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Correction to Lancet Rheumatol 2024; 6: e507–17 柳叶刀风湿病学》2024;6:e507-17 更正。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-27 DOI: 10.1016/S2665-9913(24)00303-5
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引用次数: 0
The emerging risk of overdiagnosis in rheumatoid arthritis and polymyalgia rheumatica. 类风湿性关节炎和多发性风湿性关节炎新出现的过度诊断风险。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-25 DOI: 10.1016/S2665-9913(24)00227-3
Elizabeth Nettleton, Kylie Carlson, Michael Putman

Overdiagnosis occurs when patients are diagnosed with a disease that would otherwise never have affected the quality or duration of their lives. This often happens unintentionally through well-meaning screening programmes that aim to detect diseases during so-called subclinical stages. Recently, it has been suggested that patients with polymyalgia rheumatica should be screened for giant cell arteritis to identify those at higher risk of relapse or vascular complications. Screening for interstitial lung disease for patients with rheumatoid arthritis has also been recommended to identify patients who could benefit from pulmonary interventions. These potential benefits must be weighed against foreseeable harms. Such harms include the uncovering of incidental findings that necessitate additional medical follow-up, the financial costs associated with screening initiatives, the risk of overtreatment through increased immunosuppression in patients who might not have otherwise required it, and the psychosocial burden of a new diagnosis. Randomised clinical trials and prospective cohort studies of screening interventions should be conducted to establish the risks and benefits and identify patients most likely to benefit from them. This Viewpoint covers risks that overdiagnosis presents to the field of rheumatology, with focus on rheumatoid arthritis and polymyalgia rheumatica.

过度诊断是指患者被诊断出患有一种本来不会影响其生活质量或寿命的疾病。这种情况往往是通过旨在发现所谓亚临床阶段疾病的善意筛查计划无意中发生的。最近,有人建议对多发性风湿痛患者进行巨细胞动脉炎筛查,以识别复发或血管并发症风险较高的患者。还有人建议对类风湿性关节炎患者进行间质性肺病筛查,以确定哪些患者可以从肺部干预中获益。这些潜在的益处必须与可预见的危害进行权衡。这些危害包括发现需要额外医疗随访的偶然发现、与筛查措施相关的经济成本、通过增加免疫抑制对原本不需要治疗的患者进行过度治疗的风险,以及新诊断带来的社会心理负担。应该对筛查干预措施进行随机临床试验和前瞻性队列研究,以确定其风险和益处,并确定最有可能从中受益的患者。本观点涵盖了过度诊断给风湿病学领域带来的风险,重点关注类风湿性关节炎和多发性风湿痛。
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引用次数: 0
Challenges and solutions for cellular therapy development in autoimmune diseases 自身免疫性疾病细胞疗法开发的挑战与解决方案。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-24 DOI: 10.1016/S2665-9913(24)00274-1
Elizabeth R Volkmann , John Varga , Bruce R Blazar , Steven Z Pavletic
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引用次数: 0
Research in Brief 研究简介
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/S2665-9913(24)00278-9
Jennifer Thorley
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引用次数: 0
Trials and tribulations for children with rheumatic diseases 风湿病患儿的考验和磨难
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-23 DOI: 10.1016/S2665-9913(24)00279-0
The Lancet Rheumatology
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引用次数: 0
Treating antineutrophil cytoplasmic antibody-associated vasculitis in frail older adults 治疗体弱老年人的抗中性粒细胞胞浆抗体相关性血管炎。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-18 DOI: 10.1016/S2665-9913(24)00272-8
Alexandra Legge
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引用次数: 0
Immunosuppressive agents or intravenous immunoglobulin in addition to glucocorticoids in the treatment of Susac syndrome: a French national cohort study. 除糖皮质激素外使用免疫抑制剂或静脉注射免疫球蛋白治疗苏萨克综合征:一项法国全国队列研究。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-18 DOI: 10.1016/S2665-9913(24)00220-0
Alexandra Kachaner, Arthur Mageau, Tiphaine Goulenok, Chrystelle François, Nicole Delory, Marie-Paule Chauveheid, Cedric Louenan, Serge Doan, Caroline Halimi, Isabelle Klein, Thomas Papo, Karim Sacré
<p><strong>Background: </strong>Susac syndrome is a rare disease affecting mainly young women and is characterised by an occlusive microvessel disease limited to the brain, retina, and inner ear. No randomised controlled trial has been published or declared as ongoing to investigate treatments for Susac syndrome. We aimed to compare the effect of glucocorticoids given alone or in combination with immunosuppressive agents or intravenous immunoglobulin for the prevention of relapse in patients with Susac syndrome.</p><p><strong>Methods: </strong>The Phenotypic and Etiological Characterization of Susac Syndrome-National Clinical Research Hospital Program study is a prospective national cohort study that started enrolling on Nov 29, 2011, and included all consecutive patients aged 18 years or older with Susac syndrome who were referred to the French reference centre (Department of Internal Medicine, Bichat-Claude Bernard Hospital, Paris). Susac syndrome was defined by either the triad of encephalopathy with typical brain MRI abnormalities, cochleo-vestibular damage, and multiple occlusions of retinal central artery branches, or at least two of the three criteria without any alternative diagnosis. Collected data included fundoscopy, retinal angiography, audiometry, cerebrospinal fluid, brain MRI, and treatment received at diagnosis; months 1, 3, 6, and 12 after diagnosis; and then annually for 5 years or in the case of a relapse. The primary outcome was defined as the first relapse occurring within a 36-month follow-up period from the first day of treatment, characterised by new clinical symptoms or signs, and new abnormalities observed on retinal angiography, audiometry, or brain MRI, necessitating treatment intensification. There was no involvement of people with lived experience at any stage. The study is registered at ClinicalTrials.gov, NCT01481662.</p><p><strong>Findings: </strong>Between Nov 29, 2011, and Dec 2, 2022, 64 patients were included in the study, with a mean age at diagnosis of 35 years (SD 11); 41 (64%) were women and 23 (36%) were men. At diagnosis, 60 patients received glucocorticoids; 40 (63%) of 64 patients received glucocorticoids alone as a first-line therapy while 20 (31%) received glucocorticoids in combination with immunosuppressive agents or intravenous immunoglobulin. Overall, 46 (72%) of 64 patients had a first relapse with a median relapse-free survival time of 3·96 months (95% CI 2·24-16·07). Comparison of relapse-free survival showed no significant difference between the two treatment strategies (hazard ratio [HR] 1·11 [95% CI 0·56-2·17], p=0·76), compared with glucocorticoids alone as the reference group. In patients who first relapsed while treated with glucocorticoids alone, there was no significant difference in second relapse-free survival between those who did or did not receive immunosuppressive agents or intravenous immunoglobulin as a second-line therapy (HR 2·66 [95% CI 0·63-11·18], p=0·18).</p><p><strong>In
背景:苏萨克综合征是一种主要影响年轻女性的罕见疾病,其特征是局限于大脑、视网膜和内耳的闭塞性微血管疾病。目前尚未发表或宣布正在进行随机对照试验来研究苏萨克综合征的治疗方法。我们旨在比较糖皮质激素单独使用或与免疫抑制剂或静脉注射免疫球蛋白联合使用对预防苏萨克综合征患者复发的效果:苏萨克综合征的表型和病因特征--国家临床研究医院计划研究是一项前瞻性国家队列研究,于2011年11月29日开始招募,包括所有转诊至法国参考中心(巴黎比夏-克劳德-贝尔纳医院内科)的18岁或18岁以上连续苏萨克综合征患者。苏萨克综合征的定义是:具有典型脑磁共振成像异常的脑病、耳蜗-前庭损伤和视网膜中央动脉分支多发性闭塞的三联症,或者至少具备上述三项标准中的两项,但没有任何其他诊断。收集的数据包括眼底镜检查、视网膜血管造影、听力测定、脑脊液、脑磁共振成像以及确诊时、确诊后第 1、3、6 和 12 个月、5 年内每年一次或复发时接受的治疗。主要结果的定义是:自治疗第一天起的 36 个月随访期内首次复发,表现为新的临床症状或体征,以及视网膜血管造影、听力测定或脑核磁共振成像观察到的新异常,因而有必要加强治疗。在任何阶段都没有有生活经验的人参与。该研究已在 ClinicalTrials.gov 注册,编号为 NCT01481662:2011年11月29日至2022年12月2日期间,共有64名患者参与研究,诊断时的平均年龄为35岁(SD 11);其中女性41人(占64%),男性23人(占36%)。确诊时,60 名患者接受了糖皮质激素治疗;64 名患者中有 40 名(63%)接受了单独糖皮质激素一线治疗,20 名(31%)接受了糖皮质激素联合免疫抑制剂或静脉注射免疫球蛋白治疗。总体而言,64 名患者中有 46 人(72%)首次复发,无复发生存期中位数为 3-96 个月(95% CI 2-24-16-07)。与单纯糖皮质激素治疗组相比,两种治疗策略的无复发生存期无显著差异(危险比 [HR] 1-11 [95% CI 0-56-2-17],P=0-76)。在单用糖皮质激素治疗时首次复发的患者中,接受或不接受免疫抑制剂或静脉注射免疫球蛋白作为二线治疗的患者在第二次无复发生存率方面没有显著差异(HR 2-66 [95% CI 0-63-11-18],P=0-18):与单独使用糖皮质激素相比,糖皮质激素与免疫抑制剂或静脉注射免疫球蛋白联合使用似乎并不能降低苏沙克综合征复发的风险。我们的研究结果不支持在苏沙克综合征中系统使用免疫抑制剂:资金来源:法国卫生部
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引用次数: 0
Susac syndrome: challenges of interpreting treatment data in a rare disease. 苏萨克综合征:解读罕见病治疗数据的挑战。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-18 DOI: 10.1016/S2665-9913(24)00267-4
Todd A Hardy
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引用次数: 0
The effects of age and frailty on the risks of end-stage renal disease, death, and severe infection in older adults with antineutrophil cytoplasmic antibody-associated vasculitis: a retrospective cohort study 抗中性粒细胞胞浆抗体相关性血管炎老年患者的年龄和虚弱对终末期肾病、死亡和严重感染风险的影响:一项回顾性队列研究。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-18 DOI: 10.1016/S2665-9913(24)00193-0
Sebastian E Sattui MD , Bohang Jiang MPH , Xiaoqing Fu MS , Claire Cook MPH , Shruthi Srivatsan BS , Zachary K Williams BS , Guy Katz MD , Prof Yuqing Zhang DSc , Zachary S Wallace MD
<div><h3>Background</h3><div>Frailty, a measure of biological age, might predict poor outcomes in older adults better than chronological age. We aimed to compare the effect of age and frailty on end-stage renal disease, death, and severe infection within 2 years of diagnosis in older adults with incident antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis.</div></div><div><h3>Methods</h3><div>This retrospective cohort study included individuals aged 65 years or older from the Mass General Brigham ANCA-associated vasculitis cohort in the USA who were treated between Jan 1, 2002, and Dec 31, 2019. Individuals with a diagnosis of eosinophilic granulomatosis with polyangiitis were excluded from the analysis. Baseline frailty was measured with a claims-based frailty index using data collected in the year before the date of treatment initiation in individuals with at least one health-care encounter before baseline; individuals who did not have an encounter within the 12 months before baseline were classified as pre-frail. Incidence rates of end-stage renal disease or death and severe infections (ie, infections leading to hospital admission or death) at 2 years were estimated, and multivariable analyses were performed to compare the association of age and frailty with these outcomes. Cumulative incidence rates and an additive interaction analysis were used to assess the interaction of age and frailty groupings.</div></div><div><h3>Findings</h3><div>Of the 234 individuals included, 136 (58%) were women, 98 (42%) were men, 198 (85%) were White, and 198 (85%) were positive for myeloperoxidase-specific ANCA. Frailty was present in 25 (22%) of 116 individuals aged 65–74 years and 44 (37%) of 118 aged 75 years or older. In the multivariable analysis, an age of 75 years or older was associated with an increased risk of end-stage renal disease or death (hazard ratio [HR] 4·50 [95% CI 1·83–11·09]), however, frailty was not (1·08 [0·50–2·36]). Both an age of 75 years or older (HR 2·52 [95% CI 1·26–5·04]) and frailty (8·46 [3·95–18·14]) were independent risk factors for severe infections. The effect of frailty on the incidence of end-stage renal disease or death was greater in individuals aged 65–74 years (frail <em>vs</em> non-frail or pre-frail incidence rate 7·5 cases <em>vs</em> 2·0 cases per 100 person-years) than in those aged 75 years or older (13·5 cases <em>vs</em> 16·0 cases per 100 person-years). The effect of frailty on the incidence of serious infections varied by age, with large differences observed among both individuals aged 65–74 years (frail <em>vs</em> non-frail or pre-frail incidence rate 38·9 cases <em>vs</em> 0·8 cases per 100 person-years) and individuals aged 75 years or older (61·9 cases <em>vs</em> 12·3 cases per 100 person-years). Despite the observed differences between the age groups, the additive interaction terms were not statistically significant for either frailty and end-stage renal disease or death (p for interaction
背景:虚弱是衡量生理年龄的一个指标,它可能比实际年龄更能预测老年人的不良预后。我们的目的是比较年龄和虚弱对患有抗中性粒细胞胞浆抗体(ANCA)相关性血管炎的老年人确诊后两年内终末期肾病、死亡和严重感染的影响:这项回顾性队列研究纳入了2002年1月1日至2019年12月31日期间接受治疗的美国马萨诸塞州布里格姆综合医院ANCA相关性血管炎队列中65岁或以上的患者。诊断为嗜酸性粒细胞肉芽肿伴多血管炎的患者不在分析范围内。基线虚弱度采用基于索赔的虚弱度指数进行测量,该指数使用在基线前至少有一次就医经历的患者开始治疗前一年收集的数据;基线前 12 个月内没有就医经历的患者被归类为前期虚弱。我们估算了2年内终末期肾病或死亡以及严重感染(即导致入院或死亡的感染)的发病率,并进行了多变量分析,以比较年龄和虚弱与这些结果的关系。累积发病率和加性交互分析用于评估年龄和虚弱分组的交互作用:在纳入的 234 人中,136 人(58%)为女性,98 人(42%)为男性,198 人(85%)为白人,198 人(85%)髓过氧化物酶特异性 ANCA 阳性。在 116 名 65-74 岁的患者中,有 25 人(22%)存在虚弱;在 118 名 75 岁或以上的患者中,有 44 人(37%)存在虚弱。在多变量分析中,75 岁或以上与终末期肾病或死亡风险增加有关(危险比 [HR] 4-50 [95% CI 1-83-11-09]),但与体弱无关(1-08 [0-50-2-36])。75 岁或以上(HR 2-52 [95% CI 1-26-5-04])和体弱(8-46 [3-95-18-14])是严重感染的独立风险因素。体弱对终末期肾病或死亡发病率的影响在 65-74 岁人群中(体弱与非体弱或体弱前的发病率对比为 7-5 例 vs 2-0 例/100 人-年)大于 75 岁或以上人群(13-5 例 vs 16-0 例/100 人-年)。虚弱对严重感染发病率的影响因年龄而异,在 65-74 岁人群(虚弱与非虚弱或虚弱前的发病率为每百人年 38-9 例与 0-8 例)和 75 岁或以上人群(每百人年 61-9 例与 12-3 例)中观察到的差异都很大。尽管观察到各年龄组之间存在差异,但在虚弱与终末期肾病或死亡(交互作用的 p=0-276)或虚弱与严重感染(交互作用的 p=0-650)方面,加法交互项均无统计学意义:75岁或以上的ANCA相关性血管炎患者在确诊后2年内发生终末期肾病、死亡和严重感染的几率高于65-74岁的成年人。与生理年龄近似的虚弱是严重感染的一个风险因素。对于患有ANCA相关性血管炎的老年人,超越生理年龄的评估能更好地为管理决策提供依据:美国国立卫生研究院和美国国立关节炎、肌肉骨骼和皮肤病研究所。
{"title":"The effects of age and frailty on the risks of end-stage renal disease, death, and severe infection in older adults with antineutrophil cytoplasmic antibody-associated vasculitis: a retrospective cohort study","authors":"Sebastian E Sattui MD ,&nbsp;Bohang Jiang MPH ,&nbsp;Xiaoqing Fu MS ,&nbsp;Claire Cook MPH ,&nbsp;Shruthi Srivatsan BS ,&nbsp;Zachary K Williams BS ,&nbsp;Guy Katz MD ,&nbsp;Prof Yuqing Zhang DSc ,&nbsp;Zachary S Wallace MD","doi":"10.1016/S2665-9913(24)00193-0","DOIUrl":"10.1016/S2665-9913(24)00193-0","url":null,"abstract":"&lt;div&gt;&lt;h3&gt;Background&lt;/h3&gt;&lt;div&gt;Frailty, a measure of biological age, might predict poor outcomes in older adults better than chronological age. We aimed to compare the effect of age and frailty on end-stage renal disease, death, and severe infection within 2 years of diagnosis in older adults with incident antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Methods&lt;/h3&gt;&lt;div&gt;This retrospective cohort study included individuals aged 65 years or older from the Mass General Brigham ANCA-associated vasculitis cohort in the USA who were treated between Jan 1, 2002, and Dec 31, 2019. Individuals with a diagnosis of eosinophilic granulomatosis with polyangiitis were excluded from the analysis. Baseline frailty was measured with a claims-based frailty index using data collected in the year before the date of treatment initiation in individuals with at least one health-care encounter before baseline; individuals who did not have an encounter within the 12 months before baseline were classified as pre-frail. Incidence rates of end-stage renal disease or death and severe infections (ie, infections leading to hospital admission or death) at 2 years were estimated, and multivariable analyses were performed to compare the association of age and frailty with these outcomes. Cumulative incidence rates and an additive interaction analysis were used to assess the interaction of age and frailty groupings.&lt;/div&gt;&lt;/div&gt;&lt;div&gt;&lt;h3&gt;Findings&lt;/h3&gt;&lt;div&gt;Of the 234 individuals included, 136 (58%) were women, 98 (42%) were men, 198 (85%) were White, and 198 (85%) were positive for myeloperoxidase-specific ANCA. Frailty was present in 25 (22%) of 116 individuals aged 65–74 years and 44 (37%) of 118 aged 75 years or older. In the multivariable analysis, an age of 75 years or older was associated with an increased risk of end-stage renal disease or death (hazard ratio [HR] 4·50 [95% CI 1·83–11·09]), however, frailty was not (1·08 [0·50–2·36]). Both an age of 75 years or older (HR 2·52 [95% CI 1·26–5·04]) and frailty (8·46 [3·95–18·14]) were independent risk factors for severe infections. The effect of frailty on the incidence of end-stage renal disease or death was greater in individuals aged 65–74 years (frail &lt;em&gt;vs&lt;/em&gt; non-frail or pre-frail incidence rate 7·5 cases &lt;em&gt;vs&lt;/em&gt; 2·0 cases per 100 person-years) than in those aged 75 years or older (13·5 cases &lt;em&gt;vs&lt;/em&gt; 16·0 cases per 100 person-years). The effect of frailty on the incidence of serious infections varied by age, with large differences observed among both individuals aged 65–74 years (frail &lt;em&gt;vs&lt;/em&gt; non-frail or pre-frail incidence rate 38·9 cases &lt;em&gt;vs&lt;/em&gt; 0·8 cases per 100 person-years) and individuals aged 75 years or older (61·9 cases &lt;em&gt;vs&lt;/em&gt; 12·3 cases per 100 person-years). Despite the observed differences between the age groups, the additive interaction terms were not statistically significant for either frailty and end-stage renal disease or death (p for interaction","PeriodicalId":48540,"journal":{"name":"Lancet Rheumatology","volume":null,"pages":null},"PeriodicalIF":15.0,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Development of rheumatoid arthritis after methotrexate in anticitrullinated protein antibody-negative people with clinically suspect arthralgia at risk of rheumatoid arthritis: 4-year data from the TREAT EARLIER trial. 临床怀疑有类风湿性关节炎风险的抗瓜氨酸蛋白抗体阴性关节痛患者服用甲氨蝶呤后出现类风湿性关节炎:TREAT EARLIER 试验的 4 年数据。
IF 15 1区 医学 Q1 RHEUMATOLOGY Pub Date : 2024-09-17 DOI: 10.1016/S2665-9913(24)00196-6
Quirine A Dumoulin, Doortje I Krijbolder, Karen Visser, Leroy R Lard, Annette H M van der Helm-van Mil
<p><strong>Background: </strong>Prevention of rheumatoid arthritis has become a definitive target. However, whether prevention of anti-citrullinated protein antibody (ACPA)-negative rheumatoid arthritis is possible is still unknown. We aimed to assess the efficacy of a 1-year course of methotrexate on the development of rheumatoid arthritis in ACPA-negative people with clinically suspect arthralgia and predicted increased risk of rheumatoid arthritis.</p><p><strong>Methods: </strong>For this follow-up analysis, we used 4-year data from the TREAT EARLIER trial, a randomised, double-blind, placebo-controlled, proof-of-concept trial conducted in the southwest region of the Netherlands from which we analysed data collected between April 16, 2015, and Sept 11, 2023. ACPA-positive and ACPA-negative adults aged 18 years or older with arthralgia and subclinical joint inflammation who were at risk of developing rheumatoid arthritis were eligible for enrolment. For TREAT EARLIER, participants were randomly assigned (1:1) to active treatment or placebo. Active treatment consisted of a single intramuscular glucocorticoid injection (120 mg of methylprednisolone) upon inclusion, then a 1-year course of methotrexate. Placebo consisted of a single placebo injection followed by a 1-year course of placebo tablets. Trial visits occurred every 4 months during the first 2 years, at which clinical and questionnaire data were collected. Total follow-up was 4 years. For this analysis, participants were stratified via a prediction model into low risk, increased risk, and high risk of developing persistent, clinically apparent inflammatory arthritis. The primary outcome was development of rheumatoid arthritis, defined as the presence of clinically apparent inflammatory arthritis and clinical diagnosis of rheumatoid arthritis, and was assessed in all TREAT EARLIER participants. Severity of subclinical joint inflammation, physical functioning, and grip strength in ACPA-negative participants was studied in each risk group over a period of 2 years.</p><p><strong>Findings: </strong>901 people with clinically suspect arthralgia were assessed for eligibility and 236 were enrolled in TREAT EARLIER. All 236 participants were included in the intention-to-treat analysis and 217 (92%) completed 4-year follow-up. 154 (65%) of 236 participants were women and 82 (35%) were men, 182 (77%) were ACPA-negative and 54 (23%) were ACPA-positive. Of the 182 randomly assigned ACPA-negative participants, none were predicted to be at high risk of developing persistent, clinically apparent inflammatory arthritis, 66 (36%) at increased risk, and 116 (64%) at low risk. Of the 54 ACPA-positive participants, 24 (44%) were predicted to be at high risk, 30 (56%) at increased risk, and none at low risk. After 4 years, 52 (22%) of 236 participants had developed the primary outcome of rheumatoid arthritis (25 [21%] of 119 in the treatment group and 27 [23%] of 117 in the placebo group). Of the 66 ACPA-negat
背景:预防类风湿性关节炎已成为一个明确的目标。然而,能否预防抗瓜氨酸蛋白抗体(ACPA)阴性的类风湿关节炎仍是一个未知数。我们的目的是评估为期一年的甲氨蝶呤疗程对具有临床可疑关节痛和预测类风湿关节炎风险增加的 ACPA 阴性患者类风湿关节炎发展的疗效:在本次随访分析中,我们使用了TREAT EARLIER试验的4年数据,该试验是一项随机、双盲、安慰剂对照、概念验证试验,在荷兰西南部地区进行,我们分析了2015年4月16日至2023年9月11日期间收集的数据。年龄在18岁或18岁以上、患有关节痛和亚临床关节炎症、有发展为类风湿性关节炎风险的ACPA阳性和ACPA阴性成人均符合报名条件。在 "早治疗 "项目中,参与者被随机分配(1:1)接受积极治疗或安慰剂治疗。积极治疗包括在入组时进行一次肌肉注射糖皮质激素(120 毫克甲泼尼龙),然后进行为期 1 年的甲氨蝶呤治疗。安慰剂包括一次安慰剂注射,然后服用安慰剂药片,疗程为 1 年。在头两年中,每 4 个月进行一次随访,收集临床和问卷调查数据。总随访时间为 4 年。在本次分析中,研究人员通过预测模型将参与者分为低风险、高风险和高风险人群,这些人群都有可能患上持续性、临床症状明显的炎症性关节炎。主要结果是类风湿性关节炎的发展,定义为出现临床明显的炎症性关节炎和临床诊断为类风湿性关节炎,并对所有 "早期治疗 "参与者进行了评估。对每个风险组中ACPA阴性参与者的亚临床关节炎症严重程度、身体功能和握力进行了为期2年的研究:901名临床疑似关节痛患者接受了资格评估,其中236人参加了 "早期治疗 "项目。所有 236 名参与者均被纳入意向治疗分析,其中 217 人(92%)完成了为期 4 年的随访。236 名参与者中有 154 名(65%)为女性,82 名(35%)为男性,182 名(77%)为 ACPA 阴性,54 名(23%)为 ACPA 阳性。在随机分配的 182 名 ACPA 阴性参与者中,没有人被预测为罹患持续性、临床表现明显的炎症性关节炎的高风险人群,66 人(36%)为高风险人群,116 人(64%)为低风险人群。在 54 名 ACPA 阳性参与者中,有 24 人(44%)被预测为高风险,30 人(56%)为高风险,没有人是低风险。4年后,236名参与者中有52人(22%)出现了类风湿关节炎这一主要结果(治疗组119人中有25人[21%],安慰剂组117人中有27人[23%])。在 66 名 ACPA 阴性参与者中,预测其风险会增加,治疗组 35 人中有 3 人(9%)出现主要结果,而安慰剂组 31 人中有 9 人(29%)出现主要结果(危险比 0-27,95% CI 0-07-0-99;P=0-034)。在116名被预测为低风险的ACPA阴性参与者中,治疗组53人中有4人(8%)出现主要结局,而安慰剂组63人中有6人(10%)出现主要结局(0-79,0-22-2-80;P=0-71)。因此,在对风险进行分层后,甲氨蝶呤 1 年疗程与降低 ACPA 阴性类风湿性关节炎发病率有关,而预测的发病风险会增加。在类风湿关节炎发病风险增加的ACPA阴性参与者中,亚临床关节炎症、身体功能和握力在治疗后持续得到改善,但在低风险参与者中则没有改善:风险分层有助于对临床疑似关节痛的ACPA阴性患者进行试验,以确定哪些患者可从治疗中获益,从而预防类风湿关节炎的发展:荷兰研究理事会-ZonMw、荷兰关节炎协会。
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Lancet Rheumatology
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