类风湿关节炎活动期临床判断

类风湿关节炎活动度临床判断ClinicalAssessmentofRheumatoidArthritisDiseaseActivity(PartlyquotedfromJonathanKay,MD)ContentWhyquantifyRAdiseaseactivity?CompositediseaseactivityindicesResponsecriteriaforclinicaltrialsPatient-reportedoutcomemeasuresQuantitatively-driventherapyforearlyRADatacollectiontoolsShawonMeasurement“Theonlymanwhobehavedsensiblywasmytailor;hetookmymeasureaneweverytimehesawme,whilstalltherestwentonwiththeiroldmeasurementsandexpectedthemtofitme.”-GeorgeBernardShaw(1856-1950)HowtoquantifyRAdiseaseactivityClinicalcompositeindices-DAS/DAS28-SDAS-CDAIPatient-reportedoutcomemeasuresImaging-Plainradiographs-Musculoskeletalultrasound-MRIPrimarysiteofRAdiseaseactivityPersistentsynovitisresultsin

-Jointdestruction-DisabilityGoaloftreatment(remission)isabsenceofsynovitisTender&swollenjointcountsareoutcomeuponwhichtherapeuticdecisionsarebasedWhyAssessJoints?Reportedas%improvement,comparingdiseaseactivityattwodiscretetimepoints-ACR20is≥20%improvement-ACR50is≥50%improvement

(ACR50respondersincludeACR20responders)-ACR70is≥70%improvement(ACR70respondersincludeACR20andACR50responders)UsedtomaximallydiscriminateeffectivetreatmentfromplacebotreatmentinclinicaltrialsNotdirectlyapplicabletoclinicalpracticeDTFelsonetal.ArthritisRheum.1995;38(6):727-735ACRresponsecriteria:thetraditionaldichotomousbenchmarkDiseaseActivityScore(DAS)DAS28SimplifiedDiseaseActivityIndex(SDAI)（简化的DAS评分）ClinicalDiseaseActivityIndex(CDAI)（临床DAS评分）ContinuousMeasuresofRADiseaseActivityDAS=0.54•(Tender44)1/2+0.06•(Swollen66)1/2+0.33In(ESR)+0.007(GlobalHealthonVAS)

（44个压痛关节、66个肿胀关节）ProvidesabsoluteindicationofRAdiseaseactivityonascaleof1to9-DAS>3.6=highdiseaseactivity-DAS2.4-3.6=moderatediseaseactivity-DAS1.6-2.4=lowdiseaseactivity-DAS<1.6=remissionDMvanderHeijdeetal.JRheumatol1993;20:579-81DiseaseActivityScore(DAS):AcontinuousmeasureSimplifieddiseaseactivityscoreusing28-jointcount-Integratesmeasuresofphysicalexamination,acutephaseresponse,andpatientself-assessmentDAS28=0.56•(Tender28)1/2+0.28•(Swollen28)1/2+0.70In(ESR)+0.014(GlobalHealthonVAS)

ProvidesabsoluteindicationofRAdiseaseactivityonascaleof0.49to9.07-DAS28>5.1=highdiseaseactivity-DAS283.2-5.1=moderatediseaseactivity-DAS282.6-3.2=lowdiseaseactivity-DAS28<2.6=remission

DMvanderHeijdeetal.JRheumatol1993;20:579-81DAS28:Asimplifieddiseaseactivityscore

JointsAssessedinDAS&DAS28JointsassessedonlyinDASJointsassessedinDAS&DAS28TJCandSJCcontributenumericallyto≈50%ofDAS/DAS28ESR&PatientGlobalHealthweighted≈2×inDAS28c/wDAS

EULARResponseCriteriaforRA:ContinuousvariabletodichotomousbenchmarkDAS28atendpointImprovementinDAS28frombaseline>1.2>0.6and<1.2<0.6<3.2GoodModerateNone3.2-5.1ModerateModerateNone>5.1ModerateModerateNoneAMvanGesteletal.ArthritisRheum.1996;39:34-40Simplifieddiseaseactivityscoreusing28-jointcount-Integratesmeasuresofphysicalexamination,acutephaseresponse,patientself-assessment,andevaluatorassessment-EasytocalculateSDAI=Tender28+Swollen28+CRP+PatientGlobalHealthonVAS+EvaluatorGlobalHealthonVASProvidesabsoluteindicationofRAdiseaseactivityonascaleof0.1to86.0-SDAI>26=highdiseaseactivity-SDAI11.1-26=moderatediseaseactivity-SDAI3.3-11=lowdiseaseactivity-SDAI<3.3=remission

SimplifiedDiseaseActivityIndex(SDAI)SmolenJSetal.Rheumatology(Oxford)2003;42:244-57Simplifieddiseaseactivityscoreusing28-jointcount-Immediatescoringpossible(nolaboratoryresult)-Integratesmeasuresofphysicalexamination,patientself-assessment,andevaluatorassessment-EasytocalculateCDAI=Tender28+Swollen28+PatientGlobalHealthonVAS+EvaluatorGlobalHealthonVASProvidesabsoluteindicationofRAdiseaseactivityonascaleof0to76.0-CDAI>22=highdiseaseactivity-CDAI10.1-22=moderatediseaseactivity-SDAI2.8-10=lowdiseaseactivity-SDAI<2.8=remission

ClinicalDiseaseActivityIndex(CDAI)DAletahaetal.ArthritisResTher2005;7:R796-R806DiseaseActivityMeasures:componentsACRResponseCriteriaDAS28SDAICDAIRAPIDHAQNumberofswollenjoints++++Numberoftenderjoints++++Patientpain++++Patientglobalassessment+++++Clinicianglobalassessment+++Patientfunction+++ESRorCRP+++ContributionofSwollen&TenderJointCountsImpactonCompositeIndicesACRResponseCriteria-TJCandSJCmustimproveby20%,50%,or70%,regardlessofimprovementin3oftheother5coresetmeasuresDAS&DAS28-TJCandSJCare2ofthe4outcomemeasures-TJCandSJCcontributenumericallyto≈50%ofthescore-TJCisweightedmoreheavilythanSJCSDAI&CDAI-TJCandSJCareweightedequallyECKeystone.JRheumatol2010;37:883-4

MeasurementintheBible“Forwithwhatjudgmentyejudge,yeshallbejudged:andwithwhatmeasureyemete,itshallbemeasuredtoyouagain”-MatthewPatient-ReportedOutcomeMeasuresHealthAssessmentQuestionnaire(HAQ)ModifiedHAQ(MHAQ)（简化HAQ）MultidimensionalHAQ(MDHAQ)（多维HAQ）RoutineAssessmentofPatientIndexData(RAPID)RheumatoidArthritisDiseaseActivityIndex(RADAI)HAQ,MHAQ&MDHAQVariablesHealthAssessmentQuestionnaireModifiedHealthAssessmentQuestionnaireMultidimensionalHealthAssessmentQuestionnaireDisabilityindexyesnonoNumberofquestions20818Numberofcategories8810ScoresuseofaidsordevicesyesnonoPainVASyesyesyesPatientglobalVASyesyesyesFatigueVASnonoyesScoring0-3(averageofallcategories:0or1becomes2ifpatientusesaids)0-30-3Minimumclinicallyimportantdifference-0.22-0.25-0.25RAPID-3MDHADQuestionnaireRoutineAssessmentofPatientIndexData(RAPID)3Includes3patient-reportedoutcomemeasuresfromACRCoreDataSet:-Patientself-assessedphysicalfunction-Patientpainassessment-PatientglobalassessmentRequiresnoactivityonthepartofhealthprofessional,otherthantocalculatesimplearithmetictotalsinabout5-10secondsProvidesabsoluteindicationofRAdiseaseactivityonascaleof0-30-RAPID3>12.0=highdiseaseactivity-RAPID36.1-12.0=moderatediseaseactivity-RAPID33.1-6.0=lowdiseaseactivity-RAPID30-3.0=remissionCorrelateswithDAS28&withCDAIinclinicalpractice