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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.

To analyse the efficacy, adherence, patient satisfaction, safety, pharmacodynamics and cost-effectiveness of parenteral methotrexate (MTX) in patients with rheumatic diseases.A systematic review of literature was carried out in Medline, Embase and Cochrane Central from the beginning until June 2019. Studies including adult patients with rheumatic diseases being treated with parenteral MTX were identified and data on efficacy, adherence, satisfaction, safety, pharmacokinetics, and cost-effectiveness analysed. As for the designs, systematic reviews, clinical trials, or observational studies were permitted, including cross-sectional and small-sample studies if they were pharmacokinetic studies.Out of 4160 identified articles, 80 articles were finally included. The efficacy profile of parenteral MTX seems useful in general and in those patients with insufficient response to oral MTX. The parenteral route does not seem to increase the rate or severity of adverse events due to the use of MTX. The use of parenteral MTX is an appropriate way to reduce costs in patients with inadequate response to oral MTX. Adherence and satisfaction are favoured by training programmes in the use of the parenteral route. The results in rheumatic diseases other than rheumatoid arthritis (RA) are very scarce and do not enable obtaining conclusive data.Parenteral MTX can be an alternative to the use of oral MTX, due to its profile of efficacy, safety, adherence and pharmacoeconomic results, especially in those patients with RA.

Resumen Objetivo Analizar la eficacia, adherencia, satisfaccion del paciente, seguridad, farmacodinamica y costo-efectividad del metotrexato (MTX) parenteral en pacientes con enfermedades reumaticas. Metodos Se llevo a cabo una revision sistematica basada en una estrategia de busqueda en Medline, Embase y Cochrane Library (inicio-06/2019). Se identificaron estudios que incluyeran pacientes adultos con enfermedades reumaticas en tratamiento con MTX parenteral y que analizaran datos de eficacia, adherencia, satisfaccion, seguridad, farmacocinetica o costo-efectividad. En cuanto a los disenos se permitieron revisiones sistematicas, ensayos clinicos o estudios observacionales, incluyendo transversales y estudios con muestras pequenas si eran estudios de farmacocinetica. Resultados De 4.160 articulos identificados, se incluyeron finalmente 80. El MTX parenteral parece util de manera general y en especial en aquellos pacientes con respuesta insuficiente a MTX oral. La via parenteral no parece aumentar la tasa ni la gravedad de los eventos adversos con respecto a la oral y podria reducir costes en aquellos pacientes con respuesta inadecuada a MTX oral. La adherencia y satisfaccion se ven favorecidas por programas de entrenamiento en la via parenteral. Los resultados en enfermedades reumaticas distintas a la artritis reumatoide (AR) son muy escasos y no permiten obtener datos concluyentes. Conclusiones El MTX por via parenteral podria ser una alternativa al uso de MTX oral, por su perfil de eficacia, seguridad, adherencia, satisfaccion y resultados farmaco-economicos, especialmente en pacientes con AR.

Resume Objectif: evaluer si la reponse precoce au tocilizumab (TCZ) et au sarilumab (SAR) des patients presentant une polyarthrite rhumatoide (PR) active est influencee par la prise anterieure d’agents biologiques. Methodes: Nous avons realise une revue systematique de la litterature et une meta-analyse d’etudes originales ayant analyse l’efficacite du TCZ ou du SAR dans des sous-groupes de patients atteints de PR, et avons compare d’une part des patients n’ayant jamais recu de biotherapie a des patients ayant montre une reponse insuffisante a au moins un DMARD biologique (bDMARD), et d’autre part des patients ayant eu un echec de bDMARD a des patients ayant eu au moins deux echecs de bDMARD. Resultats: a l’issue du processus de selection, l’etude a inclus 17 articles correspondant a 14 etudes, dont sept essais comparatifs randomises (ECR). Dans la litterature existante, la comparaison de la reponse des patients n’ayant jamais recu de biotherapie et de patients ayant montre une reponse insuffisante a au moins un bDMARD a donne des resultats contradictoires, toutefois une meta-analyse de six etudes publiees a montre une probabilite de remission (risque relatif [RR] 1,3 ; intervalle de confiance [IC] a 95 % 1,2-1,5) et de faible activite de la maladie (RR 1,3 ; IC 95 % 1,2-1,4) significativement plus forte dans le groupe n’ayant jamais recu de biotherapie a la semaine 24. A noter cependant que les differences entre les groupes n’etaient pas cliniquement pertinentes dans toutes les etudes et ne se maintenaient pas toujours apres 6 a 12 mois de traitement. De plus, les donnees des ECR RADIATE et TARGET suggerent que la reponse aux inhibiteurs de la voie IL-6 semble similaire quel que soit le nombre d’inhibiteurs du facteur de necrose tumorale (anti-TNF) precedemment testes. Conclusion: l’activite de la maladie a ete reduite plus rapidement au debut du traitement chez les patients n’ayant jamais recu de biotherapie. Une efficacite presque similaire peut neanmoins etre attendue chez les patients ayant eu au moins un echec de bDMARD (essentiellement anti-TNF) apres 6 a 12 mois de traitement, ce qui suggere que la reponse est independante du nombre d’anti-TNF anterieurs.

To analyze the prevalence of metabolic syndrome (MetS) in patients with psoriatic arthritis (PsA) in a systematic literature review (SLR) and in the Spanish CArdiovascular in RheuMAtology (CARMA) cohort.A SLR and a subanalysis of the CARMA cohort were performed. In the SLR, PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov up to March 2019 were searched. Systematic literature reviews, clinical trials, and observational studies that analyzed the prevalence or frequency of MetS in PsA were analyzed. Two reviewers selected the articles, assessed the quality of the studies, and collected data, independently. In addition, data on sociodemographic characteristics and MetS in patients with PsA from the CARMA cohort were collected and analyzed. Comparative descriptive analysis was performed.The SLR included 18 articles, of moderate to high quality, with PsA patients of both sexes, with mean ages between 42 and 59 years. The rate of MetS varied from 23.5% to 62.9%. The most commonly used classification method was that of the National Cholesterol Education Program. Additionally, 724 PsA patients from the CARMA cohort were analyzed; 327 (45.4%) were women, 157 (21.8%) smokers, with a mean age of 51 years and a mean PsA disease duration of 9 years. Hypertension was the most common abnormal finding (66.8%), followed by hyperglycemia (42.6%) and hypertriglyceridemia (30.6%). Notably, 222 patients (30.6%) had MetS.The prevalence of MetS in PsA varies, depending on the definition. Whereas 23.5% to 62.9% of PsA patients have MetS, in the CARMA cohort almost a third of patients with PsA have MetS.

Este trabajo evalúa los casos de arteritis de células gigantes (ACG) y polimialgia reumática (PMR) tras la vacunación con COVID-19 utilizando una base de datos global de farmacovigilancia. This work identifies cases of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) following vaccination with COVID-19 using a global pharmacovigilance database., {"references":["Vol 20, Nº 2, Pág 102732. 2021. Liozon E, Parreau S, Filloux M et al. Giant cell arteritis or polymyalgia rheumatica after influenza vaccination: a study of 12 patients and a literature review. Autoimmun Rev. Doi: https://doi.org/10.1016/j.autrev.2020.102732","Vol 9, Nº 5, Pág 435. 2021. Watad A, De Marco G, Mahajna H et al. Immune-mediated disease flares or new-onset disease in 27 subjects following mRNA/DNA SARS-CoV-2 vaccination. Vaccines. Doi: https://doi.org/10.3390/vaccines9050435","Vol 3, Nº 7, Págs 469-470. 2021. Terracina KA, Tan FK. Flare of rheumatoid arthritis after COVID-19 vaccination. Lancet Rheumatol. Doi: https://doi.org/10.1016/S2665-9913(21)00108-9"]}

Objectives To update the study of the association between obesity and treatment response in psoriatic arthritis. Methods Updating a systematic review of clinical trials, prospective or retrospective longitudinal studies and case–control studies in psoriatic arthritis in which obesity was assessed as a predictor of efficacy or toxicity. Risks of bias were assessed with validated scales. A meta-analysis of the results of studies with similar outcome variables and weight measurements was performed. Results Twenty-one studies were included (6 review of clinical trials, 6 longitudinal studies, 7 registers and one case–control studie), with moderate quality. The risk of achieving an ACR20 response if weight ≥ 100 kg was estimated at OR = 1.42 (1–2.08) and that of withdrawing treatment in an OR of 1.60 (95% CI: 1.34–1.92). Conclusions There seems to be a greater risk of withdrawal of treatment due to inefficacy and difficulty in achieving remission in patients with psoriatic arthritis if they are obese.

Resumen Objetivos Actualizar el estudio de la asociacion entre obesidad y respuesta al tratamiento en artritis psoriasica. Metodos Actualizacion de una revision sistematica previa, incluyendo ensayos clinicos aleatorizados, estudios longitudinales y casos-control en artritis psoriasica en los que se evaluase obesidad como predictor de eficacia o toxicidad. Los riesgos de sesgos se evaluaron con escalas validadas. Se realizo metaanalisis de los resultados de estudios con variables de desenlace y medidas del peso similares. Resultados Se incluyeron 21 estudios (6 ensayos clinicos aleatorizados, 6 estudios longitudinales, 7 registros y un caso-control), de calidad en general moderada. El riesgo de no respuesta ACR20 si el peso es ≥ 100 kg se estimo en OR = 1,42 (1-2,08) y el de retirar el tratamiento en una OR de 1,60 (IC 95%: 1,34-1,92). Conclusiones Parece existir un mayor riesgo de retirada del tratamiento por ineficacia y dificultad para conseguir remision en pacientes con artritis psoriasica si son obesos.

Objective: To estimate the prevalence of uveitis and to describe its etiologic and anatomical patterns based on a population study carried out in a Spanish region. Material and methods: A cross-sectional, descriptive, population-based multicenter study was conducted. The selection criteria consisted of having a diagnosis of uveitis. All data were collected from existing information in medical records.Clinical information was collected in all cases that had a diagnosis of uveitis, regardless of its etiology, in participating centers from the date of the study to the end of the following year. All patients underwent a complete ophthalmological examination, which included assessment of their visual acuity, biomicroscopy, applanation tonometry, and indirect ophthalmoscopy. Results: During the study, 389 cases of uveitis were registered. The prevalence was 58.7 (95% confidence interval [CI] 53.0-64.9). The mean age was 47.0 ± 20.6 years and 57.8% were women. The most prevalent anatomical pattern was anterior uveitis (54.2; 95% CI 48.1-60.8). For adults, the idiopathic group constituted the highest prevalence (31.7; 95% CI: 27.1-36.9), while autoimmune etiology was most frequent for children (10.6; 95% CI: 5.8-17.7). Conclusion: The results of this population-based study offer a representative estimate of the magnitude of uveitis in this area of Spain. Sociedad de Reumatología de Castilla La Mancha (España) Proyecto UveCAM No data JCR 2021 0.776 SJR (2021) Q2, 42/128 Ophthalmology No data IDR 2021 UEM

espanolObjetivos Emitir recomendaciones sobre aspectos practicos de la monitorizacion de los niveles de farmacos biologicos que puedan ser de utilidad para reumatologos. Metodos Se realizo una revision sistematica de la literatura de estudios en los que se determinaron niveles de farmaco y de anticuerpos antifarmaco en pacientes con artritis reumatoide o espondiloartritis para estudiar si podian predecir diferentes desenlaces. Con los resultados de la revision un grupo de expertos discutio bajo que circunstancias podria ser util la solicitud de niveles de farmacos biologicos y sus anticuerpos, lo que se concreto en una serie de preguntas clinicas que fueron respondidas con la evidencia cientifica disponible y creandose algoritmos para facilitar la toma de decisiones. Resultados Se establece que la determinacion de los niveles de farmaco puede ser especialmente util en 2 situaciones clinicas, cuando hay fallo al tratamiento (primario o secundario) y en remision mantenida. Se revisa tambien que tecnica de laboratorio y momento para tomar la muestra son los mas adecuados para la medicion, y se establecen recomendaciones sobre la interpretacion de los niveles de farmaco y sobre factores a tener en cuenta (por ejemplo, indice de masa corporal y farmacos modificadores de la enfermedad). Conclusiones Se han elaborado algoritmos y establecido posibles pautas y directrices para solicitar niveles de farmaco y de anticuerpos antifarmaco en pacientes con artritis reumatoide y espondiloartritis, basados en la evidencia, que pueden ayudar a la toma de decisiones clinicas. EnglishObjectives Issue recommendations on practical aspects of the monitoring of levels of biological drugs that may be useful for rheumatologists. Methods We conducted a systematic review of studies in which drug and anti-drug antibody levels were determined in patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) to study whether they could predict different outcomes. In light of the results of the review, a group of experts discussed under what circumstances testing biological drug levels and their antibodies could be useful. The discussion resulted in a series of clinical questions that were answered with the scientific evidence collected, and in algorithms that facilitate decision making. Results It was established that the determination of drug levels can be especially useful in two clinical situations, on treatment failure (primary or secondary) and on sustained remission. It is also reviewed which laboratory technique and timing for sample drawing are the most suitable for the measurement. Recommendations are issued on the interpretation of drug levels and on factors to be taken into account (for example, body mass index and disease modifying drugs). Conclusions Evidence-based algorithms and guidelines have been established to test drug levels and anti-drug antibodies in patients with RA and SpA, which can help clinical decision making.

espanolObjetivo Desarrollar un documento de consenso para estandarizar los terminos, abreviaturas y acronimos en espanol empleados en el campo de las espondiloartritis (EspA). Metodos Se creo un grupo de trabajo internacional compuesto por todos los miembros de Assessment of SpondyloArthritis International Society (ASAS) nativos de habla espanola, miembros del comite ejecutivo del Grupo para el estudio de la Espondiloartritis de la Sociedad Espanola de Reumatologia (GRESSER), 2 metodologos, 2 linguistas de la Real Academia Nacional de Medicina de Espana (RANM) y 2 pacientes de la Coordinadora Espanola de Asociaciones de Espondilitis (CEADE). Se realizo una revision de la literatura de los ultimos 15 anos (publicaciones, el CIE y CIF, guias, consensos y recomendaciones) para identificar los terminos, abreviaturas y acronimos discrepantes. Mediante un Delphi de 3 rondas y una reunion presencial, se discutieron, seleccionaron y acordaron los terminos, abreviaturas y acronimos a utilizar. Durante todo este proceso se siguieron las recomendaciones de la RANM basadas en el Diccionario panhispanico de terminos medicos. Resultados Se consensuaron 46 terminos, abreviaturas y acronimos. Se acepto la traduccion al espanol para 6 terminos y 6 abreviaturas empleados para nombrar o clasificar la enfermedad y para 6 terminos y 4 abreviaturas relacionados con las EspA. Se acordo no traducir 15 acronimos por estar ya establecidos, pero al mencionarlos, se recomendo seguir esta estructura: tipo de acronimo en espanol y acronimo y forma extensa en ingles. Con respecto a 7 terminos o abreviaturas asociados a acronimos, se acordo traducir solo la forma extensa y se consensuo una traduccion. Conclusiones Con esta estandarizacion del lenguaje de las EspA se pretende establecer un uso comun de la nomenclatura en espanol para las EspA. Su implementacion sera muy beneficiosa, evitando malentendidos y consumo de recursos. EnglishObjective To develop a consensus to standardize the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA). Methods An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Espanola de Reumatologia (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de Espana (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process. Results Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them. Conclusions Through this standardization, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes.

Short report [Abstract] Objectives: The aim of this study was to explore the preferences of patients with rheumatic diseases and their perceived experience regarding participation in shared decision making (SDM) when they were prescribed a subcutaneous (SC) biological drug. Methods: A printed survey was handed to 1,000 patients with inflammatory rheumatic diseases treated with SC biological drug. The survey included closed questions about preferences regarding decision making and about patients' experience when they were prescribed an SC biological drug. Descriptive statistics were performed with stratification by patient profiles, using chi-square for comparisons between groups. Results: A total of 592 surveys were received (response rate 59.2%, mean age 51.7 years, 57.6% women). Some 28.2% of patients reported preferring to take part in treatment selection, a percentage that was higher in younger patients, in those with higher academic degree and in those who search information in sources different to that of health care professionals. Over half of patients (56.3%) perceived that the rheumatologist considered their opinion when prescribing an SC biological drug, a percentage higher in younger people. Only in 40.8% of cases did the patients' preference match their perception of their participation in the process. No differences were observed by sex, disease or number of biologics. Conclusions: Patients with inflammatory rheumatic diseases want information about their treatments but mostly leave the prescription decision to the rheumatologist. Younger people, or those with higher academic degree, more often want to participate in the SDM. There are discrepancies between patient preferences and perceptions of this process.

Objective To investigate the barriers and facilitators of adherence to methotrexate (MTX) in people with rheumatic diseases and to explore the experience of shared decision-making. Methods A qualitative study was carried out. People diagnosed with inflammatory arthritides or systemic autoimmune diseases and who were treated with MTX were invited to participate in focus groups. The discourse was coded and synthesised with a content analysis approach. Results The groups included 12 representative patients (rheumatoid arthritis, spondylarthritis, and systemic lupus erythematosus, taking either oral or subcutaneous MTX). Four main themes were identified: (1) drug-related aspects (package insert, adverse events, administration, and difficulties with treatment); (2) patient-physician relationship; (3) social environment (lack of visibility of rheumatic diseases and the support of patient associations); and (4) medication and medical care practicalities (information, reliable sources, and expanding knowledge in other health areas). Conclusions Aspects identified might help improve adherence, including quality information, especially on adverse events, the role of the setting, and shared decision-making.

Objectives To develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). Methods Clinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. Results Five questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. Conclusions There is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.

Objectives: To explore current evidence on the management of poor prognostic factors in rheumatoid arthritis (RA) and to investigate whether this evidence is taken into account by clinicians when deciding on treatment in daily clinical practice. Methods: We performed a systematic literature review (SLR) to analyse the effects of currently available biologic disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase inhibitors (JAKi) on the classically accepted poor prognostic factors of RA. All randomized controlled trials reporting subgroup analyses about effects on prognostic factors were identified and synthesized. In a second phase, a two-round Delphi survey was carried out to contrast the SLR results with the grade of agreement of a large group of rheumatologists about the effectiveness of each drug class on each prognostic factor. Results: According to the Delphi results, the only prognostic factor that significantly influenced the selection of treatment was the presence of interstitial lung disease (ILD), being the preferred treatment in this scenario abatacept or rituximab. The rest of the poor prognostic factors (including high disease activity at baseline, disability as measured by the Health Assessment Questionnaire index, seropositivity, elevated acute-phase reactants, and evidence of erosions based on plain radiography or ultrasonography) did not seem to significantly influence rheumatologists when choosing a treatment. The results of the SLR results did not show solid evidence regarding the use of any specific therapy in the management of patients with specific poor factors, except in the case of RA-ILD, although the data in the literature in this regard are not free of bias. Conclusions: The only prognostic factor that seems to significantly influence the selection of treatment is the presence of RA-ILD. Bristol-Myers Squibb 5.263 JCR (2021) Q2, 11/34 Rheumatology 0.798 SJR (2021) Q2, 21/61 Rheumatology No data IDR 2020 UEM

Background: Although the impact of uveitis on people's lives is clear, the frequency of this condition is unclear.Objective: To estimate the prevalence and incidence of uveitis. Methods: A systematic review with meta-analysis was conducted. Medline, Embase, and Cochrane Library were searched from inception to January 2019. The quality of the included studies was critically appraised with a grading system based on the Oxford Levels of Evidence. A detailed description of the populations studied and of factors affecting estimates was undertaken. Pooled analyses were conducted using a random-effects approach and expressed as incidence rates per 100,000 with 95% confidence intervals. Subgroup analyses by geographical region were conducted along with meta-regression to analyze possible factors for heterogeneity. Results: A total of 49 studies were included and critically appraised. Twenty-two were population-based, and 27 hospital-based. Heterogeneity was substantial in terms of populations studied, methods for ascertaining uveitis, including definitions, and reporting of results. This was especially important in prevalence studies, with data ranging from 9 to 730 cases per 100,000. For incidence studies, the meta-analysis yielded a pooled incidence of 50.45 per 100.000. The meta-regression showed the geographic region as an important explanatory factor of the heterogeneity between studies. Conclusion: Population-based estimates of the epidemiology of uveitis vary widely, owing to methodologies employed, definitions of uveitis and geographical regions; the representativeness and generalizability of many epidemiological studies of uveitis are limited. Proyecto UveCAM Sociedad de Reumatología de Castilla La Mancha (España) No data JCR 2021 0.776 SJR (2021) Q2, 42/128 Ophthalmology No data IDR 2021 UEM

Objective To investigate whether early response to tocilizumab (TCZ) and sarilumab (SAR) therapy in patients with active rheumatoid arthritis (RA) is influenced by previous use of biologic agents. Methods We performed a systematic literature review and a meta-analysis of original studies that analyzed the effectiveness of TCZ or SRL in subgroups of RA patients, including biologic-naive patients versus those with inadequate response to at least one biologic DMARD (bDMARD), and patients with failure to 1 versus ≥ 2 bDMARDs. Results The study selection process finally included 17 articles corresponding to 14 studies, including 7 randomized controlled trials (RCTs). Although the existing literature that compared the response in biologic-naive patients versus those with inadequate response to at least one bDMARD showed conflicting results, meta-analysis of 6 published studies revealed a significantly higher likelihood of remission (RR = 1.3; 95% CI: 1.2–1.5) and low activity disease (RR = 1.3; 95% CI: 1.2–1.4) in the biologic-naive group at week 24. However, differences between groups were not clinically meaningful in all studies and not always maintained after 6 to 12 months of treatment. In addition, data from RCT RADIATE and TARGET suggest that the response to IL-6 pathway inhibitors seems to be similar, regardless of the number of tumor necrosis factor inhibitors (TNFis) previously tested. Conclusion Disease activity was more rapidly reduced in the early stages of treatment in biologic-naive patients. However, near similar efficacy can be expected in patients who experienced a failure of at least one bDMARD (mainly TNFis) beyond the first 6 to 12 months of treatment, suggesting that the response occurs independently of the number of prior TNFis.

Explore the perspective of patients and professionals regarding non-radiographic axial spondyloarthritis (nr-axSpA) and to define the patient's journey from diagnosis to treatment in order to identify unmet needs during the process.A qualitative study was carried out in two phases. In the first part, five focus groups were held with rheumatologists, orthopaedist, physiotherapists, primary care physicians (PCP), radiologists and six narrative interviews with nr-axSpA patients. In the second part, a nominal group meeting was held to detect which needs were not covered in the nr-axSpA (all of whom had collaborated in the previous phase).The topics discussed with professional groups and patients were the appropriateness of the term and concept of nr-axSpA, the management of low back pain and inflammatory back pain in routine clinical practice, complementary test and the problem of waiting lists and finally the unmet needs both from a practitioner's and a patient's perspective. The final group explored solutions to the problems based on what was discussed in the first part of the project. Some of these solutions were strengthening relations between specialties, implementing high resolution consultations, rethinking the disability scales, offering better information to patients, designing resource maps and using different strategies to promote knowledge of the disease.Many different perspectives on the same disease have revealed the difficult journey of the patient with suspected nr-axSpA, while identifying problems and solutions. Key Points • Diagnosis of nr-AxSpA among health professionals outside rheumatology may lead to numerous turns and difficulties in the patient's journey. • The impact of delays and complications in the journey to diagnosis is not quantified but directly affects the state of well-being and health of patients. • Multidisciplinary care is far from a reality. Primary care (key specialists in any chronic condition), radiologists, orthopaedists, and non-physicians such as physiotherapists and psychologists are generally excluded from dealing with these patients, and often have to do their work outside of physicians, rather than working together in a truly patient-centred medicine.

No published epidemiological study has specifically focused on the prevalence of established rheumatoid arthritis (RA), as epidemiologists do not study established RA separated from RA as a whole; especially no incidence studies can be found, as incidence refers to new cases (early RA). Such a study, if it existed, would find a prevalence much larger than that of recent-onset RA, and should be planned based on clear definitions that currently do not exist in epidemiology. As a result, any study addressing RA as a whole, leaving aside early arthritis, would be actually studying established RA. This work reviews the epidemiology of RA, in contraposition of early RA, and tried to highlight epidemiological characteristics of established RA in published studies as well as methodological issues, including differences between recent-onset and established RA regarding the prevalence of comorbidities and other characteristics, and differences across countries. The global epidemiology of established RA teaches us that long-term outcomes could largely depend on health care models and are modifiable.

Resumen Objetivos Identificar las comorbilidades prioritarias en la espondiloartritis axial (EspAx) y recomendar como hacer su seguimiento desde una perspectiva eminentemente practica. Metodos Se selecciono a un grupo multidisciplinar (10 reumatologos [6 expertos en EspAx], 2 medicos de familia, una internista, una cardiologa, una gastroenterologa y una psicologa). En una primera reunion de discusion, se establecieron el alcance y los usuarios, y se voto una lista de comorbilidades sobre la base de la frecuencia y el impacto. Los panelistas debian defender con argumentos consistentes la inclusion de cada comorbilidad/item en el documento. Cuatro panelistas y 2 metodologos, desarrollaron revisiones sistematicas en temas controvertidos. En una segunda reunion se presentaron los resultados de las revisiones y los argumentos de todos los items a incluir. Tras esta reunion se redacto el documento final. Resultados El documento final incluye 2 listas de comprobacion (checklist), una para profesionales sanitarios y otra para pacientes, que recogen: riesgo cardiovascular, comorbilidad renal, riesgo gastrointestinal, estilo de vida, riesgo de infecciones y vacunacion, afectacion pulmonar, medicacion concomitante, trastornos psicoafectivos, osteoporosis y riesgo de fractura. Ademas, el documento refleja los argumentos para incluir cada item y la manera de recoger los items. Asimismo, el panel considero oportuno establecer unas «practicas a evitar» aplicables a la comorbilidad de la EspAx. Conclusiones Se generaron 2 listas de comprobacion y un listado de escenarios a evitar para facilitar el manejo de las comorbilidades de la EspAx. En pasos posteriores probaremos su utilidad y su aceptacion por un grupo amplio de usuarios que incluya medicos, pacientes y enfermeras.

Resumen Objetivo Evaluar la asociacion entre la perdida de peso y cambios en la actividad en pacientes con artritis psoriasica (APs). Metodos Se llevo a cabo una revision sistematica en Medline, Embase y Cochrane Central desde el inicio hasta abril del 2015. Criterios de inclusion: 1) ensayos clinicos aleatorizados controlados (ECA); 2) pacientes con APs; 3) cualquier intervencion encaminada al control de peso, y 4) evaluacion de la actividad de la APs. Se evaluaron los riesgos de sesgos segun la escala Cochrane. Resultados De 215 articulos identificados, solo 2 ECA cumplieron los criterios de inclusion, uno de ellos en formato abstract. Ambos tenian riesgos de sesgos moderados. Los pacientes que lograban perder peso, por cualquier metodo, mostraban menores niveles de actividad e inflamacion. El porcentaje de perdida de peso correlaciona moderadamente con cambios en medidas de inflamacion. Conclusion La perdida de peso en APs podria asociarse a menor inflamacion, si bien la evidencia que lo apoya es limitada.

Background: Two antisynthetase syndrome (ASSD) diagnosis criteria sets have been proposed; both consider mandatory the presence of anti-aminoacyl transfer RNA synthetase (ARS) autoantibodies. Solomon’s criteria consider major clinical criterions (interstitial lung disease (ILD) and fulfillment of Bohan and Peter criteria for DM/PM) and minor criterions (arthritis, Raynaud’s phenomenon (RP) and mechanic’s hands (MH)) (1). In contrast, Connors criteria evaluate the presence of at least one of the previously mentioned clinical features except myositis, and includes the presence of fever without other cause (2). Objectives: 1) to evaluate the performance of Solomon’s and Connors’ criteria in patients with clinical suspicion of aSSD or myositis and positive aRS. 2) to describe their clinical characteristics. Methods: We performed an observational retrospective study in two centers. All patients with clinical suspicion of aSSD or myositis, and positive aRS in the myositis immunoblot (Euroimmun assay) were included. Results: We analyzed 37 patients; 70.3% woman, with a mean age at the moment of the aRS detection of 51.4 (SD±14.0) years, median time from the first symptom to the aRS detection of 4.0 (SD±5.8) years, and time of evolution of 7.69 (SD±6.51) years. The frequency of aRS was: anti-Jo1 (n=17), anti-PL-12 (n=8), anti-PL-7 (n=4), anti-EJ (n=4), and anti-OJ (n=4). Diagnosis criteria fulfillment and clinical manifestations: 1) Patients that met Solomon and Connors’ criteria (n=17, 45.9%): - at disease onset: ILD (n=6, 35.9%), muscle weakness (MW) (n=5, 29.4%), and arthritis (n=4, 23.5%). - During disease development: ILD (n=14, 82.3%); arthritis (n=13, 76.5%); MW (n=10, 58.8%); mechanic hands (n=10, 58.8%); Raynaud phenomenon (n=8, 47.0%); and fever (n=3, 17.5%). 2) Patients that only met Connors’ criteria (n=17, 45.9%): - at disease onset: ILD (n=5, 29.4%), MW (n=3, 17.6%), or arthritis (n=5, 29.4%). - During disease development: arthritis (n=8, 47.0%); ILD (n=6, 35.3%); MW (n=6, 35.3%); Raynaud phenomenon (n=6, 35.3%); fever (n=5, 29.4%); and mechanic hands (n=1, 5.9%). Relative risk (RR) of the different clinical manifestation for Solomon’s criteria fulfillment: - MH RR=2.98 (95%CI 1.5-5.6; P=0.002), ILD RR=3.2 (95%CI 1.1-9.2; P=0.013); other manifestations does not presented significant RR. Conclusion: More than three quarter of all patients presented as first clinical manifestation one of those included in the aSSD classic triad (ILD, MW and arthritis). These manifestations showed increasing rates during the disease development, being more frequent in patients that met Solomon’s criteria than in those who only met Connor’s criteria; more than twice as high in for ILD, and almost twice for MW and arthritis. This suggests that patients who met Solomon’s criteria, at disease onset presented incomplete clinical forms, and their clinical progression favored the criteria fulfillment. On the other hand, we cannot predict if the patients that only met Connors’ criteria are going to fulfill Solomon’s criteria; nevertheless, our results suggests it. To conclude, our results suggest that: 1) Connors criteria might be considered for screening of aSSD; 2) Solomon’s criteria can be considered at the moment the gold standard for the aSSD diagnosis; 3) the presence of mechanic hands or ILD indicates a high probability of Solomon’s criteria fulfillment in patients with positive aRS. References [1] Solomon J, et al. Jornal brasileiro de pneumologia. 2011;37(1):100-9. [2] Connors GR, et al. Chest. 2010;138(6):1464-74. Disclosure of interests: Martin Greco: None declared, Maria Jesus Garcia de Yebenes: None declared, inmaculada alarcon: None declared, anahy Brandy-Garcia: None declared, Inigo Rua-Figueroa: None declared, Estibaliz Loza Grant/research support from: Roche, MSD, Pfizer, abbvie, BMS, UCB, actelion, Celgene, Grunenthal and Sanofi, Teresa Oton: None declared, Juan Carlos Quevedo-Abeledo: None declared, Carlos Rodriguez-Lozano: None declared, Loreto Carmona Grant/research support from: abbvie, actelion, astellas, BMS, Eisay, Gebro Pharma, Grunenthal, Leo Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi-Aventis and UCB Pharma, Paid instructor for: Novartis

Background: The antisynthetase syndromes (ASSD) are characterized by the presence of anti-aminoacyl transfer RNA synthetase (ARS) autoantibodies and clinical features including myositis, arthritis, interstitial lung disease (ILD), Raynaud’s phenomenon (RP), mechanic hands (MH), and fever. Two aSSD diagnosis criteria have been developed; those proposed by Connors, and the stricter criteria proposed by Solomon (1, 2). Additionally, other symptoms of connective tissue diseases (CTD) can be present. Objectives: To describe a series of patients with positive aRS and analyze: 1) the associated non-ARS antibodies, 2) the clinical manifestations that are not included in the different aSSD diagnosis criteria; and 3) the initial diagnosis attributed by the Rheumatologist in the clinical records. Methods: We performed an observational retrospective study in two hospitals. All patients with clinical suspicion of aSSD or myopathy and positive aRS in the myositis immunoblot (Euroimmun assay) were included. Results: We analyzed 37 patients; 70.3% woman, with a mean age at the moment of the first symptom of 50.5 (SD±14.0) years, and 51.4 (SD±14.0) years at the moment of the aRS detection. The frequency of aRS was: anti-Jo1 (n=17), anti-PL12 (n=8), anti-PL7 (n=4), anti-EJ (n=4), and anti-OJ (n=4). The rate of the aSSD clinical manifestations was: arthritis (56.7%), ILD (54.1%), muscle weakness (48.6%), RP (37.8%), MH (29.7%) and fever (21.6%). Thirty-four patients (91.9%) met Connors’ criteria and 17 of them (45.9%) also met Solomon’s criteria. Non-antisynthetase characteristics: - associated non-ARS antibodies: anti-Ro52 (n=17, 46%); anti-PM/Scl75 (n=6, 16.2%); anti-PM/Scl100 (n=5, 13.5%); anticentromere (n=3, 8.1%); rheumatoid factor (n=2, 5.4%); anti-CCP (n=2, 5.4%); and anti-DNAds (n=2, 5.4%). Other antibodies detected only once: anti-SRP, lupic-anticoagulant, anti-Ku, anti-Mi2, anticardiolipin, Nor90, Th/To. - Most frequent clinical manifestations not included in the aSSD diagnosis criteria: dysphagia (n=10, 27%); dermatomyositis rash (n=9, 24.3%); and SICCA sympthoms (n=7, 18.9%). - First diagnosis attributed by the clinicians in the medical records: aSSD (n=19, 51.35%), dermatomyositis/polymyositis (DM/PM) (n= 3), overlap syndrome (n= 3), systemic lupus erythemoatous (SLE) (n= 3), primary Sjogren’s syndrome (SS) (n=2); rheumatoid arthritis (RA) (n=2); undiferenciated-CTD (UCTD) (n=2); and Systemic Sclerosis (SSc) (n=1; 2.7%). Overlaps included 2 DM/PM-SSc and 1 DM/PM-SS, and both UCTD was described with SSc pattern. Thus, of the 18 cases not diagnosed as aSSD, 6 (33.3%) presented DM/PM diagnosis pattern and 6 (33.3%) SSc pattern. - additionally, when we applied the aSSD diagnosis criteria, 7 of the 18 cases (38.8%) not diagnosed as aSSD by the Rheumatologist fulfilled Solomon’s criteria. Conclusion: In our series, the most frequent non-ASSD profiles associated to aRS positivity was DM/PM, SSc and Sjogren’s syndrome. This, considering the most frequently associated non-ARS, the most frequent non-ASSD clinical manifestations and that the most frequent non-ASSD diagnosis diagnoses or profiles described by the Rheumatologist. Our results suggest that aRS can be present in patients with other CTD without presenting aSSD, and additionally that aSSD can be present in overlaps with other CTD. References [1] Solomon J, et al. Jornal brasileiro de pneumologia. 2011;37(1):100-9. [2] Connors GR, et al. Chest. 2010;138(6):1464-74. Disclosure of interests: Martin Greco: None declared, Maria Jesus Garcia de Yebenes: None declared, inmaculada alarcon: None declared, anahy Brandy-Garcia: None declared, Inigo Rua-Figueroa: None declared, Estibaliz Loza Grant/research support from: Roche, MSD, Pfizer, abbvie, BMS, UCB, actelion, Celgene, Grunenthal and Sanofi, Teresa Oton: None declared, R. Lopez-Sanchez: None declared, Laur Caceres Martin: None declared, Loreto Carmona Grant/research support from: abbvie, actelion, astellas, BMS, Eisay, Gebro Pharma, Grunenthal, Leo Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi-Aventis and UCB Pharma, Paid instructor for: Novartis

Background: The antisynthetase syndromes (ASSD) are characterized by the presence of anti-aminoacyl transfer RNA synthetase (ARS) autoantibodies; which difficult the binding of amino acids to the transfer RNA during the protein synthesis. ARS can be detected by indirect immunofluorescence (IIF), and can be identified by immunoblot assay and ELISA (Enzyme-Linked ImmunoSorbent Assay) and immunoblotting. The main clinical features of the ASSD are myositis, arthritis, interstitial lung disease, Raynaud’s phenomenon, mechanic hands, and fever. Two ASSD diagnosis criteria have been developed; those proposed by Connors, and the stricter criteria proposed by Solomon (1, 2). Objectives: To evaluate the performance of the ARS and their IIF patterns in the ASSD diagnosis. Methods: We performed an observational retrospective study in one center during the period 06/2008-06/2018. We searched all the myositis immunoblots (Euroimmun assay) requested by the Rheumatologists under suspicion of ASSD or myositis. We assessed: 1) the rate of cases with positive ARS; 2) the rate of cases with Connor’s or Solomon’s diagnosis criteria fulfillment; and 3) their relation with the IIF patterns (Hep-2 cells; ≥1/80) evaluated by an expert in autoimmune tests. Results: A total of 140 myositis immunoblots were searched. Twenty-seven cases (19.3%) presented positive ARS: anti-Jo1 (n=13), anti-PL-12 (n=7), anti-PL-7 (n=1), anti-EJ (n=2), and anti-OJ (n=4). Twenty-five of these (17.9%) fulfilled Connors’ criteria, and 15 (10.7%) additionally met Solomon’s criteria. Thus, the fulfillment of Connor’s and Solomon’s criteria in patients with a positive ARS was of 92.6% and 55.5%, respectively. All cases (100%) with positive ARS presented positive immunofluorescence: 19 (70.4%) showed a cytoplasmic pattern (10 of them with an associated nuclear pattern) and 8 cases (29.6%) presented only a nuclear pattern. On the other hand, 99 of the 113 cases (87.6%) with negative ARS presented positive IIF: 29 (25.7%) showed a cytoplasmic pattern (21 of them with an associated nuclear pattern) and 42 cases (37.2%) presented only a nuclear pattern. Correlating the ARS positivity, IIF pattern and the diagnosis criteria fulfillment: - 13 of 15 cases (86.6%) with positive ARS and Solomon’s criteria fulfillment presented a cytoplasmic pattern; and 2 of 15 cases (13.3%) presented only a nuclear pattern. - 13 of 19 cases (68.4%) with positive ARS and cytoplasmic pattern fulfilled Solomon’s criteria; and 6 only fulfilled those from Connors’. Conclusion: One-fifth of the immunoblots requested by Rheumatologists presented positive ARS; almost all these cases fulfilled Connor’s criteria, and more than a half fulfilled the stricter Solomon’s criteria. All patients with positive ARS, and a high rate of those without ARS, presented positive IIF. The presence of a cytoplasmic pattern was considerably higher in patients with ARS positivity and in those that met Solomon’s criteria. Thus, our results suggests that in patients evaluated by a Rheumatologist, with clinical suspicion of ASSD or myositis and with ARS positivity, the probability of fulfilling Solomon’s criteria is higher when the IIF presents a cytoplasmic pattern than when only a nuclear pattern is observed. Nevertheless, presenting only a nuclear pattern does not exclude the detection of ARS in the myositis immunoblot and the fulfillment of Solomon’s criteria. References [1] Solomon J, et al. Jornal brasileiro de pneumologia. 2011;37(1):100-9. [2] Connors GR, et al. Chest. 2010;138(6):1464-74. Disclosure of Interests: Martin Greco: None declared, Maria Jesus Garcia de Yebenes: None declared, Inmaculada Alarcon: None declared, Anahy Brandy-Garcia: None declared, Inigo Rua-Figueroa: None declared, Estibaliz Loza Grant/research support from: Roche, MSD, Pfizer, Abbvie, BMS, UCB, Actelion, Celgene, Grunenthal and Sanofi, Teresa Oton: None declared, Francisco Rubino: None declared, Juan Manuel Diaz: None declared, Felix Francisco: None declared, Soledad Ojeda: None declared, Loreto Carmona Grant/research support from: Abbvie, Actelion, Astellas, BMS, Eisay, Gebro Pharma, Grunenthal, Leo Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi-Aventis and UCB Pharma, Paid instructor for: Novartis

To estimate the agreement level between patient and physician assessment of disease activity and to explore whether agreement is associated with adherence to subcutaneous (SC) biological drugs in rheumatoid arthritis (RA). Cross-sectional study of RA patients who had been prescribed a SC biological drug in the past 12–18 months was performed. Patients and physicians global disease activity on visual analogue scale (VAS) were collected. Disagreement was defined as an absolute difference ≥ 3 points between VAS scores. Adherence was assessed by the Medication Possession Ratio (MPR), considering adherence an MPR > 80%. We analysed 360 patients of whom 15.5% presented disagreement with their physicians. The mean patient global VAS was 5.75 ± 1.8 (median 5.5 [5–7]) in the disagreement group versus 2.7 ± 2.2 (median 2 [1–4]) in the agreement group (p

Background:Non-radiographic axial spondyloarthritis (nr-ax-SpA) is a relatively new disease classification that has generated controversy among payers.Objectives:To explore the perspective of patients and health care professionals (HCPs) on the journey from first symptoms to a diagnosis of non-radiographic axial spondyloarthritis (nr-ax-SpA), in order to identify gaps and unmet needs.Methods:Qualitative study in two phases: (1) focus groups with HCPs and personal interviews with patients; (2) nominal group in which results were discussed with all stakeholders and possible solutions were proposed. Content analysis, patient journey mapping, and ideas generation techniques were used.Results:Five focus groups were organised with rheumatologists, GP, orthopaedic surgeons, physiotherapists, and radiologists, and six patient interviews were held.HCPs recognised poor communication among specialists and contradictory or redundant approaches. Non-rheumatologists recognise poor training on spondyloarthritis, difficulty in identifying red-flags, and biases in differential diagnosis. Rheumatologists recognise that SpA nomenclature can be confusing, nevertheless nr-ax-SpA term is defining an early stage of ankylosing spondylitis, and it could lead to over-diagnosis.Most of the patients agreed in the narrative of a very long journey with a multitude of diagnoses, mostly wrong, ineffective treatments and much frustration; acknowledging the need for psychological support during the process and the importance of receiving a diagnosis in order to cope with the disease.The participants in the nominal group meeting recognised and discussed the problems derived from the diagnostic delay and care gaps that clearly affect people with nr-ax-SpA (Table 1).Table 1.Problems recognised by the different actors involved in the journey.ProblemRecognised byPtPTOrGPRhRaNon-recognition of symptomsXXDelay first visit to doctorXCancel appointmentsXSelf-medicationXDisease denialXInvisibilityXLack of adherenceXIgnorance of medicationXUnclear symptomsXXXXNo clinical filter by back problemsXTreatments variabilityXIneffective protocolsXXLack of timeXXXXLack of resources (human and material)XXXLack of commitmentXXXXXNot outcome measurementXXXXInadequate knowledge/trainingXXXFew explanations / patient educationXXXXFocused on “our” diagnostic codesXXXXXNo relation between specialtiesXXXXXPrioritization of tests over solutionsXXXLabelling patients (prejudice)XXXXInadequate referral circuitsXXXXXDemotivating delaysXLimited medical history / little researchXTemporality of work contractsXLimited access to testsXXNon-sustainability threatXLack of specialised supportXDiagnostic dispersionXToo much weight of local issuesXAbsence of protocols or outdatedXXPoor information transmission in all directionsXXXXXXFocus on pharmacological treatmentsXIgnorance of others’ rolesXGender biasXIncomplete order formsXAbbreviations: Pt, patient; PT, physical therapist; Or, orthopaedic surgeon; GP, general practitioner; Rh, rheumatologist; Ra, radiologist.The following were indicated as possible solutions: (1) Improving relations between specialities, (2) High resolution consultations, (3) Rethinking disability scales, (4) Better information, (5) Visibility, (6) Resource maps and (7) Citizen training.Conclusion:The patient’s journey with an nr-ax-SpA is long, complicated and frustrating for both the person who experiences it and the HCPs who care for them. It is necessary to improve the knowledge about nr-ax-SpA among non-rheumatology health HCPs along with low back pain in general, among doctors and the general population, as well as other feasible measures that affect multiple levels.Disclosure of Interests:Teresa Oton Consultant of: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), Carlos Sastré Employee of: YES; I´m Medical Advisor in Novartis Spain, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

Background:The cardiovascular burden in psroriatic arthritis (PsA) is well recognized1.Objectives:To analyze the prevalence of metabolic syndrome (MetS) in patients with PsA.Methods:We conducted a systematic literature review (SLR) and a sub-analysis of the CARMA cohort. In the SLR, we searched in Pubmed, Embase, the Cochrane Central Library, and the ClinicalTrial until March 2019 using Mesh terms and free text words. We included SLR, clinical trials and observational studies analyzing the prevalence or frequency of MetS in PsA. Two reviewers selected articles, assessed the quality of the studies and collected data independently. The CARMA cohort was designed to establish the cardiovascular (CV) morbidity and associated risk factors for CV disease. It includes data from patients with chronic inflammatory rheumatic diseases (including PsA) of 67 Spanish hospitals. A sub-analysis of the prevalence of metS in PsA was performed using the National Cholesterol Education Program Adult Treatment Panel III criteria updated in 2005, which requires the presence of ≥3 of the following: high waist circumference, low HDL cholesterol level, high triglyceride level, high blood pressure and high fasting glucose values.Results:A total of 18 articles of moderate to high quality, were selected in the SLR. The included patients presented a balanced distribution by sex, with an average age ranging from 42 to 59 years. The frequency of MetS varied from 23.5% to 62.9% depending on the definition of MetS. The most widely used classification method was the National Cholesterol Education Program, followed by the method recommended by the International Diabetes Federation in 2009. A total of 724 patients with PsA were included in the CARMA study, of whom 327 (45.4%) were women and 157 (21.8%) smokers. The mean age at baseline was 51 ± 12 years and the mean duration of PsA disease 9 (4-16) years. Hypertension was the most frequently altered parameter (66.8%), followed by fasting glucose (42.6%) and hypertriglyceridemia (30.6%). Table 1 shows the frequency of patients according to the number of MetS components. A total of 222 (30.6%) PsA patients presented metabolic syndrome.Table 1.Prevalence of metabolic syndrome.Number of componentsN 0-5Patients (n)CARMA studyPercentage of patients, SLR(%)010113,95120828,73219326,66315120,864598,155121,66Total724100Conclusion:The frequency of the individual components of the MetS is variable according to the method of classification, which makes it difficult to compare between studies. In the CARMA study, the prevalence of MetS was around 30%, which supports the control of individual factors to prevent CV disease.References:[1]Liew JW, et al. Best Pract Res Clin Rheumatol. 2018;32(3):369-389.Disclosure of Interests:ANA URRUTICOECHEA-ARANA: None declared, Santos Castañeda: None declared, Estíbaliz Loza Grant/research support from: Roche, Pfizer, Abbvie, MSD, Novartis, Gebro, Adacap, Astellas, BMS, Lylly, Sanofi, Eisai, Leo, Sobi, Teresa Oton Consultant of: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), Diego Benavent: None declared, Maria Auxiliadora Martin-Martinez: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD

Background Interleukin 6 (IL-6) inhibitors constitute a therapeutic option for patients with rheumatoid arthritis (RA). Currently, apart from Tocilizumab (TCZ), we have data from other drugs targeting the IL-6 pathway. Objectives To review published evidence on safety and efficacy of IL-6 inhibitors in RA. Methods We performed sensitive systematic literature searches in Medline and Cochrane (up to October 2017), screened EULAR and American College of Rheumatology meeting-abstracts. An expert librarian designed the strategies that included Mesh and text word terms. The search was limited to human RA, adults and the English and Spanish language. The inclusion criteria were as follow: 1) RA patients on IL-6 Inhibitors including TCZ, sarilumab (SAR), olokizumab, sirukumab and clazakizumab; 2) Placebo and an active comparator were accepted as comparators; 3) Articles including typical efficacy and safety variables such as DAS-28, radiographic progression or the infections rate; 4) Only meta-analyses, systematic reviews and clinical trials were selected. Two reviewers screened the titles and abstracts of the retrieved articles independently. They also collected the data from the studies included by using ad hoc standard forms. All collection was double by article and independent. Subsequently, a secondary manual search of the bibliography of the articles that were finally included was performed. Evidence tables were produced. The quality was evaluated with the Oxford 2009 scale. Results We included 64 articles of moderate-high quality, variable duration, between 12 and 108 weeks. These articles analysed more than 8000 patients with RA, most of them with established RA (although there are data on early RA), with high disease activity and severity criteria. More than a half of the studies are of TCZ. IL-6 inhibitors were effective both in the short and long term in terms of clinical remission, RA activity, radiographic progression, function, fatigue, bone metabolism, morning stiffness, pain, quality of life, or anaemia. They also decreased and even normalised CRP values in a rapid and sustained manner. The efficacy of blocking IL-6 has been seen in RA refractory to DMARD or anti-TNFα and in MTX-naive patients, as well as in the intravenous and subcutaneous formulations (TCZ). TCZ and SAR are more effective than adalimumab in monotherapy. In general, no statistically significant differences were found between combined therapy and monotherapy. In terms of safety, the rate of adverse events increased over time and with the concomitant use of DMARDs. Infections and hypersensitivity reactions were the most frequent adverse events and infections the most frequent serious adverse events. IL-6 inhibitors were associated with a rapid and subsequently sustainable increase in serum lipid parameters, although this was not associated with a higher prevalence of cardiovascular events and related mortality, nor was it associated with neoplasms. Transaminase elevations were generally mild and without serious disorders. The incidence of gastrointestinal perforations was very low, and it was associated with a previous history of diverticulitis. Conclusions IL-6 inhibitors are effective to control RA activity and symptoms and to prevent radiographic damage in different disease profiles, with an acceptable safety profile. Disclosure of Interest None declared

Objectives To prepare recommendations on practical aspects of biological-drug monitoring that may be useful for rheumatologist Methods A systematic review of the literature was carried out to determine in which patients and in what clinical circumstances may be most beneficial to monitor the levels of biological drugs and their antibodies in patients suffering Rheumatoid Arthritis (RA) and/or Spondyloarthritis (SpA). With the results of the review, a group of experts produced a series of clinical questions, to be answered through the available scientific evidence, and then, subsequently, to make the recommendations and clinical algorithms for instructing the decision-making process. Results Results from the systematic review showed that the biological-drug monitoring might be especially useful in two clinical situations; in case of a treatment failure (primary or secondary) and in sustained remission (see figure 1). It was also reviewed which laboratory technique might be better and the optimal time for blood withdrawal. Specific recommendations are given on the interpretation of drug levels and on factors that should be taken into account are given (i.e. body mass index and concomitant medication). Conclusions Informed algorithms have been developed regarding the optimal time for requesting drug levels and anti- drug antibodies in patients with RA and SpA. This recommendations may help in the decision-making process and could be useful as part of future guidelines in the field. Acknowledgements This study was funded by Grifols through the Asociacion para la Investigacion en Reumatologia de la Marina Baixa (AIRE-MB). The content is solely the responsibility of the authors and does not necessarily represent the official views of Grifols. Disclosure of Interest None declared

Background Several studies in rheumatic and other inflammatory diseases treated with tumour necrosis factor-alpha inhibitors (TNFi) support the association between clinical response and trough drug levels (DL). The utility of monitoring DL in rheumatoid arthritis (RA) and spondyloarthritis (SpA) patients on biological therapy is not clear, so it is important to identify clinical situations in which, the knowledge of DL, would allow an individualised therapeutic decision in the patient, more cost-effective. Objectives To answer the most relevant clinical questions related to the usefulness of DL measurement in clinical practice: 1) whether, in patients in remission who are candidates for optimisation, DL predict relapse or survival to dose-titration; 2) whether, in patients with primary or secondary failure to biological agents, DL influence prognosis; and 3) whether concomitant use of methotrexate (MTX) influences the association between DL and response. Methods An electronic search of the major databases was performed, Medline, Embase and Cochrane Library, from inception to December 2016. We included articles published in English or Spanish on patients with RA, SpA or both, treated with TNFi, tocilizumab or abatacept, and related to answer any of the three questions of the target research. Overall characteristics and outcomes of the studies were collected in a table of evidence and the quality of the studies was assessed with a scale based on the Oxford levels of Evidence. Results The electronic search strategy yielded 1749 articles, twelve of which were included in this systematic review. 2 studies responded the first question, 5 the second, and 7 the third. These studies were mainly observational studies, 6 retrospective and 4 prospective cohort studies, and 2 randomised clinical trials. Sample sized varied from 24 to 395 patients, for a total of 1482 patients analysed. A total of 1281 RA patients were included (64 in the first question, 243 in the second and 1038 in the third) and 201 SpA patients (32 in the first and second questions, 169 in the third). Studies were small and with limitations, but suggest that measurement of DL may be useful in patients in remission, that higher DL predict a longer relapse-free optimisation, and in patients with failure to a biological agent, treatment may need individual adjustment according to the presence of DL or antidrug-antibodies. In addition, MTX influences the association between response and DL in most studies, with greater controversy in tocilizumab and SpA patients. Conclusions Monitoring DL would allow optimal use of current biological therapies, but more studies and of better quality are needed to draw definitive conclusions. In addition, future research should be performed to determine therapeutic ranges of DL, so that the proposed algorithms can be used in a standardised and reliable manner. Disclosure of Interest None declared

Background In the context of complex diseases like psoriatic arthritis (PsA), in which patients are often followed by different professionals, it is important for health professionals, providers and patients to have tools for delivering and demanding optimal care. One way to organise and evaluate health care quality is by the use of validated standards of care and quality indicators. Objectives To develop nationally accepted standards of care and quality indicators for care in PsA. Methods Qualitative methodology was followed that included: 1)Two focus groups (one with patients with PsA and another with non-rheumatologists specialists involved in the care of patients with PsA; 2) A narrative literature review of published documents related to the quality of care in PsA (including the QUANTUM Report1); 3) A nominal group meeting in which 15 expert rheumatologists generated and consensuated, a series of quality criteria as well as formulas or quantifiable objective measures to evaluate them; 4) A Delphi to establish the feasibility, priority and agreement with the quality criteria; 5) A final generation of standards of care and their attributes (including quality indicators). A descriptive analysis of the results was carried out. Results A total of 59 standards of care were generated, 19 of mandatory compliance, grouped into 4 blocks according to specific objectives: 1) Early diagnosis (n=6); 2) optimising the management of the disease (n=26), 3) multidisciplinary collaboration (n=9); 4) monitoring improvement (n=18). To assess the compliance of these standards of care, in many cases the medical records will be reviewed. Other sources will be the memory of the service and hospital and bibliographic databases. Regarding to the level compliance, for some of the standards of care this is yes/no, for others the compliance will range are from 50% to 100%, and in this range for many this will be by 80%. Conclusions This set of standards of care should help improve quality of care in APs patients. Reference [1] Favier G, Gladman DD, Merola JF, Armstrong AW, Boehncke WH, Helliwell PS. Benchmarking Care in Psoriatic Arthritis – The QUANTUM Report: A Report from the GRAPPA 2016 Annual Meeting. J Rheumatol. 2017;44(5):674–8. Disclosure of Interest None declared

Background In the last three decades, major advances in the spondyloarthritis (SpA) field have been achieved leading to new terminology. Whilst this terminology is well established in English, there is concern about the disparity of translated words and acronyms in Spanish, which is used by more than 437 million people in 21 countries. Objectives To develop a consensus to standardise the use of the Spanish terms, abbreviations and acronyms employed in the field of SpA. Methods An international task force was created comprising of all ASAS Spanish-speaking native members representing 5 countries, the executive committee members of GRESSER, two methodologists, two linguists from Real Academia Nacional de la Medicina Espanola (RANM) and two patients from CEADE. First, a literature review spanning the last 15 years was performed to identify the conflicting terms/abbreviations/acronyms. This review examined available written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensus. A three-round Delphi method including a face-to-face meeting, then followed. The recommendations from the RANM based on the Panhispanic dictionary in medical terms were consistently followed throughout the process. Results Consensus was reached for 44 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name the disease or its subgroups (SpA, axSpA, nr-axSpA, pSpA, AS, r-SpA, PsA) and for 6 terms and 4 abbreviations related with the disease (enthesitis, sacroiliitis, IBP, MRI-SIJ, BME, mNY). Additionally, it was agreed not to translate into Spanish 15 acronyms because they are very well established (ASDAS, BASDAI, BASFI, BASMI, mSASSS, RASS, BASRI, BAS-G, ASQoL, PsAQoL, MASES, MASEI, PASI, PARS, ASAS). However, when mentioning these acronyms, it is recommended that the following structure is used: type of variable in Spanish and acronym and expanded form in English. With regards to the terms or abbreviations attached to 7 acronyms (ASDAS-CI, ASDAS-MI, ASAS-HI, ASASpr, ASAS 5/6, ASAS20, ASAS40 improvement criteria), it was agreed to translate only the expanded form and a translation was also selected for all of them. Conclusions A consensus in Spanish nomenclature for SpA has been developed by ASAS group. The implementation of this consensus across the Spanish-speaking community will be of substantial benefit, avoiding misunderstandings and time-consuming processes. Acknowledgements GRESSER(E. Galindez, J. Gotor, M. Moreno, J. Quiros, A. Urruticoechea), CEADE(P. Plazuelo, M. Garrido), RANM(C. Gonzalez, C. Remacha) Disclosure of Interest None declared

Background Adherence is a critical factor in the therapeutic response in rheumatoid arthritis (RA), which may be influenced by the doctor-patient relationship. In the ARCO study, we previously reported a percentage of lack of adherence to the subcutaneous biologic of 14.3% during the first 14 months of treatment, and that the adherence was better in patients without induction and with a monthly administration schedule.1 In this post hoc analysis, we explored whether doctor-patient disagreements may be related to lower adherence rates. Objectives To analyse the percentage of patients with discrepancies in the evaluation of the activity of the disease between doctors and patients and a possible association between the existence of disagreement and adherence to subcutaneous biological drugs. Methods The ARCO study was a multicenter, cross-sectional study in which patients with RA were included according to EULAR-ACR 2010 criteria, who had been prescribed a subcutaneous biological drug in the previous 12–18 months. As part of the evaluation of the disease, patients and doctors were asked to rate the disease on a visual analogue scale (VAS), with values ranging from 0 to 10; with higher values indicating worst symptoms. Disagreement was defined as a difference of >/=3 points between the absolute values. Adherence was assessed retrospectively by means of the Medication Posession Ratio (MPR), considering adherence those patients with MPR >80%. The association between adherence and disagreement was studied using bi and multivariate logistic regression models with covariates-adjustments. Results We included 360 patients (77.5% women, mean age: 55±0.6 years). Disagreement was detected in 56 (15.5%). In patients with disagreement, the mean VAS score of the patient was 5.75±1.8 versus 2.7±2.2 in the group without disagreement (p Conclusions We observed a disagreement between patients and doctor VAS scores in 15.5% of cases, with higher values coming from patients. We did not observed an association between this disagreement and adherence to subcutaneous biological drugs. Reference [1] Calvo-Alen J, Monteagudo I, Salvador G, Vazquez-Rodriguez TR, Tovar-Beltran JV, Vela P, et al. Non-adherence to subcutaneous biological medication in patients with rheumatoid arthritis: a multicentre, non-interventional study. Clin Exp Rheumatol2017;35(3):423–30. Acknowledgements This is a secondary analysis of the ARCO study, which was financed by Merck Sharp and Dohme Spain. Disclosure of Interest T. Oton: None declared, J. Calvo-Alen : None declared, L. Cea-Calvo Employee of: Merck Sharp and Dohme S.A, L. Carmona: None declared

Objective To develop a consensus to standardise the use of Spanish terms, abbreviations and acronyms in the field of spondyloarthritis (SpA). Methods An international task force comprising all native Spanish-speaking Assessment of SpondyloArthritis International Society (ASAS) members, the executive committee of Grupo para el estudio de la Espondiloartritis de la Sociedad Espanola de Reumatologia (GRESSER), two methodologists, two linguists from the Real Academia Nacional de Medicina de Espana (RANM) and two patients from the Spanish Coordinator of Spondylitis Associations (CEADE) was established. A literature review was performed to identify the conflicting terms/abbreviations/acronyms in SpA. This review examined written sources in Spanish including manuscripts, ICF and ICD, guidelines, recommendations and consensuses. This was followed by a nominal group meeting and a three-round Delphi. The recommendations from the RANM based on the Panhispanic dictionary were followed throughout the process. Results Consensus was reached for 46 terms, abbreviations or acronyms related to the field of SpA. A Spanish translation was accepted for 6 terms and 6 abbreviations to name or classify the disease, and for 6 terms and 4 abbreviations related to SpA. It was agreed not to translate 15 acronyms into Spanish. However, when mentioning them, it was recommended to follow this structure: type of acronym in Spanish and acronym and expanded form in English. With regard to 7 terms or abbreviations attached to acronyms, it was agreed to translate only the expanded form and a translation was also selected for each of them. Conclusions Through this standardisation, it is expected to establish a common use of the Spanish nomenclature for SpA. The implementation of this consensus across the community will be of substantial benefit, avoiding misunderstandings and time-consuming processes.

Objectives Issue recommendations on practical aspects of the monitoring of levels of biological drugs that may be useful for rheumatologists. Methods We conducted a systematic review of studies in which drug and anti-drug antibody levels were determined in patients with rheumatoid arthritis (RA) or spondyloarthritis (SpA) to study whether they could predict different outcomes. In light of the results of the review, a group of experts discussed under what circumstances testing biological drug levels and their antibodies could be useful. The discussion resulted in a series of clinical questions that were answered with the scientific evidence collected, and in algorithms that facilitate decision making. Results It was established that the determination of drug levels can be especially useful in two clinical situations, on treatment failure (primary or secondary) and on sustained remission. It is also reviewed which laboratory technique and timing for sample drawing are the most suitable for the measurement. Recommendations are issued on the interpretation of drug levels and on factors to be taken into account (for example, body mass index and disease modifying drugs). Conclusions Evidence-based algorithms and guidelines have been established to test drug levels and anti-drug antibodies in patients with RA and SpA, which can help clinical decision making.

Objectives To identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective. Methods A multidisciplinary group was selected (10 rheumatologists—6 of them experts in AxSpA—, 2 general practitioners, an internist, a cardiologist, a gastroenterologist and a psychologist). In a first discussion meeting, the scope and users were established and a list of comorbidities was voted based on frequency and impact. The panellists had to defend the inclusion of each comorbidity/item in the document with consistent arguments. Four panellists and two methodologists developed systematic reviews on controversial topics. In a second meeting, the results of the reviews and the arguments concerning the items to be included were presented. After the meeting, the final document was drafted. Results The final document includes two checklists, one for health professionals and another for patients; they incorporate cardiovascular risk, renal comorbidities, gastrointestinal risk, lifestyle, risk of infections and vaccinations, pulmonary involvement, concomitant medication, psycho-affective disorders, osteoporosis, and risk of fracture. In addition, the document reflects the arguments favouring the inclusion of each item and how to record the items for subsequent collection. The panel considered it also appropriate to likewise establish «practices to avoid» applicable to comorbidity in AxSpA. Conclusions Two checklists and a list of situations to avoid were generated to facilitate the management of comorbidities in AxSpA. In a future step, their utility and acceptance will be tested by a broad group of users that includes doctors, patients and nurses.

Objective To evaluate the association between weight loss and changes in disease activity in patients with psoriatic arthritis (PsA). Methods We performed a systematic review of the literature, with searches in Medline, Embase and Cochrane Central Library from inception until April 2015. Inclusion criteria: (1) randomized controlled trials (RCT); (2) PsA patients; (3) interventions were any intervention aimed at weight control; and (4) a PsA activity-related outcome measure was evaluated. Risks of bias were assessed by the Cochrane Collaboration scale. Results Of the 215 articles identified, only 2 RCT met the inclusion criteria, 1 in abstract format. Both showed moderate risk of bias. Patients who managed to lose weight-by any method-had better results in terms of activity and inflammation. The percentage of weight loss correlated moderately with changes in inflammatory outcomes. Conclusion Weight loss in PsA could be associated with less inflammation; however, the evidence to support this is limited.

Objectives. To identify patterns (clusters) of damage manifestations within a large cohort of SLE patients and evaluate the potential association of these clusters with a higher risk of mortality. Methods. This is a multicentre, descriptive, cross-sectional study of a cohort of 3656 SLE patients from the Spanish Society of Rheumatology Lupus Registry. Organ damage was ascertained using the Systemic Lupus International Collaborating Clinics Damage Index. Using cluster analysis, groups of patients with similar patterns of damage manifestations were identified. Then, overall clusters were compared as well as the subgroup of patients within every cluster with disease duration shorter than 5 years. Results. Three damage clusters were identified. Cluster (80.6% of patients) presented a lower amount of individuals with damage (23.2 vs 10096 in clusters 2 and 3. P < 0.001). Cluster 2 (11.4% of patients) was characterized by musculoskeletal damage in all patients. Cluster 3 0.096 of patients) was the only group with cardiovascular damage, and this was present in all patients. The overall mortality rate of patients in clusters 2 and 3 was higher than that in cluster 1 (P < 0.001 for both comparisons) and in patients with disease duration shorter than 5 years as well. Conclusion. In a large cohort of SLE patients, cardiovascular and musculoskeletal damage manifestations were the two dominant forms of damage to sort patients into clinically meaningful clusters. Both in early and late stages of the disease, there was a significant association of these clusters with an increased risk of mortality. Physicians should pay special attention to the early prevention of damage in these two systems.

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).

Los agentes anti-TNFa han representado un notable avance en el control sintomatico de los pacientes con espondilitis anquilosante y respuesta inadecuada a AINE. Los antagonistas del TNFa son eficaces y seguros a largo plazo pero es necesario su uso continuado para un adecuado control sintomatico. Tras el fracaso a uno de ellos, el uso de un segundo agente anti-TNFa parece ser eficaz y seguro. Aun no se ha demostrado un efecto beneficioso del tratamiento con antagonistas del TNFa sobre la evolucion radiologica en la espondilitis anquilosante, a pesar de la desaparicion rapida y mantenida de la inflamacion osea, evidenciada mediante RM. Parece necesario explorar nuevas dianas moleculares implicadas en el proceso de osificacion

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.

No effective treatment has been documented for the glandular primary Sj ¨ ogren syndrome (PSS) despite the development of oral and biologic agents that have significant activity against other autoimmune disorders. Some disease-modifying agents have been empirically evaluated for the treatment of PSS. Targeting B cells also seems very promising in SSP because of the B-cell hyperactivity recognized in this desease. This article reviews existing data on the use of disease-modifying therapy for glandular of SSP. To date, published studies and trials of oral DMARDs for the treatment of SSP have shown disappointing results. B-cell modulation is clearly a promising therapy for PSS. Many challenges in trial design and execution are evident from the studies reviewed.

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.

Rheumatoid arthritis (RA) patients have a higher risk of developing some types of cancer, such as lymphoma or lung cancer. The severity of the disease is associated with a higher risk of developing lymphoma. Anti-TNF-α agents do not increase the incidence of neoplasm, but could trigger the onset of lymphoma in a subgroup of RA patients. Anti-TNF-α agents have been associated with a higher frequency of non-melanoma skin cancer. Although methotrexate does not increase the overall incidence of lymphoma or solid neoplasm, its use is sporadically associated with the development of lymphoma. These methotrexate-induced lymphomas occasionally disappear after withdrawal of the drug.

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.

No effective treatment has been documented for the glandular primary Sjögren syndrome (PSS) despite the development of oral and biologic agents that have significant activity against other autoimmune disorders. Some disease-modifying agents have been empirically evaluated for the treatment of PSS. Targeting B cells also seems very promising in SSP because of the B-cell hyperactivity recognized in this desease. This article reviews existing data on the use of disease-modifying therapy for glandular of SSP. To date, published studies and trials of oral DMARDs for the treatment of SSP have shown disappointing results. B-cell modulation is clearly a promising therapy for PSS. Many challenges in trial design and execution are evident from the studies reviewed.