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Vol. 3. Núm. 1.
Páginas 38-44 (Enero - Febrero 2007)
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Vol. 3. Núm. 1.
Páginas 38-44 (Enero - Febrero 2007)
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¿Cómo se evalúa una respuesta inadecuada en un paciente con artritis reumatoide en la práctica clínica?
How do we evaluate an inadequate response in a patient with rheumaoid arthritis in the clinical praxis P?
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Alejandro Balsa
Autor para correspondencia
abalsa.hulp@salud.madrid.org

Correspondencia: Dr. A. Balsa. Servicio de Reumatología. Hospital Universtario La Paz. P.o de la Castellana, 261. 28046 Madrid. España.
Servicio de Reumatología. Hospital Universitario La Paz. Madrid. España
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La artritis reumatoide (AR) es una enfermedad crónica que afecta sobre todo a las articulaciones y produce destrucción articular, alteración de la capacidad functional y compromete la calidad de vida de manera considerable. Se sabe que el tratamiento precoz es capaz de reducir el daño estructural y mejorar a largo plazo la discapacidad, pero las estrategias terapéuticas óptimas todavía no están unánimemente aceptadas. Igual que en la diabetes o la hipertensión, en la AR es necesario un control estrecho de la enfermedad con el objetivo de lograr la ausencia de actividad, que se puede entender como remisión o, si no es posible, el mantenimiento de una actividad inflamatoria lo más baja posible, de modo que no origine consecuencias desfavorables, como la progresión del daño articular, y que los riesgos derivados del tratamiento sean asumibles por el paciente. Los criterios de mejoría de la ACR (American College of Rheumatology) son útiles para comparar la eficacia de tratamientos en ensayos clínicos, pero no se deben utilizar como objetivo terapéutico ya que no valoran la actividad final, que puede ser importante a pesar de haber tenido mejoría. Para valorar la respuesta, lo lógico y más cómodo para el médico, es utilizar las mismas herramientas que se utilizan para valorar la actividad de la enfermedad en la práctica clínica, como son los índices de actividad DAS y SDAI. Para mejorar su interpretación y establecer los objetivos terapéuticos se han propuesto unos límites que separan niveles de actividad diferentes. La categorización en clases según la actividad es importante para iniciar o cambiar un tratamiento (en caso de ser alta o moderada) y para definir estados de actividad conceptualmente diferentes (actividad o remisión). Los puntos de corte que separan estas categorías se propusieron hace años cuando las posibilidades terapéuticas de la AR eran limitadas y no se conocían sus consecuencias a largo plazo. En la actualidad el objetivo terapéutico de la remisión o la baja actividad es mucho más fácil de conseguir, por lo que es necesario una reconsideración de las categories terapéuticas y definir niveles de actividad más bajos como objetivo potencial. Hoy en día asumir una actividad moderada o alta como resultado de un tratamiento es inaceptable, sobre todo cuando nuestro arsenal terapéutico es ya considerable y se han propuesto estrategias y combinaciones de tratamiento que han demostrado mayor eficacia con unos riesgos tolerables. Aunque en todos los aspectos de la vida los cambios se introducen de manera paulatina, ya no hay ninguna razón para no aceptar la remisión en la AR como un objetivo no solo deseable sino alcanzable.

Palabras clave:
Artritis reumatoide
Índices de actividad
Índices de mejoría
DAS
SDAI
ACR

Rheumatoid arthritis (RA) is a chronic disease that particularly affects the joints, causing their destruction, changes in its functional capacity and considerably compromising the quality of life. It is known that early treatment can reduce structural damage and improve the disability in the long term, but the optimal therapeutic strategies are still not universally accepted. As with diabetes and hypertension, strict control of the disease is required, with the objective of achieving no disease activity, which may be seen as a remission, or if this is not possible, to keep the inflammatory activity as low as possible so that the unfavourable consequences, such as the articular damage process and the risks that the patients assume deriving from treatment, do not occur. The improvement criteria of the American College of Rheumatology (ACR) are useful for comparing the efficacy of treatment in clinical trials, but they must not be used as a therapeutic objective, since they do not evaluate the final activity, which can be as important as having an improvement. To evaluate the response, the most logical and convenient for the doctor is to use the same tools that are used to evaluate the activity of the disease in clinical practice, such as the DAS and SDAI activity scores. Some limits which separate the different levels of activity have been proposed to improve their interpretation and establish therapeutic objectives. The categorisation into classes according to activity is important for starting or changing treatment (when it is moderate or high) and to define stages of conceptually different activity (activity or remission). The cut-off points that separate these categories were proposed years ago when the therapeutic possibilities of RA were limited and their long term consequences were not known. The therapeutic objective of remission or lower activity is much easier to achieve these days, therefore the therapeutic categories need to be reconsidered and the definition of lower activity levels as a potential objective. Nowadays, to assume moderate or high activity as a result of treatment is unacceptable, particularly when our therapeutic arsenal is already considerable and strategies and therapeutic combinations have been proposed which have demonstrated higher efficacy with tolerable risks. Although changes happen gradually in all aspects of life, there is no reason not to accept remission of RA as not only a desirable objective, but also an achievable one.

Key words:
Rheumatoid arthritis
Activity indexes
Improvement indexes
DAS
SDAJ
ACR
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Copyright © 2007. Elsevier España S.L Barcelona
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