Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología / Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology

Existen varias guías de práctica clínica tanto nacionales como internacionales para el tratamiento del lupus eritematoso sistémico. No obstante, la mayoría de las guías disponibles no están diseñadas para población mexicana o solamente son para el manejo de manifestaciones específicas como nefritis lúpica o para algún estado fisiológico como el embarazo. El Colegio Mexicano de Reumatología se propuso elaborar unas guías de práctica clínica que conjuntaran la mayor parte de las manifestaciones de la enfermedad y que incluyeran adicionalmente pautas en situaciones controversiales como lo son la vacunación y el periodo perioperatorio. En el presente documento se presenta la «Guía de práctica clínica para el manejo del lupus eritematoso sistémico» propuesta por el Colegio Mexicano de Reumatología, que puede ser de utilidad principalmente a médicos no reumatólogos que se ven en la necesidad de tratar a pacientes con lupus eritematoso sistémico sin tener la formación de especialistas en reumatología. En esta guía se presentan recomendaciones sobre el manejo de manifestaciones generales, articulares, renales, cardiovasculares, pulmonares, neurológicas, hematológicas, gastrointestinales, respecto a la vacunación y al manejo perioperatorio

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus» proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period

Clinical practice guidelines for the treatment of systemic lupus erythematosus by the Mexican College of Rheumatology. / Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología.

There are national and international clinical practice guidelines for systemic lupus erythematosus treatment. Nonetheless, most of them are not designed for the Mexican population or are devoted only to the treatment of certain disease manifestations, like lupus nephritis, or are designed for some physiological state like pregnancy. The Mexican College of Rheumatology aimed to create clinical practice guidelines that included the majority of the manifestations of systemic lupus erythematosus, and also incorporated guidelines in controversial situations like vaccination and the perioperative period. The present document introduces the «Clinical Practice Guidelines for the Treatment of Systemic Lupus Erythematosus¼ proposed by the Mexican College of Rheumatology, which could be useful mostly for non-rheumatologist physicians who need to treat patients with systemic lupus erythematosus without having the appropriate training in the field of rheumatology. In these guidelines, the reader will find recommendations on the management of general, articular, kidney, cardiovascular, pulmonary, neurological, hematologic and gastrointestinal manifestations, and recommendations on vaccination and treatment management during the perioperative period.

Escenario actual de los medicamentos biocomparables en México: posicionamiento del Colegio Mexicano de Reumatología, 2016 / Current state of biosimilars in Mexico: The position of the Mexican College of Rheumatology, 2016

El presente documento refleja el posicionamiento del Colegio Mexicano de Reumatología y de expertos sobre el uso de medicamentos biocomparables (conocidos como biosimilares en otros países) en enfermedades reumáticas. En resumen, este posicionamiento considera que si bien los biocomparables deben considerarse como intercambiables, no es ética la sustitución automática de medicamentos sin previo aviso en pacientes estables durante el seguimiento; que la aprobación de un biocomparable debe llevarse a cabo solo después de revisar exhaustivamente las pruebas preclínicas y clínicas señaladas por la ley mexicana; que debe modificarse la forma de enfatizar en su nomenclatura que se trata de un medicamento biotecnológico innovador o biocomparable de manera clara; que no es adecuado elegir como tratamiento un biocomparable basándose únicamente en aspectos económicos ni realizarse la extrapolación de indicaciones basándose únicamente en la aprobación obtenida por el innovador y en ausencia de datos de seguridad y eficacia para el biocomparable

The present document is a position statement of the Mexican College of Rheumatology on the use of biosimilars in rheumatic diseases. This position considers that biosimilars should be considered as interchangeable, that automatic substitution without previous notice in stable patients during follow-up is not ethical, that the approval of a biosimilar should only be given after exhaustive review of preclinical and clinical data marked by Mexican regulations, that it should be clearly stated in the nomenclature of biologic drugs which is the innovator and which is the biosimilar, that it is not correct to choose a biosimilar as treatment based only on economic reasons or extrapolate indications based only on the approval of the innovator and in the absence of safety and efficacy data for the biosimilar

Current state of biosimilars in Mexico: The position of the Mexican College of Rheumatology, 2016. / Escenario actual de los medicamentos biocomparables en México: posicionamiento del Colegio Mexicano de Reumatología, 2016.

The present document is a position statement of the Mexican College of Rheumatology on the use of biosimilars in rheumatic diseases. This position considers that biosimilars should be considered as interchangeable, that automatic substitution without previous notice in stable patients during follow-up is not ethical, that the approval of a biosimilar should only be given after exhaustive review of preclinical and clinical data marked by Mexican regulations, that it should be clearly stated in the nomenclature of biologic drugs which is the innovator and which is the biosimilar, that it is not correct to choose a biosimilar as treatment based only on economic reasons or extrapolate indications based only on the approval of the innovator and in the absence of safety and efficacy data for the biosimilar.

Doctor-Patient Relationship Between Individuals With Fibromyalgia and Rheumatologists in Public and Private Health Care in Mexico.

The aim of this article was to describe and analyze the doctor-patient relationship between fibromyalgia patients and rheumatologists in public and private health care contexts within the Mexican health care system. This medical anthropological study drew on hospital ethnography and patients' illness narratives, as well as the experiences of rheumatologists from both types of health care services. The findings show how each type of medical care subsystem shape different relationships between patients and doctors. Patient stigmatization, overt rejection, and denial of the disease's existence were identified. In this doctor-patient-with-fibromyalgia relationship, there are difficult encounters, rather than difficult patients. These encounters are more fluid in private consultations compared with public hospitals. The doctor-centered health care model is prevalent in public institutions. In the private sector, we find the characteristics of the patient-centered model coexisting with the traditional physician-centered approach.

First acute gout attacks commonly precede features of the metabolic syndrome.

OBJECTIVE: To determine in gout patients, the temporal relationship between the first gout attack and the diagnosis of metabolic syndrome (MS), its components and complications. SUBJECTS AND METHODS: We included consecutive gout patients attending 2 Rheumatology Departments from Spain (Hospital Universitario Reina Sofía) and México (Hospital General de México). Variables included demographic, clinical, and biochemical data: Hypertension, hypertriglyceridemia, low high density lipoproteins (HDL), obesity, hyperglycemia or diabetes, MS (Adult Treatment Pane III criteria), ischemic heart disease (IHD), and chronic renal failure (CRF). Age and date (year) of the diagnosis of first acute gout attack and associated diseases were obtained. RESULTS: Four hundred seven patients were included (96% men); mean age at onset, mean age at inclusion, and mean duration of the disease were 39.7 +/- 13, 52.5 +/- 13, and 13.7 +/- 9.9 years, respectively. In 90%, the first attack of gout preceded the diagnosis of features of MS, MS itself or its complications (CRF and IHD), 9.8% had previous diagnosis of at least 1 associated disease. At the time of the inclusion (mean, 13.7 years after the first attack), 93% had at least 1 associated disease. The most common were hypertriglyceridemia, 63%; obesity, 54%; hypertension, 45.6%; MS, 40%; hyperglycemia, 37%; low HDL, 17%; diabetes, 15%; CRF, 17%; and IHD, 6.6%. Although patients from the 2 Rheumatology Departments had several demographic and clinical differences, in both groups most of the patients (70% Hospital Universitario Reina Sofía and 95% Hospital General de México) had no diagnosis of any associated disease previous to first bouts and at inclusion most of them had the diagnosis of at least 1 associated disease. CONCLUSIONS: First attacks of gout may precede the diagnosis of metabolic abnormalities and associated diseases, and provids a unique opportunity to diagnose, prevent, and/or retard long-term complications in these patients.

Registro Iberoamericano de Espondiloartritis (RESPONDIA): México / RESPONDIA. Iberoamerican Registry of Spondyloarthritis: México

Objetivo: Describir las características principales de las espondiloartritis en la población mexicana. Material y métodos: Se trata de un análisis descriptivo y transversal de la información recogida y almacenada entre enero de 2006 y diciembre de 2007, y almacenada en línea en la página electrónica del grupo de Registro de Espondiloartropatías de la Sociedad Española de Reumatología (REGISPONSER). La metodología general se expone en otro artículo de este número. Resultados: Se incluyó a 172 pacientes (102 varones, [59,3%] con una edad media desviación estándar de 38 14 años). La mayoría tenía espondilitis anquilosante; luego, espondiloartritis indiferenciada. La edad al inicio fue 28 14 años; el 30% empezó antes de los 16 años. El tiempo hasta el diagnóstico fue de 5 años. La forma de inicio más frecuente fue la combinación de artritis periférica y síntomas axiales (72,7%); el 18% había tenido uveítis. El tratamiento incluyó bloqueadores del factor de necrosis tumoral alfa en el 12%. El Bath Ankylosing Spondylitis Disease Activity Index fue de 4,5 y el Bath Ankylosing Spondylitis Functional Activity Index, de 4,0. Las diferencias entre espondilitis anquilosante, espondiloartritis indiferenciada y artritis psoriásica fueron: distribución por sexo, tiempo de evolución en el momento del diagnóstico, síntomas y signos por afección del esqueleto axial, artritis en las extremidades superiores, afección coxofemoral, tarsitis e intensidad del dolor. Conclusión: En pacientes mexicanos, las espondiloartropatías parecen tener un perfil caracterizado por la combinación de manifestaciones axiales y periféricas (AU)

Objective: To describe the main features of spondylarthritis (SpA) in Mexicans. Material and methods: This is a cross sectional, descriptive study of the information was collected and stored on-line in the Registro de Espondiloartropatías de la Sociedad Española de Reumatología (REGISPONSER) between January, 2006 and December, 2007. Methods are described elsewhere in this number. Results: We included 172 patients (102 males [59.3%]; mean age standard deviation 38 14 years). Most patients had ankylosing spondylitis; then, undifferentiated SpA. Age at onset was 28 14 years; 30% had onset < 16 years; time to diagnosis was 5 years. Combined peripheral arthritis and axial involvement was the commonest disease pattern at onset (72.7%); 18% had uveitis. Treatment included tumour necrosis factor in 12%. The Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index were 4.5 and 4.0. Differences between ankylosing spondylitis, undifferentiated SpA, and psoriatic arthritis consisted of sex distribution, time to diagnosis, axial symptoms, upper limb arthritis, hip disease, tarsitis, and pain. Conclusion: The pattern of SpA in Mexicans is characterized by combined axial and peripheral involvement (AU)

Tumor necrosis factor-alpha promoter polymorphisms in Mexican patients with spondyloarthritis.

To evaluate the role of tumor necrosis factor-alpha (TNF-alpha) gene as susceptibility marker for spondyloarthritis (SpA), two polymorphisms (-238 and -308 positions) were analyzed in 229 patients with SpA (113 with ankylosing spondylitis [AS], 92 with undifferentiated SpA [U-SpA], 24 with reactive arthritis), and 169 ethnically matched healthy control subjects. The HLA-B alleles were detected by PCR-SSP technique and the TNF-alpha polymorphism by PCR-RFLP. In comparison with healthy control subjects, the frequencies of TNF-238 in SpA were similar. In contrast, the analysis of -308 polymorphism showed increased frequencies of the T2(A) allele in the whole SpA group (p < 0.05, pC = NS, OR = 1.83) as well as the T2(A) allele (pC < 0.05, OR = 2.4) and T1T2(AG) genotype (p < 0.05, pC = NS, OR = 2.25) in U-SpA patients. Comparison of B27-negative patients and healthy control subjects yielded similar results. There was no significant correlation between TNF genotypes and clinical data. The present study demonstrates that TNF-alpha -308 polymorphism appears to be associated with the genetic susceptibility U-SpA. The association seems independent of the susceptibility conferred by the HLA-B27 in this group of patients.

Microquimerismo fetal en enfermedades reumáticas / Fetal microchimerism in rheumatic diseases

El microquimerismo fetal es la presencia de células fetales en tejidos maternos y viceversa, es decir, la coexistencia de 2 poblaciones celulares diferentes, originadas en individuos genéticamente distintos, presentes en un solo individuo. La causa más frecuente es el microquimerismo asociado al embarazo debido a un intercambio bidireccional de células feto-madre, lo cual sucede durante el embarazo y el parto. Las células fetales se han demostrado en los tejidos de pacientes con enfermedades reumatológicas, endocrinas o infecciosas, así como en sujetos sanos. La enfermedad en la que mejor se ha demostrado el papel del microquimerismo es la esclerosis sistémica. Se sugiere que, durante el embarazo, las células fetales o maternas alógenas atraviesan la placenta de forma bidireccional y persisten en la circulación y tejidos de ambos, posteriormente son activadas e inician una reacción injerto contra huésped, relacionada con el inicio de las manifestaciones clínicas. También se ha demostrado algún papel del microquimerismo en otras enfermedades del tejido conectivo(AU)

Fetal microchimerism is the presence of fetal cells in maternal tissues and vice versa, i.e., the coexistence of 2 different cellular populations from genetically different individuals within a single person. The most frequent cause of microchimerism is pregnancy, in which there is a bi-directional fetal-maternal interchange of cells during pregnancy and delivery. Fetal cells have been demonstrated in the tissues of patients with rheumatic, endocrine or infectious diseases, as well as in those of healthy individuals. Microchimerism has been most extensively studied in systemic sclerosis. It seems that during pregnancy allogenic fetal or maternal cells cross the placenta bidirectionally and persist in the systemic circulation and tissues of both mother and child. Subsequently, they are activated, resulting in is a graft-against-host reaction associated with the onset of clinical manifestations. Microchimerism has been also studied in other connective tissue diseases(AU)

[Fetal microchimerism in rheumatic diseases]. / Microquimerismo fetal en enfermedades reumáticas.

Fetal microchimerism is the presence of fetal cells inmaternal tissues and vice versa, i.e., the coexistence of2 different cellular populations from genetically differentindividuals within a single person. The most frequentcause of microchimerism is pregnancy, in which there is abi-directional fetal-maternal interchange of cells duringpregnancy and delivery. Fetal cells have been demonstrated in the tissues ofpatients with rheumatic, endocrine or infectious diseases,as well as in those of healthy individuals. Microchimerism has been most extensively studied insystemic sclerosis. It seems that during pregnancyallogenic fetal or maternal cells cross the placenta bidirectionallyand persist in the systemic circulation andtissues of both mother and child. Subsequently, they areactivated, resulting in is a graft-against-host reactionassociated with the onset of clinical manifestations.Microchimerism has been also studied in otherconnective tissue diseases.