Kısaarslan Ayşenur Paç, Sözeri Betül, Gündüz Zübeyde, Zararsız Gökmen, Poyrazoğlu Hakan, Düşünsel Ruhan
Department of Pediatric Rheumatology, Erciyes University School of Medicine, Kayseri, Turkey.
Department of Biostatistics, Erciyes University School of Medicine, Kayseri, Turkey.
Eur J Rheumatol. 2019 Apr 22;6(3):130-135. doi: 10.5152/eurjrheum.2019.18180. Print 2019 Jul.
Treatments for enthesitis-related arthritis (ERA) consist of a mono- or combination therapy with non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs (DMARDs), and biological agents, and they are primarily based on adult studies and studies on other forms of juvenile idiopathic arthritis, depending on whether there is axial or peripheral involvement. We use DMARDs frequently in our daily practice, even in patients with axial involvement. The main reason for this is that the health insurance system in Turkey does not allow the use of Tumor Negrosis Factor (TNF) blockers as the first line of treatment. The aim of this study is to evaluate the factors affecting the duration of DMARDs application in patients with ERA.
Fifty-two patients with ERA were accepted in this retrospective cohort study. These patients did not have an inflammatory bowel disease, reactive arthritis or undifferentiated arthritis, psoriasis, and familial Mediterranean fever. Demographic characteristics, medical history, the initial and follow-up physical examination, initial Juvenile Spondyloarthritis Disease Activity Index (JSpADA), initial laboratory tests, radiographic tests, Juvenile Arthritis Damage Index-articulary (JADI-A) and extra-articulary (JADI-E) on the last admission, and data on medical treatments were recorded from the registered data. The univariate Cox proportional hazards regression analyses was used to determine factors affecting the non-response time of ERA patients to DMARDs before the biological treatment was started.
Twenty-seven patients (52%) achieved remission with DMARDs, while 25 (48%) patients did not. The age at diagnosis (HR=1.12; p=0.247); gender (HR=2.53; p=0.210); family history of ankylosing spondylitis (HR=1.17; p=0.730); inflammatory back pain (HR=0.57; p=0.175); the shoulder (HR=0.75 p=0.706), hip (HR=0.45; p=0.129), and small-joint involvement (HR=1.53; p=0.439); sacroiliitis with physical examination (HR=0.90; p=0.814) and magnetic resonance imaging (MRI) (HR=2.84; p=0.110); enthesitis (HR=0.83; p=0.670); presence of uveitis (HR=2.04; p=0.342); presence of HLA-B27 (HR=1.39; p=0.524); initial high acute phase reactants levels(HR=1.89; p=0.183); initial JSpADA score (HR=0.98; p=0.944); and last JADI-A (HR=1.41; p=0.060) score did not affect the duration of DMARDs treatment before switching to biological treatments.
In our study, the absence of factors affecting the duration of DMARDs application in patients with ERA showed that DMARDs may still be applied as the first line of treatment.
附着点炎相关关节炎（ERA）的治疗包括使用非甾体抗炎药、改善病情抗风湿药（DMARDs）和生物制剂进行单一治疗或联合治疗，其主要依据成人研究以及其他形式幼年特发性关节炎的研究，并取决于是否存在轴向或外周受累情况。在我们的日常实践中，即使是轴向受累的患者，我们也经常使用DMARDs。这样做的主要原因是土耳其的医疗保险系统不允许将肿瘤坏死因子（TNF）阻滞剂作为一线治疗药物。本研究的目的是评估影响ERA患者使用DMARDs持续时间的因素。
在这项回顾性队列研究中纳入了52例ERA患者。这些患者没有炎症性肠病、反应性关节炎或未分化关节炎、银屑病以及家族性地中海热。从注册数据中记录人口统计学特征、病史、初始及随访体格检查、初始幼年脊柱关节炎疾病活动指数（JSpADA）、初始实验室检查、影像学检查、最后一次入院时的幼年关节炎损伤指数 - 关节（JADI - A）和关节外（JADI - E）情况以及医疗治疗数据。采用单因素Cox比例风险回归分析来确定在开始生物治疗前影响ERA患者对DMARDs无反应时间的因素。
27例（52%）患者使用DMARDs后病情缓解，而25例（48%）患者未缓解。诊断时的年龄（风险比[HR]=1.12；p = 0.247）；性别（HR = 2.53；p = 0.210）；强直性脊柱炎家族史（HR = 1.17；p = 0.730）；炎性背痛（HR = 0.57；p = 0.175）；肩部（HR = 0.75；p = 0.706）、髋部（HR = 0.45；p = 0.129）和小关节受累情况（HR = 1.53；p = 0.439）；体格检查发现的骶髂关节炎（HR = 0.90；p = 0.814）和磁共振成像（MRI）发现的骶髂关节炎（HR = 2.84；p = 0.110）；附着点炎（HR = 0.83；p = 0.670）；葡萄膜炎的存在（HR = 2.04；p = 0.342）；HLA - B27的存在（HR = 1.39；p = 0.524）；初始急性期反应物水平较高（HR = 1.89；p = 0.183）；初始JSpADA评分（HR = 0.98；p = 0.944）；以及最后一次JADI - A评分（HR = 1.41；p = 0.060）均未影响转换为生物治疗前DMARDs治疗的持续时间。
在我们的研究中，ERA患者中不存在影响DMARDs使用持续时间的因素，这表明DMARDs仍可作为一线治疗药物应用。
