甲氨蝶呤联合环磷酰胺治疗强直性脊柱炎的临床与实验研究

【作者】 刘雅妮；

【导师】 张莉芸；

【作者基本信息】 山西医科大学 ， 内科学， 2008， 硕士

【摘要】 第一部分甲氨蝶呤联合环磷酰胺治疗强直性脊柱炎的临床研究目的:1.评价甲氨蝶呤(MTX)、环磷酰胺(CTX)及二者联合(MTX+CTX)治疗强直性脊柱炎(AS)的临床疗效和安全性;2.探讨该组治疗对AS达到临床疗效的预测因素。方法:1.进行一项为期24周的随机、对照、单中心、前瞻性临床研究。85例纳入研究的AS患者均符合1984年修订的纽约标准,并处于疾病活动期,随机接受MTX、CTX和MTX+CTX中的任何一种治疗方案。分别在试验的0、6、12、24周进行随访,以强直性脊柱炎疗效评价标准20反应(ASAS20)为主要疗效指标,Bath强直性脊柱炎疾病活动指数改善50%(BASDAI50)和ASAS40为次要疗效指标对各组病情进行评估,并分析具体指标的变化。2.在研究终点时对72例患者(包括完成疗效评估的61例、因不良反应退出研究的4例和研究过程中失访的7例)的安全性进行评估。3.临床试验完成后,以BASDAI50和ASAS40作为疗效指标,采用Logistic回归分析对完成试验的61例患者疗效影响因素进行探索性分析。结果:1.疗效评估结果:1)治疗6周后,各组有13.64%～32.00%的患者达到ASAS20改善。24周时MTX+CTX组达ASAS20改善的患者比例(73.91%)明显高于MTX(45.45%)及CTX组(25.00%),差异有统计学意义(P<0.01～0.05)。24周时MTX+CTX组达ASAS40改善的患者比例高于CTX组(P<0.05),与MTX组之间差异尚无统计学意义(P>0.05)。2)治疗24周后MTX组和MTX+CTX组各项评价除Bath强直性脊柱炎测量指数(BASMI)和扩胸度以外其它指标均低于基线水平(P<0.01～0.05),CTX组仍有肿胀关节指数、夜间痛和ESR与基线时相比差异未达到统计学意义(P>0.05);24周时比较不同治疗组间的改善程度,MTX+CTX组BASDAI、Bath强直性脊柱炎功能指数(BASFI)、夜间痛和肌腱末端指数(EI)的改善高于MTX组和CTX组(P<0.01～0.05),病人总体评估(PGA)、肿胀关节指数和血沉(ESR)的改善程度与MTX组接近(P>0.05),高于CTX组(P<0.01～0.05);各治疗组在BASMI和扩胸度两个指标的改善方面差别尚未达到统计学意义(P>0.05)。2.安全性评估结果:无严重不良事件发生。在各治疗组与药物直接相关的不良反应发生率分别为MTX组28.00%、CTX组22.73%、MTX+CTX组32.00%,差异无统计学意义(P>0.05)。胃肠道症状是各组最为常见的不良反应,在各组中的发生率为13.64%～24.00%。各组均有患者发生肝酶异常,发生率在13.64%～16.00%之间,丙氨酸转氨酶(ALT)升高均在正常值的2倍以内。其它不良事件包括白细胞减低、脱发、口腔溃疡、乏力等,各组间差异无统计学意义(P>0.05)。3.疗效影响因素分析结果:以24周时达到ASAS40和BASDAI50为疗效标准, Logistic多因素分析显示:所有参数均未显示能预测患者在经过治疗后达到BASDAI50和ASAS40疗效标准。结论:MTX+CTX联合治疗可以缓解AS的脊柱关节病变,改善症状,优于单用药;安全耐受性较好,与单用药相比,联合治疗并不增加不良反应的发生率;基线时的人口学参数、疾病活动性的临床和实验室指标不能预测疗效。第二部分甲氨蝶呤联合环磷酰胺治疗对AS患者血清IL-6、MMP-3的影响目的:通过检测AS患者血清中细胞因子白介素(IL)-6和基质金属蛋白酶(MMP)-3的表达水平及分析其与AS患者疾病活动的相关性,进一步研究MTX、CTX及两者联合治疗前后AS患者血清细胞因子IL-6和MMP-3的变化,探讨MTX+CTX发挥作用的可能机制。方法:分别在治疗0周、24周时留取本研究临床研究中34例AS患者(MTX组11例、CTX组11例、联合用药组12例)及10例正常健康对照者空腹血清,应用酶联免疫吸附试验(ELISA)测定IL-6和MMP-3水平。结果:1.ELISA方法检测34例AS患者治疗前血清IL-6、MMP-3,结果显示:AS患者血清IL-6水平高于正常人(P<0.01),MMP-3水平与正常对照之间差异无显著性(P=0.054)。2.进一步用ELISA方法检测各组AS患者经过治疗24周时血清IL-6、MMP-3,结果显示:24周时,MTX+CTX组IL-6水平显著下降(P=0.010),与MTX组和CTX组比较差异均有统计学意义(P<0.05);MTX+CTX组MMP-3水平与基线时比较差异有统计学意义(P<0.05)。3.相关分析显示:基线时IL-6水平与脊柱炎症及ESR显著相关(P<0.05),MMP-3水平BASDAI、BASMI及ESR显著相关(P<0.05)。结论:1.IL-6和MMP-3是AS发病机制中重要的细胞因子,与病情活动性相关。2.MTX联合CTX较单用药组更能降低患者血清IL-6和MMP-3水平,这可能是其发挥临床疗效的机制。更多还原

【Abstract】 Part I:Clinical study of Methotrexate plus Cyclophosphamide in Active Ankylosing SpondylitisObjective:1. To evaluate the efficacy and safety of methotrexate(MTX), cyclophosphamide(CTX) and MTX plus CTX in active ankylosing spondylitis (AS) of 24 weeks.2. To investigate the parameters predicting the clinical response to these treatment programs in AS.Methods:1. This was a randomized, controlled, monocentric, prospective clinical study lasting 24 weeks. 85 patients of active AS eligible for this study were to be adults with a diagnosis of definite AS, as defined by the 1984 Modified New York Criteria. They were randomized to receive a kind of treatment programs of MTX, CTX and MTX plus CTX. The primary efficacy end point was a response on the assessments in AS 20% response(ASAS20) at weeks 0, 6, 12, 24. The secondary end points were responses on the ASAS40 and 50% improvement of Bath AS disease activity index(BASDAI50) improvement criteria. The change of every assessed parameters were analysed.2. The safety of 72 patients of AS(including 61 patients finishing assessment of clinical efficacy, 4 patients withdrawing from treatment for adverse effects and 7 patients withdrawing for unknown reasons) were evaluated at 24 weeks.3. The parameters predicting the clinical response were analysed with ASAS40 and BASDAI50 as responder by Logistic regression likelihood ratio tests at 24 weeks.Rusults:1. Efficacy Results1) At week 6, 13.64%~32.00% of patients in three groups reached the primary end point of ASAS20. At week 24, the percent of patients achieving ASAS20 in the MTX plus CTX group were significantly higher than that of MTX or CTX group (P<0.01~0.05). The percent of patients achieving ASAS40 in the MTX plus CTX group were significantly higher than that of CTX group (P<0.05).2) The improvements at week 24 of Bath AS metrology index(BASMI) and chest expansion were not statistically significant. At week 24, the improvement of BASDAI, Bath AS functional index(BASFI), night pain scores and enthesis index(EI) in MTX plus CTX group were significantly higher than that of MTX or CTX group (P<0.01~0.05). While the improvement of patient’s assessment of pain, total arthritis swelling index and erythrocyte sedimentation rate(ESR) in MTX plus CTX group were significantly higher than that of CTX group (P<0.01～0.05). There was no statistical difference in the improvement of BASMI and chest expansion among three groups (P>0.05).2. Safety ResultsThere were no serious adverse events. In the MTX, CTX and MTX plus CTX groups, the incidence of treatment related adverse events was 28.00%, 22.73% and 32.00% respectively. There was no statistical difference among three groups (P>0.05). The most frequently occuring in three groups were gastrointestinal complaint. The secondary occuring was elevated liver enzyme levels. Most treatment-related adverse events were mild to moderate in severity. There was no statistical difference in all adverse events among three groups (P>0.05).3. Predicting Parameters Analysis Results Logistic regression analysis showed all of demographic parameters and baseline AS activity parameters were not evaluated at week 0 including ESR, disease duration etc were predictive of the degree of improvement.Conclusions:Combination therapy with MTX and low dose CTX resulted in significant improvement in patients with active AS. The efficacy of combination therapy was better than MTX or CTX monotherapy. It ? was also safe and well tolerated compared with monotherapy. All of demographic parameters and baseline AS activity parameters were not predictors of major clinical response to our therapy in active AS. Part II: Changes of IL-6 and MMP-3 in ankylosing spondylitis after treatment with Methotrexate plus CyclophosphamideObjectiveTo investigate the changes of serum interleukin(IL)-6 and matrix metalloproteinase(MMP)-3 level before and after MTX, CTX or MTX plus CTX treatments of ankylosing spondylitis(AS) and to explor their meaning in diseases activity and possible link to therapy response.MethodsPeripheral bloods were collected from 34 patients with AS who randomly received a kind of treatment programs of MTX, CTX or MTX plus CTX respectively and 10 healthy controls. Serum IL-6 level and MMP-3 level were measured before and after treatment by sandwich enzyme-linked immunosorbent assay(ELISA).Results1. Serum level of IL-6 and MMP-3 were detected by ELISA. IL-6 level increased obviously in AS (P<0.01) compared with healthy group and MMP-3 level was no statistical difference between AS and healthy group.2. IL-6 level was statistical difference between MTX plus CTX and monotherapy groups at 24 weeks(P=0.010). MMP-3 level decreased statistically after treatment with MTX plus CTX.3. Baseline serum IL-6 level showed correlation with inflammation and ESR. Baseline serum MMP-3 level showed correlation with AS disease activity index BASDAI, BASMI and ESR.Conclusion1. Serum IL-6 level and MMP-3 level had correlation with AS disease activity.2. The combination therapy of MTX and CTX can effectively cut down the IL-6 level and MMP-3 level in AS patients than monotherapy. This is likely to be a relevant mechanism for the clinical efficacy of this therapy.更多还原