超声在RA达标治疗中的应用－多中心国际观察经验

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Application of Ultrasound to Treat to Target Management of Rheumatoid Arthritis  - Multicentre International Observational Experience   Sibel Aydin 1, Maya H. Buch2, Sarah Horton3, Kei Ikeda4, Annamaria Iagnocco5, Marwin Gutierrez6, Walter Grassi7, Esperanza Naredo8, Eugenio De Miguel9, Lene Terslev10, Marina Backhaus11, Maria-Antonietta D'Agostino12, Alberto Batticciotto2, Zunaid Karim2, Richard J. Wakefield13 and Paul Emery14, 1Goztepe Training and Research Hospital, Istanbul, Turkey, 2Leeds institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Disease Biomedical Research Unit, Leeds Teaching Hospitals, Leeds, United Kingdom, 3Leeds institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Disease Biomedical Research Unit, Leeds Teaching Hospitals, United Kingdom, 4Chiba University Hospital, Chiba, Japan, 5Uni, Jesi, Italy, 6Sapienza Universita di Roma, Rome, Italy, 7Università Politecnica delle Marche, Jesi, Italy, 8Hosptial Universitario Severo Ochoa, Madrid, Spain, 9La Paz University Hospital, Madrid, Spain, 10The Parker Institute, Copenhagen, Denmark, 11Charite University Hospital, Berlin, Germany, 12Versailles-Saint Quentin en Yvelines University- APHP, Ambroise-Paré Hospital, Boulogne-Billancourt, France, 13Leeds Institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals, Leeds, United Kingdom, 14Chapel Allerton Hospital, Leeds, United Kingdom   Presentation Number: 2144   Background/Purpose: The recent formulation of ‘treat to target’ (T2T) recommendations on the management of rheumatoid arthritis (RA) (1) aim to improve patient outcomes.  We aimed to investigate the additional role of ultrasound (US) to T2T clinical assessment. Method: An audit of 9 centres (8 countries) where musculoskeletal US is part of routine patient care was undertaken. Patients with active RA, requiring additional treatment and follow-up according to T2T recommendations were included. Clinical and US data were collected. US data from MCP 2-3, radiocarpal, intercarpal, MTP 5 joints and extensor carpi ulnaris tendon (where available) were analysed.  Result: At time of analysis, 93 patients had been audited. Baseline mean (SEM) characteristics included: Age 52.6 (15.5), disease duration 7.8 (11) years, DAS28 score 4.9 (1.5) and HAQ 2.4 (2.8).  78% were RF and 69%, ACPA positive. Thirty-five patients were on no DMARDS at baseline. At baseline, 81 % of patients had at least one joint PD signal. The pre-defined disease activity target was achieved in 25% and 49% of patients at 3 and 6 months respectively. Therapy was modified in only 16-44 % of active patients; the main reason reported as “waiting for the previous treatment escalation to work” (13-76%) (Table 1). At month 3, 50% of cases still had PD signal (38% PD≥2) in at least one joint despite achieving clinical target. Fifty percent of cases with clinical activity and PD signal did not receive any therapy modifications. Similarly at month 6, 53%  of patients achieving clinical target still had PD signal in at least one joint with 20 % with PD≥2. Twenty-eight percent of patients received no treatment modification despite clinical disease activity and PD presence (Table 2).   Conclusion: In this audit, therapy modifications were avoided in more than 50% of eligible RA patients at monthly visits, mainly due to waiting for the effect of previous treatments. A third to half of these cases also had PD signal, which has previously been demonstrated to be an independent risk factor for progression (2). US is a useful adjunct to clinical T2T approach and can inform patients who may particularly benefit from monthly treatment escalation.    Reference (1)     Smolen  JS et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69:631-7. (2)     Brown AK et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58:2958-67.	超声在RA达标治疗中的应用－多中心国际观察经验 Sibel Aydin, et al. ACR 2011. Present No: 2144   背景/目的: 近年提倡RA治疗的“达标治疗”(T2T)旨在改善患者预后(1)。 本研究目的是探讨超声检查对T2T临床评估的辅助作用。 方法:审核骨骼肌肉US作为病人诊治常规的9中心(8个国家)。根据T2T要求需要治疗升级和随访的活动性RA患者纳入本研究。收集临床和US数据。对MCP 2-3、桡掌、腕骨间、MTP 5关节和尺侧掌伸肌腱(如果有)进行分析。 结果:分析时有93例患者符合要求。基线平均(SEM)的特征包括:年龄52.6(15.5)、病程7.8(11)年,DAS28 4.9(1.5)和HAQ 2.4(2.8)。78%患者RF 阳性，69% ACPA阳性。35例患者基线时未用DMARDS。基线时,81%的病人至少一个关节有PD信号。 3和6个月时，有25%和49%的患者疾病活动度达标。只有16-44%的活动患者调整了治疗，报告的主要理由是“等待以前应用的药物逐步起效”(13—76%)(表1)。 3个月时,无论是否达标，50%患者至少一个关节仍有PD信号(38% PD≥2)。50％患者有临床活动和PD信号，但未作任何治疗调整。同样在6个月时,53%的患者达标，但仍有20％患者至少一个关节有 PD≥2。尽管有临床活动和PD信号，还是有28％患者没有调整治疗 (表2)。 结论:本次审核中，超过50％患者在每月随访时有调整治疗的适应症而未进行，主要是因为还在等待之前药物的疗效。 他们中的1/3到一半的患者同时存在 PD信号,后者已经被证实是疾病进展的独立危险因素(2)。US是一项非常有价值的T2T原则的补充，能提供患者受益于每月治疗升级的信息。
Table 1: Summary of clinical assessments in each visit  CLINICAL ASSESSMENT   Month 1 M2 M3 M4 M5 M6 n     74 59 55 48 43 49 DAS28     3.8 3.5 3.4 3.1 3.1 3.2 HAQ     2.5 1.2 1 0.9 0.9 1 Clinical target achieved n (%)     11 (15) 17 (29) 14 (25) 22 (46) 17 (40) 24 (49) Modification (in active group)   28/63 (44) 17/42 (40) 17/41 (42) 4/25 (16) 10/26 (39) 10/25 (40) Type of modification   Dose increase 25/28 10/17 8/17 2/4 4/10 1/10 Add DMARDS 1/28 2/17 4/17 2/4 3/10 7/10 Biologics 2/28 2/17 5/17 0/4 1/10 2/10 Additional steroids (n/active group)   4/63 6/42 4/41 2/25 3/26 2/25 Reason for no modification: Previous treatment to work n(%)   25/33 (76) 13/25 (52) 14/23 (61) 14/21 (67) 2/16 (13) 8/15 (53)
Table 2: PD findings according to clinical assessment at month 3 and 6.  Clinical target for disease activity   Any PD signal PD≥2 n pos neg pos neg At month 3 (n=41) Achieved 8 4 4 3 5 Not-achieved 33 28 5 19 14 Modification 14 13 1 6 8 At month 6 (n=28) Achieved 15 8 7 3 12 Not-achieved 13 11 2 10 3 Modification 9 8 1 7 2

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