Search

To develop a joint proposal for screening criteria of interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and vice versa, which serves as a guidelines in patient referral between the Rheumatology and Pneumology departments to early detection of these patients.A systematic literature review was carried out on the risk factors for the development of ILD in RA patients, and for the referral criteria to Rheumatology for suspected early RA. Based on the available evidence, screening criteria were agreed using the Delphi method by a panel of pneumologists and rheumatologists with expertise in these pathologies.Screening criteria for ILD in patients with RA and for the early detection of RA in cases with ILD of unknown etiology have been developed. In both cases, a detection strategy was based on clinical risk factors. Recommendations also included the complementary tests to be carried out in the different clinical scenarios and on the periodicity that screening should be repeated.A selective screening strategy is recommended for the first time in the early diagnosis of patients with ILD-RA. This multidisciplinary proposal aims to solve some common clinical questions and help decision-making, although its usefulness to identify these patients with good sensitivity must be confirmed in a validation study.

Resumen Objetivos La enfermedad pulmonar intersticial difusa (EPID) es una manifestacion frecuente en pacientes con artritis reumatoide (AR) y asocia una gran morbimortalidad. El objetivo de esta revision fue identificar los distintos metodos de cribado de EPID en pacientes con AR. Metodos Se realizo una busqueda sistematica en Pubmed, Embase y Cochrane Library hasta abril de 2020 y una busqueda manual en la bibliografia de los articulos recuperados. Se limito a estudios en humanos y articulos publicados en ingles, frances o espanol. Se seleccionaron estudios de cualquier diseno en los que: a) la poblacion a estudiar fuesen pacientes adultos con AR; b) la intervencion consistiese en cualquier metodo de cribado de EPID; y c) se evaluase la validez o fiabilidad del metodo de cribado, o se describiesen criterios de cribado. Dos revisoras realizaron la seleccion por titulo y abstract de forma independiente y posteriormente extrajeron la informacion utilizando plantillas especificas. Resultados Se incluyeron 25 estudios con un total de 2.593 pacientes. La herramienta mas frecuentemente utilizada para el cribado de EPID fue la tomografia computarizada de alta resolucion (TCAR) pulmonar. Tambien se evaluaron la auscultacion electronica, los marcadores bioquimicos, el lavado broncoalveolar (LBA), las pruebas de funcion respiratoria (PFR) y la ecografia pulmonar. En los diferentes estudios, la auscultacion electronica y la ecografia pulmonar alcanzaron mayor precision que las PFR, el LBA y los marcadores bioquimicos. Conclusiones La TCAR ha demostrado ser la tecnica mas sensible para el cribado de EPID en pacientes con AR. Dada su inocuidad y su alta sensibilidad, es posible que la ecografia pulmonar se posicione como tecnica de eleccion en un futuro.

Resumen Objetivo Elaborar recomendaciones para la prevencion de infeccion en pacientes adultos con enfermedades reumaticas autoinmunes sistemicas (ERAS). Metodos Un panel de expertos, seleccionados con base en su curriculum y experiencia, identifico preguntas clinicas de investigacion relevantes para el objetivo del documento. Se realizaron revisiones sistematicas de la evidencia, que se graduo de acuerdo con los criterios del Scottish Intercollegiate Guidelines Network. Tras ello, se formularon las recomendaciones. Resultados Se seleccionaron cinco preguntas, referentes a la prevencion de infeccion por Pneumocystis jirovecii con trimetoprim-sulfametoxazol, medidas profilacticas contra el virus de la hepatitis B, vacunacion contra el virus del papiloma humano, vacunacion contra el Streptococcus pneumoniae y vacunacion contra el virus de la gripe. Se formularon un total de 18 recomendaciones, estructuradas por pregunta, con base en la evidencia encontrada para las diferentes ERAS y/o consenso de expertos. Conclusiones Existe suficiente evidencia sobre la seguridad y eficacia de las vacunaciones y otras medidas profilacticas frente a los microrganismos revisados en este documento como para ser recomendadas especificamente en pacientes con ERAS.

Resumen Objetivos Analizar el riesgo de fractura calculado por FRAX® y la frecuencia de alto riesgo de fractura en la poblacion general en Espana. Metodos EPISER2016 es un estudio transversal multicentrico de base poblacional de la prevalencia de las enfermedades reumaticas en poblacion adulta en Espana. Un total de 3.154 sujetos de edad igual o superior a 40 anos (1.184 hombres y 1.970 mujeres) se seleccionaron mediante muestreo aleatorio estratificado. Las preguntas relacionadas con los factores de riesgo de fractura se realizaron mediante encuesta telefonica. El riesgo de fractura principal (RFP) y de cadera (RFC) se calcularon con la version espanola de la herramienta FRAX®, sin la inclusion de la densidad mineral osea. Para definir alto riesgo de fractura, se utilizaron los umbrales RFP ≥ 20%, RFP ≥ 10%, RFP ≥ 7,5% y RFC ≥ 3%. Resultados La mediana (rango intercuartilico) del RFP fue 2,61% (1,55-6,34%) en mujeres y 1,67% (1,15-2,87%) en hombres; la del RFC fue 0,39% (0,14-1,86%) y 0,18% (0,07-0,77%). El 3,83% de las mujeres y ningun hombre tenian un RFP ≥ 20%; el 15,71% y el 1,14% tenian un RFP ≥ 10%; el 20,62% y el 2,21%, un RFP ≥ 7,5%; y el 19,27% y el 8,05%, un RFC ≥ 3%. En las mujeres de 65 anos o mas, el RFC fue alto en el 58,09%. Conclusiones EPISER2016 nos ha permitido conocer el riesgo de fractura calculado por FRAX® y la prevalencia de alto riesgo de fractura en la poblacion general segun los diversos umbrales utilizados en Espana.

Resumen Objetivo La dificultad para el diagnostico y la variedad de manifestaciones clinicas que pueden determinar la eleccion del tratamiento del sindrome antifosfolipido (SAF) primario ha impulsado a la Sociedad Espanola de Reumatologia (SER) en la elaboracion de recomendaciones basadas en la mejor evidencia posible. Estas recomendaciones pueden servir de referencia para reumatologos y otros profesionales implicados en el manejo de pacientes con SAF. Metodos Se creo un panel formado por 4 reumatologos, una ginecologa y una hematologa, expertos en SAF, previamente seleccionados mediante una convocatoria abierta o por meritos profesionales. Las fases del trabajo fueron: identificacion de las areas claves para la elaboracion del documento, analisis y sintesis de la evidencia cientifica (utilizando los niveles de evidencia de SIGN, Scottish Intercollegiate Guidelines Network) y formulacion de recomendaciones a partir de esta evidencia y de tecnicas de «evaluacion formal» o «juicio razonado». Resultados Se han elaborado 46 recomendaciones que abordan 5 areas principales: diagnostico y evaluacion, medidas de tromboprofilaxis primaria, tratamiento del SAF o tromboprofilaxis secundaria, tratamiento del sindrome antifosfolipido obstetrico y situaciones especiales. Esta incluido tambien el papel de los nuevos anticoagulantes orales, el problema de las recurrencias o los principales factores de riesgo identificados en estos individuos. En este documento se reflejan las ultimas 25, referidas a las areas de: SAF obstetrico y situaciones especiales. El documento contiene una tabla de recomendaciones y algoritmos de tratamiento. Conclusiones Se presentan las recomendaciones de la SER sobre SAF. Este documento corresponde a la parte 2.a relacionada con el SAF obstetrico y las situaciones especiales. Estas recomendaciones se consideran herramientas en la toma de decisiones para los clinicos, teniendo en consideracion tanto la decision del medico experto en SAF como la opinion compartida con el paciente. Se ha elaborado tambien una parte I que aborda aspectos relacionados con el diagnostico, evaluacion y tratamiento.

Objective The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for primary antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. Methods A panel of four rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for drafting the document, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network [SIGN] levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). Results 46 recommendations were drawn up, addressing five main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the first 21, referring to the areas of: diagnosis, evaluation and treatment of primary APS. The document provides a table of recommendations and treatment algorithms. Conclusions An update of the SER recommendations on APS is presented. This document corresponds to part I, related to diagnosis, evaluation and treatment. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part II has also been prepared, which addresses aspects related to obstetric SAF and special situations.

Resumen Objetivos Describir la metodologia del estudio de prevalencia de las enfermedades reumaticas en la poblacion adulta en Espana, EPISER 2016, asi como sus fortalezas y limitaciones. El objetivo del proyecto es estimar la prevalencia de artritis reumatoide (AR), artropatia psoriasica (APs), espondilitis anquilosante (EA), lupus eritematoso sistemico (LES), sindrome de Sjogren (SS), artrosis (de rodilla, cadera, manos, columna cervical y lumbar), fibromialgia, gota y fractura osteoporotica clinica. Material y metodo Estudio transversal multicentrico de base poblacional en el que participan 45 municipios de las 17 comunidades autonomas. La poblacion de referencia esta compuesta por adultos de 20 o mas anos residentes en Espana. La recogida de informacion se llevara a cabo mediante encuesta telefonica empleando el sistema Computer Assisted Telephone Interview (CATI). Las sospechas diagnosticas y los diagnosticos autorreferidos seran estudiadas por reumatologos del hospital de referencia de los municipios seleccionados. Analisis estadistico: se calcularan las prevalencias de enfermedades reumaticas mediante estimadores y sus IC del 95%. Se calcularan factores de ponderacion en funcion de la probabilidad de seleccion en cada una de las etapas del muestreo. Se tendra en cuenta la distribucion de la poblacion en Espana segun datos del Instituto Nacional de Estadistica. Conclusiones Los cambios sociodemograficos y en habitos de vida durante los ultimos 16 anos justifican la realizacion de EPISER 2016. El estudio ofrecera datos actualizados de prevalencia en AR, EA, APs, LES, SS, artrosis, fibromialgia, gota y fractura osteoporotica clinica. Los resultados permitiran comparar los datos con estudios de otros paises y con el EPISER 2000.

Resumen Objetivo Describir la evolucion del grado de atractivo de la Reumatologia en las sucesivas convocatorias MIR de 1983 a 2014. Metodos Se solicito al servicio de Gestion de Formacion Sanitaria Especializada de la Subdireccion General de Ordenacion Profesional del Ministerio de Sanidad espanol datos de eleccion de Reumatologia de las convocatorias MIR de 1983 a 2014: numero de orden de eleccion de la primera y ultima plazas de Reumatologia, asi como la mediana. A efectos de comparacion, se solicito la mediana de eleccion de otras especialidades. Para definir el grado de atractivo de cada especialidad, se realizo un analisis matematico de 1.000 simulaciones sobre la mediana que habria obtenido cada especialidad si se hubieran elegido al azar y se calculo la desviacion entre la mediana observada y la mediana por azar generada mediante las simulaciones. Resultados La mediana de eleccion de Reumatologia presento un rango desde el numero 244 en la convocatoria de 1983 al numero 3.394 en la convocatoria del ano 2008, observandose, en terminos absolutos, un progresivo incremento a lo largo de los anos. La simulacion matematica permitio cuantificar la desviacion entre la mediana observada y la que habria ocurrido si las especialidades se hubieran elegido al azar. Se objetivo una tendencia a la recuperacion del atractivo de Reumatologia en los ultimos anos. Conclusiones Tras un acusado descenso en el atractivo de la Reumatologia entre los electores a plazas MIR durante los ultimos anos del siglo pasado, parece evidenciarse una recuperacion.

Objective To describe the progress of the attractiveness of rheumatology at successive MIR calls, from 1983 to 2014. Methods Candidates in the Spanish training system for medical doctors choose their specialties sequentially, ordered by their ranking in the qualifying exam (MIR). The highest, median and lowest rank of candidates choosing rheumatology training positions in every MIR call from 1983 to 2014 was requested from the Department of Management of Specialized Medical Training (General Department of Professional Regulation; Spanish Ministry of Health). To compare, the same data was requested for other specialties. In order to define and analyze the attractiveness of each specialty we introduce an ‘index of attractiveness’, based on the normalized difference of the actual median rank reported for each year and the average median obtained in 1000 simulations in which candidates choose specialties at random. Results Regarding the median of the election of rheumatology, the range went from 244th in 1983 to 3394th in 2008, showing a progressive increase over the years in absolute figures. A mathematical simulation allowed quantifying the difference between the observed median and what would have happened if specialties had been chosen by pure chance. Results show a tendency to recover the attractiveness of rheumatology in recent years. Conclusions After a sharp decline in the attractiveness of rheumatology during the last years of the 20th century, there seems to be a recovery.

Objective Relapses and failure are frequent in systemic vasculitis (SV) patients. Biological agents have been prescribed as rescue therapies. The aim of this systematic review is to analyze the current evidence on the therapeutic use of biological agents for SV. Methods MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched up to the end of April 2013. Systematic reviews and meta-analysis, clinical trials, cohort studies, and case series with >3 patients were included. Independent article review and study quality assessment was done by 2 investigators with consensus resolution of discrepancies. Results Of 3447 citations, abstracts, and hand-searched studies screened, 90 were included. Most of the studies included ANCA-associated vasculitis (AAV) patients and only a few included large vessel vasculitis (LVV) patients. Rituximab was the most used agent, having demonstrated efficacy for remission induction in patients with AAV. A number of studies used different anti-TNFα agents with contrasting results. A few uncontrolled studies on the use of abatacept, alemtuzumab, mepolizumab, and tocilizumab were found. Conclusion Current evidence on the use of biological therapies for SV is mainly based on uncontrolled, observational data. Rituximab is not inferior to cyclophosphamide for remission induction in AAV and might be superior in relapsing disease. Infliximab and adalimumab are effective as steroid-sparing agents. Etanercept is not effective to maintain remission in patients with granulomatosis with polyangiitis, and serious adverse events have been reported. For LVV, both infliximab and etanercept had a role as steroid-sparing agents, and tocilizumab might be effective also for remission induction in LVV.

Objective To provide a reference to rheumatologists and other physicians involved in the treatment of systemic lupus erythematosus (SLE) who are using, or about to use biologic therapies. Methods Recommendations were developed following a nominal group methodology and based on systematic reviews. The level of evidence and degree of recommendation were classified according to a model proposed by the Center for Evidence Based Medicine at Oxford. The level of agreement was established through a Delphi technique. Results We have produced recommendations on the use of belimumab, the only biological agent with approved indications for SLE, and other biological agents without an indication for SLE. The objective of treatment is to achieve a complete clinical response, taken as the absence of perceived or evident disease activity. Nuances regarding the use of biologic therapies in SLE were reviewed as well, such as the evaluation that should be performed prior to administration and the follow up of patients undergoing these therapies. Conclusions We present the SER recommendations for the use of biological therapies in patients with SLE.

Objetivo Elaborar unas recomendaciones que sirvan de referencia a los reumatologos y otros profesionales implicados en el tratamiento del lupus eritematoso sistemico (LES) que vayan a utilizar o consideren la utilizacion de terapias biologicas en su manejo. Metodos Las recomendaciones se emitieron siguiendo la metodologia de grupos nominales y basadas en revisiones sistematicas. El nivel de evidencia y el grado de recomendacion se clasificaron segun el modelo del Center for Evidence Based Medicine de Oxford y el grado de acuerdo se extrajo por tecnica Delphi. Resultados Se realizan recomendaciones sobre el uso de belimumab, actualmente unica terapia biologica con aprobacion para el tratamiento del LES, y otras terapias biologicas sin indicacion aprobada en LES. El objetivo del tratamiento es la respuesta clinica completa, entendida como la ausencia de actividad clinica percibida o constatable. Se matiza el uso de terapias biologicas en LES y cual debe ser la evaluacion previa y la vigilancia del paciente que recibe estos farmacos. Conclusiones Se presentan las recomendaciones SER sobre el uso de terapias biologicas en el LES.

Corticosteroids are a mainstay in the therapy of rheumatoid arthritis (RA). In recent years, a number of high-quality controlled clinical trials have shown their effect as a disease-modifying anti-rheumatic drug (DMARD) and a favorable safety profile in recent-onset RA. Despite this, they are more frequently used as bridge therapy while other DMARDs initiate their action than as true disease-modifying agents. Low-dose corticosteroid use during the first two years of disease slows radiologic damage and reduces the need of biologic therapy aimed at reaching a state of clinical remission in recent-onset RA. Thus, their systematic use in this clinical scenario should be considered.

Los glucocorticoides son un componente fundamental en el tratamiento de la artritis reumatoide (AR). En los ultimos anos, numerosos ensayos clinicos controlados de alta calidad metodologica han demostrado su accion como farmaco antirreumatico modificador de enfermedad (FAME) y un favorable perfil de seguridad en la AR de reciente comienzo. No obstante, es frecuente que se utilicen mas como terapia puente hasta que otros FAME comienzan a actuar que como autenticos agentes modificadores de enfermedad. Los glucocorticoides a dosis bajas durante los 2 primeros anos de la enfermedad frenan el deterioro radiologico y reducen la necesidad de usar agentes biologicos para conseguir la remision clinica en la AR de inicio por lo que se deberia valorar su utilizacion sistematica en este contexto clinico

a b s t r a c t Purpose: To determine the efficacy and safety of denosumab in osteoporosis. Methods: A systematic search was performed in MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (1950 to July 2010), meeting abstracts (2009-2010), trial registries, and reference lists. The selection criteria were as follows: (population) osteoporosis patients of any age; (intervention) treatment with denosumab; (outcome) efficacy and safety; (study design) randomized clinical trials (RCTs); no language restrictions. Two reviewers independently screened titles and abstracts and subse- quently extracted data from the selected studies including quality items, and on outcomes of interest. A meta-analysis was performed for safety issues. Results: A total of 25 studies were included. Denosumab reduces the risk of new radiographic vertebral fracture in a 68% compared with placebo (p < 0.001) and increases bone mineral density (BMD) at lumbar spine, total hip, and one-third radius more than alendronate and placebo. A single subcutaneous dose of denosumab resulted in a dose-dependent, rapid, profound, and sustained decrease bone turnover markers (BTMs). Denosumab was in general well tolerated. A meta-analysis has shown an increase in the incidence of urinary infections (p = 0.012) and eczema (p < 0.001) in the patients treated with denosumab. Meta-analysis of efficacy was complicated due to the study features. Conclusions: Denosumab given subcutaneously twice yearly is associated with a reduction in the risk of vertebral, nonvertebral, and hip fractures in women with osteoporosis. Denosumab is associated with greater and sustained increases in BMD and reductions in BTMs compared with placebo and/or alendronate and with a risk of urinary infections and eczema.

A biomarker is a biological parameter that can be measured in blood or other body fluids or tissues and used as a sign of a normal or abnormal process, or of a condition or disease. In medicine, a biomarker can be used to diagnose a disease, to establish its prognosis or as a surrogate marker of outcome in research. In recent years, there has been strong interest in discovering new biomarkers, as well as in the development of new uses for well-known biomarkers in distinct diseases. In this article, the utility of several biomarkers not routinely used in rheumatology (procalcitonin, natriuretic peptides and cardiac troponins) in the diagnosis and follow-up of patients with systemic autoimmune diseases is reviewed.

Some occupational factors have been implicated in the development of disorders manifested as hand pain. The associations seem to be well documented in processes such as hand-arm vibration syndrome (HAVS) or writer's cramp. There are contradictory data in the literature about the relationships of trigger finger, De Quervain's tenosynovitis (DQT) and tenosynovitis of the wrist with occupational factors. In this article, we review current knowledge about clinical manifestations, case definition, implicated occupational factors, diagnosis and treatment of the most relevant hand pain disorders that have been associated with occupational factors, excluding carpal tunnel syndrome (CTS).

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.

Shoulder pain is one of the most common presenting complaints in daily clinical practice. The assessment of patients with shoulder pain is usually complicated due to the wide variety of possible etiologies. Physical examination of the shoulder is especially important in the assessment of soft tissue disorders, since there are a number of physical examination manoeuvres specifically designed to examine particular structures. In this article, the various clinical tests and their diagnostic utility for examining subacromial impingement, supraspinatus, infraspinatus, subscapularis and biceps tendons, gleno-humeral instability and the acromioclavicular joint are reviewed and compared with procedures considered as the gold standard.

La nefritis lupica es una causa importante de morbilidad y mortalidad en los pacientes con lupus eritematoso sistemico. El tratamiento convencional de induccion de remision en la nefritis lupica grave se basa en la utilizacion de ciclofosfamida intravenosa mensual. Datos recientes han puesto de manifiesto que se consigue mantener la remision de la nefritis lupica con azatioprina o micofenolato, con un menor numero de efectos secundarios que con la administracion trimestral de ciclofosfamida intravenosa. En los ultimos anos se han publicado ensayos clinicos controlados y aleatorizados que plantean nuevas modalidades terapeuticas en la induccion de remision en nefritis lupica, como la utilizacion de pautas menos agresivas de ciclofosfamida intravenosa o el uso de micofenolato mofetilo. Son necesarios mas estudios para establecer el tratamiento optimo de los pacientes con nefritis lupica grave.

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

provide solid evidence that low-dose GC can inhibit radiographic damage in early RA, and that side effects of GC, when used in that clinical framework, are limited to hyperglycaemia, cataracts, and transient weight gain.

Interstitial lung disease (ILD) occurs frequently in patients with systemic sclerosis (SSc), with a burden of significant morbidity and mortality. SSc-ILD resembles idiopathic pulmonary fibrosis (IPF) in many respects, including a restrictive ventilatory defect that results from an active fibrosing process in the lung interstitium, a ground glass opacification on high resolution computed tomography, and inflammatory cells in bronchoalveolar lavage fluid. Differences in the classification of lung histo-pathology are noted frequently and may account for some of the differences in outcome for patients with SSc-ILD and IPF. Optimal treatment of SSc-ILD remains to be determined, but cyclophosphamide has been reported to be effective in several open observational studies. Results from the Scleroderma Lung Study are expected to add new insights into the optimal therapy for SSc-ILD.

Rheumatoid arthritis (RA) is a severe disease that leads to joint destruction, loss of function and premature death. To achieve the induction of remission is a major therapeutic goal. The use of conventional disease-modifying anti-rheumatic drugs (DMARDs) as monotherapy rarely allows to achieve and maintain an adecuate clinical response over the course of the disease. This article reviews the role of the combination therapy with conventional DMARDs in the early-onset and refractory rheumatoid disease. In addition, the role that should play these combination therapies in the current therapeutic armamentarium of RA after the advent of the new biologic agents is critically discussed.

Current treatment options for systemic lupus erythematosus (SLE) fail to control all the manifestations of the disease or fully prevent flares. The most extensively studied biological therapies are directed against B cells, although other biological targets have also been explored. Biological agents against tumor necrosis factor-alfa differ in their efficacy and have been associated with the generation of antinuclear and anti-dsDNA antibodies. Anti-interleukin-10 and anti-interleukin-6 agents have also been studied, with encouraging results. Abatacept, which has been approved in rheumatoid arthritis, has not shown efficacy in placebo-controlled clinical trials.

El tratamiento con agentes contra el factor de necrosis tumoral (TNF) alfa se ha asociado a la reactivacion de la infeccion cronica por el virus de la hepatitis B. Algunos casos publicados indican la necesidad de tratamiento cronico con lamivudina cuando se utilizan los agentes anti-TNFa. Describimos el caso de un paciente con espondilitis anquilosante y antigeno de superficie positivo tratado con infliximab y lamivudina. La respuesta clinica fue excelente, pero cuando el paciente interrumpio el tratamiento con lamivudina, se observo reactivacion de la replicacion viral. Una vez reinstaurado dicho tratamiento, se controlo nuevamente la replicacion viral y se normalizaron las concentraciones de transaminasas. Esta observacion indica que en pacientes con infeccion cronica por VHB que necesitan tratamiento anti-TNFa, se requiere un tratamiento preventivo a largo plazo con lamivudina.

Anti-tumor necrosis factor-a (TNF) therapy has been associated with reactivation of hepatitis B virus infection. Case reports have suggested the concomitant need of lamivudine treatment in patients with HBV infection treated with antiTNFa agents. We describe a case of ankylosing spondylitis with positive HBV surface antigen (HBsAg) treated with infliximab and lamivudine. Clinical response was excellent but when lamivudine therapy was stopped, reactivation of replication viral occurred. After the reintroduction of lamivudine, viral replication was controlled and liver function tests were normalized. Preventive long-term lamivudine therapy is mandatory when anti-TNFa therapy is maintained in patients with chronic HBV infection.