Spondyloarthritis: analysis of a Brazilian series compared with a large Ibero-American registry (RESPONDIA group)

Abstracts

Estudos recentes relatam as características clínicas e epidemiológicas das espondiloartrites nas populações de diversos países ibero-americanos. O objetivo deste trabalho foi comparar os dados obtidos em um estudo epidemiológico brasileiro com os dados encontrados em diversos países ibero-americanos, que utilizaram um mesmo protocolo de investigação. A casuística brasileira apresentou maior frequência de pacientes com diagnóstico de espondilite anquilosante (72,3% brasileiros vs. 57,7% ibero-americanos), estando associada ao sexo masculino (73,6% vs. 66,0%) e ao antígeno de histocompatibilidade HLA-B27 positivo (65,9% vs. 51,8%). Com relação ao tratamento, os pacientes brasileiros fizeram mais uso de anti-inflamatório não hormonal (AINH) (77,0% vs. 71,2%) e menor uso de esteroides (7,5% vs. 18,5%).

Brasil; espondiloartropatias; epidemiologia


Recent studies have outlined the clinical and epidemiological profile of the spondyloarthritides in Ibero-American countries. The objective of this study was to compare the data collected in a Brazilian epidemiological study with the data obtained from other Ibero-American countries that used the same protocol of investigation. The Brazilian series presented a higher frequency of patients with ankylosing spondylitis (72.3% Brazilian vs. 57.7% Ibero-American), being associated with the male gender (73.6% vs. 66.0%) and histocompatibility antigen positive HLA-B27 (65.9% vs. 51.8%). Regarding the treatment, hormonal anti-inflammatory drugs - NSAIDS were more frequently prescribed to Brazilian patients (77.0% vs. 71.2%) and less often, corticosteroids (7.5% vs. 18.5%).

epidemiologic study; characteristics as topic; epidemiologic measurements; demographic data; Brazil


REVIEW ARTICLE

IPhysical Therapist - Master in Rehabilitation in Rheumatology - UNIFESP

IIPhysical Therapist - Post-graduate student in Experimental Physiopathology - FMUSP

IIIRheumatologist - Assistant Physician of the Discipline of Rheumatology - HCFMUSP

IVRheumatologist - Assistant Physician of the Discipline of Rheumatology - HCFMUSP

Correspondence to

ABSTRACT

Recent studies have outlined the clinical and epidemiological profile of the spondyloarthritides in Ibero-American countries. The objective of this study was to compare the data collected in a Brazilian epidemiological study with the data obtained from other Ibero-American countries that used the same protocol of investigation. The Brazilian series presented a higher frequency of patients with ankylosing spondylitis (72.3% Brazilian vs. 57.7% Ibero-American), being associated with the male gender (73.6% vs. 66.0%) and histocompatibility antigen positive HLA-B27 (65.9% vs. 51.8%). Regarding the treatment, hormonal anti-inflammatory drugs - NSAIDS were more frequently prescribed to Brazilian patients (77.0% vs. 71.2%) and less often, corticosteroids (7.5% vs. 18.5%).

Keywords: epidemiologic study, characteristics as topic, epidemiologic measurements, demographic data, Brazil.

INTRODUCTION

The spondyloarthrites (SpA) constitute a group of rheumatic diseases of immunological origin with a familial pattern, which affect predominantly the axial skeleton and can also affect the peripheral joints and entheses, mainly of the lower limbs. The SpA, and especially the ankylosing spondylitis (AS), have a significant association with the HLA-B27 histocompatibility antigen.1

In 2008, the name "spondyloarthritis" was proposed and globally accepted, which emphasizes the axial (spondylo) and peripheral (arthritis) nature of the group. The group of the SpA comprehends the AS, the psoriatic arthritis (PA), the reactive arthritis (RA), the undifferentiated spondyloarthrites and the arthrites associated with inflammatory bowel diseases, especially Crohn's disease and ulcerative rectocolitis.1

Since 2005, more than 100 university centers from 10 countries have participated in the work group of the Registro Ibero-Americano de Espondiloartrites - RESPONDIA (The Ibero-American Registry of Spondyloarthritis).

The idea arose with the support of the Spanish Society of Rheumatology (SER), which decided to apply the protocol of investigation of the REGISPONSER (Registro de Espondiloartrites da Sociedade Espanhola de Reumatologia) group in Ibero-American countries.2 The objective was to document demographic data (sex, age, time of disease, age at symptom onset, family history, HLA-B27), clinical data (percentage of the diagnoses of different SpA, measurements of axial and peripheral assessment, enthesitis, treatment) and quality of life.2 The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Radiology Index (BASRI) and the SF-12 quality of life instrument (SF-12 ASQOL) were also validated (for the Spanish and Portuguese languages) and analyzed.

The objective of this article is to describe the clinical and demographic data and clinimetric parameters of Brazilian patients with SpA and from other nine Ibero-American countries. All articles selected for the research were part of the RESPONDIA study and analyses carried out in Argentina,3 Brasil,4 Chile,5 Costa Rica,6 Spain,7 Mexico,8 Peru,9 Portugal,10 Uruguay11 and Venezuela12 were published. The results were presented in descriptive form and the weighted means of all results from the several countries were launched, when available.

The RESPONDIA group evaluated 4,405 patients in ten Ibero-American countries, with 2,367 of them being from Spain (53.7%), 1,036 from Brazil (23.5%), 405 from Argentina (9.2%), 172 from México (3.9%), 109 from Chile (2.4%), 101 from Portugal (2.3%), 69 from Venezuela (1.5%), 60 from Peru (1.3%), 53 from Uruguay (1.2%) and 33 from Costa Rica (0.7%). Some data were not reported by all countries.

The Ibero-American series, excluding the Brazilian patients, consisted of 3,360 patients, with a mean age of 46.5 years. Of the total, 2,223 individuals were males (66%) with a mean age at symptom onset of 30.7 years and time of disease of 15.8 years. The Brazilian series analyzed 1,036 patients, with a mean age of 43.7 years. Of the total number of Brazilian patients, 763 individuals were males (73.6%), with a mean age at symptom onset of 31 years and time of disease of 12.7 years (Table 1).

The Ibero-American sample showed a predominance of patients with ankylosing spondylitis (AS), which affected 1,943 patients (57.7%), followed by PA in 697 patients (20.7%), and undifferentiated spondyloarthritis in 183 (5.4%). The Brazilian series of 1,036 patients also showed a predominance of AS (72.3%), followed by PA (13.7%) and undifferentiated SpA (6.3%) (Table 2).

Among the studied patients from eight countries, including Brazil, AS was the disease with the highest frequency, varying from 45.5% to 83.1%. Only in Argentina PA was the most frequent diagnosis, present in 46.7% of the individuals (versus 30.4% of patients with AS). The subsequent extension of the RESPONDIA study will include more patients with a diagnosis of RA and enteropathic arthritis (EA). The age at symptom onset was similar in both groups. There was also a predominance of male patients, as most of them had a diagnosis of AS.

Due to the high degree of racial heterogeneity observed in Latin-American countries, varying even from country to country (mainly regarding the indigenous and mixed populations) the variable ethnicity/race was not included in this series of articles and will be addressed in a future publication.

The HLA-B27, generally present in around 90% of patients with AS in non-mixed populations, was positive in 69.5% of the Brazilian patients and 51% of the Ibero-American patients. The lower frequency of HLA-B27 is probably associated with the higher degree of population heterogeneity observed in Latin America.

Among Brazilian patients, inflammatory low-back pain was the most common initial symptom, reported by 65.5% of the patients. The mixed involvement (axial, peripheral and entheses) was predominant, present in 47.9% of the cases; purely axial disease occurred in 36.7% of the patients, with initial peripheral articular involvement in 10.7% and enthesitis in 24.7%. The hip was the most often affected joint (51.6%). The most often observed extra-articular involvement was anterior uveitis in 20.2% of patients. HLA-B27 was positive in 69.5% of the cases and family history of SpA was reported by 16.2% of the patients. The ungueal involvement occurred in 11.4% of the patients, which corresponds to 83% of the cases of PA (Table 3).

Due to the high frequency of patients with spondylitis, there was a high prevalence of axial involvement (36.7% in the Brazilian series); however, the mixed involvement (axial, peripheral and/or enthesitic) affected 47.9% of the Brazilian patients, emphasizing the importance of peripheral symptoms in the Brazilian series.

The mean BASFI value for Ibero-American population (excluding Peru, due to absence of data) was 3.50, whereas the mean BASDAI was 4.02. The mean visual analogue scale (VAS) global score of the disease analyzed by the physician was 2.97, whereas the mean VAS global score reported by the patient in the week before was 4.35. In Brazil, the mean BASFI value was 4.53; the mean BASDAI value was 4.12 and the VAS global score reported by the physician was 3.82, whereas the VAS global score reported by the patient in the week before was 4.68. (Table 4).

Te medications more often used in the Ibero-American countries were nonsteroidal anti-inflammatory drugs (NSAIDs) in 71.2% of the patients, followed by methotrexate (MTX) in 23.9%. There is no description of the use of NSAIDs in Peru, or reports on the use of immunobiological drugs in Chile and Uruguay. Regarding the drug treatment in Brazil, NSAIDs were used by 77% of the patients, followed by MTX in 26.2%, sulphasalazine (SSZ) in 21.3%, corticosteroids in 7.5% and anti-TNF biological agents in 5.4% (Table 5). The use of biological agents in the Brazilian series was lower than that observed in the literature, as these medications only started to be routinely used in patients with SpA in the final period of the RESPONDIA study.

Some data obtained through the RESPONDIA protocol, such as degree of schooling and occupation, BASMI, BASRI, PCR, VHS, SF-12, ASQOL and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), were not reported by these articles and will be published subsequently.

In conclusion, the Brazilian series presented a high frequency of patients with a diagnosis of ankylosing spondylitis, responsible for the high number of individuals of the male sex and HLA-B27-positive. Regarding the treatment, the Brazilian patients received more NSAIDs and less steroids than the Ibero-American sample.

The RESPONDIA study represents the largest series of patients with a diagnosis of spondyloarthritides in the Americas, also including patients from Iberian countries (Spain and Portugal). The fact that a common protocol of investigation was used, which was extracted and validated from the Spanish registry (REGISPONSER), is an extremely important factor. The Brazilian sample represented approximately ¼ of the group, being representative as it included patients from the five macro-regions of the country.

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  • Spondyloarthritis: analysis of a Brazilian series compared with a large Ibero-American registry (RESPONDIA group)
    Andrea Lopes GallinaroI; Camila VenturaII; Percival Degrava Sampaio BarrosIII; Celio Roberto GonçalvesIV

Publication Dates

  • Publication in this collection
    12 Nov 2010
  • Date of issue
    Oct 2010

History

  • Accepted
    31 Aug 2010
  • Received
    09 Mar 2010
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