Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica / Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

La artritis psoriásica (APs) es una enfermedad inflamatoria sistémica crónica que afecta a la piel, las estructuras musculoesqueléticas y otros órganos y sistemas, comprometiendo la funcionalidad, la calidad de vida y reduciendo la expectativa de vida de los pacientes. Es una enfermedad compleja que requiere atención y manejo especializado y oportuno. Las alternativas para el tratamiento de las manifestaciones de la APs se han incrementado y, adicionalmente, el efecto de los distintos agentes sobre manifestaciones específicas ha sido aclarado en estudios recientes, por lo tanto, es conveniente incorporar la evidencia disponible para construir una estrategia en el tratamiento de estos pacientes. El Colegio Mexicano de Reumatología seleccionó una comisión para evaluar estas distintas alternativas y generar recomendaciones. Métodos: El grupo de estudio incluyó a 16 reumatólogos y tres dermatólogos certificados, que fueron seleccionados de diferentes instituciones de salud y regiones del país. Se conformó un comité ejecutivo que coordinó las reuniones y un comité de expertos que seleccionó los criterios de búsqueda en la literatura, elaboró las preguntas de investigación, calificó la calidad de la evidencia y generó las recomendaciones en los distintos dominios de la enfermedad con base en la metodología GRADE. Resultados: Se generaron 24 recomendaciones actualizadas para el tratamiento de pacientes con APs. Las recomendaciones establecen el papel de los medicamentos disponibles actualmente en nuestro país. Se enfatiza la importancia del control adecuado de la enfermedad, individualizando el perfil de involucramiento de cada paciente en cada uno de los seis dominios potencialmente afectados por la enfermedad. Además, se establece la secuencia en la elección de los tratamientos disponibles para cada dominio, basada en su eficacia, perfil de seguridad y accesibilidad.(AU)

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. Methods: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. Results: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. Conclusions: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.(AU)

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis. / Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Eficacia de rituximab comparado con ciclofosfamida en pacientes con manifestaciones graves de lupus eritematoso generalizado. Estudio aleatorizado y multicéntrico / Efficacy of rituximab versus cyclophosphamide in lupus patients with severe manifestations. A randomized and multicenter study

No existen a la fecha estudios controlados que evalúen la eficacia de rituximab (RTX) comparando con un tratamiento estándar, como ciclofosfamida, en pacientes con lupus eritematoso generalizado (LEG). Objetivo. Comparar la eficacia de RTX con ciclofosfamida en pacientes con manifestaciones graves de LEG. Material y método. Estudio clínico aleatorizado, multicéntrico, controlado y abierto en adultos con LEG activo. Se administró RTX o bolos de ciclofosfamida, con mismo esquema de esteroides. Se evaluó MEX-SLEDAI, dosis de esteroide y eventos adversos, durante 12 meses. Se empleó estadística descriptiva y comparativa. Resultados. Fueron 19 pacientes, 17 mujeres, con edad de: 35,7 años ±12,1, y tiempo de evolución de 5,6 años (0,35–30,8). No hubo diferencias en género, edad, tiempo de evolución, tratamientos previos o actividad de la enfermedad al inicio entre los grupos. Se observó descenso en el MEX-SLEDAI de 12 a 3 en el grupo 1, y de 9 a 2 en el grupo 2 (p=0,80). El grupo que recibió RTX tuvo mejoría más rápida. La dosis acumulada de esteroide fue similar. En ambos grupos se observó reducción en niveles de anti-DNAds e incremento de C3. Los eventos adversos fueron semejantes. Conclusión. Este ensayo clínico comparativo muestra que RTX puede ser tan eficaz como ciclofosfamida, para el control de manifestaciones graves del LEG, con respuesta más rápida. Los eventos adversos inmediatos y mediatos no fueron diferentes. RTX puede considerarse una opción terapéutica adecuada en este tipo de pacientes (AU)

There are no controlled studies that compare the efficacy of RTX with standard treatment, such as cyclophosphamide, in patients with systemic lupus erythematosus (SLE). Objective. The objective of this study was to compare the efficacy of rituximab to that of cyclophosphamide in patients with severe manifestations of SLE. Materials and method. This is a multicenter, randomized open and controlled trial in adults with a diagnosis of active SLE. Patients were randomized into two groups; group 1: treated with RTX and group 2: cyclophosphamide pulses with the same steroid scheme. We registered MEX-SLEDAI, steroid requirements and adverse events for 12 months. Descriptive and comparative statistic analysis was performed. Results. 19 patients were included, 17 females, mean age 35.7±12.1 years and duration of disease 5.6 years (range 0.35 to 30.8 years). There were no differences at baseline regarding gender, age, duration of disease, previous treatments or disease activity between both groups. MEX-SLEDAI was reduced from 12 to 3 in group 1 and from 9 to 2 in group 2 (p=0.80). Nevertheless, patients treated with RTX had a faster improvement. There was no difference in the cumulative steroid dose. Both groups had significant reduction in antinuclear antibody levels and similar increase in C3 levels. Adverse events were similar in both groups. Conclusion. This comparative clinical study in patients with SLE shows that rituximab can be as useful as cyclophosphamide for severe manifestations, maybe showing a faster response. Adverse events were no different. Rituximab should be considered as an adequate alternative for this group of patients (AU)

[Efficacy of rituximab versus cyclophosphamide in lupus patients with severe manifestations. A randomized and multicenter study]. / Eficacia de rituximab comparado con ciclofosfamida en pacientes con manifestaciones graves de lupus eritematoso generalizado. Estudio aleatorizado y multicéntrico.

UNLABELLED: There are no controlled studies that compare the efficacy of RTX with standard treatment, such as cyclophosphamide, in patients with systemic lupus erythematosus (SLE). OBJECTIVE: The objective of this study was to compare the efficacy of rituximab to that of cyclophosphamide in patients with severe manifestations of SLE. MATERIALS AND METHOD: This is a multicenter, randomized open and controlled trial in adults with a diagnosis of active SLE. Patients were randomized into two groups; group 1: treated with RTX and group 2: cyclophosphamide pulses with the same steroid scheme. We registered MEX-SLEDAI, steroid requirements and adverse events for 12 months. Descriptive and comparative statistic analysis was performed. RESULTS: 19 patients were included, 17 females, mean age 35.7±12.1 years and duration of disease 5.6 years (range 0.35 to 30.8 years). There were no differences at baseline regarding gender, age, duration of disease, previous treatments or disease activity between both groups. MEX-SLEDAI was reduced from 12 to 3 in group 1 and from 9 to 2 in group 2 (p=0.80). Nevertheless, patients treated with RTX had a faster improvement. There was no difference in the cumulative steroid dose. Both groups had significant reduction in antinuclear antibody levels and similar increase in C3 levels. Adverse events were similar in both groups. CONCLUSION: This comparative clinical study in patients with SLE shows that rituximab can be as useful as cyclophosphamide for severe manifestations, maybe showing a faster response. Adverse events were no different. Rituximab should be considered as an adequate alternative for this group of patients.

Sphygmomanometry-evoked allodynia--a simple bedside test indicative of fibromyalgia: a multicenter developmental study.

BACKGROUND: One of the 2 classification criteria for fibromyalgia (FM) is the presence of tender points on specific anatomic sites. It has been established that these tender points reflect a state of generalized allodynia (defined as pain resulting from a stimulus that does not normally provoke pain). Patients with FM often describe pain elicitation during blood pressure testing (sphygmomanometry). OBJECTIVE: The objective of this study was to define if a universally used clinical test, sphygmomanometry, is helpful in the identification of patients with FM. METHODS: The authors conducted a prospective multicenter study in 3 different public rheumatology outpatient services. Each center studied 20 patients with FM, 20 with rheumatoid arthritis, 20 with osteoarthritis, and 20 healthy individuals. The following question was asked of each participant: "When I take your blood pressure, tell me if the cuff's pressure brings forth pain." The blood pressure cuff was inflated at an approximate rate of 10 mm Hg per second up to 180 mm Hg or to the point when pain was elicited. RESULTS: Sixty-nine percent of patients with FM had sphygmomanometry-evoked allodynia in contrast to 10% of patients with osteoarthritis, 5% with rheumatoid arthritis, and 2% of healthy individuals (P < 0.001). The mean blood pressure value at which allodynia was elicited was lower in patients with FM (143 +/- 40 mm Hg) when compared with the other 3 groups (176 +/- 11 mm Hg) or higher (P < 0.001). In patients with FM, there was a significant negative correlation between the blood pressure value at which allodynia developed and total Fibromyalgia Impact Questionnaire (FIQ) score, number of tender points, and the FIQ visual analog scales for pain intensity and fatigue (P < 0.05). The test yields a diagnostic sensitivity for FM of 0.7, specificity 0.96, positive predictive value 0.86, and negative predictive value 0.91. CONCLUSIONS: In this developmental study of patients attending rheumatology clinics, the generation of pain during blood pressure testing was strongly associated with the diagnosis of FM. This robust linkage probably reflects a tautologic phenomenon. A sine qua nonelement for FM diagnosis is the presence of tender points in discrete anatomic sites. These tender points in turn reflect a state of generalized mechanical allodynia that can be locally elicited by the cuff pressure during blood pressure testing. Sphygmomanometry is a simple bedside test that may be useful in the recognition of patients with FM. Blood pressure testing is a universal procedure in all clinical environments. Based on our results, we suggest searching for FM features in any person who has sphygmomanometry-evoked allodynia.

Calidad de la atención primaria para lumbalgia aguda. Estudio multicéntrico / Quality of care in low back pain. Comparative survey

Objetivo. Evaluar la calidad de atención para pacientes con lumbagia aguda proporcionada por médicos de atención primaria y estudiantes de medicina de 4 ciudades de México. Tipo de studio. Encuesta comparativa. Material y métodos. Se interrogó sobre acciones diagnóstico terapéuticas en lumbalgia aguda a médicos de atención primaria y a estudiantes de medicina. Las acciones consideradas como aciertos se tomaron de las guías emitidas por la Quebec Task Force on Spinal Disorders (QTFSD). Resultados. Fueron evaluables los datos de 211 de 213 pacientes (30 Cd. Obregón, 43 Morelia, 80 León y 60 Mérida); 79 por ciento de los participantes habrían proporcionado calidad de atención no adecuada generalmente debida a sobresolicitud de estudios de imagen. No hubo asociación entre haber cursado reumatología en la carrera de medicina y el tipo de atención proporcionadas; sin embargo, el tener la especialidad de Medicina Familiar se asocició con proporcionar atención adecuada y en contraste, el ser estudiante de medicina estuvo asociado con proporcionar atención no adecuada. Conclusiones. Parece existir una elevada prevalencia de calidad de atención no adecuada para pacientes con lumbalgia aguda por parte de médicos de atención primaria; ésto parece ser mas frecuente en médicos en formación

Fracturas de cadera en egresos de hospitales de León, Guanajuato (México). Un indicador econométrico de osteoporosis

Aunque se desconoce la epidemiología de la osteoporosis (OP) en México, la frecuencia de las fracturas de cadera parece aumentar en los hospitales de Ortopedia. Con el propósito de conocer la frecuencia de las fracturas de cadera por trauma mínimo como un indicador de la importancia de la OP en hospitales públicos de nuestro medio, analizamos los registros de egresos de 4 hospitales generales del Sector Salud, en la ciudad de León, Guanajuato (México). Se revisaron los expedientes de todos los mayores de 50 años que sufrieron fractura de cadera. De un total de 113,410 pacientes egresados, 429 tuvieron una fractura de cadera por trauma mínimo. Estas se consideran de origen probablemente osteoporótico y se presentaron con una tasa de 3.78 por 1000 egresos por año. El 66 por ciento de estas fracturas ocurrieron en mujeres, con una edad media de 76.1 años. El 62 por ciento fueron transtrocantéricas y 19 por ciento transcervicales. Requirieron 12.2 días de hospitalización media y manejo quirúrgico en el 86 por ciento. El 12.5 por ciento de los pacientes sufrieron alguna complicación hospitalaria y 1.86 por ciento fallecieron en este lapso. El costo promedio de la estancia hospitalaria fue de US$1,266.01 (dolares americanos), más gastos quirúrgicos en la mayoría. La proyección al total de egresos hospitalarios del Sector Salud de México en 1995 revela un elevado costo directo. La fractura de cadera como una consecuencia común de la OP, representa una pesada carga económica. La única opción costo-efectiva está en la prevención tanto de la OP como de las caídas en la población general

Fractura por estrés en artritis reumatoide / Stress fracture in rheumatoid artritis

Objetivo. Describir las características clínicas y radiográficas de siete pacientes con artritis reumatoide (AR) que presentaron ocho fracturas por estrés (FE). Método. En un lapso de 10 años se reunieron retrospectivamente siete casos de pacientes con AR, que estaban bajo tratamiento y control médico. La información se obtuvo de los expedientes clínicos y estudios radiográficos. Resultados. Todas las pacientes fueron mujeres con edad promedio de 51.2 años, duración promedio de la enfermedad, 13.2 años y factor reumatoide seropositivo. Como parte de su esquema de tratamineto, todas recibían antiinflamatorio no esteroideo e inductores de remisión. Las siete pacientes estaban recibiendo dosis bajas de corticoesteroides por vía oral. Previo a la FE se enocntraban en clase funcional I-II y sin causa aparente cursaron con datos de inflamación peri o paraarticular. La radiografía inicial no fue concluyente en todos los casos, pero 3 y 4 semanas después se hizo evidente el trazo de fractura. Todas las fracturas ocurrieron en extremidad pélvica (4 en metatarsianos, 2 en el peroné y una doble en iliopubis e isquiopubis). En todos los casos se hizo un manejo conservador, con respuesta satisfactoria. Conclusiones. El dolor, la inflamación y la limitación de la función, con topografía peri o paraarticular cuando ocurre en pacientes con AR deben orientar a la posibilidad de fracturas por estrés. El seguimiento radiológico permite confirmar o descartar dicha posibilidad

Reumatólogos certificados en la República Méxicana: cuántos somos y dónde estamos

El último censo de población y vivienda (1990) reporta una cifra de 81'249,465 habitantes que se asientan sobre una superficie territorial del 1'967,183 Km cuadrados, lo cual da una densidad de población de 41 habitantes por Km cuadrado. El Consejo Mexicano de Reumatología, inicia su certificación para especialistas en 1975 con el reconocimiento de 31 reumatólogos logrando una cobertura de 10 estados con el mayor asentamiento en el Distrito Federal (16 = 51 por ciento). Con el inicio de la resistencia para especialización en Reumatología, se tiene una producción promedio de 15 especialistas por año y para 1985, se registran 169 reumatólogos, en tanto que para 1992, se tiene la cifra de 285 distribuidos en 28 estados con el mayor número en el D.F. De acuerdo con la tasa media, el crecimiento anual de la población 2.6 por ciento; la producción y distribución de reumatólogos es inadecuada ya que hay entidades que tienen un reumatólogo para una población de 84,038 a 2'620,637 habitantes. se sugiere un estudio de mercado y comportamiento del mismo para ofrecer una mejor distribución de los reumatólogos de nuevo egreso y poder obtener así una mejor cobertura poblacional

Valoración de metotrexate en artritis reumatoide refractaria / Evaluation of methotrexate in refractory rheumatoid arthritis

Con el objeto de valorar la eficacia de metotrexate en el tratamiento de la artritis reumatoide refractaria, se realizará un estudio abierto prospectivo con 20 pacientes durante dos años. Se efectuarán valoraciones clínicas y de laboratorio cada dos meses, con opción a que el paciente tenga cita abierta ante la manifestación de cualquier efecto indeseable. Para fines estadísticos, las revisiones se realizarán al inicio del tratamiento y a los dos, cuatro, seis, 12, 18 y 24 meses de iniciado el estudio. En este informe preliminar se presentan los resultados obtenidos a los seis meses de tratamiento, con los diferentes parámetros evaluados. En casi todos los análisis efectuados hasta este corte, se concluye que metotrexate es un fármaco eficaz en este tipo de padecimiento. Asimismo, en este estudio se observó que metotrexate produce una tendencia a reducir el requerimiento diario de esteroides