Update of the guidelines for the pharmacological treatment of rheumatoid arthritis by the Mexican College of Rheumatology 2023.

OBJECTIVE: To develop updated guidelines for the pharmacological management of rheumatoid arthritis (RA). METHODS: A group of experts representative of different geographical regions and various medical services catering to the Mexican population with RA was formed. Questions based on Population, Intervention, Comparison, and Outcome (PICO) were developed, deemed clinically relevant. These questions were answered based on the results of a recent systematic literature review (SLR), and the evidence's validity was assessed using the GRADE system, considered a standard for these purposes. Subsequently, the expert group reached consensus on the direction and strength of recommendations through a multi-stage voting process. RESULTS: The updated guidelines for RA treatment stratify various therapeutic options, including different classes of DMARDs (conventional, biologicals, and JAK inhibitors), as well as NSAIDs, glucocorticoids, and analgesics. By consensus, it establishes the use of these in different subpopulations of interest among RA patients and addresses aspects related to vaccination, COVID-19, surgery, pregnancy and lactation, and others. CONCLUSIONS: This update of the Mexican guidelines for the pharmacological treatment of RA provides reference points for evidence-based decision-making, recommending patient participation in joint decision-making to achieve the greatest benefit for our patients. It also establishes recommendations for managing a variety of relevant conditions affecting our patients.

Prevalence for and Factors Associated With Depression and Anxiety Symptoms in Mexican Patients With Rheumatoid Arthritis.

BACKGROUND/OBJECTIVE: It has been suggested that patients with rheumatoid arthritis (RA) often present depression and anxiety. The objective of this study was to estimate the prevalence of depression and anxiety symptoms in Mexican patients with RA and to determine associated factors of depression and anxiety in this population. METHODS: This was a cross-sectional study. We evaluated demographic characteristics, medical comorbidities, substance use, and disease characteristics in 103 patients with RA. Patients were enrolled from March 2016 to August 2017 The prevalence of depression and anxiety was estimated using the Hospital Anxiety and Depression Scale. We calculated the proportion of depression and anxiety symptoms and compared characteristics between groups. Finally, logistic regression model was used to determine the factors associated with depression and anxiety. RESULTS: Depression symptoms were present in 26.2% of patients, whereas anxiety symptoms were present in 16.5% of patients. Presence of hypertension was an associated factor with depression (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.06-9.23; p = 0.03). Low socioeconomic (OR, 3.78; 95% CI, 1.39-10.28; p = 0.009) and high scores of 28-joint Disease Activity Score were associated with anxiety (OR, 3.19; 95% CI, 1.20-8.45; p = 0.02). CONCLUSIONS: Factor related to socioeconomic conditions, comorbid medical conditions, and disease activity were related to the presence of clinical depression and anxiety in Mexican patients with RA, which may have a negative impact in the course and outcome of the disease. We suggest an early identification of depression and anxiety in these patients through an early psychiatric evaluation.

Relación entre las concentraciones de la leptina y la actividad de la enfermedad en pacientes con artritis reumatoide / Relationship between leptin concentrations and disease activity in patients with rheumatoid arthritis

Introducción y objetivo: Múltiples estudios han encontrado una relación directa entre las concentraciones de leptina y la actividad de la enfermedad en artritis reumatoide. Pacientes y métodos: Se estudiaron 77 pacientes con artritis reumatoide, la determinación de la leptina fue a través de inmunoanálisis enzimático. Se evaluó la actividad de la enfermedad mediante el DAS-28 PCR. Se realizó un modelo de regresión logística multivariante para determinar la asociación entre las variables significativas y las concentraciones de leptina. Resultados: El 40,3% de los pacientes estaban en remisión, el 41,6% actividad leve, el 11,7% actividad moderada y el 6,5% actividad grave. Se encontró una relación independiente entre mayores concentraciones de leptina y la actividad de la enfermedad (RR 1,7; IC al 95%: 1,4-3,2; p = 0,03), el número de articulación tumefactas (RR 4,6; IC al 95%: 1,7-8,3; p = 0,000), el número de articulaciones dolorosas (RR 3,4; IC al 95%: 1,6-4,6; p = 0,000) y a presencia de síndrome metabólico (RR 1,3; IC al 95%: 1,2-1,9; p = 0,045). Conclusiones: Los datos obtenidos sugieren que la leptina sérica está elevada en pacientes con AR activa

Background and objective: Multiple studies have found a direct relationship between leptin concentrations and disease activity in rheumatoid arthritis. Patients and methods: We studied 77 patients with the diagnosis of rheumatoid arthritis; the leptin determination was through an enzyme immunoassay. Disease activity was assessed by the DAS-28 CRP. A multivariate logistic regression model was used to determine the association between significant variables and leptin concentrations. Results: 40.3% of the patients were in remission, 41.6% were mildly active, 11.7% were moderately active and 6.5% were severely active. The results show an independent association between higher concentrations of leptin and disease activity (OR 1.7; 95% CI 1.4-3.2; p .03), the number of swollen joints (OR 4.6; 95% CI 1.7-8.3; p .000), the number of painful joints (OR 3.4; 95% CI 1.6-4.6; p .000), and the presence of metabolic syndrome (OR 1.3; 95% IC 1.2-1,9; p .045). Conclusion: The data suggest that serum leptin is elevated in patients with active RA

Relationship between leptin concentrations and disease activity in patients with rheumatoid arthritis. / Relación entre las concentraciones de la leptina y la actividad de la enfermedad en pacientes con artritis reumatoide.

BACKGROUND AND OBJECTIVE: Multiple studies have found a direct relationship between leptin concentrations and disease activity in rheumatoid arthritis. PATIENTS AND METHODS: We studied 77 patients with the diagnosis of rheumatoid arthritis; the leptin determination was through an enzyme immunoassay. Disease activity was assessed by the DAS-28 CRP. A multivariate logistic regression model was used to determine the association between significant variables and leptin concentrations. RESULTS: 40.3% of the patients were in remission, 41.6% were mildly active, 11.7% were moderately active and 6.5% were severely active. The results show an independent association between higher concentrations of leptin and disease activity (OR 1.7; 95% CI 1.4-3.2; p .03), the number of swollen joints (OR 4.6; 95% CI 1.7-8.3; p .000), the number of painful joints (OR 3.4; 95% CI 1.6-4.6; p .000), and the presence of metabolic syndrome (OR 1.3; 95% IC 1.2-1,9; p .045). CONCLUSION: The data suggest that serum leptin is elevated in patients with active RA.

Riesgo cardiovascular en lupus eritematoso sistémico / Cardiovascular risk in systemic lupus erythematosus

Antecedentes: Los pacientes con lupus eritematoso sistémico (LES) tienen mayor frecuencia de factores de riesgo cardiovascular (RCV) tradicionales, esto sumado a la presencia de factores de RCV no tradicionales, aumenta la probabilidad de eventos cardiacos hasta 5 veces. Objetivo: Determinar la frecuencia de los factores de RCV en una población de pacientes con LES. Materiales y métodos: Se realizó un estudio descriptivo, transversal, observacional, en 51 pacientes con diagnóstico de LES. Resultados: Se reportó el patrón lúpico de dislipoproteinemia ya que el 52,9% presentó hipoal-falipoproteinemia, 49% hipercolesterolemia, 35,3% hipertrigliceridemia y 19,6% elevación de c-LDL. Con respecto a las comorbilidades el 31,4% presentó obesidad, 27,5% hipertensión arterial y 6% diabetes mellitus. Los factores de RCV no tradicionales que predominaron fueron los asociados con la actividad de la enfermedad, el 90,1% tomaba glucocorticoides, 70,6% presentó niveles bajos de C3, 66,7% tuvo PCR > 2 mg/l, 56,9% tenía más de 4 puntos de SLEDAI-2 K, 41,2% presentó niveles bajos de C4, 29,4% tenía más de 10 arios de duración de la enfermedad, 25,5% tenía nefritis lúpica. Con lo que respecta a la presencia de anticuerpos asociados a RCV el 58,8, 9,8, 74,8 y el 3,9% presentaron anti-Smith, anticoagulante lúpico, anti-beta 2 glicoproteína I, anticardiolipinas positivas, respectivamente. Conclusiones: Los pacientes con LES presentan un estado proinflamatorio y aterogénico, aumentando el riesgo de desarrollar enfermedades cardiovasculares tanto por mayor incidencia de los factores de riesgo tradicionales, como por la presencia de factores que promueven una inflamación crónica.

Background: Patients with systemic lupus erythematosus (SLE) have a higher frequency of traditional cardiovascular risk factors (CVR). This, combined with the presence of nontraditional cardiovascular risk factors, increases the probability of cardiac events by five times. Objective: To determine the prevalence of CVR factors in a population of patients with SLE. Material and methods: A descriptive, cross-sectional, observational study in 51 patients with the diagnosis of SLE. Results: A lupus dyslipoproteinaemia pattern was reported, of which 52.9% had hypo-alphalipoproteinaemia, 49% hypercholesterolaemia, 35.3% hypertriglyceridaemia, and 19.6% with an elevated c-LDL. The comorbidities found were, 31.4% with obesity, 27.5% with high blood pressure, and 6% suffered from diabetes mellitus. Predominant non-traditional CVR factors were associated with disease activity, with 90.1% taking glucocorticoids, 70.6% had low levels of complement C3, 41.2% had low levels of complement C4, 66.7% had a CRP > 2 mg/l, 56.9% had a SLEDAI-2 K score greater than 4 points, 29.4% had more than 10 years of disease duration, and 25.5% had lupus nephritis. As regards the presence of antibodies associated with CVR, 58.8, 9.8, 74.8 and 3.9% had anti-Smith antibodies, lupus anticoagulant, antibeta2glycoprotein I, and positive anticardiolipin, respectively. Conclusions: Patients with SLE have a pro-inflammatory and atherogenic state, increasing the risk of developing cardiovascular diseases, and therefore a higher incidence of traditional risk factors, such as the presence of factors that promote chronic inflammation.

Coinfección de tuberculosis pulmonar y nocardiosis pulmonar / Co-infection of pulmonary tuberculosis and pulmonary nocardiosis

La coinfección entre Mycobacterium tuberculosis y Nocardia es poco frecuente, con una prevalencia entre el 1 y el 6%; es más frecuente en los pacientes infectados por el virus de la inmunodeficiencia humana. Las manifestaciones clínicas y radiológicas de la nocardiosis y la tuberculosis pulmonar suelen ser muy similares, lo cual dificulta el diagnóstico y puede retrasar el tratamiento específico. Existen pocos casos reportados en la literatura. Se reportan 3 casos de pacientes que presentaron datos compatibles con tuberculosis pulmonar, por lo que se realizó tinción de Ziehl-Neelsen en esputo, y se reportan bacilos ácido-alcohol resistentes compatibles con Mycobacterium tuberculosis y Nocardia, iniciándose tratamiento específico, con el cual presentaron mejoría clínica.

Coinfection with Mycobacterium tuberculosis and Nocardia is rare, with a prevalence between 1-6%, and is more frequent in patients infected with HIV. Clinical and radiological manifestations of nocardiosis and pulmonary tuberculosis are very similar, making difficult the diagnosis and delaying the specific treatment. There are few cases reported in the literature. We report 3 cases of patients who presented with pulmonary tuberculosis-compatible data, whose sputum Ziehl-Neelsen staining test revealed acid-fast bacilli compatible with Mycobacterium tuberculosis and Nocardia. Specific treatment resulted in clinical improvement.

Neurolupus and pregnancy: An ethical and therapeutic dilemma in a second level hospital / Neurolupus y embarazo: un dilema ético y terapéutico en un hospital de segundo nivel

Optic neuritis secondary to systemic lupus erythematosus is a rare manifestation with a prevalence of 1%. The case described concerns a patient who presented with optic neuritis associated with SLE. She was 19 weeks pregnant, and required pulses with methyl-prednisolone and cyclophosphamide, which are within the category D drugs used during pregnancy. Three weeks later, she presented with uterine activity, and went into labor, with a fetus of 22 weeks gestation and weighing 430 g being obtained, which died 48 h later. In medical practice there are ethical guidelines and economic obstacles to carrying out diagnostic and therapeutic protocols established by limiting clinical practice

La neuritis óptica secundaria a lupus eritematoso sistémico es una rara manifestación con una prevalencia del 1%. Presentamos el caso de una paciente que mostró neuritis óptica asociada a lupus eritematoso sistémico, con 19 semanas de gestación, requiriendo de pulsos de metilprednisolona y ciclofosfamida, que se encuentran dentro de los medicamentos categoría D utilizados durante el embarazo. Tres semanas después presentó actividad uterina y posteriormente trabajo de parto obteniéndose un producto de 22 semanas de gestación y 430 g, falleciendo a las 48 h. En la práctica médica existen lineamientos éticos y obstáculos económicos que limitan la realización de protocolos diagnósticos y terapéuticos establecidos, limitando la práctica clínica

Dislipidemia y riesgo aterogénico en pacientes con lupus eritematoso sistémico / Dyslipidaemia and atherogenic risk in patients with systemic lupus erythematosus

Introducción: La dislipidemia es una comorbilidad frecuente en los pacientes con lupus eritematoso sistémico. Pacientes y métodos: Se incluyeron 51 pacientes. Se registraron variables asociadas a la enfermedad y los fármacos empleados. Se calculó el riesgo aterogénico. Se empleó la prueba de Chi cuadrado para las variables categóricas. Se realizó ANOVA y un modelo de regresión logística para determinar la asociación de las variables con la presencia de dislipidemia. Resultados: El 68,6% presentó dislipidemia. Se encontró diferencia significativa entre la presencia de dislipidemia y el índice de actividad medido por SLEDAI, la presencia de nefropatía lúpica, el uso de prednisona ≥ 20 mg/día, la evolución de la enfermedad < 3 años y entre la ausencia de dislipidemia y el empleo de hidroxicloroquina. SLEDAI ≥ 4 y el uso de prednisona ≥ 20 mg/día se asociaron independientemente con la presencia de dislipidemia. La media del índice de Castelli fue de 5,02, la del de Kannel fue de 2,97 y la de triglicéridos/c-HDL fue de 5,24. Conclusiones: Los pacientes con lupus eritematoso sistémico presentan una gran prevalencia de dislipidemia y un alto índice aterogénico, lo cual aumenta el riesgo cardiovascular (AU)

Introduction: Dyslipidaemia is a common comorbidity in patients with systemic lupus erythematosus. Patients and methods: Fifty-one patients were included. Variables associated with the disease and the drugs used were recorded. Atherogenic risk was calculated. Chi square was used for categorical variables. ANOVA was performed and a logistic regression model to determine the association of the variables with the presence of dyslipidaemia. Results: A percentage of 68.6 had dyslipidaemia. A significant difference between the presence of dyslipidaemia and activity index measured by SLEDAI was found, the presence of lupus nephritis, use of prednisone ≥ 20 mg/day, evolution of the disease < 3 years. Significance between the absence of dyslipidaemia and use of hydroxychloroquine was found. SLEDAI ≥ 4 and the use of prednisone ≥ 20 mg/day were independently associated with the presence of dyslipidaemia. The average of Castelli rate was 5.02, the Kannel index was 2.97 and triglyceride/HDL-C ratio was 5.24. Conclusions: Patients with systemic lupus erythematosus have a high prevalence of dyslipidaemia and a high atherogenic rate, which increases cardiovascular risk significantly (AU)

Dislipidemia y riesgo aterogénico en pacientes con artritis reumatoide / Dyslipidemia and atherogenic risk in patients with rheumatoid arthritis

Introducción: Los pacientes con artritis reumatoide tienen 2 a 3 veces mayor riesgo cardiovascular; se debe en parte al patrón de los lípidos los cuales aumentan el índice aterogénico. Métodos: Se incluyó a 82 pacientes, a quienes se les determinó el perfil lipídico. Se registraron variables asociadas a la enfermedad y los fármacos empleados. Se calculó el riesgo aterogénico. Se empleó la chi al cuadrado para las variables categóricas y la prueba de Mann-Whitney para las continuas. Se realizó ANOVA para determinar relación entre las medias del perfil lipídico y un modelo de regresión logística para determinar la asociación de las variables con la presencia de dislipidemia. Resultados: El 54,9% presentó dislipidemia. Se encontró diferencia significativa entre la presencia de dislipidemia y factor reumatoide positivo (p = 0,005), obesidad (p = 0,007), remisión de la enfermedad (p = 0,037) y PCR mayor or igual a 2 mg/dl (p = 0,024); no se encontró diferencia significativa entre la presencia de dislipidemia y el género, la edad y la evolución de la enfermedad. La obesidad (RR 4,79, IC del 95%, 1,5-5,1; p = 0,008) se asoció independientemente a la presencia de dislipidemia. El uso de hidroxicloroquina (RR 0,31, IC del 95%, 0,1-0,92; p = 0,035) se asoció independientemente a la ausencia de dislipidemia. La media del índice aterogénico de Castellí fue 4,36, la del índice de Kannel fue 2,59 y la del índice triglicéridos/c-HDL fue 3,83. El 61% presentó síndrome metabólico. Conclusiones: Los pacientes con artritis reumatoide presentan un perfil de lípidos proaterogénico; es importante conocerlo y tratarlo para disminuir el riesgo cardiovascular

Introduction: Dyslipidaemia is one of the main risk factors for atherosclerotic cardiovascular disease. Patients with rheumatoid arthritis have 2-3 times more cardiovascular risk, which is partly due to the pattern of lipids which increase the atherogenic index. Methods: A descriptive, cross-sectional, observational and prospective study was conducted on 82 patients, selected for their lipid profile. Variables associated with the disease and the drugs used were recorded. Atherogenic risk was calculated, with Chi square being used for categorical variables, and the Mann-Whitney test for the continuous ones. Results: The dyslipidaemia frequency was 54.9%. The most frequent age range of dyslipidaemia was between 51 and 60 years. Patients with type i obesity had a higher frequency of dyslipidaemia. Less dyslipidaemia was found with a lower rate of disease activity. Patients with cyclic citrullinated anti-peptide antibodies and positive rheumatoid factor, erythrocyte sedimentation rate > 13 mm or CRP > 2 mg/L had a higher frequency of dyslipidaemia. The mean Castelli atherogenic index was 4.36, the index of Kannel was 2.59, and triglycerides/HDL-c ratio was 3.83.Patients with dyslipidaemia showed a higher frequency of positive rheumatoid factor (P=.0008), and those patients who were taking hydroxychloroquine had a lower frequency of dyslipidaemia P=.03. Conclusions: Patients with rheumatoid arthritis have a pro-atherogenic lipid profile. It is important to know this and treat it to reduce cardiovascular risk

[Dyslipidaemia and atherogenic risk in patients with systemic lupus erythematosus]. / Dislipidemia y riesgo aterogénico en pacientes con lupus eritematoso sistémico.

INTRODUCTION: Dyslipidaemia is a common comorbidity in patients with systemic lupus erythematosus. PATIENTS AND METHODS: Fifty-one patients were included. Variables associated with the disease and the drugs used were recorded. Atherogenic risk was calculated. Chi square was used for categorical variables. ANOVA was performed and a logistic regression model to determine the association of the variables with the presence of dyslipidaemia. RESULTS: A percentage of 68.6 had dyslipidaemia. A significant difference between the presence of dyslipidaemia and activity index measured by SLEDAI was found, the presence of lupus nephritis, use of prednisone≥20mg/day, evolution of the disease<3 years. Significance between the absence of dyslipidaemia and use of hydroxychloroquine was found. SLEDAI≥4 and the use of prednisone≥20mg/day were independently associated with the presence of dyslipidaemia. The average of Castelli rate was 5.02, the Kannel index was 2.97 and triglyceride/HDL-C ratio was 5.24. CONCLUSIONS: Patients with systemic lupus erythematosus have a high prevalence of dyslipidaemia and a high atherogenic rate, which increases cardiovascular risk significantly.

[Dyslipidemia and atherogenic risk in patients with rheumatoid arthritis]. / Dislipidemia y riesgo aterogénico en pacientes con artritis reumatoide.

INTRODUCTION: Dyslipidaemia is one of the main risk factors for atherosclerotic cardiovascular disease. Patients with rheumatoid arthritis have 2-3 times more cardiovascular risk, which is partly due to the pattern of lipids which increase the atherogenic index. METHODS: A descriptive, cross-sectional, observational and prospective study was conducted on 82 patients, selected for their lipid profile. Variables associated with the disease and the drugs used were recorded. Atherogenic risk was calculated, with Chi square being used for categorical variables, and the Mann-Whitney test for the continuous ones. RESULTS: The dyslipidaemia frequency was 54.9%. The most frequent age range of dyslipidaemia was between 51 and 60 years. Patients with type i obesity had a higher frequency of dyslipidaemia. Less dyslipidaemia was found with a lower rate of disease activity. Patients with cyclic citrullinated anti-peptide antibodies and positive rheumatoid factor, erythrocyte sedimentation rate>13mm or CRP>2mg/L had a higher frequency of dyslipidaemia. The mean Castelli atherogenic index was 4.36, the index of Kannel was 2.59, and triglycerides/HDL-c ratio was 3.83.Patients with dyslipidaemia showed a higher frequency of positive rheumatoid factor (P=.0008), and those patients who were taking hydroxychloroquine had a lower frequency of dyslipidaemia P=.03. CONCLUSIONS: Patients with rheumatoid arthritis have a pro-atherogenic lipid profile. It is important to know this and treat it to reduce cardiovascular risk.