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Abstract Psoriatic arthritis (PsA) is a chronic and systemic immune disease characterized by inflammation of peripheral and/ or axial joints and entheses in patients with psoriasis (PsO). Extra-articular and extracutaneous manifestations and numerous comorbidities can also be present. These recommendations replace the previous version published in May 2013. A systematic review of the literature retrieved 191 articles that were used to formulate 12 recommendations in response to 12 clinical questions, divided into 4 sections: diagnosis, non-pharmacological treatment, conventional drug therapy and biologic therapy. These guidelines provide evidence-based information on the clinical management for PsA patients. For each recommendation, the level of evidence (highest available), degree of strength (Oxford) and degree of expert agreement (interrater reliability) are reported.

https://doi.org/10.1186/s42358-021-00219-y

Revisiting hydroxychloroquine and chloroquine for patients with chronic immunity-mediated inflammatory rheumatic diseases
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Reis Neto, Edgard Torres dos

; Kakehasi, Adriana Maria

; Pinheiro, Marcelo de Medeiros

; Ferreira, Gilda Aparecida

; Marques, Cláudia Diniz Lopes

; Mota, Licia Maria Henrique da

; Paiva, Eduardo dos Santos

; Pileggi, Gecilmara Cristina Salviato

; Sato, Emília Inoue

; Reis, Ana Paula Monteiro Gomides

; Xavier, Ricardo Machado

; Provenza, José Roberto

Advances in Rheumatology

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2020, Volume 60 elocation 32

Abstract: En | Text: En | PDF: En

Abstract Hydroxychloroquine and chloroquine, also known as antimalarial drugs, are widely used in the treatment of rheumatic diseases and have recently become the focus of attention because of the ongoing COVID-19 pandemic. Rheumatologists have been using antimalarials to manage patients with chronic immune-mediated inflammatory rheumatic diseases for decades. It is an appropriate time to review their immunomodulatory and anti-inflammatory mechanisms impact on disease activity and survival of systemic lupus erythematosus patient, including antiplatelet effect, metabolic and lipid benefits. We also discuss possible adverse effects, adding a practical and comprehensive approach to monitoring rheumatic patients during treatment with these drugs.

https://doi.org/10.1186/s42358-020-00134-8 2393 downloads

The Brazilian Society of Rheumatology guidelines for axial spondyloarthritis – 2019
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Resende, Gustavo Gomes

; Meirelles, Eduardo de Souza

; Marques, Cláudia Diniz Lopes

; Chiereghin, Adriano

; Lyrio, Andre Marun

; Ximenes, Antônio Carlos

; Saad, Carla Gonçalves

; Gonçalves, Célio Roberto

; Kohem, Charles Lubianca

; Schainberg, Cláudia Goldenstein

; Campanholo, Cristiano Barbosa

; Bueno Filho, Júlio Silvio de Sousa

; Pieruccetti, Lenise Brandao

; Keiserman, Mauro Waldemar

; Yazbek, Michel Alexandre

; Palominos, Penelope Esther

; Goncalves, Rafaela Silva Guimarães

; Lage, Ricardo da Cruz

; Assad, Rodrigo Luppino

; Bonfiglioli, Rubens

; Anti, Sônia Maria Alvarenga

; Carneiro, Sueli

; Oliveira, Thauana Luíza

; Azevedo, Valderílio Feijó

; Bianchi, Washington Alves

; Bernardo, Wanderley Marques

; Pinheiro, Marcelo de Medeiros

; Sampaio-Barros, Percival Degrava

Advances in Rheumatology

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2020, Volume 60 elocation 19

Abstract: En | Text: En | PDF: En

Abstract Spondyloarthritis is a group of chronic inflammatory systemic diseases characterized by axial and/or peripheral joints inflammation, as well as extra-articular manifestations. The classification axial spondyloarthritis is adopted when the spine and/or the sacroiliac joints are predominantly involved. This version of recommendations replaces the previous guidelines published in May 2013. A systematic literature review was performed, and two hundred thirty-seven studies were selected and used to formulate 29 recommendations answering 15 clinical questions, which were divided into four sections: diagnosis, non-pharmacological therapy, conventional drug therapy and biological therapy. For each recommendation the level of evidence supporting (highest available), the strength grade according to Oxford, and the degree of expert agreement (inter-rater reliability) is informed. These guidelines bring evidence-based information on clinical management of axial SpA patients, including, diagnosis, treatment, and prognosis.

https://doi.org/10.1186/s42358-020-0116-2 1116 downloads

Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline
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Brito, Carlos Alexandre Antunes de

; Marques, Cláudia Diniz Lopes

; Falcão, Melissa Barreto

; Cunha, Rivaldo Venâncio da

; Simon, Fabrice

; Valadares, Lilian David de Azevedo

; Luz, Kleber Giovanni

; Melo, Carlos Frederico Campelo de Albuquerque e

; Albuquerque Filho, Dalcy de Oliveira

; Brito, Marina Coelho Moraes de

; Duarte, Angela Luzia Branco Pinto

Revista da Sociedade Brasileira de Medicina Tropical

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2020, Volume 53 elocation e20190517

Abstract: En | Text: En | PDF: En

Abstract Since the emergence of the chikungunya virus in Brazil in 2014, more than 700,000 cases have been reported throughout the country, corresponding to one-third of all cases reported in the Americas. In addition to its high attack rates, resulting in hundreds of thousands of cases, the disease has high chronicity rates with persistent joint manifestations for more than 3 months, which can spread to more than half of the patients affected in the acute phase. Pain associated with musculoskeletal manifestations, often disabling, has an effect on patients’ quality of life at different stages of the disease. Currently, the challenge faced by specialists is identifying the best therapy to be instituted for symptom relief despite the limited number of published intervention studies. In 2016, a multidisciplinary group published pharmacological treatment protocols for pain in patients with chikungunya, which was incorporated into the guidelines for clinical management of the Brazilian Ministry of Health in 2017; in that same year, a consensus was published by the Brazilian Society of Rheumatology about diagnosis and treatment. After 5 years of experience with chikungunya epidemics, in 2019, specialists involved in the protocols of the Brazilian Society of Rheumatology and Brazilian Ministry of Health prepared an update with the main objective of developing flowcharts for the therapeutic approach of musculoskeletal manifestations in adult patients to enable specialists at different levels of healthcare to spread and apply this guideline in a systematic and simplified manner.

https://doi.org/10.1590/0037-8682-0517-2019 1083 downloads

Peroxisome proliferator-activated receptor agonists (PPARs): a promising prospect in the treatment of psoriasis and psoriatic arthritis
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Lima, Emerson de Andrade

; Lima, Mariana Modesto Dantas de Andrade

; Marques, Cláudia Diniz Lopes

; Duarte, Angela Luzia Branco Pinto

; Pita, Ivan da Rocha

; Pita, Maira Galdino da Rocha

Anais Brasileiros de Dermatologia

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dec 2013, Volume 88 N. 6 Pages 1029 - 1035

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

A psoríase é uma doença poligênica, inflamatória, progressiva e recorrente, caracterizada por um ciclo evolutivo acelerado dos queratinócitos, associado à ativação imune desordenada e a alterações sistêmicas correlacionadas, sendo a artrite psoriásica o comprometimento articular inflamatório crônico que pode ocorrer em pacientes com a doença cutânea. Na inflamação autoimune, uma rede interativa entre células e citocinas suporta o início e a perpetuação da doença. A fisiopatologia da psoríase e da artrite psoriásica compreende uma disfunção das células do sistema imune e da rede de citocinas, levando à inflamação de pele, enteses e articulações. Estudos recentes têm demonstrado um papel importante da inflamação sistêmica no desenvolvimento da aterosclerose. Corroborando esses achados, pacientes portadores de psoríase grave apresentam marcada incidência de artrite psoriásica, doença cardiovascular, hipertensão arterial sistêmica, dislipidemia, obesidade e diabetes mellitus, evidenciando um risco aumentado para infarto agudo do miocárdio e sugerindo que a doença não se restringe à pele. Os receptores nucleares são fatores de transcrição ligante-dependente cuja ativação afeta genes controladores de processos vitais. Entre eles, destacam-se os receptores ativados pelo proliferador de peroxissoma, responsáveis por estabelecer a relação entre os lipídios, doenças metabólicas e imunidade inata. Na pele, os receptores ativados pelo proliferador de peroxissoma têm ação importante na homeostase dos ceratinócitos, exibindo uma função pró-diferenciação, antiproliferativa e imunomoduladora, sugerindo um papel relevante em doenças como a psoríase. Os agonistas dos receptores ativados pelo proliferador de peroxissoma representam uma relevante fonte de investigação no tratamento de doenças da pele. No entanto, estudos clínicos são necessários para definirmos o potencial de resposta dessas drogas em pacientes com psoríase e artrite psoriásica.

Psoriasis is a polygenic, inflammatory and progressive disease, characterized by an abnormal differentiation and hyperproliferation of keratinocytes, associated with impaired immunologic activation and systemic disorders, while psoriatic arthritis is a chronic inflammatory articular disease. Pathophysiology of psoriasis comprises a dysfunction of the immune system cells with an interactive network between cells and cytokines supporting the initiation and perpetuation of disease and leading to inflammation of skin, enthesis and joints. Recent studies have shown an important role of systemic inflammation in the development of atherosclerosis. Corroborating these findings, patients with severe Psoriasis have marked incidence of psoriatic arthritis, cardiovascular diseases, hypertension, dyslipidemia, obesity and diabetes mellitus, showing an increased risk for acute myocardial infarction, which suggests that the condition is not restricted to the skin. Nuclear receptors are ligand-dependent transcription factors, whose activation affects genes that control vital processes. Among them the peroxisome proliferator-activated receptor is responsible for establishing the relationship between lipids, metabolic diseases and innate immunity. In the skin, peroxisome proliferator-activated receptors have an important effect in keratinocyte homeostasis, suggesting a role in diseases such as psoriasis. The peroxisome proliferator-activated receptors agonists represent a relevant source of research in the treatment of skin conditions, however more clinical studies are needed to define the potential response of these drugs in patients with psoriasis and psoriatic arthritis.

https://doi.org/10.1590/abd1806-4841.20132653 4438 downloads

A importância dos níveis de vitamina D nas doenças autoimunes
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Marques, Cláudia Diniz Lopes

; Dantas, Andréa Tavares

; Fragoso, Thiago Sotero

; Duarte, Ângela Luzia Branco Pinto

Revista Brasileira de Reumatologia

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feb 2010, Volume 50 N. 1 Pages 67 - 80

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Além do seu papel na homeostase do cálcio, acredita-se que a forma ativa da vitamina D apresenta efeitos imunomoduladores sobre as células do sistema imunológico, sobretudo linfócitos T, bem como na produção e na ação de diversas citocinas. A interação da vitamina D com o sistema imunológico vem sendo alvo de um número crescente de publicações nos últimos anos. Estudos atuais têm relacionado a deficiência de vitamina D com várias doenças autoimunes, como diabetes mellitus insulino-dependente (DMID), esclerose múltipla (EM), doença inflamatória intestinal (DII), lúpus eritematoso sistêmico (LES) e artrite reumatoide (AR). O artigo faz uma revisão da fisiologia e do papel imunomodulador da vitamina D, enfatizando sua participação nas doenças reumatológicas, como o lúpus e a artrite reumatoide.

In addition to its role in calcium homeostasis, it is believed that the active form of vitamin D has immunomodulatory effects on cells of the immune system, particularly T lymphocytes, as well as on the production and action of several cytokines. The interaction of vitamin D with the immune system has been the target of a growing number of publications in recent years. Current studies have linked the deficiency of vitamin D with different autoimmune diseases, including insulin-dependent diabetes mellitus (IDDM), multiple sclerosis (MS), inflammatory bowel disease (IBD), systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA). This article reviews the physiology and immunomodulatory role of vitamin D, emphasizing its involvement in rheumatic diseases such as SLE and RA.

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Resposta atenuada ao PPD no diagnóstico de infecção tuberculosa latente em pacientes com artrite reumatoide
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Marques, Cláudia Diniz Lopes

; Duarte, Ângela Luzia Branco Pinto

; Lorena, Virginia Maria Barros de

; Souza, Joelma Rodrigues de

; Souza, Wayner

; Gomes, Yara de Miranda

; Carvalho, Eduardo Maia Freese de

Revista Brasileira de Reumatologia

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apr 2009, Volume 49 N. 2 Pages 121 - 125

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

INTRODUÇÃO: A utilização dos anti-TNF's na prática reumatológica tornou obrigatória a identificação de casos de infecção tuberculosa latente (ITBL) antes do início do tratamento, utilizando o PPD, RX de tórax e história de contato com tuberculose. Os pacientes com artrite reumatoide (AR) apresentam uma anormalidade da função celular imune, caracterizada por diminuição da responsividade de células mononucleares periféricas (linfócitos T Reg), o que acarreta prejuízo para a hipersensibilidade cutânea tardia, o que é fundamental para o reconhecimento de antígenos, como é o caso do PPD. OBJETIVOS: Avaliar a resposta ao PPD em pacientes com AR, comparado com pessoas saudáveis em uma área endêmica de tuberculose, como é o estado de Pernambuco. METODOLOGIA: Foram estudados 96 pacientes, 48 com AR e 48 indivíduos saudáveis, sendo a maioria do sexo feminino; foi realizada a inoculação de 0,1 mL do PPD RT-23, por via intradérmica e leitura da induração 72 horas após. RESULTADOS: No grupo AR o tempo médio de diagnóstico foi de 10,2 anos, a dose média de metotrexate foi de 15,5 mg/semana, dose média de prednisona foi de 12,7 mg/dia e a atividade média da doença medida pelo CDAI foi 30,4. Houve maior positividade do PPD no grupo de comparação (33,3%) quando comparado com o grupo AR (14,6%), com diferença estatisticamente significante (p = 0,034). CONCLUSÕES: Os autores alertam para o fraco desempenho do PPD para diagnóstico de ITBL em pacientes com AR e da necessidade de se fazer uma triagem ainda mais cuidadosa antes do início do tratamento com anti-TNF.

INTRODUCTION: With the introduction of Tumor Necrosis Factor Inhibitors (anti-TNFs) into rheumatological practice, it has become obligatory to identify cases of latent tuberculosis infection (LTBI) prior to the start of treatment, using PPD, chest radiography and clinical history of tuberculosis contact. Patients with Rheumatoid Arthritis (RA) have an abnormality of the cellular immune function, characterized by decreasing responsiveness of peripheral mononuclear cells (T Reg lymphocytes), leading to a loss in delayed hypersensitivity, which is fundamental for the recognition of antigens, such as PPD. OBJECTIVES: The purpose of our study was to evaluate the response to PPD in patients with RA, compared with healthy people, in an area where tuberculosis is endemic, as is the state of Pernambuco. METHODOLOGY: We studied 96 patients, 48 with RA and 48 healthy subjects, most of them females. All patients were given an interdermic injection of 0.1 mL PPD RT-23. The reading of the PPD result was carried out 72 hours after application, by way of palpation of maximum transverse diameter of induration, and the result was expressed in millimeters. RESULTS:In the RA group, the average time of diagnosis was 10.2 years, the average dosage of methotrexate was 15.5 mg / week, the average dosage of prednisone 12.7 mg / day and the average activity of the disease, measured using CDAI, was 30.4. In the healthy subjects group there was a greater number of positive PPD results (33.3%) when compared with the results for the RA group (14.6%), with a statistically significant difference (p = 0.034). CONCLUSION:The performance of PPB in LTBI diagnosis is poor in patients with RA. These results suggest that more careful screening needs to be undertaken before treatment with an anti-TNF drug.

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Rituximabe na síndrome de Felty refratária
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Fragoso, Thiago Sotero

; Dantas, Andréa Tavares

; Pereira, Maria Roberta Melo Gomes

; Marques, Cláudia Diniz Lopes

; Cavalcanti, Fernando de Souza

; Duarte, Ângela Pinto

Revista Brasileira de Reumatologia

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apr 2009, Volume 49 N. 2 Pages 188 - 190

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Os autores relatam o caso de uma paciente de 29 anos com diagnóstico de artrite reumatoide soropositiva que com seis meses de evolução desenvolveu granulocitopenia severa e esplenomegalia, embora mantivesse em remissão o quadro articular. Não apresentou resposta à corticoterapia oral e em forma de pulsos, além do metotrexato e leflunomida, tendo apresentado reação adversa ao uso do infliximabe e falta de resposta ao adalimumabe. Diante das infecções de repetição, apesar dos vários esquemas de antibióticos e uso crônico do G-CSF, dos altos títulos de fator reumatoide, dos níveis elevados da VHS e da PCR, utilizou-se o rituximabe no esquema clássico de tratamento da artrite reumatoide. Houve resposta clínica completa com aumento crescente do número de neutrófilos e normalização dos mesmos além da queda dos títulos de fator reumatoide, da VHS e da PCR. Atualmente, a paciente encontra-se em remissão clínica e laboratorial, em uso de prednisona 5 mg/dia e metotrexato 10 mg/semana.

The authors report a case of a 29 year old woman who has seropositive rheumatoid arthritis for six months, and developed severe granulocytopenia and important splenomegaly, however she didn´t show any joint inflammation. She did not respond either to pulse or oral steroids, or to oral methotrexate and leflunomide. She also developed an adverse reaction to the use of infliximab and did not respond well to adalimumab. Although she has had repeated infections, despite the various forms of antibiotics and long-term use of G-CSF, with high titers of rheumatoid factor, and high levels of ESR and CRP, the classic Rituximab method for treating rheumatoid arthritis was used. There was a good clinical response with an increase in the number of neutrophils following normalization of them, together with the reduction of rheumatoid factor titers, ESR and CRP. At the moment, the patient is in remission, according to both clinical and laboratory criteria and taking 5mg of prednisone per day and 10mg of methotrexate per week.

6013 downloads

Abordagem diagnóstica da tuberculose latente na artrite reumatóide
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Marques, Cláudia Diniz Lopes

; Duarte, Angela Luzia Branco Pinto

; Cavalcanti, Fernando de Souza

; Carvalho, Eduardo Maia Freese de

; Gomes, Yara de Miranda

Revista Brasileira de Reumatologia

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dec 2007, Volume 47 N. 6 Pages 424 - 430

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Apesar de terem revolucionado a prática reumatológica, o uso dos inibidores do fator de necrose tumoral (anti-TNFs) no tratamento da artrite reumatóide (AR) fez surgir um problema considerado solucionado em muitos países desenvolvidos: o risco elevado de reativação de infecção tuberculosa latente (ITBL). Desse modo, a identificação de casos de ITBL passou a ser obrigatória antes do início da terapêutica com anti-TNF. O teste cutâneo da tuberculina (PPD) não é um teste de screening ideal nesse grupo de pacientes em virtude de sua baixa especificidade, sua reação cruzada com antígenos vacinais e de outras micobactérias ambien-tais e, principalmente, por conta da incapacidade de o paciente com AR produzir uma resposta adequada ocasionada por uma anormalidade na responsividade das células T, característica da doença. Ensaios com base na detecção da produção de IFNgama in vitro por células mononucleares periféricas estimuladas por antígenos específicos (ESAT-6 e CFP-10), que não são encontrados na vacina BCG nem em outras micobactérias ambientais, parecem ser mais acurados que o PPD na detecção de ITBL em virtude de maior especificidade, melhor correlação com medidas indiretas de exposição ao Mycobacterium tuberculosis e menor reação cruzada com a vacinação por BCG e infecções por outras micobactérias.

Despite representing a major advance in rheumatology practice, the use of tumor necrosis factor blockade (anti-TNFs) in the treatment of rheumatoid arthritis (RA) has given rise to a problem that was considered solved in many developed countries, i.e. the heightened risk of reactivation of latent tuberculosis infection (LTBI). The identification of cases of LTBI has thus been made obligatory prior to starting any anti-TNF treatment. The cutaneous tuberculin test (PPD) is not the ideal screening test for this group of patients. Low specificity, cross-reactivity with vaccine antigens and other exogenous microorganisms coupled to a defect in the cell-mediated component of the immunological response account for the inadequacy of PPD as a screening tool in this subset of patients. Assays using the detection of in vitro IFNgamma production by peripheral blood mononuclear cells stimulated by specific antigens (ESAT-6 and CFP-10), which are found neither in the BCG vaccine nor in other micro-organisms in the environment should perform better than the PPD, owing to a presumed higher specificity as well as to correlation with indirect measures of exposure to Mycobacterium tuberculosis besides decreased cross-reactivity determined by prior BCG vaccination and/or other infections.

5422 downloads

10.

Doença de Castleman mimetizando doença de Still do adulto
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Marques, Cláudia Diniz Lopes

; Nunes, Patrícia Souza

; Duarte, Ângela Luzia Branco Pinto

; Cavalcanti, Fernando S.

Revista Brasileira de Reumatologia

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oct 2005, Volume 45 N. 5 Pages 331 - 334

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

A doença de Castleman (DC) é uma doença linfoproliferativa não neoplásica rara, de etiologia desconhecida, que se caracteriza clinicamente por adenomegalias isoladas ou múltiplas, podendo ou não estar associada a sintomas sistêmicos, como febre e perda de peso. Estes sintomas podem levar a um diagnóstico equivocado de doença auto-imune e o diagnóstico diferencial deve ser feito através de exame anatomopatológico do linfonodo acometido, que caracteristicamente, na DC, mostra um padrão de células plasmáticas com infiltrado hialino. Os autores relatam o caso de uma paciente de 24 anos de idade, com apresentação inicial de febre, poliartrite e "rash", sugerindo doença de Still do adulto cujo achado anatomopatológico confirmou o diagnóstico de DC.

Castleman's disease (CD) is rare nonmalignant lymphoproliferative illness, of unknown etiology, clinically characterized by isolated or multiple adenomegalies, associated or not with systemic symptoms such as fever and weight loss. These symptoms can lead to a wrong diagnosis of autoimmune illness and the differential diagnosis must be made through histological examination of involved lymph nodes, which shows, in the case of CD, a pattern of plasma cells with hyaline infiltration. A case of a woman of 24-year-old, who initially presented fever, polyarthritis and skin rash, suggestive adult-onset Still's disease is reported; the histological examination confirmed the diagnosis of Castleman's disease.

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