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.

Posterior reversible encephalopathy syndrome during convalescence from COVID-19.

Background and aim: With an ever-increasing population of patients recovering form severe coronavirus disease 2019 (COVID-19), recognizing long-standing and delayed neurologic manifestations is crucial. Here, we present a patient developing posterior reversible encephalopathy syndrome (PRES) in the convalescence form severe coronavirus disease 2019 (COVID-19).Case presentation: A 61-year-old woman with severe (COVID-19) confirmed by nasopharyngeal real-time reverse transcription-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) required invasive mechanical ventilation 24-hours after admission. During her intensive care unit stay, she developed transient acute kidney injury and septic shock. She was extubated after 22 days. On day 25, she developed generalized tonic-clonic seizures. Magnetic resonance imaging (MRI) of the brain showed bilateral subcortical lesions on the parietal and occipital lobes and multiple micro-and macro-bleeds, consistent with PRES. At this point, RT-PCR for SARS-CoV-2 in a respiratory specimen and cerebrospinal fluid was negative. She was discharged home 35 days after admission on oral levetiracetam. Control MRI five months after discharge showed bilateral focal gliosis. On follow-up, she remains seizure-free on levetiracetam.Conclusions: PRES has been observed before as a neurological manifestation of acute COVID-19; to our knowledge, this is the first PRES case occurring in a hospitalized patient already recovered from COVID-19. A persistent proinflammatory/prothrombotic state triggered by SARS-CoV-2 infection may lead to long-standing endothelial dysfunction, resulting in delayed PRES in patients recovering from COVID-19. With a rapid and exponential increase in survivors of acute COVID-19, clinicians should be aware of delayed (post-acute) neurological damage, including PRES.

Uso de medicina complementaria y alternativa y su asociación con la relación médico-paciente en enfermos con artritis reumatoide / Association between physician-patient relationship and the use of complementary and alternative medicine in patients with rheumatoid arthritis

RESUMEN Introducción: El uso de medicina complementaria y alternativa (MCA) en pacientes con enfermedades reumáticas es prevalente pero la comunicación con el reumatólogo suele ser deficiente, lo cual afecta la relación médico-paciente (RMP). Objetivos: Evaluar la asociación entre el uso de MCA y la RMP en enfermos con artritis reumatoide. Como objetivos adicionales, describir la percepción del paciente sobre la comunicación con su reumatólogo respecto al uso de MCA y el patrón de uso de las diferentes modalidades terapéuticas. Materiales y métodos: Estudio descriptivo de corte transversal. El uso de MCA y la RMP se evaluaron mediante la autoaplicación de cuestionarios validados (I-CAM-Q y PDRQ-9 respectivamente). Resultados: Se incluyó a 246 pacientes ambulatorios de una institución de tercer nivel de atención. Se encontró asociación entre una mayor satisfacción con el tratamiento y el no usar MCA, y entre el hecho de informar al reumatólogo sobre el uso de MCA con un mayor grado de acuerdo con el médico sobre el origen de los síntomas y mayor satisfacción con el tratamiento. Las modalidades más frecuentemente utilizadas fueron: quiropraxia, acupuntura y productos herbales. El 78,5% afirmaron estar de acuerdo con comunicar el uso de este tipo de medicación al reumatólogo, sin embargo, solo el 31,3% lo notificó, por temor a represalias (54,4%). Conclusiones: Pese a la alta prevalencia de uso de MCA en nuestros pacientes, la mayoría no lo comunicó al reumatólogo. Se encontró asociación entre el uso de MCA y una menor satisfacción del paciente con el tratamiento y entre la comunicación médico-paciente sobre la práctica de MCA y una mejor satisfacción con el tratamiento.

ABSTRACT Introduction: Although complementary and alternative medicine (CAM) use among patients with rheumatic diseases is extensive, discussions regarding these treatments occur rarely in the rheumatology setting, directly affecting the physician-patient relationship (PPR). Objectives: The aim of this study was to evaluate the association between patient-physician relationship and complementary and alternative medicine use. As secondary objectives, to describe the patient's perspective towards CAM use and estimate the prevalence of CAM treatments used in patients with rheumatoid arthritis. Methods and materials: A descriptive cross-sectional survey was conducted, in which CAM use and physician-patient relationship were assessed by self-reported validated questionnaires (I-CAM-Q and PDRQ-9, respectively). Results: The study included a total of 246 outpatients of a tertiary care hospital. There were no significant differences between CAM users vs. non-users, or informers vs. non-informers in terms of physician-patient relationship measured by PDQR. The most frequent used CAM treatments were: chiropractice, acupuncture, and herbal products. A large majority (78.5%) of the patients expressed agreement to the discussion of CAM use with the rheumatologist, but only 31.3% of total CAM users did so because of fear of retaliation (54.4%). Conclusion: Despite the extensive practice of CAM among patients with rheumatoid arthritis, most patients did not discuss these treatments with their physicians. Associations were found between MCA use and a lower patient's treatment satisfaction and between physician-patient communication about CAM practice and a higher patient's treatment satisfaction.