RA治疗的理想目标是疾病缓解还是最低活动度？

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What Is A Realistic Treatment Target in Rheumatoid Arthritis: Remission or Minimal Disease Activity?   Yvonne M.R. de Punder 1, Jaap Fransen1, Wietske Kievit1, Pieternella Houtman2, Henk Visser3, Mart A.F.J. van de Laar4 and Piet LC van Riel1, 1Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands, 2Medical Centre Leeuwarden, Leeuwarden, Netherlands, 3Alysis Care Group, Arnhem, Netherlands, 4Arthritis Centre Twente, Medisch Spectrum Twente and University Twente, Enschede, Netherlands   Presentation Number: 341   Background/Purpose: Treatment targets for RA do shift towards remission of disease activity. However, remission does not occur regularly in practice and the question may be raised what currently is the appropriate treatment target: remission or low disease activity? This is especially relevant in patients treated with anti-TNF. The objective in this study was to analyze the prevalence of remission and minimal disease activity (MDA) and the residual disease activity according to the new ACR/EULAR remission criteria, MDA, and DAS28<2.6, in RA patients treated with anti-TNF. Method: In the DREAM biological registry the prevalence of DAS28<2.6, MDA and ACR/EULAR remission criteria was measured in patients six months after starting a TNF blocker. The variable Patient Global Assessment of disease activity (PtGA) was only available in a subsample and was replaced by VAS Pain, as no systematic difference appeared between PtGA and VAS Pain in this subsample. Residual disease activity during MDA or remission was calculated, measured by the percentage of patients with swollen and tender joints, elevated acute phase reactants, and pain. Result: Six months after initiation of anti-TNF, the prevalence of DAS28<2.6 was 26% and prevalence of MDA was 32%, while ACR/EULAR remission was reached by 6,7% of patients. The low prevalence of ACR/EULAR remission was due to the cut point of the patient’s global assessment/pain item. Exclusion of the variable VAS Pain increased the prevalence of ACR/EULAR remission to 21%. Residual disease activity was highest in the most lenient criteria and occurred most on the level of SJC and PtGA: At least one swollen joint in DAS28<2.6, MDA and ACR/EULAR remission was present in resp. 51%, 54% and 34% of patients. VAS Pain > 1 cm was present resp. 64%, 67% and 0%. When the patient reported variable was left out of the definition of ACR/EULAR remission, 68% of patients scored VAS Pain >1. Accordingly, absence of tender and swollen joints and CRP<1 mg/dl was reached by 190/1679 patients (11%). However, 125 (66)% of these patients would not be in remission according to the complete ACR/EULAR remission criteria because VAS Pain was >1. Conclusion: In daily clinical practice, MDA and DAS28<2.6 are realistic treatment targets with sufficient prevalence, while in turn residual disease activity still is present. ACR/EULAR remission criteria leave little residual disease activity, but might be too stringent due to the strict cut point on Patient Global Assessment of Disease Activity.

RA治疗的理想目标是疾病缓解还是最低活动度？ Yvonne M.R. , et al. ACR 2011. Present No: 341     背景/目的:RA的治疗目标已经更新为疾病活动的缓解。然而,日常实践中并不总能达到缓解，那么目前最合适的目标应该是缓解还是低活动度?这与anti-TNF治疗的病人尤其相关。本研究的目的是分析anti-TNF治疗的RA患者中根据新的ACR/EULAR缓解标准、MDA 和DAS28 < 2.6达到缓解和最低MDA的比率。 方法:理想的生物制剂注册中应该在患者接受一种TNF阻滞剂治疗开始后的6个月就评价DAS28 < 2.6、MDA和ACR /EULAR缓解比例。只有部分患者有总体评估值 (PtGA),因而用疼痛目测标尺值代替，而两者在这个亚群患者中没有系统差异。通过关节肿胀和疼痛的患者比例、急性相反应物和疼痛来计算MDA或缓解时的残余活动度。 结果: anti-TNF治疗后6个月,患者达到DAS28< 2.6比例为26%,MDA为32%.ACR/EULAR/缓解比例6.7%。ACR/EULAR缓解率低的原因可能是患者总体评价／疼痛积分的限制所致。如果排除该指标，其缓解比例可达21％。 最宽松的标准残余疾病活动度最高, 主要表现为SJC和PtGA:至少一个肿胀关节在DAS28< 2.6,MDA和ACR /EULAR标准缓解出现比例分别为51%、54%和34% 。VAS疼痛> 1cm在上述标准中分别为64%、67%和0%。如果单独列出ACR/EULAR标准中患者的自我感觉变量,68%的患者VAS疼痛> 1 。相应的, 190/1679(11%)的患者没有肿胀和疼痛关节并且CRP < 1mg/dl。然而,125例(66)%这样的病人因为VAS疼痛>1而不能满足ACR／EULAR缓解标准。 结论:在日常临床实践中,MDA和DAS28< 2.6有足够的发生率，是理想的治疗目标，尽管其仍然有残余活动度存在。ACR/EULAR缓解标准的残余活动度非常低，但由于患者总体疾病评估的判定可能太过严格。