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        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the differences in the clinical and therapeutic management of early and established rheumatoid arthritis &#40;RA&#41; in clinical practice&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective and multicentre study including 360 patients diagnosed with RA&#46; During the 12 months prior to the study&#44; onset&#44; sociodemographic&#44; clinical and therapeutic data were collected by clinical chart review&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 152 patients with early RA and 208 with established RA were studied&#46; 97&#46;5&#37; had received disease-modifying anti-rheumatic drugs &#40;DMARDs&#41; and 43&#46;6&#37; a TNFa blocker between the diagnosis and the start of the study&#46; Established RA patients used TNFa blockers more frequently than early RA patients &#40;60&#46;1&#37; vs 21&#46;1&#37;&#44; P<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>001&#41;&#46; Methotrexate was the most commonly used drug &#40;70&#46;6&#37;&#41;&#46; A treatment change was seen in 79&#37; of patients with early RA and 60&#46;6&#37; of those with established RA&#46; A dose change was the most frequent modification and an inadequate response the most frequent reason&#46; A 25&#46;8&#37; of treatments were stopped due to adverse events&#46; The mean &#40;SD&#41; decrease on DAS28 score was 0&#46;9 &#40;1&#46;5&#41; on early RA and 0&#46;2 &#40;1&#46;0&#41; on established RA patients&#46; A 35&#46;8&#37; of early RA patients showed a good EULAR response&#44; while only 16&#46;2&#37; among established RA patients &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;&#46;001&#41;&#46; Rheumatoid factor and radiological progression assessment were the most requested determinations in early RA &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;&#46;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Spanish rheumatologists used biological drugs with a higher frequency in patients with more advanced disease&#44; as recommended in the main clinical practice guidelines&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar las diferencias en el manejo cl&#237;nico y terap&#233;utico de la artritis reumatoide &#40;AR&#41; precoz y establecida en la pr&#225;ctica cl&#237;nica&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo y multic&#233;ntrico en el que se incluy&#243; a 360 pacientes con diagn&#243;stico de AR&#46; Mediante la revisi&#243;n de historias cl&#237;nicas se recogieron variables sociodemogr&#225;ficas&#44; cl&#237;nicas y terap&#233;uticas en los 12 meses previos al inicio del estudio&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se estudi&#243; a 152 pacientes con AR precoz &#40;ARp&#41; y 208 con AR establecida &#40;ARe&#41;&#46; El 97&#44;5&#37; hab&#237;a recibido f&#225;rmacos modificadores de enfermedad &#40;FAME&#41; y el 43&#44;6&#37; tratamiento anti-factor de necrosis tumoral &#40;TNF&#41; entre el diagn&#243;stico y el inicio del estudio&#46; Los anti-TNF fueron utilizados con mayor frecuencia en pacientes con ARe &#40;el 60&#44;1 frente al 21&#44;1&#37;&#59; p &#60; 0&#44;001&#41;&#46; El metotrexato fue el f&#225;rmaco m&#225;s utilizado &#40;70&#44;6&#37;&#41;&#46; Se detect&#243; cambio del tratamiento en un 79&#37; de pacientes con ARp y en el 60&#44;6&#37; con ARe&#46; El cambio de dosis fue la modificaci&#243;n m&#225;s frecuente y una respuesta inadecuada el motivo m&#225;s frecuente&#46; El 25&#44;8&#37; de los tratamientos se suspendieron por reacciones adversas&#46; La disminuci&#243;n media &#177; desviaci&#243;n est&#225;ndar del DAS28 fue 0&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;5 en ARp y 0&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;0 en ARe&#46; El 35&#44;8&#37; de las ARp present&#243; buena respuesta EULAR&#44; mientras s&#243;lo el 16&#44;2&#37; de las ARe &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La determinaci&#243;n del factor reumatoide y la valoraci&#243;n de la progresi&#243;n radiol&#243;gica fueron m&#225;s solicitadas en la ARp &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los reumat&#243;logos espa&#241;oles utilizaron agentes biol&#243;gicos con mayor frecuencia en los pacientes con enfermedad m&#225;s evolucionada&#44; ajust&#225;ndose a las recomendaciones de las principales gu&#237;as de pr&#225;ctica cl&#237;nica&#46;</p>"
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                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2003"
                        "volumen" => "49"
                        "paginaInicial" => "64"
                        "paginaFinal" => "70"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12579595"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prevalence and burden of arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46;Y&#46; Reginster"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rheumatology &#40;Oxford&#41;"
                        "fecha" => "2002"
                        "volumen" => "41"
                        "numero" => "Suppl 1"
                        "paginaInicial" => "3"
                        "paginaFinal" => "6"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Costes asociados a la artritis reumatoide"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Dom&#237;nguez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Econ Salud"
                        "fecha" => "2003"
                        "volumen" => "2"
                        "paginaInicial" => "212"
                        "paginaFinal" => "217"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Marzo de 2007 &#91;accessed 2010 Jun 8&#93;&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.ser.es/practicaClinica/GUIPCAR_2007/Metodologia/Menu1_MetodolMeto.php">http&#58;&#47;&#47;www&#46;ser&#46;es&#47;practicaClinica&#47;GUIPCAR&#95;2007&#47;Metodologia&#47;Menu1&#95;MetodolMeto&#46;php</a>&#46;"
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do anti-TNF agents have equal efficacy in patients with rheumatoid arthritis&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Schwartzman"
                            1 => "R&#46; Fleischmann"
                            2 => "J&#46; Morgan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/ar1013"
                      "Revista" => array:7 [
                        "tituloSerie" => "Arthritis Res Ther"
                        "fecha" => "2004"
                        "volumen" => "6"
                        "numero" => "Suppl 2"
                        "paginaInicial" => "S3"
                        "paginaFinal" => "S11"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15228615"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the management of rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "American College of Rheumatology subcommittee on rheumatoid arthritis guidelines"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2002"
                        "volumen" => "46"
                        "paginaInicial" => "328"
                        "paginaFinal" => "346"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11840435"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Actualizaci&#243;n del Documento de Consenso de la Sociedad Espa&#241;ola de Reumatolog&#237;a sobre el uso de terapias biol&#243;gicas en la artritis reumatoide"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Tornero Molina"
                            1 => "R&#46; Sanmart&#237; Sala"
                            2 => "V&#46; Rodr&#237;guez Valverde"
                            3 => "E&#46; Mart&#237;n Mola"
                            4 => "J&#46;L&#46; Marenco de la Fuente"
                            5 => "I&#46; Gonz&#225;lez &#193;lvaro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.reuma.2009.10.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Reumatol Clin"
                        "fecha" => "2010"
                        "volumen" => "6"
                        "paginaInicial" => "23"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794674"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis Comparison with the preliminary American College of Rheumatology and the World Health Organization&#47;International League Against Rheumatism Criteria"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46;M&#46; Van Gestel"
                            1 => "M&#46;L&#46; Prevoo"
                            2 => "M&#46;A&#46; Van&#8217;t Hof"
                            3 => "M&#46;H&#46; Van Rijswijk"
                            4 => "L&#46;B&#46; Van de Putte"
                            5 => "P&#46;L&#46; Van Riel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1996"
                        "volumen" => "39"
                        "paginaInicial" => "34"
                        "paginaFinal" => "40"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8546736"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Guidance on the use of etanercept and infliximab for the treatment of rheumatoid arthritis&#46; National Institute for Clinical Excellence&#46; Technology appraisal guidance No&#46; 36 &#91;accessed 2010 Jun 8&#93;&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.nice.org.uk./">www&#46;nice&#46;org&#46;uk</a>"
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intensive treatment with methotrexate in early rheumatoid arthritis&#58; aiming for remission&#46; Computer Assisted Management in Early Rheumatoid Arthritis &#40;CAMERA&#44; an open-label strategy trial&#41;"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "on behalf of the Utrecht Rheumatoid Arthritis Cohort Study group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;M&#46; Verstappen"
                            1 => "J&#46;W&#46; Jacobs"
                            2 => "M&#46;J&#46; Van der Veen"
                            3 => "A&#46;H&#46; Heurkens"
                            4 => "Y&#46; Schenk"
                            5 => "E&#46;J&#46; Ter Borg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/ard.2007.071092"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2007"
                        "volumen" => "66"
                        "paginaInicial" => "1443"
                        "paginaFinal" => "1449"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17519278"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A review of controlled clinical trials examining the effects of antimalarial compounds and gold compounds on radiographic progression in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46; Sanders"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "2000"
                        "volumen" => "27"
                        "paginaInicial" => "523"
                        "paginaFinal" => "529"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10685827"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Ten Wolde"
                            1 => "F&#46;C&#46; Breedveld"
                            2 => "J&#46; Hermans"
                            3 => "J&#46;P&#46; Vandenbroucke"
                            4 => "M&#46;A&#46; Van de Laar"
                            5 => "H&#46;M&#46; Markusse"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1996"
                        "volumen" => "347"
                        "paginaInicial" => "347"
                        "paginaFinal" => "352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8598699"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biological agents for rheumatoid arthritis&#58; targeting both physical function and structural damage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Klinkhoff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Drugs"
                        "fecha" => "2004"
                        "volumen" => "64"
                        "paginaInicial" => "1267"
                        "paginaFinal" => "1283"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15200343"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Updated consensus statement on biological agents for the treatment of rheumatic diseases&#44; 2009"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;E&#46; Furst"
                            1 => "E&#46;C&#46; Keystone"
                            2 => "R&#46; Fleischmann"
                            3 => "P&#46; Mease"
                            4 => "F&#46;C&#46; Breedveld"
                            5 => "J&#46;S&#46; Smolen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/ard.2009.123885"
                      "Revista" => array:7 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2010"
                        "volumen" => "69"
                        "numero" => "Suppl&#46;I"
                        "paginaInicial" => "i2"
                        "paginaFinal" => "i29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19995740"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update on the British Society for Rheumatology guidelines for prescribing TNFa blockers in adults with rheumatoid arthritis &#40;update of previous guidelines of April 2001&#41;"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "on behalf of the British Society for Rheumatology Standards&#44; Guidelines and Audit Working Group &#40;SGAWG&#41;"
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Ledingham"
                            1 => "C&#46; Deighton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rheumatology &#40;Oxford&#41;"
                        "fecha" => "2005"
                        "volumen" => "44"
                        "paginaInicial" => "157"
                        "paginaFinal" => "163"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Utilization trends of tumor necrosis factor inhibitors among patients with rheumatoid arthritis in a United States observational cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46;J&#46; Lee"
                            1 => "H&#46; Chang"
                            2 => "Y&#46; Yazici"
                            3 => "J&#46;D&#46; Greenberg"
                            4 => "J&#46;M&#46; Kremer"
                            5 => "A&#46; Kavanaugh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3899/jrheum.080889"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "2009"
                        "volumen" => "36"
                        "paginaInicial" => "1611"
                        "paginaFinal" => "1617"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19369454"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of a disease activity score based on judgement in clinical practice by rheumatologists"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;M&#46; Van der Heijde"
                            1 => "M&#46; Van&#8217;t Hof"
                            2 => "P&#46;L&#46; Van Riel"
                            3 => "L&#46;B&#46; Van der Puttle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "1993"
                        "volumen" => "20"
                        "paginaInicial" => "579"
                        "paginaFinal" => "581"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8478878"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tumor necrosis factor inhibitors for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;L&#46; Scott"
                            1 => "G&#46;H&#46; Kingsley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMct055183"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2006"
                        "volumen" => "355"
                        "paginaInicial" => "704"
                        "paginaFinal" => "712"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16914706"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biological therapy in early arthritis &#8211; overtreatment or the way to go&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46; Ikeda"
                            1 => "S&#46; Cox"
                            2 => "P&#46; Emery"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/ar2177"
                      "Revista" => array:7 [
                        "tituloSerie" => "Arthritis Res Ther"
                        "fecha" => "2007"
                        "volumen" => "9"
                        "paginaInicial" => "211"
                        "paginaFinal" => "217"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17540047"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0016508510008784"
                          "estado" => "S300"
                          "issn" => "00165085"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active&#44; early&#44; moderate to severe rheumatoid arthritis &#40;COMET&#41;&#58; a randomised&#44; double-blind&#44; parallel treatment trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Emery"
                            1 => "F&#46;C&#46; Breedveld"
                            2 => "S&#46; Hall"
                            3 => "P&#46; Durez"
                            4 => "D&#46;J&#46; Chang"
                            5 => "D&#46; Robertson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(08)61000-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2008"
                        "volumen" => "372"
                        "paginaInicial" => "375"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18635256"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical remission and inhibition of radiographic progression with combination etanercept-methotrexate therapy versus monotherapy in active&#44; early rheumatoid arthritis&#58; 2-year results from the COMET trial"
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Journal Information
Vol. 7. Issue 3.
Pages 172-178 (May - June 2011)
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Vol. 7. Issue 3.
Pages 172-178 (May - June 2011)
Original article
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Differences in the management of early and established rheumatoid arthritis
Diferencias en el manejo de la artritis reumatoide precoz y establecida
Visits
5753
Santos Castañedaa,
Corresponding author
scastas@gmail.com

Corresponding author.
, Federico Navarrob, Cristina Fernández-Carballidoc, Carmelo Tornerod, Elena Marcede, Montserrat Cortegueraf
a Servicio de Reumatología, Hospital Universitario de la Princesa, Madrid, Spain
b Servicio de Reumatología, Hospital Virgen de la Macarena, Sevilla, Spain
c Servicio de Reumatología, Hospital de Elda, Alicante, Spain
d Servicio de Reumatología, Hospital Morales Meseguer, Murcia, Spain
e Departamento Médico, Wyeth Farma, Madrid, Spain
f Servicio de Reumatología, Hospital Nuestra Señora de Sonsoles, Ávila, Spain
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Abstract
Objective

To assess the differences in the clinical and therapeutic management of early and established rheumatoid arthritis (RA) in clinical practice.

Methods

Retrospective and multicentre study including 360 patients diagnosed with RA. During the 12 months prior to the study, onset, sociodemographic, clinical and therapeutic data were collected by clinical chart review.

Results

A total of 152 patients with early RA and 208 with established RA were studied. 97.5% had received disease-modifying anti-rheumatic drugs (DMARDs) and 43.6% a TNFa blocker between the diagnosis and the start of the study. Established RA patients used TNFa blockers more frequently than early RA patients (60.1% vs 21.1%, P<001). Methotrexate was the most commonly used drug (70.6%). A treatment change was seen in 79% of patients with early RA and 60.6% of those with established RA. A dose change was the most frequent modification and an inadequate response the most frequent reason. A 25.8% of treatments were stopped due to adverse events. The mean (SD) decrease on DAS28 score was 0.9 (1.5) on early RA and 0.2 (1.0) on established RA patients. A 35.8% of early RA patients showed a good EULAR response, while only 16.2% among established RA patients (P<.001). Rheumatoid factor and radiological progression assessment were the most requested determinations in early RA (P<.05).

Conclusions

Spanish rheumatologists used biological drugs with a higher frequency in patients with more advanced disease, as recommended in the main clinical practice guidelines.

Keywords:
Rheumatoid arthritis
Early arthritis
Clinical control
TNF-blocking drugs
Disease-modifying anti-rheumatic drugs
Resumen
Objetivo

Evaluar las diferencias en el manejo clínico y terapéutico de la artritis reumatoide (AR) precoz y establecida en la práctica clínica.

Pacientes y método

Estudio retrospectivo y multicéntrico en el que se incluyó a 360 pacientes con diagnóstico de AR. Mediante la revisión de historias clínicas se recogieron variables sociodemográficas, clínicas y terapéuticas en los 12 meses previos al inicio del estudio.

Resultados

Se estudió a 152 pacientes con AR precoz (ARp) y 208 con AR establecida (ARe). El 97,5% había recibido fármacos modificadores de enfermedad (FAME) y el 43,6% tratamiento anti-factor de necrosis tumoral (TNF) entre el diagnóstico y el inicio del estudio. Los anti-TNF fueron utilizados con mayor frecuencia en pacientes con ARe (el 60,1 frente al 21,1%; p < 0,001). El metotrexato fue el fármaco más utilizado (70,6%). Se detectó cambio del tratamiento en un 79% de pacientes con ARp y en el 60,6% con ARe. El cambio de dosis fue la modificación más frecuente y una respuesta inadecuada el motivo más frecuente. El 25,8% de los tratamientos se suspendieron por reacciones adversas. La disminución media ± desviación estándar del DAS28 fue 0,9±1,5 en ARp y 0,2±1,0 en ARe. El 35,8% de las ARp presentó buena respuesta EULAR, mientras sólo el 16,2% de las ARe (p<0,001). La determinación del factor reumatoide y la valoración de la progresión radiológica fueron más solicitadas en la ARp (p<0,05).

Conclusiones

Los reumatólogos españoles utilizaron agentes biológicos con mayor frecuencia en los pacientes con enfermedad más evolucionada, ajustándose a las recomendaciones de las principales guías de práctica clínica.

Palabras clave:
Artritis reumatoide
Artritis precoz
Monitorización clínica
Antagonistas del
TNF Fármacos antirreumáticos
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References
[1.]
Lozano JA. Artritis reumatoide (I). Etiopatogenia, sintomatología, diagnóstico y pronóstico accessed 2010 Jun 8]. Available from: http://www.external.doyma.es/pdf/4/4v20n08a13018371pdf001.pdf.
[2.]
L. Carmona, R. Gabriel, F.J. Ballina, A. Laffon, Grupo de Estudio EPISER. Proyecto EPISER 2000.
prevalencia de enfermedades reumáticas en la población española Metodología, resultados del reclutamiento y características de la población.
Rev Esp Reumatol, 28 (2001), pp. 18-25
[3.]
L. Carmona, V. Villaverde, C. Hernández, J. Ballina, R. Gabriel, A. Laffon, the EPISER Study Group.
The prevalence of rheumatoid arthritis in the general population of Spain.
Rheumatology (Oxford), 41 (2002), pp. 88-95
[4.]
C. Lajas, L. Abásolo, B. Bellajdel, C. Hernández-García, L. Carmona, E. Vargas, et al.
Costs and predictors of costs in rheumatoid arthritis: a prevalence-based study.
Arthritis Rheum, 49 (2003), pp. 64-70
[5.]
J.Y. Reginster.
The prevalence and burden of arthritis.
Rheumatology (Oxford), 41 (2002), pp. 3-6
[6.]
A. Domínguez.
Costes asociados a la artritis reumatoide.
Rev Esp Econ Salud, 2 (2003), pp. 212-217
[8.]
S. Schwartzman, R. Fleischmann, J. Morgan.
Do anti-TNF agents have equal efficacy in patients with rheumatoid arthritis?.
Arthritis Res Ther, 6 (2004), pp. S3-S11
[9.]
American College of Rheumatology subcommittee on rheumatoid arthritis guidelines.
Guidelines for the management of rheumatoid arthritis.
Arthritis Rheum, 46 (2002), pp. 328-346
[10.]
J. Tornero Molina, R. Sanmartí Sala, V. Rodríguez Valverde, E. Martín Mola, J.L. Marenco de la Fuente, I. González Álvaro, et al.
Actualización del Documento de Consenso de la Sociedad Española de Reumatología sobre el uso de terapias biológicas en la artritis reumatoide.
Reumatol Clin, 6 (2010), pp. 23-36
[11.]
A.M. Van Gestel, M.L. Prevoo, M.A. Van’t Hof, M.H. Van Rijswijk, L.B. Van de Putte, P.L. Van Riel.
Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis Comparison with the preliminary American College of Rheumatology and the World Health Organization/International League Against Rheumatism Criteria.
Arthritis Rheum, 39 (1996), pp. 34-40
[12.]
Guidance on the use of etanercept and infliximab for the treatment of rheumatoid arthritis. National Institute for Clinical Excellence. Technology appraisal guidance No. 36 [accessed 2010 Jun 8]. Available from: www.nice.org.uk
[13.]
S.M. Verstappen, J.W. Jacobs, M.J. Van der Veen, A.H. Heurkens, Y. Schenk, E.J. Ter Borg, on behalf of the Utrecht Rheumatoid Arthritis Cohort Study group, et al.
Intensive treatment with methotrexate in early rheumatoid arthritis: aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial).
Ann Rheum Dis, 66 (2007), pp. 1443-1449
[14.]
M. Sanders.
A review of controlled clinical trials examining the effects of antimalarial compounds and gold compounds on radiographic progression in rheumatoid arthritis.
J Rheumatol, 27 (2000), pp. 523-529
[15.]
S. Ten Wolde, F.C. Breedveld, J. Hermans, J.P. Vandenbroucke, M.A. Van de Laar, H.M. Markusse, et al.
Randomised placebo-controlled study of stopping second-line drugs in rheumatoid arthritis.
Lancet, 347 (1996), pp. 347-352
[16.]
A. Klinkhoff.
Biological agents for rheumatoid arthritis: targeting both physical function and structural damage.
Drugs, 64 (2004), pp. 1267-1283
[17.]
D.E. Furst, E.C. Keystone, R. Fleischmann, P. Mease, F.C. Breedveld, J.S. Smolen, et al.
Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2009.
Ann Rheum Dis, 69 (2010), pp. i2-i29
[18.]
J. Ledingham, C. Deighton, on behalf of the British Society for Rheumatology Standards, Guidelines and Audit Working Group (SGAWG).
Update on the British Society for Rheumatology guidelines for prescribing TNFa blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001).
Rheumatology (Oxford), 44 (2005), pp. 157-163
[19.]
S.J. Lee, H. Chang, Y. Yazici, J.D. Greenberg, J.M. Kremer, A. Kavanaugh.
Utilization trends of tumor necrosis factor inhibitors among patients with rheumatoid arthritis in a United States observational cohort study.
J Rheumatol, 36 (2009), pp. 1611-1617
[20.]
D.M. Van der Heijde, M. Van’t Hof, P.L. Van Riel, L.B. Van der Puttle.
Development of a disease activity score based on judgement in clinical practice by rheumatologists.
J Rheumatol, 20 (1993), pp. 579-581
[21.]
D.L. Scott, G.H. Kingsley.
Tumor necrosis factor inhibitors for rheumatoid arthritis.
N Engl J Med, 355 (2006), pp. 704-712
[22.]
K. Ikeda, S. Cox, P. Emery.
Biological therapy in early arthritis – overtreatment or the way to go?.
Arthritis Res Ther, 9 (2007), pp. 211-217
[23.]
P. Emery, F.C. Breedveld, S. Hall, P. Durez, D.J. Chang, D. Robertson, et al.
Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomised, double-blind, parallel treatment trial.
[24.]
P. Emery, F. Breedveld, D. Van der Heijde, G. Ferraccioli, M. Dougados, D. Robertson, et al.
Clinical remission and inhibition of radiographic progression with combination etanercept-methotrexate therapy versus monotherapy in active, early rheumatoid arthritis: 2-year results from the COMET trial.
Ann Rheum Dis, 68 (2009), pp. 119
[25.]
C.F. Allaart, Y.P. Goekoop-Ruiterman, J.K. de Vries-Bouwstra, F.C. Breedveld, B.A. Dijkmans, FARR study group.
Aiming at low disease activity in rheumatoid arthritis with initial combination therapy or initial monotherapy strategies: the BeSt study.
Clin Exp Rheumatol, 24 (2006), pp. S77-S82
[26.]
C. Grigor, H. Capell, A. Stirling, A.D. McMahon, P. Lock, R. Vallance, et al.
Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial.
[27.]
M.F. Bakker, J.W. Jacobs, S.M. Verstappen, J.W. Bijlsma.
Tight control in the treatment of rheumatoid arthritis: efficacy and feasibility.
Ann Rheum Dis, 66 (2007), pp. 56-60
[28.]
M.M. Ward.
Interpreting measurements of physical function in clinical trials.
Ann Rheum Dis, 66 (2007), pp. 32-34
[29.]
M.L. Prevoo, M.A. Van’t Hof, H.H. Kuper, M.A. Van Leeuwen, L.B. Van de Putte, P.L. Van Riel.
Modified disease activity scores that include twenty-eight-joint counts.
Arthritis Rheum, 38 (1995), pp. 44-48
Copyright © 2011. Sociedad Española de Reumatología and Colegio Mexicano de Reumatología
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