What is known and objective Rheumatoid arthritis (RA) is an autoimmune disease characterized primarily by inflammation and pain in the joints. Tofacitinib is an oral drug recently approved for RA treatment; it inhibits Janus protein kinases (JAK) that reduces RA symptoms when conventional DMARDs do not trigger a response. This study aimed to compare the efficacy of biological DMARDs in monotherapy or combined with methotrexate in RA patients and compare the treatments. Methods We reviewed the literature for articles published up to June 2017, evaluating the efficacy and safety of the biological DMARDs indicated for RA in patients with inadequate responses to conventional DMARDs and naïve to biological DMARDs, in similar populations, considering ACR50 as the efficacy variable. The odds ratio (OR) and 95% confidence interval (CI) were calculated for each drug combination, and these parameters were transformed into differences in responses to assess the effectiveness of the alternative medicines. Equivalence therapeutic alternatives (ETA) were ensured to assess the possibility of considering these medications with equivalent efficacy. A network meta‐analysis (NMA) was performed using Bayesian approaches and the fixed‐effects model. Results and discussion Twenty‐seven randomized clinical trials (RCTs) that met the pre‐established criteria were identified. The 95% CI of biological DMARDs was higher than that of placebo without methotrexate, except for certolizumab, golimumab‐m, anakinra‐m and adalimumab monotherapy. These DMARDs performed significantly better than the placebo, except for etanercept, certolizumab, tofacitinib and golimumab. Certolizumab‐m was better than anakinra‐m and adalimumab, and tocilizumab alone or combined with methotrexate was superior to adalimumab. Etanercept‐m yielded a higher difference in responses compared with the other biological DMARDs, which presented more homogeneous responses, except for adalimumab and anakinra‐m, which yielded worse results. None of the biological DMARDs displayed ETA to etanercept‐m; however, they displayed ETA with certolizumab‐m, except for adalimumab and anakinra‐m. What is new and conclusion All biological DMARDs used in combination with methotrexate, except for etanercept, anakinra, certolizumab and tocilizumab without methotrexate, were displayed ETA on using ACR50 at week 24 in patients naïve to biological DMARDs. Etanercept displayed a greater difference in responses, although the high uncertainty of the comparative results prevented the confirmation of the increased efficacy of this drug.

BackgroundBenzodiazepines (BZD) have to be reconciled within 24 h of admission to avoid withdrawal symptoms. On the other hand, it’s important to check the discharge report to avoid treatment discrepancies.PurposeTo find out the accuracy of BZD reconciliation at admission and discharge in our hospital.Material and methodsObservational prospective study carried out in a tertiary care hospital over two months. Patients over 65 years and without a relevant psychiatric condition were selected. The BZD prescribed at admission was compared with patient’s home treatment. Clinical data was obtained from the electronic clinical history and electronic prescription. The discharge report was also checked for BZD indications. Reconciliation was classified as “reconciled” (same BZD and same half-life), “partially reconciled” (change to another BZD with different half-life) or “not reconciled”. At discharge, physicians’ indications were revised.Results110 patients were included. The median age was 81 (65–95). They were 71 women (64%) and 39 men (36%). At admission the results were: 1) “Reconciled”: 63 patients (57.3%); 2) “Partially reconciled”: 9 patients (8.2%) and 3) “Not reconciled”: 38 patients (34.5%). At discharge, physicians indicated the following: 1) “Same treatment”: 69 patients (62.7%); 2) “No mention of BZD”: 25 patients (22.7%); 3) “BZD combination”: 5 patients (4.5%); 4) “Changed to other BZD”: 5 patients (4.5%) and 5) “Withdrawal”: 2 patients (1.8%). 4 patients (3.6%) died during the hospitalisation.ConclusionAlmost a third part of patients don’t have their treatment suitably reconciled. It might occur that treatment was changed because it was not warranted, regardless of reconciliation. At discharge, physicians use phrases like “same treatment” or don’t mention anything about BZD. This can lead to treatment discrepancies with Primary Care.References and/or acknowledgementsNo conflict of interest.

BackgroundSurgical patients are especially susceptible to nutritional disorders; additionally an adequate nutritional status is important in achieving prompt recovery.PurposeTo describe and analyse possible shortcomings related to nutritional status of surgical patients associated with an inadequate prescription of parenteral nutrition (PN).Material and methodsA prospective, observational study, lasting two months, of post-surgical patients in a third level hospital with PN support.Estimated calorie requirements (CR) of surgical patients were calculated. The Harris-Benedict formula was the method used to evaluate CR taking into account the degree of metabolic stress in each surgical patient.Data were collected from the medical history of each patient: age, diagnosis, duration of PN support, glycaemia, electrolytes, total proteins and other haematological parameters.An assessment was made of how many blood tests were requested for every patient, at the beginning, during and at the end of parenteral support.ResultsA total of 75 patients were studied. In 19.2% of cases the CR were successfully supplied. In 72.6% of cases the prescribed caloric intake was insufficient compared to their estimated CR. In the remaining 8.2% of cases the caloric intake exceeded their estimated CR.23.2% of the patients studied were obese. In 76.5% of them, the prescribed caloric intake differed from the estimated CR, despite the body weight calculation being adjusted for these patients.ConclusionOur study showed that 80.8% of patients were not given sufficient nutritional support, missing their estimated CR. It shows the lack of a structured protocol to addresses the nutritional assessment in surgical patients.References and/or AcknowledgementsKeith JN. Bedside nutrition assessment past, present, and future: a review of the subjective global assessment. Nutr Clin Pract 2008;23(4):410–16Martins CP, Correia JR, Do Amaral TF. Undernutrition risk screening and length of stay of hospitalized elderly. J Nutr Elder 2005;25(2):5–21No conflict of interest.

Background Imatinib, a tyrosine kinase inhibitor (TKI), is a substrate and inhibitor of cytochrome P450, therefore imatinib can be affected by concomitant drugs or a change in the concentration of other drugs. The absorption of imatinib can also be modified due to interactions. Haouala et al. (2011) reviewed available evidence about it. Purpose To investigate the incidence of, and potential interactions between, imatinib and other drugs the patients were on. Materials and methods This cross-sectional study was done in June 2013. Patients diagnosed with chronic myeloid leukaemia (CML) and treated with imatinib were selected. A database of drug interactions was made. The information was obtained from Micromedex and Lexicomp databases and from several scientific papers. Patients’ other medicines were obtained from the digital treatment histories. Interactions were analysed according to the drug, effects on concentrations, mechanism and severity. Results 41 patients were selected, 56% female. The median age was 59 years (range: 24–91). A total of 73 potential interactions were detected in 33 patients: median of 1.8 interactions per patient (0–7). 45% of the interactions affected the concentration of imatinib: 77% of them could increase its concentration and 23% decrease it. 70% of the interactions affected the metabolism of the TKI and 30% modified its absorption. 55% of the interactions could change the concentration of the other drug (88% in terms of increasing it and 12% decreasing it). Interacting drugs were omeprazole (13%), simvastatin (10%) and ibuprofen (8%). Regarding the severity, 95% were classified as ‘moderate’, 5% as ‘mild’ and none as ‘major’. Conclusions We found a high incidence of potential interactions between imatinib and other medicines. Almost half of the interactions affected imatinib. These findings led us to establish regular communication with physicians to avoid possible adverse effects or lack of efficacy. No conflict of interest.

BackgroundThe vasopressin receptor 2 antagonist tolvaptan is an aquaretic agent that promotes water elimination to resolve hyponatraemia secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). There are ongoing studies researching its effectiveness in hyponatraemia secondary to heart failure, in which patients have body water excess that dilutes sodium.PurposeTo explore the efficacy of tolvaptan off-label use in hyponatraemia secondary to heart failure.Material and methodsObservational retrospective study carried out in a tertiary care hospital. We conducted a search to find all patients treated with tolvaptan. The next step was to identify off-label use in heart failure. Once patients were identified, we extracted their demographic data, laboratory tests and tolvaptan treatment duration and dosages. The data were inserted in an Excel chart to make a descriptive analysis.Results28 patients were found, but only 6 met off-label use criteria (2 women and 4 men). 1 patient passed away 72 h after his admission and was excluded. Median age was 70 years (range 54–80). Only 2 patients had a sodium charge with hypertonic saline fluid before tolvaptan treatment, but their sodium level did not increase. Neither had NaCl oral therapy. Mean tolvaptan dosage (calculated as total tolvaptan dosage in mg divided by treatment duration in days) was 15 ± 5 mg/day. Median treatment duration was 10 days (range 5–15). Mean natraemia levels were 120 ± 6 mEq/L at baseline, 124 ± 11 mEq/L after 24 h of treatment, 127 ± 5 mEq/L after 48 h of treatment and 130 ± 6 mEq/L after 72 h of treatment. The final mean natraemia level was 136 ± 3 mEq/L. The average sodium level increase was 16 ± 3 mEq/L. During tolvaptan treatment, 3 patients were receiving furosemide, 1 furosemide and hydrochlorothiazide, and 1 furosemide, chlorthalidone and spironolactone. These results are  consistent with those found by Salterain-Gonzalez et al (2013) and Rodríguez-de Muñoz et al (2013).ConclusionBased on our data, it seems that tolvaptan is an effective option to increase natraemia in heart failure patients. However, due to our small population, we cannot conclude it categorically.No conflict of interest.