Rheumatology Clinical Practice Research Articles

Systematic review and meta-analysis for the 2024 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis.

The aim of this article is to update evidence on the efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) and provide information to the taskforce for the 2024 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis (RA). We searched various databases for randomised controlled trials on RA published until June 2022, with no language restriction. For each of the 15 clinical questions, two independent reviewers screened the articles, evaluated the core outcomes, and performed meta-analyses. Subcutaneous injection of methotrexate (MTX) showed similar efficacy to oral MTX in MTX-naïve RA patients. Ozoralizumab combined with MTX improved drug efficacy compared to the placebo in RA patients with inadequate response (IR) to conventional synthetic DMARD (csDMARD). Rituximab with and without concomitant csDMARDs showed similar efficacy to other biological DMARDs (bDMARDs) in bDMARD-IR RA patients. Combined Janus kinase inhibitors and MTX achieved similar clinical responses and equal safety during a 4-year period compared to tumour necrosis factor inhibitors in MTX-IR RA patients. Biosimilars showed efficacy equivalent to that of the original bDMARDs in csDMARD-IR and bDMARD-IR RA patients. This systematic review provides latest evidence for the 2024 update of the Japan College of Rheumatology clinical practice guidelines for RA management.

A preliminary survey of rheumatologists on the management of late-onset rheumatoid arthritis in Japan.

Objectives We investigated the current perspectives regarding the management of late-onset rheumatoid arthritis (LORA) among rheumatologists in clinical practice. Methods This study was performed in October 2021, and included 65 rheumatologists certified by the Japan College of Rheumatology, who were administered questionnaires (including multiple choice and descriptive formulae) regarding the management of LORA. We aggregated and analyzed the responses. Results All 65 rheumatologists responded to the survey; 47 (72%) answered that >50% of newly diagnosed patients were aged ≥65 years, 42 (65%) answered that achievement of remission or low disease activity was the treatment goal, and 40 (62%) considered patient safety to be the highest priority. Most rheumatologists are concerned about the management of conditions other than RA, such as comorbidities, financial constraints, and life circumstances that interfere with standard or recommended treatment implementation. Conclusion This preliminary survey highlighted various rheumatologists' perspectives regarding the management of LORA.

Systematic review for the treatment of older rheumatoid arthritis patients informing the 2024 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis.

To update an evidence base informing the 2024 JCR clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) in older adults. Four clinical questions (CQs) regarding efficacy and safety of drug treatment were evaluated, with CQ1 addressing methotrexate (MTX), CQ2 biological disease-modifying antirheumatic drugs (bDMARDs), CQ3 Janus kinase (JAK) inhibitors, and CQ4 glucocorticoids (GCs). Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system. Observational studies confirmed a pivotal role of MTX in the treatment of older RA patients. The meta-analysis showed that tumor necrosis factor inhibitors and JAK inhibitors were unequivocally effective in older RA patients. No data indicated that bDMARDs were unsafe for older patients. No safety data for JAK inhibitor use in older patients were available. One randomized controlled trial demonstrated that long-term treatment with low-dose GCs increased risks of GC-associated adverse events. The certainty of overall evidence was very low for all CQs. This systematic review provides the necessary evidence for developing 2024 JCR CPGs for managing older patients with RA. Continued updates on the evidence of JAK inhibitors and GC are desired.

Exploring Methotrexate Route of Administration Decisions for Adults with Rheumatoid Arthritis

Methotrexate is a common first-line treatment for rheumatoid arthritis, yet its widespread and habitual usage often leads physicians to overlook the choice of administration route when planning management strategies. A recent survey involving 30 consultant rheumatologists from France, Germany, Italy, Poland, Spain, and the UK, identified variation in the utilisation and perceptions regarding oral versus subcutaneous delivery for methotrexate. In November 2023, EMJ interviewed Roberto Caporali, Professor of Rheumatology at the University of Milan, and Head of the Department of Rheumatology and Medical Sciences at Gaetano Pini Hospital, Milan, Italy. Caporali’s expertise is in clinical practice, teaching, and research in rheumatology, mainly rheumatoid arthritis and other immune-mediated inflammatory diseases, with a focus on prognostic factors, biomarkers, and treatment for patients with moderate-to-severe active rheumatoid arthritis. During this interview, Caporali discussed the decision-making process for treating rheumatoid arthritis, with a particular focus on the use of methotrexate. The purpose was to gain insights from a rheumatology expert regarding the prevalence and management goals of the disease, and available treatment options. The interview considered key decision-making drivers and barriers to healthcare professionals when selecting the route of administration. Caporali suggested that the efficacy and safety profile of methotrexate when delivered subcutaneously may be the optimal choice for patients, often resulting in higher adherence compared to oral dosing. Caporali recommended education and re-evaluation of local guidelines to improve patient outcomes by better understanding the optimal use and efficacy of methotrexate.

Evolution and impact of a dedicated ultrasound clinic on clinical rheumatology practice at an academic medical center

BackgroundRheumatologic ultrasonography (RhUS) has grown in scope and application over the past 20 years. While many studies have shown the benefits of RhUS, few have investigated the efficacy of a dedicated clinic. This study explores the impact of a dedicated ultrasound clinic on patients and rheumatologists at an academic medical center (AMC). MethodsWe analyzed claims data for patient visits, X-rays (XR), magnetic resonance imaging (MRI), and RhUS from an AMC with an established RhUS clinic, alongside two affiliated community medical practices (CMPs) without RhUS. We also analyzed RhUS clinic records on referral indication, procedures, results, and follow-up treatment changes. Pre- and post-RhUS visit patient surveys and referring physician (RP) surveys assessed experience and impact of the RhUS clinic. ResultsFrom 2018 to 2021, referrals to the RhUS clinic substantially increased. In parallel, XR and MRI orders changed by −76 % and −43 % respectively, compared with 163 % and −24 % at CMPs. Discordance between RP pre-RhUS assessments and RhUS results were common. Patient surveys showed RhUS led to increased disease understanding and impacted thoughts and decisions about their therapy. RPs found utility in RhUS across a range of indications and were confident with RhUS results. ConclusionsThese findings suggest a dedicated RhUS clinic can be a valuable resource in clinical rheumatology practice. Implementation of a RhUS clinic at this AMC spurred rapid adoption of RhUS into clinical decision-making with notable benefits for patients and physicians alike. This may serve as a model for implementation of similar clinics at other institutions.

Practice Analysis and Determining the Knowledge and Skills Expected of a Pediatric Rheumatologist.

The scope of clinical practice of pediatric rheumatology has been difficult to define. The lack of definition prevents an accurate understanding of the knowledge and skills required of practicing pediatric rheumatologists. A practice analysis process was used with the goal of establishing a precise definition of clinical pediatric rheumatology practice. The definition of practice will improve training and the creation of relevant certification examinations. A practice analysis approach used meetings with a representative panel of pediatric rheumatologists to create a practice analysis document (PAD) and a test content outline (TCO). Panel experience, entrustable professional activities, and the current TCO were used to guide the process. Surveys were administered to fellowship program directors (PDs) and a broader group of practicing pediatric rheumatologists to revise and validate the content of the documents. A PAD was created, including 14 categories of conditions diagnosed or managed by pediatric rheumatologists and eight domains of practice, with the tasks, knowledge, and skills required to perform these tasks. The survey of PDs (n=10) indicated that the PAD content is important and useful. A TCO was created and consists of 18 domains used to define content areas to be assessed on certifying examinations. The survey of practicing pediatric rheumatologists (n=127) indicated that the TCO domains are relevant. A practice analysis process produced valuable resources for defining the clinical practice of pediatric rheumatology. The PAD and TCO can be used to develop more specific training curricula and to create relevant certification examinations.

Risk Factors and Clinical Outcomes Associated With Sarcopenia in Rheumatoid Arthritis: A Systematic Review and Meta-analysis.

Sarcopenia is underrecognized in patients with rheumatoid arthritis (RA). Risk factors of sarcopenia and its impact on outcomes in RA patients are relatively unknown. We conducted a systematic review to identify factors and outcomes associated with sarcopenia in RA. We conducted this review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. We searched PubMed, Embase, CINAHL, and Web of Science databases by combining the following search concepts: (1) RA and (2) sarcopenia. Articles were included if they included RA patients, assessed for sarcopenia using a consensus working group definition, and assessed for clinical outcomes. Meta-analysis was performed using studies that shared the same sarcopenia definition and consistency in reporting patient or disease variables. Our search identified 3602 articles. After removal of duplicates, title and abstract screen, and full-text review, 16 articles were included for final analysis. All studies had observational study designs. The pooled prevalence of sarcopenia ranged from 24% to 30%, depending on the criteria for sarcopenia used. Factors associated with sarcopenia included higher 28-joint Disease Activity Scale scores (+0.39; 95% confidence interval, +0.02 to +0.77) and baseline methotrexate use (odds ratio, 0.70; 95% confidence interval, 0.51-0.97). Baseline glucocorticoid use had a positive correlation with sarcopenia in multiple studies. Several studies found lower bone mineral density and higher incidence of falls and fractures in patients with sarcopenia. Sarcopenia is prevalent in RA, and it may be associated with higher RA disease activity, lower bone mineral density, and increased falls and fractures. Therefore, early screening of sarcopenia in RA patients is important to incorporate into clinical rheumatology practice.

Nailfold capillaroscopy in the rheumatological current clinical practice in Italy: results of a national survey

This cross-sectional online study was designed by the study group on Capillaroscopy and Microcirculation in Rheumatic Diseases (CAP) of the Italian Society of Rheumatology (SIR) to provide an overview of the management of nailfold capillaroscopy in Italian rheumatology centers. Therefore, SIR distributed the survey to its members in July 2021, and each center's physician with the most expertise in capillaroscopy completed the questionnaire. The survey was completed by 102 centers, with at least one representative from each Italian region. Ninety-three centers perform capillaroscopy, and 52 (56) conduct more than 200 investigations annually. Seventy-eight (84%) of respondents have more than five years of experience with the technique, and 75 centers (80.6%) have received certification from specific national or international training courses. In 85 centers, a videocapillaroscope with 200x magnification is employed (91.4%). The average waiting period for the examination is 2.4 months, and less than 3 months in 64 of the locations (68.8%). The study demonstrates that capillaroscopy is an integral part of both the diagnostic phase of Raynaud's phenomenon and the monitoring of autoimmune connective tissue diseases (CTDs). However, the reporting methods and timing of patient followup are heterogeneous.

An Exploration of the Implications of Sequencing Order on Group Pain Interventions in Veterans

Background: Efforts to increase acceptance and reduce avoidance behaviors in patients who suffer from chronic pain are likely to have additional beneficial effects on pain management. The primary aim of the current study was to evaluate whether a sequential approach to treatment, where acceptance-based coping strategies are taught prior to problem-focused coping strategies using manualized group therapies, improves pain-related outcomes. Methods: The current investigation is a single-group, longitudinal ex post facto study. A sample of 168 Veterans participated in the current study at a midwestern VA medical center. All participants were administered a standard pre- and post-intervention assessment battery. The primary outcome analysis was a 4 × 2 repeated-measures multivariate analysis of variance. Results: The current study did not find a significant interaction effect for intervention x time but did find a significant main effect for time. All treatment conditions were associated with decreases in pain severity, pain interference, illness-focused coping strategies, catastrophizing behaviors, and global distress. Participation in both of the combined groups did not produce significantly different pain-related outcomes compared to participation in one group. Conclusion: These findings reinforce common factors theory in psychotherapy and provide insight into treatment dosage for patients who suffer from chronic pain. The current findings underline the importance of researching pain management, as it is a fundamental aspect of clinical practice, training, and research in rheumatology.

Features Found in Indocyanine Green-Based Fluorescence Optical Imaging of Inflammatory Diseases of the Hands.

Rheumatologists in Europe and the USA increasingly rely on fluorescence optical imaging (FOI, Xiralite) for the diagnosis of inflammatory diseases. Those include rheumatoid arthritis, psoriatic arthritis, and osteoarthritis, among others. Indocyanine green (ICG)-based FOI allows visualization of impaired microcirculation caused by inflammation in both hands in one examination. Thousands of patients are now documented and most literature focuses on inflammatory arthritides, which affect synovial joints and their related structures, making it a powerful tool in the diagnostic process of early undifferentiated arthritis and rheumatoid arthritis. However, it has become gradually clear that this technique has the potential to go even further than that. FOI allows visualization of other types of tissues. This means that FOI can also support the diagnostic process of vasculopathies, myositis, collagenoses, and other connective tissue diseases. This work summarizes the most prominent imaging features found in FOI examinations of inflammatory diseases, outlines the underlying anatomical structures, and introduces a nomenclature for the features and, thus, supports the idea that this tool is a useful part of the imaging repertoire in rheumatology clinical practice, particularly where other imaging methods are not easily available.

A Practical Guide for Assessment of Skin Burden in Patients With Psoriatic Arthritis.

Rheumatologists play a pivotal role in the management of patients with psoriatic arthritis (PsA). Due to time constraints during clinic visits, the skin may not receive the attention needed for optimal patient outcome. Therefore, the aim of this study was to select a set of core questions that can help rheumatologists in daily rheumatology clinical practice to identify patients with PsA with a high skin burden. Baseline data from patients included in the Dutch South West Psoriatic Arthritis (DEPAR) cohort were used. Questions were derived from the Skindex-17 and Dermatology Life Quality Index (DLQI) questionnaires. Underlying clusters of questions were identified with an exploratory principal component analysis (PCA) with varimax rotation, after which a 2-parameter logistic model was fitted per cluster. Questions were selected based on their discrimination and difficulty. Subsequently, 2 flowcharts were made with categories of skin burden severity. Clinical considerations were specified per category. In total, 413 patients were included. The PCA showed 2 underlying clusters: a psychosocial domain and a domain assessing physical symptoms. We selected these 2 domains. The psychosocial domain contains 3 questions and specifies 4 categories of skin burden severity. The physical symptoms domain contains 2 questions and categorizes patients in 1 out of 3 categories. We have selected a set with a maximum of 5 questions that rheumatologists can easily implement in their consultation to assess skin burden in patients with PsA. This practical guide makes the assessment of skin burden more accessible to rheumatologists and can aid in clinical decision making.

Janus kinase inhibitors in immunoinflammatory diseases: 10 years of clinical practice in rheumatology

Despite great advances in the diagnosis and treatment of Immune-mediated inflammatory diseases (IMIDs), which have led to a significant improvement in the prognosis in many patients, the central medical problems of this pathology – restoring the quality of life and reducing mortality to the population level – are far from being resolved. This served as a powerful stimulus for the study of new approaches to the pharmacotherapy of IMIDs, one of which is associated with the discovery of targets for small-molecule therapeutics that inhibit intracellular “signaling” molecules JAKs (Janus kinases). The current achievements, trends and recommendations regarding the use of JAK inhibitors in the treatment of IMIDs and also in the hyper-response phase of COVID-19 are reviewed.

Are we asking the right questions about urate‐lowering therapy? Comment on the 2021 Asia‐Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout

Are we asking the right questions about urate‐lowering therapy? Comment on the 2021 Asia‐Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout

2022 EULAR points to consider for remote care in rheumatic and musculoskeletal diseases

BackgroundRemote care and telehealth have the potential to expand healthcare access, and the COVID-19 pandemic has called for alternative solutions to conventional face-to-face follow-up and monitoring. However, guidance is needed...

P023 Comparative Utility of Ultrasound in Known Vs Query New inflammatory Arthritis - a Retrospective Case-Note Audit

Abstract Background/Aims Ultrasound (US) imaging has become established in clinical Rheumatology practice to aid diagnosis and monitoring of inflammatory arthritis (IA). We firstly wanted to explore the utility of US in the assessment for active synovitis in subjects with known IA, but clinically uncertain disease control. Secondly we set out to compare this with the diagnostic contribution of US in patients presenting with new inflammatory joint symptoms and uncertain clinical synovitis. Methods Two contemporaneous samples of subjects were selected from consecutive, pre-Covid, Rheumatology Consultant-delivered Ultrasound Clinic lists in our department: (i) subjects with known IA where clinical disease activity was uncertain, and (ii) subjects without know IA who had symptoms with inconclusive signs of suspected IA. Both grey scale and power Doppler US imaging was used to determine a sonographic conclusion of active IA being present, absent or equivocal. Treatment changes/ decisions were ascertained from the next available clinic letter to explore diagnostic consequences following US. Results (i) In the sample of subjects with known IA (n = 30, mean age 53.9 years, 63% female, RA 76.7%, all on DMARDs [20% biologics]), 43.3%(n = 13) had US evidence of active IA, and 50% of inactive IA (and the remainder reported as equivocal). At clinic review (n = 30) only 6 of 13 subjects with active US IA had their DMARD treatment escalated (all within same DMARD) and 5 out of 15 subjects with inactive US IA their DMARD de-escalated. (ii) In the sample of subjects with suspected IA (n = 30, mean age 51.5 years, 73% female): 16.7% (n = 5) had US evidence of IA and 77.7% not (and remainder reported as equivocal). At the next clinic review seven patients were commenced on DMARDs: three patients with IA on US, and 4 without. Conclusion In our department, Rheumatology clinicians appear to be referring for diagnostic US in known IA from a situation approaching clinical equipoise which would suggest optimum referral practice. If we assume that this clinical equipoise also applies to the assessment and referral practice of new patients with arthralgia but uncertain clinical synovitis, our diagnostic sensitivity of US is approximately 16.7%, meaning: six patients with suspected IA need referral for US to identify one with sonographic IA. Irrespective of this, we observed that the sonographic diagnosis in known or suspected IA is commonly not followed by a concordant treatment decision, suggesting that the US diagnosis forms only part of the diagnostic ‘jigsaw’ decision process. Disclosure M. Adikari: None. C. Koutsianas: None. H. John: None. R. Klocke: None.

Drug treatment algorithm and recommendations from the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis-secondary publication.

The aim of this study was to update the Japan College of Rheumatology (JCR) clinical practice guidelines (CPG) for the management of rheumatoid arthritis (RA; JCR CPG for RA) according to recent changes in the medical environment in Japan. This article is a digest version of the guidance. We used the Grading of Recommendations, Assessment, Development, and Evaluation method to update the 2014 JCR CPG for RA. A consensus was formed by CPG panel members. We identified 36 important clinical questions regarding drug treatment and developed corresponding recommendations for RA. The recommendations included the following RA medications: non-steroidal anti-inflammatory drugs, corticosteroids, conventional synthetic disease-modifying antirheumatic drugs, biological disease-modifying antirheumatic drugs, anti-receptor activator for nuclear factor-κB ligand antibodies, and Janus kinase inhibitors, as well as the tapering and discontinuation of these medications. Recommendations regarding the efficacy and safety of treatments in the elderly and patients with comorbidities were also developed. Finally, we used these recommendations to create an original algorithm for drug treatment for RA based on the Treat-to-Target approach. The 2020 JCR CPG for RA provides a useful tool for rheumatologists, health care professionals, and patients with RA, enabling shared decision-making in a variety of clinical situations.

Non-drug and surgical treatment algorithm and recommendations for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis-secondary publication.

The aim of this study was to update the Japan College of Rheumatology (JCR) clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) and prepare an algorithm for non-drug and surgical treatments. This article is a digest version of the guidelines. The Japanese Ministry of Health, Labour and Welfare's research group, in collaboration with the JCR, used the Grading of Recommendations, Assessment, Development, and Evaluation method to update the 2014 JCR CPG for RA. The consensus was formed by CPG panel members. We raised 19 clinical questions regarding non-drug and surgical treatments for RA and developed recommendations. The treatments included exercise therapy; occupational therapy; joint injection of corticosteroids; and orthopaedic surgeries including cervical spine surgery, wrist and foot arthroplasty, ankle arthrodesis, and replacement arthroplasty of the shoulder, elbow, finger, hip, knee, and ankle. Recommendations regarding the risks of surgery and perioperative discontinuation of medications have also been developed. Based on these recommendations, we created an original algorithm for the non-drug and surgical treatment of RA. These recommendations are expected to serve rheumatologists, health care professionals, and patients with RA as tools for shared decision-making to treat residual limb joint symptoms and functional impairment.

Responding to and Driving Change in Rheumatology: Report from the 12th International Immunology Summit 2021.

The coronavirus disease 2019 (COVID-19) pandemic has accelerated changes to rheumatology daily clinical practice. The main goal of the 12th International Immunology Summit, held 25–26 June, 2021 (virtual meeting), was to provide direction for these active changes rather than undergoing change reactively in order to improve patient outcomes. This review describes and explores the concept of change in rheumatology clinical practice based on presentations from the Immunology Summit. Many of the changes to rheumatology practice brought about by the COVID-19 pandemic may be considered as having a positive impact on disease management and may help with the long-term development of more patient-focused treatment. Rheumatologists can contribute key knowledge regarding the use of immunosuppressive agents in the context of the pandemic, and according to the European League Against Rheumatism, they should be involved in any multidisciplinary COVID-19 guideline committees. New technologies, including telemedicine and artificial intelligence, represent an opportunity for physicians to individualise patient treatment and improve disease management. Despite major advances in the treatment of rheumatic diseases, the efficacy of available disease-modifying anti-rheumatic drugs (DMARDs) remains suboptimal and data regarding serological biomarkers are limited. Synovial tissue biomarkers, such as CD68+ macrophages, have shown promise in elucidating pathogenesis and targeting treatment to the individual patient. In spondyloarthritis (SpA) or psoriatic arthritis (PsA), information regarding the effectiveness of the available agents with different mechanisms of action may be integrated to manage patients using a treat-to-target approach. Early diagnosis of SpA and PsA is important for optimisation of treatment response and long-term outcomes. Improving our understanding of disease pathogenesis and practice methods may help reduce diagnostic delays, thereby optimising disease outcomes in patients with rheumatic diseases.

The Italian Society of Rheumatology clinical practice guidelines for the management of large vessel vasculitis.

Since of the last publication of last recommendations on primary large-vessel vasculitis (LVV) endorsed by the Italian Society of Rheumatology (SIR) in 2012, new evidence emerged regarding the diagnosis and the treatment with conventional and biologic immunosuppressive drugs. The associated potential change of clinical care supported the need to update the original recommendations. Using the grading of recommendations assessment, development and evaluation (GRADE)-ADOLOPMENT framework, a systematic literature review was performed to update the evidence supporting the European Alliance of Associations for Rheumatology (EULAR) guidelines on LVV as reference. A multidisciplinary panel of 12 expert clinicians, a trained nurse, and a patients' representative discussed the recommendation in cooperation with an Evidence Review Team. Sixty-one stakeholders were consulted to externally review and rate the recommendations. Twelve recommendations were formulated. A suspected diagnosis of LVV should be confirmed by imaging or histology. In active GCA or TAK, the prompt commencement of high dose of oral glucocorticoids (40-60 mg prednisone-equivalent per day) is strongly recommended to induce clinical remission. In selected patients with GCA (e.g., refractory or relapsing disease or patients at risk of glucocorticoid related adverse effects) the use of an adjunctive therapy (tocilizumab or methotrexate) is recommended. In all patients diagnosed with TAK, adjunctive therapies, such as conventional synthetic or biological immunosuppressants, should be given in combination with glucocorticoids. The new set of SIR recommendations was formulated in order to provide a guidance on both diagnosis and treatment of patients suspected of or with a definite diagnosis of LVV.

Problems related to sexuality are relevant but not addressed in rheumatology practice: results from a cross-sectional survey.

Sexual issues have a high prevalence in people with rheumatic diseases, but they are not commonly discussed in clinical practice, so we aim to determine the relevance and frequency of addressing problems related to sexuality in Rheumatology clinical practice in Mexico. We obtained data from an electronic survey applied to Mexican physicians involved in Rheumatology practice. The questionnaire was adapted from a previous study. The responses were analyzed and presented with descriptive statistics. We received 75 responses, 52% were from women, with an average age of 35.5years. Sixty-two (82.6%) participants considered problems related to sexuality as quite relevant to Rheumatology practice, but a lower proportion (10, 13.3%) approach them to the same extent. The main barriers to the management of sexual issues that we recognized were the patient's embarrassment, patient´s age, and time. Most of our participants (62.7%) considered the rheumatologist as responsible for initiating the dialogue about sexual issues. Mexican rheumatologists consider sexual issues as relevant. Further training in sexuality is warranted for health care professionals attending people with rheumatic diseases.