New recommendations of the Brazilian Society of Rheumatology: a new strategy

EDITORIAL

New recommendations of the Brazilian Society of Rheumatology: a new strategy

It is with great satisfaction that I see the Sociedade Brasileira de Reumatologia (SBR, Brazilian Society of Rheumatology) Recommendations for the management and treatment of psoriatic arthritis,¹ ankylosing spondylitis² and systemic sclerosis³ published in this issue of the Revista Brasileira de Reumatologia (RBR, Brazilian Journal of Rheumatology). Consensus and guidelines on diagnosis and treatment in Rheumatology have been published for over two decades. During that period, the strategies for elaborating the texts that guide most rheumatologists and clinicians in managing patients with several rheumatic disorders have evolved greatly. In the 'Recommendations' published in this RBR issue, the SBR Committees on Spondyloarthritis and Systemic Sclerosis used strategies for the search and elaboration of the final text from the Projeto Diretrizes da Associação Médica Brasileira (Brazilian Medical Association 'Guideline Project'), which requires that all statements in the text have at least one specific reference, graded according to its level of evidence. After the initial elaboration of the text according to pre-established rules and in the 'question and answer' format, some rounds of internet discussion were necessary to refine it, before approval by the SBR and Brazilian Medical Association. Both societies showed an excellent partnership to elaborate the final text that would suit the Brazilian reality, without reducing the strength of evidence of the recommendations. With that efficient partnership, the strength of the recommendations, increasingly based on consistent evidence, will also serve as an instrument to discuss the implantation of governmental strategies for the diagnosis and treatment of rheumatic diseases.

After the new classification criteria for axial⁴ and peripheral⁵ spondyloarthritis (SpA) issued by the Assessment on SpondyloArthritis International Society (ASAS) group, and the proposition of new guidelines for its treatment,^6,7 an update of the consensus on the ankylosing spondylitis and psoriatic arthritis treatment, published in the RBR in 2007,⁸ became indispensable. Regarding the Recommendations for the management and treatment of ankylosing spondylitis,² three initial questions on the importance of the following were included: classification criteria for axial and peripheral SpA (Recommendation 1); magnetic resonance imaging on the early SpA diagnosis (Recommendation 2); and HLA-B27 as a prognostic factor (Recommendation 3). The so-called conventional treatment discussed physical therapy (Recommendation 4), corticosteroids (Recommendation 5), non-steroidal anti-inflammatory drugs (NSAIDs) (Recommendation 6), and conventional baseline drugs, such as methotrexate (MTX) and sulfasalazine (SSZ) (Recommendation 7). The use of biologic drugs, which have revolutionized the AS treatment, is approached in seven questions regarding the inhibitors of tumor necrosis factor (anti-TNF) as follows: their indication (Recommendation 8); their efficacy (Recommendation 9); their safety (Recommendation 10); progression of structural damage (Recommendation 11); extra-articular manifestations (Recommendation 12); medication switching (Recommendation 13); and medication duration (Recommendation 14). In addition, one question approaches other biologic drugs (Recommendation 15).

Within the SpA spectrum, psoriatic arthritis (PA) has also been increasingly studied over the last two decades, and new classification criteria⁹ have been proposed and treatment guidelines,¹⁰ updated. The current Recommendations for the management and treatment of psoriatic arthritis¹ also represent an update of the previous 2007 Brazilian Consensus.⁸ The first three questions approach the classification criteria as follows: recommend the CASPAR criteria⁹ (Recommendation 1); emphasize the importance of cutaneous, articular and nail assessment (Recommendation 2); and highlight the significant number of comorbidities (Recommendation 3). The conventional treatment assessment comprises questions about the use of the following drugs: corticosteroids (Recommendation 4); NSAIDs (Recommendation 5); and conventional drugs, mainly MTX, cyclosporine, and leflunomide (Recommendation 6). Seven questions approach the use of biologic agents, especially anti-TNF drugs, as follows: their indication (Recommendation 7); their efficacy (Recommendation 8); their safety (Recommendation 9); progression of structural damage (Recommendation 10); concomitant use of conventional drugs (Recommendation 11); medication switching (Recommendation 12); and medication duration (Recommendation 13). In addition, one question approaches other biologic drugs (Recommendation 14) and the efficacy of the drugs acting mainly on the skin over affected joints (Recommendation 15).

One of the most fascinating and complex rheumatologic diseases is the systemic sclerosis (SSc), whose treatment still has to be improved. With the advent of the modern concepts of SSc sine scleroderma,¹¹ early SSc,¹² and very early SSc,¹³ and the establishment of organ-specific strategies already outlined in the first Recommendations of Treatment¹⁴ proposed by the EUSTAR (EULAR Scleroderma Trial and Research) group, one can foretell that early diagnosis is essential for therapeutic success. The first three questions approach the diagnosis of SSc (Recommendation 1), the importance of nailfold capillaroscopy (Recommendation 2), and specific autoantibodies (Recommendation 3) in the early diagnosis and follow-up of scleroderma patients. Regarding organ-specific strategies, there are questions about antifibrotic drugs (Recommendation 4) and the treatment of calcinosis (Recommendation 5). Regarding vascular impairment, there are questions about the treatment of Raynaud's phenomenon (Recommendation 6) and of ischemic ulcers (Recommendation 7), and about the prevention of recurrent ischemic ulcers (Recommendation 8). The most frequent visceral impairment (digestive tract) is also approached on three questions about digestive tract hypomotility (Recommendation 9), gastroesophageal reflux (Recommendation 10), and malabsorption syndrome (Recommendation 11). The impairment of vital organs is approached in specific questions about interstitial lung disease (Recommendation 12), pulmonary arterial hypertension (Recommendation 13), scleroderma renal crisis (Recommendation 14), and cardiac involvement (Recommendation 15).

In conclusion, the new strategy of producing recommendations for the diagnosis and treatment of the major rheumatic diseases, according to the modern rules of the Brazilian Medical Association 'Guideline Project', represents a significant gain in the strength of the SBR recommendations.

Percival Degrava Sampaio-Barros

President of the 2006-2012 Brazilian Society of Rheumatology Committee on Spondyloarthritides; president of the 2010-2014 Brazilian Society of Rheumatology Committee on Systemic Sclerosis

E-mail: [e-mail]

REFERENCES

• ¹
  Carneiro S, Azevedo VF, Bonfiglioli R, Ranza R, Gonçalves CR, Keiserman M, et al. Recomendações sobre diagnóstico e tratamento da artrite psoriásica. Rev Bras Reumatol 2013;53(3):227-41.
• ²
  Sampaio-Barros PD, Keiserman M, Meirelles ES, Pinheiro MM, Ximenes AC, Azevedo VF, et al. Recomendações sobre diagnóstico e tratamento da espondilite anquilosante. Rev Bras Reumatol 2013;53(3):242-57.
• ³
  Sampaio-Barros PD, Zimmermann AF, Muller CS, Borges CTL, Freire EA, Maretti GB, et al. Recomendações sobre diagnóstico e tratamento da esclerose sistêmica. Rev Bras Reumatol 2013;53(3):258-75.
• ⁴
  Rudwaleit M, van der Heijde D, Landewé R, Listing J, Akkoc N, Brandt J, et al. The development of the Assessment of SpondyloArthritis international Society classifi cation criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009;68(6):777-83.
• ⁵
  Rudwaleit M, van der Heijde D, Landewé R, Akkoc N, Brandt J, Chou CT, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011;70(1):25-31.
• ⁶
  Braun J, van den Berg R, Baraliakos X, Boehm H, Burgos-Vargas R, Collantes-Estevez E, et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2011;70(6):896-904.
• ⁷
  van der Heijde D, Sieper J, Maksymowych WP, Dougados M, Burgos-Vargas R, Landewé R, et al. 2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis. Ann Rheum Dis 2011;70(6):905-8.
• ⁸
  Sampaio-Barros PD, Azevedo VF, Bonfiglioli R, Campos WR, Carneiro SCS, Carvalho MAP, et al. Primeira Revisão do Consenso Brasileiro de Espondiloartropatias: espondilite anquilosante e artrite psoriásica. Rev Bras Reumatol 2007;47(4):234-43.
• ⁹
  Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group. Classifi cation criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 2006;54(8):2665-73.
• ¹⁰
  Ash Z, Gaujoux-Viala C, Gossec L, Hensor EM, FitzGerald O, Winthrop K, et al. A systematic literature review of drug therapies for the treatment of psoriatic arthritis: current evidence and meta-analysis informing the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2012;71(3):319-26.
• ¹¹
  Poormoghim H, Lucas M, Fertig N, Medsger TA Jr. Systemic sclerosis sine scleroderma: demographic, clinical, and serologic features and survival in forty-eight patients. Arthritis Rheum 2000;43(2):444-51.
• ¹²
  LeRoy EC, Medsger TA Jr. Criteria for the classifi cation of early systemic sclerosis. J Rheumatol 2001;28(7):1573-6.
• ¹³
  Avouac J, Fransen J, Walker UA, Riccieri V, Smith V, Muller C, et al. Preliminary criteria for the very early diagnosis of systemic sclerosis: results of a Delphi Consensus Study from EULAR Scleroderma Trials and Research Group. Ann Rheum Dis 2011;70(3):476-81.
• ¹⁴
  Kowal-Bielecka O, Landewé R, Avouac J, Chwiesko S, Miniati I, Czirjak L, et al. EULAR recommendations for the treatment of systemic sclerosis: a report from the EULAR Scleroderma Trials and Research group (EUSTAR). Ann Rheum Dis 2009;68(5):620-8.

Publication Dates

• Publication in this collection
  16 Sept 2013
• Date of issue
  June 2013