Profile of patients with rheumatic diseases undergoing treatment with anti-TNF agents in the Brazilian Public Health System (SUS), Belo Horizonte - MG

The aim of this study was to describe the baseline demographic and clinical characteristics as well as the functional status of a prospective cohort of patients with rheumatic diseases assisted by the Brazilian Public Health System (SUS). Data for 302 patients receiving tumor necrosis factor α inhibitors (anti-TNF agents) was collected through a standard form. Among patients, 229 (75.8%) were female and 155 (51.3%) were Caucasian; the mean age was 50.3 ± 12.8 years, and the mean disease duration was 9.9 ± 8.7 years. Among them 214 patients (70.9%) received adalimumab, 72 (23.8%) etanercept, and 16 (5.3%) infliximab. Mean Health Assessment Questionnaire-Disability Index (HAQ-DI) was 1.37 ± 0.67 for all participants. Poor functional response was associated with female gender, married patients and with a score of < 0.6 on the EuroQoL-5 dimensions (EQ-5D). Significant correlation was found between the HAQ-DI values, disease activity and quality of life (QOL). The results obtained in this study contribute to a better understanding of the clinical and demographic characteristics of patients with rheumatic diseases at the beginning of anti-TNF-agent treatment by SUS. Furthermore, our findings are consistent with another Brazilian and foreign cross-sectional investigations. This knowledge can be of great importance for further studies evaluating the effectiveness of biological agents, as well as, to contribute to improve the well-being of the patients with rheumatic diseases

2012 Brazilian Society Of Rheumatology Consensus On The Management Of Comorbidities In Patients With Rheumatoid Arthritis

Objective: To elaborate recommendations of the Rheumatoid Arthritis Committee of the Brazilian Society of Rheumatology (SBR) to manage comorbidities in rheumatoid arthritis (RA). Methods: To review the literature and the opinions of the SBR RA Committee experts. Results and conclusions: Recommendations: 1) Early diagnosis and proper treatment of comorbidities are recommended; 2) The specific treatment of RA should be adapted to the presence of comorbidities; 3) Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers are preferred to treat systemic arterial hypertension; 4) In patients diagnosed with rheumatoid arthritis and diabetes mellitus, the continuous use of a high cumulative dose of corticoids should be avoided; 5) Statins should be used to maintain LDL cholesterol levels under 100 mg/dL and the atherosclerotic index lower than 3.5 in patients with RA who have other comorbidities; 6) Metabolic syndrome should be treated; 7) Performing non-invasive tests to investigate subclinical atherosclerosis is recommended; 8) Greater surveillance for the early diagnosis of occult malignancy is recommended; 9) Preventive measures of venous thrombosis are suggested; 10) Bone densitometry is recommended in RA patients over the age of 50 years and in younger patients on corticoid therapy at a dose greater than 7.5 mg for over three months; 11) Patients with RA and osteoporosis should be instructed to avoid falls, to increase their dietary calcium intake and sun exposure, and to exercise; 12) Calcium and vitamin D supplementation is suggested. Bisphosphonates are suggested for patients with T score < -2.5 on bone densitometry; 13) A multidisciplinary team, with the active participation of a rheumatologist, is recommended to treat comorbidities. © 2012 Elsevier Editora Ltda.524483495McInnes, I.B., O'Dell, J.R., State-of-the-art: rheumatoid arthritis (2010) Ann Rheum Dis, 69 (11), pp. 1898-1906. , [Erratum in: Ann Rheum Dis 201170(2):399]McInnes, I.B., Schett, G., The pathogenesis of rheumatoid arthritis (2011) N Engl J Med, 365 (23), pp. 2205-2219Allaart, C.F., Huizinga, T.W., Treatment strategies in recent onset rheumatoid arthritis (2011) Curr Opin Rheumatol, 23 (3), pp. 241-244Symmons, D.P., Rheumatoid arthritis: assessing disease activity and outcome (2010) Clin Med, 10 (3), pp. 248-251Gonzalez, A., Maradit Kremers, H., Crowson, C.S., Nicola, P.J., Davis 3rd, J.M., Therneau, T.M., The widening mortality gap between rheumatoid arthritis patients and the general population (2007) Arthritis Rheum, 56 (11), pp. 3583-3587Hemminki, K., Li, X., Sundquist, J., Sundquist, K., Familial associations of rheumatoid arthritis with autoimmune diseases and related conditions (2009) Arthritis Rheum, 60 (3), pp. 661-668Michou, L., Rat, A.C., Lasbleiz, S., Bardin, T., Cornélis, F., Prevalence and distribution of autoimmune diseases in 368 rheumatoid arthritis families (2008) J Rheumatol, 35 (5), pp. 790-796Michaud, K., Wolfe, F., Comorbidities in rheumatoid arthritis (2007) Best Pract Res Clin Rheumatol, 21 (5), pp. 885-906Crowson, C.S., Myasoedova, E., Davis 3rd, J.M., Matteson, E.L., Roger, V.L., Therneau, T.M., Increased Prevalence of metabolic syndrome associated with rheumatoid arthritis in patients without clinical cardiovascular disease (2011) J Rheumatol, 38 (1), pp. 29-35Chung, C.P., Oeser, A., Solus, J.F., Avalos, I., Gebretsadik, T., Shintani, A., Prevalence of the metabolic syndrome is increased in rheumatoid arthritis and is associated with coronary atherosclerosis (2008) Atherosclerosis, 196 (2), pp. 756-763Steiner, G., Urowitz, M.B., Lipid profiles in patients with rheumatoid arthritis: mechanisms and the impact of treatment (2009) Semin Arthritis Rheum, 38 (5), pp. 372-381Solomon, D.H., Love, T.J., Canning, C., Schneeweiss, S., Risk of diabetes among patients with rheumatoid arthritis, psoriatic arthritis and psoriasis (2010) Ann Rheum Dis, 69 (12), pp. 2114-2117van Halm, V.P., Peters, M.J., Voskuyl, A.E., Boers, M., Lems, W.F., Visser, M., Rheumatoid arthritis versus diabetes as a risk factor for cardiovascular disease: a cross-sectional study, the CARRE Investigation (2009) Ann Rheum Dis, 68 (9), pp. 1395-1400Panoulas, V.F., Douglas, K.M., Milionis, H.J., Stavropoulos-Kalinglou, A., Nightingale, P., Kita, M.D., Prevalence and associations of hypertension and its control in patients with rheumatoid arthritis (2007) Rheumatology (Oxford), 46 (9), pp. 1477-1482Kitas, G.D., Gabriel, S.E., Cardiovascular disease in rheumatoid arthritis: state of the art and future perspectives (2011) Ann Rheum Dis, 70 (1), pp. 8-14Gonzalez, A., Maradit Kremers, H., Crowson, C.S., Ballman, K.V., Roger, V.L., Jacobsen, S.J., Do cardiovascular risk factors confer the same risk for cardiovascular outcomes in rheumatoid arthritis patients as in nonrheumatoid arthritis patients? (2008) Ann Rheum Dis, 67 (1), pp. 64-69Panoulas, V.F., Douglas, K.M., Stavropoulos-Kalinoglou, A., Metsios, G.S., Nightingale, P., Kita, M.D., Long-term exposure to medium-dose glucocorticoid therapy associates with hypertension in patients with rheumatoid arthritis (2008) Rheumatology (Oxford), 47 (1), pp. 72-75Alcorn, N., Saunders, S., Madhok, R., Benefit-risk assessment of leflunomide: an appraisal of leflunomide in rheumatoid arthritis 10 years after licensing (2009) Drug Saf, 32 (12), pp. 1123-1134Robert, N., Wong, G.W., Wright, J.M., Effect of cyclosporine on blood pressure (2010) Cochrane Database Syst Rev, (1), pp. CD007893Atzeni, F., Turiel, M., Caporali, R., Cavagna, L., Tomasoni, L., Sitia, S., The effect of pharmacological therapy on the cardiovascular system of patients with systemic rheumatic diseases (2010) Autoimmunity Rev, 9 (12), pp. 835-839White, W.B., Defining the problem of treating the patient with hypertension and arthritis pain (2009) Am J Med, 122 (5 SUPPL.), pp. S3-S9Peters, M.J., Symmons, D.P., McCarey, D., Dijkmans, B.A., Nicola, P., Kvien, T.K., EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis (2010) Ann Rheum Dis, 69 (2), pp. 325-331Solomon, D.H., Massarotti, E., Garg, R., Liu, J., Canning, C., Schneeweiss, S., Association between disease-modifying antirheumatic drugs and diabetes risk in patients with rheumatoid arthritis and psoriasis (2011) JAMA, 305 (24), pp. 2525-2531Tentolouris, N., Arapostathi, C., Voulgari, C., Grammatikou, S., Andrianakos, A., Sfikakis, P.P., The effect of diabetes mellitus on the prevalence of rheumatoid arthritis: a case-control study (2008) Diabet Med, 25 (8), pp. 1010-1011Han, C., Robinson Jr., D.W., Hackett, M.V., Paramore, L.C., Fraeman, K.H., Bala, M.V., Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis (2006) J Rheumatol, 33 (11), pp. 2167-2172Hoes, J.N., van der Goes, M.C., van Raalte, D.H., van der Zijl, N.J., den Uyl, D., Lems, W.F., Glucose tolerance, insulin sensitivity and β-cell function in patients with rheumatoid arthritis treated with or without low-to-medium dose glucocorticoids (2011) Ann Rheum Dis, 70 (11), pp. 1887-1894Wasko, M.C., Kay, J., Hsia, E.C., Rahman, M.U., Diabetes mellitus and insulin resistance in patients with rheumatoid arthritis: risk reduction in a chronic inflammatory disease (2011) Arthritis Care Res (Hoboken), 63 (4), pp. 512-521Antohe, J.L., Bili, A., Sartorius, J.A., Lester Kirchner, H., Morris, S.J., Dancea, S., Diabetes risk in rheumatoid arthritis: Reduced incidence with anti-tumor necrosis factor- α therapy (2012) Arthritis Care Res (Hoboken), 64 (2), pp. 215-221Bili, A., Sartorius, J.A., Kirchner, H.L., Morris, S.J., Ledwich, L.J., Antohe, J.L., Hydroxychloroquine use and decreased risk of diabetes in rheumatoid arthritis patients (2011) J Clin Rheumatol, 17 (3), pp. 115-120Liao, K.P., Gunnarsson, M., Källberg, H., Ding, B., Plenge, R.M., Padyukov, L., Specific association of type 1 diabetes mellitus with anti-cyclic citrullinated peptide-positive rheumatoid arthritis (2009) Arthritis Rheum, 60 (3), pp. 653-660Choy, E., Sattar, N., Interpreting lipid levels in the context of highgrade inflammatory states with a focus on rheumatoid arthritis: a challenge to conventional cardiovascular risk actions (2009) Ann Rheum Dis, 68 (4), pp. 460-469White, D., Fayez, S., Doube, A., Atherogenic lipid profiles in rheumatoid arthritis (2006) N Z Med J, 119 (1240), pp. U2125Nurmohamed, M.T., Atherogenic lipid profiles and its management in patients with rheumatoid arthritis (2007) Vasc Health Risk Manag, 3 (6), pp. 845-852Myasoedova, E., Crowson, C.S., Kremers, H.M., Fitz-Gibbon, P.D., Therneau, T.M., Gabriel, S.E., Total cholesterol and LDL levels decrease before rheumatoid arthritis (2010) Ann Rheum Dis, 69 (7), pp. 1310-1314Ghosh, U.C., Roy, A., Sen, K., Kundu, A.K., Saha, I., Biswas, A., Dyslipidaemia in rheumatoid arthritis in a tertiary care centre in Eastern India - a non-randomised trial (2009) J Indian Med Assoc, 107 (7), pp. 427-430Garciaa-Gómez, C., Nolla, J.M., Valverde, J., Gómez-Gerique, J.A., Castro, M.J., Pintó, X., Conventional lipid profile and lipoprotein(a) concentrations in treated patients with rheumatoid arthritis (2009) J Rheumatol, 36 (7), pp. 1365-1370Steiner, G., Urowitz, M.B., Lipid profiles in patients with rheumatoid arthritis: mechanisms and the impact of treatment (2009) Semin Arthritis Rheum, 38 (5), pp. 372-381Georgiadis, A.N., Papavasiliou, E.C., Lourida, E.S., Alamanos, Y., Kostara, C., Tselepis, A.D., Atherogenic lipid profile is a feature characteristic of patients with early rheumatoid arthritis: effect of early treatment - a prospective, controlled study (2006) Arthritis Res Ther, 8 (3), pp. R82Svenson, K.L., Lithell, H., Hallgren, R., Vessby, B., Serum lipoprotein in active rheumatoid arthritis and other chronic inflammatory arthritides. II. Effects of anti-inflammatory and disease-modifying drug treatment (1987) Arch Intern Med, 147 (11), pp. 1917-1920Raynauld, J.P., Cardiovascular mortality in rheumatoid arthritis: how harmful are corticosteroids? (1997) J Rheumatol, 24 (3), pp. 415-416Wallace, D.J., Metzger, A.L., Stecher, V.J., Turnbull, B.A., Kern, P.A., Cholesterol-lowering effect of hydroxychloroquine in patients with rheumatic disease: reversal of deleterious effects of steroids on lipids (1990) Am J Med, 89 (3), pp. 322-326van Halm, V.P., Nielen, M.M., Nurmohamed, M.T., van Schaardenburg, D., Reesink, H.W., Voskuyl, A.E., Lipids and inflammation: serial measurements of the lipid profile of blood donors who later developed rheumatoid arthritis (2007) Ann Rheum Dis, 66 (2), pp. 184-188Singh, J.A., Beg, S., Lopez-Olivo, M.A., Tocilizumab for rheumatoid arthritis. Cochrane Database of Systematic Reviews (2011) J Rheumatol, 38 (1), pp. 10-20Storage, S.S., Agrawal, H., Furst, D.E., Description of the efficacy and safety of three new biologics in the treatment of rheumatoid arthritis (2010) Korean J Intern Med, 25 (1), pp. 1-17Pollono, E.N., Lopez-Olivo, M.A., Lopez, J.A., Suarez-Almazor, M.E., A systematic review of the effect of TNF-alpha antagonists on lipid profiles in patients with rheumatoid arthritis (2010) Clin Rheumatol, 29 (9), pp. 947-955McCarey, D.W., McInnes, I.B., Madhok, R., Hampson, R., Scherbakov, O., Ford, I., Trial of Atorvastatin in Rheumatoid Arthritis (TARA): double-blind, randomised placebo-controlled trial (2004) Lancet, 363 (9426), pp. 2015-2021Chatterjee Adhikari, M., Guin, A., Chakraborty, S., Sinhamahapatra, P., Ghosh, A., Subclinical atherosclerosis and endothelial dysfunction in patients with early rheumatoid arthritis as evidenced by measurement of carotid intima-media thickness and flow-mediated vasodilatation: an observational study (2012) Semin Arthritis Rheum, 41 (5), pp. 669-675González-Juanatey, C., Llorca, J., González-Gay, M.A., Correlation between endothelial function and carotid atherosclerosis in rheumatoid arthritis patients with long-standing disease (2011) Arthritis Res Ther, 13 (3), pp. R101Pereira, I.A., Laurindo, I.M., Zimmermann, A.F., Werner Castro, G.R., Mello, F., Borba, E.F., Single measurements of C-reactive protein and disease activity scores are not predictors of carotid atherosclerosis in rheumatoid arthritis patients (2009) Acta Reumatol Port, 34 (1), pp. 58-64Chung, C.P., Oeser, A., Raggi, P., Gebretsadik, T., Shintani, A.K., Sokka, T., Increased coronary-artery atherosclerosis in rheumatoid arthritis: relationship to disease duration and cardiovascular risk factors (2005) Arthritis Rheum, 52 (10), pp. 3045-3053Maradit-Kremers, H., Crowson, C.S., Nicola, P.J., Ballman, K.V., Roger, V.L., Jacobsen, S.J., Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study (2005) Arthritis Rheum, 52 (2), pp. 402-411Nicola, P.J., Maradit-Kremers, H., Roger, V.L., Jacobsen, S.J., Crowson, C.S., Ballman, K.V., The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years (2005) Arthritis Rheum, 52 (2), pp. 412-420Westlake, S.L., Colebatch, A.N., Baird, J., Kiely, P., Quinn, M., Choy, E., The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review (2010) Rheumatology (Oxford), 49 (2), pp. 295-307Westlake, S.L., Colebatch, A.N., Baird, J., Curzen, N., Kiely, P., Quinn, M., Tumour necrosis factor antagonists and the risk of cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review (2011) Rheumatology (Oxford), 50 (3), pp. 518-531Barnabe, C., Martin, B.J., Ghali, W.A., Systematic review and metaanalysis: anti-tumor necrosis factor a therapy and cardiovascular events in rheumatoid arthritis (2011) Arthritis Care Res (Hoboken), 63 (4), pp. 522-529Gislason, G.H., Rasmussen, J.N., Abildstrom, S.Z., Schramm, T.K., Hansen, M.L., Fosbøl, E.L., Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure (2009) Arch Intern Med, 169 (2), pp. 141-149Solomon, D.H., Glynn, R.J., Rothman, K.J., Schneeweiss, S., Setoguchi, S., Mogun, H., Subgroup analyses to determine cardiovascular risk associated with nonsteroidal anti-inflammatory drugs and coxibs in specific patient groups (2008) Arthritis Rheum, 59 (8), pp. 1097-1104Söderlin, M., Petersson, I., Bergman, S., Svensson, B., Smoking at onset of rheumatoid arthritis (RA) and its effect on disease activity and functional status: experiences from BARFOT, a long-term observational study on early RA (2011) Scand J Rheumatol, 40 (4), pp. 249-255. , BARFOT study groupSaevarsdottir, S., Wedrén, S., Seddighzadeh, M., Bengtsson, C., Wesley, A., Lindblad, S., Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: observations from the Epidemiological Investigation of Rheumatoid Arthritis and the Swedish Rheumatology Register cohorts (2011) Arthritis Rheum, 63 (1), pp. 26-36Alberti, K.G., Zimmet, P., Shaw, J., Metabolic syndrome - a new worldwide definition. A Consensus Statement from the International Diabetes Federation (2006) Diabet Med, 23 (5), pp. 469-480(2001) JAMA, 285 (19), pp. 2846-2897. , Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)Grundy, S.M., Cleeman, J.I., Daniels, S.R., Donato, K.A., Eckel, R.H., Franklin, B.A., Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. 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A cross sectional study (2009) Arthritis Res Ther, 11 (4), pp. R110Bacani, A.K., Gabriel, S.E., Crowson, C.S., Heit, J.A., Matteson, E.L., Noncardiac vascular disease in rheumatoid arthritis: increase in venous thromboembolic events? (2012) Arthritis Rheum, 64 (1), pp. 53-61Matta, F., Singala, R., Yaekoub, A.Y., Najjar, R., Stein, P.D., Risk of venous thromboembolism with rheumatoid arthritis (2009) Thromb Haemost, 101 (1), pp. 134-138Aksu, K., Donmez, A., Keser, G., Inflammation-induced thrombosis: mechanisms, disease associations and management (2012) Curr Pharm Des, 18 (11), pp. 1478-1493Undas, A., Gissel, M., Kwasny-Krochin, B., Gluszko, P., Mann, K.G., Brummel-Ziedins, K.E., Thrombin generation in rheumatoid arthritis: dependence on plasma factor composition (2010) Thromb Haemost, 104 (2), pp. 224-230Bisoendial, R.J., Levi, M., Tak, P.P., Stroes, E.S., The prothrombotic state in rheumatoid arthritis: an additive risk factor for adverse cardiovascular events (2010) Semin Thromb Hemost, 36 (4), pp. 452-457Mameli, A., Barcellona, D., Marongiu, F., Rheumatoid arthritis and thrombosis (2009) Clin Exp Rheumatol, 27 (5), pp. 846-855Liang, K.P., Liang, K.V., Matteson, E.L., McClelland, R.L., Christianson, T.J., Turesson, C., Incidence of noncardiac vascular diseasein rheumatoid arthritis and relationship to extraarticular disease manifestations (2006) Arthritis Rheum, 54 (2), pp. 642-648Davies, R., Galloway, J.B., Watson, K.D., Lunt, M., Symmons, D.P., Hyrich, K.L., Venous thrombotic events are not increased in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the British Society for Rheumatology Biologics Register (2011) Ann Rheum Dis, 70 (10), pp. 1831-1834. , BSRBR Control Centre Consortium, British Society for Rheumatology Biologics RegisterSmitten, A.L., Simon, T.A., Hochberg, M.C., Suissa, S., A meta-analysis of the incidence of malignancy in adult patients with rheumatoid arthritis (2008) Arthritis Res Ther, 10 (2), pp. R45Zintzaras, E., Voulgarelis, M., Moutsopoulos, H.M., The risk of lymphoma development in autoimmune diseases: a meta-analysis (2005) Arch Intern Med, 165 (20), pp. 2337-2344Hemminki, K., Li, X., Sundquist, K., Sundquist, J., Cancer risk in hospitalized rheumatoid arthritis patients (2008) Rheumatology (Oxford), 47 (5), pp. 698-701Kim, Y.J., Shim, J.S., Choi, C.B., Bae, S.C., Mortality and incidence of malignancy in Korean patients with rheumatoid arthritis (2012) J Rheumatol, 39 (2), pp. 226-232Bongartz, T., Sutton, A.J., Sweeting, M.J., Buchan, I., Matteson, E.L., Montori, V., Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials (2006) JAMA, 295 (19), pp. 2275-2285Thompson, A.E., Rieder, S.W., Pope, J.E., Tumor necrosis factor therapy and the risk of serious infection and malignancy in patients with early rheumatoid arthritis: a meta-analysis of randomized controlled trials (2011) Arthritis Rheum, 63 (6), pp. 1479-1485Askling, J., The risk of malignancies in RA patients treated with biologics (2010) Z Rheumatol, 69 (9), pp. 774-779Thomas, E., Symmons, D.P., Brewster, D.H., Black, R.J., Macfarlane, G.J., National study of cause-specific mortality in rheumatoid arthritis, juvenile chronic arthritis, and other rheumatic conditions: a 20 year followup study (2003) J Rheumatol, 30 (5), pp. 958-965Hemminki, K., Liu, X., Ji, J., Sundquist, J., Sundquist, K., Autoimmune disease and subsequent digestive tract cancer by histology (2012) Ann Oncol, 23 (4), pp. 927-933Hellgren, K., Smedby, K.E., Feltelius, N., Baecklund, E., Askling, J., Do rheumatoid arthritis and lymphoma

Update on the 2012 brazilian society of rheumatology guidelines for the treatment of rheumatoid arthritis: position on the use of tofacitinib / QUANDO ABRE PDF, abre EM PORTUGUÊS.

In 2014, tofacitinib, a target-specific, synthetic disease modifying anti rheumatic drug (DMARD) and a selective inhibitor of Janus kinase (JAK) was approved for use in Brazil. This position paper aims to update the recommendations of the Brazilian Society of Rheumatology (SBR) on the treatment of rheumatoid arthritis (RA) in Brazil, specifically regarding the use of target-specific synthetic DMARDs. The method of this recommendation consisted of a literature review of scientific papers held on the Medline database. After this review, a text was produced, answering questions in Pico structure, considering efficacy and safety issues of tofacitinib use for RA treatment in different scenarios (such as first-line treatment after failure with methotrexate [MTX] or other conventional synthetic DMARDs after failure with biological therapy). Based on existing evidence, and considering the available data on efficacy, safety and cost of medications available to treat the disease in Brazil, the RA Commission of SBR, after a process of discussion and voting on proposals, established the following position on the use of tofacitinib for treatment of RA in Brazil: Tofacitinib, alone or in combination with MTX, is an alternative for RA patients with moderate or high activity after failure of at least two different synthetic DMARDs and one biological DMARD. The level of agreement with this recommendation was 7.5. This position may be reviewed in the coming years, in the face of a greater experience with the use of this medication.Em 2014, o tofacitinibe, um medicamento modificador do curso da doença (MMCD) sintético, alvo‐específico, inibidor seletivo das Janus quinases (JAK), foi aprovado para uso no Brasil. Este documento de posicionamento tem o objetivo de atualizar as recomend556512521sem informaçãosem informaçãoIn 2014, tofacitinib, a target-specific, synthetic disease modifying anti rheumatic drug (DMARD) and a selective inhibitor of Janus kinase (JAK) was approved for use in Brazil. This position paper aims to update the recommendations of the Brazilian Socie

High levels of polypharmacy in rheumatoid arthritis—a challenge not covered by current management recommendations : data from a large real-life study

Rheumatoid arthritis (RA) is associated with high frequency of comorbidities and increased risk of polypharmacy. Although there is a great potential for complications, there is a gap in literature on polypharmacy in patients with rheumatic arthritis. To evaluate the prevalence and factors associated with polypharmacy in a population in a real-life setting. Methods: A cross-sectional multicenter study was conducted in Brazil. Patients underwent clinical evaluation and medical records analysis. Polypharmacy was considered as a dependent variable. To test independent variables, we used Poisson regression. We evaluated 792 patients (89% female, median age 56.6 years). Median duration of disease was 12.7 years, 78.73% had a positive rheumatoid factor. The median of disease activity score-28 was 3.5 (disease with mild activity), median of the clinical disease activity index score was 9, and median of health assessment questionnaire-disability index was 0.875; 47% used corticosteroids, 9.1% used nonsteroidal anti-inflammatory drugs, 90.9% used synthetic disease-modifying antirheumatic drugs, 35.7% used biologic disease-modifying antirheumatic drugs (DMARDs). In total, 537 (67.9%) patients used 5 or more drugs. Polypharmacy showed a relationship with a number of comorbidities and use of specific drugs (corticosteroids, methotrexate, and biological DMARDs). We found a high prevalence of polypharmacy (67.9%) in RA. Solutions to management this problem should be stimulatedThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Brazilian Society of Rheumatology (BSR). For this project, BSR received specific grant support from the following companies: Bristol-Myers Squibb Farmacêutica Ltda; Eli Lilly do Brasil Ltda; Janssen-Cilag Farmacêuticos Ltda; Laboratórios Pfizer Ltda; Produtos Roche Químicos e Farmacêuticos S.A.; and UCB Biopharma Ltda. The funding body or the companies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscrip