Department of Paediatric Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.
Ann Rheum Dis. 2019 Jan;78(1):51-59. doi: 10.1136/annrheumdis-2018-213902. Epub 2018 Oct 11.
Which is the best strategy to achieve (drug-free) inactive disease in juvenile idiopathic arthritis (JIA)?
In a randomised, single-blinded, study in disease-modifying anti-rheumatic drug (DMARD)-naive patients with JIA, three treatment-strategies were compared: (1) sequential DMARD-monotherapy (sulfasalazine or methotrexate (MTX)), (2) combination therapy MTX + 6 weeks prednisolone and (3) combination therapy MTX +etanercept. Treatment-to-target entailed 3-monthly DMARD/biological adjustments in case of persistent disease activity, with drug tapering to nil in case of inactive disease.After 24 months, primary outcomes were time-to-inactive-disease and time-to-flare after DMARD discontinuation. Secondary outcomes were adapted ACRPedi30/50/70/90 scores, functional ability and adverse events.
94 children (67 % girls) aged median (IQR) 9.1 (4.6-12.9) years were enrolled: 32 in arms 1 and 2, 30 in arm 3. At baseline visual analogue scale (VAS) physician was mean 49 (SD 16) mm, VAS patient 53 (22) mm, erythrocyte sedimentation rate 12.8 (14.7), active joints median 8 (5-12), limited joints 2.5 (1-4.8) and Childhood Health Assessment Questionnaire score mean 1.0 (0.6).After 24 months, 71% (arm 1), 70% (arm 2) and 72% (arm 3) of patients had inactive disease and 45% (arm 1), 31% (arm 2) and 41% (arm 3) had drug-free inactive disease. Time-to-inactive-disease was median 9.0 (5.3-15.0) months in arm 1, 9.0 (6.0-12.8) months in arm 2 and 9.0 (6.0-12.0) months in arm 3 (p=0.30). Time-to-flare was not significantly different (overall 3.0 (3.0-6.8) months, p=0.7). Adapted ACR pedi-scores were comparably high between arms. Adverse events were similar.
Regardless of initial specific treatments, after 24 months of treatment-to-target aimed at drug-free inactive disease, 71% of recent-onset patients with JIA had inactive disease (median onset 9 months) and 39% were drug free. Tightly controlled treatment-to-target is feasible.
在幼年特发性关节炎（JIA）患者中，实现（无药物）疾病不活动的最佳策略是什么？
在一项针对疾病修饰抗风湿药物（DMARD）初治 JIA 患者的随机、单盲研究中，比较了三种治疗策略：（1）序贯 DMARD 单药治疗（柳氮磺胺吡啶或甲氨蝶呤（MTX））；（2）MTX+6 周泼尼松龙联合治疗；（3）MTX+依那西普联合治疗。治疗目标是每 3 个月进行一次 DMARD/生物调整，如果疾病持续活动，则进行药物减量，如果疾病不活动，则减至零。24 个月后，主要结局是无疾病活动时间和 DMARD 停药后的疾病发作时间。次要结局是适应性 ACRPedi30/50/70/90 评分、功能能力和不良事件。
共纳入 94 例儿童（67%为女性），年龄中位数（IQR）为 9.1（4.6-12.9）岁：1 组和 2 组各 32 例，3 组 30 例。基线时，医生视觉模拟量表（VAS）均值为 49（16）mm，患者 VAS 均值为 53（22）mm，红细胞沉降率为 12.8（14.7），活动关节中位数为 8（5-12），受限关节中位数为 2.5（1-4.8），儿童健康评估问卷评分均值为 1.0（0.6）。24 个月后，71%（1 组）、70%（2 组）和 72%（3 组）的患者疾病不活动，45%（1 组）、31%（2 组）和 41%（3 组）无药物疾病不活动。1 组无疾病活动时间中位数为 9.0（5.3-15.0）个月，2 组为 9.0（6.0-12.8）个月，3 组为 9.0（6.0-12.0）个月（p=0.30）。无疾病发作时间无显著差异（总体为 3.0（3.0-6.8）个月，p=0.7）。各臂之间适应性 ACR pedi 评分相似。不良事件相似。
在以无药物疾病不活动为目标的治疗 24 个月后，无论初始特定治疗如何，最近发病的 JIA 患者中有 71%达到疾病不活动（中位发病时间为 9 个月），39%无药物治疗。严格控制治疗目标是可行的。
1574。
