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The purposes of this study were to determine the prevalence of metabolic syndrome (MetS) in patients with ankylosing spondylitis (AS) receiving anti-TNFα therapy and evaluate the association of the two conditions with clinical and laboratory findings and predictors of cardiovascular risk. In this cross-sectional study, 63 patients diagnosed with AS according to the modified New York criteria and treated with TNFα blockers and 33 healthy controls were submitted to clinical examination and anthropometric measurements. Glucose levels, lipid profile, and inflammatory markers were registered. The Framingham score (FS), atherogenic index of plasma (AIP), and waist-to-height ratio (WHtR) were calculated. MetS was diagnosed according to the revised National Cholesterol Education Program - Adult Treatment Panel III guidelines. The prevalence of MetS was higher among AS patients than controls (27 vs. 9.1%, p = 0.04). AS patients also had greater body mass index (27.6 kg/m2 ± 4.5 vs. 24.5 kg/m2 ± 2.7; p = 0.001) and WHtR (0.59 ± 0.08 vs. 0.49 ± 0.05; p

Resumo Osteoporose, uma doenca metabolica caracterizada por baixa massa ossea, deterioracao da microarquitetura do tecido osseo e aumento da suscetibilidade a fraturas, e comumente vista como um problema de saude feminino. Essa visao tem fundamentos: em comparacao com os homens as mulheres tem densidade mineral ossea menor, tem vida mais longa e perdem massa ossea mais rapidamente, principalmente apos a menopausa, devido a diminuicao acentuada dos niveis sericos de estrogeno. Entretanto, nos ultimos 20 anos a osteoporose no homem tem sido reconhecida como um problema de saude publica devido a ocorrencia cada vez maior de fraturas por fragilidade. Cerca de 30% de todas as fraturas de quadril ocorrem em homens. Estudos recentes mostram que a probabilidade de fratura por fragilidade do quadril, vertebra ou punho em homens brancos apos os 50 anos, pelo resto de suas vidas, situa‐se em torno de 13%, 40% nas mulheres. Os homens apresentam perda de massa ossea e fraturas mais tardiamente do que as mulheres. Embora os homens mais idosos tenham maior risco de fratura, cerca de metade das fraturas de quadril ocorre antes dos 80 anos. A expectativa de vida tem aumentado para ambos os sexos no Brasil e em todo o mundo, porem em uma velocidade maior para homens do que para mulheres. Esta Diretriz foi baseada em uma revisao sistematica da literatura com relacao a prevalencia, etiologia, diagnostico e tratamento da osteoporose em homens.

Resumo A osteoporose e a principal causa de fraturas na populacao acima de 50 anos. E uma doenca silenciosa que afeta especialmente as mulheres na pos‐menopausa e idosos e tem elevada taxa de morbimortalidade. O principal objetivo do tratamento da osteoporose e a prevencao das fraturas. A identificacao dessa populacao de risco atraves do diagnostico e tratamento precoces e de fundamental importância. A ultima diretriz brasileira para tratamento da osteoporose em mulheres na pos‐menopausa foi elaborada em 2002. Desde entao foram desenvolvidas novas estrategias de diagnostico da osteoporose, bem como farmacos com novos mecanismos de acao foram adicionados ao arsenal terapeutico. A Comissao de Osteoporose e Doencas Osteometabolicas da Sociedade Brasileira de Reumatologia em conjunto com a Associacao Medica Brasileira e sociedades afins desenvolveu esta atualizacao da diretriz do tratamento da osteoporose em mulheres na pos‐menopausa de acordo com as melhores evidencias cientificas disponiveis. Esta atualizacao e destinada aos profissionais das varias especialidades medicas e da area da saude envolvidos no tratamento da osteoporose, medicos em geral e organizacoes relacionadas a saude.

Background Recommendations of the Myopathy Committee of the Brazilian Society of Rheumatology for the management and therapy of systemic autoimmune myopathies (SAM). Main body The review of the literature was done in the search for the Medline (PubMed), Embase and Cochrane databases including studies published until June 2018. The Prisma was used for the systematic review and the articles were evaluated according to the levels of Oxford evidence. Ten recommendations were developed addressing the management and therapy of systemic autoimmune myopathies. Conclusions Robust data to guide the therapeutic process are scarce. Although not proven effective in controlled clinical trials, glucocorticoid represents first-line drugs in the treatment of SAM. Intravenous immunoglobulin is considered in induction for refractory cases of SAM or when immunosuppressive drugs are contra-indicated. Consideration should be given to the early introduction of immunosuppressive drugs. There is no specific period determined for the suspension of glucocorticoid and immunosuppressive drugs when individually evaluating patients with SAM. A key component for treatment in an early rehabilitation program is the inclusion of strength-building and aerobic exercises, in addition to a rigorous evaluation of these activities for remission of disease and the education of the patient and his/her caregivers.

Bisphosphonates are considered first-line agents in the treatment of postmenopausal osteoporosis based on extensive experience of use, safety, and proven efficacy in reducing vertebral, non-vertebral and femur fractures. However, post-marketing reports based on the treatment of millions of patients/year over lengthy periods of time have revealed the occurrence of initially unexpected adverse effects, such as osteonecrosis of the jaw and atypical femoral fracture, leading to the restriction of treatment duration with bisphosphonates by global regulatory agencies. However, despite the association between these effects and bisphosphonates, this risk should be analyzed in the context of osteoporosis treatment, alongside the benefit of preventing osteoporotic fractures and their clinical consequences. Therefore, we consider it plausible to discuss the restriction to the use of bisphosphonates, possible indications for prolonged treatment and alternative therapies following the suspension of this drug class for patients with persistent high risk of fracture after initial treatment, especially considering the problems of public health funding in Brazil and the shortage of drugs provided by the government. Thus, to standardize the treatment of osteoporosis in the public health care system, we aim to develop a proposal for a scientifically-based pharmacological treatment for postmenopausal osteoporosis, establishing criteria for indication and allowing the rational use of each pharmacological agent. We discuss the duration of the initial bisphosphonate treatment, the therapeutic options for refractory patients and potential indications of other classes of drugs as first-choice treatment in the sphere of public health, in which assessing risk and cost effectiveness is a priority. RESUMO Com base na vasta experiência de uso, segurança e eficácia comprovada na redução de fraturas vertebrais, não vertebrais e femorais, os bisfosfonatos são considerados agentes de primeira linha no tratamento da osteoporose pós-menopáusica. No entanto, os relatos pós-venda baseados no tratamento de milhões de pacientes/ano durante períodos prolongados de tempo revelaram a ocorrência de efeitos adversos inicialmente inesperados, como osteonecrose da mandíbula e fratura atípica do fêmur. Isso levou as agências reguladoras globais a restringirem a duração do tratamento com bisfosfonatos. No entanto, apesar da associação entre esses efeitos e os bisfosfonatos, esse risco deve ser analisado no contexto do tratamento da osteoporose, paralelamente ao benefício na prevenção de fraturas osteoporóticas e suas consequências clínicas. Portanto, considera-se plausível discutir a restrição ao uso dos bisfosfonatos, possíveis indicações para o tratamento prolongado e terapias opcionais após a suspensão dessa classe de fármaco para pacientes com alto risco persistente de fratura após o tratamento inicial, especialmente se considerarmos os problemas financeiros de saúde pública no Brasil e a escassez de fármacos fornecidos pelo governo. Assim, para padronizar o tratamento da osteoporose no sistema público de saúde pretende-se desenvolver uma proposta de tratamento farmacológico cientificamente fundamentada para a osteoporose pós-menopáusica, estabelecer critérios de indicação e permitir o uso racional de cada agente farmacológico. Discutem-se a duração do tratamento inicial com bisfosfonatos, as opções terapêuticas para pacientes refratários e potenciais indicações de outras classes de medicamentos como tratamento de primeira linha na esfera da saúde pública, em que a avaliação do risco e custo-efetividade é uma prioridade.

Bisphosphonates are considered first-line agents in the treatment of postmenopausal osteoporosis based on extensive experience of use, safety, and proven efficacy in reducing vertebral, non-vertebral and femur fractures. However, post-marketing reports based on the treatment of millions of patients/year over lengthy periods of time have revealed the occurrence of initially unexpected adverse effects, such as osteonecrosis of the jaw and atypical femoral fracture, leading to the restriction of treatment duration with bisphosphonates by global regulatory agencies. However, despite the association between these effects and bisphosphonates, this risk should be analyzed in the context of osteoporosis treatment, alongside the benefit of preventing osteoporotic fractures and their clinical consequences. Therefore, we consider it plausible to discuss the restriction to the use of bisphosphonates, possible indications for prolonged treatment and alternative therapies following the suspension of this drug class for patients with persistent high risk of fracture after initial treatment, especially considering the problems of public health funding in Brazil and the shortage of drugs provided by the government. Thus, to standardize the treatment of osteoporosis in the public health care system, we aim to develop a proposal for a scientifically-based pharmacological treatment for postmenopausal osteoporosis, establishing criteria for indication and allowing the rational use of each pharmacological agent. We discuss the duration of the initial bisphosphonate treatment, the therapeutic options for refractory patients and potential indications of other classes of drugs as first-choice treatment in the sphere of public health, in which assessing risk and cost effectiveness is a priority.

Osteoporosis, a metabolic disease characterized by low bone mass, deterioration of the bone tissue microarchitecture and increased susceptibility to fractures, is commonly regarded as a women's health problem. This point of view is based on the fact that compared with men, women have lower bone mineral density and longer lifespans and lose bone mass faster, especially after menopause, due to a marked decrease in serum estrogen levels. However, in the last 20 years, osteoporosis in men has become recognized as a public health problem due to the occurrence of an increasingly higher number of fragility fractures. Approximately 30% of all hip fractures occur in men. Recent studies show that the probability of fracture due to hip, vertebral or wrist fragility in Caucasian men older than fifty years, for the rest of their lives, is approximately 13% versus a 40% probability of fragility fractures in women. Men show bone mass loss and fractures later than women. Although older men have a higher risk of fracture, approximately half of all hip fractures occur before the age of 80. Life expectancy is increasing for both sexes in Brazil and worldwide, albeit at a higher rate for men than for women. This Guideline was based on a systematic review of the literature on the prevalence, etiology, diagnosis and treatment of osteoporosis in men. Resumo Osteoporose, uma doença metabólica caracterizada por baixa massa óssea, deterioração da microarquitetura do tecido ósseo e aumento da suscetibilidade a fraturas, é comumente vista como um problema de saúde feminino. Essa visão tem fundamentos: em comparação com os homens as mulheres têm densidade mineral óssea menor, têm vida mais longa e perdem massa óssea mais rapidamente, principalmente após a menopausa, devido à diminuição acentuada dos níveis séricos de estrógeno. Entretanto, nos últimos 20 anos a osteoporose no homem tem sido reconhecida como um problema de saúde pública devido à ocorrência cada vez maior de fraturas por fragilidade. Cerca de 30% de todas as fraturas de quadril ocorrem em homens. Estudos recentes mostram que a probabilidade de fratura por fragilidade do quadril, vértebra ou punho em homens brancos após os 50 anos, pelo resto de suas vidas, situa-se em torno de 13%, 40% nas mulheres. Os homens apresentam perda de massa óssea e fraturas mais tardiamente do que as mulheres. Embora os homens mais idosos tenham maior risco de fratura, cerca de metade das fraturas de quadril ocorre antes dos 80 anos. A expectativa de vida tem aumentado para ambos os sexos no Brasil e em todo o mundo, porém em uma velocidade maior para homens do que para mulheres. Esta Diretriz foi baseada em uma revisão sistemática da literatura com relação a prevalência, etiologia, diagnóstico e tratamento da osteoporose em homens.

Os glicocorticoides (GC) são prescritos por praticamente todas as especialidades médicas, e cerca de 0,5% da população geral do Reino Unido utiliza esses medicamentos. Com o aumento da sobrevida dos pacientes com doenças reumatológicas, a morbidade secundária ao uso dessa medicação representa um aspecto importante que deve ser considerado no manejo de nossos pacientes. As incidências de fraturas vertebrais e não vertebrais são elevadas, variando de 30%-50% em pessoas que usam GC por mais de três meses. Assim, a osteoporose e as fraturas por fragilidade devem ser prevenidas e tratadas em todos os pacientes que iniciarão ou que já estejam em uso desses esteroides. Diversas recomendações elaboradas por várias sociedades internacionais têm sido descritas na literatura, porém não há consenso entre elas. Recentemente, o Americam College of Rheumatology publicou novas recomendações, porém elas são fundamentadas na FRAX (WHO Fracture Risk Assessment Tool) para analisar o risco de cada indivíduo e, dessa maneira, não podem ser completamente utilizadas pela população brasileira. Dessa forma, a Comissão de Osteoporose e Doenças Osteometabólicas da Sociedade Brasileira de Reumatologia, em conjunto com a Associação Médica Brasileira e a Associação Brasileira de Medicina Física e Reabilitação, implementou as diretrizes brasileiras de osteoporose induzida por glicocorticoide (OPIG), baseando-se na melhor evidência científica disponível e/ou experiência de experts. DESCRIÇÃO DO MÉTODO DE COLETA DE EVIDÊNCIA: A revisão bibliográfica de artigos científicos desta diretriz foi realizada na base de dados MEDLINE. A busca de evidência partiu de cenários clínicos reais, e utilizou as seguintes palavras-chave (MeSH terms): Osteoporosis, Osteoporosis/chemically induced*= (Glucocorticoids= Adrenal Cortex Hormones, Steroids), Glucocorticoids, Glucocorticoids/administration and dosage, Glucocorticoids/therapeutic use, Glucocorticoids/adverse effects, Prednisone/adverse effects, Dose-Response Relationship, Drug, Bone Density/drug effects, Bone Density Conservation Agents/pharmacological action, Osteoporosis/ prevention&control, Calcium, Vitamin D, Vitamin D deficiency, Calcitriol, Receptors, Calcitriol; 1-hydroxycholecalciferol, Hydroxycholecalciferols, 25-Hydroxyvitamin D3 1-alpha-hydroxylase OR Steroid Hydroxylases, Prevention and Control, Spinal fractures/prevention & control, Fractures, Spontaneous, Lumbar Vertebrae/injuries, Lifestyle, Alcohol Drinking, Smoking OR tobacco use disorder, Movement, Resistance Training, Exercise Therapy, Bone density OR Bone and Bones, Dual-Energy X-Ray Absorptiometry OR Absorptiometry Photon OR DXA, Densitometry, Radiography, (Diphosphonates Alendronate OR Risedronate Pamidronate OR propanolamines OR Ibandronate OR Zoledronic acid, Teriparatide OR PTH 1-34, Men AND premenopause, pregnancy, pregnancy outcome maternal, fetus, lactation, breast-feeding, teratogens, Children (6-12 anos), adolescence (13-18 anos). GRAU DE RECOMENDAÇÃO E FORÇA DE EVIDÊNCIA: A) Estudos experimentais e observacionais de melhor consistência; B) Estudos experimentais e observacionais de menor consistência; C) Relatos de casos (estudos não controlados); D) Opinião desprovida de avaliação crítica, com base em consensos, estudos fisiológicos ou modelos animais. OBJETIVO: Estabelecer as diretrizes para a prevenção e o tratamento da OPIG. Glucocorticoids (GC) are used in almost all medical specialties, and approximately 0.5% of the general population of the United Kingdom receives those medications. With the increased survival of patients with rheumatological diseases, morbidity secondary to the use of those medications represents an important aspect of the management of our patients. The incidences of vertebral and non-vertebral fractures are elevated, ranging from 30% to 50% of the individuals on GC for over three months. Thus, osteoporosis and frailty fractures should be prevented and treated in all patients initiating or already on GC. There are several recommendations on this topic elaborated by several international societies, but consensus still lacks. Recently, the American College of Rheumatology has published new recommendations, but they are based on the WHO Fracture Risk Assessment Tool (FRAX®) to evaluate the risk for each individual, and, thus, cannot be completely used for the Brazilian population. Thus, the Committee for Osteoporosis and Bone Metabolic Disorders of the Brazilian Society of Rheumatology, along with the Brazilian Medical Association and the Brazilian Association of Physical Medicine and Rehabilitation, has elaborated the Brazilian Guidelines for Glucocorticoid-Induced Osteoporosis (GIO), based on the better available scientific evidence and/or expert experience. METHOD OF EVIDENCE COLLECTION: The bibliographic review of scientific articles of this guideline was performed in the MEDLINE database. The search for evidence was based on real clinical scenarios, and used the following keywords (MeSH terms): Osteoporosis, Osteoporosis/ chemically induced*= (Glucocorticoids= Adrenal Cortex Hormones, Steroids), Glucocorticoids, Glucocorticoids/administration and dosage, Glucocorticoids/therapeutic use, Glucocorticoids/adverse effects, Prednisone/adverse effects, Dose-Response Relationship, Drug, Bone Density/drug effects, Bone Density Conservation Agents/pharmacological action, Osteoporosis/prevention & control, Calcium, Vitamin D, Vitamin D deficiency, Calcitriol, Receptors, Calcitriol; 1-hydroxycholecalciferol, Hydroxycholecalciferols, 25-Hydroxyvitamin D3 1-alpha-hydroxylase OR Steroid Hydroxylases, Prevention and Control, Spinal fractures/prevention & control, Fractures, Spontaneous, Lumbar Vertebrae/injuries, Lifestyle, Alcohol Drinking, Smoking OR tobacco use disorder, Movement, Resistance Training, Exercise Therapy, Bone density OR Bone and Bones, Dual-Energy X-Ray Absorptiometry OR Absorptiometry Photon OR DXA, Densitometry, Radiography, (Diphosphonates Alendronate OR Risedronate Pamidronate OR propanolamines OR Ibandronate OR Zoledronic acid, Teriparatide OR PTH 1-34, Men AND premenopause, pregnancy, pregnancy outcome maternal, fetus, lactation, breast-feeding, teratogens, Children (6-12 years), adolescence (13-18 years). GRADE OF RECOMMENDATION AND LEVEL OF EVIDENCE: A) Data derived from more consistent experimental and observational studies; B) Data derived from less consistent experimental and observational studies; C) Case reports (uncontrolled studies); D) Expert opinion without explicit critical appraisal, or based on consensus, physiological studies or animal models. OBJECTIVE: To establish guidelines for the prevention and treatment of GIO.

Recently, we discovered that New Zealand rabbits immunized with human type V collagen plus Freund's adjuvant present fibrosis and vasculitis of organs usually affected by systemic sclerosis. In this way, we studied the fibrillogenesis process to identify possible factors involved in altered remodeling observed in this scleroderma-like model. Additionally, we have done a very preliminary comparison with human skins obtained from scleroderma patients (n=3). Female New Zealand rabbits (n=10) were immunized subcutaneously with two doses of 1 mg collagen V (COL V) plus complete Freund's adjuvant for a 30-day interval, followed by two additional intramuscular booster immunizations in incomplete Freund's adjuvant for a 15-day interval. Animals from control group (n=10), were only inoculated with complete and incomplete Freund's adjuvant given at same conditions of COL V. Histological analysis of skins from animals and patients were done by Masson's trichrome staining, and immunofluorescence method to detect collagen fibers and interactions of types I, III and V collagen in the remodeling process. The analysis of animal skins showed collagen fibril deposits in the dermis after 7 days of sensibilization and an increase in these deposits after 75 and 120 days, respectively. Skin thickness and atrophy of sebaceous and sweat glands were progressively more intense in late sacrificed animals and correlated with increased amount of collagen deposition. Surprisingly, type V collagen was overexpressed both in animals and patients, forming dense and atypical collagen fibers in the dermis. We suggest that this anomalous expression of morphologically different type V collagen could justify the remodeling observed in scleroderma plaque.

The objective of this study is to characterize the lipoprotein risk levels in Takayasu arteritis (TA) patients and its possible association with disease activity and glucocorticoid use. Twenty-five female TA patients were consecutively included and compared with 30 age-, gender-, and body mass index-matched healthy controls. Demographic features and the lipid profile were determined and cardiovascular risk levels were evaluated according to NCEP/ATPIII. Total cholesterol (TC), LDL-c, HDL-c, and triglycerides were determined after a 12-h overnight fast. Exclusion criteria were conditions that interfere in the lipid profile. The disease duration was 6.6 +/- 7.4 years; 30% had clinical activity and 80% had laboratory activity. Regarding NCEP/ATPIII risk levels, TA patients presented higher frequency of lipid risk compared to controls: high TC (48% vs. 20%, p = 0.04), low HDL-c (20% vs. 0%, p = 0.015), and high triglycerides (36% vs. 10%, p = 0.026). No difference was observed related to LDL-c risk levels between both groups (40% vs. 20%, p = 0.14). Remarkably, 60% of the patients had at least one lipid risk factor for cardiovascular disease. No difference in the lipids was observed between patients with and without clinical activity; however, those with laboratory activity showed lower levels of HDL-c (1.37 +/- 0.42 vs. 2.00 +/- 0.63 mmol/L, p = 0.012) than patients without this activity. A negative correlation was found between HDL-c and CRP levels (r = -0.42, p = 0.04). Lipids were similar in patients under glucocorticoid compared to those without this therapy. This is the first study to identify that TA, an inflammatory disease, has a proatherogenic lipid profile which is associated to laboratory disease activity.

Objective Takayasu arteritis (TA) is a chronic inflammatory disorder affecting the aorta and its branches. Vascular calcification has been described in 29-54% of cases of TA, although its aetiology remains unknown. Recently the osteoprotegerin/RANKL/RANK system has emerged as an important contributing factor to atherogenesis and osteogenesis. Our aim is to investigate the association between vascular calcification, bone mineral density (BMD) and the osteoprotegerin/RANK/RANKL system in TA. Methods Thirty pre-menopausal female TA patients and 30 age- and sex-matched controls were studied. BMD was measured by dual X-ray absorptiometry. Arterial calcification in TA patients was analysed by computed tomography in thoracic and abdominal sites. Serum levels of osteoprotegerin and soluble receptor activator of nuclear factor kappaB ligand (sRANKL) were quantified by enzyme-linked immunosorbent assay. Results Patients with severe arterial calcification showed lower BMD values than controls in lumbar spine (0.965 +/- 0.055 vs 1.126 +/- 0.153 g/cm2, P = 0.009) and total body (0.993 +/- 0.065 vs 1.085 +/- 0.082 g/cm2, P = 0.019). In contrast, TA patients without calcification presented BMD values similar to controls (P > 0.05). Interestingly, lower serum levels of sRANKL (1.89 +/- 2.35 vs 2.80 +/- 2.23 pg/ml, P = 0.031) and a longer disease duration (12.20 +/- 6.61 vs 3.56 +/- 5.33 yr, P = 0.004) were observed in TA patients with severe calcification compared with patients without calcification. Conclusions Severe arterial calcification in TA is associated with low values of BMD and sRANKL, reinforcing the possible link between bone and vascular disease.

Rheumatoid arthritis is characterized by the presence of inflammatory synovitis and destruction of joint cartilage and bone. Tissue proteinases released by synovia, chondrocytes and pannus can cause cartilage destruction and cytokine-activated osteoclasts have been implicated in bone erosions. Rheumatoid arthritis synovial tissues produce a variety of cytokines and growth factors that induce monocyte differentiation to osteoclasts and their proliferation, activation and longer survival in tissues. More recently, a major role in bone erosion has been attributed to the receptor activator of nuclear factor kappa B ligand (RANKL) released by activated lymphocytes and osteoblasts. In fact, osteoclasts are markedly activated after RANKL binding to the cognate RANK expressed on the surface of these cells. RANKL expression can be upregulated by bone-resorbing factors such as glucocorticoids, vitamin D3, interleukin 1 (IL-1), IL-6, IL-11, IL-17, tumor necrosis factor-alpha, prostaglandin E2, or parathyroid hormone-related peptide. Supporting this idea, inhibition of RANKL by osteoprotegerin, a natural soluble RANKL receptor, prevents bone loss in experimental models. Tumor growth factor-beta released from bone during active bone resorption has been suggested as one feedback mechanism for upregulating osteoprotegerin and estrogen can increase its production on osteoblasts. Modulation of these systems provides the opportunity to inhibit bone loss and deformity in chronic arthritis.

A maioria das informações relativas ao curso da doença de pacientes com lúpus eritematoso sistêmico (LES) é restrita aos primeiros cinco anos após o diagnóstico. Entretanto, dados sobre a precocidade de instalação dos danos são pouco descritos. OBJETIVO: identificar os danos precoces de pacientes com LES de diagnóstico recente e verificar a influência da própria doença ou de sua terapêutica como principal causa para a instalação destes danos. MÉTODOS: foram estudados retrospectivamente 82 pacientes com LES, cujo diagnóstico foi realizado de 1998 até 1999 em nosso serviço. Em todos os pacientes o escore do índice de dano do Systemic Lupus Internacional Collaborating Clinics/American College of Rheumatology-Damage Index (SLICC/ACR-DI) foi avaliado no momento do diagnóstico e anualmente três vezes consecutivas. As manifestações clínicas e o esquema terapêutico foram avaliados nas consultas médicas. O escore do SLICC/ACR para cada órgão/sistema e a prevalência dos danos foi identificado, assim como a sua possível causa (doença ou terapia). RESULTADOS: A idade (média) inicial foi de 31,6 anos com predomínio do sexo feminino (94%). A maioria dos pacientes (94%) apresentou manifestações cutâneas e articulares, seguidas pelas renais (40%), pulmonares (28%) e neurológicas (18%). Ao final do estudo, 52 pacientes (63,4%) não apresentaram seqüelas (sem pontuação no SLICC). Dos 30 pacientes restantes, 16 tiveram escore = 1 e 14 pacientes apresentaram escore = 2. No total observamos 36 danos, sendo 23 atribuídos à doença e 13 à terapia (64% vs 36%, p < 0,05). Os sistemas mais freqüentemente acometidos foram o articular e o neurológico (27,7%), seguidos pelo renal (13,8%). Todos os pacientes com comprometimento neurológico tiveram danos precoces decorrentes da própria doença (apesar da terapêutica agressiva) enquanto a terapêutica com corticóide foi responsável pelos danos em 7/10 pacientes com dano articular (osteonecrose). O dano renal foi observado em 13,8% dos pacientes (nefrite grave não responsiva ao tratamento). Outros efeitos adversos da terapia foram angina, catarata, diabetes e menopausa precoce. CONCLUSÕES: este estudo sugere que o dano precoce é ainda um importante problema no LES. São necessárias estratégias eficazes no sentido de minimizar as seqüelas, com destaque para as neurológicas. Redução da morbidade associada à terapia com corticóide também deve ser considerada utilizando-se agentes poupadores de esteróides. The majority of the information available about the disease course of patients with systemic lupus erythematosus (SLE) is restricted to the first five years after disease onset. However, data about early damage were rarely reported. OBJECTIVE: to describe the early damage outcome of SLE patients in early disease and to discriminate the influence of disease itself or its therapy as the main cause of their damage. METHODS: we retrospectively studied 82 patients with SLE, diagnosed during the period from 1998 to 1999 in our institution. In all patients the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR-DI) was scored at the diagnosis and annually for the next three years. Clinical manifestations were evaluated at each visit as well as the therapy. The SLICC/ACR-DI scores for each organ system and the prevalence of damage within organ systems were assessed, as well as its possible main cause (disease or therapy). RESULTS: the mean age at entry was 31.6 years with female predominance of 94%. The majority of the patients (94%) presented cutaneous and articular involvement, 40% renal, 28% pulmonary, and 18% neurological manifestations. At the end of the study, 52 (63.4%) patients had no damage to score with SLICC. From the remaining 30 patients, 16 had a score of 1 and 14 had a score = 2. In total, 36 damages occurred, 23 of them attributed to the disease and 13 to the therapy (64% vs. 36%; p < 0.05). The most frequently injured systems were the articular and the neurological (27.7%) ones, followed by the renal (13.8%) system. All patients with neurological involvement have early damage due to the disease itself in spite of the aggressive therapeutic whereas from 10 patients with articular damage, 70% (7) were associated with steroid therapy (osteonecrosis). In contrast, premature renal injury was observed in 13.8%, all of them with unresponsive severe nephritis. Other adverse effect of therapy included 1 angina, 2 cataracts, 1 diabetes and 2 premature menopauses. CONCLUSIONS: this study suggests that early damage is still a major problem in SLE that reinforces the need for new strategies in order to minimize injury, particularly for neurological manifestations. Moreover, it also seems important to reduce morbidity induced by corticosteroid therapy with the use of steroid-sparing agents.

Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.