RESUMEN
OBJECTIVE: To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF). METHODS: We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations. RESULTS: The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment. CONCLUSION: The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.
Asunto(s)
Antiinflamatorios no Esteroideos/uso terapéutico , Antirreumáticos/uso terapéutico , Artritis Psoriásica/terapia , Glucocorticoides/uso terapéutico , Inmunosupresores/uso terapéutico , Modalidades de Fisioterapia , Abatacept/uso terapéutico , Adalimumab/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Artritis Psoriásica/epidemiología , Comorbilidad , Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Entesopatía/terapia , Etanercept/uso terapéutico , Medicina Basada en la Evidencia , Ejercicio Físico , Humanos , Enfermedades Inflamatorias del Intestino/epidemiología , Enfermedades Inflamatorias del Intestino/terapia , Infliximab/uso terapéutico , Interleucina-12/antagonistas & inhibidores , Interleucina-17/antagonistas & inhibidores , Interleucina-23/antagonistas & inhibidores , Terapia Ocupacional , Piperidinas/uso terapéutico , Pirimidinas/uso terapéutico , Pirroles/uso terapéutico , Reumatología , Cese del Hábito de Fumar , Sociedades Médicas , Espondilitis/terapia , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Ustekinumab/uso terapéutico , Pérdida de PesoRESUMEN
OBJECTIVE: To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF). METHODS: We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations. RESULTS: The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment. CONCLUSION: The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.
Asunto(s)
Artritis Psoriásica/terapia , Toma de Decisiones Clínicas , Guías de Práctica Clínica como Asunto/normas , Reumatología/normas , Antirreumáticos/administración & dosificación , Artritis Psoriásica/diagnóstico , Artritis Psoriásica/epidemiología , Productos Biológicos/administración & dosificación , Toma de Decisiones Clínicas/métodos , Quimioterapia Combinada , Humanos , Inmunosupresores/administración & dosificación , Reumatología/métodos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Retained placenta is a serious cause of postpartum hemorrhage. Compounding this problem is the rare finding of a retained placenta accreta. Different authors have presented management options for retained placenta accreta that include methotrexate, uterine artery embolization, dilation and curettage, hysteroscopic loop resection, and hysterectomy. We report here on a patient who was diagnosed with a retained placenta accreta and underwent successful conservative treatment with uterine artery embolization followed by hysteroscopic morcellation. Whereas other methods have failed due to bleeding and/or infection, this case illustrates a potential new means of addressing this challenging obstetrical complication.