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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Aproximadamente 125 millones de personas sufren psoriasis a nivel mundial &#40;1-3&#37;&#41;&#44; m&#225;s de un mill&#243;n en Espa&#241;a &#40;2&#44;69&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Es una enfermedad inflamatoria sist&#233;mica&#44; con efectos sin&#233;rgicos con otras enfermedades inflamatorias inmunomediadas &#40;IMIDs&#41;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Por este motivo&#44; reconocer el impacto de las comorbilidades asociadas es esencial para un manejo integral<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Entre estas comorbilidades se encuentra la hasta ahora denominada enfermedad hep&#225;tica grasa no alcoh&#243;lica&#59; que en esta revisi&#243;n denominaremos esteatosis hep&#225;tica metab&#243;lica &#40;EHmet&#41;&#44; siguiendo el consenso promovido por la Asociaci&#243;n Espa&#241;ola para el Estudio del H&#237;gado &#40;AEEH&#41;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">4</span></a>&#46; La EHmet engloba un espectro de lesiones hep&#225;ticas&#44; desde la acumulaci&#243;n de grasa en el h&#237;gado considerada un trastorno metab&#243;lico con escaso potencial evolutivo&#44; hasta la forma inflamatoria o esteatohepatitis&#44; con riesgo de evolucionar a cirrosis y sus complicaciones&#46; En la mayor&#237;a de los casos&#44; es asintom&#225;tica y se asocia con el s&#237;ndrome metab&#243;lico &#40;SM&#41;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">5</span></a>&#46; De hecho&#44; se reconoce como la manifestaci&#243;n hep&#225;tica del SM y puede aparecer antes que otras manifestaciones<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; El SM se define como un conjunto de anomal&#237;as metab&#243;licas&#44; entre las que las hep&#225;ticas se consideran fundamentales<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; La EHmet presenta un amplio espectro cl&#237;nico &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; de naturaleza din&#225;mica&#44; con periodos de progresi&#243;n&#44; regresi&#243;n y estabilidad<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; La gen&#233;tica y los cambios en el estilo de vida explican parcialmente esta variabilidad&#46; Otros factores causantes de variabilidad de la enfermedad y su respuesta al tratamiento son la edad&#44; la raza&#44; el consumo de alcohol&#44; el sexo y la microbiota<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">5</span></a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">La prevalencia de la EHmet aumenta progresiva y paralelamente a la prevalencia del SM&#44; la obesidad y la diabetes mellitus tipo 2 &#40;DM2&#41;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">8&#44;10</span></a>&#46; Se estima que la EHmet afecta a 25&#37; de la poblaci&#243;n&#44; llegando a 55&#44;5&#37; en pacientes con DM2&#46; Aunque se desconoce el porcentaje de pacientes con EHmet que desarrollan esteatohepatitis no alcoh&#243;lica &#40;EHNA&#41;&#44; se sabe que supera 10&#37;&#46; La EHNA se diagnostica mediante biopsia en 29&#44;9&#37; de los pacientes con EHmet&#44; pero recientemente esta tasa parece haber aumentado hasta 59&#44;1&#37;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La EHNA progresa a fibrosis en 40&#44;76&#37; de los pacientes<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">8</span></a>&#46; En Espa&#241;a&#44; se estima que la prevalencia de la EHmet es de 25&#44;8&#37;&#44; y el grado de fibrosis significativa&#44; estimada mediante combinaci&#243;n secuencial de elastometr&#237;a de transici&#243;n &#40;ET&#41; y biopsia hep&#225;tica&#44; es de 2&#44;8&#37;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El pron&#243;stico del paciente con EHmet viene condicionado por la evoluci&#243;n hacia EHNA&#44; fibrosis y sus comorbilidades&#59; la morbimortalidad hep&#225;tica aumenta fundamentalmente a partir del estadio de fibrosis avanzada<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; Por ello la EHmet es un importante problema de salud y una causa importante de trasplante hep&#225;tico<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">9&#44;12</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Existen numerosas evidencias de la relaci&#243;n entre psoriasis y EHmet<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">15</span></a>&#46; En general&#44; la prevalencia de EHmet aumenta en pacientes con psoriasis m&#225;s grave<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Phan et al&#46; demostraron una prevalencia de EHmet duplicada en pacientes con psoriasis&#44; comparados con no psori&#225;sicos&#44; confirmando datos publicados anteriormente<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">15&#44;18</span></a>&#46; En Espa&#241;a&#44; 42&#44;3&#37; de los pacientes con psoriasis presentan EHmet<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">19</span></a>&#46; Adem&#225;s&#44; la gravedad de la psoriasis se correlaciona directamente con la de la enfermedad hep&#225;tica<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">20</span></a>&#46; En concordancia&#44; un estudio transversal ha detectado que la fibrosis avanzada es m&#225;s prevalente en pacientes con psoriasis que en controles sanos&#44; siendo la psoriasis un predictor significativo de fibrosis hep&#225;tica avanzada independientemente de otros factores como edad&#44; sexo&#44; &#237;ndice de masa corporal&#44; hipertensi&#243;n y diabetes<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">21</span></a>&#46; De hecho&#44; la psoriasis es un factor de riesgo independiente de EHmet<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; Asimismo&#44; la hipertensi&#243;n&#44; la hiperglicemia y la obesidad son los principales factores de riesgo de EHmet en pacientes con psoriasis y la asociaci&#243;n entre psoriasis y EHmet es independiente de factores de confusi&#243;n&#44; lo que confirma una fisiopatolog&#237;a com&#250;n que implica v&#237;as inflamatorias y predisposici&#243;n gen&#233;tica<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">15</span></a>&#46; Ambas tienen como etiolog&#237;a com&#250;n una inflamaci&#243;n cr&#243;nica de baja intensidad&#44; que implica adipocinas involucradas en el balance energ&#233;tico y citocinas inflamatorias&#58; interleucina- 17 &#40;IL-17&#41;&#44; factor de necrosis tumoral-&#945; &#40;TNF-&#945;&#41; o interleucina-6 &#40;IL-6&#41;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">3&#44;24&#44;25</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Estos precedentes permiten sugerir un abordaje precoz de los pacientes con psoriasis realizando un cribado de la EHmet<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">26</span></a>&#46; La AEEH ha publicado recientemente un consenso sobre detecci&#243;n y derivaci&#243;n de enfermedades hep&#225;ticas prevalentes ocultas&#46; Dos conclusiones operativas del consenso fueron&#58; 1&#41; Hacer valoraci&#243;n y seguimiento de una posible enfermedad hep&#225;tica cr&#243;nica en pacientes con enfermedades dermatol&#243;gicas inmunomediadas&#59; y 2&#41; la prevalencia de hepatopat&#237;a cr&#243;nica aumenta en estas patolog&#237;as&#44; tanto por mecanismos inmunol&#243;gicos como inflamatorios&#44; o por hepatotoxicidad<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para incentivar el manejo multidisciplinar&#44; y con el objetivo de actualizar las recomendaciones de cribado&#44; diagn&#243;stico&#44; monitorizaci&#243;n y criterios de derivaci&#243;n ante la sospecha de EHmet en pacientes con psoriasis&#44; un panel de expertos ha elaborado este documento&#44; bas&#225;ndose en la evidencia cient&#237;fica disponible y en su experiencia en pr&#225;ctica cl&#237;nica real&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Metodolog&#237;a</span><p id="par0045" class="elsevierStylePara elsevierViewall">Para elaborar este documento siete dermat&#243;logos y cinco hepat&#243;logos&#44; especializados en el manejo de la psoriasis y la EHmet&#44; constituyeron un grupo de trabajo&#46; La metodolog&#237;a utilizada se bas&#243; en el denominado &#171;m&#233;todo formal&#187;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">27&#44;28</span></a>&#46; Se empez&#243; evaluando la evidencia cient&#237;fica disponible y cumplimentando varios cuestionarios dise&#241;ados <span class="elsevierStyleItalic">ad hoc</span> para identificar puntos clave sobre identificaci&#243;n&#44; cribado&#44; diagn&#243;stico y manejo de la psoriasis y el riesgo de enfermedad hep&#225;tica&#46; Posteriormente&#44; se analizaron los aspectos cl&#237;nicos de definici&#243;n y manejo del paciente de riesgo en tres reuniones&#46; En la &#250;ltima reuni&#243;n&#44; se desarroll&#243; un algoritmo de manejo del paciente de riesgo y unas recomendaciones de diagn&#243;stico y monitorizaci&#243;n basadas en las principales gu&#237;as de pr&#225;ctica cl&#237;nica &#40;GPC&#41; y en la experiencia en pr&#225;ctica cl&#237;nica real del grupo de expertos&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Identificaci&#243;n de los pacientes con psoriasis y riesgo de enfermedad hep&#225;tica</span><p id="par0050" class="elsevierStylePara elsevierViewall">El panel recomienda cribar los pacientes diagnosticados de psoriasis siguiendo las GPC nacionales<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">29&#44;30</span></a>&#44; independientemente del tratamiento y el tiempo desde el diagn&#243;stico&#44; siempre que presenten al menos una de las condiciones contempladas como criterios acompa&#241;antes del hallazgo de esteatosis en el diagn&#243;stico de la EHmet<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">31</span></a>&#44; es decir&#44; sobrepeso u obesidad&#44; DM2&#44; y&#47;o evidencias de alteraciones metab&#243;licas&#44; las cuales pueden resumirse as&#237;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Circunferencia de la cintura &#8805; 102 cm en hombres y &#8805; 88 cm en mujeres&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Presi&#243;n arterial &#8805; 130&#47;85 mmHg o tratamiento farmacol&#243;gico espec&#237;fico&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Triglic&#233;ridos plasm&#225;ticos &#8805; 150 mg&#47;dL &#40;&#8805; 1&#44;70&#160;mmol&#47;L&#41; o tratamiento farmacol&#243;gico espec&#237;fico&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Colesterol de HDL en plasma &#60; 40&#160;mg&#47;dL &#40;&#60; 1&#44;0&#160;mmol&#47;L&#41; para hombres y &#60; 50&#160;mg&#47;dL &#40;&#60; 1&#44;3&#160;mmol&#47;L&#41; para mujeres&#44; o tratamiento farmacol&#243;gico espec&#237;fico&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Prediabetes &#40;niveles de glucosa en ayunas&#58; 100 a 125&#160;mg&#47;dL &#91;5&#44;6 a 6&#44;9&#160;mmol&#47;L&#93;&#44; o dos horas tras sobrecarga oral&#58; 140 a 199&#160;mg&#47;dL &#91;7&#44;8 a 11&#44;0&#160;mmol&#47;L&#93; o HbA1c&#58; 5&#44;7 a 6&#44;4&#37; &#91;39 a 47&#160;mmol&#47;mol&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">HOMA-IR &#40;modelo homeost&#225;tico para evaluar la resistencia a la insulina&#41; &#8805; 2&#44;5&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Nivel de prote&#237;na C reactiva de alta sensibilidad en plasma &#62; 2&#160;mg&#47;L&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">Ante un paciente con psoriasis y al menos un factor de riesgo de SM&#44; se debe valorar el riesgo o presencia de enfermedad hep&#225;tica&#46; Al ser una enfermedad silenciosa&#44; las GPC nacionales e internacionales aconsejan la identificaci&#243;n precoz del riesgo de estadios progresivos de EHmet&#44; desde la esteatosis a estadios avanzados como la fibrosis&#44; utilizando m&#233;todos no invasivos como el FIB-4<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">10&#44;30&#44;31</span></a>&#46; Se descarta usar valores aislados de transaminasas como m&#233;todo &#250;nico para el diagn&#243;stico precoz de la EHmet&#44; ya que pueden ser normales incluso con fibrosis avanzada<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">32</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Recomendaciones de cribado de la EHmet</span><p id="par0095" class="elsevierStylePara elsevierViewall">Tras identificar un paciente de riesgo&#44; se inicia la primera etapa del algoritmo de cribado y seguimiento recomendado &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">No existe un consenso sobre estrategias de diagn&#243;stico y puntos de corte de herramientas no invasivas &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41; empleadas en lugar de la biopsia hep&#225;tica &#40;prueba de referencia<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">33</span></a>&#44; pero con complicaciones&#41;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">10&#44;22&#44;31</span></a>&#46; Las GPC recomiendan combinar &#237;ndices serol&#243;gicos y la ET&#44; que reduce aproximadamente en 50-60&#37; la necesidad de biopsia y ofrece un diagn&#243;stico preciso<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">34</span></a>&#44; empleando &#237;ndices serol&#243;gicos de fibrosis como primera herramienta de cribado y&#44; en caso de riesgo elevado&#44; la ET&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> enumera diversas herramientas no invasivas de cribado de la fibrosis hep&#225;tica&#46; Se consider&#243; que el marcador serol&#243;gico fibrosis-4 &#40;FIB-4&#41; es la herramienta m&#225;s adecuada para iniciar el cribado en dermatolog&#237;a&#44; ya que se ha validado externamente para el cribado de fibrosis en h&#237;gado graso de pacientes con psoriasis&#44; es de f&#225;cil petici&#243;n y manejo y est&#225; recomendado por las GPC<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">10&#44;22&#44;31</span></a>&#46; El FIB-4 utiliza el recuento plaquetario&#44; la edad y los valores de aspartato aminotransferasa &#40;AST&#41; y alanina aminotransferasa &#40;ALT&#41;&#59; ofrece un alto valor predictivo negativo &#40;VPN&#41; para el diagn&#243;stico de fibrosis avanzada &#40;F3-F4&#41;&#44; permitiendo evitar la biopsia hep&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">35&#44;36</span></a>&#46; Valores del FIB-4 inferiores a 1&#44;30 excluyen la fibrosis avanzada con un VPN de 85&#37;&#59; valores superiores a 2&#44;67 indican fibrosis avanzada con un VPP de 79&#37;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">37</span></a>&#46; No obstante&#44; hay que tener en cuenta el riesgo de falso positivo asociado al VPP&#44; la probabilidad relativamente elevada &#40;1&#47;3&#41; de obtener valores intermedios &#40;1&#44;30-2&#44;67&#41; y el efecto de la edad en la exactitud del pron&#243;stico &#40;se propone un valor umbral de FIB-4 &#61; 2 en mayores de 65 a&#241;os&#41;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">38</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No debe olvidarse que la precisi&#243;n del FIB-4 depende de la edad&#58; no es aplicable en menores de 35 a&#241;os y requiere valores de corte m&#225;s ajustados para incrementar su especificidad en mayores de 65<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">39</span></a>&#46; El <span class="elsevierStyleItalic">Hepamet Fibrosis Score</span> &#40;HFS&#41; es un panel serol&#243;gico m&#225;s espec&#237;fico &#40;con valores predictivos mayores que el FIB-4&#41; y preciso&#44; con menor incertidumbre diagn&#243;stica y la &#250;nica limitaci&#243;n de incluir el &#237;ndice HOMA&#44; que no suele obtenerse de rutina<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">40</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Cuando el &#237;ndice utilizado sugiera riesgo bajo&#44; se recomienda seguimiento bianual por dermatolog&#237;a con reevaluaci&#243;n del &#237;ndice de riesgo<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">31</span></a>&#46; Con riesgo medio&#47;alto&#44; se recomienda la ET<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">31&#44;38&#44;48</span></a>&#46; Esta t&#233;cnica ha demostrado ser efectiva para monitorizar peri&#243;dicamente la gravedad de la enfermedad y diagnostica con elevada precisi&#243;n los estadios avanzados de fibrosis &#40;F3-F4&#41; en correlaci&#243;n con las caracter&#237;sticas cl&#237;nicas del paciente<a class="elsevierStyleCrossRefs" href="#bib0710"><span class="elsevierStyleSup">49&#44;50</span></a> y sin a&#241;adir riesgos&#44; al ser una prueba inocua&#46; No obstante&#44; se debe tener en cuenta que&#44; independientemente de la ET&#44; un FIB-4 elevado indica riesgo aumentado&#59; por lo tanto&#44; la decisi&#243;n depender&#225; de la accesibilidad y utilidad de la ET &#40;c&#243;mo influir&#225; el resultado&#41;&#46; Asimismo&#44; se recomienda derivar para ET a pacientes con FIB-4 intermedio&#44; por su elevada incertidumbre&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Wong et al&#46; demostraron que el valor de ET &#61; 7&#44;9 kPa presenta la mayor precisi&#243;n &#40;sensibilidad 91&#37;&#44; especificidad 75&#37; y VPP 97&#37;&#41; para el diagn&#243;stico de fibrosis avanzada y cirrosis en pacientes con EHmet<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">51</span></a>&#46; Por ello&#44; el punto de corte recomendado en pacientes de riesgo elevado es 8 kPa&#46; Con FIB-4 elevado y ET &#8804; 8 kPa&#44; se reevaluar&#225; anualmente el FIB-4 y&#47;o se solicitar&#225; una nueva ET seg&#250;n disponibilidad&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Si se confirma una ET &#62;8 kPa&#44; con riesgo de fibrosis avanzada &#40;F3-F4&#41;&#44; el paciente se derivar&#225; al Servicio de Aparato Digestivo&#44; en donde se considerar&#225; el manejo m&#225;s adecuado &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Si la ET no estuviera disponible&#44; los pacientes con FIB-4 elevado deben derivarse a un especialista de digestivo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Tratamientos actuales para la psoriasis e impacto sobre la EHmet</span><p id="par0130" class="elsevierStylePara elsevierViewall">Las recomendaciones del panel de expertos se centran en pautas generales a considerar en supuestos cl&#237;nicos frecuentes adaptables&#44; seg&#250;n criterio del especialista&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Las recomendaciones de dieta y ejercicio de las GPC son el pilar del tratamiento de la EHmet<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">31</span></a>&#46; Reducciones de peso &#8805; 10&#37; pueden resolver la EHNA y reducir la fibrosis al menos un estadio&#46; P&#233;rdidas de peso menores &#40;5-10&#37;&#41; pueden mejorar algunos componentes de la EHmet&#46; La dieta mediterr&#225;nea&#44; aun sin p&#233;rdida de peso&#44; reduce el contenido graso del h&#237;gado<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">52</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Actualmente se est&#225;n desarrollando f&#225;rmacos para el tratamiento de la EHmet&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se enumeran algunos ensayos cl&#237;nicos de su eficacia y seguridad&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">En pacientes con ET 6-8 kPa&#44; independientemente del FIB-4&#44; sin enfermedad hep&#225;tica grave&#44; se deben valorar los factores de SM&#44; evaluando el grado de enfermedad metab&#243;lica para estimar el riesgo de progresi&#243;n hacia fibrosis avanzada o cirrosis<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">7</span></a>&#46; As&#237;&#44; se determinar&#225; la monitorizaci&#243;n y pruebas complementarias a realizar con respecto a las recomendaciones en estos perfiles &#40;seguimiento anual y repetici&#243;n de FIB-4&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Los pacientes con psoriasis y hepatopat&#237;a tienen riesgo aumentado de hepatotoxicidad inducida por f&#225;rmacos &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">68</span></a>&#46; Metotrexato &#40;MTX&#41; es el f&#225;rmaco sist&#233;mico convencional m&#225;s utilizado en psoriasis moderada-grave debido a su coste-efectividad y larga trayectoria cl&#237;nica&#44; pero es hepatot&#243;xico y puede favorecer la fibrosis<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">69&#8211;71</span></a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Un reciente estudio espa&#241;ol en pacientes con psoriasis moderada-grave tratados con MTX demostr&#243; correlaci&#243;n entre la duraci&#243;n del tratamiento y el riesgo de fibrosis hep&#225;tica&#58; la proporci&#243;n de pacientes con riesgo de fibrosis avanzada &#40;FIB-4 &#62; 1&#44;3&#41; aument&#243; desde 18&#44;2&#37;&#44; con MTX administrado durante 16-24 semanas&#44; hasta 27&#44;3&#37; y 32&#44;3&#37;&#44; cuando el tratamiento dur&#243; 52-104 semanas y &#62; 104 semanas&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">72</span></a>&#46; Shetty et al<span class="elsevierStyleItalic">&#46;</span> recomiendan adaptar la intensidad y frecuencia de monitorizaci&#243;n dependiendo de los factores de riesgo individuales&#44; y enfatizan el mayor riesgo de da&#241;o hep&#225;tico por MTX en pacientes con EHNA o EHNA-fibrosis<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">71</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Se recomienda monitorizar el da&#241;o hep&#225;tico de pacientes con psoriasis tratados con esteat&#243;genos<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">68</span></a>&#46; Una reciente GPC considera que la amiodarona&#44; el metotrexato&#44; el tamoxifeno y los agentes quimioterap&#233;uticos 5-fluoracilo e irinotec&#225;n son factores de riesgo de EHmet y se deben mantener o retirar en funci&#243;n de sus beneficios potenciales frente al riesgo de progresi&#243;n de la enfermedad hep&#225;tica &#40;recomendaci&#243;n de grado B basada en la extrapolaci&#243;n de estudios de nivel 1 de evidencia&#41;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">89</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Se aconseja realizar ET a pacientes con FIB-4 bajo y tratamiento hepatot&#243;xico<a class="elsevierStyleCrossRefs" href="#bib0820"><span class="elsevierStyleSup">70&#44;89&#44;90</span></a>&#46; Ante pacientes con psoriasis moderada-grave&#44; tratamiento hepatot&#243;xico y ET &#8804; 8 kPa &#40;procedente del brazo FIB-4 alto o reevaluado con FIB-4 bajo debido al tratamiento&#41;&#44; se valorar&#225; continuar el tratamiento con f&#225;rmacos hepatot&#243;xicos seg&#250;n el balance riesgo-beneficio individualizado&#44; teniendo en cuenta las recomendaciones del hepat&#243;logo&#46; Se desaconsejan los f&#225;rmacos hepatot&#243;xicos en pacientes con FIB-4 alto y&#47;o ET &#62; 8 kPa&#44; debido al riesgo de fibrosis avanzada &#40;F3-F4&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="par0170" class="elsevierStylePara elsevierViewall">La definici&#243;n consensuada entre dermat&#243;logos y hepat&#243;logos de criterios sencillos basados en la evidencia para identificar&#44; diagnosticar y monitorizar individuos de riesgo resulta fundamental para el manejo eficiente de la EHmet&#46; Las recomendaciones generales deber&#225;n adaptarse a las peculiaridades&#44; necesidades y posibilidades organizativas y asistenciales de los distintos centros y profesionales&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Debe considerarse la interacci&#243;n entre los tratamientos de la psoriasis y la EHmet&#44; teniendo en cuenta tanto la prevalencia de la patolog&#237;a hep&#225;tica como el impacto potencial y diverso de los f&#225;rmacos&#46; Es necesario ponderar el balance entre riesgo y beneficio del uso continuado de tratamientos con potencial hepatot&#243;xico en pacientes con riesgo de fibrosis hep&#225;tica&#44; realizando una evaluaci&#243;n y seguimiento individualizados&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">De todos los tratamientos investigados&#44; el riesgo de desarrollar y&#47;o empeorar la EHmet solo aumenta con el MTX&#46; La fototerapia y algunos tratamientos convencionales de nueva generaci&#243;n no han demostrado hepatotoxicidad en pacientes con esteatosis hep&#225;tica&#46; Por su parte&#44; aunque la mayor&#237;a de las terapias biol&#243;gicas presenta un balance riesgo-beneficio favorable en pacientes con esteatosis hep&#225;tica y grados variables de fibrosis&#44; su potencial hepatot&#243;xico es diverso &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="par0185" class="elsevierStylePara elsevierViewall">Ante la prevalencia de la EHmet en pacientes con psoriasis y la interrelaci&#243;n entre ambas patolog&#237;as recomendamos el despistaje de enfermedad hep&#225;tica en pacientes con psoriasis y alg&#250;n componente de EHmet&#44; independientemente del grado de alteraci&#243;n de la bioqu&#237;mica hep&#225;tica&#46; El despistaje ser&#225; sistem&#225;tico&#44; como parte del proceso asistencial de la psoriasis en las consultas o unidades asistenciales de dermatolog&#237;a&#46; La estrategia recomendada de mayor valor es la aplicaci&#243;n combinada del &#237;ndice serol&#243;gico FIB-4 y la ET y la derivaci&#243;n del paciente a hepatolog&#237;a cuando se detecte riesgo significativo de fibrosis avanzada&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Financiaci&#243;n</span><p id="par0190" class="elsevierStylePara elsevierViewall">Las reuniones del panel de expertos fueron financiadas por Novartis Farmac&#233;utica S&#46;A&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflictos de intereses</span><p id="par0195" class="elsevierStylePara elsevierViewall">Novartis ha facilitado la celebraci&#243;n de las reuniones para los integrantes del grupo&#44; pero ninguno de sus empleados ha participado en el desarrollo y elaboraci&#243;n del material cient&#237;fico&#44; las discusiones o el texto escrito&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Antonio Olveira ha participado como investigador&#44; ponente o consultor en proyectos patrocinados por&#58; Abbvie&#44; Alexion&#44; BMS&#44; Janssen&#44; MSD&#44; Gilead&#44; Novartis&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Isabel Belinch&#243;n ha sido consultora y&#47;u oradora y&#47;o particip&#243; en ensayos cl&#237;nicos patrocinados por compa&#241;&#237;as que fabrican medicamentos utilizados para el tratamiento de la psoriasis&#44; incluyendo Janssen Pharmaceuticals Inc&#46;&#44; Almirall SA&#44; Lilly&#44; Abbvie&#44; Novartis&#44; Celgene&#44; Biogen&#44; Amgen&#44; LEO Pharma&#44; Pfizer-Wyeth&#44; MSD y UCB&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Pedro Herranz ha participado como investigador&#44; ponente o consultor en proyectos patrocinados por&#58; Abbvie&#44; Almirall&#44; Amgen&#44; Celgene&#44; LEO Pharma&#44; Lilly&#44; Novartis&#44; Pfizer&#44; Sandoz&#44; Sanofi&#44; UCB&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Javier Crespo ha participado como investigador&#44; ponente o consultor en proyectos patrocinados por&#58; Abbvie&#44; Alexion&#44; BMS&#44; Amgen&#44; Celgene&#44; Gilead&#44; Janssen&#44; MSD&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Eva Vilarrasa ha percibido honorarios de consultor&#237;a&#47;orador de y&#47;o particip&#243; en ensayos cl&#237;nicos patrocinados por Abbvie&#44; Almirall&#44; Amgen&#44; Bayer&#44; Boehringer Ingelheim&#44; Celgene&#44; Gebro&#44; Isdin&#44; Janssen&#44; LEO Pharma&#44; Lilly&#44; Merck-Serono&#44; MSD&#44; Novartis&#44; Pfizer&#44; Roche&#44; Sandoz&#44; Sanofi y UCB&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Salvador Benlloch P&#233;rez ha participado como investigador&#44; ponente&#44; o consultor en proyectos y ensayos cl&#237;nicos patrocinados por Novartis&#44; Novo Nordisk&#44; Gilead&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Jorge Alonso Su&#225;rez P&#233;rez ha participado como miembro de &#171;<span class="elsevierStyleItalic">steering committee</span>&#187; y&#47;o invitado como ponente por Novartis&#44; LEO Pharma&#44; Abbvie&#44; Lilly&#44; Janssen&#44; UCB&#44; Amgen y Almirall&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Jos&#233; Manuel Carrascosa ha participado como IP&#47;SI y&#47;o asesor o miembro del comit&#233; directivo y&#47;o ponente invitado de Novartis&#44; LEO Pharma&#44; Abbvie&#44; Lilly&#44; Janssen&#44; UCB&#44; Sandoz&#44; Mylan&#44; Amgen&#44; Almirall&#44; Bristol-Myers-Squibb y Boehringer Ingelheim&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Javier Ampuero declara no tener conflictos de inter&#233;s&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Francisco Guimer&#225; declara no tener conflictos de inter&#233;s&#46;</p></span></span>"
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              "titulo" => "Recomendaciones de cribado de la EHmet"
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              "titulo" => "Tratamientos actuales para la psoriasis e impacto sobre la EHmet"
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    "fechaRecibido" => "2022-11-10"
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            1 => "Metabolic-associated fatty liver disease"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En los &#250;ltimos a&#241;os se est&#225;n haciendo notables esfuerzos para entender la relaci&#243;n existente entre la psoriasis y la esteatosis hep&#225;tica metab&#243;lica &#40;EHmet&#41;&#46; No solo se presenta este trastorno en pacientes psori&#225;sicos con una mayor prevalencia&#44; sino que adem&#225;s se acompa&#241;a de una mayor gravedad&#46; Con este precedente&#44; se evidencia la necesidad de establecer un protocolo de abordaje precoz de la enfermedad hep&#225;tica en los pacientes con psoriasis&#46; Asimismo&#44; es de especial relevancia la evaluaci&#243;n de riesgo y beneficio en referencia al uso de tratamientos con potencial hepatot&#243;xico&#46; En el presente manuscrito se exponen las recomendaciones de un panel de expertos en dermatolog&#237;a y hepatolog&#237;a para el cribado&#44; diagn&#243;stico&#44; monitorizaci&#243;n y criterios de derivaci&#243;n en pacientes con psoriasis&#44; en caso de sospecha de esteatosis hep&#225;tica metab&#243;lica&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Recent years have seen concerted efforts to understand the relation between psoriasis and metabolic-associated fatty liver disease &#40;MAFLD&#41;&#46; Not only is MALFD diagnosed more often in patients with psoriasis&#44; but its clinical course is also more aggressive&#46; A common approach is therefore needed to enable early detection of liver disease coincident with psoriasis&#46; Especially important is an analysis of risks and benefits of potentially hepatotoxic treatments&#46; This consensus paper presents the recommendations of a group of experts in dermatology and hepatology regarding screening for MALFD as well as criteria for monitoring patients and referring them to hepatologists when liver disease is suspected&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Todos los componentes del Grupo de Trabajo para el Abordaje Com&#250;n de la Psoriasis y la EHmet &#40;GACPE&#41; est&#225;n relacionados en el <a class="elsevierStyleCrossRef" href="#sec0050">anexo</a>&#46;</p>"
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            "apendice" => "<p id="par0250" class="elsevierStylePara elsevierViewall">El Grupo de Trabajo para el Abordaje Com&#250;n de la Psoriasis y la EHmet &#40;GACPE&#41; est&#225; constituido por siete dermat&#243;logos y cinco hepat&#243;logos&#44; especializados en el manejo de la psoriasis y la EHmet&#58;</p>"
            "etiqueta" => "Anexo"
            "titulo" => "Grupo de Trabajo para el Abordaje Com&#250;n de la Psoriasis y la EHmet &#40;GACPE&#41;&#58;"
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                "apendice" => "<p id="par0260" class="elsevierStylePara elsevierViewall">Jorge Alonso Su&#225;rez-P&#233;rez&#46; Departamento de Dermatolog&#237;a&#44; Hospital Universitario Virgen de la Victoria&#44; M&#225;laga&#44; Espa&#241;a&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Susana Armesto Alonso&#46; Departamento de Dermatolog&#237;a&#44; Hospital Universitario Marqu&#233;s de Valdecilla&#44; Santander&#44; Espa&#241;a&#46;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Isabel Belinch&#243;n Romero&#46; Departamento de Dermatolog&#237;a&#44; Hospital General Universitario de Alicante&#44; Instituto de Investigaci&#243;n Sanitaria y Biom&#233;dica &#40;ISABIAL&#41;&#44; Universidad Miguel Hern&#225;ndez de Elche&#44; Alicante&#44; Espa&#241;a&#46;</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Jos&#233; Manuel Carrascosa Carrillo&#46; Departamento de Dermatolog&#237;a&#46; Hospital Universitario Germans Trias i Pujol&#46; Universitat Aut&#242;noma de Barcelona&#46; IGTP Badalona&#44; Espa&#241;a&#46;</p> <p id="par0280" class="elsevierStylePara elsevierViewall">Francisco Guimer&#225; Mart&#237;n-Neda&#46; Servicio de Dermatolog&#237;a y Patolog&#237;a&#44; Hospital Universitario de Canarias&#44; La Laguna&#44; Espa&#241;a&#46;</p> <p id="par0285" class="elsevierStylePara elsevierViewall">Pedro Herranz Pinto&#46; Departamento de Dermatolog&#237;a&#44; Hospital Universitario La Paz&#44; Madrid&#44; Espa&#241;a&#46;</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Eva Vilarrasa Rull&#46; Departamento de Dermatolog&#237;a&#44; Hospital Santa Creu i Sant Pau&#44; Universitat Aut&#242;noma de Barcelona&#44; Barcelona&#44; Espa&#241;a&#46;</p>"
                "titulo" => "Dermat&#243;logos"
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          "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Progresi&#243;n de la EHmet&#46; Desde la esteatosis hep&#225;tica &#40;estable&#44; con escaso riesgo de progresi&#243;n&#44; caracterizada por la acumulaci&#243;n de grasa intracelular en el hepatocito&#41;&#44; pasando por la evoluci&#243;n a esteatohepatitis no alcoh&#243;lica &#40;EHNA&#41; &#40;cuando la infiltraci&#243;n de grasa va acompa&#241;ada de cambios inflamatorios y da&#241;o celular&#41;&#44; y el desarrollo de fibrosis hep&#225;tica &#40;dep&#243;sito de col&#225;geno en forma de septos fibrosos que provocan una alteraci&#243;n arquitectural y disfunci&#243;n progresiva del hepatocito&#41;&#46; La fibrosis predispone al desarrollo de cirrosis &#40;septos fibr&#243;ticos y n&#243;dulos de regeneraci&#243;n&#41; y carcinoma hepatocelular &#40;CHC&#41; y&#47;o fallo hep&#225;tico<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">6&#44;8&#44;10&#44;12&#8211;14</span></a>&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#205;ndice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Estadio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Par&#225;metros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t">HSI<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">41</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Esteatosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ALT&#47;AST&#44; IMC&#44; sexo&#44; diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 30&#58; bajo&#62; 36&#58; alto</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FLI<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">42</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Esteatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Per&#237;metro abdominal&#44; IMC&#44; triglic&#233;ridos&#44; GGT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 30&#58; bajo30-59&#58; intermedio&#8805; 60&#58; alto</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NAFLD-FS <a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">43</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Hiperglucemia en ayunas&#47;DM&#44; edad&#44; IMC&#44; ALT&#44; AST&#44; plaquetas&#44; alb&#250;mina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice FIB-4<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">44</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Edad&#44; ALT&#44; AST&#44; plaquetas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 1&#44;30&#58; F0-F2&#44; bajo&#62; 2&#44;67&#58; F3-F4&#44; alto</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HFS<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">40</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexo&#44; edad&#44; DM&#44; glucosa&#44; insulina&#44; HOMA &#40;No DM&#41;&#44; AST&#44; alb&#250;mina&#44; plaquetas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Valor HFS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">F2-F4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">F3-F4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">F4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">APRI<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">45</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AST&#44; plaquetas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F0-F2&#58; &#60; 0&#44;5&#59; 72&#44;7&#37;F3-F4&#58; &#62; 1&#44;5&#59; 54&#44;2&#37;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice BARD<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">46</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ALT&#44; AST&#44; DM&#44; IMC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#205;ndice ELF<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AH&#44; PIIINP&#44; TIMP-1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 7&#44;7&#58; nulo o bajo&#8805; 7&#44;7-9&#44;7&#58; moderado&#8805; 9&#44;8 alto</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#205;ndices para el diagn&#243;stico no invasivo de la EHmet</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ACC&#58; acetil-coenzima A carboxilasa&#59; ASK1&#58; cinasa reguladora de la se&#241;al de apoptosis 1&#59; CCR2&#47;5&#58; correceptor de quimiocinas 2&#47;5&#59; FGF21&#58; factor de crecimiento de fibroblastos 21&#59; FXR&#58; receptor X farnesoide&#59; GLP1&#58; p&#233;ptido similar al glucag&#243;n 1&#59; HSP47 siRNA&#58; &#225;cido ribonucleico peque&#241;o de interferencia de la prote&#237;na de choque t&#233;rmico 47&#59; PPAR&#945;&#47;&#948;&#58; receptores activados por proliferadores peroxisomales &#945;&#47;&#948;&#59; SCD&#58; estearoil-coenzima A desaturasa&#59; SGLT2&#58; cotransportador de sodio-glucosa tipo 2&#59; TLR4&#58; receptor tipo toll 4&#59; TR&#946;&#58; receptor &#946; de hormona tiroidea&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F&#225;rmaco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes&#44; resistencia a la insulina</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Semaglutida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">An&#225;logo del receptor GLP1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">54</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Canagliflozina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor SGLT2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">piloto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">55</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMS-986036&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FGF21 recombinante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dislipemia</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aramcol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor SCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Firsocostat &#40;GS-0976&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor ACC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">58</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Receptor nuclear</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;cido obetic&#243;lico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Agonista FXR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Elafibranor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Agonista PPAR&#945;&#47;&#948;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Resmetirom &#40;MGL-3196&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Agonista TR&#946;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">61</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apoptosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Emricasan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor caspasas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">62</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflamaci&#243;n&#44; fibrosis</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Selonsertib&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor ASK1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">63</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cenicriviroc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antagonista CCR2&#47;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">64</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GR-MD-02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidor de galectina-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">65</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">JKB-121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antagonista TLR4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">66</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND-LO2-s0201&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HSP47 siRNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">67</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ensayos cl&#237;nicos de tratamientos para la EHmet &#40;adaptado de<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">53</span></a>&#41;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">NA&#58; no aplicable &#40;no existen estudios al respecto&#41;&#59; BILt&#58; bilirrubina total&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El grupo de inhibidores de TNF incluye etanercept&#44; adalimumab e infliximab&#46; El grupo de anti-IL17A incluye brodalumab&#44; ixekizumab y secukinumab&#46; El grupo de anti-IL23 incluye tildrakizumab&#44; guselkumab&#44; risankizumab&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F&#225;rmaco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Toxicidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tipo de da&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">En insuficiencia hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Riesgo incrementado de da&#241;o hep&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metotrexato<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">69&#8211;73</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Da&#241;o oxidativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Uso con precauci&#243;nContraindicado si BILt &#62; 5 mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EHmet&#47;obesidad&#44; leflunomida&#44; alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acitretina<a class="elsevierStyleCrossRefs" href="#bib0855"><span class="elsevierStyleSup">74&#44;75</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disfunci&#243;n mitocondrial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contraindicado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hipertransaminemia de 15-30&#37;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">75</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inhibidores TNF<a class="elsevierStyleCrossRefs" href="#bib0865"><span class="elsevierStyleSup">76&#8211;78</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fallo hep&#225;tico&#44; hepatitis no infecciosa&#44; insuficiencia hep&#225;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento de riesgo de da&#241;o hep&#225;tico con adalimumab<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">79</span></a> y hepatitis autoinmune con infliximab<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">78</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ab IL-12&#47;23<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">79</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ab IL-23<a class="elsevierStyleCrossRefs" href="#bib0925"><span class="elsevierStyleSup">80&#8211;82</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aumento de las transaminasas<a class="elsevierStyleCrossRef" href="#tblfn0025">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ab IL-17<a class="elsevierStyleCrossRefs" href="#bib0890"><span class="elsevierStyleSup">83&#8211;85</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posible efecto protector de la inhibici&#243;n de IL-17A en modelos animales<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">86</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apremilast<a class="elsevierStyleCrossRef" href="#bib0940"><span class="elsevierStyleSup">87</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ciclosporina<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">88</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rara&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Da&#241;o oxidativo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SeguroRequiere reducci&#243;n de dosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidad&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Solo guselkumab&#44; en estudios de artritis psori&#225;sica&#44; seg&#250;n ficha t&#233;cnica&#46;</p>"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">F&#225;rmacos empleados en el tratamiento de la psoriasis y su impacto hep&#225;tico &#40;adaptada de<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">25&#44;69&#8211;88</span></a>&#41;</p>"
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Escalas de gravedad de la psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BSA<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;</a> 10&#37; o PASI<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;&#42;</span></a> &#62; 10 o DLQI<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a> &#62; 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Localizaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#193;reas expuestas &#40;regi&#243;n facial y dorso de manos&#41;&#44; palmas&#44; plantas&#44; genitales&#44; cuero cabelludo&#44; u&#241;as y placas recalcitrantes&#44; con impacto funcional o psicol&#243;gico para el paciente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fracaso de terapias previas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No controlable con tratamiento t&#243;pico o fototerapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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