Verstappen S M, Jacobs J W, Bijlsma J W
University Medical Center Utrecht, Department of Rheumatology and Clinical Immunology, F02.127, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
Clin Exp Rheumatol. 2003 Sep-Oct;21(5 Suppl 31):S165-8.
Since 1990 the Utrecht Rheumatoid Arthritis Cohort study group has performed several clinical trials on different treatment strategies in early rheumatoid arthritis (RA) patients. From 1990 till 1994, patients were randomly assigned to the pyramid strategy group or the early DMARD group. Patients in the early DMARD group were allocated to one of the three following treatment strategies: strategy I, starting with hydroxychloroquine (HCQ); strategy II, starting with intramuscular gold (iAU); or strategy III, starting with oral methotrexate (MTX). After one year, statistically significant advantages for the early DMARD group compared with the pyramid group were found for disability, pain, joint score, and ESR. The increase in radiological damage did not differ significantly between the two strategy groups. These first year results proved that early introduction of DMARDs is more beneficial than a delayed introduction. After 5 years, however, no prolongation of the clinical advantages in favor of the early DMARD group, as observed after one year, was found. It was found that patients assigned to the pyramid group received more intra-articular injections during the first two years; at the end of this period 75% of them used DMARDs, especially the more aggressive DMARDs. Based on the first year results, all patients were randomly assigned to one of the three treatment strategies in the early DMARD group between 1994 and 1998. Patients who started with MTX or iAU as the first DMARD demonstrated better results regarding clinical efficacy and radiological damage after 2 years. However, more patients who received iAU therapy had to discontinue their therapy compared with patients who took MTX. We therefore conclude that MTX is the DMARD of first choice and that treatment should be tailored to the individual patient.
自1990年以来，乌得勒支类风湿性关节炎队列研究小组对早期类风湿性关节炎（RA）患者的不同治疗策略进行了多项临床试验。从1990年到1994年，患者被随机分配到金字塔策略组或早期疾病改善抗风湿药（DMARD）组。早期DMARD组的患者被分配到以下三种治疗策略之一：策略I，从羟氯喹（HCQ）开始；策略II，从肌肉注射金（iAU）开始；或策略III，从口服甲氨蝶呤（MTX）开始。一年后，与金字塔组相比，早期DMARD组在残疾、疼痛、关节评分和红细胞沉降率（ESR）方面具有统计学上的显著优势。两个策略组之间放射学损伤的增加没有显著差异。这些第一年的结果证明，早期引入DMARDs比延迟引入更有益。然而，5年后，未发现如一年后观察到的有利于早期DMARD组的临床优势的延长。发现分配到金字塔组的患者在头两年接受了更多的关节内注射；在此期间结束时，其中75%的患者使用了DMARDs，尤其是更具攻击性的DMARDs。基于第一年的结果，1994年至1998年间，所有患者被随机分配到早期DMARD组的三种治疗策略之一。以MTX或iAU作为第一种DMARD开始治疗的患者在2年后在临床疗效和放射学损伤方面表现出更好的结果。然而，与接受MTX治疗的患者相比，接受iAU治疗的患者中有更多的人不得不停止治疗。因此，我们得出结论，MTX是首选的DMARD，治疗应根据个体患者进行调整。
