rheumatoid arthritis clinical overview幼年型类风湿性关节炎的临床观察课件

L1 Juvenile Rheumatoid Arthritis Clinical Overview Daniel J. Lovell MD, MPH Levinson Professor of Pediatrics Division of Rheumatology Cincinnati Childrens Hospital Medical Center Cincinnati, Ohio, USA L2 American College of Rheumatology Characteristics of JRA Pauciarticular Course Polyarticular Course Systemic Disease Frequency of cases60%30%10% Number of joints involved 45Variable Age at onsetEarly childhood; peak at 1-3 yrs Throughout childhood; peak at 6-7 yrs and 8-11 yrs Throughout childhood; no peak Female:male ratio5:13:11:1 Systemic involvementNot presentModerate involvement Prominent Treatment paradigmPrimarily NSAIDs or intra -articular corticosteroids DMARDs or biologics with adjunctive NSAIDs DMARDs or biologics; NSAIDs for fever and pain; corticosteroids for systemic features Cassidy and Petty. Textbook of Pediatric Rheumatology, 2005 L3 Pain is Commonly Reported in JRA Lovell and Walco. Pediatr Clin North Am 1989; 36:1015-27 Self report of pain from 462 children with JRA Cincinnati Juvenile Arthritis Database L4 Functional Impact of Pain in Children with JRA Parents assessment of activities affected by childs pain 22% pauciarticular course 48% polyarticular course 26% systemic onset Varni/Thompson Pediatric Pain Questionnaire Varni et al. Pain 1987; 28:27-38. L5 Articular Erosions in JRA Patients Cassidy et al. Arthritis Rheum 1986; 29:274-81. Articular erosions by disease onset subtype from Articular erosions by disease onset subtype from 132 children with 5 years follow-up 132 children with 5 years follow-up L6 Outcome Following Onset of JRA Systematic review of published outcome data in JIA, JCA, JRA 21 studies published over 10-year period 19 retrospective studies; 2 prospective Follow up varied 10 years in 14 studies Study sizes varied: 44 1082 patients 10 studies 200 patients Total n = 5342 patients Adib N et al. Rheumatology 2005;44:995-1001 L7 Remission Rates and Function in Studies Using ACR JRA Classification Criteria Steinbrocker III/IV 7-27% Steinbrocker III/IV 30%. Core Set Measures Physicians Global Assessment of Disease Activity Patient/Parent Global Assessment of Overall Well Being Assessment of Physical Function Number of joints with active arthritis Number of joints with limited range of motion Laboratory measure of inflammation Giannini E et al. Arthritis Rheum 1997;40(7):1202-1209 L12 Meloxicam vs Naproxen in JRA Meloxicam 0.125 mg/kg/day N=73 Meloxicam 0.25 mg/kg/day N= 74 Naproxen 10 mg/kg/day N= 78 Patient/ parent overall assessment of well being -43%-39%-41% MD global assessment of disease activity -48%-46%-44% CHAQ index -33%-37%-37% No. of joints with active arthritis -52%-46%-43% No. of joints with limited range of motion -44%-29%-37% ESR+2%-20%-5% Parents assessment of pain-50%-44%-46% Percent change from Baseline in ACR Pediatric 30 Percent change from Baseline in ACR Pediatric 30 Core Measures at 12 WeeksCore Measures at 12 Weeks Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572 L13 Meloxicam vs Naproxen in JRA ACR Pediatric 30 Response Rate over 12 MonthsACR Pediatric 30 Response Rate over 12 Months % Responders% Responders Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572 L14 Comparison of ACR Pediatric 30 Response Rates with Naproxen StudyNumber of Patients Dose mg/kg/day ACR Pediatric 30 Response Week 12 Reiff 20061011555% Ruperto 2005781064% Gedalia 20047510-1568% Foeldvari 2006831567% Reiff A et al. J Rheum 2006;33: 985-995 Ruperto N et al. Arthritis Rheum 2005;52 (2): 563-572 Gedalia A et al. Arthritis Rheum 2004;50(suppl)S95 Foeldvari et al. 2006. Arthritis Rheum 2006;54(suppl) L15 NSAID-induced GI Pain and Injury Among patients with abdominal pain who underwent GI evaluation, gastroduodenal injury was reported in: 34% of patients taking NSAIDs 7.1% of patients not taking NSAIDs No complicated events Dowd et al. Arthritis Rheum 1995; 38:1225-31. Percent of Patients Reporting Abdominal Pain No NSAIDs N = 226 NSAIDs N = 344 Retrospective review of records from 570 patients seen in a pediatric rheumatology clinic over 3-year period L16 Intolerability of NSAIDs in Children with JRA Barron KS et al. Journal of Rheumatology 1982; 9:149-55. Mean age onset 6.7 years 21% Systemic Onset 23% Polyarticular Course 57% Pauciarticular Course 22% No toxicity 78% Discontinued NSAID due to toxicity 49% No Toxicity 101 Patients 1 NSAID 51% Repeat toxicity with NSAID 38% Different toxicity 62% Same toxicity Toxicity = Laboratory abnormality or signs/ symptoms requiring NSAID discontinuation NSAIDs: Aspirin 34%; Tolmetin 21%; Naproxen 12%; Fenoprofen 11%; Ibuprofen 8%, Other 14% L17 Conclusion: JRA and Current Treatments JRA comprises a group of heterogeneous yet related disorders in children Chronic inflammatory arthritis with significant impact on function and health-related qu