Seminarios de la Fundación Espa?ola de Reumatología最新文献

Some drugs have proven efficacy in controlling the clinical symptoms of fibromyalgia. The drugs with the greatest demonstrated efficacy are tricyclic antidepressants (e.g. amitriptyline or cyclobenzaprine), selective serotonin reuptake inhibitors (e.g. fluoxetine), serotonin and norepinephrine reuptake inhibitors (e.g. duloxetine and milnazipram), some analgesics such as acetaminophen, alone or in combination with tramadol, and some anticonvulsant drugs such as pregabalin.

Other drugs such as non-steroidal antiinflammatory agents, major opioids, hormonal treatments and herbal medicines have shown no efficacy in clinical trials and consequently are not recommended in the treatment of fibromyalgia.

Some antidepressants, such as venlafaxine, moclobemide, pirlindole, mirtazapine and bupropion, have shown efficacy in some studies but more clinical trials are required before they can be recommended in patients with fibromyalgia.

Dopamine agonist receptors may be a good option in the future for the treatment of fibromyalgia if preliminary clinical studies with these drugs are confirmed.

Neonatal lupus erythematosus (NLE) is an uncommon disease caused by transport of maternal autoantibodies against Ro, La and/or ribonucleoprotein (RNP) into the fetal circulation. These IgG antibodies cross the placenta and can potentially damage fetal tissue and cause the clinical manifestations of NLE.

NLE is more common in girls, has no racial association and can affect multiple organs. Cutaneous manifestations are present in 50% of patients and are clinically similar to the lesions of subacute lupus erythematosus. Patients with NLE have a higher risk of congenital heart block, a potentially fatal complication. Other, less frequent manifestations are hepatic and hematologic. Approximately half of all patients have cutaneous manifestations and the other half cardiac manifestations. Approximately 10% of patients have both cutaneous and cardiac manifestations. Cutaneous, hematological and hepatic manifestations are transient, healing at 6 months of age, due to the clearance of maternal autoantibodies. Congenital heart block is a permanent manifestation that usually requires pacemaker implantation.

Pregnant women with autoimmune diseases or anti-Ro or anti-La antibodies should be followed-up by ultrasound during pregnancy to detect any manifestations susceptible to treatment. Currently, there is no consensus on preventive treatment in high-risk patients or in those with a risk of recurrence. Equally, there is insufficient data to confirm the efficacy of currently available preventive treatments. What seems clear is that early detection of congenital heart block should be treated with fluorinated corticosteroids.

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease. Autoantibody production plays a critical role in its pathogenic pathways. Thus, B-cell directed biologic therapy is a logical option. The present article reviews the latest advances in the development of B-cell directed biological agents in the treatment of SLE. Rituximab has been studied in a number of open series of patients that suggest efficacy but two recent controlled clinical trials have failed to show efficacy versus placebo. In contrast, a recent placebo-controlled, double-blind, randomized trial has reported that belimumab has statistically significant efficacy versus placebo. Atacicept, a fusion protein that blocks cytokines that play a critical role in the differentiation and survival of B-cells and plasma cells, markedly reduces autoantibody levels but could increase the risk of infection. Further studies are needed to establish the role of B-cell directed biologic therapy in SLE.

Blue digit syndrome (or sign) is a cutaneous manifestation of multiple diseases that produce acute or subacute ischemic compromise in one or more fingers or toes. The most frequent cause of this syndrome is a reduction in arterial blood flow due to compromise or occlusion of small peripheral vessels, with preservation of the distal pulses. The reduction in blood flow may be caused by a variety of pathogenic mechanisms including thrombosis, embolism, severe vasoconstriction, or inflammatory or non-inflammatory lesions of the vascular wall. The finger or toe affected by ischemia turns blue or violet and may develop necrosis.

Independently of the cause, blue digit syndrome is a medical emergency requiring rapid diagnosis and specific treatment, given the risk of progression to irreversible necrosis.

Although major advances have been made in the understanding of the pathogenesis, physiopathology and treatment of many rheumatic diseases, calcium pyrophosphate disease (CPPD) is a glaring omission, despite its high prevalence in rheumatology clinics. Current treatment schemes have not been tested in high quality trials and consequently clinicians’ decisions are based on clinical practice results. Non-steroidal anti-inflammatory drugs, colchicine and corticosteroids are the most widely used drugs, usually with success. However, in some patients, these drugs are ineffective, contraindicated or cannot be used because of side effects. In these patients, other drugs, such as methotrexate or antimalarials, may be useful.

Infective endocarditis is a fatal disease unless specifically treated. This entity must be suspected immediately in all patients with fever or sepsis and heart murmur and an echocardiogram should be performed to confirm the diagnosis.

In a few case series, a significant proportion of patients diagnosed with infective endocarditis showed osteoarticular involvement, which preceded, sometimes by months, the onset of specific symptoms of endocarditis.

Even when no specific musculoskeletal symptoms associated with endocarditis are found, these symptoms must be kept in mind and infective endocarditis should be suspected when musculoskeletal manifestations are the presenting symptom, because of the potentially dire consequences of delaying specific antibiotic treatment.

Infections are one of the main causes of morbidity and mortality in patients with rheumatic inflammatory disorders. Among these infections, tuberculosis (TB) is one of the most significant, due to its prevalence and severity. Nevertheless, in general terms, the possibility of reactivation of latent TB is not usually considered in rheumatic patients treated with glucocorticoids and/or non-biological immunosuppressive agents. This lack of awareness among physicians treating these patients is a problem for the epidemiological control of TB infection in countries such as Spain where the prevalence of the disease is not inconsiderable. The available evidence suggests that the incidence of TB in patients receiving glucocorticoids for inflammatory rheumatic diseases is higher than in the general population (for example, the incidence is between 4 and 6 times higher in Spain).

One approach to prevent this complication would be to follow the recommendations of the American Thoracic Society and rule out latent TB infection in all patients who are to receive ≥15 mg/day of prednisone or equivalent for more than 1 month before the treatment is started. When the results of a tuberculin test and/or interferon gamma release assays (IGRA) are positive, prophylactic treatment with isoniazid at a dose of 300 mg/day for 9 months is recommended, provided that active TB has been ruled out.