Leiden University Medical Center, Netherlands.
Leiden University Medical Center, Netherlands.
Clin Immunol. 2018 Jan;186:74-78. doi: 10.1016/j.clim.2017.09.017. Epub 2017 Sep 18.
How have the long term outcomes of RA improved in the last decade?
Patients with DMARD naïve RA were randomized to 4 treatment strategies: 1. sequential DMARD monotherapy, 2. step-up combination therapy, 3. initial combination therapy including prednisone or 4. including infliximab. Treatment-to-target was aimed at DAS≤2.4 (three-monthly calculations). Functional ability (HAQ), radiologic damage progression (Sharp/vanderHeijde Score) and overall survival were reported.
Patients in arms 3 and 4 showed earlier clinical improvement. Up to 50% achieved DAS-remission (<1.6), up to 29% achieved drug free remission. Damage progression was well suppressed (median after 10years in completers 2 SHS points), functional ability approached normality (mean HAQ 0.6). There was no increased mortality (Standardized Mortality Ratio 1.16, 95% CI 0.92-1.46).
Early treatment determines early clinical improvement, treatment-to-target determines long term outcomes. Prevention of relevant radiologic damage progression and disability, drug free remission and normalized survival are realistic goals.
过去十年中，RA 的长期预后如何改善？
将 DMARD 初治 RA 患者随机分为 4 种治疗策略：1. 序贯 DMARD 单药治疗，2. 逐步联合治疗，3. 包括泼尼松的初始联合治疗，或 4. 包括英夫利昔单抗的初始联合治疗。治疗目标是达到 DAS≤2.4（每三个月计算一次）。报告了功能能力（HAQ）、放射学损伤进展（Sharp/vanderHeijde 评分）和总体生存率。
第 3 组和第 4 组的患者更早出现临床改善。多达 50%的患者达到 DAS 缓解（<1.6），多达 29%的患者达到无药物缓解。损伤进展得到了很好的抑制（完成者中位数 10 年后为 2 SHS 点），功能能力接近正常（平均 HAQ 为 0.6）。死亡率没有增加（标准化死亡率比为 1.16，95%CI 0.92-1.46）。
早期治疗决定早期临床改善，治疗目标决定长期结局。预防相关放射学损伤进展和残疾、无药物缓解和正常化生存是现实目标。
