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OBJECTIVES: To update evidence on the efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) and provide information to the taskforce for the 2024 update of the Japan College of Rheumatology (JCR) clinical practice guidelines (CPG) for the management of rheumatoid arthritis (RA). METHODS: We searched various databases for randomised controlled trials on RA published until June 2022, with no language restriction. For each of the 15 clinical questions, 2 independent reviewers screened the articles, evaluated the core outcomes, and performed meta-analyses. RESULTS: Subcutaneous injection of methotrexate (MTX) showed similar efficacy to oral MTX in MTX-naïve RA patients. Ozoralizumab combined with MTX improved drug efficacy compared to the placebo in RA patients with inadequate response (IR) to csDMARD. Rituximab with and without concomitant csDMARDs showed similar efficacy to other bDMARDs in bDMARD-IR RA patients. Combined Janus kinase inhibitors and MTX achieved similar clinical responses and equal safety during a 4-year period compared to tumour necrosis factor inhibitors in MTX-IR RA patients. Biosimilars showed efficacy equivalent to that of the original bDMARDs in csDMARD-IR and bDMARD-IR RA patients. CONCLUSION: This systematic review provides latest evidence for the 2024 update of the JCR CPG for RA management.
RESUMO
BACKGROUND: Reconstructive hand surgery is well established for the management of patients with rheumatoid arthritis; however, with the advent of biologic drugs and methotrexate, disease activity, including the development of hand deformities, is well controlled. Nonetheless, many patients still need personalized surgery. CASE: A 61-year-old woman with a 35-year history of rheumatoid arthritis presented with right hand deformity with unstable ulnar deviation of the metacarpophalangeal joints from the index to the little finger and hyperextension of the thumb interphalangeal joint. Her hobby was playing the erhu (a traditional two-stringed bowed Chinese instrument) and she wanted to improve her ability to hold the bow. To play the erhu, the tip of the thumb must touch the index finger to make a circle, and the other fingers must keep the bow horizontal and adjust the tension of the bow hair. We carried out thumb interphalangeal joint arthrodesis, little finger metacarpophalangeal joint arthrodesis, and transfer of the fourth dorsal interosseous muscle to the little finger. After 2 months of rehabilitation, the patient could hold the bow between the thumb and index fingers and adjust the string tension with the middle and ring fingers. Additionally, she could use chopsticks and pens more naturally. DISCUSSION: Each patient with hand deformity resulting from burnt-out rheumatoid arthritis has a variety of demands for restoring hand function, depending on their personal needs. Individual treatment plans must be established through discussions among the patient, hand therapist, and surgeon based on the status of the hand and the patient's needs.
RESUMO
BACKGROUND: Iatrogenic injuries to the spinal accessory nerve (SAN) are not uncommon during cervical lymph node biopsy. Many operative treatments for SAN injury in the posterior cervical triangle have been reported, but there are no guidelines regarding the choice between operative and nonoperative treatments. Because it is believed that the nerve seldom spontaneously regenerates, some articles suggest surgical intervention within 3 months from the nerve injury to achieve good postoperative results. However, we experienced a case of spontaneous accessory nerve recovery more than 3 months after accessory nerve injury. It is necessary to carefully exclude similar patients from unnecessary surgery. CASE: A 41-year-old woman underwent cervical lymph node biopsy at an otolaryngology clinic. She experienced pain across her neck and weakness of the shoulder in abduction just after the biopsy. Three months after the biopsy, her symptoms persisted and she was referred to our hospital for surgical treatment. On careful examination, we detected signs of accessory nerve regeneration. Consequently, we prescribed physical therapy and a rehabilitation program, including active and passive range-of-motion exercises of the shoulder and muscle strengthening exercises. Six months after the injury, there was a dramatic improvement of the trapezius muscle function and the patient became pain free. DISCUSSION: When the biopsy incision is more than one finger's breadth away from the normal course of the SAN, and when Tinel-like signs advance along the trapezius muscle over time, spontaneous SAN recovery can be anticipated.