目标

甲氨蝶呤治疗脊柱关节炎的作用仍不确定。本研究的目的是比较甲氨蝶呤和TNF抑制剂(TNFi)在脊柱关节炎与类风湿关节炎中的持续性，并确定在脊柱关节炎中同时使用传统合成的改善病情的抗风湿药物(csDMARD)是否能改善 TNF抑制剂的持续性。

方法

这项回顾性队列研究使用了2000年至2004年来自Optum Clinformatics®的去身份标签化数据，首次确定了类风湿关节炎(RA)、银屑病关节炎(PsA)和强直性脊柱炎(SpA)患者，这些患者既往未采用过由甲氨蝶呤或 TNFi 启动治疗的生物制剂治疗模式。Cox 比例风险模型比较了 RA、PsA 或 AS 患者间未来两年停药的时间，调整了潜在混杂因素。在类似的按疾病分层的分层分析中，使用Cox模型评估同时使用csDMARDs是否与TNFi的持续性相关。

结果

我们确定了 31,527 例甲氨蝶呤启动治疗患者(26,708例RA患者,2,939例 PsA患者,1880例AS患者)和 34,651 例 TNFi 启动治疗患者(24,134例 RA患者,6,705例PsA患者,3,812 例AS患者)。相比RA患者，甲氨蝶呤在 PsA [aHR 1.10 (1.04-1.16)]和 AS [aHR 1.23 (1.16-1.31)]患者中更早停用，而 TNF抑制剂在 RA和AS 患者中的停用率相似，在PsA患者中更晚停用[aHR 0.93 (0.89-0.97)]。在 RA患者[aHR 0.85 (0.80-0.89)]、PsA患者[aHR 0.81 (0.74-0.89)]和 AS患者[aHR 0.79(0.67-0.93]中，同时使用甲氨蝶呤的患者 TNFi 停药率较低(与不使用 csDMARD 的患者相比)。

结论

银屑病患者停药比类风湿关节炎和强直性脊柱炎早，甲氨蝶呤和TNFi联合使用可以提升三种疾病中TNFi药效的持久性。

原 文

Comparative persistence on methotrexate and TNF inhibitors in rheumatoid arthritis, psoriatic arthritis, andankylosing spondylitis.

Objective

The role of methotrexate for the treatment of spondyloarthritis remains uncertain. Aims were to compare methotrexate and tumor necrosis factor inhibitor (TNFi) persistence in spondyloarthritis vs. RA and to determine whether concomitant conventional synthetic DMARD (csDMARD) use is associated with improved TNFi persistence in spondyloarthritis.

Methods

This retrospective cohort study using Optum's de-identified Clinformatics® Data Mart Database 2000-2014 identified patients with RA, psoriatic arthritis (PsA), and ankylosing spondylitis (SpA) without prior biologic use initiating methotrexate or a TNFi for the first time. Cox proportional hazards models compared time to medication discontinuation over the next two years between patients with RA, PsA, or AS, adjusting for potential confounders. In similar analyses stratified by disease, Cox models were used to assess whether concomitant use of csDMARDs was associated with TNFi persistence.

Results

We identified 31,527 methotrexate initiators (26,708 RA, 2,939 PsA, 1,880 AS) and 34,651 TNFi initiators (24,134 RA, 6,705 PsA, 3,812 AS). Methotrexate was discontinued sooner in patients with PsA [aHR 1.10 (1.04-1.16)] and AS [aHR 1.23 (1.16- 1.31)] vs. RA, while TNFi were discontinued at similar rates in RA and AS and discontinued later in PsA [aHR 0.93 (0.89-0.97)]. Concomitant use of methotrexate (compared to no csDMARD) was associated with lower rates of TNFi discontinuation in RA [aHR 0.85 (0.80-0.89)], PsA [aHR 0.81 (0.74-0.89)], and AS [aHR 0.79 (0.67-0.93].

Conclusion

Methotrexate discontinuation occurs sooner in patients with PsA and AS vs. RA. Concomitant use of methotrexate with a TNFi, however, is associated with improved TNFi persistence in all three diseases.

文章出处:

https://www.ncbi.nlm.nih.gov/pubmed/31474599

George MD, et al.

J Rheumatol.

2019.09.01