Takaisin

Nivelreumapotilaan tulehtuneiden nivelten kortisoni-injektiot

Näytönastekatsaukset
Kari Puolakka
30.3.2015

Näytön aste: C

Tulehtuneiden nivelten hoito kortikoidi-injektiolla saattaa vähentää radiologisia vaurioita nivelreumapotilailla.

In a randomised, controlled double-blind in Denmark 160 patients with early RA (duration < 6 months) were randomised to receive intra-articular betamethasone in any swollen joint in combination with step-up treatment with either methotrexate and placebociclosporine (monotherapy) or methotrexate plus ciclosporine (combination therapy) during the first 76 weeks «Hetland ML, Østergaard M, Ejbjerg B ym. Short- and...»1. At week 68 hydroxychlorochine 200 mg daily was added. From week 76–104 ciclosporine/placebociclosporine was tapered to zero. During 2 years of follow-up 160 patients received intra-articular betamethasone in up to four swollen joints/ 1373 unique joints (ankles, elbows, knees, metacarpophalangeal (MCP), metatarsophalangeal, proximal interphalangeal (PIP), shoulders, wrists) were injected; 531 Joints received a second injection, and 262 a third. Long-term efficacy was assessed by Kaplan-Meier plots of the joint injection survival (ie, the time between injection and renewed flare).

After 1 and 2 years, respectively, 62.3 % (95 % CI 58.1–66.9 %) and 55.5 % (51.1–60.3 %) of the joints injected at baseline had not relapsed. All joint areas had good 2-year joint injection survival, longest for the PIP joints: 73.7 % (79.4–95.3 %). 2-year joint injection survival was higher for first injections: 56.6 % (53.7–59.8 %) than for the second: 43.4 % (38.4–49.0 %) and the third: 31.3 % (25.0–39.3 %). Adverse events were mild and transient.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Näyttö injektioiden tehosta jäi epäsuoraksi, koska kontrollihoito puuttui.

In the same trial as no 1 «Hetland ML, Østergaard M, Ejbjerg B ym. Short- and...»1, American College of Rheumatology 20 % improvement (ACR20), ACR50 and ACR70 levels were achieved in 88 %, 79 % and 59 % of patients in the combination vs 72 %, 62 % and 54 % in the monotherapy group (p = 0.03, 0.02–0.6 between groups) «Hetland ML, Stengaard-Pedersen K, Junker P ym. Agg...»2. The patients globally declined from 50 to 12 vs 52 to 9, with 51 % and 50 % in Disease Activity Score (DAS) remission, respectively. Mean (SD) progressions in total Sharp-van der Heijde scores were minimal: 1.42 (3.52) and 2.03 (5.86) in combination and monotherapy groups, respectively.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Näyttö injektioiden tehosta jäi epäsuoraksi, koska kontrollihoito puuttui.

In the 5-year analysis «Hetland ML, Hørslev-Petersen K. The CIMESTRA study...»3 of the previous trial, the radiographic progression of hands and feet were examined. Radiographic progression in both groups was only < 1 TSS unit/year. After 1 and 2 years, 62 % and 56 % of the injected joints had not relapsed (both groups). Cumulated i.a. GC dose < 1 mg prednisolone/day. Treatments were well tolerated.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Näyttö injektioiden tehosta jäi epäsuoraksi, koska kontrollihoito puuttui.

In a study «Haugeberg G, Morton S, Emery P ym. Effect of intra...»4 performed in the UK, 19 patients with early rheumatoid arthritis (RA) received methotrexate (MTX) alone and 21 received MTX and intra-articular corticosteroid injections (IAST) injections into clinically inflamed joints in the first 3 months. In the following 9 months, all patients received MTX + IAST. Bone mineral density was assessed at the hand and periarticular regions at metacarpo-phalangeal (MCP) joints 2–5 at baseline, 3 and 12 months.

In the first 3 months a numerically lower percentage rate of bone loss was seen in MTX + IAST-treated patients compared with MTX-treated patients. This observation was more pronounced at the MCP periarticular regions (eg, partial proximal phalanges: digit 2, -0.45 % vs -2.69 %, p = 0.045; digit 3, -0.34 % vs -3.32 %, p = 0.003; digit 4, -0.39 % vs -2.57 %, p = 0.14; digit 5, -0.59 % vs -2.70 %, p = 0.24) than for the whole hand (-1.53 % vs -2.42 %, p = 0.32). In the 3–12 month period, only minor non-statistically significant differences were seen between the two groups.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: hyvä

Kommentti: Näytön astetta laskivat pieni aineisto, lyhyt seuranta ja toissijainen tulosmuuttuja.

Yleiskommentit

Suositus on vahva ruiskuttaa kortikoidia tulehtuneisiin niveliin, koska kortikoidi-injektiot tehoavat nopeasti oireisiin, hoito on turvallista ja halpaa.

Kirjallisuutta

  1. Hetland ML, Østergaard M, Ejbjerg B ym. Short- and long-term efficacy of intra-articular injections with betamethasone as part of a treat-to-target strategy in early rheumatoid arthritis: impact of joint area, repeated injections, MRI findings, anti-CCP, IgM-RF and CRP. Ann Rheum Dis 2012;71:851-6 «PMID: 22302316»PubMed
  2. Hetland ML, Stengaard-Pedersen K, Junker P ym. Aggressive combination therapy with intra-articular glucocorticoid injections and conventional disease-modifying anti-rheumatic drugs in early rheumatoid arthritis: second-year clinical and radiographic results from the CIMESTRA study. Ann Rheum Dis 2008;67:815-22 «PMID: 17878209»PubMed
  3. Hetland ML, Hørslev-Petersen K. The CIMESTRA study: intra-articular glucocorticosteroids and synthetic DMARDs in a treat-to-target strategy in early rheumatoid arhtritis. Clin Exp Rheumatol 2012;30:S44-9 «PMID: 23079125»PubMed
  4. Haugeberg G, Morton S, Emery P ym. Effect of intra-articular corticosteroid injections and inflammation on periarticular and generalised bone loss in early rheumatoid arthritis. Ann Rheum Dis 2011;70:184-7 «PMID: 20805297»PubMed