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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "39" "paginaFinal" => "41" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Francisco Javier Nóvoa Medina, Félix Francisco Hernández" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Francisco Javier" "apellidos" => "Nóvoa Medina" "email" => array:1 [ 0 => "fnovmed@hotmail.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Félix" "apellidos" => "Francisco Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canarias, Las Palmas, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital de Gran Canaria Dr. Negrín. Las Palmas de Gran Canaria, Las Palmas, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se puede suspender la medicación en los pacientes con artritis reumatoide en remisión?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Rheumatoid arthritis (RA) is the most prevalent chronic inflammatory joint disease and affects 0.5%–1% of the population of our country. Without proper treatment it causes significant morbidity and mortality. The introduction of biological therapies has significantly improved clinical outcomes and functional imaging of patients. The therapeutic goal in clinical practice is to try to achieve remission or low disease activity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Once achieved, it is advisable (if possible) to reduce or remove biological treatment and reduction and removal of disease-modifying drugs (DMARDs).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The aim of this review is to analyze the possibility of suspending medication in patients with RA in prolonged remission and when the risk of recurrence exists with suspension.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definition of Remission</span><p id="par0010" class="elsevierStylePara elsevierViewall">Although still far from curing the disease, recent years have seen changes in the therapeutic strategies in RA with early use of DMARDs and the introduction of biological therapies, which led to better results in RA treatment, in order to achieve remission or low disease activity level.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the 1990s various organizations, such as the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) proposed a number of variables to be assessed at each patient visit and included the quantification of painful (TJC) and swollen joints (SJC), the assessment of pain and disease activity by both the patient and physician through a visual analog scale (VAS), functional capacity of patients and acute phase reactants (ESR and CRP). From these variables, the proposed definitions of remission were: the ACR through the fulfillment of criteria (ACR criteria) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), and EULAR through an index (DAS) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Another index that has been proposed is SDAI (Simplified Disease Activity Index), which has the advantage that it is performed through a calculated arithmetic sum of the SJC in 28 joints (SJC28), and TJC in 28 joints (TJC28), patient and physician VAS and CRP (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although there are currently no remission criteria universally accepted, these are the indices used. Therefore, both ACR and EULAR are working together to validate criteria that define what remission is, and this collaboration has recently published provisional criteria whose application is intended for clinical<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> trials.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Remission can be defined as a state in which there is no inflammatory activity and no progression of structural damage. This concept of remission is difficult to achieve in clinical practice, because there the concept does not rule out the subclinical activity detectable by imaging<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> techniques. Therefore, many authors propose therapy to achieve a state of low disease activity as an alternative.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Withdrawal of Treatment in Remission of Early Rheumatoid Arthritis Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">It is increasingly clear that early treatment with DMARDs in RA results in lower long-term<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> radiological damage.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In RA there seems to be a period called “window of opportunity” in which the appropriate treatment may suppress or even reverse disease activity and lead the patient to an asymptomatic state, slowing joint damage. This window of opportunity presents itself at an early stage of the disease, lasting approximately 12 weeks.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The need for early diagnosis has conditioned the recent publication by ACR and EULAR of diagnostic criteria for RA 9, whose purpose is to achieve an earlier diagnosis of disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Among the studied that have reviewed the possible withdrawal of treatment in patients with early RA we find the following.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A Finnish cohort of early RA (n=70 patients) with a mean duration at the time of inclusion of 8 months was treated with DMARD monotherapy, or in combination in cases of ineffective response. They studied remission without medication and remission in a period of about 15 years.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Patients were divided into 3 groups according to the pattern of DMARD received. DMARD were suspended only in patients who remained in remission with 1981 ACR criteria for at least 12 months or who for a long time had low disease activity without symptoms. Twenty patients were able to discontinue medication, of which 9 had to restart treatment after a mean 50 months, most of them again reached low levels of activity. One possible explanation might be that patients were in remission after stopping the medication and therefore only patients with true clinical remission should discontinue DMARDs.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study enrolled 508 BeSt<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> patients with early RA of less than 2 years of progression (mean disease duration of 23 weeks) and were assigned to 4 treatment strategies: sequential monotherapy with DMARDs (group 1), combined step-up therapy (group 2), combination therapy with high doses of prednisone (group 3) or with infliximab (group 4). Treatment adjustments were made every 3 months with the aim of reaching a state of low activity according to DAS (DAS<2.4). If the clinical response with monotherapy was adequate for 6 months, medication was discontinued. In the analysis of remission without treatment after 5 years of follow up,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> the authors found that 23% of patients achieved remission without treatment, without differences between groups, but in 46% of these patients DMARDs had to be restarted upon reactivation of the disease, with retreatment being effective in 96%.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Withdrawal of Treatment in the Remission of Established Rheumatoid Arthritis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with established RA (more than 2 years of evolution) have sequelae in the form of joint erosions. In these patients, the theory of “the window of opportunity” is no longer achievable to reverse the disease,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> so reaching remission without treatment is more complicated.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Various studies have addressed the suspension of treatment with DMARDs in patients with established RA in remission. Among them we highlight the following.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In a Swiss cohort of 304 patients with established RA, predictors of long-term remission were studied after stopping anti-TNF-α therapy in patients who were in remission (DAS28<2.6) for at least 6 months with a stable dose of both the biologic and prednisone (<5<span class="elsevierStyleHsp" style=""></span>mg) and without NSAID.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Twenty (6.9%) patients met criteria for stopping biological therapy with a mean time of 11.3 years, and a mean of 19.4 months in remission with anti-TNF-α. At one year, 16 (71%) patients required re-treatment with anti-TNF-α for recurrence after a mean 14.7 weeks. Baseline differences in patients who relapsed compared to those who remained in remission were the least time in treatment with anti-TNF-α (35 months vs 56 months) and a shorter time in remission before stopping anti-TNF (14.5 months vs 35 months). However, the sample size was small.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In a Japanese multicenter study of induction of remission in RA treated with infliximab (RRR study),<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> those subjects who achieved a low level of activity (DAS28<3.2) for more than 24 months were invited to stay on infliximab. One hundred and two patients, of which 83 were in clinical remission, with a mean disease duration of 5.9 years, agreed to suspend infliximab and participate in the study. At one year, 56 (55%) patients remained on a low level of activity, 44 of them in remission, while the disease recurred in 46 patients. In these, retreatment with infliximab was effective in 32 of them reaching a low level of activity within 6 months. Patients who achieved remission had lower duration of illness (4.8 vs 7.8 years) and less radiographic progression.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In a prospective study involving 47 patients with RA treated with methotrexate and biological therapy (anti-TNF-α) in remission according to EULAR criteria (DAS28<2.6),<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> 27 patients (mean duration of disease 19 months) received combination therapy as first-line treatment for 12 months and 20 patients (mean duration of illness of 120 months) were treated with biological therapy (anti-TNF-α) after inadequate response to DMARDs. It was observed that a shorter duration of disease was a predictor of remission.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Recently, there has been a meta-analysis of high-quality studies that included patients with RA of more than 2 years and in remission with DMARD treatment, who suspended medication.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It was observed that the suspension of medication must be done in a careful manner, monitoring the degree of disease activity to restart treatment as early as possible.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">The therapeutic goal in RA is to attain remission or at least a low activity, to introduce DMARD therapy as early as possible, to induce remission or low disease activity and, if feasible, achieve remission without treatment.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We do not have enough information about patients who should stop treatment and when to stop it when remission of the disease is reached.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In early RA, the “window of opportunity” can be used for treatment with DMARDs alone or in combination to induce remission and prevent radiological deterioration. In patients with sustained clinical remission after a year of therapy, one could try stopping the medication and closely monitoring patients looking for signs of activity in order to reintroduce therapy as soon as possible.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In established RA treatment, discontinuation is more controversial. One could try to suspend it in patients with RA in remission for at least a year, with close monitoring to reintroduce it when activity is detected.</p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no data to establish guidelines regarding the possibility of reducing treatment dose or prolonging the administration time interval.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Disclosures</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres125681" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec112975" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125682" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec112974" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition of Remission" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Withdrawal of Treatment in Remission of Early Rheumatoid Arthritis Patients" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Withdrawal of Treatment in the Remission of Established Rheumatoid Arthritis" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Disclosures" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-10-26" "fechaAceptado" => "2011-08-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec112975" "palabras" => array:4 [ 0 => "Anti-tumor necrosis factor-alpha" 1 => "Disease modifying drugs" 2 => "Remission" 3 => "Rheumatoid arthritis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec112974" "palabras" => array:4 [ 0 => "Artritis reumatoide" 1 => "Fármacos modificadores de la enfermedad" 2 => "Remisión" 3 => "Tratamiento anti-factor de necrosis tumoral alfa" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis is a chronic systemic inflammatory disease that causes significant morbidity and mortality. The combined use of methotrexate and biological agents, which directed against tumor necrosis factor (TNF) has achieved significant improvement in clinical, radiographic and functional parameters not seen previously and has revolutionized the therapeutic goal of achieving remission in clinical, structural and functional parameters. The next goal should be to achieve remission without the use of biological drugs and later without medication. Although there is evidence about the efficacy and safety of TNF inhibitors, there is none on remission without the use of biological agents or disease modifying drugs.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La artritis reumatoide es una enfermedad inflamatoria crónica sistémica que ocasiona una significativa morbilidad y mortalidad. El uso combinado de metotrexato y agentes biológicos dirigidos contra el factor de necrosis tumoral (TNF) ha logrado mejorías significativas en parámetros clínicos, radiográficos y funcionales que no se habían visto previamente y que han revolucionado el objetivo terapéutico de conseguir la remisión en parámetros clínicos, estructurales y funcionales. El próximo objetivo debería ser alcanzar la remisión sin el uso de fármacos biológicos y posteriormente sin medicación. Aunque hay evidencia acerca de la eficacia y la seguridad de los inhibidores del TNF, no la hay acerca de remisión sin el empleo de agentes biológicos ni fármacos modificadores de la enfermedad.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Nóvoa Medina FJ, Francisco Hernández F. ¿Se puede suspender la medicación en los pacientes con artritis reumatoide en remisión? Reumatol Clin. 2012;<span class="elsevierStyleBold">8(1)</span>:39–41.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ACR: American College of Rheumatology; ESR: Erythrocyte Sedimentation Rate.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>At least 4 criteria must be present for at least 3 months.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Modified from Balsa.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Morning stiffness under 15 min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Pain visual analog scale<10<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. No joint pain on examination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. No tendon or joint inflammation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. ESR<30<span class="elsevierStyleHsp" style=""></span>mm/h (women) or <20<span class="elsevierStyleHsp" style=""></span>mm/h (men) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab212177.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Modified ACR Remission Criteria (1995).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Modified from Balsa.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">Degree of RA activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">DAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">DAS28 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Low disease activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">1.6–2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">2.6–3.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Remission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle"><1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle"><2.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab212176.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">EULAR Remission Criteria (DAS and DAS28).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Modified from Balsa.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">Degree of RA activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">SDAI \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Low disease activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">5–20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Remission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle"><5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab212178.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">SDAI (Simple Disease Activity Index).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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Year/Month | Html | Total | |
---|---|---|---|
2024 November | 9 | 16 | 25 |
2024 October | 49 | 17 | 66 |
2024 September | 57 | 22 | 79 |
2024 August | 80 | 52 | 132 |
2024 July | 62 | 30 | 92 |
2024 June | 56 | 27 | 83 |
2024 May | 69 | 23 | 92 |
2024 April | 58 | 28 | 86 |
2024 March | 80 | 36 | 116 |
2024 February | 42 | 24 | 66 |
2024 January | 53 | 24 | 77 |
2023 December | 33 | 34 | 67 |
2023 November | 57 | 35 | 92 |
2023 October | 44 | 26 | 70 |
2023 September | 85 | 42 | 127 |
2023 August | 47 | 21 | 68 |
2023 July | 37 | 31 | 68 |
2023 June | 41 | 31 | 72 |
2023 May | 42 | 24 | 66 |
2023 April | 33 | 19 | 52 |
2023 March | 84 | 40 | 124 |
2023 February | 54 | 25 | 79 |
2023 January | 38 | 34 | 72 |
2022 December | 70 | 50 | 120 |
2022 November | 56 | 38 | 94 |
2022 October | 58 | 48 | 106 |
2022 September | 43 | 38 | 81 |
2022 August | 28 | 39 | 67 |
2022 July | 40 | 54 | 94 |
2022 June | 32 | 38 | 70 |
2022 May | 43 | 51 | 94 |
2022 April | 39 | 67 | 106 |
2022 March | 49 | 71 | 120 |
2022 February | 36 | 54 | 90 |
2022 January | 41 | 46 | 87 |
2021 December | 28 | 38 | 66 |
2021 November | 51 | 41 | 92 |
2021 October | 40 | 67 | 107 |
2021 September | 30 | 49 | 79 |
2021 August | 48 | 44 | 92 |
2021 July | 43 | 31 | 74 |
2021 June | 39 | 43 | 82 |
2021 May | 56 | 60 | 116 |
2021 April | 102 | 88 | 190 |
2021 March | 50 | 51 | 101 |
2021 February | 31 | 25 | 56 |
2021 January | 31 | 17 | 48 |
2020 December | 32 | 33 | 65 |
2020 November | 31 | 23 | 54 |
2020 October | 24 | 14 | 38 |
2020 September | 46 | 39 | 85 |
2020 August | 32 | 19 | 51 |
2020 July | 25 | 15 | 40 |
2020 June | 37 | 35 | 72 |
2020 May | 30 | 14 | 44 |
2020 April | 39 | 25 | 64 |
2020 March | 30 | 14 | 44 |
2020 February | 1 | 0 | 1 |
2019 January | 1 | 0 | 1 |
2018 May | 5 | 0 | 5 |
2018 April | 61 | 14 | 75 |
2018 March | 133 | 18 | 151 |
2018 February | 40 | 9 | 49 |
2018 January | 37 | 4 | 41 |
2017 December | 51 | 5 | 56 |
2017 November | 58 | 10 | 68 |
2017 October | 76 | 7 | 83 |
2017 September | 68 | 5 | 73 |
2017 August | 72 | 8 | 80 |
2017 July | 57 | 7 | 64 |
2017 June | 85 | 13 | 98 |
2017 May | 100 | 13 | 113 |
2017 April | 87 | 13 | 100 |
2017 March | 79 | 7 | 86 |
2017 February | 58 | 2 | 60 |
2017 January | 73 | 4 | 77 |
2016 December | 113 | 11 | 124 |
2016 November | 122 | 10 | 132 |
2016 October | 144 | 9 | 153 |
2016 September | 217 | 7 | 224 |
2016 August | 135 | 8 | 143 |
2016 July | 56 | 9 | 65 |
2016 June | 0 | 7 | 7 |
2016 April | 2 | 0 | 2 |
2016 March | 3 | 13 | 16 |
2015 December | 2 | 0 | 2 |
2015 October | 2 | 0 | 2 |
2015 September | 1 | 0 | 1 |
2015 August | 1 | 0 | 1 |
2015 July | 40 | 6 | 46 |
2015 June | 84 | 5 | 89 |
2015 May | 88 | 11 | 99 |
2015 April | 97 | 7 | 104 |
2015 March | 115 | 5 | 120 |
2015 February | 98 | 4 | 102 |
2015 January | 114 | 9 | 123 |
2014 December | 110 | 8 | 118 |
2014 November | 106 | 9 | 115 |
2014 October | 120 | 11 | 131 |
2014 September | 90 | 10 | 100 |
2014 August | 95 | 13 | 108 |
2014 July | 77 | 15 | 92 |
2014 June | 108 | 12 | 120 |
2014 May | 82 | 17 | 99 |
2014 April | 54 | 7 | 61 |
2014 March | 63 | 16 | 79 |
2014 February | 60 | 14 | 74 |
2014 January | 80 | 10 | 90 |
2013 December | 55 | 5 | 60 |
2013 November | 68 | 12 | 80 |
2013 October | 57 | 8 | 65 |
2013 September | 58 | 11 | 69 |
2013 August | 47 | 16 | 63 |
2013 July | 34 | 8 | 42 |
2013 June | 57 | 10 | 67 |
2013 May | 120 | 9 | 129 |
2013 April | 42 | 6 | 48 |
2013 March | 39 | 11 | 50 |
2013 February | 39 | 9 | 48 |
2013 January | 25 | 6 | 31 |
2012 December | 26 | 2 | 28 |
2012 November | 21 | 4 | 25 |
2012 October | 14 | 10 | 24 |
2012 September | 15 | 1 | 16 |
2012 July | 4 | 0 | 4 |
2012 June | 3 | 0 | 3 |
2012 May | 8 | 0 | 8 |
2012 April | 5 | 0 | 5 |
2012 March | 11 | 0 | 11 |
2012 February | 9 | 0 | 9 |