Zusammenfassung
Hintergrund
Glukokortikoide sind von erheblicher therapeutischer Bedeutung bei der Behandlung entzündlicher Erkrankungen, jedoch insbesondere bei langfristiger Anwendung mit ...Knochenmineraldichteverlust, Osteoporose und Frakturen assoziiert.
Ziel dieser Arbeit
Es sollten Empfehlungen zum Management der Glukokortikoid-induzierten Osteoporose (GIOP) bei erwachsenen Patienten unter Langzeit-Glukokortikoid(GC)-Therapie entwickelt werden.
Methodik
Es wurde eine systematische Literatursuche (SLR) durchgeführt, um die Evidenz für Präventions- und Behandlungsoptionen der GIOP zusammenzufassen. Mithilfe zuvor definierter Fragestellungen wurden, basierend auf SLR und dem Evidenzgrad, Empfehlungen in einem strukturierten Gruppenkonsensprozess erarbeitet.
Ergebnisse
Die Empfehlungen umfassen zunächst die Supplementation mit Kalzium und Vitamin D bei Erwachsenen unter Langzeit-GC-Therapie. Wenn eine spezifische osteologische Therapie angezeigt ist, empfehlen wir als Erstlinientherapie Bisphosphonate oder Denosumab. Bei hohem Frakturrisiko empfehlen wir Teriparatid als primäre spezifische osteologische Therapie. Bei hochgradiger Niereninsuffizienz soll Denosumab (nach Ausschluss renaler Osteopathie) eingesetzt werden und bei Schwangerschaft keine spezifische osteologische Therapie erfolgen. Für Patienten, die das Therapieziel nicht erreicht haben, sollte die Umstellung auf eine andere Klasse spezifischer osteologischer Medikamente erfolgen. Wir empfehlen eine Reevaluation nach einer Therapiedauer von 3 bis 5 Jahren oder nach Beendigung der Langzeit-GC-Therapie.
Fazit
Diese Arbeit soll evidenz- und konsensbasierte Empfehlungen für ein bestmögliches Management der GIOP in Deutschland geben und bei Behandlungsentscheidungen unterstützen.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Zusammenfassung
Hintergrund
Vor operativen Eingriffen stellt sich Ärzten und Patienten mit entzündlich rheumatischen Erkrankungen weiterhin die Frage nach einer Unterbrechung oder Fortsetzung der ...entzündungshemmenden Medikation. Die Deutsche Gesellschaft für Rheumatologie hat hierfür ihre Empfehlungen von 2014 aktualisiert.
Methoden
Nach einer systematischen Literaturrecherche mit Einschluss von Publikationen bis zum 31.08.2021 wurden die Empfehlungen zum Umgang mit Glukokortikoiden, konventionell synthetischen „disease-modifying antirheumatic drugs“ (csDMARDs) und Biologika (bDMARDs) überarbeitet und Empfehlungen zu neueren Substanzen und „targeted synthetic (ts) DMARDs“ ergänzt.
Ergebnisse
Die Glukokortikoiddosis sollte 2 bis 3 Monate vor elektiven Eingriffen so niedrig wie möglich reduziert (in jedem Fall <10 mg/Tag), 1 bis 2 Wochen vor und am Operationstag jedoch stabil gehalten werden. csDMARDs können in vielen Fällen fortgeführt werden, Ausnahmen sind eine Reduktion hoher Methotrexat-Dosierungen auf ≤15 mg/Woche und Auswaschen des Leflunomid bei hohem Infektionsrisiko. Azathioprin, Mycophenolat und Ciclosporin sollten 1 bis 2 Tage vor der Operation pausiert werden. Unter bDMARDs können Operationen zum Ende des jeweiligen Therapieintervalls geplant werden. Januskinase(JAK)-Inhibitoren sollten bei größeren Eingriffen für 3 bis 4 Tage pausiert werden. Apremilast kann fortgeführt werden. Bei notwendiger Unterbrechung gilt für alle Substanzen, die Therapie in Abhängigkeit der Wundheilung baldmöglichst wieder zu beginnen.
Schlussfolgerungen
Ob bDMARDs das Infektionsrisiko perioperativ erhöhen und welche Rolle die Absetzzeit dabei spielt, bleibt bei gegenwärtiger Evidenz noch unklar. Um das Risiko eines Krankheitsschubs unter längerer Therapiepause zu minimieren, wurde in den aktualisierten Empfehlungen die perioperative Pausierung von bDMARDs von mindestens 2 Halbwertszeiten auf ein Therapieintervall reduziert.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The differential diagnosis of inflammatory arthritis as an immune-related adverse event can be challenging as patients with cancer can present with musculoskeletal symptoms that can mimic arthritis ...because of localized or generalized joint pain. In addition, immune checkpoint inhibitors can exacerbate joint conditions such as crystal-induced arthritis or osteoarthritis, or induce systemic disease that can affect the joints such as sarcoidosis. This distinction is important as the treatment of these conditions can be different from that of immune-related inflammatory arthritis.
Background
Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this ...reason, the German Society for Rheumatology has updated its recommendations from 2014.
Methods
After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.
Results
The glucocorticoid dose should be reduced to as low as possible 2–3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1–2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1–2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3–4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.
Conclusion
Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
T cells, in particular CD4+ T cells, have been implicated in mediating many aspects of autoimmune inflammation. However, current evidence suggests that the role played by CD4+ T cells in the ...development of rheumatoid inflammation exceeds that of activated proinflammatory T-helper (Th)1 effector cells that drive the chronic autoimmune response. Subsets of CD4+ T cells with regulatory capacity, such as CD25+ regulatory T (Treg) cells and Th2 cells, have been identified, and recent observations suggest that in rheumatoid arthritis the function of these regulatory T cells is severely impaired. Thus, in rheumatoid arthritis, defective regulatory mechanisms might allow the breakdown of peripheral tolerance, after which the detrimental Th1-driven immune response evolves and proceeds to chronic inflammation. Here, we review the functional abnormalities and the contribution of different T cell subsets to rheumatoid inflammation.
•Few apps fulfill legal standards for patient usage.•“Rheuma-Auszeit” was the highest-rated app for patients with psoriatic arthritis.•Patients rated the app slightly lower than healthcare ...professionals.•Star ratings are not significantly correlated to MARS ratings.
Psoriatic arthritis (PsA) is a chronic musculoskeletal disease. Functional limitations result in significant patient burden. The use of smartphone apps to complement medical treatments could increase patients’ adherence resulting in better clinical outcome and consequently increased quality of life.
This study aimed to assess and compare currently available smartphone apps for PsA patients using a standardized rating scale.
We conducted a systematic screening of apps for PsA patients in German App Stores and selected apps meeting inclusion criteria: availability in both app stores, German or English language, relevant for patients with psoriatic arthritis, not developed for congress use or clinical studies, no fee-based apps. Three reviewers evaluated apps using the Mobile Application Rating Scale (MARS). Analysis included technical features and mean scores as well as interrater agreement and linear regression. The best-rated app was then rated by PsA patients.
Among 232 screened apps, 8 met all inclusion criteria. The app “Rheuma-Auszeit” scored highest with a healthcare provider MARS rating of 4.4 and a patient userMARS rating of 3.7. Subjective quality was lower for all apps. App store star ratings and MARS ratings were not significantly correlated (P=0.34). No app was Conformité Européenne (CE) certified and no underlying clinical studies were found.
App quality was heterogenous and generally low. Star ratings – the only accessible tool for patients – does not suffice to identify high-quality apps. We suggest involving patients in development of apps. Since patients and physicians have different perceptions of app quality, we recommend a joint development and evaluation process.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To study the role of interleukin 22 (IL-22) in rheumatoid arthritis (RA).
IL-22 serum levels were measured in patients with early, treatment-naive RA (n=49) and in 45 age- and sex-matched healthy ...individuals as controls. Patients were assessed clinically and radiographically at baseline and followed up for 2 years. Correlations of IL-22 serum levels were sought with parameters of disease activity, serological markers, demographic factors and the incidence of erosions. IL-22 production by peripheral blood T cells was investigated by intracellular flow cytometry.
24 of 49 patients with RA demonstrated elevated IL-22 levels compared with the range of healthy controls. At baseline, a high percentage of these patients (8/24, 33%) demonstrated bone erosions, whereas only one patient (4%) from the group with normal IL-22 had erosions. During the 2 years of follow-up, six additional patients with increased IL-22 at baseline developed erosions. In contrast, none of the patients in whom IL-22 levels were normal developed erosions despite similar treatment regimens. Multivariate regression analysis accounting for other parameters predictive for erosions, such as the presence of rheumatoid factor or anti-cyclic citrullinated peptide antibodies and disease activity, showed that elevated IL-22 baseline levels were independently and significantly associated with erosive RA. Cellular analysis demonstrated enhanced expression of IL-22 from CD4 T cells in RA.
IL-22 is elevated in the serum of half of the patients with RA. Elevated serum IL-22 allows discrimination between patients with different radiographic progression and indicates a possible involvement of IL-22 in the pathophysiology of RA.
Endothelial dysfunction precedes atherosclerosis and smoking is a well-known risk factor for the development of endothelial dysfunction. The aim of our study was to analyse the effect of smoking on ...circulating markers of endothelial function and to investigate whether such effects have an influence on the potential use of these markers to estimate cardiovascular risk.
Stratified for smoking, levels of sE-/sP-/sL-selectin, von Willebrand (vWF), sICAM-1 and sVCAM-1, their association with mortality using Cox regression, and their accuracy of risk prediction using area-under-the-ROC-curve and net-reclassification-index were analysed in 1926 participants from the Ludwigshafen Risk and Cardiovascular Health (LURIC) – a prospective case-control study in patients who underwent coronary angiography with a median mortality follow-up of 10.6 years.
In smokers, higher concentrations of sICAM-1, sE-selectin sP-selectin, but lower concentrations of sL-selectin and sVCAM-1, were detected compared to never-smokers. A direct association with mortality was found for levels of sICAM-1, sVCAM-1 and vWF regardless of smoking. Low sL-selectin levels were inversely associated with mortality in heavy and light smokers, with hazard ratios of 0.72 and 0.67 per 1-SD increase, adjusted for cardiovascular risk factors. Adding sL-selectin to a model based on traditional risk factors significantly improved AUC from 0.725 to 0.752 (p = 0.034) with an NRI of 43% (16.9%–62.3%).
Smoking alters the concentration of circulating markers of endothelial function. sL-selectin is decreased in smokers, inversely associated with risk, and could be a useful marker to improve risk prediction.
Display omitted
•Smokers exhibited higher concentrations of sICAM-1, sE-selectin, sP-selectin.•Smokers exhibited lower concentrations of sL-selectin and sVCAM-1.•sL-selectin was reduced even after 20 years of smoking abstinence.•sL-selectin was inversely associated with mortality in active smokers.•sL-selectin significantly improved risk prediction in smokers.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, SAZU, SBCE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Zusammenfassung
Hintergrund
Chronisch entzündliche Erkrankungen („immune-mediated inflammatory diseases“ IMID) können aufgrund klinischer Gemeinsamkeiten überlappen oder gleichzeitig auftreten. Die ...daraus resultierende Inanspruchnahme von Versorgungsstrukturen wurde bisher nicht fachübergreifend untersucht, ist aber für eine optimierte Behandlung der Patienten mit IMID potenziell von Bedeutung.
Ziel der Arbeit
Analyse epidemiologischer Daten einschließlich Inanspruchnahme von Versorgungsleistungen bei Patienten mit ausgewählten IMID: Psoriasis, Psoriasisarthritis (PsA), rheumatoide Arthritis (RA), Spondylitis ankylosans, Colitis ulcerosa, Morbus Crohn und Kollagenosen.
Material und Methoden
In einer retrospektiven Querschnittanalyse, basierend auf Abrechnungsdaten der gesetzlichen Krankenversicherung (GKV) mit einer Stichprobe von ca. 4 Mio. Versicherten, wurden die Prävalenz o. g. IMID und die Häufigkeit von IMID-Kombinationen anhand dokumentierter Diagnosen (ICD-10 GM) analysiert. Die Häufigkeit von Hospitalisierungen und Inanspruchnahmen ambulanter Arztkontakte wurde in vordefinierten Fachdisziplinen (Allgemeinmedizin, Dermatologie, Gastroenterologie, Rheumatologie) erfasst und mit einer alters- und geschlechtsadjustierten Referenzpopulation verglichen.
Ergebnisse
Insgesamt wiesen 188.440 Patienten mindestens eine der analysierten IMID-Diagnosen auf (4,7 %), mit einem Altersgipfel von 61 bis 70Jahren. Die höchste Prävalenz wurde für die Psoriasis (1,85 %), gefolgt von der rheumatoiden Arthritis (1,38 %) gesehen. Kombinationen mit mindestens einer weiteren IMID kamen insgesamt relativ häufig vor (29 %), wobei dies bei Patienten mit Psoriasisarthritis am häufigsten zu verzeichnen war (82,9 %, wobei hiervon 68,2 % Psoriasis), gefolgt von Spondylitis ankylosans (27,5 %) und Morbus Crohn (21,6 %). Patienten mit IMID wurden im Vergleich zur Referenzpopulation häufiger hospitalisiert und wiesen häufigere Inanspruchnahmen der betrachteten ambulanten Fachdisziplinen auf.
Diskussion
Die Studienergebnisse beschreiben, dass IMIDs gehäuft koexistieren und die Patienten Versorgungsstrukturen verschiedener Fachgebiete vergleichsweise mehr in Anspruch nehmen. Ein multidisziplinärer Ansatz könnte die Effizienz der Versorgung steigern, eine Evaluierung steht aus.
Abstract
Background
Chronic inflammatory diseases (immune-mediated inflammatory diseases, IMID) can overlap or occur simultaneously due to clinical similarities. The resulting utilization of heathcare structures has not yet been investigated across disciplines but is of potential importance for optimizing the treatment of patients with IMID.
Aim of the work
Analysis of epidemiological data including utilization of care services in patients with selected IMIDs: psoriasis, psoriatic arthritis (PsA), rheumatoid arthritis (RA), ankylosing spondylitis, ulcerative colitis, Crohn’s disease and connective tissue disease.
Material and methods
In a retrospective cross-sectional analysis based on health insurances accounting data with a sample of approximately 4 million insured persons, the prevalence of the abovementioned IMID and the frequency of IMID combinations were analyzed based on documented diagnoses (ICD-10 GM). The frequency of hospitalizations and utilization of outpatient physician contacts was recorded in predefined specialist disciplines (general medicine, dermatology, gastroenterology, rheumatology) and compared with an age-adjusted and gender-adjusted reference population.
Results
A total of 188,440 patients had at least 1 of the IMID diagnoses analyzed (4.7%), with an age peak of 61–70 years. The highest prevalence was observed for psoriasis (1.85%), followed by rheumatoid arthritis (1.38%). Combinations with at least one other IMID were relatively common (29%), with this being most common in patients with psoriatic arthritis (82.9%, of which 68.2% had psoriasis), followed by ankylosing spondylitis (27.5%) and Crohn’s disease (21.6%). Compared to the reference population, patients with IMID were hospitalized more often and more frequently utilized the outpatient disciplines.
Discussion
The study results describe that IMIDs occur in combination and that the patients make comparatively more use of care structures of different disciplines. A multidisciplinary approach could increase the efficiency of care; an evaluation is still pending.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
PDF
