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糖皮质激素、传统和靶向合成的疾病修饰抗风湿药物的疗效:一项系统文献回顾,为 2016 年更新 EULAR 类风湿关节炎管理建议提供信息。

Efficacy of glucocorticoids, conventional and targeted synthetic disease-modifying antirheumatic drugs: a systematic literature review informing the 2016 update of the EULAR recommendations for the management of rheumatoid arthritis.

机构信息

Karolinska Institute, Stockholm, Sweden.

Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.

出版信息

Ann Rheum Dis. 2017 Jun;76(6):1102-1107. doi: 10.1136/annrheumdis-2016-210711. Epub 2017 Mar 29.


DOI:10.1136/annrheumdis-2016-210711
PMID:28356243
Abstract

OBJECTIVES: To perform a systematic literature review (SLR) informing the 2016 update of the recommendations for the management of rheumatoid arthritis (RA). METHODS: An SLR for the period between 2013 and 2016 was undertaken to assess the efficacy of glucocorticoids (GCs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and targeted synthetic DMARDs (tsDMARDs) (tofacitinib and baricitinib) in randomised clinical trials. RESULTS: For GCs, four studies were included in the SLR. Patients without poor prognostic factors experienced benefit when GCs were added to methotrexate (MTX). Lower doses of GCs were similar to higher doses. For csDMARDs, two new studies comparing MTX monotherapy with combination csDMARD were included in the SLR. In the tREACH trial at the end of 12 months no difference between the groups in disease activity, functional ability and radiographic progression was seen, using principles of tight control (treat-to-target). In the CareRA trial, combination therapy with csDMARDs was not superior to MTX monotherapy and monotherapy was better tolerated.For tsDMARDs, tofacitinib and baricitinib were shown to be more effective than placebo (MTX) in different patient populations. CONCLUSIONS: Addition of GCs to csDMARD therapy may be beneficial but the benefits should be balanced against the risk of toxicity. Under tight control conditions MTX monotherapy is not less effective than combination csDMARDs, but better tolerated. Tofacitinib and baricitinib are efficacious in patients with RA, including those with refractory disease.

摘要

目的:对 2016 年类风湿关节炎(RA)管理建议的更新进行系统文献回顾(SLR)。

方法:进行了一项 SLR,以评估 2013 年至 2016 年期间糖皮质激素(GCs)、传统合成疾病修饰抗风湿药物(csDMARDs)和靶向合成 DMARDs(托法替尼和巴利替尼)在随机临床试验中的疗效。

结果:GCs 方面,SLR 纳入了四项研究。无不良预后因素的患者,GCs 联合甲氨蝶呤(MTX)治疗可获益。低剂量 GCs 与高剂量 GCs 疗效相当。csDMARDs 方面,SLR 纳入了两项新的比较 MTX 单药与联合 csDMARD 的研究。在 12 个月时的 tREACH 试验中,两组在疾病活动度、功能能力和放射学进展方面没有差异,采用严格控制(达标治疗)原则。在 CareRA 试验中,联合 csDMARD 治疗并不优于 MTX 单药治疗,且单药治疗的耐受性更好。对于 tsDMARDs,托法替尼和巴利替尼在不同的患者人群中均比安慰剂(MTX)更有效。

结论:GCs 联合 csDMARD 治疗可能有益,但应权衡其毒性风险与获益。在严格控制条件下,MTX 单药治疗并不逊于联合 csDMARDs,但耐受性更好。托法替尼和巴利替尼对 RA 患者有效,包括难治性疾病患者。

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