最新银屑病关节炎治疗指南 -----2015年美国风湿病

最新银屑病关节炎治疗指南

-----2015年美国风湿病学会年会重要进展

GRAPPA一直致力于银屑病及银屑病关节炎的研究，不断推出相关的指南及指导意见。在2015年的ACR年会上他们再次发布了银屑病关节炎治疗推荐，更好地指导临床医师诊治银屑病关节炎。指南的推荐意见如下：

1对于未使用DMARD的周围关节型：

强推荐：DMARDs(MTX,柳氮磺吡啶,来氟米特),TNFi；弱推荐：NSAIDs,口服糖皮质激素,关节内注射糖皮质激素，PDE4i（阿普斯特）；因为缺乏证据不推荐：IL12/23抑制剂,IL17抑制剂；

2对于DMARD效果不好的周围关节型：

强推荐：TNFi,ustekinumab,PDE4i；弱推荐：NSAIDs,口服糖皮质激素,关节内注射糖皮质激素,IL17抑制剂；

3对于生物制剂效果不好的周围关节型：

强推荐：TNFi；弱推荐：NSAIDs,口服糖皮质激素,关节内注射糖皮质激素,IL12/23抑制剂,IL17抑制剂,PDE4i；

4对于未使用生物制剂的中轴关节型：

强推荐：NSAIDs,物理治疗,简单止痛,TNFi；弱推荐：IL17抑制剂,糖皮质激素骶髂关节注射,二膦酸盐(IL12/23抑制剂)；强不推荐：DMARDs,IL6抑制剂,CD20抑制剂；

5对于生物制剂效果不好的中轴关节型：

强推荐：NSAIDs,物理治疗,简单止痛；弱推荐：TNFi,IL12/23抑制剂,IL17抑制剂；

6附着点炎：

强推荐：TNFi,IL12/23i；弱推荐：NSAIDs,物理治疗,糖皮质激素（应高度注意承重部位附着点注射糖皮质激素可能导致附着点断裂）,PDE4i,IL17抑制剂；因为缺乏证据不推荐：DMARDs；

7指趾炎

强推荐：TNFi(英夫利昔单抗、阿达木单抗、戈利木单抗、赛妥珠单抗)；弱推荐：糖皮质激素注射,DMARDs(MTX,来氟米特，柳氮磺吡啶),TNFi(依那西普),IL12/23抑制剂,IL17抑制剂,PDE4i；

8银屑病（斑块）

强推荐：热疗，光疗，DMARDs(MTX,来氟米特，环孢素A),TNFi,IL12/23抑制剂,IL17抑制剂,PDE4i；

9甲银屑病

强推荐：TNFi,IL12/23抑制剂；弱推荐：热疗,程序性治疗,DMARDs(环孢素A,来氟米特,阿维酸A,MTX),IL17抑制剂,PDE4i。

（福建省福清市医院俞建钰林星编译，全文见《风湿病与关节炎》2016，（3））

参考文献

【1】ClementsPJ,TashkinD,RothM,etal.TheSclerodermaLungStudyII(SLSII)ShowsThatBothOralCyclophosphamide(CYC)andMycophenolateMofitil(MMF)AreEfficaciousinTreatingProgressiveInterstitialLungDisease(ILD)inPatientswithSystemicSclerosis(SSc)[abstract].ArthritisRheumatol,2015;67(suppl10).

【2】NarváezJ,BorrellPañosH,CastellviI,etal.AlegreJJ.EfficacyofMycophenolateAsaMaintenanceTherapyFollowingtheAdministrationofCyclophosphamideintheTreatmentofInterstitialLungDiseaseAssociatedwithSystemicSclerosis[abstract].ArthritisRheumatol,2015;67(suppl10).

【3】LionakiS,FragoulisG,VenetsanopoulouA,etal.RituximabAsaCyclophosphimideSparingAgentforPatientswithMulti-RelapsingAntineutrophilCytoplasmicAntibodyAssociatedSmallVesselVasculitis[abstract].ArthritisRheumatol,2015;67(suppl10).

【4】GillT,AsquithM,BrooksS,etal.ColbertRA.AnalysisofHLA-B27TransgenicRatsRevealsSpecificGutTranscriptomeandMicrobiomeSignaturesAssociatedwithInflammation[abstract].ArthritisRheumatol,2015;67(suppl10).

【5】SilvermanGJ,GetuL,NiuH,etal.DoesDysbiosiswithintheIntestinalMicrobiomeContributetoSLEPathogenesis?[abstract].ArthritisRheumatol,2015;67(suppl10).

【6】HendricksonJ,MehtaG,BANDAN,etal.etal..AlterationsintheColonicMicrobiomePrecedetheDevelopmentofMurineInflammatoryArthritis[abstract].ArthritisRheumatol,2015;67(suppl10).

【7】ScherJU,JoshuaV,UbedaC,etal.TheLungMicrobiomeinRheumatoidArthritisandAssociatedLocal/SystemicAutoimmunity[abstract].ArthritisRheumatol,2015;67(suppl10).

【8】DocampoE,FangM,DmitrievaJ,etal.PrioritizingLikelyCausativeGenesinGenome-WideAssociationStudies(GWAS)IdentifiedRiskLociforImmune-MediatedInflammatoryDisordersUsingCell-TypeSpecificExpressionQuantitativeLoci(eQTL)Information[abstract].ArthritisRheumatol,2015;67(suppl10).

【9】OkadaY,TanakaT.SignificantImpactofMicrorna-TargetGeneNetworksontheGeneticsofRheumatoidArthritis[abstract].ArthritisRheumatol,2015;67(suppl10).

【10】MorelL,ChoiSC,XuZ,etal.TherapeuticTargetingofCD4+TCellMetabolisminMurineModelsofLupus[abstract].ArthritisRheumatol,2015;67(suppl10).

【11】WermuthPJ,JimenezSA.SalinomycinInducesPotentSuppressionofTGF-β1-MediatedExpressionofProfibroticGenesinCulturedDermalFibroblastsfromNormalDonorsandfromDonorswithSystemicSclerosis(SSc):ANovelAnti-FibroticTreatmentforTissueFibrosisinSSc[abstract].ArthritisRheumatol,2015;67(suppl10).

【12】MaierC,BeyerC,DistlerJH,etal..InhibitionofPhosphodiesterase4(PDE4)ReducesDermalFibrosisByInterferingwiththeReleaseofPro-FibroticCytokinesfromM2-Macrophages[abstract].ArthritisRheumatol,2015;67(suppl10).

【13】SandnerP,DeesC,DistlerJHW,etal.StimulatorsofSolubleGuanylateCyclase(sGC)InhibitExperimentalSkinFibrosisofDifferentAetiologies[abstract].ArthritisRheumatol,2015;67(suppl10).

【14】YamashitaT,AsanoY,TaniguchiT,etal.GlycyrrhizinAmelioratesFibrosis,Vasculopathy,andImmuneAbnormalitiesinAnimalModelsofSystemicSclerosis[abstract].ArthritisRheumatol,2015;67(suppl10).

【15】CoatesLC,etal.GroupforResearchandAssessmentofPsoriasisandPsoriaticArthritis(GRAPPA):TreatmentRecommendationsforPsoriaticArthritis2015[abstract].ArthritisRheumatol,2015;67(suppl10).

【16】SinghJA,etal.2015AmericanCollegeofRheumatologyGuidelinefortheTreatmentofRheumatoidArthritis.ArthritisRheumatol,2016Jan;68(1):1-26.

【17】WardMM,etal.AmericanCollegeofRheumatology/SpondylitisAssociationofAmerica/SpondyloarthritisResearchandTreatmentNetwork2015RecommendationsfortheTreatmentofAnkylosingSpondylitisandNonradiographicAxialSpondyloarthritis.ArthritisRheumatol,2016Feb;68(2):282-98.

【18】DejacoC,etal.2015Recommendationsforthemanagementofpolymyalgiarheumatica:aEuropeanLeagueAgainstRheumatism/AmericanCollegeofRheumatologycollaborativeinitiative.AnnRheumDis,2015Oct;74(10):1799-807.

【19】NeogiT,etal.2015Goutclassificationcriteria:anAmericanCollegeofRheumatology/EuropeanLeagueAgainstRheumatismcollaborativeinitiative.AnnRheumDis,2015Oct;74(10):1789-98.