National organization of rheumatology managers 2016

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Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan.

All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method. It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.

In recent years, several guidelines regarding the management of axial spondyloarthritis axSpA have been published, 1 , 2 , 3 , 4 , 5 , 6 predominantly by societies and experts in Europe and the USA. Moreover, the incidence and prevalence of tuberculosis, 12 hepatitis B, 13 and hepatitis C 14 are higher in Taiwan as compared to Europe or the USA, and this may limit treatment options for Taiwanese patients, particularly regarding the use of biologics.

Therefore, aspects of axSpA that have local relevance were discussed in these guidelines, and recommendations with an emphasis on improving awareness, diagnosis, management, and outcomes in Taiwanese patients were formulated. Axial spondyloarthritis is a chronic type of arthritis that primarily affects the sacroiliac joints and the spine. Importantly, these guidelines seek to address less explored issues in axSpA that are important for clinical management from both a local and global perspective.

Regarding treatment, recommendations for exercise have been broadened to include evidence for yoga, Tai Chi, qigong, and other types of exercise that are common in Taiwan. The formulation of these guidelines was undertaken by a committee of rheumatology and rehabilitation experts on behalf of the Taiwan Rheumatology Association TRA. The guideline committee was convened by W. Each committee member was assigned to conduct a systematic literature review for a specific section of these guidelines, with a special emphasis on recent studies published between and and issues not addressed by other guidelines.

Collected evidence was presented to the committee for review and discussion by all members, and based on these discussion results, each member prepared the wording for the recommendations and accompanying statements in their responsible section.

Recommendations and statements based on direct level I evidence were graded as A; those based on direct level II evidence or extrapolated from level I evidence were graded as B; those based on direct level III evidence or extrapolated from level I or level II evidence were graded as C; and those based on direct level IV evidence or extrapolated from levels I, II, or III evidence were graded as D.

Levels of agreement were derived through anonymous electronic voting at a committee meeting. The final guidelines and manuscript were reviewed and approved by all committee members, and were then reviewed and ratified by the TRA Executive Committee before submission to this journal.

Taiwan Rheumatology Association consensus recommendations for the management of axSpA. These guidelines are intended for the use of all healthcare professionals involved in the management of axSpA, including rheumatologists, physiatrists, and clinicians of other disciplines. Considering that these guidelines are intended to focus on the management of axSpA, other aspects of the disease such as classification, diagnosis, and pathogenesis will not be discussed, unless they are relevant to treatment decisions.

These principles define the main considerations, influencing factors, and best approaches regarding axSpA care in Taiwan today. Overarching Principle 1: The rheumatologist serves as the main coordinator of care for axSpA, a disease with diverse manifestations that is best managed through multidisciplinary care.

Taken together, these studies show that axSpA encompasses a diverse range of manifestations and comorbidities that require an integrated, multidisciplinary approach to effectively manage them. In such a situation, the rheumatologist, having broad knowledge of the axSpA disease spectrum and the patient's condition, represents the ideal candidate to serve as the main coordinator of care with clinicians and health professionals in other specialties.

Rheumatologists should recognize this role and take a proactive approach in securing multidisciplinary support for axSpA patients to achieve better management outcomes. It is also important to recognize that the cost of axSpA includes both direct costs related to treatment and indirect costs from loss of work productivity, inability to work, and restrictions in daily function, and all these costs should be considered when optimizing treatment for patients.

The management of axSpA should not be limited to a single treatment strategy, but likely requires a range of strategies, the combination, sequence, time of initiation, and duration of which may be important for patient outcomes. Although not part of the four management strategies described above, axSpA patients in Taiwan may seek out complementary and alternative medicine CAM such as herbal remedies, acupuncture, moxibustion, and therapeutic massage eg tuina , either voluntarily or on the advice of family and friends.

No randomized controlled trials RCTs with herbal remedies have been conducted in axSpA patients to date, and it should be noted that the use of herbal remedies can vary widely in terms of source ingredients, dose, regimen, and formulation.

The goal of axSpA treatment is to enable the patient to secure quality of life and normalized function, but the patient's definition of normal life and function may be significantly different from that of the rheumatologist or other healthcare professionals. Therefore, it is important to work closely with the patient to understand his or her treatment goals, identify and explain potential barriers to achieving those goals, and help the patient make an informed decision regarding treatment options.

This process needs to continue throughout the management of axSpA. Overarching Principle 5: The management of axSpA in Taiwan is strongly influenced by the National Health Insurance reimbursement system and local health circumstances.

In addition, local health circumstances such as availability of medications, approved indications, prevalence of tuberculosis and hepatitis B, and patient preferences can also affect treatment. The endemic presence of tuberculosis 12 and hepatitis B 13 in Taiwan is a critical issue. The incidence and prevalence of tuberculosis in Taiwan are both considerably higher than that seen in the USA or Europe. In a pooled analysis of safety data from three controlled trials of secukinumab in psoriatic arthritis and two trials in AS, involving psoriatic arthritis patients and AS patients, no cases of tuberculosis activation were recorded.

Treatment for axSpA patients should be individualized according to the signs and symptoms of disease, patient characteristics, and treatment goals. This recommendation stems from the overarching principles, and considering that axSpA is a disease with diverse manifestations axial symptoms, peripheral symptoms, and EAM that require multiple treatment strategies, rheumatologists should expect that a high level of individualization will be needed in the management of axSpA patients, and plan accordingly for this.

The diagnosis and monitoring of axSpA disease activity should be based on clinical symptoms and signs, laboratory tests, and imaging, while the frequency of monitoring should be decided on an individual basis.

In order to diagnose axSpA and track subsequent clinical improvement or worsening, methods of disease evaluation are necessary. The diagnosis of axSpA is based upon the ASAS classification criteria, 15 and factors such as new bone formation syndesmophytes can be used to evaluate prognosis. MRI can detect early inflammation before structural damage is radiographically visible, and a high degree of spinal inflammation observed on MRI has been correlated with a successful response to TNFi.

Generally, the frequency of monitoring should be decided on an individual basis, 1 in line with Recommendation 1 of these guidelines. However, patients who have active disease, are receiving biologics, or have undergone recent changes in treatment may need to be more frequently monitored. Ultrasound may sometimes be used in axSpA patients to evaluate peripheral arthritis, enthesitis, and EAM, and can be used for monitoring in such cases; however, ultrasound is not effective for spinal imaging.

The use of these scores and laboratory tests should also be determined on an individual basis, and may be used to track progress in patients receiving TNFi or other biologics.

In rheumatoid arthritis, T2T is clearly defined as either remission or low disease activity, but this is not the case for axSpA, which also lacks a definition for MDA. It should be noted that this recommendation does not override the need to help the patient achieve his or her desired treatment objectives; indeed, it is expected that the achievement of T2T will facilitate this outcome.

Moreover, treatment targets for axSpA may need to be flexibly adjusted according to disease duration, as ASDAS appears to correlate with radiographic progression mostly during the early years of disease. Patients with axSpA should be encouraged to stop smoking and start an individualized regular exercise program as soon as possible. The program should emphasize flexibility training, especially spinal mobility exercises, but aerobic exercise, resistance training, breathing exercises, and physiotherapy are also recommended.

A recent study from Taiwan observed a strong association between smoking and poor disease prognosis in AS patients, 78 and it has also been reported that axSpA patients who smoke have a reduced response to TNFi treatment 79 and greater disease activity. Regular exercise is recommended in axSpA patients, and is associated with benefits such as improved joint mobility, reduced disease activity, and decreased cardiovascular CV risk.

Postural education and exercise are important to help patients avoid positions that lead to prolonged stooping. These recommendations are largely in line with the NICE guidance, 3 which recommend that axSpA patients should be referred to a physiatrist or a physiotherapist to start a structured exercise program, or referred to other specialists eg occupational therapist, orthotist, podiatrist, etc when difficulties with daily activities emerge.

EAM are an important part of axSpA and should be actively evaluated and managed to improve patient outcomes. A significant proportion of axSpA patients will experience EAM and other comorbidities, and these can have a serious impact on physical function and quality of life.

Uveitis is the most common EAM by far, with a reported pooled prevalence rate of A study of 11 Taiwanese AS patients has observed a greater risk of comorbidities compared to the general population, 21 and EAM in the lung, kidney, and heart can also develop. Ongoing monitoring of renal function, as well as gastrointestinal and cardiovascular side effects, should be determined on an individual basis. Analgesics may be considered to treat residual pain.

Renal function may need to be monitored in patients receiving NSAIDs, to be determined on an individual basis. Several trials have been performed in patients with rheumatoid arthritis or osteoarthritis, but the immunomodulatory effects of csDMARDs cannot be excluded from the study results.

This result was mirrored by two other studies, , which showed that lack of exposure to NSAIDs was a risk factor for vascular mortality in AS patients. Therefore, it is recommended that continuous use of NSAIDs should be guided by patient symptoms and objective measures of inflammation, rather than by the treatment goal of preventing structural progression. In the event of treatment failure with conventional therapy, after evaluating other causes, biologic therapy should be considered for axSpA.

In the event of treatment failure with conventional therapy, other causes should be evaluated and addressed first, including but not limited to osteoporosis, spinal fractures, malignancy, fibromyalgia, tuberculosis, or tuberculosis spine. It should be noted that the risk of osteoporosis and spinal fractures in axSpA patients is significant even in the early stages of disease 20 ; however, osteoporosis is generally asymptomatic until fractures develop, and for axSpA patients with unknown persistent back pain other than that known to be associated with inflammation, the possibility of spinal fracture should be considered and assessed.

Once other causes have been evaluated and excluded, biologic therapy may be considered. Although the availability of biologics may vary between countries, in the event that both classes are available, the choice of biologic should be made according to disease severity, EAM, comorbidities, and other characteristics of individual patients. In patients with refractory pain or disability and radiographically visible structural damage of the hip joint, hip arthroplasty should be considered, while corrective osteotomy may be considered for patients with disabling spinal deformity.

These guidelines have endeavored to include the latest evidence concerning the management of axSpA, and have also incorporated issues of local relevance to clinicians in Taiwan. It should be noted that the Overarching Principles and Recommendations should be read with the accompanying statements to derive the best picture of current evidence, and the listed references may need to be consulted when more information is needed.

Although significant challenges still remain with the recognition of axSpA as a category of disease that can be used in drug indications and reimbursement criteria, initiatives aimed at increasing clinician acceptance, promoting related research, and advising healthcare policymakers will be undertaken in the near future.

All authors were involved in the discussions and formulation of the recommendations. All authors reviewed and commented extensively on the manuscript. All authors approved the final version of the manuscript. Expert consensus for these recommendations were finalized during 3 committee meetings which were funded by Novartis Taiwan. No funding or sponsorship was received for publication of this article. The authors report no competing interests with regard to the development and publication of this manuscript.

Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis. Int J Rheum Dis. Read article at publisher's site DOI : J Saudi Heart Assoc , 33 2 , 08 Jul Int J Rheum Dis , 23 1 , 27 Nov To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.

Int J Rheum Dis , 22 3 , 28 Feb Cited by: 9 articles PMID: J Rheumatol , 42 4 , 15 Feb Cited by: 17 articles PMID: Int J Rheum Dis , 23 2 , 24 Nov Cited by: 1 article PMID: Ann Rheum Dis , 73 1 , 08 Jun Arthritis Rheumatol , 68 2 , 24 Sep Free to read.

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rheumatologists, 1 radiologist, 2 general practitioners, EULAR recommendations () for the management of gout.

Diagnosis and management of axial spondyloarthritis in primary care

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Evelyn Hsieh, MD, PhD

national organization of rheumatology managers 2016

Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method.

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The changing landscape of biosimilars in rheumatology

To be a forum by which we promote and support education, expertise, and advocacy for rheumatology practices and their patients. During this process, one of Quality staff members are hard to find and even harder to replace. Turnover is an inevitable aspect of every business Now that summer has arrived, staff and physicians are beginning to request time off for vacations.

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However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. After duplicate search in the Endnote reference management software version X9. Key issues were identified using the collocate analysis. The treat to target T2T initiative was identified as fundamental paradigm.

Past President, National Organization of Rheumatology Managers *Mean difference calculated from , , and annual compensation reports (the.

Executive summary. Full guideline. Guideline for the management of paediatric, adolescent and adult patients with idiopathic inflammatory myopathy myositis. Read the guideline.

The National Osteoporosis Guideline Group NOGG , established in , is a multidisciplinary group that includes patient representation and professionals involved in the care of people with osteoporosis. NOGG provides a clinical guideline that reviews the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the approaches for the prevention of fragility fractures, in postmenopausal women, and in men aged 50 years or older. In October NICE reaccredited the process used by the National Osteoporosis Guideline Group to produce this clinical guideline for the prevention and treatment of osteoporosis. The NOGG guideline is intended for all healthcare professionals involved in the prevention and treatment of osteoporosis and fragility fractures. This includes primary care practitioners, allied health professionals and relevant specialists in secondary care including rheumatologists, gerontologists, gynaecologists, endocrinologists, clinical biochemists and orthopaedic surgeons. The guideline includes recommendations for training in osteoporosis care.

We continue to improve our organization and our conference in response to that interest. Our and Conferences were held in St.

Angela M. She is board certified in rheumatology and internal medical and has been practicing rheumatology in Pittsburgh since Stupi received her undergraduate training at the Medical College of Pennsylvania with internships and residency programs at the Medical College of Pennsylvania and Fellowship training at the University of Pittsburgh School of Medicine. From Dr. Stupi held the position of Chief of Rheumatology at St. Stupi has been involved in over 50 pharmaceutical sponsored clinical trials and has been a national speaker in the treatments of Osteoporosis and Rheumatoid Arthritis. Christine Matelan is a certified research coordinator accredited by the Association of Clinical Research Professionals and a member of the National Organization of Rheumatology Managers.

About 1 in 4 US adults Arthritis prevalence increases with age. Arthritis can have substantial impacts on individuals and their function.

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