Agarwal S, Zaman T, Handa R
Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Singapore Med J. 2009 Jul;50(7):686-92.
Disease-modifying anti-rheumatic drugs (DMARDs) currently form the mainstay of treatment of rheumatoid arthritis (RA). We aimed to evaluate the retention rates of "therapeutic segments" of DMARDs in patients with RA.
This was a cross-sectional study of RA patients with at least one year of follow-up. A therapeutic segment is said to begin when one DMARD combination is instituted and it ends with a subsequent change. The disability index for each patient was calculated using a modified health assessment questionnaire. Retention rates were calculated using the Kaplan Meier survival analysis.
375 DMARD courses in 102 patients were analysed. 99 courses were being continued at the time of the study and hence were censored for the purposes of analysis. The respective median (interquartile range [IQR]) retention period for segments containing methotrexate (MTX), sulfasalazine, hydroxychloroquine and leflunomide was 28 (15-45), 12 (3-20), 18 (9-24), 15 (4-32) months. The log-rank statistical test indicated that MTX was retained longer singly (median [IQR] 43 [32-70] months) than in combination (median [IQR] 19 [10-24] months) (p-value is 0.001). The commonest reason for the discontinuation of the DMARD segment was the disease "slipping out" of control (51.1 percent) followed by adverse effects (24.3 percent). Treatment termination on account of disease control was encountered in 16.3 percent of courses only. As many as 63 percent of single DMARD segments were changed because of disease "slip out" as compared to 41 percent of combination DMARD segments. Adverse effects were a more frequent cause of termination of the combination segments (32 vs. 15 percent).
MTX, used singly, had the highest retention rates among all the DMARDs used in RA patients. Disease "slip out" and adverse effects frequently required a change of the therapeutic segment.
改善病情抗风湿药物（DMARDs）目前是类风湿关节炎（RA）治疗的主要手段。我们旨在评估RA患者中DMARDs“治疗阶段”的保留率。
这是一项对至少随访一年的RA患者进行的横断面研究。当开始使用一种DMARD组合时，一个治疗阶段开始，随后的改变则标志着该阶段结束。使用改良的健康评估问卷计算每位患者的残疾指数。使用Kaplan-Meier生存分析计算保留率。
分析了102例患者的375个DMARD疗程。研究时99个疗程仍在继续，因此为分析目的进行了截尾处理。含甲氨蝶呤（MTX）、柳氮磺吡啶、羟氯喹和来氟米特的治疗阶段各自的中位（四分位间距[IQR]）保留期分别为28（15 - 45）、12（3 - 20）、18（9 - 24）、15（4 - 32）个月。对数秩统计检验表明，MTX单独使用时保留时间更长（中位[IQR] 43 [32 - 70]个月），而联合使用时较短（中位[IQR] 19 [10 - 24]个月）（p值为0.001）。DMARD治疗阶段停用的最常见原因是疾病“失控”（51.1%），其次是不良反应（24.3%）。仅16.3%的疗程因疾病得到控制而终止治疗。与41%的联合DMARD治疗阶段相比，多达63%的单一DMARD治疗阶段因疾病“失控”而改变。不良反应是联合治疗阶段终止的更常见原因（32%对15%）。
在RA患者使用的所有DMARDs中，单独使用MTX的保留率最高。疾病“失控”和不良反应常常需要改变治疗阶段。
