一种用于预测类风湿性关节炎持续临床缓解患者复发及传统改善病情抗风湿药成功减停的联合模型。

A combination model to predict relapse and successful conventional DMARDs de-escalation in rheumatoid arthritis patients with sustained clinical remission.

作者信息

Wang Liujun, Geng Yan, Han Jingjing, Sun Xiaoying, Zhang Zhuoli

机构信息

Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.

Department of Geriatrics, Peking University First Hospital, Beijing, China.

出版信息

Clin Exp Rheumatol. 2019 Jan-Feb;37(1):120-126. Epub 2018 Jul 18.

PMID:30148433

Abstract

OBJECTIVES

To determine the long-term outcomes of RA patients in sustained clinical remission under different therapeutic strategies and explore the risk factors to relapse.

METHODS

RA patients in sustained clinical remission (DAS28(CRP) ≤2.6 for at least 6 months) were enrolled. Their baseline clinical features, ultrasonography and x-ray of hands were collected. The usage of conventional synthetic disease-modified anti-rheumatic drugs (csDMARDs) at baseline and every follow-up visits were recorded. Patients were divided into maintain-therapy group or de-escalate-therapy group according to their treatment during follow-up. The time-point of follow-up visits reaching 2 years or flare (DAS28(CRP)>2.6) was defined as the endpoint of the study. The risk factors to predict flare was analysed by logistic regression model.

RESULTS

94 patients were enrolled in the study, with 59 in de-escalate-therapy group and 35 in maintain-therapy group. During an average of 20.8 months of follow-up, 40 (42.6%) patients relapsed, with 31 (52.5%) from de-escalate-therapy group and 9 (25.7%) from maintain-therapy group. De-escalate-therapy increased the risk of flare by 2.3 times (OR=3.38, p=0.044). Baseline DAS28(CRP) (OR=6.97, p=0.038), presence of subclinical synovitis (OR=3.67, p=0.024), combination of 2 csDMARDs (OR=3.72, p=0.030) were the risk factors for relapse, and the best cut-off value of DAS28(CRP) for relapse prediction through ROC curve was 1.82. Taking the three parameters into the model for a combined prediction probability, the area under the ROC curve was 0.722 (95% CI 0.61, 0.82, p=0.000).

CONCLUSIONS

De-escalation therapy was associated with higher risk of relapse in RA patients with sustained clinical remission. A combination model of DAS28(CRP)<1.82 and no subclinical synovitis may help to predict successful csDMARDs reduction in RA patients with sustained clinical remission receiving csDMARDs monotherapy.

摘要

目的

确定不同治疗策略下达到持续临床缓解的类风湿关节炎（RA）患者的长期结局，并探索复发的危险因素。

方法

纳入达到持续临床缓解（DAS28（CRP）≤2.6至少6个月）的RA患者。收集其基线临床特征、手部超声及X线检查结果。记录基线及每次随访时传统合成改善病情抗风湿药（csDMARDs）的使用情况。根据随访期间的治疗情况将患者分为维持治疗组或降阶梯治疗组。随访达到2年或病情复发（DAS28（CRP）>2.6）的时间点定义为研究终点。采用逻辑回归模型分析预测病情复发的危险因素。

结果

94例患者纳入研究，其中降阶梯治疗组59例，维持治疗组35例。平均随访20.8个月期间，40例（42.6%）患者复发，其中降阶梯治疗组31例（52.5%），维持治疗组9例（25.7%）。降阶梯治疗使病情复发风险增加2.3倍（OR=3.38，p=0.044）。基线DAS28（CRP）（OR=6.97，p=0.038）、亚临床滑膜炎的存在（OR=3.67，p=0.024）、联合使用2种csDMARDs（OR=3.72，p=0.030）是复发的危险因素，通过ROC曲线确定预测复发的DAS28（CRP）最佳截断值为1.82。将这三个参数纳入模型进行联合预测概率分析，ROC曲线下面积为0.722（95%CI 0.61，0.82，p=0.000）。