Primary Sjögren's syndrome as independent risk factor for subclinical atherosclerosis.

OBJECTIVE: To assess the prevalence of subclinical atherosclerosis in patients with primary Sjögren's syndrome (pSS) and its possible association with clinical and analytical parameters of the disease. METHODS: In this cross-sectional study, 38 consecutive patients with pSS were compared with 38 age and sex healthy controls. Demographic variables and classic cardiovascular risk factors (CVRFs): Hypertension, dyslipidemia, diabetes mellitus, obesity, and smoking habit were assessed in both groups, and also disease-related features were collected in pSS group. The presence of subclinical atherosclerosis was assessed by carotid ultrasound, with carotid intima-media thickness (CIMT) measurement and determination of the presence of atheromatous plaques. RESULTS: Subclinical atherosclerosis presence was remarkably greater in patients with pSS than in healthy controls (OR = 4.17, 95%CI [1.27-16.54]), as well as CIMT values (0.79 ± 0.43mm vs. 0.66 ± 0.27mm; P = .02). No differences for classic CVRFs were found between both groups. An association of subclinical atherosclerosis with erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF) was observed in patients with pSS. CONCLUSION: This cohort showed a greater prevalence of subclinical atherosclerosis in patients with pSS, indicating this disease as an independent risk factor for presence of early vascular damage.

Recomendaciones de la Sociedad Española de Reumatología sobre el uso de terapias biológicas en espondiloartritis axial / Recommendations by the Spanish Society of Rheumatology on the Use of Biological Therapies in Axial Spondyloarthritis

Objetivo: La aparición de nueva información sobre las terapias biológicas en la espondiloartritis axial (EspAax) ha impulsado una nueva revisión de las recomendaciones de la Sociedad Española de Reumatología (SER) basadas en la mejor evidencia posible. Estas nuevas recomendaciones pueden servir de referencia para reumatólogos implicados en el tratamiento de estos pacientes. Métodos: Se creó un panel formado por nueve reumatólogos expertos en EspAax, previamente seleccionados por la SER mediante una convocatoria abierta. Las fases del trabajo fueron: identificación de las áreas clave para la actualización del consenso anterior, análisis y síntesis de la evidencia científica (sistema modificado de Oxford, CEBM, 2009) y formulación de recomendaciones a partir de esta evidencia y de técnicas de consenso. Resultados: Esta revisión de las recomendaciones comporta una actualización en la evaluación de actividad de la enfermedad y objetivos de tratamiento. Incorpora también los nuevos fármacos disponibles, así como sus nuevas indicaciones, y una revisión de los factores predictivos de respuesta terapéutica y progresión del daño radiográfico. Finalmente, estas recomendaciones abordan también las situaciones de fracaso a un primer anti-TNF, así como la posible optimización de la terapia biológica. El documento incluye una tabla de recomendaciones y un algoritmo de tratamiento. Conclusiones: Se presenta la actualización de las recomendaciones SER para el uso de terapias biológicas en pacientes con EspAax

Objective: Recent data published on biological therapy in axial spondyloarthritis (axSpA) since the last publication of the recommendations of the Spanish Society of Rheumatology (SER) has led to the generation of a review of these recommendations based on the best possible evidence. These recommendations should be a reference for rheumatologists and those involved in the treatment of patients with axSpA. Methods: Recommendations were drawn up following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Centre for Evidence Based Medicine at Oxford. The level of agreement was established through the Delphi technique. Results: In this review, we did an update of the evaluation of disease activity and treatment objectives. We included the new drugs with approved therapeutic indication for axSpA. We reviewed both the predictive factors of the therapeutic response and progression of radiographic damage. Finally, we drafted some recommendations for the treatment of patients refractory to anti-tumor necrosis factor, as well as for the possible optimization of biological therapy. The document also includes a table of recommendations and a treatment algorithm. Conclusions: We present an update of the SER recommendations for the use of biological therapy in patients with axSpA

Recommendations by the Spanish Society of Rheumatology on the Use of Biological Therapies in Axial Spondyloarthritis. / Recomendaciones de la Sociedad Española de Reumatología sobre el uso de terapias biológicas en espondiloartritis axial.

OBJECTIVE: Recent data published on biological therapy in axial spondyloarthritis (axSpA) since the last publication of the recommendations of the Spanish Society of Rheumatology (SER) has led to the generation of a review of these recommendations based on the best possible evidence. These recommendations should be a reference for rheumatologists and those involved in the treatment of patients with axSpA. METHODS: Recommendations were drawn up following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Centre for Evidence Based Medicine at Oxford. The level of agreement was established through the Delphi technique. RESULTS: In this review, we did an update of the evaluation of disease activity and treatment objectives. We included the new drugs with approved therapeutic indication for axSpA. We reviewed both the predictive factors of the therapeutic response and progression of radiographic damage. Finally, we drafted some recommendations for the treatment of patients refractory to anti-tumor necrosis factor, as well as for the possible optimization of biological therapy. The document also includes a table of recommendations and a treatment algorithm. CONCLUSIONS: We present an update of the SER recommendations for the use of biological therapy in patients with axSpA.

Drug survival of anti-tumour necrosis factor α therapy in spondyloarthropathies: results from the Spanish emAR II Study.

OBJECTIVE: To assess drug survival and the reasons for switching anti-TNF-α therapy in SpA patients in a Spanish nationwide study. METHODS: A cross-sectional study was performed. Sample size was calculated to represent all regions and hospitals throughout the country. Demographic data, patient characteristics and disease activity parameters were obtained. Drug survival and reasons for switching anti-TNF therapy were also recorded. RESULTS: A total of 467 SpA patients receiving at least one anti-TNF agent were identified. Among patients who received a first, second and third anti-TNF course, 39.4%, 37.4% and 23.1% discontinued treatment, respectively. The main reasons for switching anti-TNF agents in the first course were lack or loss of efficacy (LOE) and adverse events (AEs) in 40% and 30% of switchers, respectively. Similarly, reasons for switching during the second anti-TNF course were LOE in 48% and AEs in 28% of switchers. Of the 467 SpA patients starting anti-TNF therapy, 28% switched to a second and 8% switched to a third therapy. Mean drug survival for the first, second and third anti-TNF courses were 84.4 (95% CI 78.4, 90.5), 70.2 (95% CI 61.6, 78.9) and 64.8 (95% CI 51.1, 78.5) months, respectively (P = 0.315). CONCLUSION: Twenty-eight per cent of SpA patients starting anti-TNF therapy switched to a second anti-TNF agent. Drug survival did not differ among anti-TNF courses. The main reason for switching anti-TNF therapy was LOE. Switchers were more frequently women and had higher disease activity parameters at the time of the study than non-switchers.

Calcium pyrophosphate crystal deposition disease: diagnosis and treatment.

Calcium pyrophosphate dihydrate crystal deposition disease (CPPD) is an inflammatory arthritis produced by the deposition of calcium pyrophosphate (CPP) crystals in the synovium and periarticular soft tissues. It is the third most common inflammatory arthritis. Diagnosis is suspected on the basis of the clinical picture and radiographic/laboratory findings. The reference standard for the diagnosis of CPPD is based on the identification of CPP crystals in synovial fluid by light microscopy, compensated polarized light microscopy, or phase contrast microscopy. Most treatment approaches for CPPD are based upon clinical experience and not upon controlled trials. They range - depending on the subtype and the characteristics of symptoms - from no treatment to interleukin-1 blockade antibodies or specific therapy for an underlying disease. This review summarizes all we know so far about the diagnosis and management of CPPD.

Vitamin D insufficiency is associated with higher carotid intima-media thickness in psoriatic patients.

BACKGROUND: Psoriasis has been associated with vitamin D insufficiency and cardiovascular risk factors. Reports show that serum 25-hydroxyvitamin D (25-OHD) levels are inversely associated with chronic inflammatory systemic diseases, cardiovascular risk factors and cardiovascular outcomes. OBJECTIVE: To analyze the association between 25-hydroxyvitamin D serum levels and subclinical carotid atherosclerosis (maximal intima-media thickness (MIMT)) in psoriasis patients and controls. MIMT was compared and associated factors were analyzed. PATIENTS AND METHOD: This was a case-control study with 44 psoriatic patients without arthritis from a Dermatology outpatient clinic in Granada (Spain) and 44 controls. Confounding factors related to 25-OHD serum levels and cardiovascular risk factors were also analyzed. RESULTS: 25-OHD levels were significantly lower in the psoriatic than in the control group (29.20 vs. 38.00 ng/mL p<0.0001) and a significant negative correlation was found between serum 25-OHD levels and the MIMT (rs=-0.678, p<0.0001) in psoriatic patients. No correlation was found in healthy controls. This association remained after adjusting for confounders. Serum 25-OHD levels were significantly lower (p=0.003) in psoriatic patients with carotid atheromatous plaque (22.38±10.23 ng/mL) than in those without (31.74±8.62 ng/mL). Patients with a longer history of psoriasis presented significantly higher MIMT than controls (638.70±76.21 vs 594.67±80.20 µm; p=0.026 for ≥6 yrs with psoriasis). CONCLUSIONS: In psoriasis patients, lower serum 25-OHD levels were associated with higher MIMT after adjusting for selected confounding factors. The MIMT risk increases with a longer history of psoriasis, regardless of the patient's age.

Cardiovascular risk assessment according to a national calibrated score risk index in psoriatic arthritis patients without clinically evident cardiovascular disease or classic atherosclerosis risk factors.

OBJECTIVE: To assess cardiovascular (CV) risk in psoriatic arthritis (PsA) patients without clinically evident CV disease or classic atherosclerosis risk factors according to the SCORE chart following the EULAR recommendations. METHODS: Eighty PsA patients without previous CV events or atherosclerosis risk factors and eighty matched controls were included. Information on demographic, anthropometric and clinical-serological data of disease was assessed. The national calibrated Systematic Coronary Risk Evaluation (SCORE) index was calculated and the association between this SCORE and clinical-serological data of these patients was analyzed. RESULTS: PsA patients had higher acute phase reactants as well as higher SCORE mean values than healthy controls (1.99±3.52 vs. 1.0±1.74; P=0.028). According to SCORE definitions, 71 (89%) patients had low-intermediate CV risk and 9 (11%) were above the threshold of high risk. In the control group, 76 (95%) had low-intermediate risk and four (5%) had high CV risk. However, there were no differences in CV risk stratification between both groups (P=0.148). PsA patients with high-very high CV risk had longer disease duration (P=0.001) and higher levels of triglycerides (P=0.009). PsA patients showed a significant correlation between SCORE values and disease duration (ß=0.185; P=0.0001) and the average annual levels of C reactive protein (CRPa), ß=2.38; P=0.014. CONCLUSION: CV risk assessment in PsA patients without clinically evident CV disease or classic atherosclerosis risk factors may be underestimated by using only the SCORE chart. In these patients, disease duration and the CRPa may help to establish a better stratification of the actual CV risk.

Association of 25-hydroxyvitamin D serum levels and metabolic parameters in psoriatic patients with and without arthritis.

BACKGROUND: Psoriasis has been related to a higher prevalence of cardiovascular risk factors. Vitamin-D deficiency has been associated with metabolic syndrome, cardiovascular disease, and psoriasis. However, there has been no comparative study on the effects of vitamin-D status between patients with and without psoriatic arthritis. OBJECTIVE: The objective was to assess the relationship of 25-hydroxyvitamin D [25-(OH)D] levels with lipid and glucose metabolism parameters in psoriatic patients with and without arthritis. METHODS: We studied 122 patients with psoriasis (61 without arthritis and 61 with arthritis) from the psoriasis unit (dermatology department) and rheumatology department of our hospital, analyzing lipid and glucose metabolism variables and serum 25-(OH)D concentrations. Measurements were conducted within a 2-month period to minimize seasonal bias in 25-(OH)D levels. RESULTS: In the psoriatic patients without arthritis, serum 25-(OH)D levels were inversely correlated with fasting glucose (r = -0.285; P = .026), total cholesterol (r = -0.440; P = .000), low-density lipoprotein (r = -0.415; P = .001), total cholesterol/high-density lipoprotein (r = -0.303; P = .01), and triglyceride (r = -0.280; P = .029) values. This association remained statistically significant for glucose, total cholesterol, and low-density lipoprotein after controlling for confounding factors in multivariate analysis. No association was found between serum 25-(OH)D levels and any metabolic parameter in the patients with psoriatic arthritis. LIMITATIONS: This is a cross-sectional study that supports the hypothesis of an association between vitamin D and metabolic parameters but does not establish a causal relationship. CONCLUSIONS: Serum 25-(OH)D was inversely related to lipid and glucose metabolism parameters in psoriatic patients without arthritis, whereas no such association was observed in psoriatic patients with arthritis. Interventional studies are warranted to assess the effects of vitamin-D supplements on the metabolic profile of psoriatic patients without arthritis.

Life-threatening vasculo-Behçet following discontinuation of infliximab after three years of complete remission.

Behçet's disease (BD) is a chronic, complex multisystem vasculitis of unknown cause characterised for its ability to involve blood vessels of all sizes on both the arterial and venous sides of the circulation. It has been suggested that TNF-alpha plays a main role in the pathogenesis of BD. This hypothesis is supported by the efficacy of TNF-blocking antibodies in these patients, which have been shown to be very powerful in the induction of remission and as maintenance treatment on different BD manifestations, including severe vascular involvement. However, little is known about when and how to stop IFX after long-standing complete remission of these patients to avoid relapses. We describe a case of BD without previous vascular involvement that developed myocardial infarction and severe venous thromboses only four months after discontinuation of infliximab (IFX) after more than three years of complete remission. The patient did not respond to corticosteroids and intravenous cyclophosphamide and only recovered completely after reintroducing IFX.

Successful use of tocilizumab in a patient with nephrotic syndrome due to a rapidly progressing AA amyloidosis secondary to latent tuberculosis.

AA (secondary) amyloidosis is one of the most severe and uncommon complications of several rheumatic disorders and chronic infections such as tuberculosis (TB). Successful treatment depends on the control of the underlying inflammatory process, what can lead to an improvement or a regression in organ dysfunction. If the disorder persists, it has been reported in some cases of AA amyloidosis secondary to rheumatic diseases, that the use of biologic therapy is so far the only opportunity to reduce the development of AA amyloidosis and to reverse established deposits. We report herein a case of a latent TB infection complicated by a life-threatening AA amyloidosis presented as nephrotic syndrome. After an adequate antituberculostatic treatment, AA amyloidosis remained active and Tocilizumab (TCZ) was started with a dramatic resolution of the proteinuria, stabilization of the amyloid deposits and improvement in general condition.

Septic arthritis due to Cellulosimicrobium cellulans.

Cellulosimicrobium cellulans has been reported as a rare cause of human pathogenesis. Infections mainly occur in immunocompromised patients and very often are associated with a foreign body. We report the first case of septic arthritis caused by C. cellulans in an immunocompetent patient. Our patient suffered a penetrating palm tree thorn injury to his left knee 8 weeks before admission. Although no foreign objects were found, they were suspected because previous reports suggest a frequent association with this microorganism, and open debridament was performed. Removal of foreign bodies related to this organism must be considered a high-priority treatment in these patients to achieve a complete recovery.