RA的早期治療北京協(xié)和醫(yī)院風(fēng)濕免疫科沈敏RA預(yù)后指標(biāo)性別女性年齡年青受累關(guān)節(jié)數(shù)＞20骨侵蝕發(fā)生早，數(shù)量多關(guān)節(jié)功能喪失出現(xiàn)早，積累增加治療前病史＞5RA預(yù)后指標(biāo)類風(fēng)濕結(jié)節(jié)存在，數(shù)量多RF效價高關(guān)節(jié)外表現(xiàn)存在急相反應(yīng)物ESR、CRP高跖趾滑膜炎存在全身癥狀如發(fā)熱貧血乏力存在早期激素治療不能完全緩解RA的治療原則早期積極治療，盡可能達(dá)到臨床緩解的目標(biāo)（treat-to-target）嚴(yán)格控制（tight-control），密切隨訪早期使用傳統(tǒng)DMARDs，尤其是MTX合理使用生物制劑和皮質(zhì)激素功能鍛煉，病人教育EULAR2009對RA的治療建議提出了RA治療策略：目標(biāo)治療（treat-to-target）參考了“真實(shí)（realworld）”治療經(jīng)驗(yàn)，追求個體化治療充分考慮到了科學(xué)性和經(jīng)濟(jì)性的關(guān)系提出了皮質(zhì)激素治療RA的地位涉及到了減藥和停藥的問題Recommendation1

TreatmentstartTherapywithsyntheticDMARDsshouldbestartedassoonasthediagnosisofRAismadeRecommendation2

Treat-to-targetTreatmentshouldbeaimedatreachingatargetofremissionorlowdiseaseactivityassoonaspossibleineverypatient;aslongasthetargethasnotbeenreached,adjustmentofthetreatmentshouldbedonebyfrequent(onceper1-3months)andstrictmonitoring目標(biāo)治療以降低RA疾病活動度達(dá)到臨床緩解為目標(biāo)的更加個體化的治療策略早期強(qiáng)化治療密切隨訪，根據(jù)病情活動度調(diào)整治療方案，直至臨床緩解精確的疾病活動評價體系個體化治療目標(biāo)治療目標(biāo)：臨床緩解或低度活動（目前主要指DAS28＜2.6~3.2）方法：嚴(yán)格控制（tightcontrol）密切隨訪（1~3月）根據(jù)病情活動度調(diào)整治療方案直至臨床緩解，并維持緩解目標(biāo)治療早期DMARDs治療，每1~3月隨訪一次MTX7.5~25mg/w+(皮質(zhì)激素或聯(lián)合HCQ/SSZ)判斷是否達(dá)標(biāo)：每次隨訪改善在20%以上，6~12月內(nèi)達(dá)到目標(biāo)繼續(xù)，維持緩解6個月以上，可逐漸減藥DMARDs+TNFa或IL-6拮抗劑另一DMARDs（CyA，LEF，T2）+（激素）是否Recommendation3

FirstDMARDsMTXshouldbepartofthefirsttreatmentstrategyinpatientwithactiveRAMTX：核心藥物（Anchordrug）小劑量（7.5~20mg/w）長期有效安全大劑量（20~30mg/w）有細(xì)胞毒和其他副作用，根據(jù)個體差異選用初始治療可單用MTX快加：5mg/w；慢減：2.5mg/w合并使用葉酸明顯減少胃腸副作用Recommendation4

AlternativefirstDMARDsIncaseofMTXcontraindications(orintolerance),thefollowingDMARDsshouldbeconsideredaspartofthe(first)treatmentstrategy:SSZ,LEFandinjectablegold雷公藤多甙？Recommendation5

Monovs.comboInDMARDs-naivepatients,syntheticDMARDmonotherapyratherthancombinationtherapywithothersyntheticDMARDsmaybeappliedRecommendation6

GlucocorticoidsGlucocorticoidscanbeusefulasinitialshorttermtherapyincombinationwithsyntheticDMARDs大劑量（40~60mg/d）可作為誘導(dǎo)緩解應(yīng)避免激素＞10mg/d長期使用小劑量（＜5mg/d）長期維持有爭議：預(yù)防骨質(zhì)疏松，無高血壓、糖尿病等Recommendation7

BiologicalsIfthetreatmenttargetisnotachievedwiththefirstDMARDstrategy,additionofabiologicalDMARDshouldbeconsideredincaseofpresenceofindividualpoorprognosticfactors.IntheabsenceofpoorprognosticfactorsaswitchtoanothersyntheticDMARDstrategyshouldbeconsideredInpatientsrespondinginsufficientlytoMTXand/orothersyntheticDMARDs,biologicalDMARDsshouldbecommenced.CurrentpracticewouldbetostartaTNFinhibitorwhichshouldbecombinedwithMTX藥物選擇：生物制劑TNFa抑制劑首選，聯(lián)合MTX使用MTX和其他傳統(tǒng)DMARDs治療不理想者應(yīng)加用TNFa抑制劑有預(yù)后不好因素者可初始使用MTX+TNFa抑制劑生物制劑生物制劑Recommendation8

AfteraTNFfailurePatientswithRAwhohavefailedafirstTNFinhibitortherapy,shouldreceiveanotherTNFinhibitor,abatacept,rituximabortocilizumabRecommendation9

RefractoryRAIncaseofrefractorysevereRAorcontraindicationstobiologicalagentsorthepreviouslymentionedsyntheticDMARDs,thefollowingsyntheticDMARDsmightbealsoconsidered,asmonotherapyorincombinationwithsomeoftheabove:AZA,CyA,CTXRecommendation10

StrategiesIntensivemedicationstrategiesshouldbeconsideredineverypatient,althoughpatientswithbadprognosticfactorshavemoretogainRecommendation11

TaperingIfapatientisinpersistentremission,glucocorticoidsshouldbetaperedandonecanconsidertaperingbiologicalDMARDs,espciallyifthistreatmentiscombinedwithasyntheticDMARDIncaseofsustainedlong-termremission,cautioustitrationofsyntheticDMARDdosecouldbeconsidered,asasharedecisionbetweenpatientandphysicianRecommendation12

Poor-prognosispatientsDMARD-na?vepatientswithpoorprognosticmarkersmightbeconsideredforcombinationtherapyofMTXplusabiolo