Asunto(s)
Reumatología , Curriculum , Educación de Postgrado en Medicina , Humanos , Reumatología/educaciónAsunto(s)
Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales/efectos adversos , Productos Biológicos/administración & dosificación , Productos Biológicos/efectos adversos , Enfermedades Reumáticas/tratamiento farmacológico , Enfermedades Reumáticas/inmunología , Antiinflamatorios/administración & dosificación , Antiinflamatorios/efectos adversos , Antirreumáticos/administración & dosificación , Antirreumáticos/efectos adversos , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Monitoreo de Drogas/métodos , Medicina Basada en la Evidencia , Humanos , Enfermedades Reumáticas/diagnóstico , Resultado del TratamientoRESUMEN
In the 1970s and 1980s the course of rheumatoid arthritis (RA) could be defined as fateful despite the introduction of methotrexate as well as other immunosuppressive treatments. In most patients at this time RA was combined with an early disability due a progressive destruction of joints. In addition, comorbidity was known to be one of the major causes for a decreased life expectancy. These less than optimal options for treating RA patients led to intensive research in the pathogenesis with the aim to develop new treatment principles. Based on the increasing knowledge of pathogenically important mechanisms, so-called biologicals were developed targeting T and B cells and proinflammatory cytokines, such as tumor necrosis factor alpha. Over the past 10 years the repertoire of biologicals for treating RA has steadily and significantly increased, which was necessary especially for those patients classified as non-responders to available biological compounds. In the present overview cellular structures, T and B cells as well as cells of the monocyte/macrophage system are discussed as targets for immune interventions.
Asunto(s)
Artritis Reumatoide/inmunología , Artritis Reumatoide/patología , Linfocitos B/inmunología , Modelos Inmunológicos , Sistema Mononuclear Fagocítico/inmunología , Linfocitos T/inmunología , Animales , Artritis Reumatoide/tratamiento farmacológico , Linfocitos B/efectos de los fármacos , Linfocitos B/patología , Productos Biológicos/uso terapéutico , Sistemas de Liberación de Medicamentos/métodos , Humanos , Sistema Mononuclear Fagocítico/efectos de los fármacos , Sistema Mononuclear Fagocítico/patología , Linfocitos T/efectos de los fármacos , Linfocitos T/patologíaAsunto(s)
Antirreumáticos/uso terapéutico , Inmunosupresores/uso terapéutico , Enfermedades Reumáticas/tratamiento farmacológico , Abatacept , Anticuerpos Monoclonales Humanizados/efectos adversos , Anticuerpos Monoclonales Humanizados/uso terapéutico , Antirreumáticos/efectos adversos , Femenino , Humanos , Inmunoconjugados/efectos adversos , Inmunoconjugados/uso terapéutico , Inmunosupresores/efectos adversos , Masculino , Polietilenglicoles/efectos adversos , Polietilenglicoles/uso terapéutico , Embarazo , Enfermedades Reumáticas/complicaciones , Resultado del Tratamiento , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Urato Oxidasa/efectos adversos , Urato Oxidasa/uso terapéuticoAsunto(s)
Antirreumáticos/uso terapéutico , Enfermedades Reumáticas/tratamiento farmacológico , Abatacept , Anticuerpos Monoclonales de Origen Murino/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Medicina Basada en la Evidencia/métodos , Humanos , Inmunoconjugados/uso terapéutico , Proteína Antagonista del Receptor de Interleucina 1/uso terapéutico , Rituximab , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
Following similar examples for diabetes mellitus and hypertension an attempt was made to establish a treat-to-target (T2T) program for rheumatic diseases in order to improve the course of the disease. Nevertheless, it is a factum that rheumatology, a recognized discipline in internal medicine, was not represented in university clinics corresponding to its scientific, clinical and socioeconomic importance. On the question how rheumatology in university clinics can contribute to the implementation of a T2T program, several aspects have to be considered. These include improvement in training and further education, establishment of clinical scientific core topics, formulation of guidelines, initiation of controlled studies, establishment of long-term cohorts and the incorporation of pathogenetic and therapeutic information in international networks and national symposia.
Asunto(s)
Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Programas Nacionales de Salud/economía , Academias e Institutos/economía , Antirreumáticos/economía , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/economía , Conducta Cooperativa , Ahorro de Costo , Análisis Costo-Beneficio , Educación Médica Continua , Educación de Postgrado en Medicina , Alemania , Necesidades y Demandas de Servicios de Salud , Humanos , Comunicación Interdisciplinaria , Cooperación Internacional , Guías de Práctica Clínica como Asunto , Inducción de Remisión , Reumatología/educación , Investigación Biomédica Traslacional/economíaRESUMEN
New therapeutic principles and considerable diagnostic advances have made it possible to define different rheumatic diseases and especially rheumatoid arthritis (RA) at an early stage and by starting an early and aggressive medication a considerable proportion of patients with RA will reach the status of low disease activity or even remission. With the additional development of composite measures to estimate the disease activity of RA, it was the goal of an international working group consisting of rheumatologists and patients to develop recommendations for treating rheumatoid arthritis in a similar way as for patients with hypertension or diabetes, with the aim to achieve remission as often as possible. This treat-to-target initiative has taken off in quite a number of different countries including Germany leading to discussions on how this initiative can be integrated into the specific national healthcare systems and what possibilities would exist for its implementation. To develop strategies for an improved healthcare of people suffering from rheumatic diseases and using RA as an example, action elements and postulates were developed which will be discussed in more detail in the present manuscript.
Asunto(s)
Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Enfermedades Endémicas , Programas Nacionales de Salud , Artritis Reumatoide/diagnóstico , Terapia Combinada , Comorbilidad , Conducta Cooperativa , Alemania , Implementación de Plan de Salud , Humanos , Comunicación Interdisciplinaria , Mejoramiento de la Calidad , Inducción de Remisión , Prevención SecundariaAsunto(s)
Antirreumáticos/uso terapéutico , Factores Inmunológicos/uso terapéutico , Enfermedades Reumáticas/tratamiento farmacológico , Abatacept , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados , Anticuerpos Monoclonales de Origen Murino/uso terapéutico , Medicina Basada en la Evidencia/métodos , Humanos , Inmunoconjugados/uso terapéutico , Interleucina-1/antagonistas & inhibidores , Rituximab , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresAsunto(s)
Antirreumáticos/uso terapéutico , Inmunosupresores/uso terapéutico , Enfermedades Reumáticas/tratamiento farmacológico , Abatacept , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados , Anticuerpos Monoclonales de Origen Murino , Humanos , Inmunoconjugados/uso terapéutico , Rituximab , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
Whether the differences in the clinical picture and in the pathogenesis between rheumatoid arthritis (RA) and ankylosing spondylitis (AS) will lead to different therapeutic approaches is unclear at present. Since anti-TNF-alpha agents and other biologics are not efficacious in all patients new developments are clearly needed.
Asunto(s)
Antirreumáticos , Artritis Reumatoide/terapia , Terapia Biológica/tendencias , Espondilitis Anquilosante/terapia , Animales , Terapia Biológica/métodos , Modelos Animales de Enfermedad , Humanos , Proteínas Recombinantes , Reumatología/tendencias , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
There are clear differences in the clinical picture and in the pathogenesis between rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Biologic agents targeting TNF-alpha are efficacious in both diseases, with some tendency to work even better in spondyloarthritides (SpA) on a clinical basis. However, anti-TNF therapy was shown to inhibit radiographic progression in RA but not in AS. This is probably due to the outstanding difference in pathogenesis: while in RA osteodestructive lesions such as erosions predominate, AS patients will rather develop osteoproliferative changes such as syndesmophytes. There is some evidence that anti-TNF agents may show longterm efficacy and acceptable safety profiles over 5-10 years. There are some differences between the agents.Whether the recent developments of targeted therapies in RA with agents such as rituximab, abatacept and tocilizumab will also work for AS is unknown at present.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Antirreumáticos/uso terapéutico , Artritis Reumatoide/terapia , Terapia Biológica/métodos , Espondilitis Anquilosante/terapia , Artritis Reumatoide/patología , Artrografía , Progresión de la Enfermedad , Humanos , Osteítis/patología , Osteítis/terapia , Espondilitis Anquilosante/patología , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
OBJECTIVE: To examine the association of radiographic progression and disease activity states in patients with rheumatoid arthritis (RA) treated with methotrexate with or without infliximab. METHODS: Patients (n = 1049) with active RA for 3 years or less and no previous methotrexate treatment were randomly assigned (4 : 5 : 5) to receive methotrexate plus placebo or methotrexate plus infliximab 3 or 6 mg/kg at weeks 0, 2 and 6, and every 8 weeks thereafter to week 46. Disease activity was classified by the simplified disease activity index as remission (< or =3.3), low (>3.3 to < or =11), moderate (>11 to < or =26), high (>26). Radiographic progression was measured as a change from baseline to week 54 in total Sharp score. RESULTS: At weeks 14 and 54, more patients receiving methotrexate plus infliximab than methotrexate plus placebo were in remission (10.7% versus 2.8% week 14; 21.3% versus 12.3% week 54; p<0.001 for both). Methotrexate plus placebo halted radiographic progression only if patients achieved remission within 3 months, whereas methotrexate plus infliximab also halted or minimised progression in patients with low or moderate activity, respectively. Patients with persistently high disease activity levels had much less progression of joint damage if treated with methotrexate plus infliximab versus methotrexate monotherapy. Even with infliximab plus methotrexate there was a direct relationship between disease activity and radiographic changes, although the slope was deflected when compared with methotrexate monotherapy. CONCLUSION: With methotrexate, joint damage progresses even at low and moderate disease activity levels, whereas methotrexate plus infliximab inhibits radiographic progression across all disease activity states.