类风湿关节炎的诊断和治疗,JAMA

当前位置： X-MOL 学术 › JAMA › 论文详情

Our official English website, www.x-mol.net, welcomes your feedback! (Note: you will need to create a separate account there.)

类风湿关节炎的诊断和治疗
JAMA ( IF 63.1 ) Pub Date : 2018-10-02 , DOI: 10.1001/jama.2018.13103
Daniel Aletaha ₁ , Josef S Smolen ₁

Affiliation

重要性类风湿性关节炎 (RA) 发生在每 1000 人中约 5 人，可导致严重的关节损伤和残疾。在过去的 20 年中，在对疾病病理生理学、最佳结果测量和有效治疗策略的理解方面取得了重大进展，包括认识到早期诊断和治疗 RA 的重要性。观察 RA 的早期诊断和治疗可以在多达 90% 的患者中避免或显着减缓关节损伤的进展，从而防止不可逆转的残疾。用于测量疾病活动和确定是否存在缓解的新型仪器的开发促进了新的治疗策略，以在关节受到不可逆转的损害之前阻止 RA。通过认识到早期诊断和早期治疗疾病改善抗风湿药物 (DMARDs) 的益处，结果得到了改善。治疗目标是缓解或至少处于低疾病活动状态，应在 6 个月内达到。甲氨蝶呤是一线治疗药物，应以每周 25 毫克的最佳剂量开具处方，并与糖皮质激素联合使用；40% 至 50% 的患者通过该方案达到缓解或至少低疾病活动性。如果这种治疗失败，靶向治疗的序贯应用，例如生物制剂（例如，肿瘤坏死因子 [TNF] 抑制剂）或 Janus 激酶抑制剂与甲氨蝶呤联合使用，可使多达 75% 的患者达到治疗目标超过时间。针对新的发病机制发现，已经开发了新的疗法。一些疗法的成本相当可观，但随着生物仿制药（与原始生物药物基本相同但通常成本较低的药物）的出现，这些成本正在降低。结论和相关性科学进步改进了治疗方法，可防止多达 90% 的 RA 患者出现不可逆关节损伤的进展。早期使用甲氨蝶呤加糖皮质激素治疗，随后使用其他 DMARDs，如 TNF、IL-6 或 Janus 激酶抑制剂，可改善预后并预防 RA 相关残疾。旨在在 3 个月内将疾病活动性降低至少 50% 并在 6 个月内达到缓解或低疾病活动性的靶向治疗策略，如果需要，进行序贯药物治疗，可以预防 RA 相关的残疾。但随着生物仿制药（与原始生物药物基本相同但通常成本较低的药物）的出现，这些成本正在降低。结论和相关性科学进步改进了治疗方法，可防止多达 90% 的 RA 患者出现不可逆关节损伤的进展。早期使用甲氨蝶呤加糖皮质激素治疗，随后使用其他 DMARDs，如 TNF、IL-6 或 Janus 激酶抑制剂，可改善预后并预防 RA 相关残疾。旨在在 3 个月内将疾病活动性降低至少 50% 并在 6 个月内达到缓解或低疾病活动性的靶向治疗策略，如果需要，进行序贯药物治疗，可以预防 RA 相关的残疾。但随着生物仿制药（与原始生物药物基本相同但通常成本较低的药物）的出现，这些成本正在降低。结论和相关性科学进步改进了治疗方法，可防止多达 90% 的 RA 患者出现不可逆关节损伤的进展。早期使用甲氨蝶呤加糖皮质激素治疗，随后使用其他 DMARDs，如 TNF、IL-6 或 Janus 激酶抑制剂，可改善预后并预防 RA 相关残疾。旨在在 3 个月内将疾病活动性降低至少 50% 并在 6 个月内达到缓解或低疾病活动性的靶向治疗策略，如果需要，进行序贯药物治疗，可以预防 RA 相关的残疾。

"点击查看英文标题和摘要"

Diagnosis and Management of Rheumatoid Arthritis

Importance Rheumatoid arthritis (RA) occurs in about 5 per 1000 people and can lead to severe joint damage and disability. Significant progress has been made over the past 2 decades regarding understanding of disease pathophysiology, optimal outcome measures, and effective treatment strategies, including the recognition of the importance of diagnosing and treating RA early. Observations Early diagnosis and treatment of RA can avert or substantially slow progression of joint damage in up to 90% of patients, thereby preventing irreversible disability. The development of novel instruments to measure disease activity and identify the presence or absence of remission have facilitated new treatment strategies to arrest RA before joints are damaged irreversibly. Outcomes have been improved by recognizing the benefits of early diagnosis and early therapy with disease-modifying antirheumatic drugs (DMARDs). The treatment target is remission or a state of at least low disease activity, which should be attained within 6 months. Methotrexate is first-line therapy and should be prescribed at an optimal dose of 25 mg weekly and in combination with glucocorticoids; 40% to 50% of patients reach remission or at least low disease activity with this regimen. If this treatment fails, sequential application of targeted therapies, such as biologic agents (eg, tumor necrosis factor [TNF] inhibitors) or Janus kinase inhibitors in combination with methotrexate, have allowed up to 75% of these patients to reach the treatment target over time. New therapies have been developed in response to new pathogenetic findings. The costs of some therapies are considerable, but these costs are decreasing with the advent of biosimilar drugs (drugs essentially identical to the original biologic drugs but usually available at lower cost). Conclusions and Relevance Scientific advances have improved therapies that prevent progression of irreversible joint damage in up to 90% of patients with RA. Early treatment with methotrexate plus glucocorticoids and subsequently with other DMARDs, such as inhibitors of TNF, IL-6, or Janus kinases, improves outcomes and prevents RA-related disability. A treat-to-target strategy aimed at reducing disease activity by at least 50% within 3 months and achieving remission or low disease activity within 6 months, with sequential drug treatment if needed, can prevent RA-related disability.

更新日期：2018-10-02

点击分享查看原文

点击收藏

阅读更多本刊新发论文