Dale James, Alcorn Nicola, Capell Hilary, Madhok Rajan
Ayr County Hospital, and Glasgow Royal Infirmary, Centre for Rheumatic Diseases, Castle Street, Glasgow, UK.
Nat Clin Pract Rheumatol. 2007 Aug;3(8):450-8; quiz, following 478. doi: 10.1038/ncprheum0562.
Early aggressive treatment of rheumatoid arthritis is associated with improved disease control, slower radiological progression and improved functional outcomes. Tumor necrosis factor blocking therapy is effective but there remain concerns about long-term risks. Combining disease-modifying antirheumatic drugs (DMARDs) is a widely used therapeutic alternative; however, there is uncertainty surrounding the most effective regimen. A popular combination is methotrexate plus sulfasalazine, but each of these DMARDs can also be used in combination with other DMARDs and in triple therapy regimens. However, wide variations in study size, design, steroid usage and approaches to combination therapy have made it difficult to form firm conclusions regarding their efficacy. Generally, combination therapy is well tolerated and associated with no significant increase in the rate of adverse events compared with monotherapy. Methotrexate-sulfasalazine, methotrexate-chloroquine, methotrexate-cyclosporin, methotrexate-leflunomide, methotrexate-intramuscular-gold and methotrexate-doxycycline are effective combination regimens. Triple DMARD therapy is better than various DMARD monotherapy and dual therapy regimens. Methotrexate and hydroxychloroquine may have synergistic anti-inflammatory properties. Clinical trial evidence to support the use of other methotrexate and sulfasalazine combinations is often weak or lacking. Further investigation is required to determine the most effective regimen and approach to combination therapy.
类风湿关节炎的早期积极治疗与疾病控制改善、放射学进展减缓及功能预后改善相关。肿瘤坏死因子阻断疗法有效，但长期风险仍令人担忧。联合使用改善病情抗风湿药（DMARDs）是一种广泛应用的治疗选择；然而，关于最有效的治疗方案仍存在不确定性。一种常见的联合用药是甲氨蝶呤加柳氮磺胺吡啶，但这些DMARDs中的每一种也可与其他DMARDs联合使用，并用于三联疗法方案。然而，研究规模、设计、类固醇使用情况以及联合治疗方法的广泛差异使得难以就其疗效得出确凿结论。一般来说，联合治疗耐受性良好，与单药治疗相比，不良事件发生率没有显著增加。甲氨蝶呤 - 柳氮磺胺吡啶、甲氨蝶呤 - 氯喹、甲氨蝶呤 - 环孢素、甲氨蝶呤 - 来氟米特、甲氨蝶呤 - 肌肉注射金和甲氨蝶呤 - 强力霉素都是有效的联合治疗方案。三联DMARD疗法优于各种DMARD单药治疗和双联疗法方案。甲氨蝶呤和羟氯喹可能具有协同抗炎特性。支持使用其他甲氨蝶呤和柳氮磺胺吡啶联合用药的临床试验证据往往薄弱或缺乏。需要进一步研究以确定联合治疗的最有效方案和方法。
