类风湿性关节炎伴间质性肺病患者药物治疗的特殊性

A. V. Gordeev, E. Galushko, E. V. Matyanova, E. V. Pozhidaev, E. Zotkin, A. Lila
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引用次数: 0

摘要

目的:对存在和不存在间质性肺病(ILD)的类风湿性关节炎(RA)药物治疗的特殊性进行比较研究。研究纳入了1034名符合2010年ACR/EULAR标准的活动性RA患者。患者被分为两组:根据肺部高分辨率计算机断层扫描结果显示患有间质性肺病的患者(82人)和未患有间质性肺病或其他类型慢性阻塞性肺部疾病(包括支气管哮喘)的患者(52人除外;900人)。根据医疗文件、存档病历和病史,为活动性 RA 患者各阶段的药物治疗建立了 "药物卡"。累积疾病指数评分(CIRS)用于评估合并症的概况和严重程度。两组患者的主要RA活动指标相当,但ILD组的合并症数量更多(p˂0.0001),CIRS多病指数值更高(p˂0.0001)。ILD 的存在对糖皮质激素(GC)的处方频率、总使用时间和最大剂量没有影响(p˂0.05)。从统计学角度看,患有 ILD 组患者的糖皮质激素平均剂量明显更高(p=0.008)。这些患者服用改变病情抗风湿药(DMARDs):甲氨蝶呤(p=0.04)、来氟米特(p=0.02)和柳氮磺胺吡啶(p=0.03)的频率较低,但服用羟氯喹的频率明显更高(p=0.02),每种药物的总用药时间相当。有ILD和无ILD的RA患者中,分别有62.2%和59.6%的患者接受了生物DMARDs(bDMARDs)和靶向合成DMARDs(tsDMARDs)治疗(p˂0.05)。同时,无 ILD 的患者服用过更多不同的 bDMARDs/tsDMARDs (p=0.03)。在患有 ILD 的组别中,患者接受抗 B 细胞治疗的频率更高(p˂0.0001),而接受其他类药物治疗的频率则明显较低:肿瘤坏死因子 α 抑制剂(p˂0.0001)、白细胞介素 6 抑制剂(p=0.01)、T 细胞刺激阻断剂(p=0.04)和 Janus 激酶抑制剂(p=0.001)。据统计,ILD患者在开始接受bDMARD/tsDMARD治疗时年龄明显较大(p˂0.0001),两组患者从RA发病到开始接受bDMARD/tsDMARD治疗的时间相当(p˂0.05)。在 ILD 组中观察到的药物治疗的特殊性(GC、DMARDs、生物制剂和 tsDMARDs 的使用频率、选择和剂量)一方面可能与 ILD 的存在有关,另一方面可能与伴随的病理特征和年龄较大有关,因为在我们的患者中,有 ILD 和没有 ILD 的患者的 RA 活性相当。
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Peculiarities of pharmacotherapy of patients with rheumatoid arthritis associated with interstitial lung disease
Objective: a comparative study of the peculiarities of pharmacotherapy of rheumatoid arthritis (RA) in presence and in absence of interstitial lung disease (ILD).Material and methods. The study included 1034 patients with active RA who met the 2010 ACR/EULAR criteria. Patients were divided into two groups: with ILD according to high-resolution computed tomography of the lungs (n=82) and without ILD or other types of chronic obstructive pulmonary diseases, including bronchial asthma (52 patients excluded; n=900). Based on medical documentation, archived medical records and medical history, a “drug card” was created for all stages of pharmacotherapy of patients with active RA. The Cumulative Illness Index Score (CIRS) was used to assess the profile and severity of comorbidities.Results and discussion. The main indicators of RA activity in the patients of the two groups were comparable, but a greater number of comorbidities (p˂0.0001) and a higher value of the CIRS multimorbidity index (p˂0.0001) were found in the group with ILD. The presence of ILD had no influence on the frequency of prescription, the total duration of use and the maximum dose of glucocorticoids (GC) (p˂0.05). The average dose of GC was statistically significantly higher in the group with ILD (p=0.008). These patients were taking disease-modifying antirheumatic drugs (DMARDs): methotrexate (p=0.04), leflunomide (p=0.02) and sulfasalazine (p=0.03), less frequently, but they took hydroxychloroquine significantly more frequently (p=0.02) with a comparable total duration of use of each medication. RA patients with ILD and without ILD received biologic DMARDs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) in 62.2 and 59.6% of cases, respectively (p˂0.05). At the same time, patients without ILD had experience of taking a greater number of different bDMARDs/tsDMARDs (p=0.03). In the group with ILD, patients more frequently received anti-B-cell therapy (p˂0.0001) and significantly less frequently drugs of other classes: tumour necrosis factor α inhibitors (p˂0.0001) and interleukin 6 inhibitors (p=0.01), T-cell costimulation blocker (p=0.04) and Janus kinase inhibitors (p=0.001). Patients with ILD were statistically significantly older at the start of bDMARD/tsDMARD therapy (p˂0.0001), and the period from the onset of RA to the start of bDMARD/tsDMARD therapy was comparable in both groups (p˂0.05).Conclusion. The observed peculiarities of pharmacotherapy in the group with ILD (frequency of use, choice and dose of GC, DMARDs, biologics and tsDMARDs) are probably related to the presence of ILD on the one hand and to the characteristics of concomitant pathology and older age on the other, as the activity of RA was comparable in our patients with and without ILD.
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