Análise sistemática da influência do antifator de necrose tumoral [anti-TNF] sobre as taxas de infecção em pacientes com artrite reumatoide / A systematic review of the influence of anti-TNF on infection rates in patients with rheumatoid arthritis

OBJETIVO: O presente trabalho tem como objetivo fornecer uma análise sistemática da influência do anti-TNF sobre as taxas de infecção em pacientes com artrite reumatoide (AR). MÉTODO: Pesquisamos na Medline para obter informações de controle de qualidade sobre as taxas de infecção em pacientes com AR tratados com anti-TNF. RESULTADOS: Atualmente, uma proporção elevada de pacientes com AR é usuária de agentes anti-TNF. Dados de registros nacionais em países da Europa de pacientes com AR tratados com anti-TNF sugerem que terapias biológicas estão intimamente ligadas à sepse. Apesar de estudos anteriores terem relatado um maior risco de infecções, atualmente há dados emergentes com maior duração de acompanhamento que sugerem um risco ajustado de 1,2. Os pacientes idosos e os com doença de longa data poderão apresentar uma taxa mais elevada de infecções graves em comparação às suas contrapartes mais novas com doença inicial. Hoje, há dados emergentes que sugerem que a terapia com anti-TNF está associada ao desenvolvimento de neutropenia logo após o início do tratamento. Os registros biológicos constataram que os pacientes com ARES tratados com anticorpos monoclonais apresentam aumento no risco de tuberculose (TB), em comparação aos tratados com bloqueadores dos receptores de TNF. Esse risco de infecção precisa ser ponderado em relação aos benefícios estabelecidos dos bloqueadores de TNF. CONCLUSÃO: A evidência atual sugere que o tratamento com anti-TNF na AR está intimamente associado à infecção. Os pacientes precisam estar cientes do risco de infecção, assim como dos benefícios estabelecidos dos bloqueadores de TNF, para que possam fornecer o consentimento informado para o tratamento.

OBJECTIVE: The present article aims to provide a systematic review of the influence of antitumor necrosis factor (TNF) on infection rates in patients with rheumatoid arthritis (RA). METHOD: Medline was searched to obtain quality control information on infection rates in RA patients treated with anti-TNF. RESULTS: A high proportion of RA patients are now established users of anti-TNF agents. Data from national registries in European countries of patients with RA treated with anti-TNF suggest that biological therapies are closely linked to sepsis. Although previous studies reported a higher risk of infections, there are now emerging data with longer duration of follow-up that suggested an adjusted hazard risk of 1.2. Elderly patients and those with longstanding disease may have a higher rate of serious infections compared to their counterparts who were younger with early disease. There are now emerging data to suggest that anti-TNF therapy is associated with the development of neutropenia shortly after the commencement of treatment. The biologic registries found that RA patients treated with monoclonal antibodies are at increased risk of tuberculosis (TB) compared to those on TNF receptor blockers. This risk of infection needs to be weighed against the established benefits of TNF blockers. CONCLUSION: Current evidence suggests that anti-TNF treatment in RA is closely linked to infection. Patients need to be aware of the risk of infection together with the established benefits of TNF blockers in order to give informed consent for treatment.

A systematic review of the influence of anti-TNF on infection rates in patients with rheumatoid arthritis.

OBJECTIVE: The present article aims to provide a systematic review of the influence of antitumor necrosis factor (TNF) on infection rates in patients with rheumatoid arthritis (RA). METHOD: Medline was searched to obtain quality control information on infection rates in RA patients treated with anti-TNF. RESULTS: A high proportion of RA patients are now established users of anti-TNF agents. Data from national registries in European countries of patients with RA treated with anti-TNF suggest that biological therapies are closely linked to sepsis. Although previous studies reported a higher risk of infections, there are now emerging data with longer duration of follow-up that suggested an adjusted hazard risk of 1.2. Elderly patients and those with longstanding disease may have a higher rate of serious infections compared to their counterparts who were younger with early disease. There are now emerging data to suggest that anti-TNF therapy is associated with the development of neutropenia shortly after the commencement of treatment. The biologic registries found that RA patients treated with monoclonal antibodies are at increased risk of tuberculosis (TB) compared to those on TNF receptor blockers. This risk of infection needs to be weighed against the established benefits of TNF blockers. CONCLUSION: Current evidence suggests that anti-TNF treatment in RA is closely linked to infection. Patients need to be aware of the risk of infection together with the established benefits of TNF blockers in order to give informed consent for treatment.

Update on biologic therapies in ankylosing spondylitis: a literature review.

AIM: The present paper aims to review the recent advances in diagnosis and management of ankylosing spondylitis (AS). METHOD: Medline and abstracts submitted to the recent European League Against Rheumatism (EULAR) congress were searched to obtain quality-controlled information on the management of AS. RESULTS: The use of magnetic resonance imaging (MRI) allows the diagnosis of AS to be made in the pre-radiographic stage. The Assessment in Spondylarthritis International Society recommendations for the management of AS have been modified so that patients with non-radiographic spondyloarthritis (SpA) can now be considered for biological therapy. The 'older' anti-tumour necrosis factor (TNF) continued to be effective in longer-term studies. Studies with longer duration of follow-up have shown that some patients with pre-radiographic SpA entered into prolonged drug-free remission. It is likely that in the foreseeable future, more AS patients will be treated with biological therapies at an earlier stage of the disease. New biologic therapies, golimumab and secukinumab, are looking promising in improving the signs and symptoms of AS, at least in the short-term. CONCLUSION: Longer-term studies of AS patients treated with infliximab, etanercept and adalimumab continued to show a good clinical response. There is a need for more long-term studies to examine the longitudinal efficacy of golimumab and secukinumab in AS.

Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing elective orthopaedic surgery? A systematic review of the evidence.

Anti-tumour necrosis factor (TNF) therapies have revolutionized the management of rheumatoid arthritis (RA). A high proportion of RA patients are now established users of anti-TNF agents. Unfortunately, many RA patients with longstanding disease still require elective orthopaedic procedures. Published studies on the influence of TNF antagonist on infection rates in RA patients undergoing surgery are conflicting. However, national registries of RA patients on anti-TNF reported an increased risk of infection. The risk of anti-TNF-related infection is highest at the start of treatment with frequent involvement of the skin and subcutaneous tissue. Infection at these sites could negatively influence the healing of surgical wound. Current guidelines suggest that treatment with biologics should be discontinued prior to surgery. Patients with established disease are more likely to flare compared to those with early disease on stopping treatment. Consequently, TNF blockers need to be reinstated promptly after surgery to avoid the risk of RA flare.

Increasing hepatitis A IgG prevalence rate in men who have sex with men attending a sexual health clinic in London: implications for immunization policy.

The aims of this study were to audit an immunization policy to vaccinate men who have sex with men (MSM) attending a large London sexual health clinic, and to undertake an approximate cost analysis of different strategies, using the estimated prevalence rate of anti-hepatitis A virus (HAV) immunoglobulin G (IgG). A retrospective study of the seroprevalence of anti-HAV IgG among MSM was conducted for a 12-month period, involving 395 homosexual or bisexual men attending the genitourinary medicine clinic at St Mary's Hospital, London, for the first time. Overall seroprevalence of anti-HAV IgG in the 2004 population surveyed was 46.6% (140/300); 75.1% (300/395) were offered screening on their first visit and 49.9% (197/395) were offered vaccination. We concluded that anti-HAV IgG screening prior to vaccination of MSM in an area of relatively low prevalence of HAV is still the most cost-effective approach. The audit data also showed that in 2004 the British Association for Sexual Health and HIV targets for hepatitis A screening and vaccination were not reached. If a one-dose policy is seen to establish long-term immunity, then the cost of hepatitis A prevention will be drastically reduced.

Rheumatology nurse practitioners' perceptions of their role.

OBJECTIVES: To identify the current practices of rheumatology nurse practitioners and ascertain their perceptions of how their role could be enhanced. METHOD: A cross-sectional questionnaire study of currently employed nurse practitioners in rheumatology in the United Kingdom (UK) was undertaken. RESULTS: 200 questionnaires were distributed and 118 nurses responded. Ninety-five respondents met the inclusion criteria for undertaking an advanced nursing role. Typical conditions dealt with included: rheumatoid arthritis (96.8%); psoriatic arthritis (95.8%); osteoarthritis (63.2%); ankylosing spondylitis (62.8%); systemic lupus erythematosus (51.6%); and scleroderma (34.7%). Drug monitoring, education, counselling of patients and arranging basic investigations were routinely performed by more than 80% of respondents. A smaller proportion performed an extended role that included dealing with referrals, research and audit, the administration of intra-articular injections, and admission of patients. Specific attributes identified as being necessary for competence were: knowledge and understanding of rheumatic diseases (48.4%); drug therapy (33.7%); good communication skills (35.8%); understanding of the roles of the team (27.4%); working effectively (23.2%) as part of a multidisciplinary team; assessment of patients by physical examination (28.4%); teaching (26.3%), research (17.9%); organizational skills (14.7%); and the interpretation of investigations (9.5%). Factors that could enhance their role included: attendance at postgraduate courses (30.5%); obtaining further qualifications (13.7%); active participation in the delivery of medical education (41.1%); training in practical procedures (31.6%); protected time and resources for audit and research (11.6%); formal training in counselling (11.6%); and implementation of nurse prescribing (10.5%). CONCLUSION: Nurse practitioners already have a wide remit and play an invaluable part in the delivery of modern rheumatology services. An extended role could improve patient care and enhance nursing career pathways in rheumatology.

Role of magnetic resonance imaging in the clinical management of the acutely locked knee.

OBJECTIVE: To explore prospectively the hypothesis that MRI of the acutely locked knee can alter surgical decision-making. DESIGN AND PATIENTS: The study group comprised patients with a clinical diagnosis of knee locking requiring arthroscopy. The decision to carry out arthroscopy was made by an experienced consultant orthopaedic surgeon specialising in trauma and recorded in the patient's notes prior to MRI. Preoperative MRI was carried out using a 1.5 T system. The management was altered from surgical to conservative treatment in 20 (48%) patients on the basis of the MR findings. Arthroscopy was limited to patients with an MR diagnosis of a mechanical block, usually a displaced meniscal tear or loose body. Both patient groups were followed clinically until symptoms resolved. RESULTS: Forty-two patients were entered into the study. MRI identified a mechanical cause for locking in 22 patients (21 avulsion meniscal tears and 1 loose body). All were confirmed at arthroscopy. Twenty patients were changed from operative to non-operative treatment on the basis of the MRI findings. One patient in this group required a delayed arthroscopy for an impinging anterior cruciate ligament stump. The sensitivity/specificity/accuracy of MRI in identifying patients who require arthroscopy was therefore 96%/100%/98% respectively. CONCLUSION: MRI can successfully segregate patients with a clinical diagnosis of mechanical locking into those who have a true mechanical block and those who can be treated conservatively. MRI should precede arthroscopy in this clinical setting.