03类风湿关节炎的诊治进展2015继教班(胡建东)概述.pptx

类风湿关节炎的诊治进展 上海中医药大学附属岳阳中西医结合医院 风湿科 胡建东 2015.9.17 RA临床特点 放射学破坏 (c) 1972-2004 American College of Rheumatology Clinical Slide Collection. Used with permission. 5D Discomfort Disability Drug toxicity Dollar lost Death 病理机制 诊断分类标准 1987年ACR的RA分类标准 注：以上7条满足4条或4条以上并排除其他关节炎可诊断RA，条件1～4必须持续至少6周(引自Arthritis Rheum，1988，31：315-324) 病情评估 Instruments Used to Measure Rheumatoid Arthritis Disease Activity Clinical Measurement Tools to Guide Treatment Decisions Aletaha D, et al. Clin Exp Rheumatol. 2005;23(suppl 39):S100-S108. Cush JJ. Arthritis Rheum. 2005;52(9 suppl):S686. Low Disease Activity Moderate Disease Activity High Disease Activity Remission CDAI ≤ 2.8 22 2.9-10 11-22 DAS ≤ 2.4 SDAI 22 5.5 3.6 N/A SDAI ≤ 3.3 3.4-11 12-26 26 ACR/EULAR Definitions of Remission in Rheumatoid Arthritis Clinical Trials * Include 28 joints plus feet and ankles. RA的临床缓解标准 2013年版EULAR关于RA治疗的推荐 2013年版EULAR关于RA治疗的推荐 早期治疗 早期诊断 早期诊断 2010类风湿关节炎早期分类标准配合MRI 早期治疗（治疗窗） What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? van Nies JAB, et al. Ann Rheum Dis 2014;73:861–870. doi:10.1136/annrheumdis-2012-203130 Meta-analysis on the association between symptom duration (in weeks) and achieving DMARD-freesustained remission over time inrheumatoid arthritis (RA). (A) Univariable analysis on symptom duration (B) Multivariable analysis on symptom duration, adjusted for age, gender and treatment (C) Multivariable analysis on symptom duration,adjusted for age, gender, treatment,rheumatoid factor and ESR, van Nies JAB, et al. Ann Rheum Dis 2014;73:861–870. doi:10.1136/annrheumdis-2012-203130 目标治疗（treat to target) Remission Low disease activity 目标治疗(treat to target) 未达到治疗目标前， 应严格控制（tight control)，需定期（1-3个月）调整治疗方案，并密切监测 Progression of structural damage Comorbidities Safety 调整治疗方案时除了上述疾病活动因素外，还应考虑 指南解读 指南解读 指南解读 指南解读 指南解读 药物治疗 非甾体抗炎药(NSAIDs) 糖皮质激素(GC) 改善病情抗风湿药(DMARDs) 生物制剂（Biologics) 草药（herbal medicine) 非甾体抗炎药(NSAIDs) Effect of Nonsteroidal Antiinfl