Recommendations of the Brazilian Society of Rheumatology for the use of JAK inhibitors in the management of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic and autoimmune systemic inflammatory disease that can cause irreversible joint deformities, with increased morbidity and mortality and a significant impact on the quality of life of the affected individual. The main objective of RA treatment is to achieve sustained clinical remission or low disease activity. However, up to 40% of patients do not respond to available treatments, including bDMARDs. New therapeutic targets for RA are emerging, such as Janus kinases (JAKs). These are essential for intracellular signaling (via JAK-STAT) in response to many cytokines involved in RA immunopathogenesis. JAK inhibitors (JAKi) have established themselves as a highly effective treatment, gaining increasing space in the therapeutic arsenal for the treatment of RA. The current recommendations aim to present a review of the main aspects related to the efficacy and safety of JAKis in RA patients, and to update the recommendations and treatment algorithm proposed by the Brazilian Society of Rheumatology in 2017.

Can climate and soil conditions change the morpho-anatomy among individuals from different localities? A case study in Aldama grandiflora (Asteraceae)

Vegetative aerial organs are considerably more exposed to environmental conditions and can reflect the specific adaptations of plants to their local environment. Aldama grandiflora species are known to be widely distributed in Brazil; therefore, individuals from different populations of this species are thought to be exposed to different abiotic and biotic conditions. Several anatomical studies conducted on Brazilian Aldama species have mainly focused on the qualitative anatomical characters or traits of these species, but not on their quantitative traits. In this study, we evaluated whether climate and soil conditions can change the morphometry among individuals of A. grandiflora collected from six sites in the Goiás State, Brazil, by assessing their anatomical characters. Further, soil sampling was performed, and climate data were collected from all the six sites. The analysis indicated few statistical differences among the populations evaluated, showing that A. grandiflora presented consistent leaf and stem anatomical characteristics. The small morpho-anatomical differences found among individuals of the different populations evaluated, reflected the soil conditions in which these populations were grown. Therefore, environmental factors have a significant influence on the morpho-anatomy of Aldama grandiflora.

The 17D-204 and 17DD yellow fever vaccines: an overview of major similarities and subtle differences

INTRODUCTION

The yellow fever vaccine is a live attenuated virus vaccine that is considered one of the most efficient vaccines produced to date. The original 17D strain generated the substrains 17D-204 and 17DD, which are used for the current production of vaccines against yellow fever. The 17D-204 and 17DD substrains present subtle differences in their nucleotide compositions, which can potentially lead to variations in immunogenicity and reactogenicity. We will address the main changes in the immune responses induced by the 17D-204 and 17DD yellow fever vaccines and report similarities and differences between these vaccines in cellular and humoral immunity . This is a relevant issue in view of the re-emergence of yellow fever in Uganda in 2016 and in Brazil in the beginning of 2017.

AREAS COVERED

This article will be divided into 8 sections that will analyze the innate immune response, adaptive immune response, humoral response, production of cytokines, immunity in children, immunity in the elderly, gene expression and adverse reactions.

EXPERT COMMENTARY

The 17D-204 and 17DD yellow fever vaccines present similar immunogenicity, with strong activation of the cellular and humoral immune responses. Additionally, both vaccines have similar adverse effects, which are mostly mild and thus are considered safe.

Measuring fatigue with multiple instruments in a Brazilian cohort of early rheumatoid arthritis patients

OBJECTIVE

To assess the prevalence of fatigue in a Brazilian population with early rheumatoid arthritis using multiple instruments, and the predictors of these instruments by differents independent variables.

METHODS

Cross-sectional study with direct interview and medical records review. Fatigue, dependent variable, was assessed using eight instruments: Profile of Mood States (POMS), Multidimensional Assessment of Fatigue scale (MAF), Fatigue Severity Scale (FSS), Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ), Numerical Rating Scales (BRAF-NRS), Short-form Survey 36 (SF-36), Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F) and Visual Analogic Scale for Fatigue (VASf).

INDEPENDENT VARIABLES

sociodemographic, clinical and serological, were measured using medical records and direct interview. Disability and disease activity were assessed using the Health Assessment Questionnaire (HAQ) and disease activity assessed using the Disease Activity Score 28 joints (DAS28). The scores of scales demonstrated the level of fatigue and multiple linear regression method used in statistical analysis to demonstrate prediction models.

RESULTS

A total of 80 patients was assessed, and 57 reported clinically relevant fatigue (VASf>2), representing 71.25% prevalence point (51 women [89.5%], mean age 48.35±15 years, and mean disease duration of 4.92±3.8 years). Eight predictive models showed statistical significance, one for each fatigue instrument. The highest coefficient of determination (R²) was 56% for SF-36 and the lowest (R²=21%) for FSS. The HAQ was the only independent variable to predict fatigue on all instruments.

CONCLUSION

Clinically relevant fatigue is a highly prevalent symptom and is mostly predicted by disability and age in the population assessed.

Prevalence of sexual dysfunction among female patients followed in a Brasília Cohort of early rheumatoid arthritis

OBJECTIVE

To determine the prevalence of sexual dysfunction in women diagnosed with early rheumatoid arthritis (RA) (less than one year of symptoms at the time of diagnosis), as well as to evaluate the possible association between sexual dysfunction with AR activity and functional disability.

METHODS

Cross-sectional study assessing women diagnosed with early RA, accompanied per protocol in the Brasilia Cohort, Hospital Universitário de Brasília. Demographics, disease activity index (Disease Activity Score 28 - DAS 28) and functional disability questionnaire (Health Assessment Questionnaire - HAQ), were obtained by direct interviews. The Female Sexual Function Index (FSFI) was used, questionnaire which contains 19 items that assess six domains: sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction and pain.

RESULTS

68 patients studied, of whom 54 (79.4%) reported sexual activity in the last four weeks. The participants were 49.7±13.7 (mean±SD) years old and the majority were married (61.4%). The mean DAS 28 was 3.6±1.5 and the mean HAQ was 0.7. The prevalence of sexual dysfunction (FSFI ≤26) was 79.6%. There was no association of disease activity or of functional disability with the occurrence of sexual dysfunction in the female patients evaluated.

CONCLUSION

The prevalence of sexual dysfunction found in this study was higher than that reported in the literature in healthy women. A knowledge of the extent of the problem is needed to provide adequate therapeutic options for these patients.

How the rheumatologist can guide the patient with rheumatoid arthritis on sexual function

Sexuality, an integral part of human life and quality of life, is one of those responsible for our individual welfare. Sexual dysfunction can be defined as a change in any component of sexual activity, which may cause frustration, pain and decreased sexual intercourse. Although it is known that chronic diseases, such as rheumatoid arthritis (RA), influence the quality of sexual life, sexual dysfunction is still underdiagnosed, due to two reasons: both patients fail to report the complaint because of shame or frustration, and this subject is rarely called into question by doctors. Rheumatologists are increasingly willing to discuss areas which are not directly related to drug treatment of joint diseases, such as quality of life, fatigue, and education of patients; however, sexuality is rarely addressed. The aim of this review is to present some useful concepts to Rheumatologists for orientation of their patients with RA with respect to sexual function/dysfunction, some considerations concerning the role of these professionals in order to instruct the patient, general notions about sexual function, including practical concepts about the more appropriate sexual positions for patients with RA, and a multidisciplinary approach to sexual dysfunction.

[Occupational therapy in rheumatoid arthritis: what rheumatologists need to know?]

Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of intervention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient's functionality. Occupational therapy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupational therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and coping with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and independence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA.

[Vaccination in patients from Brasília cohort with early rheumatoid arthritis]

INTRODUCTION

Patients with a diagnosis of rheumatoid arthritis (RA) are at increased risk of infections. Vaccination is a recommended preventive measure. There are no studies evaluating the practice of vaccination in patients with early RA.

OBJECTIVES

To evaluate the frequency of vaccination and the orientation (by the doctor) about vaccines among patients with early RA diagnosis.

METHODS

Cross-sectional study including patients from the early RA Brasilia cohort. Demographic data, disease activity index (Disease Activity Score 28 - DAS28), functional disability (Health Assessment Questionnaire - HAQ), and data on treatment and vaccination after diagnosis of RA were analyzed.

RESULTS

68 patients were evaluated, 94.1% women, mean age 50.7±13.2 years. DAS28 was 3.65±1.64, and HAQ was 0.70. Most patients (63%) had vaccination card. Only five patients (7.3%) were briefed by the doctor about the use of vaccines. Patients were vaccinated for MMR (8.8%), tetanus (44%), yellow fever (44%), hepatitis B (22%), influenza (42%), H1N1 (61.76%), pneumonia (1.4%), meningitis (1.4%), and chickenpox (1.4%). All patients vaccinated with live attenuated virus were undergoing immunosuppressive therapy, and were vaccinated inadvertently, without medical supervision. There was no association between the use of any vaccine and disease activity, functional disability, years of education, lifestyle, and comorbidities.

CONCLUSION

Patients were infrequently briefed by the physician regarding use of vaccines, with high frequency of inadvertent vaccination with live attenuated component, while immunization with killed virus was below the recommended level.

Physical activity among patients from the Brasília cohort of early rheumatoid arthritis

INTRODUCTION

The 2012 Consensus of the Brazilian Society of Rheumatology (SBR) for the treatment of Rheumatoid Arthritis (RA) recommends that patients should regularly perform physical exercises. There have been no studies in Brazil on physical activity among patients with early RA.

OBJECTIVE

To investigate the physical activity practice among patients with early RA and the possible association between physical activity, disease activity and functional disability.

METHODS

Cross-sectional study of patients from the Brasilia cohort of early RA. Demographic data (sex, age and level of schooling), physical activity practice, Disease Activity Score 28 (DAS 28), functional disability (Health Assessment Questionnaire - HAQ), as well as data on smoking status, alcohol consumption, comorbidities and RA treatment were analyzed.

RESULTS

A total of 72 patients were evaluated, 90.27% females, mean age 50.2 ± 13.3 years, mean DAS 28: 3.66 and HAQ: 0.69. Of them, 43.05% were regularly active, with walking being the most often practiced exercise (80.64%). The mean duration of exercise was 48.22 ± 27.18 min, with a frequency of 3.7 ± 1.64 times per week. There was no association between physical activity and gender, age, educational level, disease activity, functional disability, alcoholism or smoking, presence of comorbidities and treatment with drugs that alter the course of disease.

CONCLUSION

Given the importance of regular physical activity practice, it is necessary to recommend it to patients, especially resistance physical activities, which are not frequent among the patients in our study.