BackgroundThe Sjögren syndrome (SS) is an autoimmune disease where the cellular and humoral mechanisms affect the exocrine glands. In 2016, new classification criteria validated by ACR and EULAR were established.ObjectivesTo compare the new criteria with those used so far in our hospital, as well as to assess the need for changes in the current diagnostic strategy.MethodsRetrospective observational study in which 65 patients diagnosed with SS at the Hospital of Leόn were randomly included. We reviewed the diagnostic tests performed and the fulfilment of the different classification criteria developed since 1993. Other variables studied were: sex; age at the time of diagnosis and the months from the onset of symptoms; xerostomia and xerophthalmia; extraglandular involvement, ESSDAI; immunosuppression; Raynaud; lymphoma development; and analytical alterations.ResultsThe mean age at the time of diagnosis was 54.9 years ±14 | 23–82 |, with an average of months from the onset of symptoms to the diagnosis of 10.2±9.5 | 0–36|. 90.8% were women. 87.7% presented xerostomia; and 91% showed xerophthalmia, being severe in 43.1%. 64.6% had extraglandular manifestations; being the most prevalent the joint manifestation (60%) and the cutaneous one (18.4%). Over the past year, 37% developed haematological alterations in the form of cytopenias, and 73% biological alterations. At the time of the study, 32.8% presented low activity, 38.5% moderate activity and 9.2% high activity, measured by ESSDAI; being higher in anti-Ro positive patients (p=0.011). There was no association between ESSDAI and other antibodies, Raynaud or severe ocular involvement. 10.8% required systemic immunosuppression (RTX 5, AZA 2) and 18.5% needed ocular immunosuppression (topical cyclosporine). Only one patient developed lymphoma.A Schirmer's test (ST) was performed in 92.3% (positive in 89.2%), saving the Van Bijsterveld test for patients with severe ocular involvement. The Ocular Staining Score (OSS) was not performed in any patient.The scintigraphy of the salivary glands was positive in 70.8% of the patients and was not performed in 21.5%. The parotid sialography was only performed in two patients and the study of the salivary flow was not stimulated in none of them.Regarding the autoimmunity, 80% presented positive antiRo; 61.5% antiLa; 89% ANA; 61.5% RF; 43% quadruple positivity.Labial gland biopsy was performed only in 18.4%, with a positive result in 75%.All patients met the 1993 European Criteria; 86.2% met the European-American criteria of 2002; and only 10.8% met the SICCA-ACR Criteria. The new criteria validated by ACR and EULAR were verified in 80%. Four patients who fulfilled the European criteria did not meet the new criteria, coinciding with those patients with negative ST, but positive scintigraphy.ConclusionsIn our hospital, the method for electing the xerostomia study was the salivary scintigraphy; therefore, we cannot establish direct comparisons with the new criteria.The incorporation of non-stimulated salivary flow in our diagnostic str...
BackgroundSarcoidosis is a systemic granulomatous disease, being the joint involvement a poorly studied manifestation.ObjectivesTo describe the clinical and demographic characteristics of patients with sarcoidosis, paying particular attention to the joint involvement and its possible relationship with other extra-articular manifestations, as well as the treatment recieved.MethodsA retrospective, observational study that included 104 patients who were admitted to the Hospital of Leόn between January 2011 and December 2015 with main or secondary diagnosis of sarcoidosis; according to clinical onset, imaging tests and/or anatomopathological study. The variables studied were: age at the time of diagnosis, sex, type of joint involvement, forms of extra-articular involvement, serologic parameters and drugs received. Statistical analysis was performed using SPSSv22.0, p<0.005.Results57.7% of the patients included in the study were women with a mean age of 53.42±18.4 years. At the systemic level, 35% of them presented fever, 66.3% lymphadenopathy and 4.8% splenomegaly. 97.1% of the patients presented pulmonary involvement, with stage II being the most common (46.2%). Only 8 patients had cardiac abnormalities. Ocular involvement was observed in 10.6%, predominating uveitis. The most common renal manifestation was hypercalciuria in 6.7%. The presence of neurological involvement was exceptional, detecting 3 cases of neurosarcoidosis. In the cutaneous involvement (2.9%), erythema nodosum predominated (17.3%). The CRP levels were normal in 44.3% (<5mg/dl) and high levels of CRP were found in 25.3% of the sample (>30mg/dl). 62.6% presented pathological figures of ACE. The joint involvement was present in 38.5% of the patients (14.4% in the form of arthralgia, 2.9% as periarthritis, 13.5% as acute arthritis, 4.8% as chronic arthritis and 2.9% as sacroiliitis). The 19,23% debuted as Löefgren syndrome, being seen an association between the presence of acute arthritis and erythema nodosum (p0,000). The mean age observed in patients with acute arthritis was lower than the one of the other patients with other joint manifestations (p0.044) and a statistically significant relationship was observed between the absence of joint and ocular involvement (p0,011). Regarding the treatment of joint manifestations, 30.77% of the cases were resolved with NSAIDs, 46.15% with corticosteroids in a monotherapy and 15.38% required an immunosuppressant. In our study, most patients treated with corticosteroids did not show articular nor ocular involvement (p0,018), although when analysing the ocular involvement separately, many received corticoid treatment (42.86%). Only one patient required Adalimumab for refractory uveitis and another presented anti-TNFα-induced sarcoidosis (Infliximab).ConclusionsThe pulmonary involvement is the predominant one in patients with sarcoidosis. The acute arthritis occurs in younger patients and is associated with the onset of erythema nodosum. The joint involvement is usually not severe and, although it has not been dem...
Background:A bias has been described with the lowest prescription of biologic treatments (bDMARD) in patients with rheumatoid arthritis (RA) in the elderly, despite presenting activity rates comparable to young population and higher risk of functional disability. This could be due to concerns about co-morbidities and polypharmacy1.Objectives:1) To define the characteristics of patients with RA ≥65 years and bDMARD to follow up in the Day Hospital of University Assistance Complex of León during the last year. 2) To record the incidence rate (IT) and ratio of incidence rates (RDI) of infections, neoplasms and cardiovascular events (CD) during the course of your therapy.Methods:Observational, retrospective study of patients diagnosed with RA according to ACR 1987 and/or ACR 2010 criteria in intravenous biological treatment during 2019 with ≥65.Results:40 patients with an average age at diagnosis of 55.9±15.76 years were included, 67.5 % of them were women. The average duration of the disease was 17.65±13.15 years. 40% had a history of smoking, 35% hypertension, 20% dyslipemia and 20% diabetes mellitus. A 97.5% were positive FRRA, 57% positive ACPA, 37.5% nodular and 65% erosive. As for pre-treatment, 70% had been with conventional (cDMARD) ≥2DMARD (Methotrexate (MTX) (92.5%) and Leflunomide (60%)). The mean dose of prednisone was 8.79 ±10.14 mg/day. The incidence rate of infections was 1.5%, and neoplasms and CD were 0.75% per person-years. The age at the beginning of the first bDMARD was 67.45 ± 8 years, the second (n=20) 67.98±6.64 and the third (n=7) 71.79±7.49. The first biological was a 52.5% anti-TNF, 5% anti-CTLA4, 30% anti-CD20 and 12.5% antiIL6 (25% monotherapy and combined with MTX 57.5%). The second was 30% anti-TNF, 25% antiCTLA4, 15% antiIL6 and 30% antiCD20 (50% in monotherapy and 40% methotrexate); with the third anti-TNF 42.85%, antiCTLA4 14.29%, antiIL6 14.29% and antiCD20 28.57% (42.86% in monotherapy and 42.46 with methotrexate). The mean doses of prednisone were 6.08±6.82, 4.38±7.21 and 6.95±5.94 mg/day respectively. The IT of bDMARD infections were 8.81%, 19.81% and 7.4% person-years; of neoplasia 1.04%, 0 and 0; and EC 3.63%, 0 and 1.85 person-years. The RTIs with first, second and third biological infections were: 5.88, 13.25, 4.95; with neoplasms 1.38; with EC 1.38, 0 and 0.69. The mean total accumulated corticosteroid dose was 17.69±15.01 mg/day.Conclusion:1) Patients over 65 years old receiving bDMARD in our Day Hospital in 2019 were long-standing RA with aggression data, who had not responded to ≥2 cDMARD and required medium-high doses of prednisone.2) In our sample there is a link between incidence of infection and the introduction of biological therapy, which is maintained with the increasing age of our patients, and it is not so clear with neoplasms and CD. These data are consistent with the existing literature1,2,3.3) Larger, comparative studies with RA under 65 years are needed, but it is reasonable to conclude that if bDMARD is required, elderly patients could be a high-risk group for infections, requiring special monitoring and follow-up.References:[1]Alla Ishchenko, Rik J. Lories. Safety and Efficacy of Biological Disease-Modifying Antirheumatic Drugs in Olfer Rheumatoid Arthritis Patients: Staying the distance. Drugs Aging 2016;(33):387-398.[2]Atsuko Murota, Yuko Kaneko, Kunihiro Yamaoka y Tsutomu Takeuchi. Safety of Biologic Agents in Elderly Patients with Rheumatoid Arthritis. J Rheumatol 2016; (43): 1984-1988.[3]Kosuke Ebina, Motomu Hashimoto, Wataru Yamamoto, Toru Hirano, Ryota Hara, Masaki Katayama et al. Drug tolerability and reasons for discontinuation of seven biologics in elderly patients with rheumatoid arthritis. The ANSWER cohort study. PLoS ONE 14 (15):e0216624Disclosure of Interests:None declared
Background:The antimalarials remain to be the main treatment for Systemic Lupus Erythematosus (SLE). Its most important limitation when you want to increase dose or remain using them is the occurrence of retinal toxicity, which appears in a small number of patients. Since the lesions can progress even with drug withdrawal is important to perform a screening for an early diagnosis.Objectives:To describe ocular toxicity in patients with SLE treated with antimalarials that attended the rheumatology office and to identify possible associated risk factors.Methods:We performed a cross-sectional, retrospective study of SLE patients diagnosed of antimalarial drugs associated retinopathy, that were included in the data base of the Rheumatology department in León`s Hospital between 2014-2019. Multiple clinical and therapeutic factors potentially associated with retinal toxicity were analyzed including: age, chronic kidney disease (CKD), liver failure, smoking, hypertension, Diabetes mellitus, presence of previous retinopathy, type of treatment, duration, daily dose and cumulative dose and tamoxifen intake. The diagnosis of retinopathy was performed by the Ophthalmology department. The dose of hydroxychloroquine (HCQ) used was of 400mg/day and chloroquine (CQ) 250mg/day.Results:437 medical records were analyzed, 20 patients diagnosed of antimalarial retinopathy were included (4,57%), 90% of them were women. The age of diagnosis was more than 40 years in 18 patients (90%) and more than 60 years in 10 (50%) with a median of 60 years (IQR: 32,25).The duration of treatment was ≤ 5 years in 10 patients (50%), between 6-10 years in 6 (30%), between 11-15 years in 2(10%) and between 16-20 years in 2 (10%) with a median of exposure of 5,5 years (IQR: 6,5); 15 patients (75%) were in treatment with HCQ, with CQ 2 patients (10%) and with both of them sequentially 3 patients (15%).Of the group of patients treated with HCQ 35 % were above the global accumulated recommended dose (1000 g) and 71% of them were on treatment more than 10 years. In the group treated with CQ none were above the global recommended dose (460g). Of the 3 patients that took both drugs, two were above the recommended dose for HCQ.25% of the patients had CKD and 10% liver failure, 20% of the patients were active smokers and 15% ex-smokers.10% of the sample had previous retinopathy related with other comorbidities (age related retinopathy and diabetes), associating hypertension and diabetes mellitus in the same percentage (15%).Severe retinopathy was found in 1 patient (5%), mild-moderate in 9 patients (45%), retinopathy stages were not specified in 10 patients (50%).Conclusion:In our sample we observed a prevalence of antimalarials retinopathy of 4,57%, similar of what is found in the literature. Half of the patients had retinopathy in a period of treatment ≤ 5 years, being a described risk factor the duration of treatment of more than 6 years. This early manifestation could be related to the presence of other comorbidities like hypertension, diabetes and CKD.Dose readjustment should be considered in patients with a period of treatment of more than 10 years. Age seems to be an associated factor for the development of antimalarials retinopathy and to perform a screening in the first year of treatment is important to rule out basal disease related with more risk to develop ocular toxicity.References:[1]Jorge, A., Ung, C., Young, L.H. et al. Hydroxychloroquine retinopathy — implications of research advances for rheumatology care. Nat Rev Rheumatol 14, 693–703 (2018).[2]Mukwikwi ER, Pineau CA, Vinet E. et al. Retinal Complications in Systemic Lupus Erythematosus Patients Treated with Antimalarial Drugs. J Rheumatol. 2019 Sep 1. jrheum.181102[3]Abdulaziz N, Shah AR, McCune WJ. Hydroxychloroquine: balancing the need to maintain therapeutic levels with ocular safety: an update. Curr Opin Rheumatol. 2018 May;30(3):249-255.Disclosure of Interests:None declared
Background:Tofacitinib (TOFA) is the first inhibitor of JAK kinases with approval for the treatment of psoriatic arthritis (PsA) in Europe (July 2018)1. ToFA has shown efficacy in refractory patients to anti-TNF2.Objectives: A) to assess efficacy and safety of TOFA in the first cases in Spain in clinical practice. B) to compare the profile of clinical practice patients with clinical trial.Methods:Study of 41 patients of clinical practice with PsA treated with TOFA in Spain. The diagnosis of PsA was made using CASPAR criteria. Patients who received at least one dose of TOFA were included. Results are expressed as percentage, mean±SD or median [IRQ].Results:41 patients (23♀/18♂), mean age of 50.2±10.7 years (table 1). Pattern joint involvement was as follows: peripheral (n=25), axial (1) and mixed (15). During the PsA evolution, in addition to arthritis, patients also presented enthesitis (60.9%), nail involvement (39%) and dactylitis (31.7%).Prior TOFA, most patients had received oral prednisone or equivalent (max. 17.9±13.6 mg/d), synthetic immunosuppressants (mean 1.9±0.7) and biological therapy (TB) (3.4±1.9). TB were as follows: etanercept (29), adalimumab (29), infliximab (16), golimumab (13), certolizumab (14), secukinumab (30), ustekinumab (22). Apremilast was used in 10.After a mean follow-up of 12.6±9.1 years after the PsA diagnosis, TOFA was started (5 mg/12 h). 60.9% associated prednisone (9.4±6.1 mg/d). In 17 (41.5%) TOFA was started in combined therapy: methotrexate (9) and leflunomide (8); in the remaining 24, monotherapy was prescribed. In addition to active arthritis patients presented skin involvement (53.6%), enthesitis (26.8%), nail involvement (29.2%) and dactylitis (17.1%).Patients of clinical practice compared with clinical trial have a longer duration of PsA, functional disability (HAQ) and received a higher proportion of corticosteroids and TB (anti-TNF and non-anti-TNF) ( table 1 ).After a median follow-up of 4 [3-10.5] months, patients showed prompt improvement in the main variables, both in activity indexes (PASI, DAS28, DAPSA) and laboratory test (table 2). Minor side effects were reported in 10 patients (gastrointestinal symptoms), and TOFA was discontinued in 1 due to persistent symptoms.Conclusion:In this preliminary study, first patients of clinical practice in Spain with TOFA in PsA had a longer evolution and received a greater number of TB than those of clinical trial. As in the TOFA clinical trial, it seems effective, rapid and relatively safe in daily clinical practice for refractory PsA.References[1] https://www.ema.europa.eu/documents/overview/xeljanz-epar-medicine-overview_es.pdf[2] Gladman D. N Engl J Med2017; 377: 1525-36.Disclosure of interests:José Luis Martín-Varillas: None declared, Eva Galindez: None declared, Esteban Rubio Romero: None declared, agusti Sellas-Fernández: None declared, Roberto Daniel Gonzalez Benitez: None declared, Beatriz Joven-Ibáñez Speakers bureau: Celgene, Novartis, MSD, Pfizer, abbVie, and Janssen, José Campos Esteban: None declared, Olga Rusinov...
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