Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance.

Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.

Biologic therapy in large and small vessels vasculitis, and Behçet's disease: Evidence- and practice-based guidance.

OBJECTIVE: Vasculitis are a very heterogenous group of systemic autoimmune diseases, affecting large vessels (LVV), small vessels or presenting as a multisystemic variable vessel vasculitis. We aimed to define evidence and practice-based recommendations for the use of biologics in large and small vessels vasculitis, and Behçet's disease (BD). METHODS: Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice on autoimmune diseases management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2022. Preliminary recommendations were drafted by working groups for each disease and voted in two rounds, in June and September 2021. Recommendations with at least 75% agreement were approved. RESULTS: A total of 32 final recommendations (10 for LVV treatment, 7 for small vessels vasculitis and 15 for BD) were approved by the experts and several biologic drugs were considered with different supporting evidence. Among LVV treatment options, tocilizumab presents the higher level of supporting evidence. Rituximab is recommended for treatment of severe/refractory cryoglobulinemic vasculitis. Infliximab and adalimumab are most recommended in treatment of severe/refractory BD manifestations. Other biologic drugs can be considered is specific presentations. CONCLUSION: These evidence and practice-based recommendations are a contribute to treatment decision and may, ultimately, improve the outcome of patients living with these conditions.

Hidroterapia e exercícios respiratórios associados à massoterapia na reabilitação de paciente com queimaduras acometendo a região torácica / Hydrotherapy, respiratory kinesiotherapy and massotherapy reabilitation program in patient with thoracic region burns

Em uma lesão por queimadura, existe o prejuízo e/ou perdas de funções da pele além de complicações pulmonares quando associado à inalação de gases aquecidos. Objetivou-se com o estudo avaliar o efeito de um programa de hidroterapia e cinesioterapia respiratória associado a massoterapia sobre as variáveis respiratórias em uma voluntária portadora de queimadura na região torácica e cervical que foi submetida à avaliação fisioterapêutica constituída de espirometria, pico de fluxo expiratório, força muscular respiratória, mobilidade toracoabdominal e aplicação de Escala Análoga Visual (EVA) para avaliação de dor, desconforto e aderência cicatricial. O tratamento englobou alongamentos gerais para membros superiores e coluna cervical, recursos terapêuticos manuais, hidroterapia associada a cinesioterapia respiratória. Os resultados indicaram melhora da ADM de cervical e membros superiores, dos volumes, fluxos, capacidades e endurance respiratórias, da sensação de dor e desconforto. Verificou uma melhora nas variáveis respiratórias e amplitude de movimento, permitindo a reabilitação funcional e bem-estar do paciente grande queimado.

A burn injury can induce decrease of some or all skin function and can cause pulmonary complications when occur an association of warm gases inhalation. The aim of this work was to evaluate the effect of a hydrotherapy, respiratory kinesiotherapy and massotherapy program in respiratory volumes and flows in a burn volunteer with scars in thoracic and cervical regions. This volunteer was submitted to a physical therapy evaluation with range motion measurement (ROM) of cervical and arms (shoulder), spirometry, peak flow and respiratory muscular strength, thoracoabdominal mobility and application of Visual Analogous Scales (EVAs) for pain, discomfort and cicatrix malleability. The treatment was constituted by muscle stretching for superior member and cervical column, massotherapy using Cyriax, Watterwald, classic massage and respiratory kinesiotherapy performed in a 60 minutes session, totalizing 10 sessions. The results showed an increase in shoulder and cervical ROM, in respiratory capacities and strength and a decrease in pain and discomfort. Therefore it can be concluded in this program using hydrotherapy, respiratory kinesiotherapy and massotherapy was benefic for burned patient inducing an improvement in functional and welfare.