风湿

类风湿关节炎早期缓解者的预后最佳

作者:北医三院建磊磊 来源:中国风湿病公众论坛 日期:2017-12-12
导读

         早期RA患者进行5年的DFR指导治疗可达到几乎正常的功能活动,且在治疗组之间未发生临床相关的关节损伤。

关键字:  类风湿关节炎 

        目的

        明确早期诱导缓解治疗5年的结局,而后针对早期类风湿关节炎患者进行无药物靶向缓解(DFR)治疗。

        方法

        12家医院的610例早期(<2年)类风湿关节炎(RA)或未分化关节炎(UA)患者起始给予甲氨蝶呤(MTX)25mg/周,泼尼松(60mg /天逐渐减至7.5mg /天)。非早期缓解的患者(4个月后的疾病活动评分<1.6)随机分至臂1(单盲),加400mg/日羟氯喹和柳氮磺胺吡啶2000mg/天,或随机分至臂2,调整为MTX加阿达木单抗40mg/2周。随时间调整治疗以达到DFR。结局是5年的缓解率、功能变化、毒性和放射学损伤进展。

        结果

        治疗4个月后,387例患者处于早期缓解状态,83例患者随机分至臂1和78例随机分至臂2.5年后,610例中有295例患者(48%)获得缓解,26%患者获得持续性DFR(SDFR)(≥1年)[(387例早期缓解组中220例(57%)患者缓解和135例(35%)SDFR),随机对照组中的50%缓解,11%SDFR,组间无差异)]。37%UA患者(RA占23%,P= 0.001)和37%抗瓜氨酸蛋白抗体(ACPA)阴性患者(ACPA阳性患者占18%,P<0.001)达到SDFR。总体来看,平均健康评估问卷 为0.6(0.5),中位(IQR)损伤进展为0.5(0-2.7)夏普/范德赫伊德点,5年内仅有5例患者进展大于25分。

        结论

        早期RA患者进行5年的DFR指导治疗可达到几乎正常的功能活动,且在治疗组之间未发生临床相关的关节损伤。早期缓解的患者临床疗效最佳。随机分组之间没有差异。SDFR是一个现实的治疗目标。

        原 文

        Abstract

        OBJECTIVES:To determine the 5-year outcomes of early remission induction therapy followed by targeted treatment aimed at drug-free remission (DFR) in patients with earlyarthritis.

        METHODS:In 12 hospitals, 610 patients with early (<2 years)rheumatoid arthritis(RA) or undifferentiatedarthritis(UA)started on methotrexate (MTX) 25 mg/week and prednisone (60mg/day tapered to 7.5mg/day). Patientsnotin early remission (Disease Activity Score <1.6 after 4 months) were randomised (single blind) to arm 1, adding hydroxychloroquine 400mg/day and sulfasalazine 2000mg/day, or arm 2, switching to MTX plus adalimumab 40mg/2weeks. Treatment adjustments over time aimed at DFR. Outcomes were remission percentages, functional ability, toxicity and radiological damage progression after 5years.

        RESULTS:After 4months, 387 patients were in early remission,83 were randomised to arm 1 and 78 to arm 2. After 5years, 295/610 (48%) patients were in remission, 26% in sustained DFR (SDFR) (≥1year) (220/387 (57%) remission and 135/387 (35%) SDFR in the early remission group, 50% remission, 11% SDFR in the randomisation arms without differences between the arms). More patientswith UA (37% vs 23% RA, p=0.001) and more anticitrullinated protein antibody(ACPA)-negative patients (37% vs 18% ACPA-positive, p<0.001) achieved SDFR.Overall, mean Health Assessment Questionnaire was 0.6 (0.5), and median (IQR) damage progression was 0.5 (0-2.7) Sharp/van der Heijde points, with only five patients showing progression >25 points in 5 years.

        CONCLUSIONS:Five years of DFR-steered treatment in patients with early RA resulted in almost normal functional ability without clinically relevant joint damage across treatment groups.Patients who achieved early remission had the best clinical outcomes. There were no differences between the randomisation arms. SDFR is a realistic treatment goal.

        引自:Akdemir G,HeimansL,Bergstra SA, et al. Clinical and radiological outcomes of 5-year drug-free remission-steered treatment in patients with earlyarthritis:IMPROVED study [J]. Ann Rheum Dis.2017 Sep28. pii : annrheumdis - 2017 - 211375. doi : 10. 1136 / annrheumdis - 2017 - 211375.

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