Wenting-Van Wijk M J, Blankenstein M A, Lafeber F P, Bijlsma J W
Department of Rheumatology & Clinical Immunology, University Medical Centre Utrecht, The Netherlands.
Clin Exp Rheumatol. 1999 May-Jun;17(3):305-12.
The clinical effects of high dosage pulse glucocorticosteroid (GS) infusion as a treatment for rheumatoid arthritis (RA) differ considerably between patients. The aim of the present study was to gain more insight into these differences in clinical response.
Twenty-three RA patients (6 M/17 F) with treatment-resistant active erosive disease were treated with GS pulse therapy, consisting of 3 infusions of 200 mg dexamethasone at 3-day intervals. Plasma dexamethasone and plasma cortisol levels, as well as the mononuclear cell glucocorticosteroid receptor density, were determined on days 0, 2, 6, 12 and 40 after the start of therapy. Clinical evaluation consisted of the Thompson articular index, the erythrocyte sedimentation rate (ESR), and the serum concentration of C reactive protein (CRP).
Plasma dexamethasone levels in RA patients determined during pulse therapy revealed the existence of two groups. One group reached significantly (p < 0.05) higher plasma levels than another group comparable for age and sex. The CRP, ESR and Thompson joint score prior to the start of pulse therapy were all higher (p < 0.05) for the high plasma dexamethasone group. The decrease in ESR, CRP and the Thompson joint score was also significantly greater (all p < 0.05) for the high plasma dexamethasone group. Plasma cortisol, as well as the GS receptor density at the start of treatment, did not differ between the two groups; both decreased after the first pulse in both groups and returned to pre-treatment values shortly after the last infusion.
The treatment of refractory RA with dexamethasone pulse therapy is, on average, beneficial. The high plasma dexamethasone levels reached might depend on the greater severity of the disease in these patients prior to the start of the treatment, and result in greater changes in the disease parameters. Glucocorticosteroid receptor density measurements made during and directly after high dose pulse dexamethasone treatment proved to be unreliable because of the high plasma dexamethasone levels.
高剂量脉冲糖皮质激素（GS）输注治疗类风湿关节炎（RA）的临床效果在患者之间存在显著差异。本研究的目的是更深入了解这些临床反应差异。
23例患有治疗抵抗性活动性侵蚀性疾病的RA患者（6例男性/17例女性）接受了GS脉冲疗法，即每隔3天输注3次200mg地塞米松。在治疗开始后的第0、2、6、12和40天测定血浆地塞米松和血浆皮质醇水平，以及单核细胞糖皮质激素受体密度。临床评估包括汤普森关节指数、红细胞沉降率（ESR）和C反应蛋白（CRP）的血清浓度。
在脉冲治疗期间测定的RA患者血浆地塞米松水平显示存在两组。一组在年龄和性别匹配的另一组相比，血浆水平显著更高（p<0.05）。高血浆地塞米松组在脉冲治疗开始前的CRP、ESR和汤普森关节评分均更高（p<0.05）。高血浆地塞米松组的ESR、CRP和汤普森关节评分的下降也显著更大（均p<0.05）。两组治疗开始时的血浆皮质醇以及GS受体密度没有差异；两组在第一次脉冲后均下降，并在最后一次输注后不久恢复到治疗前值。
平均而言，用地塞米松脉冲疗法治疗难治性RA是有益的。达到的高血浆地塞米松水平可能取决于这些患者在治疗开始前疾病的更严重程度，并导致疾病参数发生更大变化。由于血浆地塞米松水平较高，在高剂量脉冲地塞米松治疗期间及治疗后直接进行的糖皮质激素受体密度测量被证明是不可靠的。
