Rheumatology：TNF抑制剂治疗持续性oJIA患者有效

持续性少关节型幼年特发性关节炎（oJIA）通常在6岁前起病，女性多见，表现为膝关节和踝关节为主的非对称性关节炎。其合并葡萄膜炎及抗核抗体（ANA）阳性者多见。TNF抑制剂在说明书中并没有治疗持续性oJIA的适应症，但在临床工作中，针对这一疾病，医师并非均按照说明书用药。为评估oJIA患者使用TNF抑制剂的有效性，来自荷兰Erasmus MC索菲亚儿童医院儿童风湿病科的Janneke Anink等人进行了一项研究。研究结果发表于2013年4月的《风湿病学》（Rheumatology）杂志上。研究认为，TNF抑制剂治疗持续性oJIA患者有效。

荷兰儿童关节炎与生物制剂注册中心（ABC）是一项进行中的旨在纳入全荷兰所有使用生物制剂的JIA儿童的多中心前瞻性研究。从此研究中，研究者获取了持续性oJIA患者的资料。对患者的治疗反应通过JIA核心病情活动度变量进行评估，对病情稳定者使用修正的华莱士标准评估。

至2011年2月，共有16例持续性oJIA患者（68.8%为女性）在该研究中心进行了登记。患者的病程平均为8.4年[四分位距（IQR）2.1-13.5年]，合并葡萄膜炎者占18.8%，ANA阳性者占56.3%。所有患者都有MTX用药史，81.3%的患者接受过关节腔注射糖皮质激素（IA CSs）。开始生物制剂后的随访中位期为13.7个月（IQR 8.3-16.7月）。十四例患者使用依那西普，两例活动性关节炎合并葡萄膜炎患者使用阿达木单抗。尽管持续性oJIA患者受累关节较少[在开始生物制剂治疗时，活动性关节炎个数的中位数为2（IQR 1-3）]，但患者/双亲评估的疼痛[可视模拟积分（VAS）中位数为51（IQR 1-64）]及安乐指数[VAS中位数为44（IQR 6-66）]仍较高。此外，医师评估的疾病活动度为中高度活动[VAS中位数为36（IQR 4-65）]。经过3个月后，此项积分降至0（IQR 0-30），63%的患者达到病情稳定。在15个月后，所观察的10例患者中有9例病情稳定。TNF抑制剂的耐受性也很好。

研究者认为，在持续性oJIA患者中，当使用MTX或关节腔注射糖皮质激素治疗无效时，TNF抑制剂可能是有效的，其可作为治疗选择之一。

与TNF相关的拓展阅读：

• Ann Rheum Dis：当使用一种TNFi治疗银屑病关节炎无效时应换用其他作用机制药物
• Ann Rheum Dis：长期抗TNF治疗或不增加新骨生成
• Clin Gastroenterol Hepatol：TNF-α拮抗剂与肝损伤：34例病例分析
• Ann Rheum Dis：抗TNF治疗增加分枝杆菌病发生率
• ACR 2012：TNF抑制剂似乎不增加淋巴瘤风险
• Arthritis Rheum：TNFi类型不影响RA患者死亡率 更多信息请点击：有关TNF更多资讯

Tumour necrosis factor-blocking agents in persistent oligoarticular juvenile idiopathic arthritis: results from the Dutch Arthritis and Biologicals in Children Register.
Objective
Because TNF inhibitors are not approved for persistent oligoarticular JIA (oJIA), although they are used off-label, we evaluated their effectiveness in patients in this category.
Methods
Persistent oJIA patients were selected from the Dutch Arthritis and Biologicals in Children (ABC) register, an ongoing multicentre prospective study that aims to include all Dutch children with JIA using biologic agents. Response was assessed by the JIA core-set disease activity variables and modified Wallace criteria for inactive disease.
Results
Until February 2011, 16 persistent oJIA patients (68.8% females) had been included in the register. Median age of onset was 8.4 years [interquartile range (IQR) 2.1-13.5 years]; history of uveitis in 18.8%; ANA-positive 56.3%. All had previously used MTX, and 81.3% had used IA CSs. Median follow-up after the introduction of biologic treatment was 13.7 months (IQR 8.3-16.7 months). Fourteen patients started etanercept and two patients who had active arthritis as well as uveitis started adalimumab. Although patients with persistent oJIA had few affected joints [median of two active joints at the start of biologic (IQR 1-3)], the patient/parent assessments of pain [median visual analogue score (VAS) 51 (IQR 1-64)] and well-being [median VAS 44 (IQR 6-66)] were high. Additionally, their physician evaluated the disease activity as moderately high [median VAS 36 (IQR 4-65)]. After 3 months this decreased to 0 (IQR 0-30) and 63% achieved inactive disease. After 15 months the disease was inactive in 9/10 observed patients. TNF inhibitors were tolerated well.
Conclusion
TNF blocking agents seem an effective and justifiable option in persistent oJIA when treatment with IA CS injections and MTX has failed.