Alefacept, proteína de fusão de origem humana cuja função é bloquear a interacção entre LFA –
3 presente na APC – célula apresentadora de antigénio e o CD2 presente no linfócito T, através da quimiotaxia dos linfócitos NK, que posteriormente interagem com o CD2 e levam á apoptose dos clones dos linfócitos T. Está aprovado no tratamento da psoríase, contudo a sua eficácia moderada limitou o seu uso na AP, no entanto pode ser utilizado em pacientes sem resposta a outros fármacos ou com efeitos laterais166,167.
Abatacept - proteína de fusão de origem humana, que faz a ligação entre CD80 e 86 numa APC,
bloqueando o sinal de activação do CD28 presente no linfócito T. Um estudo demostrou que é bem tolerado e que tem uma taxa maior de infecção, quando comparado com outros biológicos168.
Ustekinumab – anticorpo monoclonal humano inibidor da IL-12/IL-23, demostrou a sua
eficácia na psoríase169 e também na AP, havendo progressos a nível cutâneo, a nível da entese, melhorando assim a funcionalidade, sendo no geral bem tolerada 18.
ABT – 874 – inibidor da IL-12/IL-23 que demostrou ser eficaz a nível cutâneo, e será
futuramente estudado para AP.
Rituximab – anti- CD20, que causa deplecção dos linfócitos B, usado no tratamento de linfomas
e AR, demostrou eficácia moderada no tratamento articular da AP, principalmente no subgrupo de doentes que não tinham sido expostos a anti-TNF 18.
Apremilast – inibidor da fosfodiesterase-4, que suprime múltiplos mediadores e citoquinas pró-
inflamatórias, foi testado e demostrou um eficácia moderada, estando a ser avaliado em estudos na fase III.
Ana Isabel Parente Abreu Nunes
Tocilizumab – anticorpo monoclonal que inibe a IL-6, está aprovado para o tratamento da AR, e
será testado para aplicação na AP.
Denosumab – fármaco cujo alvo não é a diminuir a inflamação, mas sim a redução das erosões
ósseas, reduzindo a osteoclastogenese. Este concretamente, é inibidor do RANK, estando provada a sua eficácia na osteoporose e AR 18, mantêm -se expectativas do uso deste fármaco na AP, um vez
que existe um excesso produção de osteoclastos e sua activação exagerada.
Ana Isabel Parente Abreu Nunes Um ponto-chave no diagnóstico precoce e no tratamento eficaz é a abordagem multidisciplinar, entre medicina geral e familiar, dermatologia e reumatologia.
A história natural da doença proporciona uma janela de oportunidade potencial para o diagnóstico precoce da AP e o início de tratamento agressivo e eficaz para evitar as consequências devastadoras da doença, como dano articular irreversível. No entanto este assunto levanta limitações pois a severidade real da inflamação ainda é subestimada.
Com o crescente potencial para intervenção precoces, para terapêuticas de longa duração e o uso de cada vez mais terapêuticas eficazes e agressivas, é muito importante podermos conseguir prever a evolução das manifestações reumáticas na AP, de modo a modificar o seu risco e o seu prognóstico.
A avaliação dos pacientes com AP inclui avaliação da inflamação articular, nomeadamente o número de articulações atingidas, avaliação do dano articular, quer clinico quer radiológico, contudo a AP apresenta-se como uma entidade pleomórfica, e consequentemente a relação entre alterações radiológicas – erosão, diminuição do espaço interarticular, anquilose e osteólise – e as alterações clinicas – deformação, limitação do movimento, anquilose – ainda continua desconhecida.
Detecção precoce da AP nos pacientes com doença subclínica é essencial, pois tem o potencial de influenciar positivamente o prognóstico e evolução da doença. Neste contexto a ecografia e a RM desempenham um papel fundamental, na medida que detectam com elevado grau de sensibilidade atingimento subclínico das articulações, tendões e enteses. A ressonância magnética pode avaliar e quantificar as alterações ósseas, podendo ser um exame sensível na avaliação da progressão, no entanto a diversidade de manifestações imagiológicas e a heterogeneidade de apresentação nos diferentes pacientes, constitui um desafio na avaliação da AP. Claramente na AP, a ECO pode definir com mais exactidão o padrão de envolvimento articular. Tanto a Eco como a RM demostraram o seu potencial no diagnóstico precoce de inflamação e monitorização da terapêutica.
Devido á paucidade de informação acerca da AP, estão a ser compilados esforços para desenvolver e validar instrumentos que permitam uma abordagem completa e precisa da AP, que possam desvendar a sus história natural, demonstrar o crescente impacto positivo dos novos esquemas terapêuticos na funcionalidade e qualidade de vida dos pacientes. A maioria dos biomarcadores e ferramentas de avaliação para a AP advém de conhecimentos acerca da AR, o que implica uma semelhança na evolução e fenómeno fisiopatológico, contudo estudos recentes
Ana Isabel Parente Abreu Nunes demonstram a diferença na etiologia e patogenese entre as duas entidades e consequentemente este “copy paste” pode conduzir á escolha inapropriada de biomarcadores e instrumentos de diagnóstico e consequentemente a conclusões erróneas.
Verifica-se que na presença de deformação e erosão articular, os pacientes tem qualidade de vida diminuída significativamente, sendo por isso muito importante o uso de DMARD´s o mais precoce possível, particularmente em pacientes cuja manifestação inicial é o atingimento de padrão poliarticular, pois este grupo de pacientes tem um dano de base maior e por isso um risco elevado de dano futuro, sendo muito importante monitorizar este grupo muito de perto.
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