类风湿关节炎、脊柱关节炎和银屑病关节炎患者的量身定制一线生物
导读
类风湿关节炎、脊柱关节炎和银屑病关节炎患者的量身定制一线生物制剂疗法 2016-12-21 中华风湿 类风湿关节炎、脊柱关节炎和银屑病关节炎患者的量身定制一线生物制剂疗法 摘 要 目的 意大利量身定制疗法(ITABIO)专委会组织一个多学科专家组,制定一套类风湿...
类风湿关节炎、脊柱关节炎和银屑病关节炎患者的量身定制一线生物制剂疗法
类风湿关节炎、脊柱关节炎和银屑病关节炎患者的量身定制一线生物制剂疗法
摘 要
目的
意大利量身定制疗法(ITABIO)专委会组织一个多学科专家组,制定一套类风湿关节炎(RA)、脊柱关节炎(SpA)和银屑病关节炎(PsA)患者量身定制一线生物制剂治疗的循证决策意见。
方法
进行文献的系统回顾,寻找影响一线生物制剂选择因素的英文文献,包括药物疗效和安全性,给药途径,是否有预测治疗应答的生物标记物,单药治疗的需求,患者的社会-经济状况,生活习惯,文化水平,个性,女性的生殖能力和生育潜力,是否有共患病,感染和结核感染潜伏(LTBI)再激活的宿主相关风险因素,心血管(CV)风险,以及治疗成本。
结果
一些因素,如患者选药倾向于生物制剂,有潜在生育需求女性适合使用抗TNF单药治疗,以及肥胖患者可以剂量调整后静脉给药使得量身定制疗法对三种风湿疾病均有效。而且发现,伊娜西普(ETN)和英福利西单抗(IFX)生物仿制药治疗RA有更好的疗效-成本证据。所有生物制剂都可使用,即便在影响RA用药选择因素不存在的情况下。高感染风险或LTBI阳性会驱使患者选用阿巴西普(ABA)、妥珠单抗(TCZ)、或ETN。如果选择单药治疗,TCZ应当是首选。风湿因子(RF)和抗环瓜氨酸肽抗体(ACPA)高滴度会促使患者选择TCZ或ABA,而有CVD高风险的患者,则会选择抗TNF,优先ETN。出现前葡萄膜炎或炎性肠病会促使患者选择抗TNF单抗(抗TNFs MoAb)。对于PsA患者,如果有高感染和TB风险,首选优特克单抗(UTK),其次也可使用ETN。选择抗TNFs或UTK是由皮肤或关节病严重程度、附着点炎和指趾炎决定,但如果PsA伴随代谢综合症或高CV风险,则应该优选ETN。
结论
鉴于有多种生物制剂选择的影响因素,一线生物制剂治疗可能要在RA、SpA和PsA患者中进行优化。
原文
Tailored first-line biologic therapy in patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis
Abstract
Objective
A multidisciplinary expert panel, the Italian board for the TAilored BIOlogic therapy (ITABIO), was constituted to formulate evidence-based decisional statements for the first-line tailored biologic therapy in patient with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA).
Methods
Systematic review of the literature to identify English-language articles on the variables influencing the first-line biologic choice, including the efficacy and safety of the drug, the route of administration, the availability of response predictor biomarkers, the need of monotherapy, the patient socio-economic status, lifestyle, cultural level, personality, fertility and childbearing potential in women, the presence of comorbidities, the host-related risk factors for infection and latent tuberculosis infection (LTBI) reactivation, the cardiovascular (CV) risk, and costs.
Results
Some variables, including the patients’ preference, the indication for anti-TNF monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects resulted valid for all the three rheumatic conditions. Further, evidence of a better cost-effectiveness profile for etanercept (ETN) and biosimilar infliximab (IFX) in RA was found. Any biologic may be employed in absence of choice driving factors in RA. Otherwise, a high infection risk or LTBI positivity drive the choice toward abatacept (ABA), tocilizumab (TCZ), or ETN. TCZ should be the first choice if monotherapy is required. High rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) titers should drive the choice toward TCZ or ABA, while in patients at high CVD risk anti-TNF choice, with preference for ETN, seems appropriate. Presence of anterior uveitis or inflammatory bowel disease drives the choice to monoclonal antibody anti-TNFs (MoAb anti-TNFs). In PsA, ustekinumab (UTK), and to a lesser extent ETN, represents the first choice in patients at high infection and TB risk. Anti-TNFs or UTK choice is guided by skin or articular disease severity, enthesitis, and dactylitis, whereas ETN should be preferred if metabolic syndrome or high CV risk complicate PsA.
Conclusion
Taking in account of multiple choice driving variables, first-line biologic therapy may be optimized in patients with RA, SpA, and PsA.
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