RESUMO
Background: Rheumatoid arthritis (RA) in elderly population represents a challenge for physicians in terms of therapeutic management. Methotrexate (MTX) is the first-line treatment among conventional synthetic-disease-modifying anti-rheumatic drugs (cs-DMARDs); however, it is often associated with adverse events (AEs). Therefore, the objective of this study was to identify the incidence and risk factors of MTX discontinuation due to AEs in elderly patients with RA in a long-term retrospective cohort study. Methods: Clinical sheets from elderly RA patients taking MTX from an outpatient rheumatology consult in a university centre were reviewed. To assess MTX persistence, we used Kaplan-Meir curves and Cox regression models to identify the risk of withdrawing MTX due to adverse events. Results: In total, 198 elderly RA patients who reported using MTX were included. Of them, the rates of definitive suspension of MTX due to AEs were 23.0% at 5 years, 35.6% at 10 years and 51.7% at 15 years. The main organs and system involved were gastrointestinal (15.7%) and mucocutaneous (3.0%). Factors associated with withdrawing MTX due to AEs were MTX dose ≥ 15 mg/wk (adjusted HR: 2.46, 95% CI: 1.22-4.96, p = 0.012); instead, the folic acid supplementation was protective for withdrawal (adjusted HR: 0.28, 95% CI: 0.16-0.49, p < 0.001). Conclusions: Higher doses of MTX increase the risk of withdrawals in elderly RA, while folic acid supplementation reduces the risk. Therefore, physicians working in therapeutic management for elderly patients using MTX must focus on using lower MTX doses together with the concomitant prescription of folic acid.
RESUMO
The use of complementary therapies is highly prevalent among patients with rheumatoid arthritis (RA). Nevertheless, the use of complementary medicine could involve problems in the following of scientifically accepted treatments. To date, there is limited information regarding the association of nonconventional therapies with problems regarding compliance with the treatment. Therefore, the objective of this study was to identify whether the utilization of complementary therapies is associated with a high risk of problems regarding therapeutic adherence to conventional synthetic disease-modifying anti-rheumatic drugs (cs-DMARDs) in RA patients. A survey was performed with RA patients in an outpatient rheumatology clinic in a university hospital; the use of complementary therapies, as well as their type, was identified. To assess problems with therapeutic adherence, we used the four-item Morisky-Green scale. A comprehensive assessment of clinical and therapeutic characteristics was performed. Univariable and multivariable models were performed to identify the risk of problems with therapeutic adherence in users of complementary therapies. In total, 250 RA patients were included; 92% used complementary therapies. Of them, the most frequently used were herbal medicine (65%), homeopathy (64%), and cannabis and its derivatives (51%). In the univariable logistic regression analysis, the factors associated with problems in the therapeutic adherence to cs-DMARDs were age (p = 0.019), the presence of other comorbidities (p = 0.047), and the use of complementary therapies (p = 0.042). After controlling for potential confounders, the use of complementary therapies increased the risk of problems with therapeutic adherence to cs-DMARDs (adjusted OR = 2.84, 95% CI = 1.06-7.63, p = 0.037). We concluded that the use of complementary therapies increases the risk of problems with therapeutic adherence. Therefore, for physicians and healthcare professionals, the early identification of the use of nonconventional therapies in their RA patients is required, followed by a directed discussion with their patients about the risks and benefits to which they could be exposed to complementary therapies.
RESUMO
El herbicida ácido 2,4 - diclorofenoxiacético (2,4-D) es un ácido selectivo y sistémico que, desde 1940, es ampliamente utilizado en suelo agrícolas, de todo el mundo. Su uso radica a su selectividad entre la vegetación de hoja ancha y cultivos de gramíneas y como regulador del crecimiento vegetal; sin embargo, este herbicida se puede acumular en el ambiente y, adicionalmente, puede ser transportado por lixiviación, a través del suelo, llegando a contaminar aguas subterráneas, lo que genera un alto riesgo para el ambiente y la salud del ser humano. El estudio de la movilidad del 2,4-D en suelos con alto contenido de materia orgánica permitió conocer, que no solo la materia orgánica se correlaciona indirectamente con la movilidad de este compuesto, sino que, también, influye la humedad, al reducir la lixiviación y el potencial de contaminación del recurso hídrico subterráneo, mientras que la conductividad hidráulica se relaciona, de manera directa, con la lixiviación de este herbicida.
The herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) is a selective and systemic acid that has been widely used in agricultural soils since 1940. Its use lies in its selectivity between broadleaf vegetation and grass crops, and as a regulator of plant growth. However, this herbicide can accumulate in the environment, and additionally, it can be transported by leaching through the soil, contaminating groundwater, which generates a high risk for the environment and human health. In this study, the mobility of 2,4-D in organic-matter-rich soils was assessed. The results revealed that not only the organic material is indirectly correlated with the mobility of this compound but also influences humidity and reduces leaching and potential pollution of groundwater resources, whereas hydraulic conductivity is directly related to herbicide leaching.
