多疾病状态对起始使用改善病情抗风湿药的类风湿关节炎患者治疗反应的影响。
The impact of multimorbidity status on treatment response in rheumatoid arthritis patients initiating disease-modifying anti-rheumatic drugs.
机构信息
Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA, Department of Internal Medicine III, Division of Rheumatology, Medical University Vienna, Vienna, Austria and
Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
出版信息
Rheumatology (Oxford). 2015 Nov;54(11):2076-84. doi: 10.1093/rheumatology/kev239. Epub 2015 Jul 10.
OBJECTIVE
When treating RA patients, remission (REM) or at least low disease activity (LDA) is the ultimate therapeutic goal. The aim of this study was to assess the impact of multimorbidity on achieving REM or LDA.
METHODS
In a prospective RA cohort, we identified patients initiating any DMARD with follow-up data 1 year after. Treatment effects were measured using the clinical disease activity index (CDAI) and the modified health assessment questionnaire (MHAQ); multimorbidity status was assessed using a counted multimorbidity index (cMMI). The proportion of patients reaching REM or LDA 1 year after DMARD commencement with respect to the cMMI was evaluated. In regression models, we calculated the odds ratio of achieving REM or LDA, and predicted CDAI and MHAQ 1 year after DMARD commencement for various levels of cMMI, adjusting for age, sex, disease duration, serostatus, disease activity at DMARD commencement, number of previous DMARDs, and type of DMARD, steroid and NSAID use.
RESULTS
A total of 815 patients started DMARDs; 414 were on the same DMARD after 1 year. The proportion of these patients achieving REM or LDA after 1 year was significantly lower in the patients with higher cMMI, following a linear trend (P < 0.01). After accounting for covariates, the odds ratio for REM associated with each additional morbidity in the cMMI was 0.72 (95% CI 0.55, 0.97) and 0.81 (95% CI 0.70, 0.94) for LDA. One year after DMARD initiation, CDAI (+0.16 per additional morbidity) and MHAQ scores (+0.15 per additional morbidity) were significantly worse (both P < 0.05).
CONCLUSION
Increased multimorbidity negatively affects the therapeutic goal of REM and LDA.
目的
在治疗类风湿关节炎（RA）患者时，缓解（REM）或至少低疾病活动度（LDA）是最终的治疗目标。本研究旨在评估共病对实现 REM 或 LDA 的影响。
方法
在一项前瞻性 RA 队列中，我们确定了开始任何 DMARD 治疗并在 1 年后有随访数据的患者。使用临床疾病活动指数（CDAI）和改良健康评估问卷（MHAQ）测量治疗效果；使用计数共病指数（cMMI）评估共病状态。评估 DMARD 开始后 1 年达到 REM 或 LDA 的患者中 cMMI 的比例。在回归模型中，我们计算了达到 REM 或 LDA 的优势比，并预测了 DMARD 开始后 1 年的 CDAI 和 MHAQ，调整了年龄、性别、疾病持续时间、血清状态、DMARD 开始时的疾病活动度、之前 DMARD 的数量以及 DMARD、类固醇和 NSAID 的类型。
结果
共有 815 名患者开始 DMARD 治疗；1 年后有 414 名患者仍在使用相同的 DMARD。在 cMMI 较高的患者中，1 年后 REM 或 LDA 的患者比例明显较低，呈线性趋势（P<0.01）。在考虑了协变量后，cMMI 中每增加一种共病，REM 的优势比为 0.72（95%CI 0.55，0.97），LDA 的优势比为 0.81（95%CI 0.70，0.94）。DMARD 开始后 1 年，CDAI（每增加一种共病增加 0.16）和 MHAQ 评分（每增加一种共病增加 0.15）明显更差（均 P<0.05）。
结论
共病增多会对 REM 和 LDA 的治疗目标产生负面影响。
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