Background:The incidence of Pneumocistis jirovencii pneumonia (PCP) has increased substantially during the past years in patients with systemic autoimmune diseases (SAD). Mortality associated to PCP was reported to be up to 20 to 58%, particularly in those receiving immunosuppressive therapy, such as tumoral necrosis antagonist factors or glucocorticoid therapy. Though, there is clear evidence of the effectiveness of Cotrimoxazole against PCP, the risk of adverse effects is important, increasing morbidity and mortality. Up to date, there is no consensus about the need of PCP prophylaxis in SAD patients with immunosuppressed therapies.Objectives:To analyse the efficacy and safety of Cotrimoxazole prophylaxis against PCP in SAD adult patients receiving immunosuppressive therapies.Methods:We performed a comprehensive literature search, screening different databases, MEDLINE, EMBASE and Cochrane Library up to April 2019. Outcomes covered prevention of PCP or other infections, morbidity, mortality and safety. All categories of studies were included. Two reviewers selected and extracted data from studies. The information obtained was summarized through a narrative review and results tabulated.Results:From the initial 340 identified references, 12 were finally included. Two were randomized controlled trials, six observational studies, and four case reports. The quality in the majority of studies resulted moderate or low, with limited level of evidence. Besides, all Cotrimoxazole prophylaxis regimens described in each study were distinct. Results were consistent to exhibit the efficacy of Cotrimoxazole prophylaxis, compared to non-prophylaxis in the prevention of PCP in patients receiving immunosupresor therapy, particularly, those taking high glucocorticoid dose above 20mg/day. In terms of efficacy, Cotrimoxazole 400mg/80mg/day, given three times per week, or 200mg/40mg/day or in dose escale exhibited a similar performance. In contrast, Cotrimoxazole 400mg/80mg/day displayed a higher incidence of adverse effects.Conclusion:Cotrimoxazole prophylaxis against PCP exhibited efficacy compared to non-prophylaxis, mainly in patients treated with high dose of glucocorticoids (≥20mg/day), causing a significant reduction in mortality. Positive efficacy results did not differ despite the diverse Cotrimoxazol regimens exposed. However, Cotrimoxazole adverse effects were observed after two months from initiation; particularly with daily dose of 400mg/80mg. In contrast, escalate dose or 200mg/40mg/day dose regimens appeared better tolerated.**This review is part of the Spanish Rheumatology Society –SER- recommendations on Systemic Autoimmune Diseases.References:[1] Utsunomiya, M., et al. (2017). “Optimal regimens of sulfamethoxazole-trimethoprim for chemoprophylaxis of Pneumocystis pneumonia in patients with systemic rheumatic diseases: results from a non-blinded, randomized controlled trial.” Arthritis Res Ther 19(1): 7.[2] Yamamoto, T., et al. (2014). “A feasibility study assessing tolerability of daily versus twice weekly trimethoprim-sulfamethoxazole regimen for prophylaxis against pneumocystis pneumonia in patients with systemic autoimmune diseases on glucocorticoid therapy.” Japanese Journal of Clinical Pharmacology and Therapeutics 45(3): 89-92.Disclosure of Interests:None declared
BackgroundSarcopenia is the loss of skeletal muscle mass, strength and function that occurs as a consequence of aging. This condition result in physical disability, which limits the capacity to walk, increases the risk of falls and osteoporotic fractures. Several studies suggested an inverse relation between 25OHD serum levels, muscular strength and physical performance in the eldest.ObjectivesTo evaluate if vitamin D supplementation in patients > 50 years improves muscle mass, strength and performance in older patients.MethodsWe performed a systematic review through Medline, Cochrane Library, and EMBASE. Inclusion criteria: 1) patients > 50 years old, 2) receiving treatment with vitamin D 3) muscle mass and muscle strength measurements 4) systematic reviews (SR) 5) randomized clinical trials (RCT) 6) Papers written in English or Spanish.ResultsFive studies were included (4 SR and 1 RCT), n patients ranged from 121 to 5615. Patients mean age oscillated between 58-88 years, receiving variable vitamin D dose. Follow-up period fluctuated from 6 to 12 months. Author N° clinical studies-patients Results Beaudart 2014SRN=30(CS) n=5.615Significant increment in patients with 25OHD < 30nmol/L and > 65 years.Muscular strength SMD 0.17 (P=0.02)Muir 2011SRN=13(CS) n=2.268Significant improvement with vitamin D supplementation in:1-Postural balance reduction DME -0.20 (IC95% -0.39 a -0.01,P=0.04, I2 = 0%)2-Reduction in time to finish the test TUG -0.19 (IC95% -0.35 a -0.02, P =0.03, I2 = 0%)Beaudart 2017SRN=2 (CS) n=121No additional effect of vitamin D, except for TUG (n=1)Stockton 2011SRN=17(CS) n=5.072Patients with serum 25(OH)D <25 nmol/L caused significant improvement in hip muscular strength with vit D supplementation (DME 3.52, IC95% 2.18, 4.85).(n=2)Cangussu 2015RCTN=160Significant increment in vitamin D group.Muscular strength (chair test) 25.3% (p <0.0001)CS= Clinical studies, SR=Systematic reviews, RCT=Randomized clinical trials, SMD=Standardized mean difference, TUG= Time UP and Go.Conclusion· Vitamin D supplementation in patients > 65 years with inadequate 25OHD serum levels, improve muscular strength.· There were no benefits in muscle mass or muscular performance.References[1] Beaudart C, Dawson A, Shaw S C, Harvey N H, Kanjis J A, Binkley N, et al. Nutrition and Physical activity in the prevention and treatment of sarcopenia.: systematic review. Osteopor Int2017; 28: 1817-1833.[2] Cangussu LM, Nahas-Neto J, Orsatti CL, Bueloni-Dias FN, Nahas EAP. Effect of Vitamin D supplementation alone on muscle function in postmenopausal women: a randomized double-blind, placebo-controlled clinical trial. Osteopor Int 2015; 26:2413-2421.Disclosure of InterestsNone declared
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