目标

评估美国强直性脊柱炎患者中AS相关合并症和关节外表现(EAM)的发病率和流行率。

方法

该研究基于三个商业保险索赔数据库(多付款人理赔数据库[MPCD 2007–2010]，Truven健康市场商业数据库[2010–2014]，美国医保定额理赔数据库[2006–2014])进行回顾性队列研究，以评估AS患者的EAM(葡萄膜炎、牛皮癣、炎症性肠病)和经医师确诊的合并症(心脏、肾、肺、神经系统)。AS患者经由风湿病医师确诊(标志日期)，在标志日期前有6个月的基线数据，确诊后服用特定药物(ICD-9 720.0)。研究对三个互相排斥分层用药组进行检查(从低到高)：1. NSAIDs;2. DMARDs; 3. anti-TNFs，确认了12个月期内(标志日期前后各6个月)合并症的流行率，以及自治疗启动到死亡、医保失效、研究终止、首次结局出现、治疗暂停或较高暴露层级启动治疗中的最早日期期间，合并症和EAMs的发病率。发病率评估剔除了有既往病史(感染除外)的病人。研究还利用逆处理概率加权考克思比例危险模式来预估anti-TNFs、DMARDs、NSAIDs/无治疗之间的危险比。

结果

共有37,566名AS患者参与研究，MPCD患者群中AS患病率为0.26%，医保群体为1.21%。在所有照射组中，医保群体相比MPCD或Truven健康市场商业数据库人群，合并症更为普遍。相比仅接受NSAIDs或DMARDs的患者，anti-TNF治疗患者中肿瘤、心肌梗塞、传导阻滞、脊髓压迫及椎体骨折的倾向评分加权发病率更低，但是医保患者群中anti-TNF治疗患者EAMs(如银屑病关节炎、葡萄膜炎和溃疡性结肠炎)的发病率更高。

结论

对美国AS患者合并症和EAMs流行率和发病率的研究表明，anti-TNFs治疗与某些合并症的发病率较低和EAMs发病率较高有关，这可能反映了越来越多病情严重的AS患者会选择anti-TNFs。尽管由于数据来源可能导致结果有所不同，不同的基线特征(例如Medicare患者年龄较大)可以解释这一点，但研究结果表明，anti-TNF治疗与合并症(AS患者中发病率较高)的发病率较低有关。

原 文

Do tnf inhibitors impact the comorbidities and extra-articular manifestations, and thereby alter the natural history of ankylosing spondylitis?

Objectives

To evaluate the incidence and prevalence of AS-related comorbidities and EAMs in AS pts in the US.

Methods

This was a retrospective cohort study of 3 commercial insurance claims databases (Multi-Payer Claims Database [MPCD 2007–2010], Truven MarketScan [2010–2014], and US Medicare Fee-for-Service Claims [2006–2014]) to evaluate EAMs (uveitis, psoriasis, inflammatory bowel disease) and physician-diagnosed comorbidities (cardiac, renal, pulmonary, neurologic) in AS pts diagnosed by a rheumatologist (index date), having 6 months’ baseline data prior to the index date, and drug-specific exposures after AS diagnosis (ICD-9 720.0). Three mutually exclusive hierarchical exposure groups were examined (low to high):1 no therapy or prescription NSAIDs;2 conventional DMARDs;3 anti-TNFs. Prevalence of comorbidities was ascertained in a 12?month period (6 months pre- and post-index date). Incidence of comorbidities and EAMs was assessed during the period between treatment initiation and the earliest of death, loss of medical coverage, end of study, first outcome occurrence, treatment discontinuation or initiation of therapy at a higher level in exposure hierarchy. Pts with a history of prior events (except infections) were excluded from the incidence assessment for that event. Hazard ratios comparing anti-TNFs vs DMARDs and NSAIDs/no therapy were estimated using inverse probability treatment weighted Cox proportional hazards models.

Results

A total of 37,566 AS pts were included. Prevalence of AS in the MPCD population was 0.26% and in the Medicare population was 1.21%. As expected, comorbidities were more common in Medicare AS pts vs those in MPCD or MarketScan databases in all exposure groups. The propensity score-weighted incidences of solid cancers, myocardial infarction, conduction block, cord compression and vertebral fractures were lower in anti-TNF treated pts vs those treated with NSAIDs or DMARDs alone, although anti-TNF treated Medicare pts had a higher incidence of EAMs such as psoriatic arthritis, uveitis and ulcerative colitis

Conclusions

This investigation of the prevalence and incidence of comorbidities and EAMs of AS in US pts suggests that anti-TNF use is associated with a lower incidence of some comorbidities, and a trend of higher incidence of EAMs, which may reflect channelling of more severe AS pts to anti-TNFs. Although results vary somewhat by data source and may be explained by different baseline characteristics (e.g. Medicare pts were older), our results suggest that anti-TNF use is associated with lower incidence of those comorbidities that confer substantial morbidity in AS.

文章出处：

A. Deodhar1, K.L. Winthrop1, R.L. Bohn2, B.K. Chan1, R.Y. Suruki2, J.L. Stark3, H. Yun4, S.A.R. Siegel1, L. Chen4, M. Yassine3, J.R. Curtis4. Annals of the Rheumatic Diseases.

Saturday, 16 JUNE 2018

https://ard.bmj.com/content/77/Suppl_2/1000