Revue du Rhumatisme Monographies最新文献

Osteoporosis and fragility fractures represent a public health issue, responsible for an increased morbidity and mortality. We should consider the prevention of this chronic disease. We can differentiate primary prevention, meaning bone loss prevention in patients with normal bone density, and secondary prevention, meaning fracture prevention in patients with low bone density. We will not discuss about tertiary prevention, which is prevention of fracture recurrence. We will discuss here drug prevention treatment in post-menopausal women, in cancer with hormonotherapy, and in cortico-induced osteoporosis.

Pulmonary manifestations often occur in connective tissue diseases (CTD) affecting the different component of the respiratory system (the lung parenchyma, the airways, the pleura, the vascular system…). The frequency and the severity of these manifestations vary according to the type of manifestation and the corresponding CTD. Systematic assessment by chest high resolution computed tomography (HRCT) lead to reconsider the frequency of some pulmonary manifestations with a long asymptomatic phase such as rheumatoid arthritis (RA) associated interstitial lung disease (ILD). Among the pulmonary manifestations associated with CTD, some will progress and may lead to an important disease burden and increase mortality. If a CTD related pulmonary manifestation is detected in a patient, it may impact the therapeutic management including the prescriptions of specific treatments or the restriction of pulmonary toxic drugs. The screening for such manifestations in asymptomatic patients, which enable early deification, is therefore indicated. For systemic sclerosis, dermatomyositis and Sjögren syndrome, lung involvement screening has been established in National Diagnostic and Care Protocols (PNDS) that will be developed in this review. For other CTD, there are still no guidelines. Beside a relatively high frequency of RA-ILD, no recommendations have been developed for the screening of RA-ILD. In this review, we will give the recent data that help to discuss and argue the necessity of a screening, notably in high-risk patients.

Cardiovascular disease is the main comorbidity of chronic inflammatory rheumatisms. This increase in prevalence is directly related to systemic inflammation, which increases athematosis processes, but also to the high prevalence of cardiovascular risk factors associated with chronic inflammatory rheumatisms. The rheumatologist has a central role in the management of patients with chronic inflammatory rheumatism and has to know how to assess the cardiovascular risk, to choose the most adapted disease modifying anti-rheumatic drug, to limit the use of long-term NSAIDs and to initiate corticosteroid withdrawal. He should be able to give lifestyle advices, adapted to the level of risk and the capacities of the patients and refer to the specialist high cardiovascular risk patients.

Patients with chronic inflammatory rheumatisms (CIR) have a higher risk of infections compared to healthy subjects. Viral and bacterial pneumonia are the most frequent infections observed in CIR under targeted DMARDs. Moreover, drugs used to treat CIR and especially biologic and synthetic targeted disease modifying anti-rheumatic drugs (DMARDs) increase this risk of infection and expose CIR patients to opportunistic infections such as tuberculosis reactivation. In order, to limit the risk of infection, the benefit and risk ratio has to be evaluated for each patient according to characteristics and comorbidities. To prevent infections, an initial pretreatment work up has to be performed especially before initiation of conventional synthetic DMARDs or biological and synthetic targeted DMARDs. This pre-therapeutic assessment is based on questioning, biological and morphological explorations as well. Vaccination's update has to be checked and recommended vaccines for patients with auto-immune diseases and treated with conventional synthetic DMARDs, bDMARDs, tsDMARDs and/or steroids should be done. Information and education of patients are very important. During specific workshop, they learn how to manage drugs in situations at risk and they learn symptoms that require drug discontinuation.

A Mediterranean diet appears to be beneficial for bone health. It is recommended for the prevention of osteoporosis, especially since this diet has other health benefits unlike an unbalanced Western diet. Exclusion diets among vegetarians and especially vegans are to be avoided in the prevention of osteoporosis. In vegetarians and especially vegans, vitamin D, calcium supplementation, and sufficient protein intake must be systematically prescribed in order to reduce the excess risk of fracture. The literature globally shows a positive effect of dairy products in terms of impact on bone mineral density and fracture risk. This effect appears more marked for fermented milk products (yogurt, cheese). It is recommended to consume several varied dairy products (2 to 3) daily to prevent osteoporosis. Regarding vitamin D fortified foods, the scientific evidence is not sufficient to affirm an equivalence with vitamin D supplementation in terms of bone health. Certain strains of probiotics can reduce bone loss in a modest way, but the target population, the optimal bacterial strains and the methods of consumption remain insufficiently defined to specifically recommend their use in the prevention of osteoporosis. For Western women, there is insufficient data to recommend a soy food consumption or isoflavone supplements for the prevention of osteoporosis.

Low back pain (LBP) is the leading cause of disability in France and worldwide and is increasing in France and worldwide. The burden is mainly related to chronic low back pain due to its personal, financial and professional repercussions. This article aims to detail the benefits of prevention of low back pain. Screening for people at risk of chronic low back pain is important to identify the most appropriate management. Prevention of LBP can be primary (when no LBP is present), secondary (to reduce the duration of its development) or tertiary (to reduce the prevalence of chronic disability or recurrence). At all stages, physical activity is the best achievable prevention, if possible coupled with information and education based on reassurance. Limiting spinal imaging could also be beneficial for secondary prevention. Prevention and promotion of physical activity is particularly important in two risk situations : occupational situations with heavy or frequently repeated load bearing and pregnancy. Workplace ergonomics has not yet proven to be very effective. Insoles and lumbar belts are not effective in primary or secondary prevention, in the general population or at work.

Although the prognosis of rheumatoid arthritis (RA) has been revolutionised by the advent of targeted disease-modifying anti-rheumatic drugs, chronic pain persists in many RA patients. While some of this pain is related to failure of the current therapies to control inflammation, a large majority is non-inflammatory refractory pain. Understanding, managing and preventing this pain remains a major challenge. In this narrative review, we will first present the risk factors associated with their occurrence and the mechanisms involved. We will then discuss the prevention strategies that can be put in place today.

Rheumatoid arthritis (RA) is an uncurable chronic disease. Managing people at risk, i.e. before the disease starts, could possibly prevent its occurrence. The pre-clinical stages of RA are now identifiable, and this has allowed the development of clinical trials for prevention. In this article, we will present for each stage the therapeutic trials that have been conducted and are ongoing (corticosteroids, ritxumab, abatacept, atorvastatin, methotrexate and hydroxychloroquine) and then we will discuss the non-pharmacological measures that can be proposed in view of the literature (vitamin D and correction of environmental risk factors).

The efficacy of NSAIDs in many rheumatological indications, for analgesic and anti-inflammatory purposes, is no longer in question. However, their prescription may be hindered by co-morbidities that could be aggravated by these drugs, such as coronary artery disease, chronic renal failure or a history of bleeding gastric ulcers. This article provides an update on preventive measures to avoid these complications.

Cancer is a major public health issue, and screening for cancer is a current situation in our routine practice. The risk of cancer in patients with rheumatic diseases varies according to their personal medical history, underlying rheumatic disease and treatment. However, to date, no rheumatological learnt society has established specific recommendations for cancer screening in our patients with rheumatic diseases. In this review, we provide an overview of the risk of cancer in rheumatic diseases (related to the disease itself or its treatment), cancer screening in the general population and in immunocompromised subjects, and cancer screening in rheumatic diseases.