Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, , Vienna, Austria.
Ann Rheum Dis. 2014 Mar;73(3):492-509. doi: 10.1136/annrheumdis-2013-204573. Epub 2013 Oct 25.
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
本文更新了 2010 年欧洲抗风湿病联盟(EULAR)关于类风湿关节炎(RA)管理的建议,包括合成和生物疾病修饰抗风湿药物(sDMARDs 和 bDMARDs,分别)。2013 年的更新由一个国际工作组制定,该工作组的决策主要基于三项系统文献综述(一项关于 sDMARDs,包括糖皮质激素,bDMARDs 和 DMARD 治疗安全性方面)的证据;治疗策略也涵盖在搜索范围内。在共识发现和投票过程中,专家们对提出的证据进行了讨论和总结。得出了证据水平和建议等级,并确定了建议的一致性(建议的强度)。制定了 14 项建议(2010 年为 15 项)。删除了 2010 年的一些建议,其他建议则进行了修订或拆分。建议涵盖了一般方面,例如采用靶向治疗方法达到缓解或低疾病活动度,以及风湿病医生和患者之间需要共同决策。更具体的项目涉及使用传统的 sDMARD(csDMARD)联合糖皮质激素开始 DMARD 治疗,如果在 6 个月内未达到治疗目标(或 3 个月内未见改善),则添加 bDMARD 或另一种 csDMARD 策略(根据是否存在不良危险因素进行分层)。肿瘤坏死因子抑制剂(阿达木单抗、依那西普、戈利木单抗、英夫利昔单抗、赛妥珠单抗、生物类似药)、阿巴西普、托珠单抗,在某些情况下,利妥昔单抗被认为具有相似的疗效和安全性。如果第一种 bDMARD 策略失败,可以使用任何其他 bDMARD。建议还包括托法替尼作为靶向 sDMARD(tsDMARD),在至少使用一种 bDMARD 后,在获得许可的情况下推荐使用。还涉及生物类似药。这些建议旨在向风湿病医生、患者、国家风湿病学会和其他利益相关者告知 EULAR 关于 RA 用 sDMARDs、糖皮质激素和 bDMARDs 管理的最新共识。它们基于证据和专家意见,旨在改善 RA 患者的预后。