Rheumatism Recommendations Research Articles

Vaccination in paediatric rheumatology.

As awareness of the risk of vaccine-preventable diseases for children with rheumatic diseases has increased, vaccination has become an important clinical consideration and focus of research in paediatric rheumatology. Conflicting reports in the literature and differing advice from national bodies regarding the safety of different vaccines for this patient population have led to confusion in the minds of many rheumatologists as to what is appropriate. This article will provide an overview of crucial aspects of the recently published European League Against Rheumatism recommendations regarding vaccination of paediatric patients with rheumatic disease, and will review advances in this field since their publication.

Etanercept induces remission of polyarteritis nodosa: a case report.

Etanercept induces remission of polyarteritis nodosa: a case report.

SAT0251 Three Biological DMARDS of Different Classes Exhibit Equivalent Efficacy in Rheumatoid Arthritis Patients with Inadequate Response to Anti-TNF Monoclonal Antibodies

BackgroundThe treatment of RA has improved significantly over the past decade with the introduction of highly effective tumor necrosis factor inhibitors (TNFi). However, these drugs have little or no effect...

AB0440 Effectiveness of TNF Inhibitor versus Abatacept following Tocilizumab Failure in Patients with Rheumatoid Arthritis

BackgroundIn 2013 European League Against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA), tocilizumab (TCZ) has been added as a choice to biologic agents which are first used...

FRI0386 Efficacy and Safety of Off-Label Use of Rituximab in Refractory Lupus: Data from the Italian Multicenter Registry

BackgroundDespite the failure of two randomized controlled trials a number of open-label studies and registries suggested the efficacy of rituximab (RTX) in systemic lupus erythematosus (SLE).ObjectivesThe aim of this observational...

When and for how long should glucocorticoids be used in rheumatoid arthritis? International guidelines and recommendations.

Glucocorticoids are widely used in rheumatoid arthritis (RA); however, their effectiveness and safety is still a subject of debate. In particular, when to introduce glucocorticoids, but also when and how to taper them, are important questions for clinicians. In this paper, we will discuss the place of glucocorticoids in the European League Against Rheumatism (EULAR) recommendations for the management of RA and review the literature that was the basis for these recommendations. The recommendations cover the introduction of glucocorticoids (and for whom they are recommended), doses and duration of treatment, and tapering strategies. Items still on the research agenda include more data on safety, particularly for long-term use, and small doses of glucocorticoids.

Further Evidence for Influenza and Pneumococcal Vaccination in Patients Treated with Disease Modifying Antirheumatic Drugs and Anti-Tumor Necrosis Factor Agents

Patients with rheumatoid arthritis (RA) have increased risk of infections including possible vaccine-preventable ones1,2,3,4,5,6,7. Susceptibility to infections is considered to be partly associated with RA itself, i.e., immunological alterations as a part of the disease, disease activity, and disability2,3. Antirheumatic treatment, in particular longterm use of glucocorticoids, but also traditional disease modifying antirheumatic drugs (DMARD) and biological remedies have all been shown to increase risk of infections4,5,6. In addition, higher age, concomitant smoking, common comorbidities such as chronic obstructive pulmonary disease, diabetes mellitus, kidney disease, or malignancies contribute to increased infection risk2,3,5. Vaccination is an appealing strategy in the attempt to reduce the burden of infectious diseases in RA. The recent European League Against Rheumatism (EULAR) recommendations, based on current evidence and expert opinion, recommend that rheumatologists strongly consider annual inactive influenza and pneumococcal vaccination for their patients with inflammatory rheumatic diseases7. Similarly, the US Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) recommends these vaccines to all subjects ≥ 65 years and those treated with immunosuppressive agents8. Thus, the majority of patients with RA should get annual seasonal influenza vaccine, and pneumococcal vaccine at least once in life. However, vaccine coverage among patients with RA, including those treated with anti-tumor necrosis factor (TNF) agents is still low7,8. There are a number of reasons for low influenza and pneumococcal vaccination rates. Anti-TNF treatments as first biologics for treatment of RA have been available for some 15 years, so data on safety, immunogenicity, and effectiveness of vaccines performed under treatment with these and other biologics are still limited. Prelicensure studies … Address correspondence to Dr. Kapetanovic, E-mail: meliha.c_kapetanovic{at}med.lu.se

Dissemination and evaluation of the European League Against Rheumatism recommendations for the role of the nurse in the management of chronic inflammatory arthritis: results of a multinational survey among nurses, rheumatologists and patients

The aims of this study were to disseminate, assess agreement with, assess the application of and identify potential barriers for implementation of the European League Against Rheumatism (EULAR) recommendations for the role of nurses in the management of chronic inflammatory arthritis (CIA) using a survey of nurses, rheumatologists and patients. A Web-based survey was distributed across Europe and the USA using snowball sampling. Levels of agreement and application were assessed using a 0-10 rating scale (0 = none, 10 = full agreement/application). Reasons for disagreement and potential barriers to application of each recommendation were sought. Regional differences with respect to agreement and application were explored. In total, 967 nurses, 548 rheumatologists and 2034 patients from 23 countries participated in the survey. Median level of agreement was high in all three groups, ranging from 8 to 10 per recommendation. Median level of application was substantially lower, ranging from 0 to 8 per recommendation. Agreement and application were lowest in Eastern and Central Europe. The most commonly reported reasons for incomplete agreement were too many other responsibilities (nurses), doubts about knowledge of the nurse (rheumatologists) and fear of losing contact with the rheumatologist (patients). The most commonly reported barriers to the application were time constraints and unavailability of service. Rheumatologists responses suggested that nurses had insufficient knowledge to provide the recommended care. The EULAR recommendations for the role of nurses in the management of CIA have been disseminated among nurses, rheumatologists and patients across Europe and the USA. Agreement with these recommendations is high, but application is lower and differed across regions.

Safety of synthetic and biological DMARDs: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis

ObjectivesTo update the evidence for the safety of synthetic disease-modifying antirheumatic drugs (sDMARDs), glucocorticoids (GC) and biological DMARDs (bDMARDs) in patients with rheumatoid arthritis (RA) to inform the European League...

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update

In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have...

German guidelines for the sequential medical treatment of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs

The German Society of Rheumatology approved new German guidelines for the sequential medical treatment of rheumatoid arthritis (RA) based on the European League Against Rheumatism (EULAR) recommendations for the management of RA published in 2010. An update of the EULAR systematic literature research was performed in Medline, Embase, and Cochrane databases. Meta-analyses, controlled trials, cohort studies, and registry data addressing traditional and biologic disease-modifying antirheumatic drugs, glucocorticoids, and treatment strategies published between January 2009 and August 2011 were included. Two reviewers independently evaluated and compared the additional data that had been published after the time limit set by the EULAR recommendations. A national guideline working group developed an adapted set of recommendations. The new German guidelines were accepted by vote using an informal Delphi approach. Twelve recommendations and the resulting updated treatment algorithm were developed and approved as a practical orientation for rheumatologists. These recommendations are based on a successive treatment with traditional and biologic disease-modifying drugs depending on the individual progress of the disease and distinct patient characteristics. The German guidelines have been developed on the basis of the internationally well-recognized EULAR recommendations. In addition, more recent evidence from a systematic literature research was considered. They have been developed and approved by a group of national experts aiming at guidance for rheumatologists to reach best medical practice.

Nurse management of cardiovascular risk factors in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, multi-system inflammatory disease. The incidence and prevalence of RA varies considerably between geographic areas and over time; the prevalence of RA in adults aged > 20 years in Spain is around 0.5% (Carmona et al, 2002). People with RA also have extra-articular manifestations, presenting an increased cardiovascular morbidity and mortality risk; therefore, cardiovascular risk screening and management strategies are necessary in individuals with RA. The importance of interventions in the management of people with RA and cardiovascular risk factors is recognised by the European League Against Rheumatism (EULAR) recommendations (Peters et al, 2010). Rheumatology specialist nurses are well placed to include routine cardiovascular risk assessment for people with RA attending clinic, and to provide educational interventions to reduce cardiovascular risk, such as smoking cessation, weight loss, eating a balanced, low-fat diet and exercising regularly.

AB0455 Clinical manifestations of vascular behçet’s disease complicated with pulmonary thromboembolism

BackgroundBehçet’s disease (BD) is a chronic multisystemic vasculitis of unknown etiology with recurrent oral aphthous ulcers, genital ulcers, skin and ocular lesions. Serious complications may also occur in the intestinal...

AB0583 Does „minimal disease activity“ correlates with composite indices in patients with psoriatic arthritis?

BackgroundMinimal disease activity (MDA) [1] was proposed by EULAR as an alternative target of treatment of psoriatic arthritis (PsA) pats. in the absence of remission [2]. MDA comprises 7 items...

SAT0367 Low-Dose Anakinra is Effective for the Prophylaxis of Acute Episodes of Inflammation In Severe Tophaceous Gout.

Backgroundanakinra has been used off-label for the treatment of severe episodes of acute inflammation (EAIs) in gout [1], only a small retrospective series of 3 patients reported as prophylaxis with...

AB0989 Relationship between calcium pyrophosphate dihydrate crystal and osteoarthritis of the knee

BackgroundCalcium pyrophosphate dihydrate (CPPD) is one of the common crystals that causes crystal induced arthritis. But the relation between CPPD crystal and osteoarthritis (OA) remains controversy1. Is the crystal directly...

OP0268-PARE Patients as Partners in Research: Practical Guidelines to Optimize Collaboration

BackgroundPatient involvement in research is increasing and aims to improve relevance, validity and acceptability of research outcomes. EULAR recognizes the important role of patients and supports the collaboration between the...

SCORE and REGICOR function charts underestimate the cardiovascular risk in Spanish patients with rheumatoid arthritis

IntroductionOur objective was to determine which one of the two function charts available in Spain to calculate cardiovascular (CV) risk, Systematic COronary Risk Evaluation (SCORE) or Framingham-REgistre GIroní del COR (REGICOR), should be used in patients with rheumatoid arthritis (RA).MethodsA series of RA patients seen over a one-year period without history of CV events were assessed. SCORE, REGICOR, modified (m)SCORE and mREGICOR according to the European League Against Rheumatism (EULAR) recommendations were applied. Carotid ultrasonography (US) was performed. Carotid intima-media thickness (cIMT) > 0.90 mm and/or carotid plaques were used as the gold standard test for severe subclinical atherosclerosis and high CV risk (US+). The area under the receiver operating curves (AUC) for the predicted risk for mSCORE and mREGICOR were calculated according to the presence of severe carotid US findings (US+).ResultsWe included 370 patients (80% women; mean age 58.9 ± 13.7 years); 36% had disease duration of 10 years or more; rheumatoid factor (RF) and/or anticyclic citrullinated peptide (anti-CCP) were positive in 68%; and 17% had extra-articular manifestations. The EULAR multiplier factor was used in 122 (33%) of the patients. The mSCORE was 2.16 ± 2.49% and the mREGICOR 4.36 ± 3.46%. Regarding US results, 196 (53%) patients were US+. The AUC mSCORE was 0.798 (CI 95%: 0.752 to 0.844) and AUC mREGICOR 0.741 (95% CI; 0.691 to 0.792). However, mSCORE and mREGICOR failed to identify 88% and 91% of US+ patients. More than 50% of patients with mSCORE ≥1% or mREGICOR >1% were US+.ConclusionsNeither of these two function charts was useful in estimating CV risk in Spanish RA patients.

Maintaining remission in granulomatosis with polyangiitis (Wegener’s)

Since the introduction of combined immunosuppressive therapy with oral cyclophosphamide (CYC) and glucocorticosteroids in the 1970s, the outcome of antineutrophil cytoplasmic antibody-associated vasculitides, for example, in granulomatosis with polyangiitis (Wegener`s), improved dramatically. However, the long-term follow-up of patients treated with CYC plus glucocorticosteroids has revealed high treatment-related morbidity and mortality and a high relapse rate (up to 50%), often re-requiring CYC and glucocorticosteroids. Today, according to the European League Against Rheumatism recommendations for the management of small- and medium-vessel vasculitis, the treatment paradigm for severe courses of granulomatosis with polyangiitis consists of CYC for the induction of remission, followed by a less-toxic maintenance therapy for the prevention of relapses. Azathioprine, methotrexate, leflunomide and mycophenolate mofetil proved efficacy for maintaining remission in randomized controlled trials. However, despi...

Systemic Sclerosis in Small Bowel

e t s P t p A man with systemic sclerosis was admitted with progressive abdominal distention and vomiting. Previusly, he had recurrent episodes of vomiting. There was no istory of abdominal surgery, and a recent colonoscopy was nremarkable. Physical examination showed a tympanitic, disended abdomen with hypoactive bowel sounds. A digital rectal xamination revealed low anal sphincter tone. Laboratory inestigations indicated a total white blood cell count of 0,930/ L and mild hypoalbuminemia (3.5 g/dL). Liver and enal function was normal, and urinalysis showed no protein. A lain abdominal radiograph and computed tomography reealed the dilation of the entire small intestine (Figure A). asting and fluid supplementation relieved his symptoms. Upper endoscopy revealed reflux esophagitis. Double-balloon ndoscopy by oral route revealed a narrow separation between ircular folds of the small intestine (Figures B and C). Villous tructure was normal. A biopsy specimen from the jejunum howed only mild chronic inflammation. He received a diagnois of systemic sclerosis–related pseudo-obstruction. The paient’s symptoms improved with prokinetic drugs for motility isturbance and antibiotics for bacterial overgrowth. Systemic sclerosis is a multisystem disease characterized by xcess deposition of connective tissue in skin and internal rgans. Gastrointestinal involvement is the most frequent inernal organ complication of systemic sclerosis, with more than 0% of patients experiencing a change in gastrointestinal funcion.1 Impairment in bowel motility leads to stasis of luminal contents and secondary bacterial overgrowth. The European League Against Rheumatism recommends prokinetic drugs for motility disturbance and antibiotic rotating therapy for bacterial overgrowth or malabsorption in systemic sclerosis.2 Typical ndoscopic appearance of small bowel manifestation of sysemic sclerosis is narrow separation between circular folds depite bowel dilation. This sign is referred to as hide-bound. redominant muscle atrophy and collagenous replacement of he outer longitudinal layer relative to the inner circular layer robably account for this characteristic appearance.3