Early factors associated with the initiation of treatment with biologics in patients with Axial Spondyloarthritis - results from a single centre retrospective cohort study.

BACKGROUND: Axial Spondyloarthritis (axSpA) refers to a group of rheumatic diseases that mainly affect the axial skeleton. Treatment with Biological Disease Modifying Anti-Rheumatic Drug (bDMARDs) is indicated when low disease activity is not achieved with Non-Steroid Anti-inflammatory Drugs. Certain clinical and socio-demographic features may be predictive of future need for treatment with bDMARDs in a patient with axSpA. OBJECTIVES: To study a population of patients with axSpA and determine whether the presence of certain factors at diagnosis is associated with a later need for biological treatment. METHODS: A single centre retrospective cohort study was conducted comprising 150 patients with axSpA that attended the Rheumatology Outpatient Clinic from January to December 2019. Logistic Multivariate Regression was performed to understand which factors independently contributed to the use of bDMARDs. RESULTS: Fifty-two patients (34,7%) were under biological treatment. In comparison to the group that was not under treatment with bDMARDs, these were significantly more likely to be hard-workers (57,8% vs 29,7%; p = ,003), to have had elevated C-Reactive Protein at the time of diagnosis (81,6% vs 48,9%; p < ,001), to have had a grade of sacroiliitis at diagnosis greater than 2 (67,4% vs 29,5%; p < ,001) and to have history of enthesitis, (32,7% vs 13,3%; p = ,006). In multivariate regression analysis, only the hard-worker type (OR = 3.09, CI: 1.14 - 8.37; p = .027) and the highest grade of sacroiliitis (OR = 4.41, CI: 1.69 - 11.50; p = .002) were found to be independently associated with the use of bDMARDs. CONCLUSION: In this study, the performance of work associated with greater biomechanical stress and the presence of greater structural damage at diagnosis were shown to be associated with the use of bDMARDs. The authors highlight the importance of recognizing these factors that seem to relate to more aggressive disease, with higher use of bDMARDs, thus suggesting a need for a tighter control management strategy in these patients.

ANCA-associated vasculitis in a patient with enteropathic spondylarthritis: a case report and literature review.

Coexistence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and inflammatory bowel disease (IBD) is rare (Sy et al. in Semin Arthritis Rheum 45:475-482, 2016). Nevertheless, we present a case of an AAV in a 53-year-old female with enteropathic spondylarthritis previously treated with tumor necrosis factor α inhibitors (TNFi). Management of vasculitis in a patient with IBD may be problematic due to the difficulty in distinguishing if the vasculitis is an extraintestinal manifestation of the IBD or a new coexistent entity. Moreover, in our report, the previous treatment with TNFi is a possible confounding factor due to the paradoxical effects induced by TNFi, including vasculitis (Ramos-Casals et al. in Curr Rheumatol Rep 10:442-448, 2008). The reported case alerts to the complexity in the management of patients with enteropathic spondylarthritis and vasculitis, as well as discusses the diversity of differential diagnosis in this particular clinical scenario.

Prevalence and clinical manifestations of Erasmus syndrome in systemic sclerosis: a cross-sectional study.

INTRODUCTION: Erasmus syndrome (ErS) is a rare entity in which Systemic Sclerosis (SSc) develops following exposure to silica, with or without associated silicosis. The objectives of this study were: 1) to evaluate the prevalence of ErS in our SSc cohort; 2) to characterize the cases; 3) to evaluate the clinical and laboratory characteristics of SSc in patients with (Ers) or without silica exposure. METHODS: Cross-sectional and analytical study. Sociodemographic, clinical and laboratory data were collected from all patients with SSc diagnosed in our department according to ACR / EULAR criteria. Data on professional activity and possible exposure to silica were obtained by phone interview. RESULTS: Among 48 patients with SSc, the prevalence of ErS was 16.7% (8/48). All cases identified were male, corresponding to 72.7% of men with SSc followed at our department. There was a statistically significant association between ErS and male gender (p.

Shoulder pain: are there predictive factors of response to treatment and of ultrasound findings?

INTRODUCTION: Shoulder pain is a common cause of consultation in Primary Health Care, and may correspond to up to 30% of the reasons for consultation. Pathology of the rotator cuff is the most common cause of pain. Ultrasound is a valuable diagnostic tool in assessing shoulder disorders; it can be as effective as magnetic resonance imaging. OBJECTIVE: To determine the predictive factors of response to treatment and ultrasound findings in shoulder pain. METHODS: We performed an analysis of the patients' cases sent to the rheumatology consultation with shoulder pain, every patient had an echography shoulder evaluation, and the rheumatologist decided treatment based on the guidelines for the treatment of shoulder tendinopathies. The use of nonsteroidal anti-inflammatory drug (NSAIDs) and muscle relaxant medications as well as the following techniques: corticosteroids local injection, barbotage, capsular distension and physiotherapy programs were some of the variables assessed. Posteriorly, the patients were clinically assessed in a follow-up visit. RESULTS: A total of 119 patients were evaluated. There was a statistically significant relationship between the time from the beginning of the symptomatology and treatment response. Diabetes mellitus, arterial hypertension and dyslipidaemia were statistically significantly associated with some rotator cuff lesions and distention of the subscapular bursa. Age is the main predictor of rotator cuff ultrasound findings. CONCLUSION: In patients with shoulder pain, early intervention positively influences the response to treatment. Thus, it is important that these patients are evaluated more promptly. Some comorbidities seem to be associated with a higher risk of specific rotator cuff lesions. No relationship was found between response to treatment and age, sex, occupation, previous treatments or type of therapy selected. The associations found in this study seem to have clinical implications. Prevention of rotator cuff disease is a matter of major relevance as well as early institution of treatment.

The role of opioid analgesics in rheumatic disorders: a position paper from the Portuguese Rheumatology Society.

Pain is a common feature of most rheumatic diseases and it is often the main reason for the patient to seek for a clinical appointment. Chronic pain has a major impact on patient's quality of life, being frequently associated with functional incapacity, sleep and mood disorders. This leads to absenteeism and heavy consumption of health resources, both representing huge burdens on national economy. Managing musculoskeletal pain is pivotal but can be challenging. The use of the available pharmaceutical armamentarium should be parsimonious. Opioids are strong analgesic drugs that mostly act through their agonist action on µ-receptors in the central nervous system. Opioid-related side effects are not negligible and are mediated through both central and peripheral opioid receptors. The use of opioids is well established in the treatment of oncologic pain but their role in the management of musculoskeletal pain is still controversial. Inflammatory rheumatic diseases, osteoarthritis, osteoporotic fractures, chronic low back pain and fibromyalgia represent diverse major rheumatic conditions that frequently lead to chronic pain. In order to standardize and optimize management of musculoskeletal chronic pain in these prevalent diseases, the Portuguese Rheumatology Society elaborated this position paper. The objectives were: a) to define the importance of pain assessment and classification; b) to guide patient selection, appropriate choice of opioids, their management, and raise awareness of their adverse effects; c) to review the existent data on possible indications of opioid therapy on rheumatic diseases.

Tocilizumab and rituximab have similar effectiveness and are both superior to a second tumour necrosis factor inhibitor in rheumatoid arthritis patients who discontinued a first TNF inhibitor.

OBJECTIVES: To compare the effectiveness of a 2nd TNF inhibitor (TNFi), Tocilizumab (TCZ) and Rituximab (RTX), measured by drug retention and by response rates, in RA patients after discontinuing a first-line TNFi and to clarify the reasons and predictors for discontinuation of a second-line biologic. MATERIAL AND METHODS: Non-interventional prospective study of RA patients exposed to a 2nd TNFi, TCZ or RTX after previous TNFi discontinuation using real-world data from Reuma.pt database. Drug retention was estimated using Kaplan-Meier analysis and Cox models. Crude and LUNDEX adjusted response rates were evaluated at 6 months, 1 and 2 years and reasons for discontinuation were compared according to biologic class. RESULTS: In total, 643 patients were included, 88.8% females, with a mean age of 59.4±12.8 years. Of those, 390 (60.7%) initiated a 2nd TNFi, 147 (22.9%) TCZ and 106 (16.5%) RTX. Drug retention was significantly greater among patients who initiated TCZ (76.4±4.3 months) or RTX (80.8±4.8 months), compared with those who initiated a 2nd TNFi (52.7±2.6 months) (log rank test, p < 0.001). In the adjusted Cox model, hazards of discontinuation were significantly lower for TCZ (HR 0.39, 95% CI 0.23-0.64, p < 0.001) and RTX (HR 0.42, 95% CI 0.25-0.72, p=0.001). Smokers had a significantly higher risk for discontinuation (HR 2.43, 95%CI 1.50-3.95, p < 0.001) as well as patients with higher HAQ at baseline (HR 1.51, 95%CI 1.14-2.00, p=0.004). The proportion of patients in remission or low disease activity according to Clinical Disease Activity Index (CDAI) at 6 months, 1 and 2 years was, respectively, 46.5%/50.0%/61.2% for TNFi, 52.9%/53.6%/ 69.2% for TCZ and 37.7%/48.0%/50.0% for RTX. After LUNDEX adjustment, response rates were, respectively, 33.0%/31.0%/31.8% for 2nd TNFi, 42.8%/41.8%/53.3% for TCZ and 32.0%/39.4%/39.0% for RTX. The main reasons for discontinuation were inefficacy for 2nd TNFi and RTX and adverse events for TCZ (p < 0.001). CONCLUSIONS: Our findings showed a significantly higher drug retention for TCZ and RTX, compared with 2nd TNFi, and similar persistence among TCZ and RTX, in patients who discontinued a first-line TNFi. These data corroborate the notion that switching to a biologic with a different mode of action is more effective than to a second TNFi.

Intravenous human immunoglobulin for the treatment of recurrent focal myositis.

We present a case of recurrent focal myositis treated with intravenous human immunoglobulin, after ineffectiveness of analgesics, non-steroidal anti-inflammatory drugs, corticosteroids and immunosuppressive therapies. There was a prompt clinical and laboratorial improvement. To the best of our knowledge, this is the first case reporting the administration of this treatment in recurrent focal myositis.

Obesity, metabolic syndrome and other comorbidities in rheumatoid arthritis and psoriatic arthritis: influence on disease activity and quality of life.

In obesity, especially if visceral, and in rheumatic diseases, the production of pro-inflammatory cytokines contributes to an increased cardiovascular risk. Moreover, classic cardiovascular risk factors are more common in these patients. We intended to assess the influence of body mass index (BMI), abdominal circumference (AC) and metabolic syndrome (MS) on disease activity and quality of life in Rheumatoid Arthritis (RA) and Psoriatic Arthritis patients and to compare the results between the RA and PsA patients. We performed a cross-sectional study, including 150 patients with RA and 75 patients with PsA. PsA patients had significantly higher BMI, AC and total of comorbidities than RA patients . Independently the underlying pathology (RA or PsA), the number of comorbidities was correlated positively with DAS28, HAQ , CRP and ESR. In RA group, overweight/obesity (BMI≥25kg/m2) were associated with at least one painful joint and the risk of having at least one swollen joint was 3.4 times higher in patients with increased AC. There was an association between the BMI and AC and the CRP value. Patients with BMI≥25 kg/m2 and increased AC had significantly higher DAS28 scores. MS was associated with significantly higher ESR. There was a positive correlation of both BMI and AC with HAQ and also MS was associated with highest HAQ values. In PsA group, patients with BMI≥25kg/m2 had equally more painful joints and higher CRP values. Patients with MS had higher CRP values, more joint pain and higher disease activity according to DAS28. None of the patients with normal BMI had swollen joints, however 20.4% of overweight patients had at least one swollen joint. The number of comorbidities showed to influence inflammatory parameters, disease activity and quality of life. We found that BMI, AC and MS are associated with disease activity, which may be improved by weight reduction and comorbidities control.

Systemic sclerosis and myositis as a paraneoplastic syndrome secondary to multiple myeloma.

We present a case of paraneoplastic systemic sclerosis (SSc) and myositis associated to a multiple myeloma (MM) in a 52-year-old Caucasian man. After MM treatment, skin and muscle changes improved, with no further relapses. Although rare, "scleroderma-like" or myositis lesions may be associated with MM. However, to the best of our knowledge, this is the first case reporting these two clinical conditions simultaneously associated with MM.