一、类风湿关节炎的治疗策略

1.治疗的目标是控制症状、阻止损害，防止残疾和改善生活质量，即达到病情缓解（证据水IV，推荐力度A)，如不能达到，也应达最低病情活动度(证据水I，推荐力度A )。

2.在治疗前和制定治疗方案时应评估和考虑是否存在如下疾病预后不佳因素：RF阳性、抗CCP抗体阳性、功能受限、肿胀和关节数多、早期糜烂、关节外表现及ESR或CRP增高（II， B）。

3. 活动性类风湿关节炎患者应每1~3个月监测1次病情活动度（I，A），病情控制良好的患者监测间隔可拉长(IV,A)。

4.只要是治疗目标未达到，就应每3~6个月调整传统或生物制剂类DMARD治疗（I, IV；B）。

5.对于新发病例，应6~12个月拍一次手和足部X线片（II，B），而晚期患者则间隔可更长一些（IV,B）

6. 虽达临床缓解，但放射线仍进展的患者，应考虑调整治疗方案。

二、糖皮质激素治疗

7. 患者在如下情况可加用激素（口服、肌注或关节内）：初始治疗在DMARD治疗基础上（I）；病情加重、为等待DMARD发挥疗效而起桥梁作用；无其他药物选择，作为一种症状控制药（IV）。激素应使用最低有效剂量，尽可能快速减量（IV）

三、MTX/DMARD治疗

8.对于有持续滑膜炎的患者，DMARD应尽快加用（I,A）

9.MTX在疗效和安全性方面来说，是一种首选药，除非有禁忌证（I,A）

10.在开始MTX治疗前，应检查血常规（I）、肝功能（I）、肾功能（II）及胸片（II，B）。筛查乙型肝炎（III)及对高危患者筛查HIV（IV,D）。

11.MTX剂量应个体化（IV,A），口服或注射给药，并可快速增量，最高量可达25mg/w。对于口服MTX不能耐受或疗效不佳，应考虑注射用药(I,A)。

12.开始治疗应考虑传统DMARD联合治疗，尤其是有预后不佳因素、中重度病情活动及最近发作者。对于单一疗法疗效不佳者，也应联合治疗（I,B）

13.采用联合治疗时，MTX应作为“锚”药，除非有禁忌证。根据具体情况，联合方案中也可不包括MTX（I,A）

14.来氟米特与MTX的联合要谨慎，因毒性较高（胃肠道和肝脏毒性）（I）,与其他DMARD联合治疗相比，该联合疗法未带来更多的益处（IV）。

四、生物制剂治疗

15. 对DMARD疗效不佳应考虑用生物制剂：即至少采用2种正规剂量DMARD(包括MTX,除非有禁忌证)单独或联合治疗3个月无效的中高度病情活动者(IV,D)。

16.在开始用生物制剂前，应常规行实验室检查如血常规、肝肾功能、乙肝和丙肝筛查（高危患者行HIV筛查）。在用抗TNF、阿巴西普和妥珠单抗前，应筛查潜在结核。用抗TNF前应行基线ANA检查（IV,D）。

17.为获得更好的疗效，生物制剂应与MTX联合使用（I,A）

18.DMARD疗效不佳者可抗TNF治疗（I）。在个别情况下，当DMARD单一疗法失败或尚未用DMARD时，如存在DMARD禁忌证，且有病情高度活动和预后不佳因素（尤其是疾病早期），可选用抗TNF治疗（I,A）。

19. 对抗TNF或DMARD疗效不佳情况下，可用阿巴西普治疗（I,A）

20.对RF阳性的类风湿关节炎，用DMARD或抗TNF治疗疗效不佳情况下，可选用利妥昔单抗（I,A）

21. 再次用利妥昔单抗前，希望患者病情不出现活动（IV）。如患者用利妥昔单抗已获初步疗效，但尚存持续性滑膜炎，再次用可早至6个月。

22.对于DMARD或抗TNF治疗无效的类风湿关节炎，推荐用妥珠单抗（I,A）。

23.对于用一种抗TNF治疗无效或有毒性者，可选择如下方案：换为另一种TNF（I,II）；换为另一种作用机制不同的生物制剂（阿巴西普、利妥昔单抗、妥珠单抗）（I）；如仅用抗TNF单一治疗，可加MTX(或其他MDARD)（I,II,B）。

24.如对两种抗TNF治疗无效者，应改为其他作用机制不同的生物制剂（阿巴西普、利妥昔单抗、妥珠单抗）（II/IV,C）

25. 尚缺乏阿巴西普、利妥昔单抗或妥珠单抗无效者的治疗策略。可考虑如下选择：换为以前未使用过或失败过的任一种生物制剂；增加或换为以前未用过或失败过的传统DMARD；或入组新药临床试验（IV,D）。

26.停用NSAID和激素后，患者已获持续缓解，可谨慎减少传统和生物制剂DMARD（医生与患者共同商量决定）。

附原文：

一、General RA management strategies

1.The goal of treatment is remission and, when not possible, minimal disease activity (I) while controlling symptoms, halting damage, preventing disability, and improving quality of life (IV) （Level I, IV ；Strength A）

2.The presence of the following poor prognostic features should be assessed at baseline and considered when making treatment decisions: RF positivity, anti-CCP positivity, functional limitation, high number of swollen and tender joints, early erosions, extraarticular features, high ESR or CRP （II ， B）

3.RA care providers should monitor disease activity as frequently as every 1 to 3 months in patients with active RA (I). Patients with well controlled disease and patients in remission can be monitored at longer intervals (IV)（ I, IV；A）

4. Traditional and biologic DMARD therapy should be adjusted every 3–6 months, as long as the goal has not been achieved （I, IV；B）

5.Radiographs of the hands and feet are recommended as frequently as every 6–12 months in patients with recent-onset disease (II). Radiographs can be performed at longer intervals in patients with established disease (IV) （II, IV， B）

6.A change in therapy should be considered in patients with radiographic progression despite adequate clinical response（IV， D）

二、Treatment with glucocorticoids

7.Glucocorticoids (oral, intramuscular, or intraarticular) can be added to DMARD therapy as part of the initial treatment strategy of patients with RA (I), and may be an option for managing flares, as bridge therapy while waiting for DMARD to take effect, or for symptom control if no other options exist (IV). Glucocorticoids should be used in the lowest possible dose and tapered as rapidly as clinically feasible (IV)（ I, IV ，A/D）

三、Treatment with MTX/DMARD

8.In patients with persistent synovitis, DMARD should be introduced as soon as possible （I， A）

9.MTX is the preferred DMARD with respect to efficacy and safety and should be the first DMARD used in patients with RA unless contraindicated（I， A）

10.A complete blood count (II), liver (I) and renal biochemistry (II), and a chest radiograph (II) should be ordered prior to initiating MTX therapy. Screening for hepatitis B and C should be considered (III), and HIV testing is recommended in high-risk patients (IV)（ I–IV， B/D）

11.Dosing of MTX should be individualized to the patient (IV). MTX should be started oral or parenteral and titrated to a usual maximum dose of 25 mg/week by rapid dose escalation. In patients with an inadequate response or intolerance to oral MTX, parenteral administration should be considered (I) （I, IV； A）

12.Initial combination therapy with traditional DMARD should be considered, particularly in patients with poor prognostic features, moderate-high disease activity, and in patients with recent-onset disease. Combination therapy should also be considered in patients who have an inadequate response to monotherapy （I，B）

13.When treating with combination therapy, MTX should be used as the anchor drug unless contraindicated. Combinations not including MTX can be considered on a case-by-case basis （I,A)

14.Combination therapy with leflunomide and MTX should be used with caution as it is associated with higher toxicity (gastrointestinal and liver) (I) and has no added benefit relative to other DMARD combinations (IV)

（I, IV； A）

四、Treatment with biologics

15.In patients being considered for biologic therapy, an inadequate response to DMARD is defined as moderate to high disease activity despite treatment with at least 2 DMARD (including MTX unless contraindicated) in mono or combination therapy after 3 months at target dose（ IV， D）

16.Routine laboratory tests (complete blood count, liver and renal biochemistry) and screening for hepatitis B and C (and HIV in high-risk patients) are recommended prior to initiating all biologic therapy. Screening for latent tuberculosis is recommended prior to anti-TNF, abatacept, and tocilizumab. Baseline antinuclear antibody testing could be considered prior to starting anti-TNF（ IV， D

17.MTX coprescription with biologics is recommended for improved efficacy（I,A)

18.Anti-TNF therapy is recommended for treatment of patients with RA after an inadequate response to DMARD (I). In exceptional circumstances involving patients with DMARD contraindications or high disease activity and poor prognostic factors (particularly early disease), anti-TNF therapy may be an option after failure of DMARD monotherapy or in DMARD naive patients（I,A)

19.Abatacept is recommended for the treatment of patients with RA after inadequate response to DMARD or anti-TNF therapy（I,A)

20.Rituximab is recommended for the treatment of patients with RF-positive RA after an inadequate response to DMARD or anti-TNF therapy （I,A)

21.Patients should not be expected to flare before they are retreated with rituximab (IV). Retreatment can occur as early as 6 months if the patient has had an initial response but has persistent synovitis (II) （II, IV；C）

22.Tocilizumab is recommended for the treatment of patients with RA after inadequate response to DMARD or anti-TNF therapy（I,A)

23.In patients who have failed treatment with 1 anti-TNF due to lack of efficacy or toxicity the following options are recommended: switch to another anti-TNF (I, II), switch to another biologic with a different mechanism of action (abatacept, rituximab, tocilizumab) (I), or add MTX (or other DMARD) if anti-TNF was used in monotherapy (II)（ I, II； B）

24.In patients who have failed treatment with 2 anti-TNF a switch to another biologic with a different mechanism of action (abatacept, rituximab, tocilizumab)) is recommended （II/IV，C)

25.In the absence of data on therapeutic strategies after failure of abatacept, rituximab, or tocilizumab the following options can be considered: switch to any biologic not previously tried and failed, add or switch to a traditional DMARD not previously tried and failed, or enroll the patient in a clinical trial with a new agent（IV,D)

26.If a patient achieves sustained remission after discontinuation of NSAID and glucocorticoids, a reduction in traditional and biologic DMARD can be attempted with caution as a shared decision between the patient and physician（IV,D)

引自：Bykerk VP, Akhavan P, Hazlewood GS, et al.Canadian Rheumatology Association recommendations for pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs. J Rheumatol ,2012,39(8):1559-82