不同缓解标准下类风湿关节炎临床缓解与持续临床缓解率:一项单中心观察性研究

目的分析本中心RA队列中不同缓解标准下的临床缓解率与持续临床缓解率。方法纳入2011年1月1日至2016年12月31日所有就诊于北京大学第一医院风湿免疫科门诊的RA患者,收集首次就诊至2018年6月或末次随访的所有门诊病历资料,分别以DAS28-ESR、简化疾病活动度指数(SDAI)、临床疾病活动度指数(CDAI)、Boolean标准评价疾病活动度值和/或临床缓解状态,持续缓解定义为维持临床缓解时间>6个月。采用Kaplan-Meier生存分析计算RA患者的累积缓解率与中位达临床缓解时间。采用Cox多因素回归分析持续缓解的相关因素。结果本研究共连续纳入648例患者,在中位24个月的随访过程中,分别有510例(78.7%)、459例(70.8%)、443例(68.4%)、445例(68.7%)患者至少1次达到过临床缓解。其中,第3、6、12个月的累积临床缓解率分别为10.6%~24.4%、25.3%~43.5%、51.8%~65.2%,患者达首次临床缓解的中位时间为7.2~11.4个月。在随访过程中,分别有338例(52.2%)、302例(46.6%)、292例(45.1%)、283例(43.7%)患者至少1次实现DAS28-ESR、SDAI、CDAI和Boolean标准定义下的持续缓解。在这些达持续缓解的患者中,维持缓解状态的中位时间分别为16.0个月(DAS28-ESR),15.4个月(CDAI),14.9个月(SDAI)和15.0个月(Boolean标准)。在达到持续缓解的患者中,DMARDs单药和联合用药的比例分别为18.7%(73/390)、81.3%(317/390),此外,22.3%(87/390)的患者接受小剂量激素治疗,超过半数患者(51/87)在持续临床缓解期间减停激素。结论在临床工作中,临床缓解是切实、可行的治疗目标,经过规范的临床治疗,超过半数的患者可在治疗1年内实现临床缓解。而在实现临床缓解的患者中,大部分可实现持续临床缓解,维持缓解状态的中位时间为15个月左右。

Proportion of patients with clinical remission and sustained clinical remission measured by various validated indices in patients with rheumatoid arthritis:a single-institution observational study

Objective To investigate the proportion of patients with clinical remission and sustained remission in Chinses patients with rheumatoid arthritis(RA).Methods We retrospectively reviewed the medical records of RA patients in our center from January 1,2011 to December 31,2016.Disease activity scores and remission status at each visit were assessed by the disease activity score in 28 joints(DAS28),the simplified disease activity index(SDAI),the clinical disease activity index(CDAI),and the American Ccollege of Rheumatology/European league Against Rheumatism(ACR/EULAR)Boolean criteria.Patients were considered in sustained remission if they maintained remission during consecutive visits for 6 months.Kaplan-Meier method was applied to plot cumulative possibility of achieving remission and calculate the median time to first clinical remission.Cox multivariate regression analysis was used to analyze the relative factors of sustained remission.Results A total of 648 patients were included in the present study.During the median follow-up of 24 months,around 70%of patients reached clinical remission at least once(DAS28:78.7%,SDAI:70.8%,CDAI:68.4%,Boolean criteria:68.7%).Specifically,the cumulative probability of achieving remission at 3-,6-and 12-month was 10.6%-24.4%,25.3%-43.5%and 51.8%-65.2%respectively,depending on instruments applied.The median time to first remission was 7.2(DAS28),10.1(SDAI),11.7(CDAI),11.4(Boolean criteria)months.Regarding the sustained remission,nearly half of patients experienced SR defined by DAS28(52.2%),CDAI(46.6%),SDAI(45.1%),and Boolean definitions(43.7%)respectively.Among those patients in sustained remission,the median time of persistence remission during study period was 16.0 months(DAS28-ESR),15.4 months(CDAI),14.9 months(SDAI)and 15.0 months(Boolean criteria).Among patients achieving sustained remission,the percentage was 18.7%and 81.3%for DMARD monotherapy and combination therapy,respectively.Additionally,22.3%of patients received low-dose glucocorticoids treatment concomitantly and over half of them successfully tapered or discontinued the glucocorticoids during the period of sustained remission.Conclusion In daily practice,clinical remission is a realistic target in the setting of treat-to-target strategy,and over half of patients achieveclinical remission in the first year of follow-up.Among those patients who achieve clinical remission,around half of them reach sustained remission over the subsequent follow-up period.The median time of persistent remission in patients achieving remission is about 15 months.