The disability caused by RA cannot be underestimated, and it is imperative to keep the patient's unrenewable green waters and mountains

*It is only for medical professionals to read for reference.
Rheumatoid arthritis is an important cause of physical disability.
How to inhibit the patient's imaging progress and delay structural damage? The experts have something to say.

The results of the second national sample survey of persons with disabilities in 2006 showed that arthropathy is the main cause of physical disability.
Among these joint diseases, rheumatoid arthritis (RA) has the highest disability rate [1].

With the prolongation of the course of RA, the progress of joint structural destruction will cause irreversible disability.

A considerable proportion of RA patients have suffered joint structural destruction early in the course of the disease.

A Korean real-world study included 374 patients with RA.
Subjects received the first hand X-ray examination when symptoms occurred on average 0.
6 years.
The results showed that 25% of patients had modified Sharp scores ≥5 [2].

In addition, an epidemiological survey in China also showed that about one-fifth of RA patients have developed disability (joint deformity with dysfunction) early in the course of the disease (Figure 1) [3].

The disease has a serious impact on the work and employment of patients [4].

In this issue, we invited Zheng Zhaohui, director of the Department of Clinical Immunology, the First Affiliated Hospital of the Air Force Military Medical University of the Chinese People's Liberation Army, to talk about the issues related to RA disability.

Figure 1 More than 20% of patients with RA have had a disability when the course of RA is less than 5 years.
Patients with RA should be wary of structural damage! Which patients are at higher risk of rapid progression of structural damage? The researchers explored this.

The PREMIER study included 149 patients with RA who were not treated with methotrexate (MTX).
After 12 months of MTX treatment, the risk of rapid radiological progression (modified Sharp score change> 3.
5) was analyzed to find relevant Predictor. The results showed that the modified DAS28-CRP score of patients at baseline, that is, the total number of tender joints (TJC), the number of swollen joints (SJC) 28, C-reactive protein (CRP) and the physician's overall assessment (PhGA), etc.
, were calculated according to different weights.
The score obtained has a significant correlation with the rapid structural progress of the patient [5].

A randomized controlled trial (RCT) of the placebo group enrolled 306 patients with RA who received traditional synthetic disease-improving anti-rheumatic drugs (csDMARD) for 12 months, and received hand/wrist/foot treatment at baseline and 12 months.
Radiological examination, using multivariate regression to analyze the independent predictors of new bone erosion and new cartilage destruction.

The results showed that the patient’s baseline erosion score (ES) ≥ 3 was associated with new bone erosion (ES score at 12 months compared to baseline change ≥ 1) and new cartilage destruction (JSNS score at 12 months compared to baseline ≥ 1 ) Are significantly correlated.

This reminds us that RA patients with multiple bone erosions should pay special attention to the prevention of new bone erosion and cartilage destruction (Figure 2, Figure 3) [6].

Figure 2 The patient's baseline ES score is correlated with the occurrence of new bone erosion at 12 months.
Figure 3 The patient's baseline ES score is correlated with the occurrence of new cartilage destruction at 12 months.
Even in patients with RA who have stabilized and reached the standard after treatment, it may still occur Obvious structural progress.

A number of studies were pooled to analyze the effects of average SJC 28 and CRP on radiological progression during a period of 6 months to 1 year on 1184 patients with RA who received disease-improving anti-rheumatic drugs (DMARD) for 1 year.

The results showed that when the average SJC 28≥1 of the patients who reached the standard, the risk of structural progression was significantly higher than that of patients with SJC 28<1.

This reminds us that if there is significant joint swelling in patients who reach the standard, we should also be extra vigilant about the progress of structural damage [7].

Biological agents effectively inhibit the radiological progress of RA patients Since the new century, a variety of biological agents have been on the market one after another, setting off a new trend for the treatment of RA.

Biological agents have the advantages of fast onset of action, long-lasting efficacy, and high safety.
Clinical studies have shown that the world's first fully human anti-tumor necrosis factor-α (TNF-α) monoclonal antibody-the original research adalimumab for the treatment of RA, not only It can quickly relieve clinical symptoms such as joints and inflammation, increase the rate of treatment compliance, and effectively inhibit the progress of radiology, helping patients to return to normal work and life as soon as possible.

Basic research shows that the typical deformities of RA hands and wrists (such as swan neck deformity and button deformity of fingers) are related to persistent synovitis of specific joints [8].

In the animal model test, arthritis mice received different doses of original adalimumab or placebo for 3 weeks, biopsy analysis and comparison of synovial inflammation changes, the results showed that the original adalimumab treatment can effectively reduce synovial osteoclasts , Inhibit bone erosion [9].

The OPTIMA study is a randomized, controlled study designed to evaluate the efficacy and safety of the original research adalimumab on RA.

A total of 1032 patients with moderate to severe RA were enrolled in the study.
They were given the original adalimumab 40mg every other week + MTX (n=515) or placebo + MTX (n=517) for 26 weeks, and then all received the original adalimumab.
Monoclonal antibody 40mg once every other week + MTX treatment.

The primary endpoint was the proportion of patients with DAS28 (CRP) <3.
2 and a change of mTSS ≤ 0.
5 from baseline at 78 weeks.

The results showed that after receiving the original research adalimumab for 2 weeks, the SJC and CRP of RA patients had been significantly improved compared with the placebo group [10].

Figure 4 When RA patients received the original adalimumab treatment for 2 weeks, SJC was significantly improved compared to the placebo group.
Figure 5 When RA patients received the original adalimumab treatment for 2 weeks, CRP was significantly improved compared to the placebo group in the DE019 study This showed that when patients with moderate to severe RA received the original adalimumab combined with MTX treatment for 52 weeks, compared with the placebo group, the change in mTSS score from baseline was significantly lower, confirming that the original adalimumab long-term treatment of RA patients can significantly inhibit radiation Study progress [11]. Figure 6 In the original research adalimumab treated RA patients for 52 weeks, the change in mTSS score from baseline was significantly lower than that in the placebo group.
Among the biological preparations, which one has a stronger inhibitory effect on the progression of RA? A Meta analysis explored this.

The analysis included 9 clinical studies to evaluate the radiological effectiveness of RA patients receiving different biological agents for 1 year.

The researchers used MTX as a reference control to compare the changes in mTSS of different treatment regimens during 1 year of treatment.

The results showed that, except for golimumab, the average change in mTSS from baseline in patients treated with other biological agents was significantly better than that of MTX.
Among the biological agents, the mTSS score of RA patients treated with the original adalimumab had the largest change [12].

Figure 7: The mean change in mTSS from baseline in RA patients treated with different biological agents for 1 year.
The German Real World Study included 783 full-time or part-time RA patients (of which 336 patients had more than 5 sick leave days in the past 6 months), and the original research Ada was started.
Lumumab treatment lasted 24 months, and the patient's sick leave and work performance changes were evaluated.

The results show that the original research adalimumab can effectively and lastingly improve the work performance of RA patients, reduce sick leave, and increase attendance.

The DE032 study also shows that the original research adalimumab can continuously and effectively reduce the impact of RA on patients' work and housework [13].

Figure 8 The original research adalimumab lastingly improved the work performance of RA patients In the OPTIMA study, 98 RA patients achieved stable clinical compliance (≥4 weeks) after the original research adalimumab + MTX treatment, and the original research adalimumab was discontinued and used MTX continued to be treated for 52 weeks to evaluate the radiological progress.

The results showed that 81% of patients had no progress in radiology [14].

Figure 9 For patients who met the standard of the original research adalimumab treatment, after 52 weeks of discontinuation, most of the patients maintained the course of disease without progression.
In addition, studies have shown that there is a certain correlation between the compliance of RA patients receiving biological treatment and the risk of structural damage progression [ 15].

Real-world studies such as the Corrona cohort and the SCQM cohort have shown that the original research adalimumab has good compliance in the treatment of RA [16,17].

Based on rich evidence-based evidence, the European Union Against Rheumatism (EULAR) guidelines emphasize that RA patients with adverse prognostic factors need to start biologics as soon as possible [18].

Summary: RA can cause the continuous progress of the damage to the joint structure of patients and even cause disability.
A considerable proportion of patients have functional impairment even in the early course of the disease, which seriously affects work and life.

Persistent active synovitis, systemic inflammatory manifestations, and existing bone erosion are poor prognostic factors for the progression of RA structural destruction.
For patients with these adverse factors, clinical management must pay attention to and intensive treatment as soon as possible.

Clinical studies have shown that the original research adalimumab (Humira) can quickly and lastingly improve the SJC and CRP of RA patients, comprehensively inhibit bone erosion and cartilage destruction, strongly effectively inhibit the structural destruction of RA, and comprehensively improve the quality of life and work of RA patients.

Expert profile Zheng Zhaohui, director of the Department of Clinical Immunology, the First Affiliated Hospital of the Air Force Military Medical University, deputy chief physician, associate professor, doctor of medicine, member of the Youth Committee of the Rheumatology Branch of the Chinese Medical Association, deputy chairman of the Youth Committee of the Rheumatology Branch of Shaanxi Province, physician of Shaanxi Province The Standing Committee/Director General of the Rheumatology and Immunology Branch of the Association published 19 SCI papers as the first author or corresponding author, and the editor in chief/associate editor/participating editor/participating in translation 10 departments wrote and completed 1 national expert consensus, and took the lead in completing the consensus of experts in Shaanxi Province.
1 path won 1 first prize of Shaanxi Provincial Science and Technology Progress Award and 2 national utility model patents; presided over 8 reference materials for various funds including the National Natural Science Foundation: [1] Li Zhanguo.
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