Diagnose und Therapie der rheumatoiden Arthritis

Zusammenfassung

Die RA ist zwar nach wie vor nicht heilbar, aber heute zu einer gut behandelbaren Erkrankung geworden, bei der das Therapieziel eine komplette Remission unter Einschluss eines intakten radiologischen und funktionellen Status und erhaltener Arbeitsfähigkeit und Lebensqualität ist. Eine optimale Voraussetzung für einen solchen günstigen Langzeitverlauf ist eine frühe Diagnosestellung und ein umgehender Beginn gezielter Therapie. Die Therapie wird nach dem Treat-to-Target-Prinzip mit Überprüfung und ggf.Modifikation in regelmäßigen Abständen, bis das Therapieziel erreicht ist, durchgeführt. In der Regel besteht die Starttherapie aus Mtx + GC, bei ausbleibendem Erfolg dann aus einer Kombination mehrerer kDMARD bzw. bei einem erneuten Misserfolg Mtx + Biologika. In Fällen sehr hoher Aktivität und ungünstiger Prognose können Biologika auch bereits als Zweittherapie zum Einsatz kommen. Neben Medikamenten sind eine Reihe nicht-medikamentöser Behandlungsverfahren wie Krankengymnastik elementare Bestandteile der multimodalen Therapie. Insgesamt ist die Krankheitslast der RA durch das optimierte Vorgehen in den letzten zwanzig Jahren dramatisch zurückgegangen.

Abstract

Rheumatoid arthritis today is still not curable but satisfactory treatable. Treatment targets include clinical remission (or at least low disease activity), lack of radiological destructions and functional disability as well as acceptable life quality and unimpaired working ability. Diagnosing and adequately treating the disease as early as possible is essential for a favourable long-term outcome. Treatment to target with validation and if necessary modification at least every three months until target is achieved ensures good results. Predominantly treatment starts with a combination of methotrexate and glucocorticoids followed by a conventional DMARD combination and then addition of a biologic DMARD in case of failing target. Presence of adverse risk factors and/or high disease activity a cDMARD/bDMARD combination might be used already after starting treatment failure. Additional treatment options such as physiotherapy should be added. Altogether with current treatment possibilities burden of disease declined dramatically in recent years.

Schlüsselwörter

Rheumatoide Arthritis - Diagnose - Behandlung - konventionelle DMARD - Biologika

Keywords

rheumatoid arthritis - diagnosis - treatment - conventional disease-modifying antirheumatic drugs - biologics

• Literatur

• 1 Aletaha D, Neogi T, Silman AJ et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010; 62: 2569-2581
• 2 Allaart CF, Lems WF, Huizinga TWJ. The BeSt way of withdrawing biologic agents. Clin Exp Rheumatol 2013; 31 (Suppl. 78) S14-S18
• 3 Bakker MF, Jacobs JWG, Welsing PMJ et al. Low-Dose Prednisone Inclusion in a Methotrexate-Based, Tight Control Strategy for Early Rheumatoid Arthritis. Ann Intern Med 2012; 156: 329-339
• 4 Bili A, Tang X, Pranesh S et al. Tumor Necrosis Factoralpha-Inhibitor Use and Decreased Risk for Incident Coronary Events in Rheumatoid Arthritis. Arthritis Care Res 2014; 66: 355-363
• 5 Burgers LE, van Nies JAB, Ho LY et al. Long-term outcome of Rheumatoid Arthritis defined according to the 2010-classification criteria. Ann Rheum Dis 2014; 73: 428-432
• 6 Cipriani P, Ruscitti P, Carubbi F et al. Methotrexate in Rheumatoid Arthritis: Optimizing Therapy Among Different Formulations. Current and Emerging Paradigms. Clin Therap 2014; 36: 427-435
• 7 Combe B, Logeart I, Belkacemi MC et al. Comparison of the long-term outcome for patients with rheumatoid arthritis with persistent moderate disease activity or disease remission during the first year after diagnosis: data from the ESPOIR cohort. Ann Rheum Dis 2014; online Jan 7. DOI: 10.1136/annrheumdis-2013-204178.
• 8 Deutsches Rheuma-Forschungszentrum Berlin. Daten der Kerndokumentation 2012. Unpubliziert.
• 9 Gossec L, Paternotte S, Combe B et al. Repeated Anticitrullinated Protein Antibody and Rheumatoid Factor Assessment Is Not Necessary in Early Arthritis: Results from the ESPOIR Cohort. J Rheumatol 2014; 41: 41-46
• 10 Graudal N, Jürgens G. Similar effects of disease-modifying antirheumatic drugs, glucocorticoids, and biologic agents on radiographic progression in rheumatoid arthritis: meta-analysis of 70 randomized placebo-controlled or drug-controlled studies, including 112 comparisons. Arthritis Rheum 2010; 62: 2852-2863
• 11 Hetland ML, Østergaard M, Ejbjerg B et al. Short- and long-term efficacy of intra-articular injections with betamethasone as part of a treat-to-target strategy in early rheumatoid arthritis: impact of joint area, repeated injections, MRI findings, anti-CCP, IgM-RF and CRP. Ann Rheum Dis 2012; 71: 851-856
• 12 Huscher D, Thiele K, Gromnica-Ihle E et al. Dose-related patterns of glucocorticoid-induced side effects. Ann Rheum Dis 2009; 68: 1119-1124
• 13 Kavanaugh A, Smolen JS. The when and how of biologic agent withdrawal in rheumatoid arthritis: learning from large randomised controlled trials. Clin Exp Rheumatol 2013; 31 (Suppl. 78) S19-S21
• 14 Keystone EC, Breedveld FC, van der Heijde D et al. Longterm Effect of Delaying Combination Therapy with Tumor Necrosis Factor Inhibitor in Patients with Aggressive Early Rheumatoid Arthritis: 10-year Efficacy and Safety of Adalimumab from the Randomized Controlled PREMIER Trial with Open-label Extension. J Rheumatol 2014; 41: 5-14
• 15 Kievit W, Fransen J, de Waal Malefijt MC et al. Treatment changes and improved outcomes in RA: an overview of a large inception cohort from 1989 to 2009. Rheumatology 2013; 52: 1500-1508
• 16 Krüger K, Wollenhaupt J, Albrecht K et al. S1-Leitlinie der DGRh zur sequenziellen medikamentösen Therapie der rheumatoiden Arthritis 2012: adaptierte EULAR Empfehlungen und aktualisierter Therapiealgorithmus. Z Rheumatol 2012; 71: 592-603
• 17 Kyburz D, Finckh A. The importance of early treatment for the prognosis of rheumatoid arthritis. Swiss Med Wkly 2013; 143: w13865
• 18 Listing J, Kekow J, Manger B et al. Mortality in rheumatoid arthritis: the impact of disease activity, treatment with glucocorticoids, TNFα inhibitors and rituximab. Ann Rheum Dis 2013; online Nov 29, DOI: 10.1136/annrheumdis-2013-204021.
• 19 O'Dell JR, Mikuls TR, Taylor TH et al. Therapies for Active Rheumatoid Arthritis after Methotrexate Failure. N Engl J Med 2013; DOI: 10.1056/NEJMoa1303006.
• 20 Schiff MH, Simon LS, Freundlich B et al. Drug Exposure Limitations of Oral Methotrexate (MTX) At Doses>15mgs May be Overcome By Using a Subcutaneous MTX Auto-Injector in Patients With Rheumatoid Arthritis (RA). Arthritis Rheum 2013; 65: S 337
• 21 Schneider M, Krüger K. Rheumatoide Arthritis – Frühdiagnose und Krankheitskontrolle. Dtsch Ärztebl 2013; 110: 477-484
• 22 Schneider M, Lelgemann M, Abholz HH et al. Management der frühen rheumatoiden Arthritis. Heidelberg: Springer Verlag; 2011. http://dgrh.de/leitlinien.html
• 23 Shea B, Swinden MV, Ghogomu ET et al. Folic Acid and Folinic Acid for Reducing Side Effects in Patients Receiving Methotrexate for Rheumatoid Arthritis. J Rheumatol 2014; online April 15 DOI: 10.3899/jrheum.130738.
• 24 Smolen JS, Landewé R, Breedveld FC et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73: 492-509
• 25 Sokka T, Abelson B, Pinkus T. Mortality in rheumatoid arthritis: 2008 update. Clin Exp Rheumatol 2008; 26 (Suppl. 51) S35-S61
• 26 Soubrier M, Lukas C, Sibilia J et al. Disease activity score-driven therapy versus routine care in patients with recent-onset active rheumatoid arthritis: data from the GUEPARD trial and ESPOIR cohort. Ann Rheum Dis 2011; 70: 611-615
• 27 Sun J, Zhang Y, Liu L et al. Diagnostic accuracy of combined tests of anti cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis: a meta-analysis. Clin Exp Rheumatol 2014; 32: 11-21
• 28 Ter Wee MM, den UylD, Boers M. Intensive combination treatment regimens, including prednisolone, are effective in treating patients with early rheumatoid arthritis regardless of additional etanercept: 1-year results of the COBRA-light open-label, randomised, non-inferiority trial. Ann Rheum Dis 2014; online May 12 DOI: 10.1136/annrheumdis-2013-205143.
• 29 Van der Heijde D, van der Helm-van Mil AHM, Aletaha D et al. EULAR definition of erosive disease in light of the 2010 ACR/EULAR rheumatoid arthritis classification criteria. Ann Rheum Dis 2013; 72: 479-481
• 30 Van der Kooij SM, de Vries-Bouwstra JK, Goekoop-Ruiterman YPM et al. Limited efficacy of conventional DMARDs after initial methotrexate failure in patients with recent onset rheumatoid arthritis treated according to the disease activity score. Ann Rheum Dis 2007; 66: 1356-1362
• 31 Van der Linden MPM, Knevel R, Huizinga TWJ et al. Classification of Rheumatoid Arthritis – Comparison of the 1987 American College of Rheumatology Criteria and the 2010 American College of Rheumatology/European League Against Rheumatism Criteria. Arthritis Rheum 2011; 63: 37-42
• 32 Villeneuve E, Haraoui B. To switch or to change class – the biologic dilemma in rheumatoid arthritis. Nat Rev Rheumatol 2010; 6: 301-305