类风湿关节炎活动期临床判断.ppt

,类风湿关节炎活动度临床判断,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 clinical 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 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-CDAIPatient-reported outcome measuresImaging-Plain radiographs-Musculoskeletal ultrasound-MRI,Primary site of RA disease activityPersistent synovitis results in-Joint destruction-DisabilityGoal of treatment(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 points-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 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 criteria:the traditional dichotomous benchmark,Disease Activity Score(DAS)DAS28Simplified Disease Activity Index(SDAI)（简化的DAS评分）Clinical Disease Activity Index(CDAI)（临床DAS评分）,Continuous Measures of RA Disease Activity,DAS=0.54(Tender 44)1/2+0.06(Swollen 66)1/2+0.33 In(ESR)+0.007(Global Health on VAS)（44个压痛关节、66个肿胀关节）Provides absolute indication of RA disease activity on a scale of 1 to 9-DAS 3.6=high disease activity-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,Simplified 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(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 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 assessed only in DAS,Joints assessed in DAS&DAS28,TJC and SJC contribute numerically to 50%of DAS/DAS28ESR&Patient Global Health weighted 2in DAS28 c/w DAS,EULAR Response Criteria for RA: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,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 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 et 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,and 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 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-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 3 of the other 5 core set measuresDAS 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,Patient-Reported Outcome Measures,Health Assessment Questionnaire(HAQ)Modified HAQ(MHAQ)（简化HAQ）Multidimensional HAQ(MDHAQ)（多维HAQ）Routine Assessment of Patient Index Data(RAPID)Rheumatoid Arthritis Disease Activity 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-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 disease 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 35:773-778,Quantitatively-Driven Therapy for Early RA:Clinical trials,TICORA(Tight control for rheumatoid arthritis)Best(Behandel-Strategien)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 recent 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 calculator-METEOR(Calculates DAS/DAS28/SDAI/CDAI)CORRONAiPhone DAS28 calculator applicationOther,Thanks,