原文

译文

Ann Rheum Dis 2011;70:733-739 doi:10.1136/ard.2010.138693

Physical disability in rheumatoid arthritis is associated with cartilage damage rather than bone destruction

1.       Daniel Aletaha1,

2.       Julia Funovits1,

3.       Josef S Smolen1,2

Abstract

Background Joint destruction in rheumatoid arthritis is comprised of cartilage and bone damage, which can be evaluated radiographically separately by the joint space narrowing (JSN) and erosion (ERO) scores. It is currently unclear to which extent these components affect irreversible functional disability. The aim of the present work was to determine these contributions.

Methods Data, kindly provided by the sponsors, was evaluated from several randomised controlled clinical trials on adalimumab, etanercept, infliximab and leflunomide. Patients who reached stringent remission according to the Simplified Disease Activity Index (SDAI≤3.3) were extracted to eliminate the activity related (ie, reversible) component of disability. In these patients, residual Health Assessment Questionnaire Disability Index (HAQ-DI) score at the time of remission (to reflect the level of ‘irreversible’ disability) was determined and related to baseline measures of ERO and JSN scores univariately, by stratification and in adjusted regression models.

Results A total of 748 patients who achieved a state of remission were analysed (16.3% of the total pooled population of 4602 patients). In the univariate analyses, mean residual HAQ-DI values in remission were significantly larger in higher tertiles of JSN and ERO (ERO: 0.21, 0.25, 0.35; JSN: 0.19, 0.24, 0.39; p<0.001 for both). In stratified analyses, mean residual HAQ-DI scores were larger in higher tertiles of JSN within the first tertile of ERO (0.18, 0.25, 0.29; p=0.05), as well as the second (0.21, 0.24, 0.29; p=0.19) and the third (0.12, 0.23, 0.42; p<0.001). In contrast, there was no such trend across ERO tertiles within the first JSN tertile (0.18, 0.21, 0.12; p=0.99) and the second tertile (0.25, 0.24, 0.23; p=0.77), and only marginally within the third tertile of JSN (0.29, 0.29, 0.42; p=0.07). Adjusted multivariate regression models supported the significant association of JSN on residual disability.

Conclusions Cartilage damage appears to be the more clearly associated with irreversible physical disability than bony damage. These data suggest that particular attention should be given to therapeutic interference with cartilage destruction.

RA病人关节残障与软骨破坏而非骨破坏相关

Aletaha D, et al. Ann Rheum Dis.2011;70:733-9.

背景: RA病人关节结构破坏包括软骨和骨破坏，可以通过放射学摄片分析关节腔狭窄(JSN)、骨侵蚀(ERO)的评分来判断破坏程度。这些结构破坏达到何种程度就可导致不可逆的关节功能残障，目前尚无不清楚。本研究将就此进行研究。

方法: 我们对赞助商慷慨提供的多个随机对照临床试验数据进行了分析，其中涉及的药物包括阿达木单抗、依那西普

英夫利昔和来氟米特。本研究采用严谨的临床缓解定义(SDAI≤3.3)，以期消除与关节残障相关的残余(可逆性)炎性活动。采集病人获临床缓解时的健康评估问卷残障指数(HAQ-DI)(反映不可逆残障的水平)，并利用单变量分析评估基线ERO和JSN评分与不可逆残障的关联度。

结果: 有748例病人获得临床缓解（在总计4602例的病人群中所占比例为16.3%）。单变量分析显示，三分区段JSN和ERO评分平均值越高，则获缓解时的残余HAQ-DI平均值越大(ERO: 0.21, 0.25, 0.35; JSN: 0.19, 0.24, 0.39; 两者的统计学P值均<0.001)。分层分析显示，在ERO三分区段的第1区段中，随着JSN三分区段的各段均值增高，残余HAQ-DI均值也增高(0.18, 0.25, 0.29; p=0.05)，ERO三分区段第2段(0.21, 0.24, 0.29; p=0.19)、第3段(0.12, 0.23, 0.42; p<0.001)也有相似的现象。与此截然不同的是，在JSN三分区段的第1区段，ERO三分区段中的残余HAQ-DI均值无上升趋势(0.18, 0.21, 0.12; p=0.99)，第2区段也是如此(0.25, 0.24, 0.23; p=0.77)，仅在第3区段出现略微趋势(0.29, 0.29, 0.42; p=0.07)。校正后多变量回归模型分析的结果也支持JSN与关节残余残障的显著相关性。

结论: 本研究结果显示，与骨破坏相比，软骨损伤与RA关节不可逆残障的相关性明显更高一些。这些数据提示我们应该关注那些能抑制软骨破坏的治疗手段。