[S2e guideline: treatment of rheumatoid arthritis with disease-modifying drugs].

Background: Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes.

Objective: Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany.

[Recommendations on the use of rituximab for ANCA-associated vasculitis].

Rituximab (Rtx) has been approved in Germany since April 2013 for treatment of granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). This therapy can be used in severe manifestations of these diseases and in relapses. It is administered as infusions of 375 mg rituximab per m(2) every 4 weeks after high dose intravenous prednisolone for 3 days and continued parallel to concomitant oral prednisolone therapy.

[Recommendations for use of rituximab in patients with rheumatoid arthritis].

Treatment with rituximab (RTX) has been approved since 2006 for patients with rheumatoid arthritis who previously failed to respond to tumor necrosis factor (TNF) inhibitor therapy or who experienced side effects. In these updated treatment recommendations new data relating to evaluation of the therapeutic response, retreatment, the role of predictive factors as well as safety data are incorporated and discussed.

German guidelines for the sequential medical treatment of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs.

The German Society of Rheumatology approved new German guidelines for the sequential medical treatment of rheumatoid arthritis (RA) based on the European League Against Rheumatism (EULAR) recommendations for the management of RA published in 2010. An update of the EULAR systematic literature research was performed in Medline, Embase, and Cochrane databases. Meta-analyses, controlled trials, cohort studies, and registry data addressing traditional and biologic disease-modifying antirheumatic drugs, glucocorticoids, and treatment strategies published between January 2009 and August 2011 were included.

[Vaccination in adult patients with chronic inflammatory rheumatic diseases].

Patients with chronic inflammatory rheumatic diseases often have an intrinsic and therapy associated increased susceptibility to infections which substantially contributes to morbidity and mortality of the patients. A large proportion of these infections are preventable by vaccination. For this reason in 2005 the standing vaccination committee (STIKO) recommended for patients with immunosuppression vaccination against pneumococcus, influenza, Haemophilus influenza b and meningococcus in addition to standard vaccinations, independent of age.

[German 2012 guidelines for the sequential medical treatment of rheumatoid arthritis. Adapted EULAR recommendations and updated treatment algorithm].

Following the EULAR recommendations published in 2010 German guidelines for the medical treatment of rheumatoid arthritis were developed based on an update of the systematic literature search and expert consensus. Methotrexate is the standard treatment option at the time of diagnosis, preferably in combination with low dose glucocorticoids. Combined disease-modifying antirheumatic drugs (DMARD) therapy should be considered in patients not responding within 12 weeks.

[Recommendations of the German rheumatology society on the use of tocilizumab in rheumatoid arthritis].

The humanized anti-IL-6 receptor monoclonal antibody tocilizumab (TCZ) represents a new therapy approach for moderately severe to severe cases of rheumatoid arthritis (RA). The IL-6 concentration in the synovial fluid and peripheral circulation of patients with RA is elevated. TCZ recognises the IL-6 binding site of human IL-6R and blocks the IL-6 signaling pathway.

[Vasculitis. Treatment outcome parameters].

The definition of outcome parameters has improved the care of vasculitis patients dramatically in recent decades. In the first phase of joint European studies, disease stages and activity were defined. In the second and third phases results of the randomized and controlled trials were summarized and published as European recommendations for the care of small and large vessel vasculitis.

[B lymphocyte differentiation in granulomatous tissues of the lung and the nasal mucosa in Wegener's granulomatosis: origin of anti-neutrophil cytoplasmic antibody formation?].

Wegener's granulomatosis (WG) starts with granulomatous inflammation of the respiratory tract before it converts into a potentially organ and life threatening systemic vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCA). The site of formation of the highly specific ANCA directed against "Wegener's autoantigen" proteinase 3 (PR3) is still unknown. Previously, we have shown that follicle-like B lymphocytic infiltrates in the vicinity to PR3 expressing cells in WG-granulomata.

[Revision of the recommendations of the Commission on Pharmacotherapy of the German Society for Rheumatology. Recommendations for supportive therapy for Sjögren's syndrome].

For the treatment of sicca symptoms as a manifestation of Sjögren's syndrome there are various tear substitutes as well as artificial saliva. The appropriate substances are discussed in this article. In addition to reducing symptoms, some of the effective compounds offer the advantage of infection prophylaxis in the form of better lubrication of the mucous membranes in the airways as well as reduced susceptibility to candidiasis.

B lymphocyte maturation in Wegener's granulomatosis: a comparative analysis of VH genes from endonasal lesions.

Background: Anti-neutrophil cytoplasmic antibodies (ANCA) directed against proteinase 3 (PR3) are highly specific for Wegener's granulomatosis (WG). Evidence for a pivotal role of PR3-ANCA in the induction of vasculitis has been demonstrated. B cell clusters have been observed within endonasal biopsy specimens.

[New therapeutic concepts for vasculitis and collagenosis].

After improvement of the prognosis of the primary systemic vasculitides and systemic lupus erythematosus from a desperate diagnosis with hardly a one year survival after diagnosis to a 5-year-survival-rate of more than 90% actual therapeutic regimes aim at those patients refractory to standard therapeutic regimes, not achieving a remission by standard approaches or having organ damage or contraindications. Furthermore less toxic regimes are looked for with the aim to avoid secondary complications of the standard therapy. New drugs used successfully in rheumatology, transplantation medicine and haematology are used for these purposes in the last years.

Churg Strauss syndrome--successful induction of remission with methotrexate and unexpected high cardiac and pulmonary relapse ratio during maintenance treatment.

Objective: To examine the safety and efficacy of methotrexate (MTX) plus low-dose prednisolone for induction of remission in non life- or organ-threatening courses and for remission maintenance in Churg-Strauss syndrome (CSS).

Methods: In an open-label study 11 patients were treated with MTXfor induction of remission at initial diagnosis and relapse. Twenty-five patients received MTX for maintenance of remission.

Prevalence of ANCA in mixed cryoglobulinemia and chronic hepatitis C virus infection.

Objective: To determine the prevalence, target antigens and clinical associations of antineutrophil cytoplasmic antibodies (ANCA) in chronic hepatitis C without extrahepatic manifestations and in chronic hepatitis C virus (HCV)-associated mixed cryoglobulinemia (MC) in two European centers.

Methods: 50 sera from patients with chronic hepatitis C and 116 sera from HCV-associated MC were tested for cytoplasmic or perinuclear pattern (C-ANCA/P-ANCA) by indirect immunofluorescence test (IFT). ANCA target antigens were determined by enzyme-linked immunosorbent assay (ELISA).

Rituximab induces remission in refractory HCV associated cryoglobulinaemic vasculitis.

Objectives: To report the successful induction of remission with the monoclonal anti-CD20 antibody rituximab in a patient with hepatitis C virus (HCV) associated cryoglobulinaemic vasculitis and a non-Hodgkin's lymphoma (NHL) resistant to previously advocated conventional treatments.

Case Report: The patient was a 45 year old woman with HCV associated cryoglobulinaemic vasculitis, with purpura, arthralgia, constitutional symptoms, and a polyneuropathy. A malignant NHL was found as underlying lymphoproliferative disease.

[Rheumatology 2003-part I: research news concerning pathogenesis, epidemiology, diagnosis, and therapy of chronic inflammatory joint diseases].

Due to the partial elucidation of the immunopathogenesis of chronic inflammatory diseases during the last years, clinical rheumatology has made a rapid development, which by the consequent use of immunomodulatory therapies including recombinant proteins (biologicals) led to a significantly ameliorated prognosis of these diseases. On this basis, new research projects are continuously performed in the fields of pathogenesis, new drug development, outcome and therapy studies. New developments of imaging techniques and serologic testing facilitate a better classification and definition of disease activity and remission criteria.

[Treatment of primary systemic vasculitis with TNF alpha-antagonists].

After the introduction of the TNF alpha blocking drugs Etanercept and Infliximab for the standard therapy of rheumatoid arthritis these effective substances have also been used successfully in many patients with primary systemic vasculitides, who were unresponsive to standard therapy. From pathophysiologic findings their use is justified by the prominent role of TNF alpha in the inflammation of small and large vessels. So far only open studies with a maximum of 20 patients and case reports are published.

Treatment of refractory Churg-Strauss-Syndrome (CSS) by TNF-alpha blockade.

Churg-Strauss-Syndrome (CSS) often takes a mild course and is in many cases treated successfully by glucocorticosteroids (GC) alone. However, there are also several reports demonstrating the necessity of more intensive treatment in life threatening courses with cyclophosphamide and in less severe cases with other immunosuppressive or immunomodulatory drugs like azathioprine, methotrexate or interferon alpha. Relapses of the CSS are detected clinically and serologically and may require cyclophosphamide therapy as well as high-dose GC.