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DOI: 10.1055/s-0029-1220906
© Georg Thieme Verlag KG Stuttgart · New York
Aktualisiertes Therapieschema der Rheumatoiden Arthritis. Ergebnisse eines Konsensusprozesses deutscher Rheumatologen 2009
Recommendations for the Treatment of Rheumatoid Arthritis. Results from a German Consensus Conferenence: Update 2009Publication History
Publication Date:
07 May 2009 (online)
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Zusammenfassung
Das Therapieziel bei der Behandlung von Patienten mit neu diagnostizierter Rheumatoider Arthritis (RA) heisst heute komplette Remission. Dies bedeutet nicht nur eine Reduktion der klinischen Krankheitsaktivität auf einen DAS28 kleiner 2,6, sondern auch den Ausschluss einer klinisch stummen Restsynovitits und/oder radiologischen Progredienz von Erosionen durch Sonografie bzw. MRT. Wir berichten über einen Konsensusprozess deutscher Rheumatologen mit dem Ziel, ein praktisch einsetzbares Update für einen Therapiealgoritmus bei RA zu geben. Methotrexat bleibt danach das Primärtherapeutikum. Bei unzureichendem Effekt kann auf Leflunomid gewechselt oder eine Kombination vom Methotrexat mit konventionellen Basistherapeutika angewendet werden. Partielle Responder auf eine konventionelle Basistherapie sollten einen TNF-Antagonisten (Adalimumab, Etanercept, Infliximab; in Kürze auch Golimumab bzw. Certolizumab-Pegol). Bei unzureichendem Ansprechen auf einen TNF-Blocker kommen grundsätzlich vier Möglichkeiten in Frage: Einsatz eines zweiten TNF-Blockers (z. B. bei sog. Sekundärversagen) oder Wechsel auf den Anti-Interleukin6-Antagonisten Tozilizumab, den B-Zell Inhibitor Rituximab oder den Inhibitor der T-Zell-Kostimulation Abatacept. Die Auswahl der Therapeutika hängt von zahlreichen Einzelfaktoren ab und ist durch den Rheumatologen daher stets individuell gesteuert. Bei längerfristiger Remission sollte eine De-Eskalalation der Therapie erwogen werden.
Abstract
The aim of treatment for newly diagnosed rheumatoid arthritis (RA) is to achieve a complete remission, which means not only a reduction of disease activity (DAS28) below 2.6, but also the absence of clinically silent synovitis and/or radiographic progression as shown by negative ultrasound or MRI. We report the results of a consensus process towards an update of the practical recommendations for the treatment of rheumatoid arthritis. Methotrexate remains the anchor drug and should be used as monotherapy or in a DMARD combination, for example, with Leflunomide. Partial responders should then receive one of the available TNF antagonists, i. e., adalimumab, etanercept or infliximab. In the near future, further TNF antibodies (golimumab and certolizumab-pegol) will become available. For patients exhibiting an inadequate response to a TNF blocker, four options are available: the use of a second TNF antagonist (especially in patients with a loss of the initial response), or a switch to one of three other modes of action: the anti-interleukin-6-antagonist tozilizumab, the anti-CD20 B-cell inhibitor rituximab, or the inhibitor of T-cell costimulation abatacept, respectively. Individual factors are taken into consideration to help to decide upon a treatment escalation. In patients with long-standing remission, a step-down approach should be considered.
Schlüsselwörter
rheumatoide Arthritis - Therapie - Basistherapie - Biologicals
Key words
rheumatoid arthritis - therapy - biologicals - recommendations - consensus
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Korrespondenzadresse
Prof. Jürgen Wollenhaupt
Schön-Klinik Hamburg-Eilbek
Abteilung Rheumatologie und klinische Immunologie
Dehnhaide 120
22081 Hamburg
Phone: +49/40/2092 13 51
Fax: +49/40/2092 13 50
Email: wollenhaupt@rheumatologikum.de