合理治疗强直性脊柱炎2019.ppt

* 比较2003年和2006年治疗流程的变化更清晰的看出：对于中轴症状而言，TNF拮抗剂是首选。 强直性脊柱炎的附着点炎 Enthesitis Khan MA: In: Hochberg et al. RHEUMATOLOGY (3rd Ed.) 2003, Courtesy W Maksymowych Weber U, Pfirrmann CWA, Khan MA. Ankylosing spondylitis: update on imaging and therapy. Int J Adv Rheumatol.2007;5(1):2-7 Weber U, Pfirrmann CWA, Khan MA. Ankylosing spondylitis: update on imaging and therapy. Int J Adv Rheumatol. 2007; 5(1): 2-7 Courtesy of J Sieper SpA病程演变 放射学前阶段 （中轴型uSpA） 放射学阶段 （AS） 背痛 （MRI：可提示骶髂关节炎） 背痛 放射学和 骶髂关节炎 背痛 韧带钙化 时间（Years） 1984改良纽约分类标准 Differences in Bone Response to Inflammation in RA and AS/SpA BMP = bone morphogenic proteins; TGF = transforming growth factor beta; DKK = Dickkopf proteins; RANKL = RANK ligand;; Wnt = Wingless proteins. Schett et al. Ann Rheum Dis. 2007;66:709-711. (This figure is from the cover of the July 2007 issue.) Osteoclast Osteoblast Syndesmophyte DKK-1 inhibits Wnt-mediated proliferation differentiation of osteoblasts 判定炎性下腰痛的新标准 旧标准(Calin 1977) [2]： 以下5项需满足≥4项: age at onset40 years; duration of back pain≥3 months; insidious onset; morning stiffness; improvement with exercise 特异性：75% 敏感性：23% - 38% 柏林标准(2006) [1] 1. Rudewaleit M, et al. Ann Rheum Dis.2006;54:569-578. 2. Calin A, et al. JAMA.1977;237:2613-2614. ASAS/EULAR推荐AS治疗流程 (2006) 教育 锻炼 物理治疗 康复 病友会 自助组 NSAIDs 中轴疾病 外周疾病 DMARDs 局部皮质激素 TNF拮抗剂 镇痛药 外科手术治疗 J Zochling, et al., Ann Rheum Dis 2006; 65:442-52 Thanks Clinical Features of AS Sacroiliitis is the hallmark feature of AS1 and the earliest, most consistent findings are traceable to effects of sacroiliitis and enthesitis. Inflammation of the discovertebral, apophyseal, costovertebral, and costotransverse joints of the spine, and paravertebral ligamentous structures are frequently associated with AS. After many years, chronic inflammation can cause bony ankylosis.2 ? Chronic low back pain and stiffness, which typically worsens following a period of prolonged inactivity (eg, morning stiffness), are common presentations.1 Over time, lumbar spi