能量都卜勒超音波證實類風濕性關節炎復發常見於生物製劑減量

Power Doppler Ultrasonography-documented Rheumatoid Arthritis Relapse is Common during Dose Reduction of Biologics

Objective: According to the policy of Taiwan’s National Health Insurance Administration, patients withclinically remitted rheumatoid arthritis (RA) should undergo dose reduction of biologics. However, theincidence of clinical and ultrasonographic relapse during dose reduction of biologics is unknown.Methods: Nineteen RA patients who were beginning to taper biologics were enrolled. Ultrasonographyand clinical assessments were performed at weeks 0 and 24. Eight joints including bilateral elbows, wrists,and 2nd and 3rd metacarpophalangeal joints were scanned for synovitis scoring. The primary endpoints werethe clinical, gray-scale ultrasonography (GSUS), and power Doppler ultrasonography (PDUS) relapserates at week 24.Results: The mean age was 57.7±12 years (range 30-80). The male-to-female ratio was 3:16. The meandisease duration was 4.9±3.0 years (range 1.3-10.8). Sixteen patients were seropositive. The baseline datawere as follows: erythrocyte sedimentation rate (ESR)19.5±22.4 mm/hr (range 2-101), C-reactive protein0.39±0.71mg/dl (range 0-2.74), 28-joint disease activity score (DAS28)-ESR 3.1±1.2 (range 1-6), total GSscore 6.8±3.7 (range 3-15), and total PD score 1.8±2.6 (range 0-8). At week 24, the clinical, GSUS, andPDUS relapse rates were 15.8%, 31.6%, and 63.2%, respectively (PDUS vs. clinical, p <0.01). None ofthe baseline status variables including negative rheumatoid factor (RF), negative anti-cyclic citrullinatedpeptide (anti-CCP), disease duration <3.5 years, DAS28-ESR <2.6, total GS score <6, and total PD scoreof zero had a protective effect on any type of relapse at week 24.Conclusion: PDUS detected more patients with RA relapse than did clinical assessment. Dose reductionof biologics led to substantial subclinical relapse ofRA at week 24. 目的：根據台灣衛生福利部中央健康保險署的政策，類風濕性關節炎病人於臨床緩解後應考慮生物製劑減量。然而，於生物製劑減量後，臨床及超音波關節炎復發率至今仍不清楚。方法：本研究於民國104年4月1日至民國106年1月31日間收集了19位將接受生物製劑減量的類風濕性關節炎病人，並於減量前及減量後第24周接受臨床理學檢查及超音波檢查。超音波檢查包括雙側肘、腕、第二及第三掌指關節等八個關節掃描，並依各個關節之滑膜炎程度給予評分。主要終點為生物製劑減量後第24周的臨床、灰階超音波及能量都卜勒超音波所偵測的類風濕性關節炎復發率。結果：19位類風濕性關節炎病人的平均年紀為57.7±12歲（30－80歲），男女比為3：16，平均病程為4.9±3.0年（1.3－10.8年），其中類風濕性因子陽性或抗環瓜氨酸抗體陽性或兩者皆為陽性者占16人。生物製劑減量前的其他數據如下：紅血球沉降率（erythrocyte sedimentation rate, ESR）為19.5±22.4mm／hr（2－101mm／hr），C－反應蛋白（C-reactive protein, CRP）為0.39±0.71mg／dl（0－2.74mg／dl），28關節疾病活動度指數為3.1±1.2（1－6），灰階超音波總分為6.8±3.7（3－15），能量都卜勒超音波總分為1.8±2.6（0－8）。於生物製劑減量後第24周，臨床、灰階超音波及能量都卜勒超音波所偵測的類風濕性關節炎復發率分別為15.8％、31.6％及63.2％。而生物製劑減量前之類風濕性因子陰性、抗環瓜氨酸抗體陰性、病程小於3.5年、28關節疾病活動度指數小於2.6、灰階超音波總分小於6或能量都卜勒超音波總分為0均不會降低減量後24周的關節炎復發率。結論：類風濕性關節炎病患於生物製劑減量後24周可能產生潛在的關節炎復發。能量都卜勒超音波比臨床評估更能偵測出生物製劑減量後的類風濕性關節炎復發。