發炎性腰背痛的臨床及標靶治療的最新發展

The Clinical Features and Targeting Therapy in Patients with Inflammatory Back Pain

周昌德(Chung-Tei Chou)

《內科學誌》 23卷5期 (2012/10) Pp. 313-317

https://doi.org/10.6314/JIMT.2012.23(5).01

摘要

脊椎關節炎（英文簡稱SpA）為一常見侵犯脊椎為主之發炎性疾病。此家族疾病包括僵直性脊椎炎（AS）、乾癬關節炎（PSA）、發炎性腸道疾病（IBD）、幼年型脊椎關節炎（Juvenile SpA）與無法區分之脊椎關節炎（USpA）。臨床上常出現之症狀為發炎性下背痛，不對稱下肢關節炎，肌腱附著點發炎、趾骨炎、虹彩炎等。發炎性下背痛為脊椎病變（Axial SpA）最初期症狀，此時使用核磁共振（MRI）可在薦腸骨及脊椎骨表現出骨髓內水腫（Bone marrow edema）。Axial SpA目前之診斷需藉助2009年Rudwaleit等人提出之診斷要件，其中包括X光或MRI及HLA-B27加上臨床症狀。其實早期診斷之主要目的為Axial SpA尚未出現X光之發炎破壞前，及早介入或積極治療，可將發炎降到最低。除了復健運動、藥物治療的第一線仍以非類固醇抗發炎藥物（NSAIDS）為主。如治療無效時，需使用抗腫瘤壞死因子抑制劑（anti-TNFa）。在台灣目前有三種可使用，最早使用為etanercept （Enbrel 恩博），其次為adalimumab（Humira復邁）及剛上市的golimumab（Simponi欣普尼）。Enbrel為receptor binding結合游離之TNFa，而Humira及Simponi為單株抗體可結合游離及細胞表面之TNFa。當anti-TNFa治療無效時，目前尚在研究包括anti-IL6R、anti-IL17或anti-CD20（如莫須瘤，rituximab）及anti-P40（Ustekinumab）等。未來須更進一步研發是否可抑制脊椎粘連之藥物，因為anti-TNFa可有效控制發炎，但尚無證據顯示可有效抑制骨贅形成。

關鍵字

脊椎關節炎 ； 脊椎病變 ； 發炎性下背痛 ； 脊椎病變之診斷 ； 治療

並列摘要

Spondyloarthritis (SpA) is a common rheumatic disease and SpA consists of a lot of diseases in this family which includes ankylosing spondylitis (AS), psoriatic arthritis (PSA), inflammatory bowel disease (IBD), juvenile SpA and undifferentiatied SpA (UsPA), etc. The common clinical features in SpA are inflammatory back pain, peripheral arthritis, enthesitis, dactylitis, and uveitis, etc. In order to define the axial SpA, ASAS group in 2009 proposed new classification criteria which included the sacroiliitis on either MRI or x-ray plus one of the SpA features. Without x-ray or MRI, axial SpA is considered if HLA-B27 is positive plus 2 of the SpA features. For management of axial SpA, except for physical therapy, non-steroid antiinflamatory drugs (NSAIDs) are still the first line remedy. Only 20% to 30% patients are failed, and they require anti-tumor necrosis factor (anti-TNFα) therapy. In Taiwan, 3 anti-TNFa drugs are available now; etnarcept (Enbrel) was the first drug to enter into the market and then adalimmumab (Humira) and the recent one was golimmumab (Simponi). The mechanism to remove soluble TNFα by using receptor binding is etanercept. Adalimmumab and golimmumab are monoclonal antibodies which can remove both soluble and membrane TNFα. When anti-TNFα fails, other drugs including anti-IL6R (tocilizmab), anti-CD20 (rituximab), anti-IL17 have been used but the efficacy, in general, was not satisfied. Other than anti-TNFα therapy in axial SpA, more new drugs either for anti-inflammation or for anti-syndesmophyte are warranted.

並列關鍵字

Spondyloarthritis ； Axial spondyloarthropathy ； Inflammatory back pain ； New classification criteria ； Treatment