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Neue Optionen für die Praxis

„Update S1/S2-Leitlinie Rheumatoide Arthritis“?

New options for the practice

Update S1/S2 guidelines on rheumatoid arthritis?

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Zusammenfassung

Leitlinien zur medikamentösen Behandlung der rheumatoiden Arthritis leisten einen wesentlichen Beitrag zu einer evidenzbasierten Versorgung der Betroffenen. Die Empfehlungen unterstützen den Behandler bei seiner Entscheidungsfindung, die letztliche Entscheidung sollte aber immer in einer partizipativen Entscheidung gemeinsam von Patient und Arzt getroffen werden. Dieser Prozess wird eher durch grundlegende Konzepte der Leitlinien, wie z. B. „treat-to-target“, gesteuert als durch konkrete Empfehlungen für oder gegen eine bestimmte Substanz(klasse). Dort, wo die Empfehlungen schon sehr konkret sind, wie z. B. für Methotrexat als Ersttherapie, sind diese eher ökonomisch getrieben als evidenzbasiert. Das ist nicht grundsätzlich falsch, sollte allerdings bei der Entscheidungsfindung deutlich werden. Eine differenziertere Empfehlung über Leitlinien benötigt eine bessere Risikostratifizierung für den Einzelnen und eine deutlichere Profilbildung der verschiedenen Substanzen.

Abstract

Guidelines are important tools for evidence-based pharmacological treatment of patients suffering from rheumatoid arthritis. Recommendations assist physicians in identifying the best form of treatment but ultimately, the final decision is based on joint participation by the patient and physician. Nowadays, general concepts, such as treat to target seem to be more important in rheumatoid arthritis than differencies between various drugs or drug classes. The universal recommendation to use methotrexate as the initial disease-modifying antirheumatic drug (DMARD) is driven more by economic reasons than by scientific data, which is not completely wrong but should be disclosed. For the future, more differentiated recommendations need better individual risk stratification and more distinct profiling of the different substances.

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Literatur

  1. Agca R, Heslinga SC, Rollefstad S et al (2017) EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 76(1):17–28. doi:10.1136/annrheumdis-2016-209775

    Article  CAS  PubMed  Google Scholar 

  2. Albrecht K, Callhoff J, Edelmann E et al (2016) Klinische Remission bei rheumatoider Arthritis. Daten aus der Früharthritiskohortenstudie CAPEA. Z Rheumatol 75:90–96

    Article  CAS  PubMed  Google Scholar 

  3. Albrecht K, Callhoff J, Schneider M, Zink A (2015) High variability in glucocorticoid starting doses in patients with rheumatoid arthritis: observational data from an early arthritis cohort. Rheumatol Int 35:1377–1384

    Article  CAS  PubMed  Google Scholar 

  4. Aletaha D, Funovits J, Keystone EC, Smolen JS (2007) Disease activity early in the course of treatment predicts response to therapy after one year in rheumatoid arthritis patients. Arthritis Rheum 56:3226–3235

    Article  CAS  PubMed  Google Scholar 

  5. Bijlsma JW, Welsing PM, Woodworth TG et al (2016) Early rheumatoid arthritis treated with tocilizumab, methotrexate, or their combination (U-Act-Early): a multicentre, randomised, double-blind, double-dummy, strategy trial. Lancet 388:343–355

    Article  CAS  PubMed  Google Scholar 

  6. Conaghan PG, Østergaard M, Bowes MA et al (2016) Comparing the effects of tofacitinib, methotrexate and the combination, on bone marrow oedema, synovitis and bone erosion in methotrexate-naive, early active rheumatoid arthritis: results of an exploratory randomised MRI study incorporating semiquantitative and quantitative techniques. Ann Rheum Dis 75:1024–1033

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Detert J, Bastian H, Listing J et al (2013) Induction therapy with adalimumab plus methotrexate for 24 weeks followed by methotrexate monotherapy up to week 48 versus methotrexate therapy alone for DMARD-naive patients with early rheumatoid arthritis: HIT HARD, an investigator-initiated study. Ann Rheum Dis 72:844–850

    Article  CAS  PubMed  Google Scholar 

  8. Emery P, Bingham CO 3rd, Burmester GR et al (2016) Certolizumab pegol in combination with dose-optimised methotrexate in DMARD-naïve patients with early, active rheumatoid arthritis with poor prognostic factors: 1‑year results from C‑EARLY, a randomised, double-blind, placebo-controlled phase III study. Ann Rheum Dis. doi:10.1136/annrheumdis-2015-209057

    Google Scholar 

  9. Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF et al (2007) Comparison of treatment strategies in early rheumatoid arthritis: a randomized trial. Ann Intern Med 146:406–415

    Article  PubMed  Google Scholar 

  10. Grigor C, Capell H, Stirling A et al (2004) Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lancet 364(9430):263–269

    Article  PubMed  Google Scholar 

  11. Guyatt GH, Oxman AD, Kunz R et al (2008) What is „quality of evidence“ and why is it important to clinicians? BMJ 336:995–998

    Article  PubMed  PubMed Central  Google Scholar 

  12. Haschka J, Englbrecht M, Hueber AJ et al (2016) Relapse rates in patients with rheumatoid arthritis in stable remission tapering or stopping antirheumatic therapy: interim results from the prospective randomised controlled RETRO study. Ann Rheum Dis 75:45–51

    Article  PubMed  Google Scholar 

  13. Heimans L, Wevers-de Boer KV, Visser K et al (2014) A two-step treatment strategy trial in patients with early arthritis aimed at achieving remission: the IMPROVED study. Ann Rheum Dis 73:1356–1361

    Article  CAS  PubMed  Google Scholar 

  14. van Herwaarden N, van der Maas A, Minten MJ et al (2015) Disease activity guided dose reduction and withdrawal of adalimumab or etanercept compared with usual care in rheumatoid arthritis: open label, randomised controlled, non-inferiority tria. BMJ 350:h1389. doi:10.1136/bmj.h1389

    Article  PubMed  PubMed Central  Google Scholar 

  15. Hørslev-Petersen K, Hetland ML, Junker P, OPERA Study-Group et al (2014) OPERA Study-Group. Adalimumab added to a treat-to-target strategy with methotrexate and intra-articular triamcinolone in early rheumatoid arthritis increased remission rates, function and quality of life. The OPERA Study: an investigator-initiated, randomised, double-blind, parallel-group, placebo-controlled trial. Ann Rheum Dis 73:654–661

    Article  PubMed  Google Scholar 

  16. Klarenbeek NB, Güler-Yüksel M, van der Kooij SM et al (2011) The impact of four dynamic, goal-steered treatment strategies on the 5‑year outcomes of rheumatoid arthritis patients in the BeSt study. Ann Rheum Dis 70:1039–1046

    Article  PubMed  Google Scholar 

  17. Krüger K, Wollenhaupt J, Albrecht K et al (2012) S1-Leitlinie der DGRh zur sequenziellen medikamentösen Therapie der rheumatoiden Arthritis 2012 Adaptierte EULAR-Empfehlungen und aktualisierter Therapiealgorithmus (EULAR). Z Rheumatol 71:592–603

    Article  PubMed  Google Scholar 

  18. Nam JL, Ramiro S, Gaujoux-Viala C et al (2014) Efficacy of biological disease-modifying antirheumatic drugs: a systematic literature review informing the 2013 update of the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 73:516–528

    Article  CAS  PubMed  Google Scholar 

  19. Radner H, Smolen JS, Aletaha D (2014) Remission in rheumatoid arthritis: benefit over low disease activity in patient-reported outcomes and costs. Arthritis Res Ther 16(1):R56

    Article  PubMed  PubMed Central  Google Scholar 

  20. Rantalaiho V, Kautiainen H, Korpela M, NEO-RACo Study Group et al (2014) NEO-RACo Study Group.. Targeted treatment with a combination of traditional DMARDs produces excellent clinical and radiographic long-term outcomes in early rheumatoid arthritis regardless of initial infliximab. The 5‑year follow-up results of a randomised clinical trial, the NEO-RACo trial. Ann Rheum Dis 73:1954–1961

    Article  CAS  PubMed  Google Scholar 

  21. Saleem B, Brown AK, Keen H et al (2011) Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments. Ann Rheum Dis 70:792–798

    Article  PubMed  Google Scholar 

  22. Schneider M, Lelgemann M, Abholz HH et al (2011) Management der frühen rheumatoiden Arthritis. Interdisziplinäre Leitlinie, 3. Aufl. Steinkopf, Darmstadt

    Google Scholar 

  23. Singh JA, Saag KG, Bridges SL Jr et al (2016) 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 68:1–26

    PubMed  Google Scholar 

  24. Smolen JS, Landewé R, Breedveld FC et al (2014) EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 73:492–509

    Article  CAS  PubMed  Google Scholar 

  25. van Tuyl LHD, Felson DT, Wells G et al (2010) Systematic review: evidence for predictive validity of remission on long term outcome in rheumatoid arthritis. Arthritis Care Res (Hoboken) 62:108–117

    Article  Google Scholar 

  26. Vashisht P, Sayles H, Cannella AC, Mikuls TR, Michaud K (2016) Generalizability of patients with rheumatoid arthritis in biologic agent clinical trials. Arthritis Care Res (Hoboken) 2016(68):1478–1488

    Article  Google Scholar 

  27. Verstappen SM, van Albada-Kuipers GA, Bijlsma JW et al (2005) A good response to early DMARD treatment of patients with rheumatoid arthritis in the first year predicts remission during follow up. Ann Rheum Dis 64:38–43

    Article  CAS  PubMed  Google Scholar 

  28. van Vollenhoven RF, Geborek P, Forslind K et al (2012) Conventional combination treatment versus biological treatment in methotrexate-refractory early rheumatoid arthritis: 2 year follow-up of the randomised, non-blinded, parallel-group Swefot trial. Lancet 379:1712–1720

    Article  PubMed  Google Scholar 

  29. van Vollenhoven RF, Østergaard M, Leirisalo-Repo M et al (2016) Full dose, reduced dose or discontinuation of etanercept in rheumatoid arthritis. Ann Rheum Dis 75:52–58

    Article  PubMed  Google Scholar 

  30. Zink A, Strangfeld A, Schneider M et al (2006) Effectiveness of tumor necrosis factor inhibitors in rheumatoid arthritis in an observational cohort study: comparison of patients according to their eligibility for major randomized clinical trials. Arthritis Rheum 54:3399–3407

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Poliklinik und Funktionsbereich für Rheumatologie, Hiller Forschungszentrum, Heinrich-Heine-Universität Universitätsklinikum Düsseldorf, HHUD Moorenstr. 5, 40225, Düsseldorf, Deutschland

    M. Schneider

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Correspondence to M. Schneider.

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Interessenkonflikt

M. Schneider weist auf folgende Beziehung hin: Beratung und Vorträge für Abbvie, Astra-Zeneca, BMS, Boehringer-Ingelheim, Chugai, Lilly, MSD, Pfizer, Roche, Sanofi-Aventis, UCB. Zudem erhält M. Schneider Forschungsförderung von Abbvie, Chugai und UCB.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

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A. Zink, Berlin

B. Hellmich, Kirchheim-Teck

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Schneider, M. Neue Optionen für die Praxis. Z Rheumatol 76, 125–132 (2017). https://doi.org/10.1007/s00393-016-0261-5

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  • DOI: https://doi.org/10.1007/s00393-016-0261-5

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