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It is only for medical professionals to read for reference.
Take a small book and write it down! The 2021 European Union Against Rheumatism (EULAR) annual meeting has been held online
.
At the meeting, Professor Filip van den Bosch introduced 5 treatment strategies for spondyloarthritis (SpA) based on his diagnosis and treatment experience, which are very practical, let's learn together! Strategy 1: Use the classic "old medicine" correctly.
Professor Bosch said that when it comes to the treatment and relief of SpA, people always think of a variety of new medicines, but this does not mean that those classic traditional medicines should be forgotten
.
For example, a study in 2005 showed that after 6 weeks of treatment with traditional non-steroidal anti-inflammatory drugs (NSAIDs) such as etoricoxib and naproxen, the vast majority of patients with ankylosing spondylitis (AS) It met the partial remission (PR) criteria set by the International Ankylosing Spondylitis Assessment Task Force (ASAS), and 40 people reported a treatment response rating of "good" or "very good" (Figure 1)
.
Figure 1 Research results A 2014 study showed that after 28 weeks of naproxen treatment in patients with axial SpA (ax-SpA), 35.
3% can reach ASAS-PR; a 2012 study found that psoriatic arthritis (PsA) After 16 weeks of treatment with methotrexate (MTX), 24.
1% achieved minimum disease activity (MDA)
.
However, this kind of curative effect pales in comparison with "new drugs"
.
In the two studies, the efficacy of naproxen+infliximab (IFX) or MTX+IFX was significantly better than that of naproxen or MTX alone (Figure 2)
.
Figure 2 The results of the study This will talk about our second strategy-Strategy 2: The use of "advanced new drugs" biologics/small molecule targeted disease-improving anti-rheumatic drugs (b/tsDMARDs) and other new drugs have come out greatly Improved the clinical treatment of SpA and provided patients with more choices
.
Tumor Necrosis Factor Inhibitors (TNFi) are also a class of biological agents with excellent efficacy
.
After 24 weeks of treatment with TNFi such as etanercept (ENC), IFX, adalimumab (ADA), and pecelizumab (CZP) in AS patients, its efficacy was significantly better than placebo (Figure 3)
.
Figure 3 Results after 24 weeks of TNFi treatment of AS.
In patients with AS, non-TNFi biologics were used to treat AS patients, such as Skuchizumab (SEC), Ixekizumab, Upatinib (UPA) and other drugs, and similar results were obtained (Figure 4) )
.
Figure 4 The results of non-TINFi treatment of AS after 16 weeks.
How should the remission of enthesitis be achieved? According to a 16-week study, in PsA, patients in the SEC 300 mg treatment group had the highest response rate, reaching 65%; in AS, the SEC 150 mg treatment group had the highest response rate (Figure 5)
.
Figure 5 Results of the study In other studies, gusecumab (GUS) Q8W can achieve a 50% remission rate of enthesitis; 24 weeks of UPA treatment can achieve better efficacy than ADA (Figure 6)
.
Figure 6 Research results Professor Bosch said humorously: “From these data, if you ask me what is the safest treatment for enthesitis? I might say, stay calm and we will wait 6 months to see!” ( Here I also played a "Keep calm and carry on" stem, Figure 7) Figure 7 Keep calm and wait to observe Strategy 3: Standard treatment strategy and intensive treatment strategy In PsA, compared with standard treatment, standard treatment (T2T) )/Strict control therapy (TC) can obviously obtain better curative effect, no matter from the 20% remission (ACR20), ACR70, psoriasis lesion area and severity index (PASI) 75 specified by the American College of Rheumatology (ACR) Which of the other indicators to measure (Figure 8)
.
Figure 8 The efficacy of T2T/TC in PsA.
The multi-center, prospective study TICOSPA also yielded similar results, that is, T2T/TC is better than general treatment
.
Among axSpA patients, 47% of patients with T2T/TC treatment for 48 weeks, ASAS health index (ASAS-HI) improved ≥30%, and ASDAS-low disease activity (ASDAS-LDA) patients accounted for 77%; while conventional The treatment group was only 36% and 60% respectively (Figure 9)
.
Compared with conventional treatment, although T2T/TC treatment did not reach a statistically significant difference in the primary end point (ASAS-HI), experts’ interpretation of this result differs depending on the benevolent and the wise, and this kind of goal-based treatment attempts are The axSpA treatment field is undoubtedly the most advanced
.
Figure 9 Research results Strategy 4: "DEER" treatment strategy, that is, comprehensive and friendly conventional treatment of DEER, that is, "focused, compassionate, well-educated rheumatologist"
.
Professor Bosch cited some literature and pointed out that depression and anxiety state reduce the possibility of joint symptom relief
.
In addition, comorbidities are also a factor that needs to be considered.
In addition to depression, hypertension is also a common comorbidity in patients with axSpA
.
The existence of these factors means that SpA patients are not easy to benefit from the treatment of pure biological agents (Figure 10), and the treatment effect and health status of such patients will be worse
.
Paying attention to comorbidities and comprehensively solving patients' problems are issues that should be paid attention to by clinicians in SpA treatment, but are easily overlooked in real life
.
Figure 10 Literature cover Professor Bosch believes that clinicians should not ignore the patient's mental state and burden of comorbidities while taking up-to-standard treatment or intensive treatment measures.
These issues should be taken into consideration when formulating treatment strategies
.
Strategy 5: Post-remission maintenance and reduction and withdrawal strategies The CRESPA study included patients with early active peripheral SpA and adopted induction therapy
.
At 12 and 24 weeks, the proportion of patients in the golimumab treatment group who achieved clinical remission was significantly higher than that in the placebo control group (Figure 11)
.
Figure 11 Results of the CRESPA study For patients who have achieved remission, reduction therapy may be a better strategy than complete withdrawal
.
Studies have shown that more than 80% of patients in the CZP treatment of axSpA continue to remission after remission, while only about 20% of patients in the placebo group who stopped after remission maintained remission; medication at a 2-week interval compared with medication at a 4-week interval sustained remission.
The proportion of patients is higher (Figure 12)
.
Therefore, rapid remission, maintenance after remission, and individualized, appropriate drug reduction and discontinuation strategies are the cornerstones of axSpA treatment
.
Figure 12 The proportion of patients with sustained remission who took medication at two-week intervals is higher than that at 4-week intervals.
Expert comments.
In recent years, recommendations on the treatment of axial spondyloarthritis have been continuously updated, and the development of clinical research on new therapeutic drugs has brought more patients Treatment options
.
This EULAR conference not only announced the research results of a variety of new biologically targeted drugs in axSpA, but also conducted an in-depth discussion on the radiological progress of biologic therapy and axSpA, and also discussed the comprehensive treatment, treatment strategy and complication treatment of axSpA.
Made an update
.
Professor Filip van den Bosch’s treatment "experience" is from the perspective of clinicians, explaining how to select the most practical treatment method from a variety of "dazzling" options and at the same time conform to the current guidelines in the latest guidelines.
.
Of course, this EULAR conference also discussed axSpA's imaging diagnosis, prognostic analysis, pathogenesis, and re-understanding of the disease from multiple perspectives.
The content is rich and worthy of repeated learning
.
Expert profile Professor Liu Xu, chief physician and doctor of medicine, currently serves as a member of the Department of Rheumatology and Immunology of Peking University, a member of the Infectology Group of the Rheumatology Committee of the Cross-Strait Medical and Health Exchange Association, and a member of the Rheumatology Committee of the Beijing Association of Integrated Traditional Chinese and Western Medicine.
The reviewer of IJRD, "Clinical Rheumatology" and "PLoS ONE" as the project leader, is responsible for 2 National Natural Science Foundations, 1 capital characteristic clinical project and 1 capital clinical diagnosis and treatment technology major project sub-project first or responsibility The author has published more than 20 articles in domestic core journals and SCI journals.
The main research direction is the genetic epidemiology of rheumatoid arthritis, and the basic and clinical research of ankylosing spondylitis.
Participated in the compilation of 6 monographs
Take a small book and write it down! The 2021 European Union Against Rheumatism (EULAR) annual meeting has been held online
.
At the meeting, Professor Filip van den Bosch introduced 5 treatment strategies for spondyloarthritis (SpA) based on his diagnosis and treatment experience, which are very practical, let's learn together! Strategy 1: Use the classic "old medicine" correctly.
Professor Bosch said that when it comes to the treatment and relief of SpA, people always think of a variety of new medicines, but this does not mean that those classic traditional medicines should be forgotten
.
For example, a study in 2005 showed that after 6 weeks of treatment with traditional non-steroidal anti-inflammatory drugs (NSAIDs) such as etoricoxib and naproxen, the vast majority of patients with ankylosing spondylitis (AS) It met the partial remission (PR) criteria set by the International Ankylosing Spondylitis Assessment Task Force (ASAS), and 40 people reported a treatment response rating of "good" or "very good" (Figure 1)
.
Figure 1 Research results A 2014 study showed that after 28 weeks of naproxen treatment in patients with axial SpA (ax-SpA), 35.
3% can reach ASAS-PR; a 2012 study found that psoriatic arthritis (PsA) After 16 weeks of treatment with methotrexate (MTX), 24.
1% achieved minimum disease activity (MDA)
.
However, this kind of curative effect pales in comparison with "new drugs"
.
In the two studies, the efficacy of naproxen+infliximab (IFX) or MTX+IFX was significantly better than that of naproxen or MTX alone (Figure 2)
.
Figure 2 The results of the study This will talk about our second strategy-Strategy 2: The use of "advanced new drugs" biologics/small molecule targeted disease-improving anti-rheumatic drugs (b/tsDMARDs) and other new drugs have come out greatly Improved the clinical treatment of SpA and provided patients with more choices
.
Tumor Necrosis Factor Inhibitors (TNFi) are also a class of biological agents with excellent efficacy
.
After 24 weeks of treatment with TNFi such as etanercept (ENC), IFX, adalimumab (ADA), and pecelizumab (CZP) in AS patients, its efficacy was significantly better than placebo (Figure 3)
.
Figure 3 Results after 24 weeks of TNFi treatment of AS.
In patients with AS, non-TNFi biologics were used to treat AS patients, such as Skuchizumab (SEC), Ixekizumab, Upatinib (UPA) and other drugs, and similar results were obtained (Figure 4) )
.
Figure 4 The results of non-TINFi treatment of AS after 16 weeks.
How should the remission of enthesitis be achieved? According to a 16-week study, in PsA, patients in the SEC 300 mg treatment group had the highest response rate, reaching 65%; in AS, the SEC 150 mg treatment group had the highest response rate (Figure 5)
.
Figure 5 Results of the study In other studies, gusecumab (GUS) Q8W can achieve a 50% remission rate of enthesitis; 24 weeks of UPA treatment can achieve better efficacy than ADA (Figure 6)
.
Figure 6 Research results Professor Bosch said humorously: “From these data, if you ask me what is the safest treatment for enthesitis? I might say, stay calm and we will wait 6 months to see!” ( Here I also played a "Keep calm and carry on" stem, Figure 7) Figure 7 Keep calm and wait to observe Strategy 3: Standard treatment strategy and intensive treatment strategy In PsA, compared with standard treatment, standard treatment (T2T) )/Strict control therapy (TC) can obviously obtain better curative effect, no matter from the 20% remission (ACR20), ACR70, psoriasis lesion area and severity index (PASI) 75 specified by the American College of Rheumatology (ACR) Which of the other indicators to measure (Figure 8)
.
Figure 8 The efficacy of T2T/TC in PsA.
The multi-center, prospective study TICOSPA also yielded similar results, that is, T2T/TC is better than general treatment
.
Among axSpA patients, 47% of patients with T2T/TC treatment for 48 weeks, ASAS health index (ASAS-HI) improved ≥30%, and ASDAS-low disease activity (ASDAS-LDA) patients accounted for 77%; while conventional The treatment group was only 36% and 60% respectively (Figure 9)
.
Compared with conventional treatment, although T2T/TC treatment did not reach a statistically significant difference in the primary end point (ASAS-HI), experts’ interpretation of this result differs depending on the benevolent and the wise, and this kind of goal-based treatment attempts are The axSpA treatment field is undoubtedly the most advanced
.
Figure 9 Research results Strategy 4: "DEER" treatment strategy, that is, comprehensive and friendly conventional treatment of DEER, that is, "focused, compassionate, well-educated rheumatologist"
.
Professor Bosch cited some literature and pointed out that depression and anxiety state reduce the possibility of joint symptom relief
.
In addition, comorbidities are also a factor that needs to be considered.
In addition to depression, hypertension is also a common comorbidity in patients with axSpA
.
The existence of these factors means that SpA patients are not easy to benefit from the treatment of pure biological agents (Figure 10), and the treatment effect and health status of such patients will be worse
.
Paying attention to comorbidities and comprehensively solving patients' problems are issues that should be paid attention to by clinicians in SpA treatment, but are easily overlooked in real life
.
Figure 10 Literature cover Professor Bosch believes that clinicians should not ignore the patient's mental state and burden of comorbidities while taking up-to-standard treatment or intensive treatment measures.
These issues should be taken into consideration when formulating treatment strategies
.
Strategy 5: Post-remission maintenance and reduction and withdrawal strategies The CRESPA study included patients with early active peripheral SpA and adopted induction therapy
.
At 12 and 24 weeks, the proportion of patients in the golimumab treatment group who achieved clinical remission was significantly higher than that in the placebo control group (Figure 11)
.
Figure 11 Results of the CRESPA study For patients who have achieved remission, reduction therapy may be a better strategy than complete withdrawal
.
Studies have shown that more than 80% of patients in the CZP treatment of axSpA continue to remission after remission, while only about 20% of patients in the placebo group who stopped after remission maintained remission; medication at a 2-week interval compared with medication at a 4-week interval sustained remission.
The proportion of patients is higher (Figure 12)
.
Therefore, rapid remission, maintenance after remission, and individualized, appropriate drug reduction and discontinuation strategies are the cornerstones of axSpA treatment
.
Figure 12 The proportion of patients with sustained remission who took medication at two-week intervals is higher than that at 4-week intervals.
Expert comments.
In recent years, recommendations on the treatment of axial spondyloarthritis have been continuously updated, and the development of clinical research on new therapeutic drugs has brought more patients Treatment options
.
This EULAR conference not only announced the research results of a variety of new biologically targeted drugs in axSpA, but also conducted an in-depth discussion on the radiological progress of biologic therapy and axSpA, and also discussed the comprehensive treatment, treatment strategy and complication treatment of axSpA.
Made an update
.
Professor Filip van den Bosch’s treatment "experience" is from the perspective of clinicians, explaining how to select the most practical treatment method from a variety of "dazzling" options and at the same time conform to the current guidelines in the latest guidelines.
.
Of course, this EULAR conference also discussed axSpA's imaging diagnosis, prognostic analysis, pathogenesis, and re-understanding of the disease from multiple perspectives.
The content is rich and worthy of repeated learning
.
Expert profile Professor Liu Xu, chief physician and doctor of medicine, currently serves as a member of the Department of Rheumatology and Immunology of Peking University, a member of the Infectology Group of the Rheumatology Committee of the Cross-Strait Medical and Health Exchange Association, and a member of the Rheumatology Committee of the Beijing Association of Integrated Traditional Chinese and Western Medicine.
The reviewer of IJRD, "Clinical Rheumatology" and "PLoS ONE" as the project leader, is responsible for 2 National Natural Science Foundations, 1 capital characteristic clinical project and 1 capital clinical diagnosis and treatment technology major project sub-project first or responsibility The author has published more than 20 articles in domestic core journals and SCI journals.
The main research direction is the genetic epidemiology of rheumatoid arthritis, and the basic and clinical research of ankylosing spondylitis.
Participated in the compilation of 6 monographs
