类风湿关节炎活动期临床判断.ppt

,类风湿关节炎活动度临床判断,clinical assessment of rheumatoid arthritis disease activity (partly quoted from jonathan kay, md),content,why quantify ra disease activity? composite disease activity indices response criteria for clinical trials patient-reported outcome measures quantitatively-driven therapy for early ra data collection tools,shaw on measurement,“the only man who behaved sensibly was my tailor; he took my measure anew every time he saw me, whilst all the rest went on with their old measurements and expected them to fit me.” -george bernard shaw (1856-1950),how to quantify ra disease activity,clinical composite indices -das / das28 -sdas -cdai patient-reported outcome measures imaging - plain radiographs - musculoskeletal ultrasound - mri,primary site of ra disease activity persistent synovitis results in -joint destruction -disability goal of treatment (remission) is absence of synovitis tender & swollen joint counts are outcome upon which therapeutic decisions are based,why assess joints?,reported as %improvement, comparing disease activity at two discrete time points -acr20 is 20% improvement -acr50 is 50% improvement (acr50 responders include acr20 responders) -acr70 is 70% improvement (acr70 responders include acr20 and acr50 responders) used to maximally discriminate effective treatment from placebo treatment in clinical trials not directly applicable to clinical practice dt felson et al. arthritis rheum.1995;38(6):727-735,acr response criteria:the traditional dichotomous benchmark,disease activity score (das) das28 simplified disease activity index(sdai)（简化的das评分） clinical disease activity index(cdai)（临床das评分）,continuous measures of ra disease activity,das=0.54(tender 44)1/2 +0.06 (swollen 66)1/2 + 0.33 in(esr)+ 0.007 (global health on vas) （44个压痛关节、66个肿胀关节） provides absolute indication of ra disease activity on a scale of 1 to 9 -das 3.6 = high disease activity -das 2.4- 3.6 = moderate disease activity -das 1.6- 2.4= low disease activity -das 1.6 = remission dm van der heijde et al. j rheumatol 1993;20:579-81,disease activity score (das):a continuous measure,simplified disease activity score using 28-joint count -integrates measures of physical examination, acute phase response, and patient self-assessment das28=0.56(tender 28)1/2 +0.28 (swollen 28)1/2 + 0.70 in(esr)+ 0.014 (global health on vas) provides absolute indication of ra disease activity on a scale of 0.49 to 9.07 -das28 5.1 =high disease activity -das28 3.2- 5.1= moderate disease activity -das28 2.6- 3.2=low disease activity -das28 2.6 = remission dm van der heijde et al. j rheumatol 1993;20:579-81,das28:a simplified disease activity score,joints assessed in das &das28,joints assessed only in das,joints assessed in das & das28,tjc and sjc contribute numerically to 50% of das / das28 esr & patient global health weighted 2in das28 c/w das,eular response criteria for ra: continuous variable to dichotomous benchmark,am van gestel et al. arthritis rheum. 1996;39:34-40,simplified disease activity score using 28-joint count -integrates measures of physical examination, acute phase response, patient self-assessment, and evaluator assessment -easy to calculate sdai=tender 28+ swollen28 + crp + patient global health on vas+ evaluator global health on vas provides absolute indication of ra disease activity on a scale of 0.1 to 86.0 -sdai 26 = high disease activity -sdai 11.1-26 = moderate disease activity -sdai 3.3-11= low disease activity -sdai 3.3 = remission,simplified disease activity index(sdai),smolen js et al. rheumatology(oxford) 2003;42:244-57,simplified disease activity score using 28-joint count -immediate scoring possible (no laboratory result) -integrates measures of physical examination, patient self-assessment, and evaluator assessment -easy to calculate cdai=tender 28+ swollen28 + patient global health on vas+ evaluator global health on vas provides absolute indication of ra disease activity on a scale of 0 to 76.0 -cdai 22 = high disease activity -cdai 10.1-22 = moderate disease activity -sdai 2.8-10 = low disease activity -sdai 2.8 = remission,clinical disease activity index(cdai),d aletaha et al. arthritis res ther 2005;7:r796-r806,disease activity measures: components,contribution of swollen & tender joint counts impact on composite indices,acr response criteria -tjc and sjc must improve by 20%, 50%, or 70%, regardless of improvement in 3 of the other 5 core set measures das 37:883-4,measurement in the bible,“for with what judgment ye judge, ye shall be judged: and with what measure ye mete, it shall be measured to you again” -matthew,patient-reported outcome measures,health assessment questionnaire (haq) modified haq (mhaq)（简化haq） multidimensional haq(mdhaq)（多维haq） routine assessment of patient index data(rapid) rheumatoid arthritis disease activity index(radai),haq,mhaq & mdhaq,rapid-3 mdhad questionnaire,routine assessment of patient index data(rapid)3,includes 3 patient-reported outcome measures from acr core data set: -patient self-assessed physical function -patient pain assessment -patient global assessment requires no activity on the part of health professional, other than to calculate simple arithmetic totals in about 5-10 seconds provides absolute indication of ra disease activity on a scale of 0-30 -rapid3 12.0 = high disease activity -rapid3 6.1-12.0 = moderate disease activity -rapid3 3.1-6.0 = low disease activity -rapid3 0-3.0 = remission correlates with das28 35:773-778,quantitatively-driven t