Recommendations of the Moroccan Society of Rheumatology (SMR) for Diagnostic Management of Spondyloarthritis (SpA) and Psoriatic Arthritis (PsA).

In 2017, the Moroccan Society of Rheumatology (SMR) issued guidelines for the treatment of severe ankylosing spondylitis. The emergence of new therapeutic classes, the update of international guidelines for axial SpA and psoriatic arthritis, and the diagnostic and therapeutic challenges encountered by rheumatologists has led to the development of recent SMR guidelines for the management of SpA patients. A group-work included rheumatologists, specialists in physical medicine and rehabilitation, and epidemiologists from various sectors was tasked with writing these recommendations based on a literature review, then adapting them to the national context. Thus, 33 recommendations were selected and organized into two sections: diagnostic and therapeutic. The diagnostic section included three general principles and fourteen recommendations. The first, second, and third recommendations concerned the definition and diagnostic criteria for psoriatic arthritis and psoriatic arthritis. In the management of SpA, Recommendation 4 prioritized the importance of opportunity windows. The recommendation5 concerned the diagnostic and prognostic significance of HLAB27. The sixth and seventh recommendations related to imaging of the sacroiliac joints and the spine. The eighth recommendation focuses on the diagnosis and evaluation of perivascular thrombosis activity. The ninth and tenth recommendations concerned the evaluation of SpA activity and psoriatic arthritis. The eleventh and twelfth recommendations concern the evaluation of function and structural progression. The recommendation number thirteen concerned the diagnosis and treatment of coxitis. Recommendation 14 focuses on the most common co-morbidities and extra-rhinitological manifestations observed in SpA.

Recommendations of the Moroccan Society of Rheumatology (SMR) for the Therapeutic Management of Spondyloarthritis (SpA) including Psoriatic Arthritis (PsA).

The advent of new therapeutic classes and the updating of international recommendations have justified the development of recent recommendations by the Moroccan Society of Rheumatology. Methods Guidelines were drafted by a core steering committee after performing a literature search. A multidisciplinary task force, including three fellows, eleven rheumatologists, a specialist in physical medicine and rehabilitation, an epidemiologist from hospital-university, hospital and liberal sectors and one patient assessed the Best Practice Guidelines using 2 rounds of anonymous online voting by modified Delphi process. Thus, 19 recommendations were developed. Recommendation 1 concerns the therapeutic principles, recommendation 2 insists on the information and education of the patient, recommendation 3 concerns the general measures to be adopted, namely physical activity, smoking cessation and psychological support, recommendation 4 concerns Non-Steroidal Anti-Inflammatory Drugs which constitute the first-line treatment, recommendations 5 to 7 concern the use of analgesics, of general and local corticosteroid therapy and conventional synthetic disease-modifying antirheumatic drugs, recommendations 8 to 13 deal with the use of biologic agents, including new classes and their indications in radiographic and nonradiographic axial and peripheral spondyloarthritis, follow-up and management in case of failure or remission, recommendation 14 deals with the indication for Janus kinase inhibitors drugs, recommendation 15 deals with physical treatment and recommendation 16 deals with the indication of surgery. Recommendations 17 to 19 deal with special situations, namely fibromyalgia, vaccination and pregnancy. A well-defined therapeutic strategy with first- and second-line treatments has been established.

Liver Fibrosis in Rheumatoid Arthritis Patients Treated with Methotrexate.

INTRODUCTION: Methotrexate (MTX) is a highly effective therapy for patients with rheumatoid arthritis (RA). However, it has been associated with a range of liver related adverse events. The aim of our study was to evaluate the prevalence rate of liver fibrosis in RA patients and to assess the correlation of cumulative MTX dose with hepatic fibrosis in our context. MATERIALS AND METHODS: This is a cross-sectional study, whose goal is to describe and analyze the factors correlated with the liver fibrosis in RA patients treated with methotrexate especially the cumulative dose of MTX, along the period lying between January 2012 and March 2019. The study was carried out in the Rheumatology Department of the University Hospital Hassan II of Fez. The patients have met the assessment of the ACR 2010 criteria. The data was recorded and analyzed using SPSS v20 univariate and bivariate analysis. A value of p <0.05 has been used to identify factors associated with liver fibrosis. RESULTS: A total of 319 patients with RA were recruited who were on MTX treatment. There were 276 female and 43 male patients (female: male ratio of 6.3). The average age was 53 years + /-12.4 years. The average duration of symptoms was 10.68 +/-6.9 years. RA was seropositive for the rheumatoid factor or the anti-ccp in 90.3 %. Six patients (2%) had developed liver fibrosis while on MTX therapy. In the bivariate analysis, the liver fibrosis is significantly related to the hepatic cytolysis (p<0.001) and to the combination of MTX with other DMARDs (p<0.05). However, the multiple logistic regression analysis did not find any significant association between the groups. CONCLUSION: In our context, the prevalence rate of hepatic fibrosis in patients with rheumatoid arthritis under methotrexate is low. It is seen much more in patients treated with methotrexate in combination with other disease-modifying anti-rheumatic drugs (DMARDs). These results require confirmation in a larger number of patients.

Comparison of Non-radiographic Axial Spondyloarthritis and Ankylosing Spondyltis from a Single Rheumatology Hospital in Morocco.

BACKGROUND: According to the new classification criteria developed by The Assessment of SpondyloArthritis International Society, patients with axial spondyloarthritis (axSpA) can be classified in 2 subgroups: Patients with radiographic axial spondyloarthritis: ankylosing spondylitis patients (AS) and those with non-radiographic axial spondyloarthritis (nr-axSpA). OBJECTIVE: The aim of the present study is to describe and discuss the differences and similarities between the two subgroups. PATIENTS AND METHODS: A cross-sectional study was conducted in a single rheumatology hospital in Morocco. These included patients diagnosed as having axial spondyloarthritis according to ASAS criteria 2010, during a period of 6 years. The AS and the nr-axSpA subgroups were compared for the various axSpA-related variables. RESULTS: Of the 277 patients with a diagnosis of axial SpA who were included in this study, 160 had AS and 117 had nr-axSpA. AS and nr-ax-SpA shared a similar age at diagnosis, similar prevalence of low back pain, lumbar stiffness, extra-articular manifestations, BASDAI and BASFI. In the multivariate analysis, AS patients were mainly male with cervical stiffness, enthesitis, coxitis and high level of ESR (erythrocyte sedimentation rate). The females generally had a family history of SpA and arthritis and were associated to the nr-axSpA form in the univariate analysis. CONCLUSION: This was the first study to characterise patients with AS and nr-axSpA in Morocco. Consistent with other studies published, this study showed that patients with nr-axSpA and patients with AS shared a comparable degree of disease burden.

Successful treatment of tumor necrosis factor receptor-associated periodic syndrome (TRAPS) with tocilizumab: A case report.

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) is an autosomal dominant autoinflammatory disease linked to chromosome 12p13 and, more specifically, with mutations within the tumor necrosis factor receptor superfamily, member 1A gene (TNFRSF1A gene). It is characterized by the presence of fever, abdominal pain, myalgia, arthralgia or arthritis, and skin rash. In this report, we describe the case of a patient with tumor necrosis factor receptor-associated periodic syndrome (TRAPS) treated successfully with the anti-interleukin-6 (anti-IL-6) receptor monoclonal antibody tocilizumab, while treatment with anti-TNF α etanercept and infliximab had both failed.

Articular and abarticular manifestations in type 2 diabetes mellitus.

OBJECTIVE: Diabetes mellitus (DM), a worldwide high-prevalence disease, is associated with a large variety of rheumatic manifestations. It affects the connective tissues in many ways and causes alterations in the periarticular and the musculoskeletal systems. In most cases, these manifestations are associated with functional disability and pain, affecting the quality of life of the diabetic patient. The aim of our study is to review the different articular and abarticular manifestations in diabetic patients and the associated factors of these rheumatic manifestations. MATERIAL AND METHODS: A cross-sectional study that includes all patients suffering from type 2 DM who present with articular or abarticular manifestations. RESULTS: We included 116 diabetic patients presenting with articular or abarticular manifestations. Our study showed four important findings. First, a large variety of articular and abarticular manifestations were present in patients with type 2 DM. Second, osteoarthritis (OA) of the knee was the most frequent articular manifestations. It was seen in 49% of our patients. Third, the most common manifestations in diabetic Moroccan patients were carpal tunnel syndrome (CTS), adhesive capsulitis of the shoulder, and diabetic cheiroarthropathy (29%, 23%, and 16%, respectively). Fourth, there was a significant association between vascular complications and the development of articular and abarticular manifestations. CONCLUSION: This study shows that the articular and abarticular manifestations in diabetic Moroccan patients are dominated by CTS, adhesive capsulitis of the shoulder, and diabetic cheiroarthropathy, with a significant association between vascular complications and the development of some of these manifestations.

An unusual cause of shoulder pain in an elderly woman: a case report.

INTRODUCTION: Stress fracture of the clavicle is a rare entity. It can manifest itself with an atypical shoulder pain. The clavicle is vulnerable to pathological fractures from several causes such as neoplasm, infection and rarely metabolic bone disease. CASE PRESENTATION: We report a case of a bone insufficiency fracture of the clavicle, in a 67-year-old Moroccan woman patient with several risk factors of bone insufficiency including osteoporosis, osteomalacia and primary hyperparathyroidism. CONCLUSION: The diagnosis of bone insufficiency-related fracture of the clavicle can be challenging. It should be considered in the differential diagnosis of shoulder or clavicle pain.

Rheumatic complications of long term treatment with hemodialysis.

Patients undergoing hemodialysis therapy develop serious osteoarticular diseases. The treatment is based on prevention. The aim of our study is to determine the frequency and the associated factors to the rheumatic manifestations in hemodialysis patients. A cross-sectional study was conducted, including all hemodialysed patients in our dialysis unit. Information was obtained from patients' symptoms, examination findings, and biological and radiological signs. The frequency of symptoms was 70% in our patients. It was proportional to the duration of hemodialysis and number of hemodialysis sessions per week. Early transplantation is of course a plausible solution, but other therapies such as improved dialysis must be considered.

Diffuse uremic tumoral calcinosis in a patient on long-term hemodialysis.

Tumoral calcinosis is an uncommon and severe complication of hemodialysis therapy. The most important pathogenic factor involved in uremic tumoral calcinosis is an increase in calcium-phosphorus product, not necessarily related to hyperparathyroidism. We report here a patient on hemodialysis who presented with increasing multifocal and uncommon sites of massive calcifications. The patient was examined, and a diagnosis of uremic tumor calcinosis was made. The patient was treated with the noncalcemic phosphate binder sevelamer, a strict diet, multiple hemodialysis sessions per week, and a low calcium dialysate, with improvement on biological findings a decrease in the volume of some tumors on his fingers and a global stable disease. Some nodes in hands and feet disappeared; in other sites, their diameter was reduced, and the largest nodule decreased from 5- to 2-cm diameter.

Frohse's arcade syndrome revealing sarcoidosic myopathy.

We report the first case of an unusual sarcoidosic muscular involvement, complicated with radial nerve palsy. A 58-year-old woman suffering from a mediastinopulmonary sarcoidosis, was admitted for a driving deficit of the hands with a radially deviation during the wrist extension. She had been given a diagnosis of motor branch radial nerve entrapment syndrome. The patient had neurolysis with many muscle biopsies compatible with multiples sarcoidosic nodules, especially at the level of supinator muscle at the origin of the radial nerve compression.

Short- and long-term therapeutic effects of thermal mineral waters in knee osteoarthritis: a systematic review of randomized controlled trials.

The objective of the study was to evaluate short- and long-term therapeutic effectiveness of natural thermal mineral waters in patients with knee osteoarthritis (OA). We performed a systematic review of randomized controlled trials (RCTs) testing efficacy of thermal mineral water for treating patients with knee OA. Trials were identified by systematic searches of PubMed, Cochrane Central Register of Controlled trials, and Amed. We used the MeSH terms balneotherapy, balneology, and mineral water in combination with knee and osteoarthritis. Literature screening and data extraction were performed in duplicate. Nine RCTs satisfied the inclusion criteria, all published as full journal articles. Trial duration ranged from 10 to 24 weeks (median 15.33 +/- 5.56 weeks). The final sample included 493 patients who provided data at the ends of the studies. All interventions that were used in these trials found out an improvement in pain and functional capacity, which were sustained until week 24. No serious adverse events were reported to be associated with thermal mineral waters treatment. This work provide the most current and comprehensive review of the existing evidence of short- and long-term therapeutic effects of thermal mineral waters in knee OA. Additional RCTs with similar intervention comparisons and outcome measures, bigger sample size, and longer follow-up are required to confirm these results and to assess the biological effect of thermal mineral waters in patients with knee OA.