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

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

Nutritional aspects and cardiovascular risk in systemic lupus erythematosus

OBJECTIVE: Patients with systemic lupus erythematosus present with a higher number of classic risk factors for coronary diseases and a higher prevalence of metabolic syndrome resulting from the disease itself. To evaluate the nutritional indicators of the cardiovascular risk of patients with systemic lupus erythematosus by analyzing eating habits, anthropometry, laboratory data, and disease activity and to describe the prevalence of patients fulfilling the criteria for metabolic syndrome. METHODS: Anthropometric measurements including waist circumference, food recall, and laboratory tests. RESULTS: The population presented an insufficient daily intake of micronutrients. Anthropometry revealed that 37.5% of the patients were classified with degree II obesity by body mass index and 76.8% by abdominal obesity. Regarding metabolic syndrome, 18 patients (16%) fulfilled the diagnostic criteria. CONCLUSIONS: Individuals with systemic lupus erythematosus presented with increased risk factors, as determined using anthropometric measurements and laboratory tests, for cardiovascular disease, indicating the need for nutritional guidance in this population to reduce cardiovascular risk, increase the quality of life, and increase survival of these patients

Guidelines on COVID-19 vaccination in patients with immune-mediated rheumatic diseases : a Brazilian Society of Rheumatology task force

Objective To provide guidelines on the coronavirus disease 2019 (COVID-19) vaccination in patients with immune-mediated rheumatic diseases (IMRD) to rheumatologists considering specific scenarios of the daily practice based on the shared-making decision (SMD) process. Methods A task force was constituted by 24 rheumatologists (panel members), with clinical and research expertise in immunizations and infectious diseases in immunocompromised patients, endorsed by the Brazilian Society of Rheumatology (BSR), to develop guidelines for COVID-19 vaccination in patients with IMRD. A consensus was built through the Delphi method and involved four rounds of anonymous voting, where five options were used to determine the level of agreement (LOA), based on the Likert Scale: (1) strongly disagree; (2) disagree, (3) neither agree nor disagree (neutral); (4) agree; and (5) strongly agree. Nineteen questions were addressed and discussed via teleconference to formulate the answers. In order to identify the relevant data on COVID-19 vaccines, a search with standardized descriptors and synonyms was performed on September 10th, 2021, of the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and LILACS to identify studies of interest. We used the Newcastle–Ottawa Scale to assess the quality of nonrandomized studies. Results All the nineteen questions-answers (Q&A) were approved by the BSR Task Force with more than 80% of panelists voting options 4—agree—and 5—strongly agree—, and a consensus was reached. These Guidelines were focused in SMD on the most appropriate timing for IMRD patients to get vaccinated to reach the adequate covid-19 vaccination response. Conclusion These guidelines were developed by a BSR Task Force with a high LOA among panelists, based on the literature review of published studies and expert opinion for COVID-19 vaccination in IMRD patients. Noteworthy, in the pandemic period, up to the time of the review and the consensus process for this document, high-quality evidence was scarce. Thus, it is not a substitute for clinical judgment

Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Background There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann–Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren’s syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03–2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19–6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31–3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46–0.98). Conclusion Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection

First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus : Latin American Group for the Study of Lupus (GLADEL, Grupo Latino Americano de Estudio del Lupus)–Pan-American League of Associations of Rheumatology (PANLAR)

Systemic lupus erythematosus (SLE), a complex and heterogeneous autoimmune disease, represents a significant challenge for both diagnosis and treatment. Patients with SLE in Latin America face special problems that should be considered when therapeutic guidelines are developed. The objective of the study is to develop clinical practice guidelines for Latin American patients with lupus. Two independent teams (rheumatologists with experience in lupus management and methodologists) had an initial meeting in Panama City, Panama, in April 2016. They selected a list of questions for the clinical problems most commonly seen in Latin American patients with SLE. These were addressed with the best available evidence and summarised in a standardised format following the Grading of Recommendations Assessment, Development and Evaluation approach. All preliminary findings were discussed in a second face-to-face meeting in Washington, DC, in November 2016. As a result, nine organ/system sections are presented with the main findings; an ’overarching’ treatment approach was added. Special emphasis was made on regional implementation issues. Best pharmacologic options were examined for musculoskeletal, mucocutaneous, kidney, cardiac, pulmonary, neuropsychiatric, haematological manifestations and the antiphospholipid syndrome. The roles of main therapeutic options (ie, glucocorticoids, antimalarials, immunosuppressant agents, therapeutic plasma exchange, belimumab, rituximab, abatacept, low-dose aspirin and anticoagulants) were summarised in each section. In all cases, benefits and harms, certainty of the evidence, values and preferences, feasibility, acceptability and equity issues were considered to produce a recommendation with special focus on ethnic and socioeconomic aspects. Guidelines for Latin American patients with lupus have been developed and could be used in similar settings

MBL2 gene polymorphisms and its relation to infection in Brazilian systemic lupus erythematosus patients : a 10-years followup study

Introduction: Systemic lupus erythematosus (SLE) is a multifactorial disease and MBL2 genetic variants, which are associated to differential peripheral MBL levels, potentially affect its etiology and increase infection risk in this population. Objective: To evaluate the potential association of MBL2 polymorphisms of the coding and promoter gene region and haplotypes on hospitalization, number of admission and days of admission for major infection causes in Brazilian SLE patients. Methods: 325 SLE patients from a southern Brazilian outpatient SLE clinic were genotyped in 2006 for MBL2 gene polymorphisms from coding and promoter region (rs1800450, rs1800451, rs5030737, rs11003125, and rs7096206) and followed until 2016. Clinical and laboratory data from each patient were obtained and information regarding the need for hospitalization, the number of admissions and number of days admitted for infection treatment were compiled and compared with MBL2 gene polymorphisms and haplotypes. A linear regression analysis was constructed considering the variables of bivariate which demonstrated an association (p<0.05) and variables which had a theoretical basement. Results: No difference was found in polymorphism prevalence when comparing the group that was admitted for infection treatment and the group who did not. Allele C, and haplotypes LY and HY correlated with more infection hospitalizations [wild-type homozygosis for C: 2 (IQR 1–3), heterozygosis for C: 3 (IQR 2–6) p=0.038; LY 2 (IQR 1–3) p=0.049; HY 2 (IQR 1–3) p=0.005] and haplotype HY carriers stayed fewer days in hospital for infection treatment: 18 (IQR 10–38) p=0.041. When linear regression was applied HY associated with shorter admission time for infections ( 18.11 days, p=0.021) and HY ( 1.52 admission, p 0.001) carriers with older age at diagnosis had less admissions for infection (HY regression model: 0.42, p=0.006; LY regression model 0.04, p=0.010; 0.04, p=0.013). Conclusion: The presence of the HY promoter haplotype associated to fewer in hospital care for infection treatment probably due to higher MBL plasma levels. Also, HY haplotype and older age at SLE diagnosis is related to less admissions for infection. This factor should be taken into consideration, since infection is a very import cause of mortality in SLE patients being also related to aggressive immunosuppressive treatment

The landscape of systemic lupus erythematosus in Brazil : an expert panel review and recommendations

Purpose: The objective of this review is to address the barriers limiting access to diagnosis and treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) in Brazil, specifically for patients in the public healthcare system, arguably those with the least access to innovation. Design: A selected panel of Brazilian experts in SLE/LN were provided with a series of relevant questions to address in a multi-day conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved. Results: The authors propose specific and realistic recommendations for implementing access to innovative diagnostic tools and treatment alternatives for SLE/LN in Brazil. Moreover, in creating these recommendations, the authors strived to address barriers and impediments for technology adoption. The multidisciplinary care required for SLE/LN necessitates the collective participation of all involved stakeholders. Conclusion: A great need exists to expand the adoption of innovative diagnostic tools and treatments for SLE/LN not only in Brazil but also in most countries, as access issues remain an urgent demand. The recommendations presented in this article can serve as a strategy for new technology adoption in other countries in a similar situation

BIOCONTROLE DE Macrophomina phaseolina COM ESPÉCIES DE Trichoderma APLICADAS NO TRATAMENTO DE SEMENTES DE FEIJÃO E NO SOLO

Four species of Trichoderma (T. harzianum, T. koningii, T. viride and T. pseudokoningii) were evaluatedunder greenhouse conditions using two methods: a) Treatment of bean seeds with a conidialsuspension of the antagonists, adjusted to 1x10e conidia/ml of sterilized water, and planting innatural and sterilized soils, which were artificially infested with M. phaseolina in three differentperiods, in relation to the planting of the treated seeds; b) Treatment of both kinds of soil withthe antagonists, following the same periods of applying, in relation to the planting of theinoculated seeds with phytopathogen. In general, Trichoderma species showed potential asbiocontrol agents of M. phaseolina. Among the studied species, T. harzianum revealed the bestAnais da Academia Pernambucana de Ciência Agronômica, vol. 1, p.133-140, 2004.BIOCONTROLE DE Macrophomina phaseolina COM ESPÉCIES DE Trichoderma APLICADAS NOTRATAMENTO DE SEMENTES DE FEIJÃO E NO SOLO134results for both, seed and soil treatments, as indicated by higher Ievel of plant survival.Quatro espécies de Trichoderma (T. harzianum, T. koningii, T. viride e T. pseudokoningii) foram avaliadas,em condições de casa-de-vegetação, empregando-se dois métodos: a) Tratamento de sementesde feijão com uma suspensão conidial dos antagonistas, ajustada para 1x106 conídiospor mililitro de água destilada-esterilizada, seguido do plantio em solo esterilizado e natural,porém infestados, artificialmente, com Macrophomina phaseolina, em três períodos distintos, emrelação ao plantio das sementes tratadas com Trichoderma; b) Tratamento dos dois tipos de solocom os antagonistas, obedecendo os mesmos períodos de aplicação, em relação ao plantio dassementes inoculadas com M. phaseolina. Em geral, as espécies de Trichoderma mostraram potencialno controle do fitopatógeno presente nas sementes de feijão ou no solo, quando comparadasàs testemunhas (sem antagonistas). Das espécies de Trichoderma estudadas, T. harzianummostrou melhor resultado, tanto no tratamento de sementes, como no tratamento do solo,indicado pelo percentual de plantas sobreviventes