Real-world persistence of initial targeted therapy strategy in monotherapy versus combination therapy in patients with chronic inflammatory arthritis

OBJECTIVE

The persistence of biologic (b) and targeted synthetic (ts) disease-modifying antirheumatic drugs(DMARDs) in monotherapy versus in combination with conventional synthetic (cs) DMARDs is still a controversial topic in rheumatic diseases. To clarify this issue, the retention of the initial treatment strategy of b/tsDMARD in combination with csDMARD versus monotherapy in rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) patients under real-life conditions was evaluated. Factors associated with maintenance of the initial strategy were analysed.

METHODS

Nested cohort study within the Spanish BIOBADASER III registry. Bivariate comparisons and multivariate Cox proportional hazards models were used for the analyses.

RESULTS

A total of 2521 patients were included in the study. In the multivariate model, the initial strategy of combination therapy was associated with shorter persistence in patients with RA (hazard ratio [HR] 1.58;95% confidence interval [CI] 1.00-2.50; p = .049), PsA (HR 2.48; 95% CI 1.65-3.72) and AS (HR 16.77; 95% CI 7.37-38.16; p < .001), regardless of sex, time of disease progression, baseline disease activity, glucocorticoid use or type of b/tsDMARD. Overall, the combination strategy was associated with an increased incidence of adverse events (incidence rate ratio [IRR] 1.13; 95% CI 1.05-1.21).

CONCLUSIONS

In this real-life study, the strategy of combining a b/tsDMARD with a csDMARD is associated with lower persistence and worse safety profile compared to monotherapy in RA and especially in PsA and AS, suggesting that combination therapy should be rethought as first choice in RA patients, but especially in PsA and AS patients.

Juvenile idiopathic arthritis in the young adult. Methodology, objectives, and initial data from the JUVENSER registry

OBJECTIVES

To describe the methodology, objectives, and initial data of the registry of young adult patients diagnosed with Juvenile Idiopathic Arthritis (JIA), JUVENSER. The main objective of the project is to know the sociodemographic and clinical characteristics, and disease activity of patients with JIA reaching the transition to adulthood.

MATERIAL AND METHOD

Longitudinal, prospective, multicentre study, including patients between 16 and 25 years old, with a diagnosis of JIA in any of its categories. The main objective is to determine the characteristics and activity of JIA in the young adult. It includes sociodemographic variables, clinical variables, disease activity and joint damage rates, data on the use of health resources, and treatments used. The total duration of the project will be 3 years. A cohort of 534 young adult patients was obtained.

CONCLUSIONS

The JUVENSER registry will constitute a cohort of young adults with JIA, which will allow the evaluation of the clinical characteristics and response to treatment of patients with disease onset in childhood, moving to adult clinics.

What drives the decision to optimise biological treatment in children and youngsters with juvenile idiopathic arthritis? A discrete-choice experiment

OBJECTIVE

To analyse factors involved in the decision to optimise biologics in juvenile idiopathic arthritis.

METHODS

A "discrete-choice" methodology was used. In a nominal group meeting, factors which may influence physicians' decisions to optimise biological dose were identified, together with decision nodes. 1000Minds® was used to create multiple fictitious clinical scenarios based on the factors identified, and to deploy surveys that were sent to a panel of experts. These experts decided for each item which of two clinical scenarios prompted them to optimise the dose of biologic. A conjoint analysis was carried out, and the partial-value functions and the weights of relative importance calculated.

RESULTS

In the nominal group, three decision nodes were identified: (1) time to decide; (2) to maintain/reduce or prolong interval; (3) what drug to reduce. The factors elicited were different for each node and included patient and drug attributes. The presence of macrophage activation syndrome (MAS), systemic involvement, or subclinical inflammation made the decision easier (highest weights). The presence of joints of difficult control and year of debut influenced the decision in some but not all, and in different directions. Immunogenicity, adherence, and concomitant treatments were also aspects taken into account.

CONCLUSIONS

The decision to optimise the dose of biological therapy in children and youngster can be divided into several nodes, and the factors, both patient and therapy-related, leading to the decision can be detailed. These decisions taken by experts may be transported to practice, study designs, and guidelines.

Prevalence of systemic lupus erythematosus in Spain: higher than previously reported in other countries?

OBJECTIVES

Prevalence of SLE varies among studies, being influenced by study design, geographical area and ethnicity. Data about the prevalence of SLE in Spain are scarce. In the EPISER2016 study, promoted by the Spanish Society of Rheumatology, the prevalence estimate of SLE in the general adult population in Spain has been updated and its association with sociodemographic, anthropometric and lifestyle variables has been explored.

METHODS

Population-based multicentre cross-sectional study, with multistage stratified and cluster random sampling. Participants were contacted by telephone to carry out a questionnaire for the screening of SLE. Investigating rheumatologists evaluated positive results (review of medical records and/or telephone interview, with medical visit if needed) to confirm the diagnosis. To calculate the prevalence and its 95% CI, the sample design was taken into account and weighing was calculated considering age, sex and geographic origin. Multivariate logistic regression models were defined to analyse which sociodemographic, anthropometric and lifestyle variables included in the telephone questionnaire were associated with the presence of SLE.

RESULTS

4916 subjects aged 20 years or over were included. 16.52% (812/4916) had a positive screening result for SLE. 12 cases of SLE were detected. The estimated prevalence was 0.21% (95% CI: 0.11, 0.40). SLE was more prevalent in the rural municipalities, with an odds ratio (OR) = 4.041 (95% CI: 1.216, 13.424).

CONCLUSION

The estimated prevalence of SLE in Spain is higher than that described in most international epidemiological studies, but lower than that observed in ethnic minorities in the United States or the United Kingdom.

Prevalence of Sjögren's syndrome in the general adult population in Spain: estimating the proportion of undiagnosed cases

To estimate the prevalence of Sjögren's syndrome (SS) in the adult Spanish population we performed a population-based multicenter cross-sectional study. Cases were defined by the American-European Consensus Group criteria proposed in 2002. A total of 4,916 subjects aged 20 years or over were included. The estimated prevalence of SS (including primary and secondary forms) in the adult population in Spain was 0.33% (95% CI 0.21-0.53). Extrapolating to the total population of the country aged ≥ 20 years (around 37.7 million persons), there would be around 125,000 cases of SS in Spain. Considering only primary SS, the estimated prevalence was 0.25% (95% CI 0.15-0.43) or 1 person in 400. The prevalence of primary SS in Spain is comparable to that reported in other European studies with a similar design and diagnostic criteria. Based on these results, primary SS could not be considered a rare (orphan) disease. Only 50% of cases had already been diagnosed with SS prior EPISER 2016 study, confirming the existence of a non-negligible proportion of undiagnosed cases in the general population.

AB0903 VITAMIN D LEVELS IN PRIMARY CARE AND RHEUMATOLOGY PATIENTS

Background:

Although many studies are calling into question the benefits commonly attributed to the vitamin D out of the bone sphere, in the recent years its determination and supplementation has been generalized in the population. Causes of this trend are not clear, but generalist media pressure or even specialized over patients and doctors, along with overrated normality levels could be contributing to this fact. Actual literature123indicates that 25-OH vitamin D levels of 30ng/ml or higher are not necessary, and most of the authors agree that 20ng/ml levels are enough for the general population, and only levels below 12.5ng/ml must be considered deficient and subsidiaries of supplementation.

Objectives:

Obtain the vitamin D levels distribution from a sample of individuals with no bone pathology, or supplementation prescription in Tenerife’s North Area.

Methods:

Retrospective descriptive study of the 25-OH vitamin D levels requests from the Tenerife’s North Area, made for any reason by the Primary Care Doctor or the rheumatologist, both in the Primary Care Centers and the Hospital Universitario de Canarias (HUC). 25-OH vitamin D values were gathered from 2662 blood samples from a total of 2635 patients, from September to November of 2018 (2241 from Primary Care and 421 from rheumatology). In order to determine the use of calcium and vitamin D supplements, and the presence of bone pathology, either renal or from a malabortive process, 400 individuals were randomized (250 from primary care and 150 from rheumatology. Demographic data (age and gender), calcium serum, phosphor and 25-OH vitamin D levels were gathered for the individual records. With regards to the treatment, data about vitamin D supplements, calcium with vitamin D, or the sum of both, that the patient may have in electronic prescriptions at that time; as well as osteoporosis treatment (biphosphonates, denosumab or teriparatide) were gathered.

Results:

Using the age, gender, male/female relation, the levels of vitamin D, calcium and phosphor, as comparison factors; the characteristics of the random population were statistically indistinguishable from the global population. Regarding the random sample characteristics, from the 150 rheumatology patients, 11 were men (7.3%) and 139 women (92.7%). While from the 250 primary care patients, 66 were men (26.4%) and 184 were women (73.6%). The average age of the primary care sample was 55.76±19.72 years and 65.16±13.84 years in the rheumatology sample.

In the total random healthy population: without bone pathology, renal or malabortive and without calcium, vitamin D or antiresorptive drug (n=181) treatment, the levels of vitamin D were 31±14ng/ml with a normal distribution and without clear differences between the primary care and rheumatology patients. When the healthy population distribution was studied by vitamin D levels, the 55% presented values below 30ng/ml, 12% below 20ng/ml and 4% showed levels under 12.5ng/ml: levels agreed as deficient (see graph).

Conclusion:

The 55% of the patients studied in primary care and rheumatology, without renal, digestive or bone disease and without vitamin D supplement, presented vitamin levels below the actual limits of 30ng/ml. These limits, used by most of the laboratories, tend to overestimate the vitamin D deficiency.

References:

[1]Manson, JE. N Engl J Med 2018, DOI: 10.1056/NEJMoa1809944.

[2]Spector, TD. BMJ 2016: 355: i6183

[3]Wu, F. Osteoporosis International 2017; 28: 505-515.

Disclosure of Interests:

None declared

FRI0577 VITAMIN D LEVEL IN HEALTHY CANARIAN ADULT POPULATION

Background:

Vitamin D (VitD) was first used to treat rickets in children in depressed urban areas of England, due to malnutrition and lower sun exposure. During the last decade its use has become widespread in western societies because it has been associated with lower risk of suffering from multiple diseases and there is also a lack of consensus in establishing adequate levels for the general population. Regarding the beneficial effects of VitD, well-designed current observational studies are calling them into question and many authors believe that levels of 30 ng/mL, adopted as optimal, are overestimated1-2. All this has led many individuals who come to our consultations to use supplements without scientific evidence of their benefits.

Objectives:

The main objective was to determine the distribution of VitD levels in the healthy canarian population, an area with high solar radiation and stratified according to demographic factors (age, sex and place of residence). As a secondary objective, the study was established to determine prevalence of hyperparathyroidism hypercalcemic in the canarian population.

Methods:

Cross-sectional population study to determine VitD levels in healthy subjects. The EPIRCAN study screen was used, a population study carried out between 2004 and 2005 to determine the prevalence of rheumatic diseases in the Canary Islands. In 949 serums, the levels of VitD, phosphorus and calcium were determined, as well as Parathyroid hormone (PTH), only in which calcium levels were >10,4 mg/dl. Data were analysed according to demographic characteristics, comorbidities and medication. For the statistical analysis the SPSS was used.

Results:

The sociodemographic characteristics (age, sex and rural/urban population) of the 949 samples were representative of the Canarian population in the period studied according to data of the ISTAC (Canary Institute of Statistics) with a level of accuracy of 0.7 ng/ml for the vitD and a confidence level of 95%. Healthy (n=876, 92.3%) and sick subjects (n= 73, 7.7%) (renal failure, dialysis, Crohn’s, ulcerative colitis, osteoporosis, calcium supplements, vitD, bisphosphonates or calcitonin). The median and Interquartile range of vitD levels in the entire population studied was 26.3 (20.9-32.9) ng/ml. The VitD levels distribution of healthy population was: 66% were below 30 ng/ml,23% were below 20 mg/ml and 4% were below 12,5 ng/ml. According to the age groups, sex and location: women versus men have 2.8 ng/ml less VitD (CI95%: 1.487;4.177). As the age increases the VitD values decrease; those aged 20-45 with respect to ≥65 years have 5.5 ng/ml more (CI95%: 3.574;7.592), those 45-65 years old have 2.397 ng/ml more (CI95% 0.255;4.539) with respect to ≥65 years, being statistically significant. There were no significant differences between the rural and urban population. The prevalence of hyperparathyroidism hypercalcemic was 0.2%.

Conclusion:

In the healthy population, baseline levels of VitD are higher in men than in women and tend to decrease with age. Due to the distribution of VitD levels in a healthy population, in an area of high sun exposure, seems to be more reasonable to establish the optimal VitD levels in the general population at 20 ng/ml instead of the established 30 mg/ml.

References:

[1] F. Wu et al. Cut-points for associations between vitamin D status and multiple musculoskeletal outcomes in middle-aged women. (2017). Osteoporosis International; Volume 28, Issue 2, pp 505–515.

[2] E. Manson, J. (2016). Vitamin D Deficiency — Is There Really a Pandemic? The New England Journal of Medicine, pp.75;19.

Disclosure of Interests:

None declared

Association between periodontitis and anti-citrullinated protein antibodies in rheumatoid arthritis patients: a cross-sectional study

AIM

The aim of this study was to evaluate the association between periodontal parameters related with the periodontal disease severity and the presence and levels of anti-citrullinated protein antibodies (ACPAs) in rheumatoid arthritis (RA) patients.

MATERIALS AND METHODS

This cross-sectional study included 164 RA patients. Socio-demographics and RA disease characteristics, including ELISA-detected ACPA (anti-CCP-2), were recorded. Exposure was assessed by periodontal parameters: plaque index (PI), bleeding on probing (BoP), probing pocket depth, and clinical attachment levels (CAL). Presence and levels of ACPAs (outcome) and exposure variables were compared by both parametric and non-parametric tests and associations were evaluated by adjusted odds ratio (OR).

RESULTS

A significant association was observed between the presence of anti-CCP antibodies and severity of periodontal outcomes such as the mean CAL (OR 1.483, p = 0.036), mean PI (OR 1.029, p = 0.012), and the number of pockets ≥ 5 mm (OR 1.021, p = 0.08). High anti-CCP antibodies levels were associated with mean CAL, mean PI, and number of pockets ≥ 5 mm with an OR of 1.593 (p = 0.043), 1.060 (p <  0.001), and 1.031 (p = 0.031), respectively. Furthermore, a significant increase of 4.45 U/mL in anti-CCP antibodies levels (p = 0.002) in RA patients was found for each pocket ≥ 5 mm after adjusting for age, gender, smoking, time of disease evolution, and RA activity.

CONCLUSIONS

In RA patients, the severity of periodontal conditions such as mean CAL, mean PI, and the number of pockets ≥ 5 mm were linearly associated with both the presence and levels of anti-CCP antibodies.

Expert Recommendations on the Interleukin 6 Blockade in Patients with Rheumatoid Arthritis

OBJECTIVE

To draft recommendations on interleukin 6 (IL-6) blockade in rheumatoid arthritis (RA), based on best evidence and experience.

METHODS

A group of 10 experts on IL-6 blockade in RA was selected. The 2 coordinators formulated 23 questions about IL-6 blockade (indications, efficacy, safety, etc.). A systematic review was conducted to answer the questions. Using this information, inclusion and exclusion criteria were established, as were the search strategies (Medline, EMBASE and the Cochrane Library were searched). Two different reviewers selected the articles. Evidence tables were created. At the same time, European League Against Rheumatism and American College of Rheumatology abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted on in a nominal group meeting. The level of evidence and grade of recommendation were established using the Oxford Centre for Evidence Based Medicine and the level of agreement with the Delphi technique (2 rounds). Agreement was established if at least 80% of the experts voted yes (yes/no).

RESULTS

The 8 preliminary recommendations were accepted after the Delphi process. They covered aspects such as the use of these therapies in monotherapy, in combination, in patients with refractory disease or intolerant patients, response evaluation, optimization and risk management.

CONCLUSIONS

The manuscript aims to solve frequently asked questions and aid in decision making strategies when treating RA patients with IL-6 blockade.

Objectives and methodology of BIOBADASER phase iii

OBJECTIVE

Describe the objectives, methods and results of the first year of the new version of the Spanish registry of adverse events involving biological therapies and synthetic drugs with an identifiable target in rheumatic diseases (BIOBADASER III).

METHODOLOGY

Multicenter prospective registry of patients with rheumatic inflammatory diseases being treated with biological drugs or synthetic drugs with an identifiable target in rheumatology departments in Spain. The main objective of BIOBADASER Phase III is the registry and analysis of adverse events; moreover, a secondary objective was added consisting of assessing the effectiveness by means of the registry of activity indexes. Patients in the registry are evaluated at least once every year and whenever they experience an adverse event or a change in treatment. The collection of data for phase iii began on 17 December 2015.

RESULTS

During the first year, 35 centers participated. The number of patients included in this new phase in December 2016 was 2,664. The mean age was 53.7 years and the median duration of treatment was 8.1 years. In all, 40.4% of the patients were diagnosed with rheumatoid arthritis. The most frequent adverse events were infections and infestations.

CONCLUSIONS

BIOBADASER Phase III has been launched to adapt to a changing pharmacological environment, with the introduction of biosimilars and small molecules in the treatment of rheumatic diseases. This new stage is adapted to the changes in the reporting of adverse events and now includes information related to activity scores.

Undifferentiated connective tissue disease: predictors of evolution into definite disease

OBJECTIVES

The natural evolution of undifferentiated connective tissue diseases (UCTD) has not yet been established. The aim of our study was to analyse the clinical outcomes of a cohort of UCTD patients followed in a routine outpatient setting and to establish which clinical, serological or capillaroscopy features are associated with an increased risk of evolution to definite connective tissue disease (CTD).

METHODS

Data for this study were collected by a retrospective review of 758 patients referred to our hospital, between 1999 and 2008, with suspected CTD. After selection criteria, 98 patients were considered eligible and their records, laboratory findings and nailfold-capillaroscopy pattern (NCP) were analysed until clinical outcome. Three groups of patient outcomes were established: remission, UCTD, and definite CTD. Logistic regression analysis was performed to study the association of baseline clinical features, including NCP progression during monitoring, with clinical outcomes.

RESULTS

After a mean follow-up of 11±3 years, 62% of the patients continued to suffer from UCTD, 24% regressed to a remission state and 14% developed definite CTD. Cytopenias (p=0.030), positivity for antibody specificities (ENA) (p=0.008), anti-Ro (p=0.036) and antiphospholipid antibodies (p=0.032), and the presence of an altered NCP (p=0.026) at baseline proved different between groups and were more frequently encountered in the group that evolved to definite CTD when compared with the others two groups. Specifically, cytopenias (odds ratio -OR- 4.20 [1.30-13.56] p=0.016), the presence of an antinuclear antibody (ANA) titre ≥1/640 (OR 7.00 [1.99-24.66], p=0.002) and anti-centromere positivity (OR 3.77 [1.03-13.79], p=0.045) at baseline and NCP progression (OR 6.63 [1.70-25.87], p=0.007) were associated with the future presence of definite CTD.

CONCLUSIONS

Most patients with UCTD remain in an undifferentiated state after routine outpatient clinic follow-up. High ANA titres or the presence of cytopenias at baseline, as well as progression of NCP during follow-up, are the leading factors associated with evolution to definite CTD.

Prevalence of rheumatic diseases in adult population in Spain (EPISER 2016 study): Aims and methodology

AIMS

To describe the methodology of the EPISER 2016 (study of the prevalence of rheumatic diseases in adult population in Spain), as well its strengths and limitations. The aim of this study is to estimate the prevalence of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), osteoarthritis (knee, hip, hands, and cervical and lumbar spine), fibromyalgia, gout and clinical osteoporotic fracture.

MATERIAL AND METHOD

Population-based, multicenter, cross-sectional study, with the participation of 45 municipalities in the 17 Spanish autonomous communities. The reference population will consist of adults aged 20 years and over residing in Spain. A computer-assisted telephone interview (CATI) system will be used for data collection. Diagnostic suspicions and diagnoses received by the participants will be studied by rheumatologists in the referral hospitals in the selected municipalities.

STATISTICAL ANALYSIS

the prevalence of the rheumatic diseases will be calculated using estimators and their 95% confidence intervals. Weights will be calculated in each of the sampling stages in accordance with the probability of selection. The distribution of the population in Spain will be obtained from the Spanish Statistics Institute.

CONCLUSIONS

Sociodemographic and lifestyle changes over the last 16 years justify EPISER 2016. This study will provide current data about the prevalences of RA, AS, PsA, SLE, SS, osteoarthritis, fibromyalgia, gout and clinical osteoporotic fracture. The results will allow comparisons with studies from other countries and EPISER 2000.

Non-adherence to subcutaneous biological medication in patients with rheumatoid arthritis: a multicentre, non-interventional study

OBJECTIVES

To evaluate non-adherence to prescribed subcutaneous biologicals in rheumatoid arthritis (RA) patients in Spain.

METHODS

ARCO (Study on Adherence of Rheumatoid Arthritis patients to SubCutaneous and Oral Drugs) was a multicentre, non-interventional retrospective study involving 42 rheumatology clinics from representative hospitals throughout Spain. The primary objective was to assess the percentage of patients (aged ≥18 years with an established RA diagnosis) with non-adherence to prescribed subcutaneous biologicals using clinical records and hospital pharmacy dispensing logs as the primary information sources. Adherence was assessed using the Medication Possession Ratio (MPR). Additionally, patients completed the Morisky-Green Medication Adherence Questionnaire.

RESULTS

A total of 364 patients (77.5% females, mean age 54.9 years, median RA duration since diagnosis 7.8 years) were enrolled in ARCO. Non-adherence (MPR ≤80%) was reported in 52/363 evaluable patients (14.3%), and was lower in patients receiving initial monthly drug administration (6.4%) than with weekly (17.4%; p=0.034) or every two weeks (14.4%; p=0.102) administration. By multivariate analysis, non-adherence was positively associated with RA duration above the median and with using induction doses. Monthly administration, compared to weekly administration, was inversely associated with non-adherence. Age, gender, order of administration, and changes in the interval of administration, showed no association with non-adherence. Compared with the MPR, the Morisky-Green questionnaire performed poorly in detecting non-adherence.

CONCLUSIONS

Non-adherence to the prescribed subcutaneous biological drug occurred in 14.3% of patients with RA. Patients using the most convenient administration period (i.e. monthly) had better adherence than those using more frequent dosing schedules.

Differential Antigen-presenting B Cell Phenotypes from Synovial Microenvironment of Patients with Rheumatoid and Psoriatic Arthritis

OBJECTIVE

To study the qualitative and quantitative phenotypic changes that occur in molecules involved in antigen presentation and costimulation in synovial B cells from rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

METHODS

The presence of HLA-DR, CD86, and CD40 in CD20+ cells was studied in RA synovium biopsies using immunohistochemistry and immunofluorescence. Expression was assessed by flow cytometry of the Class II molecules CD40, CD86, CD23, and CD27 on B cells from the synovial fluid (SF), with respect to peripheral blood, from 13 patients with RA and 15 patients with PsA. Expression of interferon-induced protein with tetratricopeptide repeats 4 (IFIT4) in immune-selected CD20+ cells from patients with RA was assessed by quantitative realtime PCR.

RESULTS

Infiltrating synovial RA, B cells expressed HLA-DR, CD40, and CD86. Increased expression of CD86, HLA-DR, and HLA-DQ in B cells from SF was found in patients with RA and PsA. HLA-DP was also elevated in rheumatoid SF B cells; conversely, a significantly lower expression was observed in SF from patients with PsA. CD40 expression was increased in SF B cells from PsA, but not in patients with RA. Interestingly, CD20 surface expression level was significantly lower in SF B cells (CD19+, CD138-) from RA, but not in patients with PsA. CD27 upregulation and CD23 downregulation were observed in synovial B cells in both pathologies. Finally, a 4-fold increase in IFIT4 mRNA content was shown in B cells from SF in patients with RA.

CONCLUSION

Synovial B cells from patients with RA and patients with PsA express different antigen-presenting cell phenotypes, suggesting that this cell type plays a dissimilar role in the pathogenesis of each disease.

[Recommendations for the use of methotrexate in patients with juvenile idiopathic arthritis]

OBJECTIVES

To develop a consensus document of recommendations for the use of methotrexate (MTX) in patients with juvenile idiopathic arthritis (JIA).

MATERIAL AND METHOD

A group of eleven experts proposed several clinical questions on the use of MTX in patients with JIA. A systematic review was conducted and the evidence and recommendations for each question were extracted. The results were discussed and validated by the experts in a work session to establish the final recommendations.

RESULTS

MTX is recommended as the first drug for inducing remission in JIA, and its indication should be made according to the clinical category of the patient. Prior to treatment, it is recommended to perform a complete blood count, including white cells, levels of liver enzymes, serum creatinine, and other analytical parameters according to specific risk factors. Treatment should be initiated with a dose of 10-15 mg/m(2)/week. In cases of uveitis or polyarthritis, an initial dose of 15 mg/m(2)/week should be considered. For a better bioavailability and tolerability, it is preferable to administer MTX parenterally if the dose is ≥15 mg/m(2)/week. It is necessary to periodically perform an analytical monitoring of the patient and to assess possible alterations in liver enzymes to make changes if necessary. Combinations with biological agents may be necessary, as well as the concomitant addition of folic or folinic acid.

CONCLUSIONS

This document describes the main recommendations for the appropriate use of MTX in JIA patients, according to scientific evidence and clinical experience.

[The search for new autoantigens in Sjögren's syndrome]

OBJECTIVE

To identify new autoantigens related to Sjögren's syndrome and to determine their prevalence in patients and healthy individuals.

MATERIAL AND METHODS

Serological sampling was performed in a patient with Sjögren's syndrome through the use of a human brain expression genotec (SEREX technique) to determine expression of known autoantigens and previously undescribed proteins. The presence of a previously unknown protein was found. Several proteins were obtained and two were selected to be studied (a human protein called Tau and an unknown protein described by our group and named hlscA). Both Tau and hIscA cDNA were transformed into an expression plasmid to obtain their recombinant proteins.

RESULTS

Using a Western-blot technique we investigated the presence of anti-Tau and anti-hlscA autoantibodies in the sera of 19 patients with Sjögren's syndrome and in the sera of 20 controls. No statistically significant differences were found in the expression of anti-Tau antibodies between patients with Sjögren's syndrome and controls but values of anti-hlscA autoantibodies were significantly lower in patients with Sjögren's syndrome.

CONCLUSION

We identified Tau and hIscA proteins as new autoantigens in Sjögren's syndrome. Anti-hlscA antibody values were significantly lower in patients with Sjögren's syndrome than in healthy controls. Although no statistically significant differences in values of anti-Tau antibodies were found between Sjögren's syndrome patients and controls, this is the first time antibodies against this protein have been detected in Sjögren's syndrome.

Undernutrition in rheumatoid arthritis patients with disability

Clinical evaluation of nutritional status (NS) was performed in 75 rheumatoid arthritis patients. They were distributed according to functional class, radiological stage and other prognostic factors (rheumatoid factor, extraarticular disease, disease duration). Evaluation of the different anthropometrical measurements in this group of long-standing RA patients (average disease duration: 10 years) revealed a significant impairment of lean body mass (LBM), especially among those with greater disability (Functional Class III and IV). Patients in more severe radiological stages (Radiological Stage III and IV) or patients with extraarticular disease also presented a significant loss of LBM compared with a matched cohort of the general population and patients with a more benign-course disease. There was less impairment of the fat mass, according to our clinical evaluation. Serological parameters of undernutrition (albumin and transferrin) did not show significant differences among the groups of patients. Clinical evaluation of NS in RA patients is a useful procedure for recognising patients at high risk of related complications by means of their poor nutritional status.

[The evolution of the clinical activity of systemic lupus erythematosus after a kidney transplant]

BACKGROUND

To study the clinical activity of systemic lupus erythematosus (SLE) in recipients of renal transplants (rT) performed by terminal renal failure (TRF) secondary to lupus nephritis.

METHODS

The clinical evolution of 11 patients with SLE (ARA criteria) and TRF were evaluated with a descriptive character by the modified index of activity SLE-DAI during dialysis periods and post rT as well as in the course prior to disease. A comparative analysis was carried out in a control group of 25 patients with SLE without renal failure.

RESULTS

The indexes of activity of the group investigated were higher than those of the control group during the predialysis period, similar in the dialysis period and significantly decreased (p < 0.01) in the post rT. In the group with rT a significant decrease was reported in the indexes of activity in the periods of dialysis (p < 0.05) and post rT (p < 0.01) with respect to the previous period. A significant reduction was observed in the post rT therapeutic options.

CONCLUSIONS

The clinical activity of systemic lupus erythematosus is reduced in the terminal renal failure in dialysis. The most significant reduction of clinical activity is found after renal transplantation.