Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
JAMA. 2018 Oct 2;320(13):1360-1372. doi: 10.1001/jama.2018.13103.
Rheumatoid arthritis (RA) occurs in about 5 per 1000 people and can lead to severe joint damage and disability. Significant progress has been made over the past 2 decades regarding understanding of disease pathophysiology, optimal outcome measures, and effective treatment strategies, including the recognition of the importance of diagnosing and treating RA early.
Early diagnosis and treatment of RA can avert or substantially slow progression of joint damage in up to 90% of patients, thereby preventing irreversible disability. The development of novel instruments to measure disease activity and identify the presence or absence of remission have facilitated new treatment strategies to arrest RA before joints are damaged irreversibly. Outcomes have been improved by recognizing the benefits of early diagnosis and early therapy with disease-modifying antirheumatic drugs (DMARDs). The treatment target is remission or a state of at least low disease activity, which should be attained within 6 months. Methotrexate is first-line therapy and should be prescribed at an optimal dose of 25 mg weekly and in combination with glucocorticoids; 40% to 50% of patients reach remission or at least low disease activity with this regimen. If this treatment fails, sequential application of targeted therapies, such as biologic agents (eg, tumor necrosis factor [TNF] inhibitors) or Janus kinase inhibitors in combination with methotrexate, have allowed up to 75% of these patients to reach the treatment target over time. New therapies have been developed in response to new pathogenetic findings. The costs of some therapies are considerable, but these costs are decreasing with the advent of biosimilar drugs (drugs essentially identical to the original biologic drugs but usually available at lower cost).
Scientific advances have improved therapies that prevent progression of irreversible joint damage in up to 90% of patients with RA. Early treatment with methotrexate plus glucocorticoids and subsequently with other DMARDs, such as inhibitors of TNF, IL-6, or Janus kinases, improves outcomes and prevents RA-related disability. A treat-to-target strategy aimed at reducing disease activity by at least 50% within 3 months and achieving remission or low disease activity within 6 months, with sequential drug treatment if needed, can prevent RA-related disability.
类风湿关节炎（RA）的发病率约为每 1000 人中有 5 人，可导致严重的关节损伤和残疾。在过去的 20 年中，人们对疾病病理生理学、最佳结果测量和有效治疗策略有了更深入的了解，包括认识到早期诊断和治疗 RA 的重要性。
早期诊断和治疗 RA 可以阻止或大大减缓多达 90%患者的关节损伤进展，从而预防不可逆转的残疾。新型疾病活动测量仪器和缓解识别工具的发展促进了新的治疗策略的制定，即在关节不可逆损伤之前阻止 RA 的发生。通过认识到早期诊断和早期使用疾病修饰抗风湿药物（DMARDs）的益处，改善了结果。治疗目标是缓解或至少低疾病活动状态，应在 6 个月内达到。甲氨蝶呤是一线治疗药物，应在每周 25mg 的最佳剂量下开具，并与糖皮质激素联合使用；40%至 50%的患者通过该方案达到缓解或至少低疾病活动状态。如果这种治疗失败，随后应用靶向治疗，如生物制剂（如肿瘤坏死因子[TNF]抑制剂）或 Janus 激酶抑制剂联合甲氨蝶呤，可以使多达 75%的患者随着时间的推移达到治疗目标。针对新的发病机制发现，已经开发出了新的治疗方法。一些治疗方法的成本相当高，但随着生物类似药（与原生物制剂基本相同但通常成本较低的药物）的出现，这些成本正在降低。
科学进步改善了治疗方法，可预防高达 90%的 RA 患者不可逆关节损伤的进展。早期使用甲氨蝶呤加糖皮质激素，随后使用其他 DMARDs，如 TNF、IL-6 或 Janus 激酶抑制剂的抑制剂，可改善结果并预防 RA 相关残疾。一种以目标为导向的治疗策略旨在在 3 个月内至少降低 50%的疾病活动度，并在 6 个月内达到缓解或低疾病活动度，如果需要，可进行序贯药物治疗，从而预防 RA 相关残疾。
