類風(fēng)濕關(guān)節(jié)炎活動期臨床判斷

1、,,類風(fēng)濕關(guān)節(jié)炎活動度臨床判斷,Clinical Assessment of Rheumatoid Arthritis Disease Activity(Partly quoted from Jonathan Kay, MD),Content,Why quantify RA disease activity?Composite disease activity indicesResponse criteria for clin

2、ical trialsPatient-reported outcome measuresQuantitatively-driven therapy for early RAData collection tools,Shaw on Measurement,“The only man who behaved sensibly was my tailor; he took my measure anew every time he

3、saw me, whilst all the rest went on with their old measurements and expected them to fit me.”-George Bernard Shaw(1856-1950),How to quantify RA disease activity,Clinical composite indices-DAS / DAS28 -SDAS-CDAIPati

4、ent-reported outcome measuresImaging- Plain radiographs- Musculoskeletal ultrasound- MRI,Primary site of RA disease activityPersistent synovitis results in -Joint destruction -DisabilityGoal of treatment

5、(remission) is absence of synovitisTender & swollen joint counts are outcome upon which therapeutic decisions are based,Why Assess Joints?,Reported as %improvement, comparing disease activity at two discrete time po

6、ints -ACR20 is ≥ 20% improvement -ACR50 is ≥ 50% improvement (ACR50 responders include ACR20 responders) -ACR70 is ≥ 70% improvement (ACR70 responders include ACR20 and ACR50 responders)Used to

7、maximally discriminate effective treatment from placebo treatment in clinical trialsNot directly applicable to clinical practice DT Felson et al. Arthritis Rheum.1995;38(6):727-735,ACR response

8、criteria:the traditional dichotomous benchmark,Disease Activity Score (DAS)DAS28Simplified Disease Activity Index(SDAI)（簡化的DAS評分）Clinical Disease Activity Index(CDAI)（臨床DAS評分）,Continuous Measures of RA Disease Activit

9、y,DAS=0.54?(Tender 44)1/2 +0.06 ?(Swollen 66)1/2 + 0.33 In(ESR)+ 0.007 (Global Health on VAS) （44個壓痛關(guān)節(jié)、66個腫脹關(guān)節(jié)）Provides absolute indication of RA disease activity on a scale of 1 to 9-DAS > 3.6 = high disease acti

10、vity-DAS 2.4- 3.6 = moderate disease activity-DAS 1.6- 2.4= low disease activity-DAS < 1.6 = remissionDM van der Heijde et al. J Rheumatol 1993;20:579-81,Disease Activity Score (DAS):A continuous measure,Sim

11、plified disease activity score using 28-joint count-Integrates measures of physical examination, acute phase response, and patient self-assessmentDAS28=0.56?(Tender 28)1/2 +0.28 ?(Swollen 28)1/2 + 0.70 In(ESR)+ 0.014

12、 (Global Health on VAS) Provides absolute indication of RA disease activity on a scale of 0.49 to 9.07-DAS28 > 5.1 =high disease activity-DAS28 3.2- 5.1= moderate disease activity-DAS28 2.6- 3.2=low disease

13、 activity-DAS28 <2.6 = remission DM van der Heijde et al. J Rheumatol 1993;20:579-81,DAS28:A simplified disease activity score,,Joints Assessed in DAS &DAS28,Joints a

14、ssessed only in DAS,Joints assessed in DAS & DAS28,TJC and SJC contribute numerically to ≈ 50% of DAS / DAS28ESR & Patient Global Health weighted ≈ 2×in DAS28 c/w DAS,,EULAR Response Criteria for RA:

15、Continuous variable to dichotomous benchmark,AM van Gestel et al. Arthritis Rheum. 1996;39:34-40,Simplified disease activity score using 28-joint count-Integrates measures of physical examination, acute phase response,

16、patient self-assessment, and evaluator assessment-Easy to calculateSDAI=Tender 28+ Swollen28 + CRP + Patient Global Health on VAS+ Evaluator Global Health on VASProvides absolute indication of RA disease activity on a

17、 scale of 0.1 to 86.0-SDAI >26 = high disease activity-SDAI 11.1-26 = moderate disease activity-SDAI 3.3-11= low disease activity-SDAI <3.3 = remission,Simplified Disease Activity Index(SDAI),Smolen JS e

18、t al. Rheumatology(Oxford) 2003;42:244-57,Simplified disease activity score using 28-joint count-Immediate scoring possible (no laboratory result)-Integrates measures of physical examination, patient self-assessment, a

19、nd evaluator assessment-Easy to calculateCDAI=Tender 28+ Swollen28 + Patient Global Health on VAS+ Evaluator Global Health on VASProvides absolute indication of RA disease activity on a scale of 0 to 76.0-CDAI >

20、22 = high disease activity-CDAI 10.1-22 = moderate disease activity-SDAI 2.8-10 = low disease activity-SDAI <2.8 = remission,Clinical Disease Activity Index(CDAI),D Aletaha et al. Arthritis Res Ther 2005;7:R796

21、-R806,Disease Activity Measures: components,Contribution of Swollen & Tender Joint CountsImpact on Composite Indices,ACR Response Criteria-TJC and SJC must improve by 20%, 50%, or 70%, regardless of improvement in

22、3 of the other 5 core set measuresDAS & DAS28-TJC and SJC are 2 of the 4 outcome measures-TJC and SJC contribute numerically to ≈50% of the score-TJC is weighted more heavily than SJCSDAI & CDAI-TJC and SJC

23、 are weighted equallyEC Keystone. J Rheumatol 2010; 37:883-4,Measurement in the Bible,“For with what judgment ye judge, ye shall be judged: and with what measure ye mete, it shall be measured to you again”-Matthew,

24、Patient-Reported Outcome Measures,Health Assessment Questionnaire (HAQ)Modified HAQ (MHAQ)（簡化HAQ）Multidimensional HAQ(MDHAQ)（多維HAQ）Routine Assessment of Patient Index Data(RAPID)Rheumatoid Arthritis Disease Activity

25、Index(RADAI),HAQ,MHAQ & MDHAQ,RAPID-3 MDHAD Questionnaire,Routine Assessment of Patient Index Data(RAPID)3,Includes 3 patient-reported outcome measures from ACR Core Data Set:-Patient self-assessed physical function

26、-Patient pain assessment-Patient global assessmentRequires no activity on the part of health professional, other than to calculate simple arithmetic totals in about 5-10 secondsProvides absolute indication of RA dise

27、ase activity on a scale of 0-30-RAPID3 >12.0 = high disease activity-RAPID3 6.1-12.0 = moderate disease activity-RAPID3 3.1-6.0 = low disease activity-RAPID3 0-3.0 = remissionCorrelates with DAS28 & with CDA

28、I in clinical practice T Pincus et al. Rheum Dis Clin N Am. 2009;35:773-778,Quantitatively-Driven Therapy for Early RA: Clinical trials,TICORA(Tight control for rhe

29、umatoid arthritis)Best(Behandel-Strategie?n)CAMERA-Evaluated the clinical and radiographic outcomes of different treatment protocols for RA-18-to 24-month blinded, controlled trials-Patients with early (≤2 yrs) or r

30、ecent onset(≤2 yrs) active RAGrigor et al. Lancet. 2004;364:263-269Goekoop-Ruiterman et al. Arthritis Rheum. 2005;52:3381-90;Verstappen et al. Ann Rheum Dis 2007;66:1443-9,Data Collection Tools,Online - DAS28 calc