Alexander and the Guidelines: the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis

EDITORIAL

Alexander and the Guidelines - the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis

Alexander and the Guidelines - the importance of strategy and the guidelines for the diagnosis and medicamentous treatment of rheumatoid arthritis

Alexander III, who would enter History as "the Great", son of Philip II and Olympias, was born in Pella, the capital of the Ancient Greek Kingdom of Macedon, in the year 356 b.C. When he died, at the age of 33 years, somewhere in Babylon, he had conquered all the world then known - and had the following titles King of Macedon, King of Greece, Lord of Asia, Shahanshah of Persia, Pharaoh of Egypt and Hegemon of the Hellenic League. As his greatest legacy, Alexander had fused the Greek culture to the Eastern culture, forming the base of the later called Hellenistic Civilization, which influenced profoundly several aspects of the current Western culture.¹

But why are we writing about Alexander, the Great, in a scientific editorial on the guidelines for rheumatoid arthritis (RA)? Because Alexander was, more than a great conqueror, a brilliant strategist, maybe the greatest in entire History. The word 'strategy' comes from the ancient Greek (stratos, "army", and ago, "leadership" or "command"), and designated the military commander at the time of Athenian democracy. Currently, the term 'strategy' can be understood as a way to plan the future, integrated in the decision making process and based on a formalized procedure that articulates results. Using the figure of a great strategist to illustrate the elaboration and publication of guidelines is part of the strategy of the Brazilian Society of Rheumatology (SBR) to spread and implant knowledge based on scientific evidence for the diagnosis and treatment of RA in Brazil.

Rheumatoid arthritis is a chronic systemic disease, usually progressive, that affects 0.5%-1% of the world population, characterized by inflammatory involvement of the synovial membrane, mainly in peripheral joints. The daily fight of rheumatologists against that disease comprises treating the pain and preventing or delaying both structural joint damage and functional and labor disability, in addition to preventing early mortality of the patients. Success in this battle depends mainly on the adoption of proper strategies, including early diagnosis and adequate treatment as soon as possible in the RA natural history.

The SBR, through its Rheumatoid Arthritis Committee, has elaborated over the past two years four consensual documents guiding the diagnosis and treatment of RA in Brazil, including peculiarities such as management of comorbidities and vaccination of patients immunosuppressed by the disease and its treatment.^2-5

Consensus documents are educational instruments, rather than normative guidelines, that allow their authors to add information originating from experience and experts' opinion to scientific evidence. If, as a publication, the consensus loses in grade of recommendation and level of evidence, it gains as an educational tool to prize the experience of those who deal with daily practice difficulties in managing the disease.^6,7

The Guidelines Project of the Brazilian Medical Association (AMB) and the Federal Board of Medicine (CFM), was aimed at producing diagnostic, therapeutic and, when applicable, preventive guidance, based on scientific evidence, conciliating information of the medical area to standardize management that helps physician's reasoning and decision making. The documents present the grade of recommendation and level of scientific evidence published, preserving in its elaboration the autonomy of the authors, medical experts, of the texts.⁸

Thus, that was the strategy of the Rheumatoid Arthritis Committee when elaborating both documents presented in this issue of the Revista Brasileira de Reumatologia - the Guidelines for the Diagnosis of RA⁹ and the Guidelines for the Medicamentous Treatment of RA.¹⁰ The elaboration of the texts carefully followed the recommendations of the AMB and the CFM, the result being evidence-based responses to the following questions: Are the new 2010 ACR/EULAR classification criteria for RA superior to the 1987 classification criteria of the early phase of disease? Are genetic markers (search for HLA-DRB1 alleles - shared epitope and PTPN22 genes) useful to characterize patients with poorer prognosis of RA? Is it feasible to treat the disease to achieve remission? Does the use of corticosteroids in the early phase of disease improve the patient's prognosis?

Although the personality and some actions of Alexander the Great might be questioned, studying how he managed his armies and his actions to conquer Persia and Asia, including the historical battles of Gaugamela, Issus, Granicus and Hydaspes, leads us to conclude that there is a close relationship between the success achieved by Alexander and the proper use of the entire management process, formally conceived and used to a specific purpose, i.e., the implementation of strategies.¹¹ We hope that, by reading and applying the strategies proposed by the guidelines currently published, rheumatologists, and, to a lesser extent, their patients, can be as victorious in their fight against RA as was the magnificent strategist Alexander in his many battles.

"And it happened afterwards that Alexander, the son of Philip the Macedonian, who first reigned in Greece having come from the land of Kittim, struck Darius the king of the Persians and the Medes. He appointed many battles, and took hold of all the fortifications and he executed the kings of the earth. And he passed through even to the ends of the earth. And he received the spoils of many nations. And the earth was silenced in his sight."

Maccabees 1, 1-3

Licia Maria Henrique da Mota

Medical School, Universidade de Brasília (UnB),

Brasília, DF, Brazil

Brazilian Society of Rheumatology Rheumatoid

Arthritis Committee

E-mail: [e-mail]

Geraldo da Rocha Castelar Pinheiro

Discipline of Rheumatology, Universidade do Estado do

Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil

REFERENCES

• ¹
  Bose P. Alexander the Great's Art of Strategy. Crows Nest, N.S.W: Allen & Unwin; 2003.
• ²
  Mota LMH, Cruz BA, Brenol CV, Pereira IA, Fronza LS, Bertolo MB, et al. 2011 Consensus of the Brazilian Society of Rheumatology for diagnosis and earlyassessment of rheumatoid arthritis. Rev Bras Reumatol. 2011;51(3):199-219.
• ³
  da Mota LM, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al.; Brazilian Society of Rheumatology. 2012 Brazilian Society of Rheumatology Consensus for the treatment of rheumatoid arthritis. Rev Bras Reumatol. 2012;52(2):152-74.
• ⁴
  Pereira IA, Mota LM, Cruz BA, Brenol CV, Fronza LS, Bertolo MB, et al.; Brazilian Society of Rheumatology. 2012 Brazilian Society of Rheumatology Consensus on the management of comorbidities in patients with rheumatoid arthritis. Rev Bras Reumatol. 2012;52(4):474-95.
• ⁵
  Brenol CV, Mota LCH, Cruz BA, Pileggi GS, Pereira IA, Rezende LS, et al. Consenso 2012 da Sociedade Brasileira de Reumatologia sobre vacinação em pacientes com artrite reumatoide. Rev Bras Reumatol. 2013;53(1):4-23.
• ⁶
  da Mota LM. Considerations about the 2011 consensus of the Brazilian Society of Rheumatology for diagnosis and early assessment of rheumatoid arthritis. Rev Bras Reumatol. 2011;51(3):197-8.
• ⁷
  Mota LM. On mosaics and consensus: Gaudí, Brazil and rheumatoid arthritis. Rev Bras Reumatol. 2012;52(2):133-4.
• ⁸
  Projeto Diretrizes. [Accessed on: 22 fevereiro 2013] Available from: http://www.projetodiretrizes.org.br
• ⁹
  Mota LMH, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al., Sociedade Brasileira de Reumatologia, Sociedade Brasileira de Pneumologia e Tuberculose, Colégio Brasileiro de Radiologia. Diretrizes para o diagnóstico da artrite reumatoide. Rev Bras Reumatol. 2013;53(2):141-57.
• ¹⁰
  Mota LMH, Cruz BA, Brenol CV, Pereira IA, Rezende-Fronza LS, Bertolo MB, et al., Sociedade Brasileira de Reumatologia. Diretrizes para o tratamento da artrite reumatoide. Rev Bras Reumatol. 2013;53(2):158-83.
• ¹¹
  Rodrigues RC. Alexandre, "o Grande", e a informação para o planejamento estratégico. Inf Soc. 2007;17(2):74-85.

Publication Dates

• Publication in this collection
  30 Oct 2015
• Date of issue
  Apr 2013