American College of Rheumatology Updates Rheumatoid Arthritis Guidelines 2008

The American College of Rheumatology (ACR) has updated its 2002 guidelines on the use of nonbiologic disease-modifying antirheumatic drugs (DMARDs) for rheumatoid arthritis (RA), which now include data on the use of biologic agents as well. The updated recommendations are reported in the June 15 issue of Arthritis Care and Research.

"The majority of patients with a confirmed diagnosis of . . . RA use nonbiologic. . . DMARDs and the rate of biologic DMARD use is rising rapidly," write Kenneth G. Saag, MD, MSc, from the University of Alabama, Birmingham, and colleagues.

"The . . . ACR has not updated its recommendations for nonbiologic DMARDs since 2002 and has not previously developed recommendations for biologic agents. Although past guidelines have been derived from an informal consensus approach, we used a formal group process to develop recommendations that were as evidence-based as possible."

These guidelines were developed following the principles set forth by the Appraisal of Guidelines for Research and Evaluation Collaboration. A systematic review of scientific evidence was conducted to create an evidence report and draft guidelines addressing 5 domains prespecified by the ACR: (1) indications for use, (2) screening for tuberculosis (TB; for biologic DMARDs only), (3) monitoring for adverse effects, (4) evaluating clinical response, and (5) the roles of cost and patient preferences in decision making (for biologic DMARDs only).

A Task Force Panel that critiqued and rated proposed recommendations included internationally recognized clinicians, methodologists, and patient representatives with broad expertise in the use of nonbiologic and biologic DMARDs, evidence-based medicine, patient preference, and healthcare economics.

Indications for starting or resuming a nonbiologic or biologic DMARD highlight the use of these agents on the background of optimal and appropriate use of nonmedical therapy such as physical and occupational therapy as well as the use of nonsteroidal anti-inflammatory drugs and intraarticular and oral glucocorticoids.

Biologic DMARDs should be used only after failure of nonbiologic DMARDs. Patients with RA should be seen regularly to evaluate disease activity and severity and to determine whether alternative therapies should be used.

The only nonbiologic agents included in these recommendations are hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine, and the only biologics included are abatacept, adalimumab, etanercept, infliximab, and rituximab. The remaining DMARDs were not included because of very infrequent use, the high incidence of adverse events, or both.

Nonbiologic DMARD combinations best supported by evidence and used most commonly are methotrexate plus hydroxychloroquine, methotrexate plus sulfasalazine, methotrexate plus leflunomide, sulfasalazine plus hydroxychloroquine, and sulfasalazine plus hydroxychloroquine followed by methotrexate.

Methotrexate or leflunomide monotherapy should be started for patients with all disease durations and for all degrees of disease activity irrespective of poor prognostic features.

Hydroxychloroquine monotherapy is recommended for patients without poor prognostic features, with low disease activity, and with disease duration not greater than 24 months.

Minocycline monotherapy is recommended for patients without poor prognostic features, with low disease activity, and with short disease duration.

Sulfasalazine monotherapy is recommended for patients with all disease durations and without poor prognostic features and includes those with all degrees of disease activity.

Methotrexate plus hydroxychloroquine is recommended for patients with moderate to high disease activity regardless of disease duration or poor prognostic features.

Methotrexate plus leflunomide is recommended for patients with intermediate or longer disease duration (≥ 6 months), with high disease activity irrespective of prognostic features.

Methotrexate plus sulfasalazine is recommended in patients with all disease durations provided they have high disease activity and poor prognostic features.

Hydroxychloroquine plus sulfasalazine is recommended only for patients with intermediate disease duration (6 - 24 months) and high disease activity but without poor prognostic features.

The triple DMARD combination of sulfasalazine, hydroxychloroquine, and methotrexate is recommended for all patients with poor prognostic features and moderate or high levels of disease activity, regardless of disease duration.

Recommendations for the use of biologic DMARDs are separated according to disease duration (<>

An anti-TNFα agent plus methotrexate is recommended for patients with high disease activity for 3 months or longer with poor prognosis and no barriers related to treatment cost and no insurance restrictions to accessing medical care.

In intermediate-duration and longer-duration RA, the anti-TNFα agents can be used interchangeably in patients with inadequate response to prior methotrexate monotherapy, moderate disease activity, and features of a poor prognosis as well as for patients with high disease activity, regardless of prognostic features.

Anti-TNFα agents can also be used interchangeably in patients with inadequate response and at least moderate residual disease activity after previous therapy with methotrexate in combination or with sequential administration of other nonbiologic DMARDs, regardless of prognostic features.

Contraindications to the use of nonbiologic and biologic DMARDs may include infectious disease or pneumonitis, or both; and hematologic, oncologic, cardiac, liver, renal, neurologic, and pregnancy and breast-feeding contraindications.

"Using a formal group process and the scientific evidence as much as possible, we provide recommendations for the use of nonbiologic and biologic therapies in patients with RA when starting or resuming these therapies," the guidelines authors conclude. "These recommendations are not meant to take the place of personalized patient care and are intended to help guide therapy rather than proscribe appropriate therapies. The recommendations are extensive but not comprehensive, and it is intended that they will be regularly updated to reflect the rapidly growing scientific evidence in this area along with changing practice patterns in rheumatology."

Dr. Saag's work was supported by the Agency for Healthcare Research and Quality, the University of Alabama, Birmingham Center for Education and Research on Therapeutics of Musculoskeletal Diseases, and the American College of Rheumatology. Four other guidelines authors have received support from the ACR, and one of these authors also was supported by the National Institutes of Health. Some of the guidelines authors have disclosed various financial relationships with Roche, UCB, Nitec, Amgen, Abbott, Centocor, Wyeth, Merck, Procter and Gamble, Eli Lilly, Novartis, Mathematica, Bristol-Myers Squibb, WellPoint, Genentech, Pfizer, Incyte, Hoffman-LaRoche, Actelion, Array, Biogenidec, Gilead, GlaxoSmith-Kline, Encysive, TAP, Xoma, Actelion, and Celgene.

Arthritis Care Res. 2008;59:762-784.

Clinical Context

The ACR has not updated its recommendations for the use of nonbiologic DMARDs since 2002 and has not previously developed recommendations for biologic agents. The use of biologic DMARDs has increased significantly recently. This is a systematic review of evidence for the use of both types of DMARDs by a panel of experts familiar with the assessment and treatment of RA and is intended to provide guidance to clinicians in the care of their patients with RA.

The investigators conducted a search of the literature for studies up to February 2007. Articles were selected based on quality, and the strength of evidence for 5 domains was assessed. The 5 domains examined were indications for use, screening for TB (biologic DMARDs only), adverse effects, clinical response, and cost and patient preferences. For nonbiologic agents, hydroxychloroquine, leflunomide, methotrexate, minocycline, and sulfasalazine were considered. For biologic agents, abatacept, adalimumab, etanercept, infliximab, and rituximab were considered. Other DMARDs were not considered because of a high incidence of adverse events or infrequent use and limited evidence. Disease activity was rated as low, moderate, or high, and disease duration was categorized as less than 6 months, 6 to 24 months, and more than 24 months.

Study Highlights

• Methotrexate or leflunomide is recommended as the initiating therapy for most patients with RA for all disease durations and all degrees of disease activity.
• For patients with moderate to high disease activity, the combination of methotrexate plus hydroxychloroquine is endorsed irrespective of disease duration or poor prognostic features.
• Triple DMARD therapy with methotrexate, hydroxychloroquine, and sulfasalazine is recommended for moderate to high disease activity irrespective of disease duration or poor prognostic features.
• For patients with early RA of 3 months' duration or less and high disease activity who have never received DMARDs, the anti-TNFα agents etanercept, infliximab, or adalimumab are recommended.
• For those with intermediate or longer duration of RA, the anti-TNFα agents etanercept, infliximab, or adalimumab are recommended for those with failed response to methotrexate.
• For those patients with at least moderate disease activity and poor prognosis in whom methotrexate combined with sequential administration of other nonbiologic DMARDs led to an inadequate response, the fusion protein abatacept and the B-cell antibody rituximab are recommended.
• DMARDs are contraindicated in those with a history of active or latent TB, severe upper respiratory tract infection, or nonhealing skin ulcers.
• Methotrexate is contraindicated in the presence of RA-associated pneumonitis or interstitial lung disease of unknown cause.
• Leflunomide and methotrexate are contraindicated with a history of myelodysplasia.
• For anti-TNFα agents, a history of lymphoproliferative disease within 5 years, multiple sclerosis or demyelinating disorders, and class III to IV heart failure are contraindication for use.
• For those considering biologic DMARDs, potential risk factors for TB should be assessed and a TB skin test conducted regardless of previous Bacillus Calmette-Guérin status.
• Those at high risk for TB such as the homeless or prison inmates are at higher risk for reactivation of latent TB with anti-TNFα agents.
• The preferred regimen for management of latent TB infection is 9 months of daily isoniazid.
• Therapy for TB should be initiated by clinician with expertise in TB management.
• Use of DMARDs is contraindicated in the presence of acute hepatitis B or C, and use of nonbiologic DMARDs in patients with chronic hepatitis B or C should be stratified according to hepatitis type, Child-Pugh grade, and use of antiviral agents.
• Elevation of liver transaminase levels of 2 times or higher is a contraindication to initiating or resuming therapy with methotrexate, leflunomide, and sulfasalazine.
• When starting or resuming a DMARD, baseline tests of complete blood count, liver transaminase, and creatinine levels are recommended.
• In those receiving methotrexate, leflunomide, or sulfasalazine, the test should be repeated every 2 to 4 weeks for 3 months for new treatment or dose escalation.
• Hepatitis B and C screening is recommended for high-risk patients.
• Influenza and pneumococcal vaccine status should be updated before starting therapy.
• Live vaccines are contraindicated during biologic therapy.
• Patients starting hydroxychloroquine should have a complete ophthalmologic examination within the first year of treatment with dilated pupils and central field testing, and the examination should be repeated annually for those in a high-risk category and in 5 years for those with low risk.
• Patients with RA planning for pregnancy should avoid methotrexate, leflunomide, and minocycline before and during pregnancy and breast-feeding.

Pearls for Practice

• Methotrexate or leflunomide is recommended as the initiating therapy for most patients with RA for all disease durations and all degrees of disease activity, with other regimens recommended for other levels of disease activity and response.
• Contraindications for DMARD use include a history of TB infection, lymphoproliferative disease, hepatitis B or C infection, pregnancy, and lactation.

Más información en :


http://www.medscape.com/viewarticle/575597

Management of Obesity in Adults: European Clinical Practice Guidelines 2008

Obesity is now recognized as the most prevalent metabolic disease world-wide, reaching epidemic proportions in both developed and developing countries and affecting not only adults but also children and adolescents. The WHO has already declared obesity a global epidemic that constitutes one of the biggest current health problems . In the European region, obesity also presents an unprecedented and underestimated public health challenge , with its prevalence rising rapidly and expected to include 150 million adults and 15 million children by 2010.

Overweight and obesity are responsible for about 80% of cases of type 2 diabetes, 35% of ischaemic heart disease and 55% of hypertensive disease among adults in Europe. They together cause more than 1 million deaths and 12 million lifeyears of ill health each year. It is estimated that one in 13 annual deaths in the EU is likely to be related to excess weight . The consequent economic implications and the burden on national health costs are quite substantial.

Despite steady progress in the management of obesity, its prevalence continues to rise, stressing the necessity for prevention and intervention strategies not only at the individual
but also at the communities and the population as a whole.


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http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=000126822&Ausgabe=237351&ProduktNr=233731&filename=000126822.pdf

Pediatric Obesity Guidelines Released 2008

IN LIGHT OF THE EVER-INCREASING prevalence of obesity in children, a task force formed by the Endocrine Society—an organization devoted to research on hormones and the clinical practice of endocrinology—has issued new clinical practice guidelines to help clinicians focus on prevention and early intervention in children—a strategy they hope will also help stem the rising tide of obesity in adults. “In kids 6 to 11 years old, obesity has increased 4-fold since 1970, and childhood obesity is a good predictor of adult obesity,” said Gilbert August, MD, professor emeritus of pediatrics at the George Washington University School of Medicine in Washington, DC. August was chair of the task force that developed the guidelines on pediatric obesity (available at http://jcem .endojournals.org/cgi/rapidpdf/jc .2007-2458v1). The document offers
specific criteria for defining overweight and obesity in children and outlines strategies for averting and treating these conditions. “My impression is that physicians feel quite powerless to help obese children and families, so this guidance will be welcome,” said Marlene Schwartz, PhD,
deputy director for the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Conn, who was not involved with drafting the guidelines. Other similar guidelines have also been published by organizations such as the American Academy of Pediatrics (http://www.aap.org/obesity/PolicyandGuidelines.htm).
Standards for preventing and treating pediatric overweight and obesity are important for safeguarding both the health of children today and the health of adults in the future, said August.
Children who are overweight or obese have an increased risk for developing a number of conditions, most notably dyslipidemia, type 2 diabetes, and psychosocial issues.


Más información : copie e procure este link

http://jcem.endojournals.org/cgi/rapidpdf/jc.2007-2458v1

Thyroid function disorders - Guidelines of the Netherlands Association of Internal Medicine 2008

Thyroid function disorders are common with a female to male ratio of 4 to 1. In adult women primary hypothyroidism and thyrotoxicosis have a prevalence of 3.5/1000 and 0.8/1000, respectively. This guideline is aimed at secondary care providers especially internists, but also contains relevant information for interested general practitioners and gynaecologists.
A multidisciplinary working group, containing delegates of professional and patient organisations, prepared the guideline. According to principles of ‘evidence-based medicine’ available literature was studied and discussed. Considering the availability and quality of published studies a practical advice was formulated. For a full overview of the literature and considerations the reader is referred to the original version of the guideline (accessible through NIV-net). In this manuscript we have aimed to provide the practicing internist with practical and ‘as evidence-based as possible treatment guidelines with respect to thyroid function
disorders.

Más informacíon accesando en este link .


http://www.njmonline.nl/njm/getpdf.php?t=a&id=10000296

Diagnóstico y clasificación de la Diabetes Mellitus 2008

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.

Several pathogenic processes are involved in the development of diabetes. These range from autoimmune destruction of the β-cells of the pancreas with consequent insulin deficiency to abnormalities that result in resistance to insulin action. The basis of the abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient action of insulin on target tissues. Deficient insulin action results from inadequate insulin secretion and/or diminished tissue responses to insulin at one or more points in the complex pathways of hormone action. Impairment of insulin secretion and defects in insulin action frequently coexist in the same patient, and it is often unclear which abnormality, if either alone, is the primary cause of the hyperglycemia.

Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision. Impairment of growth and susceptibility to certain infections may also accompany chronic hyperglycemia. Acute, life-threatening consequences of uncontrolled diabetes are hyperglycemia with ketoacidosis or the nonketotic hyperosmolar syndrome.

Long-term complications of diabetes include retinopathy with potential loss of vision; nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot joints; and autonomic neuropathy causing gastrointestinal, genitourinary, and cardiovascular symptoms and sexual dysfunction. Patients with diabetes have an increased incidence of atherosclerotic cardiovascular, peripheral arterial, and cerebrovascular disease. Hypertension and abnormalities of lipoprotein metabolism are often found in people with diabetes.

The vast majority of cases of diabetes fall into two broad etiopathogenetic categories (discussed in greater detail below). In one category, type 1 diabetes, the cause is an absolute deficiency of insulin secretion. Individuals at increased risk of developing this type of diabetes can often be identified by serological evidence of an autoimmune pathologic process occurring in the pancreatic islets and by genetic markers. In the other, much more prevalent category, type 2 diabetes, the cause is a combination of resistance to insulin action and an inadequate compensatory insulin secretory response. In the latter category, a degree of hyperglycemia sufficient to cause pathologic and functional changes in various target tissues, but without clinical symptoms, may be present for a long period of time before diabetes is detected. During this asymptomatic period, it is possible to demonstrate an abnormality in carbohydrate metabolism by measurement of plasma glucose in the fasting state or after a challenge with an oral glucose load.

The degree of hyperglycemia (if any) may change over time, depending on the extent of the underlying disease process. A disease process may be present but may not have progressed far enough to cause hyperglycemia. The same disease process can cause impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) without fulfilling the criteria for the diagnosis of diabetes. In some individuals with diabetes, adequate glycemic control can be achieved with weight reduction, exercise, and/or oral glucose-lowering agents. These individuals therefore do not require insulin. Other individuals who have some residual insulin secretion but require exogenous insulin for adequate glycemic control can survive without it. Individuals with extensive β-cell destruction and therefore no residual insulin secretion require insulin for survival. The severity of the metabolic abnormality can progress, regress, or stay the same. Thus, the degree of hyperglycemia reflects the severity of the underlying metabolic process and its treatment more than the nature of the process itself.

Más información: Observar que es un artículo pago para tenerlo en pdf pero aqui en esta dirección lo puedes leer completo en la pagina web de la revista .


http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S55

Guide to management of hypertension 2008

Higher levels of blood pressure (BP) are strongly associated with increasing rates of cardiovascular disease, cardiovascular events and death. Observational studies show that the lower the BP, the lower the risk of stroke, coronary heart disease, chronic kidney disease (CKD), heart failure and death. This relationship applies across whole range of BP levels usually encountered in clinical practice. Systolic BP is a stronger and more consistent predictor of cardiovascular events such as stroke than diastolic BP. Among patients with hypertension, lowering BP reduces cardiovascular risk. Hypertension is responsible for more deaths and disease than any other biomedical risk factor worldwide. It is the major risk factor for stroke and coronary heart disease, and is a major contributor to chronic heart failure (CHF), CKD, and their progression.7 The total burden of cardiovascular disease, particularly CHF, is expected to increase over the next few decades due to population ageing. The dividing line between normotension and hypertension is arbitrary, and the decision to intervene depends on the individual’s overall cardiovascular risk profile and the presence or absence of end-organ damage. Antihypertensive drug treatment and lower targets are recommended for all patients with Psensitive conditions (e.g. stroke,* diabetes10 or CKD11) even if initial BP is within the ‘normal’ range.


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http://www.heartfoundation.org.au/document/NHF/A_Hypert_Guidelines2008_Guideline_FINAL.pdf

Revisión de hora límites de trabajo - recomendaciones da OIM para la Seguridad del Paciente y la educación del Residente

On December 2, about 5 years after the Accreditation Council for Graduate Medical Education (ACGME) imposed national limits on the duty hours of medical residents, the Institute of Medicine
(IOM) issued a report recommending that further measures be taken to ensure that hospitals provide safer conditions for patients and trainees while maintaining rigorous teaching programs.


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http://content.nejm.org/cgi/reprint/NEJMp0808736v1.pdf