between CRP concentrations and a higher body mass index or other adiposity measures, but the statistical significance was not sustained when pooling their data together. Through the estimates provided in the present review, it is noted that CRP tends to be more elevated in female patients with RA that have a higher BMI. However, this association is not present in men. CONCLUSION: CRP tends to be elevated in female patients with RA that have a higher BMI. Further research is required to assess this possible sex-related difference and to aid shared decision-making in order to avoid over-treatment and increased burden in patients with obesity and RA. PROSPERO registration number: CRD42022314580.

The COVID-19 epidemic curve and vaccine acceptance among patients with rheumatic diseases: an ecological study.

The attitudes toward emerging COVID-19 vaccines have been of great interest worldwide, especially among vulnerable populations such as patients with rheumatic and musculoskeletal diseases (RMDs). The aim of this study was to analyze the relationship between the nationwide number of COVID-19 cases and deaths, and vaccine acceptance or hesitancy of patients with RMDs from four patient care centers in Mexico. Furthermore, we explored differences in acceptance according to specific diagnoses: rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). This ecological study was a secondary analysis of a cross-sectional study using a validated questionnaire to measure vaccine acceptance. We generated a global Likert scale to evaluate overall attitudes toward the COVID-19 vaccine. We analyzed data from 1336 patients from March to September 2021: 85.13% (1169) were women, with a mean age of 47.87 (SD 14.14) years. The most frequent diagnoses were RA (42.85%, 559) and SLE (27.08%, 393). 635(47.52%) patients were unvaccinated, 253(18.93%) had one dose and 478(35.77%) had two doses. Of all participating patients, 94% were accepting toward the COVID-19 vaccine. Vaccine acceptance remained consistently high throughout the study. However, differences in vaccine acceptance are identified when comparing diagnoses. The peak of the national epidemic curve coincided with an increase in hesitancy among patients with RA. Contrastingly, patients with SLE became more accepting as the epidemic curve peaked. Mexican patients show high acceptance of the COVID-19 vaccine, influenced in part by a patient's specific diagnosis. Furthermore, vaccine acceptance increased mirroring the curve of COVID-19 cases and deaths in the country. This should be taken into consideration when updating recommendations for clinical practice.

Silicone breast implants and connective tissue diseases: How does current evidence add to the no-association consensus? Systematic review and meta-analysis.

To evaluate the current state of the evidence regarding the association of silicone breast implantation with the onset of connective tissue diseases, constitutional symptoms, and rheumatic serological profile in adult women. A comprehensive search was carried out using MEDLINE, Embase, Web of Science and Scopus, from inception to September 2, 2020. Cohort studies assessing the clinical and serological profile of women with cosmetic breast implants were included. Meta-analyses were conducted using risk ratios. A total of 10 cohorts with overall moderate quality of evidence were included in this systematic review. Exposure to silicone breast implants was slightly associated with the development of rheumatoid arthritis [RR: 1.35; (95% CI 1.08 to 1.68); P = .008; I2 = 0%]. However, no significant differences were exhibited between the breast implant-exposed population and controls regarding the rest of the outcomes. In adult women, exposure to silicone breast implantation is not associated with the onset of constitutional symptoms and most connective tissue diseases. A marginal association with rheumatoid arthritis was exhibited, but the certainty of this result is jeopardized by the significant amount of self-reported data for this outcome. Further research is required to adequately explore the clinical significance of these results.

Factors associated to COVID-19 vaccine acceptance in Mexican patients with rheumatic diseases: A cross-sectional and multicenter study.

COVID-19 vaccination is recommended in patients with rheumatic diseases (RDs) to prevent hospitalized COVID-19 and worse outcomes. However, patients' willingness to receive a SARS-CoV-2 vaccine and the associated factors vary across populations, vaccines, and time. The objective was to identify factors associated with COVID-19 vaccine acceptance (VA) in Mexican outpatients with RDs. This multicenter study was performed between March 1 and September 30, 2021, and four national centers contributed with patients. Participants filled out a questionnaire, which included 32 items related to patients' perception of the patient-doctor relationship, the COVID-19 vaccine component, the pandemic severity, the RD-related disability, comorbid conditions control, immunosuppressive treatment impact on the immune system, and moral/civil position of COVID-19 vaccine. Sociodemographic, disease-related, and treatment-related variables and previous influenza record vaccination were also obtained. Multiple logistic regression analyses identified factors associated with VA, which was defined based on a questionnaire validated in our population. There were 1439 patients whose data were analyzed, and the most frequent diagnoses were Rheumatoid Arthritis in 577 patients (40.1%) and Systemic Lupus Erythematosus in 427 (29.7%). Patients were primarily middle-aged women (1235 [85.8%]), with (mean±SD) 12.1 (±4.4) years of formal education. Years of education, corticosteroid use, patient perceptions about the vaccine and the pandemic severity, patient civil/moral position regarding COVID-19 vaccine, and previous influenza vaccination were associated with VA. In Mexican patients with RDs, COVID-19 VA is associated with individual social-demographic and disease-related factors, patient´s perceptions, and previous record vaccination. This information is crucial for tailoring effective vaccine messaging in Mexican patients with RDs.

Bone erosions by MRI in first-degree relatives of patients with RA: an exploratory study.

INTRODUCTION/OBJECTIVES: First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) are at increased risk of RA diagnosis. Magnetic resonance imaging (MRI) has been proposed as a useful tool to detect subclinical synovitis and bone abnormalities as predictors of progression to RA. The presence of grade ≥ 2 bone erosions in RA MRI scoring system (RAMRIS) was reported to be RA-specific. We aim to describe the prevalence and characteristics of MRI findings in RA patients and FDR. METHODS: A cross-sectional and exploratory study of 60 individuals was performed in 38 RA patients and 22 FDR with hand arthralgia without clinical arthritis and positive rheumatoid factor or anticitrullinated protein antibodies. All patients underwent an MRI and were evaluated for synovitis, bone erosion, and bone marrow edema. We evaluated second to fifth metacarpophalangeal joints of the dominant hand according to RAMRIS. RESULTS: Among the total population, eighteen (30%) subjects had grade ≥ 2 bone erosions, and 42 (70%) had at least one erosion of any grade. In patients with grade ≥ 2 bone erosions, 12 (31.6%) were from RA patients and 6 (27.2%) from FDR (p = 0.72). In patients with erosions of any grade, 26 (68.4%) were from RA patients and 15 (68.2%) were from FDR (p = 0.98). CONCLUSION: A high prevalence of bone erosions was found in RA patients' FDR who had symptoms without clinical arthritis and positive serology. MRI might be helpful in this population for an early detection of RA-specific erosions. The prognosis and the treatment decisions in these subjects should be elucidated. KEY POINTS: • First-degree relatives (FDR) of rheumatoid arthritis (RA) patients with positive serology and joint symptoms constitute a select subpopulation of individuals with an increased risk of developing RA. • Magnetic resonance imaging (MRI) of FDR shows a high prevalence of bone erosions of any grade, grade ≥ 2 erosions, and synovitis. • MRI might be helpful in FDR of RA patients to screen for the presence of RA-specific erosions or clinically undetectable synovitis.

Cardiovascular risk reclassification according to six cardiovascular risk algorithms and carotid ultrasound in psoriatic arthritis patients.

The objective was to compare the prevalence of subclinical atherosclerosis and cardiovascular risk (CVR) reclassification using six CVR algorithms and a carotid ultrasound in psoriatic arthritis (PsA) patients and controls. The method was cross-sectional study. A total of 81 patients aged 40-75 years, who fulfilled the 2006 CASPAR criteria and 81 controls matched by age, gender, and comorbidities were recruited. CVR was evaluated according to six CVR algorithms, including Framingham Risk Score (FRS)-lipids, FRS-body mass index (BMI), Atherosclerotic Cardiovascular Disease (ASCVD) Algorithm, Systematic Coronary Risk Evaluation (SCORE), QRISK3, and Reynolds Risk Score (RRS). A carotid ultrasound was performed to identify the presence of carotid plaque (CP) defined as a carotid intima media thickness ≥ 1.2 mm or a focal narrowing of the surrounding lumen ≥ 0.5mm. Patients with presence of CP, classified in the low-moderate risk by the CVR algorithms, were reclassified to a higher risk category. CP was more prevalent in PsA patients (44.4% vs 24.7%, p = 0.008), as was subclinical atherosclerosis (51.9% vs 33.3%, p = 0.017). When comparing the CVR reclassification to a higher risk category, a difference was found in the six CVR algorithms. The reclassification was more prevalent in PsA patients: 30.8% vs 12.3%, p = 0.004 with FRS-lipids; 28.4% vs 9.9%, p = 0.003 with FRS-BMI; 40.7% vs 19.8%, p = 0.003 with SCORE; 30.9% vs 16.0%, p = 0.026 with ASCVD algorithm; 37.0% vs 19.8%, p = 0.015 with RRS; and 33.3% vs 16.0%, p = 0.011 with QRISK3. The CVR algorithms underestimate the actual CVR of PsA patients. A carotid ultrasound should be considered as part of the CVR evaluation of PsA patients. KEY POINTS: • Subclinical atherosclerosis was more prevalent in psoriatic arthritis patients than controls. • Cardiovascular risk reclassification, through a carotid ultrasound, according to traditional cardiovascular risk algorithms was more common in psoriatic arthritis patients. • The cardiovascular risk algorithm that showed the lowest reclassification rate in psoriatic arthritis patients was the FRS-BMI. • All cardiovascular risk algorithms underestimate the actual risk of psoriatic arthritis patients, preventing the initiation of an adequate cardiovascular treatment.

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis. / Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Does current evidence on disease-modifying antirheumatic drugs for psoriatic arthritis reinforce an effect on radiographic progression? Results from a systematic review and meta-analysis.

This study aims to estimate the effect of synthetic and biologic disease-modifying antirheumatic drugs (DMARDs) on radiographic progression and quality of life in adult patients with psoriatic arthritis. A comprehensive search was performed using MEDLINE, Embase, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CCRCT). Clinical trials comparing DMARDs with placebo for ≥ 12 weeks were included. The meta-analysis was conducted with a random-effects model using mean differences (MD). A total of 16 trials with overall moderate quality of evidence were included. Exposure to a biologic agent reduced radiographic progression at 24 weeks of treatment (MD: - 0.66; [95% CI - 0.97 to - 0.34]; P < .00001; I2 = 100%). The reduction of the baseline score was more than two times higher for TNF blockers compared with IL-17 and IL-12/IL-23 inhibitors (MD: - 0.94 vs - 0.41). Improvement in health-related quality of life scores was observed in biologic-treated populations (MD: - 0.21; [95% CI - 0.25 to - 0.18]; P < .00001; I2 = 97%). No sufficient data were available regarding conventional synthetic agents. Our data analyses suggest a better control of radiological damage with bDMARDs, as compared to placebo, after 24 weeks of treatment. However, the accuracy of these results in real life are jeopardized by the exceedingly high level of heterogeneity exhibited within and across included studies, and the true intervention effect cannot be determined with confidence. Further research is required to assess long-term outcomes and to control heterogeneity in the evaluation of treatments for psoriatic arthritis. PROSPERO registration number: CRD42019122223. Key Points • Radiographic progression is not the primary outcome for most efficacy studies in psoriatic arthritis; hence, baseline data are substantially diverse in major clinical trials. • The best available evidence on this particular outcome is currently at a moderate risk of bias. • Existing reports of the effect of DMARDs on structural damage must be taken with caution. • Further research is required to assess long-term outcomes and to control heterogeneity between studies.

Communication skills in candidates for accreditation in rheumatology are correlated with candidate's performance in the objective structured clinical examination. / Las habilidades de comunicación de los aspirantes a la certificación en Reumatología se asocian con su desempeño en el examen clínico objetivo estructurado.

BACKGROUND: The Mexican Accreditation Council for Rheumatology annually certifies trainees in Rheumatology using a multiple-choice test and an objective structured clinical examination (OSCE). Since 2015, candidate's communication skills (CS) have been rated by both patients and by physician examiners and correlated with results on the OSCE. This study compared the CS from candidates to annual accreditation in Rheumatology as rated by patients and by physician examiners, and assessed whether these correlated with candidate's performance in the OSCE. MATERIAL AND METHODS: From 2015 to 2017, 8areas of CS were evaluated using a Likert scale, in each OSCE station that involved a patient. Both patient and physician evaluators were trained annually and their evaluations were performed blindly. The associations were calculated using the Pearson correlation coefficient. RESULTS: In general, candidates were given high CS scores; the scores from patients of the candidate's CS were better than those of physician examiners; within the majority of the stations, both scores were found to correlate moderately. In addition, the scoring of CS correlated with trainee performance at the corresponding OSCE station. Interestingly, better correlations were found when the skills were rated by the patients compared to physician scores. The average CS score was correlated with the overall OSCE performance for each trainee, but not with the multiple-choice test, except in the 2017 accreditation process, when a weak correlation was found. CONCLUSIONS: CS assessed during a national accreditation process correlated with the candidate's performance at the station level and with the overall OSCE.

The method used to set the pass mark in an objective structured clinical examination defines the performance of candidates for certification as rheumatologists. / El método para establecer el punto de corte en el examen clínico objetivo estructurado define el desempeño de los candidatos a la certificación como reumatólogo.

BACKGROUND: The Mexican Accreditation Council for Rheumatology certifies trainees (TR) on an annual basis using both a multiple-choice question (MCQ) test and an objective structured clinical examination (OSCE). For 2013 and 2014, the OSCE pass mark (PM) was set by criterion referencing as ≥6 (CPM), whereas overall rating of borderline performance method (BPM) was added for 2015 and 2016 accreditations. We compared OSCE TR performance according to CPM and BPM, and examined whether correlations between MCQ and OSCE were affected by PM. METHODS: Forty-three (2015) and 37 (2016) candidates underwent both tests. Altogether, OSCE were integrated by 15 validated stations; one evaluator per station scored TR performance according to a station-tailored check-list and a Likert scale (fail, borderline, above range) of overall performance. A composite OSCE score was derived for each candidate. Appropriate statistics were used. RESULTS: Mean (±standard derivation [SD]) MCQ test scores were 6.6±0.6 (2015) and 6.4±0.6 (2016) with 5 candidates receiving a failing score each year. Mean (±SD) OSCE scores were 7.4±0.6 (2015) and 7.3±0.6 (2016); no candidate received a failing CPM score in either 2015 or 2016 OSCE, although 21 (49%) and 19 (51%) TR, respectively, received a failing BPM score (calculated as 7.3 and 7.4, respectively). Stations for BPM ranged from 4.5 to 9.5; overall, candidates showed better performance in CPM. In all, MCQ correlated with composite OSCE, r=0.67 (2015) and r=0.53 (2016); P≤.001. Trainees with a passing BPM score in OSCE had higher MCQ scores than those with a failing score. CONCLUSIONS: Overall, OSCE-PM selection impacted candidates' performance but had a limited affect on correlation between clinical and practical examinations.

Gender differences among patients with primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease in an iberoamerican spondyloarthritis cohort.

The aim of the study was to compare clinical manifestations, disease activity, functional capacity, spinal mobility, and radiological findings between men and women from a multicenter, multiethnic Ibero-American cohort of patients with Spondyloarthritis (SpA).This observational cross-section study included 1264 consecutive SpA patients who fulfilled the modified New York criteria for ankylosing spondylitis (AS). Demographic, clinical, and radiologic data were evaluated. Categorical data were compared by X or Fisher's exact tests and continuous variables by ANOVA with post-hoc tests.Primary AS was diagnosed in 1072 patients, psoriatic spondylitis in 147, and spondylitis associated to inflammatory bowel disease (IBD) in 45 patients. Overall, male patients were significantly younger, had longer diagnostic delay, lower disease activity, worse spinal mobility, better quality of life, and more severe radiologic damage. Dactylitis and enthesitis, as well as swollen joint count, were significantly more common among women. In primary AS, there was a marked male predominance (76.2%). Among patients with psoriatic spondylitis, male predominance was lower (57.8%), but was also associated with worse spinal mobility and more severe radiologic damage. In the total population, male patients with primary AS referred higher permanent work disability (13.2% vs 6.9%; P < 0.05), although no difference was observed in psoriatic or IBD spondylitis according to the gender.Among Ibero-American SpA patients, there are some differences in clinical and radiological manifestations, men showing more structural damage, whereas women more active disease. These data suggest that the phenotype of SpA differs between genders. This can influence the subsequent diagnostic approach and therapeutic decisions.

Retinal toxicity induced by antimalarial drugs: literature review and case report. / Toxicidad retiniana asociada al uso de medicamentos antipalúdicos: revisión de la literatura y presentación de un caso.

Antimalarial drugs are widely used in several countries for control of rheumatologic diseases such as systemic lupus erythematosus and rheumatoid arthritis. They are still used in Mexico because of their low cost and few secondary effects, most of which are mild and reversible. Even so, at an ophthalmological level, they could produce irreversible visual damage, which is why it is important to have ophthalmological evaluation and proper follow up. We present a clinical case as an example of characteristic ophthalmological findings as well as risk factors for retinal toxicity. We then discuss guidelines for diagnosis and follow up of patients who use antimalarial drugs for the treatment of rheumatologic illnesses.

Los antipalúdicos son fármacos ampliamente utilizados en varios países para el control de enfermedades reumatológicas como el lupus eritematoso sistémico y la artritis reumatoide. En México continúan siendo muy aceptados por su bajo costo y pocos efectos adversos, la mayoría de ellos no graves y reversibles. Sin embargo, a nivel oftalmológico se produce acúmulo de los metabolitos de estos medicamentos que provoca un daño visual que puede llegar a ser irreversible. Por esta razón es importante una evaluación oftalmológica y un seguimiento adecuado de estos pacientes. A través de un caso clínico ejemplificamos los hallazgos oftalmológicos característicos así como los factores de riesgo de la toxicidad retiniana y finalmente se discuten los lineamientos actuales para el diagnóstico y seguimiento en pacientes que utilizan estos medicamentos.