类风湿关节炎的诊治进展继教班胡建东2015

类风湿关节炎的诊治进展,上海中医药大学附属岳阳中西医结合医院风湿科 胡建东,2015.9.17,RA临床特点,放射学破坏,(c) 1972-2004 American College of Rheumatology Clinical Slide Collection. Used with permission.,病理机制,诊断分类标准,1987年ACR的RA分类标准,注：以上7条满足4条或4条以上并排除其他关节炎可诊断RA，条件14必须持续至少6周(引自Arthritis Rheum，1988，31：315-324),病情评估,Instruments Used to Measure Rheumatoid Arthritis Disease Activity,Clinical Measurement Tools to Guide Treatment Decisions,Aletaha D, et al. Clin Exp Rheumatol. 2005;23(suppl 39):S100-S108.Cush JJ. Arthritis Rheum. 2005;52(9 suppl):S686.,Low Disease Activity,Moderate Disease Activity,High Disease Activity,Remission,CDAI 2.8, 22,2.9-10,11-22,DAS 2.4,SDAI 22, 5.5, 26,ACR/EULAR Definitions of Remission in Rheumatoid Arthritis Clinical Trials,* Include 28 joints plus feet and ankles.,RA的临床缓解标准,2013年版EULAR关于RA治疗的推荐,2013年版EULAR关于RA治疗的推荐,早期治疗,早期诊断,早期诊断,2010类风湿关节炎早期分类标准配合MRI,早期治疗（治疗窗）,What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis?van Nies JAB, et al. Ann Rheum Dis 2014;73:861870. doi:10.1136/annrheumdis-2012-203130,Meta-analysis on the association between symptom duration(in weeks) and achieving DMARD-freesustained remission over time inrheumatoid arthritis (RA). (A)Univariable analysis on symptomduration (B) Multivariable analysis onsymptom duration, adjusted for age,gender and treatment (C) Multivariable analysis on symptom duration,adjusted for age, gender, treatment,rheumatoid factor and ESR,van Nies JAB, et al. Ann Rheum Dis 2014;73:861870. doi:10.1136/annrheumdis-2012-203130,目标治疗（treat to target),Remission,Low disease activity,目标治疗(treat to target),指南解读,指南解读,指南解读,指南解读,指南解读,药物治疗,非甾体抗炎药(NSAIDs)糖皮质激素(GC)改善病情抗风湿药(DMARDs)生物制剂（Biologics)草药（herbal medicine),非甾体抗炎药(NSAIDs),Effect of Nonsteroidal Antiinflammatory Drugs on the C-Reactive Protein Level in Rheumatoid Arthritis,Haemoglobin decreases in NSAID users over time: an analysis of two large outcome trials,Haemoglobin decreases in NSAID users over time: an analysis of two large outcome trials,Haemoglobin decreases in NSAID users over time: an analysis of two large outcome trials,Haemoglobin decreases in NSAID users over time: an analysis of two large outcome trials,Aliment Pharmacol Ther 2011; 34: 808816,糖皮质激素(GC),重症RA伴有心、肺或神经系统等受累的患者，可给予短效激素，其剂量依病情严重程度而定。针对关节病变，如需使用，通常为小剂量激素(泼尼松7.5 mg/d)仅适用于少数RA患者。RA患者激素适用指征：伴有血管炎等关节外表现的重症RA。不能耐受NSAIDs的RA患者作为“桥梁”治疗。其他治疗方法效果不佳的RA患者。伴局部激素治疗指征(如关节腔内注射)。激素治疗RA的原则：小剂量、短疗程。使用激素必须同时应用DMARDs。激素治疗过程中，应补充钙剂和维生素D。,糖皮质激素(GC),糖皮质激素使用的指南,改善病情抗风湿药(DMARDs),传统DMARDs生物制剂DMARDs,Disease-Modifying Antirheumatic Drugs,生物制剂,Anti-TNF单抗 人源单抗：adalimumab 鼠人嵌合单抗 : infliximab 可溶性受体: etanercept 作用机制： 拮抗TNF 应用：RA，SPACD20单抗 作用机制：去除前B细胞、B细胞 应用：RA，ITP，SLE， ANCA相关性小血管炎,3/4为人源性， 1/4为鼠源性，抗原结合区可结合可溶性及细胞膜上的TNF，阻断炎症反应单独使用或与MTX联用,Infliximab (Remicade),Etanercept (Enbrel),为一可溶性TNF受体，可中和TNF的体内活性单独使用与MTX疗效相当，副作用小于MTX,TEAR Radiographic Results,Intensive intervention can lead to a treatment holiday from biological DMARDs in patients with rheumatoid arthritis,Intensive intervention can lead to a treatment holiday from biological DMARDs in patients with rheumatoid arthritis,Intensive intervention can lead to a treatment holiday from biological DMARDs in patients with rheumatoid arthritis,Intensive intervention can lead to a treatment holiday from biological DMARDs in patients with rheumatoid arthritis,草药（包括中药）,雷公藤制剂青藤碱（Sinomenine）姜黄（curcuma longa),姜黄素（Curcumin)莪术（curcuma phaeocaulis)姜（zingiber officinale),草药（包括中药）,过山枫,猫爪藤,玛卡,雷公藤,青口贝,大果漆树腰果,Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis,本研究共纳入207例活动性RA患者，按1：1：1随机分入3组：单用甲氨蝶呤组(125 mg周)、单用雷公藤多甙组(20 m次，3次d)，两药联合治疗组(剂量同单药组)，持续治疗24周，主要疗效终点为美国风湿病学会(ACR)推荐的RA疗效缓解50(ACR50)标准。Ann Rheum Dis 2015 Jun;74(6):1078-86 PMID:24733191,Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis,结果显示，单用甲氨蝶呤组、单用雷公藤多甙组和两药联合治疗组分别有464、551、768的患者达到ACR50。经非劣效性检验分析，提示单用雷公藤多甙的疗效不劣于单用甲氨蝶呤(P=0014)。同时探索性对比分析显示，两药联合治疗疗效显著优于单用甲氨蝶呤(P0，001)。在其他评价指标(包括ACR20、ACR70、cDAI、疾病缓解率及低疾病活动度等)方面也显示，单用雷公藤多甙的疗效不劣于单用甲氨蝶呤(P005)，两药联合治疗疗效显著优于单用甲氨蝶呤(P005)。,Comparison of Tripterygium wilfordii Hook F with methotrexate in the treatment of active rheumatoid arthritis,安全性分析显示，3组间不良事件(包括胃肠反应、性腺抑制、肝肾功异常等)的发生率差异无统计学意义。,饮酒对类风湿关节炎的影响,饮酒对RA的影响,吸烟对RA的影响,Smoking as a risk factor for the radiological severityof rheumatoid arthritis: a study on six cohorts,吸烟对RA的影响,吸烟对RA的影响,Meta-analysis on the effect of smoking (assessed as past and present smokers vs never smokers) on joint damage progression in six cohorts. Depicted are the results of the individual cohorts and of the meta-analysis. (A) Meta-analysis without adjustment for anti-citrullinated protein antibodies (ACPA) status;,Meta-analysis on the effect of smoking (assessed as past and present smokers vs never smokers) on joint damage progression in six cohorts. Depicted are the results of the individual cohorts and of the meta-analysis. (