With the advent of early, aggressive treatment and more effective drugs,rheumatoid arthritis (RA)与20年前相比，现在接受关节手术的患者要少得多。
十多年前，当风湿病学家埃达尔·迪里(Erdal Diri)开始在北达科他州迈诺特(Minot)的三一健康中心(Trinity Health Center)工作时，他看到许多由外科医生转给他的风湿性关节炎患者对他们看到的关节炎症水平感到沮丧。他说，更好的抗炎药物和一种更积极治疗类风湿性关节炎的新方法改变了这一点。在这家乡村医院，每年平均有30至40名RA患者被送往医院接受手术，而Diri医生现在只送了4或5名患者。
Research Backs a Decline in RA Joint Surgeries
A study conducted by rheumatologists at the Mayo Clinic in Rochester, Minn., and published inJournal of Rheumatologyin March 2012, tracked surgeries among 813 RA patients from 1980 to 2007. The researchers, led by Eric L. Matteson, MD, found that the incidence of any joint surgery within 10 years of diagnosis went from 27.3% in the 1980 to 1994 period, to 19.5% in the 1995 to 2007 period.
Surgeons also notice the decline in RA patients coming to their offices to seek joint replacements, notes Jeffrey N. Katz, MD, associate physician at Brigham and Women’s Hospital, and professor of medicine at Harvard Medical School. In the past, about 20% of the joint replacements performed by his department were related to RA; now they only perform 10% of joint replacements on RA patients.
卡茨博士说，如今，需要进行关节手术的风湿性关节炎患者大多是在新一批药物上市之前就患上类风湿关节炎的老年患者，或者是没有机会获得这些药物的人，包括没有保险的人和来自无法获得治疗的贫穷国家的移民。
Inflammation Control Is Key to Preventing Joint Damage
Doctors now have many different weapons to fightinflammationin RA. The disease-modifying antirheumatic drug methotrexate is still the standard first-line drug used to treat RA inflammation, says Dr. Diri. If he doesn’t see results from methotrexate after about two months, biologic drugs are added. This is a big change from the approach to RA in the past, when doctors might wait several months to see if drugs were fighting inflammation – a period when irreversible joint damage might occur, he says. “Now, patients who are diagnosed with rheumatoid arthritis start with methotrexate and we get the biologic on board if they don’t respond. We don’t hang around too much anymore.”
巴斯顿博士说，生物药物对大约一半的类风湿性关节炎患者有效，所以如果一种疗法不起作用，风湿病学家可以将患者转到另一种疗法。她补充说，由于这些药物更有效，而且更早地用于对抗类风湿性关节炎炎症，我们认为这些患者不再需要进行多次关节手术。“人们经常做手部手术、足部手术、肩膀和膝盖置换手术。,”她说。然而，她说，抗炎症的新药物系列，包括口服、注射和注射生物药物，效果足够好，可以为类风湿性关节炎患者提供更大的机会过上正常的生活。
Educating PCPs and Medical Students About RA
The challenges for rheumatologists now include educating primary-care physicians and medical students to recognize the signs of RA early so patients can be referred for aggressive treatment before joint deformity can take place, says Dr. Diri. “When I observe students doing a rotation with me, when I mention even something like an anti-CCP (anti-cyclic citrullinated peptide antibody) test, they say, ‘Oh, is that new?’ And this student, in a few months, will be a physician! If they’re not educated about the new things in rheumatology, then they think that they can manage RA with NSAIDs or 5 to 7.5 milligrams of methotrexate a week, delaying appropriate treatment of the patient.”
Biomarkers May Help Improve Outcomes
Rheumatologists are also focusing on more effective, precise tests to determine which drug treatment is best for each patient, says Dr. Bathon. “Research in biomarkers is key. Is there a genetic polymer? Is there a particular protein marker in the blood? That’s where the field is heading.”
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