Anti-TNF-α tedavi ile remisyon sağlanmış ve tedavisi kesilmiş romatoid artrit, ankilozan spondilit ve psöriatik artrit hastalarındaki hastalık sürecinin değerlendirilmesi
Loading...
Date
2014
Authors
Kutlu, Nagehan Dik
Journal Title
Journal ISSN
Volume Title
Publisher
Uludağ Üniversitesi
Abstract
Romatoid Artrit (RA), Psöriatik Artrit (PsA) ve Ankilozan Spondilit (AS) kronik, inflamatuvar, etiyolojilerin tam aydınlatılamadığı sistemik hastalıklardır. Yetersiz tedavi edilen hastalarda zamanla erozif hastalık ortaya çıkmakta, ilerleyici seyir sonunda fonksiyon, iş gücü kaybı ve sakatlık gelişmekte ve hatta bazı geniş serilerde mortalitede artış belirtilmektedir. Bugün için bu hastalıkların kesin bir tedavisi olmamakla birlikte özellikle son 10-15 yılda tedavi açısından çok önemli ilerlemeler elde edilmiştir. Çalışmalarda RA, PsA ve AS'nin patogenezinde proinflamatuvar bir sitokin olan tümör nekrozis faktör-alfa'nın (TNF-α) kıkırdak ve kemik hasarında önemli rol oynadığı gösterilmiş, önce RA sonra AS ve PsA'de anti-TNF-α ajanlar kullanıma girmiştir. Bunlardan etanersept, infliksimab, adalimumab, golimumab ve sertozilumab Amerika Ulusal Gıda ve İlaç Kurulu (FDA) onayı almışlardır. Ancak bu TNF inhibitörlerinin (TNFi) -bu ajanların tüberküloz aktivasyonu ve enfeksiyon sıklığını arttırması, malignite riski ile ilgili endişeler, yüksek tedavi maliyetleri nedeniyle- kullanımı uzun yıllar akıllarda soru işaretleri oluşturmuş, klinik kullanım ve tecrübe arttıkça bu ilaçlara olan güven de artmıştır. Tedavideki ana hedefin ilaçsız remisyon olması ve TNFi ile ilgili tartışmalar, hekimleri hastalık remisyona girdiğinde tedaviyi keserek hastaları izleme yoluna gitmeye teşvik etmiştir. Bu süreçte, günlük pratikte TNFi ileri evre hastalara başlanmış olduğundan olsa gerek çoğu hastada hastalıkların reaktivasyonu ile karşılaşılmıştır. Biz bu çalışmada TNFi ile remisyonda iken herhangi bir nedenle tedavisi kesilmiş olan RA, PsA ve AS tanılı hastalarda hastalıklarının nasıl bir seyir izlediğini ortaya koymayı amaçladık. Çalışmaya Ocak 2000-Aralık 2013 tarihleri arasında Uludağ Üniversitesi Romatoloji Bilim Dalı Polikliniği'ne başvurmuş olan 37 AS, 22 RA ve 5 PsA hastası dahil edildi. Bu hastalar etanersept, infliksimab ya da adalimumab tedavilerinden herhangi birini kullanıyorken remisyon sağlanmış, takipte herhangi bir nedenle TNFi kesilmiş ve poliklinik izlemi devam etmiş olan hastalardı. AS tanısı ile izlenen hasta grubu için remisyon ve reaktivasyon kararı verilirken Bath Ankylosing Spondylitis Activity Index (BASDAI), RA tanısı ile izlenen hasta grubu için Dissease Activity Score (DAS28), PsA hasta grubu için Classification Criteria For Psoriatic Arthritis (CASPAR) kriterleri kullanıldı. Hastalık şiddeti ile ilgili kararlar, çalışmaya dahil edilen AS hasta grubundaki bireylerin kontrol için polikliniğe her geldiklerinde doldurmuş olduğu BASDAI için evvelce hazırlanmış olan değerlendirme formlarına göre verildi. Çalışmamızda TNFi tedavisinin kesilmesiyle hastaların büyük çoğunluğunda reaktivasyon geliştiğini saptadık.
An Evaluation of the Disease Course in Patients With Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis Who Achieved Remission with Anti-TNF-α Therapy and Whose Therapy Had Been Withdrawn for Any Reason Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), and Ankylosing spondylitis (AS) are chronic systemic inflammatory diseases with unclear etiologies. Erosive diseases occur in the insufficiently treated patients in time, functional and workforce loss and disability develop after progressive course, moreover, increased mortality has been reported in some broad series. Although there is still no definitive treatment of these diseases for the day, considerable advancements have been obtained for the medication, exclusively in the last 10-15 years. The studies have shown that the tumour necrosis factor-alfa (TNF-α) which is a proinflammatory cytokine in the pathogenesis of RA, PsA, and AS has got a significant role in the cartilage and bone damage, and anti-TNF agents have come into use firstly in RA and then in AS and PsA. Those of etanercept, infliximab, adalimumab, golimumab and certolizumab have been approved by the US Food and Drug Administration (FDA). However - since TNF inhibitors (TNFi) increase the tuberculosis activation and the infection frequency, and because of ongoing questions about malignity risk, and also since they are high cost treatments - the usage of them kept question marks in minds for years, and as the clinical usage and the experience rose up, trust in them increased, too. Since the main goal in the treatment is drug-free remission and also because of the disputes about the TNFi, the clinicians have chosed to discontinue the medication and to follow the patients, when remission occured. In this course, maybe just because the TNFi therapy has been started in the patients who have been in the advanced stage in everyday practice, reactivation of the diseases occured in most of the patients. In this study, we aimed to manifest the course of the diseases in the patients with RA, PsA, or AS diagnosis whose treatment have been discontinued by any reason during the remission with TNFi. 37 AS, 22 RA and 5 PsA patients who had come to the polyclinic of the Division of Rheumatology of the Faculty of Medicine, Uludağ University, between January 2000 and December 2013 were included in the study. These were the patients in whom, remission was obtained during they were receiving either of etanercept, infliximab or adalimumab, and TNFi has been discontinued for any reason in monitoring, and whose follow up in the polyclinic has been continued. To determine the remission and the reactivation, Bath Ankylosing Spondylitis Activity Index (BASDAI) for the patient group with AS diagnosis, and Dissease Activity Score (DAS28) score for the patient group with RA diagnosis, and Classification Criteria For Psoriatic Arthritis (CASPAR) for the the patient group with PsA diagnosis, were used. The estimation of the frequency of the disease was done according to the assestment forms which had been recently prepared for the BASDAI, and had been filled at each polyclinic control visit by each member of AS patient group included to the study. We have determined in our study, that reactivation occured in the majority of the patients after withdrawal of TNFi threapy.
An Evaluation of the Disease Course in Patients With Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis Who Achieved Remission with Anti-TNF-α Therapy and Whose Therapy Had Been Withdrawn for Any Reason Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), and Ankylosing spondylitis (AS) are chronic systemic inflammatory diseases with unclear etiologies. Erosive diseases occur in the insufficiently treated patients in time, functional and workforce loss and disability develop after progressive course, moreover, increased mortality has been reported in some broad series. Although there is still no definitive treatment of these diseases for the day, considerable advancements have been obtained for the medication, exclusively in the last 10-15 years. The studies have shown that the tumour necrosis factor-alfa (TNF-α) which is a proinflammatory cytokine in the pathogenesis of RA, PsA, and AS has got a significant role in the cartilage and bone damage, and anti-TNF agents have come into use firstly in RA and then in AS and PsA. Those of etanercept, infliximab, adalimumab, golimumab and certolizumab have been approved by the US Food and Drug Administration (FDA). However - since TNF inhibitors (TNFi) increase the tuberculosis activation and the infection frequency, and because of ongoing questions about malignity risk, and also since they are high cost treatments - the usage of them kept question marks in minds for years, and as the clinical usage and the experience rose up, trust in them increased, too. Since the main goal in the treatment is drug-free remission and also because of the disputes about the TNFi, the clinicians have chosed to discontinue the medication and to follow the patients, when remission occured. In this course, maybe just because the TNFi therapy has been started in the patients who have been in the advanced stage in everyday practice, reactivation of the diseases occured in most of the patients. In this study, we aimed to manifest the course of the diseases in the patients with RA, PsA, or AS diagnosis whose treatment have been discontinued by any reason during the remission with TNFi. 37 AS, 22 RA and 5 PsA patients who had come to the polyclinic of the Division of Rheumatology of the Faculty of Medicine, Uludağ University, between January 2000 and December 2013 were included in the study. These were the patients in whom, remission was obtained during they were receiving either of etanercept, infliximab or adalimumab, and TNFi has been discontinued for any reason in monitoring, and whose follow up in the polyclinic has been continued. To determine the remission and the reactivation, Bath Ankylosing Spondylitis Activity Index (BASDAI) for the patient group with AS diagnosis, and Dissease Activity Score (DAS28) score for the patient group with RA diagnosis, and Classification Criteria For Psoriatic Arthritis (CASPAR) for the the patient group with PsA diagnosis, were used. The estimation of the frequency of the disease was done according to the assestment forms which had been recently prepared for the BASDAI, and had been filled at each polyclinic control visit by each member of AS patient group included to the study. We have determined in our study, that reactivation occured in the majority of the patients after withdrawal of TNFi threapy.
Description
Keywords
Romatoid artrit, Psöriatik artrit, Ankilozan spondilit, Anti-TNF-α, TNFi, Reaktivasyon, Rheumatoid arthritis, Psoriatic arthritis, Ankylosing spondylitis, Reactivation
Citation
Kutlu, N. D. (2014). Anti-TNF-α tedavi ile remisyon sağlanmış ve tedavisi kesilmiş romatoid artrit, ankilozan spondilit ve psöriatik artrit hastalarındaki hastalık sürecinin değerlendirilmesi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.