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.

The economic burden of systemic lupus erythematosus in Mexico.

AIMS: Our cost of illness study aimed to provide an estimate of the burden related to systemic lupus erythematosus (SLE) in the Mexican context. METHODS: Our model was used to simulate the resource utilization and economic consequences over a period of 5 years for patients with SLE in Mexico. The model simulated four health states-three phenotypes of SLE, including mild, moderate, and severe states, and death. Clinical parameters were retrieved from the literature. Resource utilization in our model represents the most common practice in the Mexican healthcare system. These include disease management, transient events (e.g. infections, flares, and complications due to SLE-related organ damage), and indirect costs. Direct non-medical costs were not considered. One-way sensitivity analysis was performed. RESULTS: The number of targeted Mexican SLE patients was 57,754. The numbers of SLE patients diagnosed with mild, moderate, and severe phenotypes were 8,230, 44,291, and 5,233, respectively. Disease management costs, including the treatment of each phenotype and disease follow-up, were MXN 4 billion ($ 415 million); the costs of transient events (infections, flares, and consequences of SLE-related organ damage) were MXN 5 billion ($ 478 million). Productivity loss costs among adult employed Mexican patients with SLE were estimated at MXN 17 billion ($ 1.6 billion). The total SLE cost in Mexico over 5 years from the payer and societal perspectives is estimated at MXN 9 billion ($ 893 million) and 26 billion ($ 2.5 billion), respectively. Over 5 years, the costs per patient per year from the payer and societal perspectives were MXN 32,131($ 3,095) and MXN 91,661($ 8,830), respectively. CONCLUSION: The findings pointed out the substantial economic burden associated with SLE, including the costs of disease progression and SLE transient events, such as flare-ups, infections, and organ damage, in addition to productivity loss due to work capacity impairment.

Geographical Latitude Remains as an Important Factor for the Prevalence of Some Myositis Autoantibodies: A Systematic Review.

The idiopathic inflammatory myopathies (IIM) are characterized by muscular weakness, cutaneous manifestations, muscle damage revealed by increase of muscular enzymes, muscle biopsy, electromyography and changes on magnetic resonance imaging. However, the hallmark of these IIM, is the development of myositis specific antibodies (MSA) or myositis associated antibodies (MAA). The theories about their presence in the serum of IIM is not known. Some studies have suggested that some of these MSA, such as anti-Mi-2 increases according to the intensity of UV radiation. There is scarce information about the environmental factors that might contribute in order to be considered as triggering factors as UV radiation might be. In this review, we analyzed the reported prevalence of MSAs and MAAs regarding to their geographical location and the possible relation with UV radiation. We collected the prevalence data of fifteen MSA and thirteen MAA from 22 countries around the world and we were able to observe a difference in prevalence between countries and continents. We found differences in anti-PL7, anti-Ro52, anti-La and anti-Ku prevalence according to UV radiation level. Otherwise, we observed that anti-Mi-2 prevalence increases near to the Equator meanwhile anti-MJ/NXP2 and anti-ARS prevalence had an opposite behavior increasing their prevalence in the geographical locations farther to the Equator. Our results highlighted the importance to include the UV radiation and other environmental factors in IIM studies, in order to clarify its association with MSA and MAA prevalence as well as its possible role in the immunopathogenesis of these diseases.

Correction to: Clinical predictors of remission and low disease activity in Latin American early rheumatoid arthritis: data from the GLADAR cohort.

The original version of this article, unfortunately, contained an error. The first and family name of Loreto Massardo was interchanged and is now presented correctly in this article.

Clinical predictors of remission and low disease activity in Latin American early rheumatoid arthritis: data from the GLADAR cohort.

OBJECTIVES: To identify baseline predictors of remission and low disease activity (LDA) in early rheumatoid arthritis (RA) from the GLADAR (Grupo Latino Americano De estudio de la Artritis Reumatoide) cohort. METHODS: Patients with 1- and 2-year follow-up visits were included. Remission and LDA were defined by DAS28-ESR (< 2.6 and ≤ 3.2, respectively). Baseline predictors examined were gender, ethnicity, age at diagnosis, socioeconomic status, symptoms' duration, DMARDs, RF, thrombocytosis, anemia, morning stiffness, DAS28-ESR (and its components), HAQ-DI, DMARDs and corticosteroid use, and Sharp-VDH score. Multivariable binary logistic regression models (excluding DAS28-ESR components to avoid over adjustment) were derived using a backward selection method (α-level set at 0.05). RESULTS: Four hundred ninety-eight patients were included. Remission and LDA/remission were met by 19.3% and 32.5% at the 1-year visit, respectively. For the 280 patients followed for 2 years, these outcomes were met by 24.3% and 38.9%, respectively. Predictors of remission at 1 year were a lower DAS28-ESR (OR 1.17; CI 1.07-1.27; p = 0.001) and HAQ-DI (OR 1.48; CI 1.04-2.10; p = 0.028). At 2 years, only DAS28-ESR (OR 1.40; CI 1.17-1.6; p < 0.001) was a predictor. Predictors of LDA/remission at 1 year were DAS28-ESR (OR 1.42; CI 1.26-1.61; p < 0.001), non-use of corticosteroid (OR 1.74; CI 1.11-2.44; p = 0.008), and male gender (OR 1.77; CI 1.2-2.63; p = 0.036). A lower baseline DAS28-ESR (OR 1.45; CI 1.23-1.70; p < 0.001) was the only predictor of LDA/remission at 2 years. CONCLUSIONS: A lower disease activity consistently predicted remission and LDA/remission at 1 and 2 years of follow-up in early RA patients from the GLADAR cohort. Key Points • In patients with early RA, a lower disease activity at first visit is a strong clinical predictor of achieving remission and LDA subsequently. • Other clinical predictors of remission and LDA to keep in mind in these patients are male gender, non-use of corticosteroids and low disability at baseline. • Not using corticosteroids at first visit is associated with a lower disease activity and predicts LDA/remission at 1 year in these patients.

Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology. / Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología.

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus¼ proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period.

Detection of autoantibodies to DSF70/LEDGFp75 in Mexican Hispanics using multiple complementary assay platforms.

PURPOSE: Antinuclear autoantibodies (ANA) targeting the dense fine speckled antigen DFS70, also known as lens epithelium-derived growth factor p75 (LEDGF/p75), are attracting attention due to their low frequency in systemic rheumatic diseases but increased frequency in clinical laboratory referrals and healthy individuals (HI). These ANA specifically recognize the stress protein DFS70/LEDGFp75, implicated in cancer, HIV-AIDS, and inflammation. While their frequency has been investigated in various ethnic populations, there is little information on their frequency among Hispanics/Latinos. In this study, we determined the frequency of anti-DFS70/LEDGFp75 autoantibodies in Mexican Hispanics using multiple detection platforms. METHODS: The frequency of anti-DFS70/LEDGFp75 antibodies was determined in 171 individuals, including 71 dermatomyositis (DM) patients, 47 rheumatoid arthritis (RA) patients, 30 obesity (OB) patients, and 23 HI. Antibody detection was achieved using four complementary assay platforms: indirect immunofluorescence, Western blotting, ELISA, and chemiluminescent immunoassay. RESULTS: We detected relatively low frequencies of anti-DFS70/LEDGFp75 antibodies in patients with DM (1.4%), RA (4.3%), and OB (6.6%), and elevated frequency (17.4%) in HI. A strong concordance between the different antibody detection platforms was observed. CONCLUSIONS: The low frequency of anti-DFS70/LEDGFp75 antibodies in Mexican patients with rheumatic diseases, but relatively higher frequency in HI, is consistent with previous observations with non-Hispanic populations, suggesting that geographic differences or ethnicity do not influence the frequency of these autoantibodies. Our results also highlight the importance of confirmatory assays for the accurate detection of these autoantibodies. Future studies with larger cohorts of healthy Hispanics/Latinos are needed to confirm if their anti-DFS70/LEDGFp75 antibody frequencies are significantly higher than in non-Hispanics.

Clinical practice guidelines for the management of pregnancy in women with autoimmune rheumatic diseases of the Mexican College of Rheumatology. Part II.

BACKGROUND: Pregnancy in women with autoimmune rheumatic diseases is associated with several maternal and fetal complications. The development of clinical practice guidelines with the best available scientific evidence may help standardize the care of these patients. OBJECTIVES: To provide recommendations regarding prenatal care, treatment, and a more effective monitoring of pregnancy in women with lupus erythematosus, rheumatoid arthritis (RA) and antiphospholipid syndrome (APS). METHODOLOGY: Nominal panels were formed for consensus, systematic search of information, development of clinical questions, processing and staging of recommendations, internal validation by peers and external validation of the final document. The quality criteria of the AGREE II instrument were followed. RESULTS: The panels answered 37 questions related to maternal and fetal care in lupus erythematosus, RA and APS, as well as for use of antirheumatic drugs during pregnancy and lactation. The recommendations were discussed and integrated into a final manuscript. Finally, the corresponding algorithms were developed. In this second part, the recommendations for pregnant women with RA, APS and the use of antirheumatic drugs during pregnancy and lactation are presented. CONCLUSIONS: We believe that the Mexican clinical practice guidelines for the management of pregnancy in women with RA and APS integrate the best available evidence for the treatment and follow-up of patients with these conditions.

Clinical practice guidelines for the management of pregnancy in women with autoimmune rheumatic diseases of the Mexican College of Rheumatology. Part I.

BACKGROUND: Pregnancy in women with autoimmune rheumatic diseases is associated with several maternal and fetal complications. The development of clinical practice guidelines with the best available scientific evidence may help standardize the care of these patients. OBJECTIVES: To provide recommendations regarding prenatal care, treatment, and a more effective monitoring of pregnancy in women with lupus erythematosus (SLE), rheumatoid arthritis (RA) and antiphospholipid antibody syndrome (APS). METHODOLOGY: Nominal panels were formed for consensus, systematic search of information, development of clinical questions, processing and grading of recommendations, internal validation by peers, and external validation of the final document. The quality criteria of the AGREE II instrument were followed. RESULTS: The various panels answered the 37 questions related to maternal and fetal care in SLE, RA, and APS, as well as to the use of antirheumatic drugs during pregnancy and lactation. The recommendations were discussed and integrated into a final manuscript. Finally, the corresponding algorithms were developed. We present the recommendations for pregnant women with SLE in this first part. CONCLUSIONS: We believe that the Mexican clinical practice guidelines for the management of pregnancy in women with SLE integrate the best available evidence for the treatment and follow-up of patients with these conditions.

Performance of an objective structured clinical examination in a national certification process of trainees in rheumatology.

OBJECTIVE: To assess reliability and validity of the objectively-structured clinical examination (OSCE) applied in postgraduate certification processes by the Mexican Board of Rheumatology. METHOD: Thirty-two (2013) and 38 (2014) Rheumatology trainees (RTs) underwent an OSCE consisting of 12 and 15 stations respectively, scored according to a validated check-list, as well as 300-multiple-choice 300 question examination (MCQ). Previously, 3 certified rheumatologists underwent a pilot-OSCE. A composite OSCE score was obtained for each participant and its performance examined. RESULTS: In 2013, OSCE mean score was 7.1±0.6 with none RT receiving a failing score while the MCQ score was 6.5±0.6 and 7 (21.9%) RTs receiving a failing (< 6) score. In 2014, the OSCE score was 6.7±0.6, with 3 (7.9%) RTs receiving a failing score (2 of them also failed MCQ) while the MCQ score was 6.4±0.5 and 7 (18.5%) RTs were disqualified (2 of them also failed OSCE). A significant correlation between the MCQ and the OSCE scores was observed in the 2013 (r=0.44; P=0.006). Certified rheumatologists performed better than RTs at both OSCE. Overall, 86% of RTs obtaining an OSCE passing score also obtained a MCQ passing score, while this was only 67% (P=.02) among those who obtained an OSCE failing score. Nine stations were applied at both consecutive years. Their performance was similar in both certification processes, with correlation coefficients ranging from 0.81 to 0.95 (P≤0.01). CONCLUSION: The OSCE is a valid and reliable tool to assess the Rheumatology clinical skills in RTs.

Implications in the difference of anti-Mi-2 and -p155/140 autoantibody prevalence in two dermatomyositis cohorts from Mexico City and Guadalajara.

INTRODUCTION: Autoantibodies and clinical manifestations in polymyositis/dermatomyositis (PM/DM) are affected by both genetic and environmental factors. The high prevalence of DM and anti-Mi-2 in Central America is thought to be associated with the high UV index of the area. The prevalences of autoantibodies and the clinical manifestations of PM/DM were evaluated comparing two cohorts in Mexico. METHODS: Ninety-five Mexican patients with PM/DM (66 DM, 29 PM; 67 Mexico City, 28 Guadalajara) were studied. Autoantibodies were characterized by immunoprecipitation using 35S-methionine labeled K562 cell extract. Clinical information was obtained from medical records. RESULTS: DM represented 69% of PM/DM and anti-Mi-2 was the most common autoantibody (35%), followed by anti-p155/140 (11%); however, anti-Jo-1 was only 4%. The autoantibody profile in adult-onset DM in Mexico City versus Guadalajara showed striking differences: anti-Mi-2 was 59% versus 12% (P = 0.0012) whereas anti-p155/140 was 9% versus 35% (P = 0.02), respectively. A strong association of anti-Mi-2 with DM was confirmed and when clinical features of anti-Mi-2 (+) DM (n = 30) versus anti-Mi-2 (-) DM (n = 36) were compared, the shawl sign (86% versus 64%, P < 0.05) was more common in the anti-Mi-2 (+) group (P = 0.0001). Levels of creatine phosphokinase (CPK) were higher in those who were anti-Mi-2 (+) but they responded well to therapy. CONCLUSIONS: Anti-Mi-2 has a high prevalence in Mexican DM and is associated with the shawl sign and high CPK. The prevalence of anti-Mi-2 and anti-p155/140 was significantly different in Mexico City versus Guadalajara, which have a similar UV index. This suggests roles of factors other than UV in anti-Mi-2 antibody production.

Encuesta de pacientes en la consulta del reumatólogo: informe preliminar / Patient syrvery in a rheumatologistïs daily practice: preliminary report

Con propósito de conocer las características demográficas, epidemiológicas y de la terapéutica empleada en pacientes que acuden a consulta del reumatólogo en México, se hizo este estudio multicéntrico formal, en 12 ciudades del país, con colaboración de 17 especialistas certificados (en su mayoría egresados del Centro Médico Nacional. "20 de Noviembre", ISSSTE). Los pacientes fueron elegidos aleatoriamente, de la consulta diaria privada e institucional de cada participante durante 3 meses.Material y método. Empleando un mismo cuestionario diseñado para el estudio, los participantes hicieron el registro en una sola ocasión de datos demográficos, aspectos socioculturales y económicos, así como los inherentes al padecimiento y sus repercusiones, régimen terapéutico vigente en el momento de la entrevista y su costo. además, antecedentes, complicaciones y enfermedades concomitantes. Resultados. Este informe preliminar comprende sólo la información obtenida de 1958 pacientes por los 17 participantes y ofrece datos demográficos, diagnósticos, y de apego al seguimiento por parte del especialista (consultas por primera vez y subsecuentes). Distribución por sexo 7:3 (74 por ciento y 26 por ciento) para mujeres y varones respectivamente; la edad media de la población fue 50.5 y 5l.6 años en el mismo orden anotado para sexo. Se identificaron 12 entidades nosológicas distribuidas entre 1717 pacientes (88 por ciento), 141 quedaron agrupadas como otras enfermedades del tejido conjuntivo (33: 1.7 por ciento), otras enfermedades reumáticas (81: 4.1 por ciento) y sin enfermedad reumática (127= 6 por ciento). Según el número identificado las 10 enfermedades más comunes fueron, en orden decreciente: artritis reumatoide, osteoartrosis, reumatismo no articular, gota, lupus eritematoso sistémico, artritis séptica y reactiva, espondilitis anquilosante, otras enfermedades del tejido conuntivo, artritis crónica juvenil y síndrome de Sjögren. La proporción entre consultas de primera vez y subsecuentes varió entre 1:1 y 1:5 para polimialgia reumática y artritis reumatoide respectivamente y para los diagnósticos más frecuentes fue: AR=l:4.9, OA=1:1.5, RNA=1:1.2, gota, 1.2:1, LES=1:2.8, AS/Re 1:2.2, EA 1:4.7, ACJ 1:3.1 y SS 1:1. La distribución por sexo F:M varió entre 1:0 y 14.2:1, y para las diez primeras entidades en orden de frecuencia fue: AR 6.9:1, OA 3.4:1, RNA 3.5:1, gota 1:24.5, LES 14:2:1, AS/RE 1:2.2, EA 1:4.7. ACJ 1:3.1 y SS 1:0.

Caracteríticas de las miopatías inflamatorias idiopáticas en la población mexicana / Idiopathic inflammatory myophaty: characteristics in the Mexican population

La mayoría de las descripciones epidemiológicas y clínicas respecto a las miopatías inflamatorias idiopáticas (MII) corresponden a población anglosajona y existen muy pocos estudios sobre las características de este grupo de padecimientos en la población mestiza mexicana. En este estudio se analizaron las características de los pacientes con diagnóstico de MII atendidos en el Servicio de Reumatología del Centro Médico Nacional 20 de Noviembre del Instituto de Seguridad y Servicio Social para Trabajadores del Estado de enero 1996 a julio de 1997. Fueron incluidos 42 pacientes con diagnóstico de MII, 34 del sexo femenino y ocho del masculino, todos de raza mestiza. La MII se clasificó como polimiositis en 12 casos, dermatomiositis en 22, juvenil en seis y asociada a otra enfermedad de tejido conectivo en dos. La edad promedio de los grupos adultos fue 33.3 años y en el grupo juvenil fue de siete años. Un gran porcentaje de pacientes (84 por ciento) refirió síntomas inespecíficos previos a la aparición de debilidad muscular o alteraciones cutáneas típicas. La evolución del padecimiento fue limitada en 15 enfermos, con exacerbaciones y remisiones en 23 y progresiva en cuatro. Se encontró mayor frecuencia de MII tipo II que lo reportado en población anglosajona, que se caracterizó además por inicio a edad temprana, evolución más agresiva y peor pronóstico en relación con los otros tipos. Del total de pacientes, sólo el 19 por ciento remitió con esteroides, el resto requirió de la adición de uno o más inmunosupresores. Se observó relación estadísticamente significativa entre el menor tiempo de evolución al iniciar el tratamiento y la obtención de remisión

Dermatitis reumatoide neutrofílica: reporte de un caso y revisión de la literatura / Neutrophilic rheumatoid dermatitis: case report and literature review

La dermatitis reumatoide neutrofílica fue descrita por primera vez en 1978, pertenece a las dermatosis neutrofílicas y ocurre exclusivamente en pacientes con artritis reumatoide seropositiva, constituyendo al parecer una manifestación extraarticular más de este padecimiento. Hasta el momento se han descrito sólo 15 casos en la literatura mundial. Se reporta una paciente con artritis reumatoide y dermatitis reumatoide neutrofílica demostrada tanto por clínica como por histología. El caso representa el primero notificado en la literatura mexicana

Poliangeítis microscópica con afección al sistema nervioso central: reporte de un caso / Microscopic polyangiitis with central nervous system involvement: a case report

La poliangeítis microscópica (PAM) es una vasculitis necrosante de pequeños vasos asociada a glomerulonefritis focal y segmentaria y capilaritis pulmonar, con ANCA positivos, y que ha sido clasificada recientemente como una entidad independiente. Informamos el caso de un varón de 30 años de edad, con diagnóstico de PAM y que, además de afección cutánea y renal características, presentó daño severo a nivel del sistema nervioso central. Destacamos la importancia de considerar la posibilidad de PAM en los pacientes con lesiones neurológicas centrales sugestivas de vasculitis

Alteraciones cognoscitivas en lupus generalizado (LEG) / Systemic lupus erythematosus cognitive impairment

Objetivo. Investigar la prevalencia de trastornos cognoscitivos en una muestra de población con LEG en nuestro medio y analizar si existe alguna relación entre la frecuencia y magnitud de este tipo de alteraciones con el tiempo de evolución de la enfermedad, grado de actividad, afección a determinados órganos o perfil de anticuerpos y otras alteraciones inmunológicas. Material y método. Se evaluaron 20 pacientes con criterios del ACR para LEG, realizándose examen clínico, neurológico, paraclínico, determinación de actividad por SLEDAI y evaluación psicológico por Escala de Inteligencia para Adultos de Weschler. Resultados. Se encontró deterioro en las funciones cognoscitivas en 14 pacientes (70 por ciento), que se calificó como leve en 9 (64.2 por ciento), moderado en 4 (28.5 por ciento) y severo en 1 (7.2 por ciento). No se observó relación significativa entre la presencia de trastornos cognoscitivos y el tiempo de evolución de la enfermedad, o la calificación del SLEDAI. No se encontró relación entre la presencia de daño cognoscitivo y algún tipo específico de AAN o con la positividad de anticuerpos anticardiolipina. Al comparar las manifestaciones clínicas de los pacientes, sólo encontramos relación estadísticamente significativa (p<0.01) entre la presencia de alteraciones cognoscitivas y de daño renal. Conclusión. Las alteraciones cognoscitivas en los pacientes con LEG son muy prevalentes y en gran parte de los casos pueden pasar desapercibidas si no se buscan en forma intencionada. La relación encontrada en este trabajo con daño renal sugiere que el daño cognoscitivo forma parte del proceso patológico del LEG

Ciclosporina A y metrotexate en artritis reumatoide refractaria. Reporte preliminar / Cyclosporin A and methotrexate in refractory theumatoid arthritis. Preliminar report

Once pacientes con artritis reumatoide severa refractaria a tratamiento, pertenecientes a la consulta externa del CMN 20 de Noviembre ISSSTE y siguiendo un diseño de estudio ciego-simple fueron tratados con ciclosporina (6 casos) o metotrexate (5 casos) por vía oral durante dos meses. La dosis inicial de ciclosporina fue de 1 mg/kg/día, y la de metotrexate de 7.5 mg por semana; ambas se aumentaron en forma cuidadosa, cuando fue necesario, vigilando la aparición de efectos tóxicos. En la evaluación a las ocho semanas de tratamiento se encontró mejoría significativa en los pacientes tratados con ciclosoporina en los siguientes aspectos: rigidez matutina, escala visual análoga del dolor, índice de Ritchie y VSG, con una p significativa < 0.06. Los pacientes tratados con metotrexate mejoraron en forma significativa en la rigidez matutina, la fuerza de prensión y el índice de Ritchie. No se encontraron efectos adversos que obligaran a la reducción o suspensión de los medicamentos. Consideramos que la ciclosporina A, como el metotrexate, pueden ser útiles en pacientes con artritis reumatoide activa refractaria a otros modificadores de la enfermedad