迟发型类风湿关节炎的疾病活动特征及治疗现状分析

目的 比较迟发型类风湿关节炎（LORA）与早发型类风湿关节炎（YORA）的临床特征与治疗现状，探讨LORA疾病特点。方法 回顾性分析259例类风湿关节炎患者病历资料。LORA与YORA分界为发病年龄是否≥60岁。比较患者性别比、病程、受累关节特征、关节外表现、实验室检查、疾病活动评分及治疗策略的差异，分析LORA疾病特征。结果 LORA患者性别比（男/女）1/1.88,性别差异缩小（P=0.009），发病至确诊时间较YORA长（P<0.001），肩关节受累比例更高(P<0.001)，而肘关节、腕关节、掌指关节、近端指间关节以及踝关节受累在YORA更常见(P<0.001)。LORA患者贫血发生率高于YORA(P<0.05)。特异性血清学指标方面，类风湿因子及抗环瓜氨酸多肽抗体阳性率两组间差异无统计学意义。由C-反应蛋白计算的28关节疾病活动指数（DAS28-CRP）与临床疾病活动指数（CDAI）两组间差异无统计学意义，简化的疾病活动指数（SDAI）在LORA组更高（P=0.002）。67.4%的LORA患者使用了糖皮质激素治疗，高于YORA（29.3%，P<0.001）。近73.7%的LORA患者使用了改善病情的抗风湿药物（DMARDs），低于YORA（97.6%，P<0.001）。结论 LORA患者可能因发病不典型导致延误诊断，对大关节发病的老年患者需注意排查有无类风湿关节炎。LORA更易合并贫血，但在其他血清学及关节外表现方面与YORA无明显差异。合并疾病允许的情况下仍建议LORA患者和YORA一样积极使用DMARDs治疗。

Disease Activity and Therapeutic Strategy of Patients with Late-onset Rheumatoid Arthritis

Objective To compare the disease activity and therapeutic strategy of late-onset rheumatoid arthritis （LORA）with young-onset rheumatoid arthritis （YORA）. Methods Medical records of 259 patients with rheumatoid arthritis (RA) were reviewed retrospectively. The cut-off between LORA and YORA was operationally set at 60 years of age at disease onset. Gender ratio, disease duration, feature of involved joint, extra-articular features, laboratory features, disease activity score and treatment strategy were compared between LORA and YORA. Results The LORA patients had a gender ratio (male/female) of 1/1.88, which was approaching 1/1 in the older age group. It took longer for LORA to be diagnosed than YORA (P<0.001). LORA had more frequent involvement of shoulders (P<0.001), while elbow, wrist, metacarpophalangeal joint （MCP），proximal interphalangeal joint （PIP） and ankle joints were more common in YORA (P<0.001). LORA patients were more likely to have anemia than YORA patients (P<0.05). No significant differences were found between LORA and YORA in specific serologic index, including rheumatoid factor and anti-cyclic citrullinated peptide antibody, and disease activity score 28-C-reactive protein （DAS28-CRP） and clinical disease activity index （CDAI）. But LORA had a higher simplified disease activity index （SDAI） (P=0.002). Glucorcoticoid was used in 67.4% LORA patients, compared with 29.3% in YORA patients (P<0.001). In contrast, disease-modifying anti-rheumatic drugs（DMARDs） were used in 73.7% LORA patients, compared with 97.6% in YORA patients (P<0.001). Conclusion Delayed diagnose of LORA is common due to atypical presentation at disease onset. RA should be considered in elderly patients with large joints for differential diagnosis. LORA is more likely to have anemia than YORA, albeit no significant differences in serological index and extra-articular presentations. LORA patients should be treated with DMARDs as aggressively as YORA patients, if their comorbidities allow to do so.