来氟米特循证治疗类风湿关节炎1例报告

目的了解来氟米特用于类风湿关节炎治疗的有效性、安全性和经济性，为1例类风湿关节炎患者制定治疗方案。方法计算机检索ACP Journal Club、Cochrane图书馆（2007年第2期）、MEDLINE（1990～2007．4），查寻来氟米特治疗类风湿关节炎的系统评价、临床随机对照试验、队列研究和病例对照研究等，并对所获证据进行质量评价，进而应用于本例患者进行临床治疗。结果现有A级证据表明，来氟米特可改善关节疼痛、肿胀、患者及医生总体评价、患者功能残疾自我评价、血沉、CRP和晨僵时间，其疗效和不良反应与甲氨蝶呤相当，但甲氨蝶呤治疗总费用较低。对甲氨蝶呤治疗无效的患者，来氟米特和甲氨蝶呤联用可提高疗效，并节约成本。结合医生经验及患者意愿，对患者采用甲氨蝶呤20rag／周治疗6个月后效果不佳，改用来氟米特10mg／d和甲氨蝶呤20mg／周联合治疗3个月后，患者关节肿痛明显好转，目前仍在随访中。结论现有A级证据表明联用来氟米特和甲氨蝶呤能有效控制类风湿关节炎的关节症状。

Evidence-based Treatment of a Patient with Rheumatoid Arthritis with Leflunomide

Objective To investigate the effectiveness, safety and cost-effectiveness ofleflunomide for rheumatoid arthritis, and formulate an evidence-based treatment plan for a patient with rheumatoid arthritis. Methods We searched the ACP Journal Club, The Cochrane Library （Issue 2, 2007） and MEDLINE （1990 to 2007）, and critically appraised the available evidence. Results The available of leflunomide were comparable to those Level A （high quality） evidence showed that the efficacy and adverse events of methotrexate. The total cost of treating patients with lefiunomide was significantly higher when compared to methotrexate. The combination of lefiunomide and methotrexate in patients with active rheumatoid arthritis unresponsive to methotrexate monotherapy was less costly and more effective than the strategy excluding lefiunomide. Given the current evidence, together with our clinical experience and the patient＇s preference, methotrexate was administered to the patient. There was an inadequate response after 6 months of treatment. And then, adding lefiunomide to methotrexate attained a remarkable response 3 months later. The patient is still being followed up. Conclusion Combination treatment with leflunomide and methotrexate in RA patients can improve the clinical outcomes. Long-term efficacy and toxicity remain to be established.