2019 年美国风湿病学会/脊柱关节炎协会/脊柱关节炎研究与治疗网络关于治疗强直性脊柱炎和非放射学中轴型脊柱关节炎的建议更新。
2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis.
机构信息
National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland.
Oregon Health & Science University, Portland.
出版信息
Arthritis Care Res (Hoboken). 2019 Oct;71(10):1285-1299. doi: 10.1002/acr.24025. Epub 2019 Aug 21.
OBJECTIVE
To update evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).
METHODS
We conducted updated systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat-to-target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel.
RESULTS
Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co-administration of low-dose methotrexate with TNFi is not recommended, nor is a strict treat-to-target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended.
CONCLUSION
These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
目的
更新针对强直性脊柱炎（AS）和非放射学中轴型脊柱关节炎（SpA）患者治疗的循证推荐意见。
方法
我们针对 2015 年指南中涉及药物治疗的 20 个临床问题进行了更新的系统文献综述，并针对 26 个新的药物治疗、治疗目标策略以及影像学使用问题进行了综述。新问题涉及使用司库奇尤单抗、依奇珠单抗、托法替布、肿瘤坏死因子抑制剂（TNFi）生物类似药以及生物制剂的逐渐减少/停药等。我们使用推荐分级、评估、制定与评价（GRADE）方法评估证据质量，并制定推荐意见，需要投票小组成员至少 70%的一致意见。
结果
AS 和非放射学中轴型 SpA 的推荐意见相似。与司库奇尤单抗或依奇珠单抗相比，TNFi 被推荐作为首选生物制剂。对于首次 TNFi 治疗无应答的患者，建议使用司库奇尤单抗或依奇珠单抗，而不是再次使用 TNFi。TNFi、司库奇尤单抗和依奇珠单抗优于托法替布。不建议 TNFi 联合低剂量甲氨蝶呤，也不建议在疾病稳定的患者中采用严格的治疗目标策略或停止或减少生物制剂的使用。只有在 TNFi 禁忌的情况下，才建议使用柳氮磺胺吡啶治疗持续性外周关节炎。对于疾病活动度不明确的患者，脊柱或骨盆磁共振成像可辅助评估。不建议常规监测连续脊柱 X 线片的影像学变化。
结论
这些推荐意见为 AS 和非放射学中轴型 SpA 的管理提供了有关新药物和轴性骨骼影像学使用的最新指导。
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