目的:这篇叙述性综述的目的是提供有关银屑病关节炎(PsA)治疗策略的最新数据,使用基于领域的方法支持治疗决策。
方法:这篇关于PsA治疗策略的叙述性综述集中在几个疾病领域(即,外周关节炎,附着性炎,轴向疾病,牙龈炎,皮肤和指甲疾病),以及所谓的葡萄膜炎的“相关条件”,克罗恩病,和溃疡性结肠炎.我们搜索了PubMed,EMBASE,国际准则,和最近的国会摘要。
结果:目前,多种批准的治疗方案提供了广泛的选择,如肿瘤坏死因子(TNF)抑制剂;白细胞介素-17(IL-17)的抑制剂,IL-12/23(IL-12/23),IL-23(IL-23),和Janus激酶;磷酸二酯酶4抑制剂apremilast;和T细胞调节剂abatacept。然而,没有治疗选择显示出明显的优势,关于疗效对周围关节炎和指炎比其他。而有限的证据表明,IL-17抑制剂ixekizumab和IL-12/23抑制剂ustekinumab在治疗附着点炎方面可能优于TNF抑制剂.关于附着点炎的最新数据也显示了甲氨蝶呤的有希望的结果。轴向PsA的治疗主要来自轴向脊柱关节炎,需要更多的数据集中在这个特定的PsA患者亚组。到目前为止,该特定人群中唯一一项随机对照试验的最重要发现是,IL-17抑制剂苏金单抗在轴向PsA的临床和放射学终点方面优于安慰剂.关于牛皮癣皮肤受累,针对PsA和皮肤银屑病的头对头试验显示,IL-17,IL-23和IL-12/23抑制剂优于TNF抑制剂.当治疗PsA并发葡萄膜炎时,根据现有数据,应首选单克隆TNF抑制剂抗体。在PsA和伴随的炎症性肠病中,治疗决策必须包括考虑存在哪种特定类型的炎症性肠病(克罗恩病或溃疡性结肠炎),因为一些药物要么缺乏数据,要么治疗这两种情况无效。在这两种类型中,应避免使用IL-17抑制剂。在确定治疗策略时,合并症应仔细评估,应考虑各自治疗方式的相应风险特征。
结论:有许多批准的治疗PsA患者的治疗选择,和其他新兴的治疗方案正在酝酿之中。每个患者的个性化治疗决策,根据主要的疾病表型,潜在的合并症,和病人的喜好,应该基于共同的决策。
OBJECTIVE: The goal of this narrative review was to provide current data on psoriatic arthritis (PsA) therapeutic strategies, supporting treatment decisions with a domain-based approach.
METHODS: This narrative review of treatment strategies for PsA focused on several disease domains (ie, peripheral arthritis, enthesitis, axial disease, dactylitis, skin and nail disease), as well as the so-called \"related conditions\" of uveitis, Crohn\'s disease, and ulcerative colitis. We searched PubMed, EMBASE, international guidelines, and recent congress abstracts.
RESULTS: Currently, multiple approved treatment options offer a wide range of options, such as tumor necrosis factor (TNF) inhibitors; inhibitors of interleukin-17 (IL-17), IL-12/23 (IL-12/23), IL-23 (IL-23), and Janus kinase; the phosphodiesterase 4 inhibitor apremilast; and the T-cell modulator abatacept. However, no treatment option shows clear superiority concerning efficacy on peripheral arthritis and dactylitis over the others, whereas limited evidence suggests that the IL-17 inhibitor ixekizumab and the IL-12/23 inhibitor ustekinumab may be superior to TNF inhibitors in treating enthesitis. Recent data on enthesitis have also shown promising results for methotrexate. Treatment of axial PsA is mostly derived from axial spondyloarthritis, and more data are needed focusing on this specific subgroup of PsA patients. Thus far, the most important finding from the only randomized controlled trial in this specific population is that the IL-17 inhibitor secukinumab was superior to placebo in terms of clinical and radiologic end-points in axial PsA. Regarding psoriatic skin involvement, head-to-head trials in PsA as well as skin psoriasis showed the superiority of IL-17, IL-23, and IL-12/23 inhibitors over TNF inhibitors. When treating PsA with concurrent uveitis, according to the existing data, monoclonal TNF inhibitor antibodies should be preferred. In PsA and concomitant inflammatory bowel disease, treatment decisions must include the consideration of which specific type of inflammatory bowel disease (Crohn\'s disease or ulcerative colitis) is present, as some of the agents either lack data or are ineffective in treating these 2 conditions. In both types, IL-17 inhibitors should be avoided. When determining treatment strategy, comorbidities should be carefully assessed, and the corresponding risk profile of the respective treatment modalities should be taken into consideration.
CONCLUSIONS: There are many approved therapeutic options for treating patients with PsA, and additional emerging treatment options are in the pipeline. Individualized treatment decisions for each patient, depending on the leading disease phenotype, underlying comorbidities, and patient preferences, should be made based on shared decision-making.