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Vol. 19. Issue 3.
Pages 173 (March 2023)
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Vol. 19. Issue 3.
Pages 173 (March 2023)
Letter to the Editor
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Reply to the Letter to the Editor from Drs Suárez-Diaz and Caminal-Montero in reference to the special article “Recommendations for prevention of infection in systemic autoimmune rheumatic diseases”
En respuesta a la Carta al Editor de los Dres. Suárez-Diaz y Caminal-Montero en referencia al artículo especial «Recomendaciones SER sobre prevención de infección en enfermedades reumáticas autoinmunes sistémicas»
Íñigo Rúa-Figueroa Fernández de Larrinoaa, Patricia Carreira Delgadob, Noé Brito Garcíac,
Corresponding author

Corresponding author.
, Beatriz Tejera Segurad, Julián de la Torre Cisnerose,f
a Servicio de Reumatología, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
b Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, Spain
c Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain
d Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
e Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica (IMIBIC), Córdoba, Spain
f Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Córdoba, Córdoba, Spain
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Dear Editor,

We are sincerely grateful for the interest shown by Dr. Suárez-Díaz and Dr. Caminal-Montero in the SER recommendations for the prevention of infection in patients with systemic autoimmune rheumatic diseases, as well the interesting questions they raise in their letter about the same.

Respecting the first question, about the dose of trimethoprim–sulfamethoxazole (TMP/SMX) for prophylaxis of Pneumocystis jirovecii, drawing up the final recommendation involved a long discussion within the multidisciplinary panel. This was because the most widely used dose in rheumatology is the high dose (160mg TMP and 800mg SMX), administered 3 days a week. Nevertheless, as we argue in the document, and given that the recommendations are based on the available evidence, the lower dose (i.e., 400mg sulfamethoxazole and 80mg trimethoprim) administered daily is considered to be better supported in the scientific literature, and it may also give rise to a higher probability of adherence, as the doses are not intermittent. Another factor that was taken into consideration for the final decision on the dose was precisely the availability in Spain of the 400mg/80mg, format, while no 200mg/40mg, format was available here when the recommendations were prepared.1 We do not believe that our recommendation may lead to confusion, as the authors of the letter suggest, as the discussion of the same clearly indicates that the high dose (160mg TMP and 800mg SMX), should always be administered 3 times a week. In any case, the systematic review on which the recommendation was based recognised alternative dosage regimes which are effective and safe.2 As there are several options, it is of course necessary to be especially careful when prescribing and offering information to the patient. Another aspect which should be clarified solely affects the wording of the recommendation, and it consists of the order in which doses are mentioned when given in combination. Although it is true that trimethoprim is mentioned prior to sulfamethoxazole in the recommendation, the dose mentions 400mg/80mg. It may have been desirable to mention the doses in reverse order, as 80mg/400mg. In any case, it is also true that several generic formulations available in our country show sulfamethoxazole first.

With respect to the second, very relevant question asked by the authors of the letter, the fact that no recommendations for tuberculosis are included is due to a question of economy of resources. According to the normalized procedures of the Spanish Society of Rheumatology, the documents of recommendations it produces are limited in scope. This is because they only aim to cover specific areas of patient management, and therefore only answer a restricted number of research questions. Infection by tuberculosis is excluded because the panel of experts who prepared the document understood that it would be of less interest to include recommendations for the treatment of latent tuberculosis. This is because no specific peculiarities for specific autoimmune rheumatic systemic diseases could be foreseen here that would have justified the effort and replaced another research question. As occurs in the prevention of other infections, the panel decided to mention the need for this, referring to generic high-quality documents which are already available and have recently been updated.3


Fundación Española de Reumatología.

Í. Rúa-Figueroa Fernández de Larrinoa, P.E. Carreira, N. Brito García, P. Díaz Del Campo Fontecha, J.M. Pego Reigosa, J.A. Gómez Puerta, et al.
Recommendations for prevention of infection in systemic autoimmune rheumatic diseases.
Reumatol Clin (Engl Ed), 24 (2021),
C.A. Pereda, M.B. Nishishinya-Aquino, N. Brito-García, P. Díaz Del Campo Fontecha, I. Rua-Figueroa.
Is cotrimoxazole prophylaxis against Pneumocystis jirovecii pneumonia needed in patients with systemic autoimmune rheumatic diseases requiring immunosuppressive therapies?.
Rheumatol Int, 41 (2021), pp. 1419-1427
T.R. Sterling, G. Njie, D. Zenner, D.L. Cohn, R. Reves, A. Ahmed, et al.
Guidelines for the treatment of latent tuberculosis infection: recommendations from the National Tuberculosis Controllers Association and CDC, 2020.
MMWR Recomm Rep, 69 (2020), pp. 1-11
Copyright © 2022. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Reumatología Clínica (English Edition)
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