Volume 9 Issue 9, September 2013

Clinicians now have the therapies and outcome tools to implement treat-to-target strategies aimed at achieving and maintaining adequate function and control of symptoms in spondyloarthritis and psoriatic arthritis. However, validation of surrogate markers of structural progression is a prerequisite for treat-to-target strategies aimed at improving long-term outcomes such as joint damage.

An incident fracture sustained during treatment for osteoporosis does not necessarily represent treatment failure, an outcome that was redefined in 2012. Predictors of the new definition have now been reported and include ≥2 falls within the past year. Preventing fractures in the most at-risk patients, however, requires improved management strategies.

Since the 1990s, patients with rheumatoid arthritis have been treated with at least one DMARD. Methotrexate, which is usually the first-line treatment, elicits good or even excellent clinical results in 20–30% of patients—but in most patients it does not. Thus, an important question is what to do after methotrexate failure.

Despite having increased cardiovascular risk, patients with rheumatoid arthritis (RA) often have low serum cholesterol levels. In this Review, the authors discuss this putative 'lipid paradox', highlighting the relationships of inflammation and anti-inflammatory therapy with lipid profiles in RA.

Prevention and recognition of mycobacterial disease is of increasing importance to the practicing rheumatologist. Tuberculosis remains a well-known problem for patients and clinicians wishing to use immunosuppressive therapies. Less well recognized, and yet perhaps more important to consider in this context, is nontuberculous mycobacterial disease. Epidemiological data and mechanistic explanations for the increased risk of mycobacterial infection in patients with RA are reviewed herein, and appropriate strategies to prevent and manage these comorbidities are outlined.

Vaccinating children with underlying rheumatic diseases is important to reduce their risk of acquiring infectious diseases. These vaccines are safe to use in this patient group, with the exceptions of profoundly immunosuppressed pateints or those with malevonate kinase deficiency. Some vaccines also induce lower than normal immune responses in these children.

In the past decade, knowledge of the pathogenesis of primary Sjögren's syndrome and the lymphomagenesis associated with this disease has advanced considerably. This Review summarizes our current understanding of these processes, highlighting the importance of crosstalk between the innate and adaptive immune systems.

Many advances in the treatment of juvenile idiopathic arthritis have been underpinned by the development of organizations such as PRINTO and PRCSG. This Perspectives provides a timeline for these advances, including clinical trial designs and diagnostic criteria essential to performing research in this small group of patients whose age necessitates a cautious approach to treatment.