Evolution of treatment for rheumatoid arthritis
Evolution of treatment for rheumatoid arthritis
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DOI：
10.1093/rheumatology/kes278
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发表时间：
2012-12-01
期刊：
影响因子：
5.5
通讯作者：
Kay, Jonathan
中科院分区：
文献类型：
--
作者：
Upchurch, Katherine S.;Kay, Jonathan
过去 25 年里，RA 的治疗发生了深刻的变化，从缓解症状的策略发展到实施影响疾病活动性的治疗方案，并最终证明可以减缓或阻止结构性关节损伤。 RA 的药物治疗已经从水杨酸盐发展到 NSAID、CS、DMARD、MTX，最后发展到生物反应调节剂。 MTX 已成为大多数 RA 患者的首选药物，有些患者在不添加其他药物的情况下使用 MTX 单药治疗效果良好。包括 MTX 和其他常规 DMARD 在内的联合治疗方案可能是治疗 RA 的有效早期方法。基于我们对 RA 滑膜炎症分子介质的了解，生物反应调节剂（生物制剂）于 20 世纪 90 年代末问世。第一种生物制剂抑制 TNF-α，这是一种在宿主防御某些感染和恶性肿瘤中具有活性的细胞因子，但也会促进炎症和骨质侵蚀。 TNF-α 抑制剂大多与 MTX 一起使用，但有些可以作为单一疗法使用。研究一致表明，MTX + TNF-α 抑制剂联合治疗比单独使用任一药物可获得更好的结果。严格的控制策略，采用客观的措施，也能改善结果。当患者使用一种或多种 TNF-α 抑制剂 + MTX 治疗失败时，可以尝试许多其他可能的替代方案，包括使用具有其他机制的生物制剂治疗，例如针对某些 IL、其他细胞因子和炎症介质的抗体。目前对 RA 的治疗使得从症状出现到严重残疾的进展不再是不可避免的，并且 RA 患者可以通过药物治疗期待舒适和富有成效的生活。
Treatment for RA has changed profoundly over the past 25 years, evolving from a strategy of providing symptomatic relief, to implementation of therapeutic regimens that impact disease activity and ultimately have been shown to slow or arrest structural joint damage. Drug therapy for RA has evolved from salicylates, to NSAIDs, CSs, DMARDs, MTX, and finally to biologic response modifiers. MTX has become the initial drug of choice in most patients with RA, and some do well on MTX monotherapy without the addition of other agents. Combination regimens including MTX and other conventional DMARDs may be an effective early approach to treatment of RA. The biologic response modifiers (biologics) became available in the late 1990s, based on our understanding of the molecular mediators of synovial inflammation in RA. The first biologics inhibited TNF-alpha, a cytokine active in host defences against some infections and malignancies, but which also promotes inflammation and bone erosion. Inhibitors of TNF-alpha are mostly given with MTX, although some can be given as monotherapy. Studies consistently show that combination MTX + TNF-alpha inhibitor therapy leads to better outcomes than with either agent alone. Tight control strategies, employing objective measures, also lead to improved outcomes. When patients fail treatment with one or more TNF-alpha inhibitor + MTX, a number of other possible alternatives may be tried, including treatment with biologics having other mechanisms, such as antibodies to certain ILs, other cytokines and inflammatory mediators. Current therapy for RA is such that progression from symptom onset to significant disability is now no longer inevitable, and RA patients can anticipate comfortable and productive lives on medical therapy.