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用于成人类风湿关节炎初始治疗的甲氨蝶呤替代药物

Authors
Stanley Cohen, MD
Ted R Mikuls, MD, MSPH
Section Editor
James R O'Dell, MD
Deputy Editor
Paul L Romain, MD
Translators
毛志国, 副主任医师，副教授

引言

类风湿关节炎(rheumatoid arthritis, RA)的治疗旨在控制滑膜炎和预防关节损伤，关节损伤在病程早期即可出现，最终可能致残。活动性疾病的持续时间越长，患者对治疗反应良好的可能性越小，所以人们普遍认为活动性RA患者应在疾病最早期，理想情况下应在症状发作不足3个月内，即采用改变病情的抗风湿药(disease-modifying antirheumatic drug, DMARD)进行治疗。 (参见“成人类风湿关节炎治疗的一般原则”，关于‘预后’一节和“成人类风湿关节炎治疗的一般原则”，关于‘早期使用DMARD’一节)

最常用于RA初始治疗的DMARD是甲氨蝶呤(methotrexate, MTX)，但是部分患者不能或不愿应用该药，因此有时需使用其他药物作为初始DMARD以代替甲氨蝶呤。治疗药物(包括抗炎药和DMARD)的选择受诸多因素的影响。 (参见下文‘治疗方法’和“成人中度到重度活动性类风湿关节炎的初始治疗”)

本文将总结其他药物替代甲氨蝶呤作为初始DMARD用于治疗活动性RA患者。对RA治疗一般原则更全面的描述，RA的初始治疗，RA的诊断与鉴别诊断，以及初始治疗难治性RA的治疗，参见其他专题。 (参见“成人类风湿关节炎治疗的一般原则”和“成人中度到重度活动性类风湿关节炎的初始治疗”和“类风湿关节炎的诊断与鉴别诊断”和“对初始非生物性DMARD治疗抵抗的成人类风湿关节炎的治疗”和“初始生物性DMARD治疗抵抗的类风湿关节炎成人的治疗”)

治疗方法

甲氨蝶呤是常用于治疗RA的初始DMARD，但由于患者的共存疾病是甲氨蝶呤的绝对或相对禁忌证而不能使用该药，或者由于患者或临床医生的偏好，甲氨蝶呤的替代药物有时用于RA的初始治疗。 (参见“成人中度到重度活动性类风湿关节炎的初始治疗”)

甲氨蝶呤替代药物的选择主要基于以下因素：来自间接比较和数量有限的头对头比较的证据，疾病严重程度与预后特征，共存疾病，患者关于相对风险与获益以及给药途径的偏好，以及监管、保险及成本的限制。 (参见下文‘治疗的选择’)

                        

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Literature review current through: 2017-06 . | This topic last updated: 2016-09-13.
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