Biologickou l\u00e9\u010dbu dost\u00e1v\u00e1 v \u010cesku odhadem jen pouh\u00fdch p\u011bt procent pacient\u016f s revmatoidn\u00ed artritidou. Ve vysp\u011bl\u00fdch zem\u00edch je ov\u0161em po\u010det takto l\u00e9\u010den\u00fdch dvakr\u00e1t a\u017e p\u011btkr\u00e1t vy\u0161\u0161\u00ed.<\/p>\n
„Biologick\u00e1 l\u00e9\u010dba by m\u011bla b\u00fdt nasazena v\u017edy, pokud nen\u00ed onemocn\u011bn\u00ed kontrolov\u00e1no st\u00e1vaj\u00edc\u00ed l\u00e9\u010dbou,“ upozor\u0148uje profesor MUDr. Ladislav \u0160enolt, Ph. D., \u010dlen v\u00fdboru \u010cesk\u00e9 revmatologick\u00e9 spole\u010dnosti (\u010cRS) \u010cLS JEP, kter\u00e1 pr\u00e1v\u011b p\u0159ipravuje nov\u00e9 doporu\u010den\u00e9 postupy pro l\u00e9\u010dbu t\u00e9to choroby. <\/p>\n
– V \u010dem se chystan\u00e1 doporu\u010den\u00ed \u010cRS pro l\u00e9\u010dbu revmatoidn\u00ed artritidy nejv\u00edc li\u0161\u00ed od t\u011bch p\u0159edchoz\u00edch? <\/p>\n
Asi nejd\u016fle\u017eit\u011bj\u0161\u00edm rozd\u00edlem je fakt, \u017ee v minul\u00fdch doporu\u010den\u00edch bylo nasazen\u00ed biologick\u00fdch l\u00e9k\u016f podm\u00edn\u011bno aktivitou onemocn\u011bn\u00ed podle kompozitn\u00edho indexu DAS28 ( 3,9), p\u0159i\u010dem\u017e v sou\u010dasn\u00e9 dob\u011b jsme v souladu s Evropskou ligou proti revmatismu (EULAR) specifikovali pro nasazen\u00ed biologick\u00e9 l\u00e9\u010dby st\u0159edn\u00ed a vysokou aktivitu nemoci. Existuje v\u00edce index\u016f aktivity revmatoidn\u00ed artritidy posuzovat; p\u0159i pou\u017eit\u00ed indexu DAS28 je pak prahem pro mo\u017en\u00e9 nasazen\u00ed biologick\u00e9 l\u00e9\u010dby ji\u017e hodnota 3,2. Z\u00e1sadn\u00ed d\u016fraz doporu\u010den\u00ed je tak\u00e9 kladen na v\u010dasnou diagnostiku, okam\u017eit\u00e9 zah\u00e1jen\u00ed terapie a uplat\u0148ov\u00e1n\u00ed princip\u016f l\u00e9\u010dby k c\u00edli ve snaze navodit remisi, nebo alespo\u0148 n\u00edzkou aktivitu nemoci. Pro klinickou praxi je nejlep\u0161\u00edm ukazatelem dlouhodob\u011b dobr\u00e9 odpov\u011bdi v\u00fdznamn\u00e9 zlep\u0161en\u00ed aktivity, co\u017e p\u0159edstavuje v\u00edce ne\u017e pades\u00e1tiprocentn\u00ed \u00falevu od p\u0159\u00edznak\u016f nemoci, v kr\u00e1tk\u00e9m \u010dasov\u00e9m intervalu po zah\u00e1jen\u00ed l\u00e9\u010dby, obvykle ji\u017e po t\u0159ech m\u011bs\u00edc\u00edch l\u00e9\u010dby. Pokud nenastane \u017e\u00e1dn\u00e9 zlep\u0161en\u00ed po t\u0159ech m\u011bs\u00edc\u00edch intenzivn\u00ed l\u00e9\u010dby nebo nen\u00ed dosa\u017eeno l\u00e9\u010debn\u00e9ho c\u00edle po \u0161esti m\u011bs\u00edc\u00edch, je nutn\u00e9 l\u00e9\u010dbu upravit. V p\u0159\u00edpad\u011b nep\u0159\u00edzniv\u00fdch prognostick\u00fdch faktor\u016f (erozivn\u00ed posti\u017een\u00ed, z\u00e1n\u011bt, autoprotil\u00e1tky) je t\u0159eba p\u0159idat biologickou l\u00e9\u010dbu. <\/p>\n
– M\u016f\u017eete up\u0159esnit, kdy a za jak\u00fdch podm\u00ednek pova\u017eujete za \u00fa\u010dinn\u00e9, aby byla nasazena biologick\u00e1 l\u00e9\u010dba? <\/p>\n
Sou\u010dasn\u00e9 znalosti ukazuj\u00ed, \u017ee nen\u00ed velk\u00fd rozd\u00edl mezi \u00fa\u010dinnost\u00ed l\u00e9\u010dby a dal\u0161\u00edm pr\u016fb\u011bhem onemocn\u011bn\u00ed, pokud je biologick\u00e1 l\u00e9\u010dba pod\u00e1na s ur\u010dit\u00fdm odstupem, pravd\u011bpodobn\u011b ne d\u00e9le ne\u017e \u0161est m\u011bs\u00edc\u016f, po selh\u00e1n\u00ed intenzivn\u00ed l\u00e9\u010dby metotrex\u00e1tem (MTX) proti stavu, kdy je biologick\u00e1 l\u00e9\u010dba p\u0159id\u00e1na k MTX inici\u00e1ln\u011b. Existuje v\u0161ak ur\u010dit\u00e1 mo\u017enost, tzv. okno p\u0159\u00edle\u017eitosti, je\u017e trv\u00e1 asi do t\u0159\u00ed m\u011bs\u00edc\u016f od za\u010d\u00e1tku nemoci, kdy lze p\u0159i v\u010dasn\u00e9 a intenzivn\u00ed l\u00e9\u010db\u011b navodit setrval\u00fd stav remise, kter\u00fd nevy\u017eaduje dal\u0161\u00ed farmakologickou l\u00e9\u010dbu. Tohoto stavu lze v\u0161ak doc\u00edlit u naprost\u00e9 men\u0161iny pacient\u016f. Na druh\u00e9 stran\u011b je u revmatoidn\u00ed artritidy p\u0159i v\u010dasn\u00e9m zah\u00e1jen\u00ed a pokra\u010dov\u00e1n\u00ed konven\u010dn\u00ed l\u00e9\u010dby dosa\u017eeno remise a\u017e u 50 procent pacient\u016f. Biologick\u00e1 l\u00e9\u010dba by m\u011bla b\u00fdt nasazena v\u017edy, pokud nen\u00ed onemocn\u011bn\u00ed kontrolov\u00e1no st\u00e1vaj\u00edc\u00ed l\u00e9\u010dbou, pokud nap\u0159. po t\u0159ech m\u011bs\u00edc\u00edch intenzivn\u00ed l\u00e9\u010dby st\u00e1le p\u0159etrv\u00e1v\u00e1 vysok\u00e1 aktivita nemoci nebo pokud po \u0161esti m\u011bs\u00edc\u00edch nen\u00ed dosa\u017eeno c\u00edle l\u00e9\u010dby, tj. remise nebo n\u00edzk\u00e9 aktivity nemoci. Biologick\u00e1 l\u00e9\u010dba je prokazateln\u011b \u00fa\u010dinn\u011bj\u0161\u00ed v kombinaci s MTX, a proto by v\u0161echny biologick\u00e9 l\u00e9ky m\u011bly b\u00fdt pod\u00e1v\u00e1ny v kombinaci s MTX, p\u0159\u00edpadn\u011b jin\u00fdm konven\u010dn\u00edm syntetick\u00fdm DMARD. <\/p>\n
– Jak\u00fd je nyn\u00ed v \u010cesku po\u010det lid\u00ed s RA na biologick\u00e9 l\u00e9\u010db\u011b, kolik lid\u00ed by z n\u00ed m\u011blo u\u017eitek a jak\u00e1 je v \u010cesku situace ve srovn\u00e1n\u00ed s vysp\u011bl\u00fdmi zdravotnick\u00fdmi syst\u00e9my? <\/p>\n
To se velmi obt\u00ed\u017en\u011b odhaduje, v \u010cR chyb\u011bj\u00ed p\u0159esn\u00e9 \u00fadaje o prevalenci revmatoidn\u00ed artritidy. Pohybuje se v rozmez\u00ed p\u016fl procenta a\u017e jedno procento, z \u010deho\u017e lze odvodit, \u017ee na biologick\u00e9 l\u00e9\u010db\u011b v na\u0161\u00ed republice je p\u0159ibli\u017en\u011b p\u011bt procent jedinc\u016f. Ve vysp\u011bl\u00fdch zem\u00edch p\u0159edstavuje pod\u00edl pacient\u016f s revmatoidn\u00ed artritidou na biologick\u00e9 l\u00e9\u010db\u011b 10 a\u017e 25 procent. <\/p>\n
– Li\u0161\u00ed se va\u0161e doporu\u010den\u00ed pro biologickou l\u00e9\u010dbu od preskrip\u010dn\u00edch omezen\u00ed S\u00daKL a lze s t\u00edm n\u011bco d\u011blat? <\/p>\n
Bohu\u017eel ano, preskrip\u010dn\u00ed omezen\u00ed S\u00daKL je stanoveno dlouhodob\u011b na hodnotu indexu DAS28 5,1 a v\u00fd\u0161e, co\u017e p\u0159edstavuje vysoce aktivn\u00ed pr\u016fb\u011bh nemoci. Ji\u017e doporu\u010den\u00e9 postupy \u010cesk\u00e9 revmatologick\u00e9 spole\u010dnosti pro l\u00e9\u010dbu revmatoidn\u00ed artritidy z roku 2010 m\u011bly prahovou hodnotu pro nasazen\u00ed biologick\u00e9 l\u00e9\u010dby DAS28 3,9. P\u0159i formulov\u00e1n\u00ed doporu\u010den\u00fdch postup\u016f vych\u00e1z\u00edme z \u010desk\u00fdch doporu\u010den\u00ed z roku 2010, z nov\u00fdch doporu\u010den\u00ed EULAR a Americk\u00e9 revmatologick\u00e9 asociace (ACR). <\/p>\n
– Jak definujete spolupr\u00e1ci s pacienty? <\/p>\n
Ka\u017ed\u00e9ho nemocn\u00e9ho je t\u0159eba hned zpo\u010d\u00e1tku dostate\u010dn\u011b pou\u010dit o charakteru onemocn\u011bn\u00ed, c\u00edlech l\u00e9\u010dby a o p\u0159\u00ednosu i mo\u017en\u00fdch rizic\u00edch l\u00e9\u010debn\u00fdch postup\u016f. Terapeutick\u00e1 rozhodnut\u00ed maj\u00ed b\u00fdt v\u00fdsledkem sd\u00edlen\u00e9ho rozhodov\u00e1n\u00ed mezi l\u00e9ka\u0159em a pacientem a m\u011bla by respektovat pacientovy preference a hodnoty. I proto p\u0159izveme pacienty k z\u00e1v\u011bre\u010dn\u00e9 diskusi nad nov\u011b formulovan\u00fdmi doporu\u010den\u00fdmi postupy pro l\u00e9\u010dbu revmatoidn\u00ed artritidy. <\/p>\n
– Z\u016fst\u00e1v\u00e1 princip l\u00e9\u010dby stejn\u00fd? <\/p>\n
Ano, z\u00e1kladem l\u00e9\u010dby je farmakoterapie a p\u0159i zah\u00e1jen\u00ed l\u00e9\u010dby by m\u011bl b\u00fdt nasazen konven\u010dn\u00ed syntetick\u00fd chorobu modifikuj\u00edc\u00ed l\u00e9k, preferen\u010dn\u011b MTX, u aktivn\u00edho onemocn\u011bn\u00ed zpravidla v kombinaci s kr\u00e1tkodobou l\u00e9\u010dbou glukokortikoidy. C\u00edlem l\u00e9\u010dby je remise, nebo alespo\u0148 n\u00edzk\u00e1 aktivita, a pokud nen\u00ed tohoto stavu dosa\u017eeno, je doporu\u010deno do kombinace p\u0159idat biologickou l\u00e9\u010dbu. <\/p>\n
– M\u011bn\u00ed se re\u017eim u pod\u00e1v\u00e1n\u00ed glukokortikoid\u016f? <\/p>\n
Existuje \u0159ada d\u016fkaz\u016f, \u017ee racion\u00e1ln\u011b veden\u00e1 l\u00e9\u010dba glukokortikoidy m\u016f\u017ee m\u00edt u pacient\u016f s RA \u0159adu p\u0159\u00edzniv\u00fdch \u00fa\u010dink\u016f, jako je zlep\u0161en\u00ed kontroly nad z\u00e1n\u011btlivou aktivitou onemocn\u011bn\u00ed a zpomalen\u00ed struktur\u00e1ln\u00ed progrese, nicm\u00e9n\u011b jejich dlouhodob\u00e9 u\u017e\u00edv\u00e1n\u00ed vede k \u0159ad\u011b ne\u017e\u00e1douc\u00edch \u00fa\u010dink\u016f. Ve vymezen\u00fdch situac\u00edch ale jejich pou\u017eit\u00ed doporu\u010dujeme. V sou\u010dasn\u00e9 dob\u011b je doporu\u010dov\u00e1na kr\u00e1tkodob\u00e1, nap\u0159. t\u0159i a\u017e \u0161est m\u011bs\u00edc\u016f trvaj\u00edc\u00ed l\u00e9\u010dba glukokortikoidy v pr\u016fb\u011bhu aktivn\u00ed f\u00e1ze na za\u010d\u00e1tku onemocn\u011bn\u00ed, na krat\u0161\u00ed dobu lze tak\u00e9 vyu\u017e\u00edt kortikoterapii p\u0159i zm\u011bn\u011b l\u00e9\u010dby z d\u016fvodu ne\u00fa\u010dinnosti t\u00e9 st\u00e1vaj\u00edc\u00ed. U pacient\u016f s etablovanou nemoc\u00ed na chronick\u00e9 l\u00e9\u010db\u011b glukokortikoidy je nezbytn\u00e9, aby byla p\u0159i zachov\u00e1n\u00ed \u00fa\u010dinnosti d\u00e1vka p\u0159\u00edpravku co nejni\u017e\u0161\u00ed. V praxi lze \u010dasto vyu\u017e\u00edt i d\u00e1vky ni\u017e\u0161\u00ed ne\u017e 5 mg prednisonu, kter\u00e9 jsou u n\u011bkter\u00fdch pacient\u016f dosta\u010duj\u00edc\u00ed k udr\u017een\u00ed klinick\u00e9 remise nebo n\u00edzk\u00e9 aktivity, a to za cenu men\u0161\u00edho rizika ne\u017e\u00e1douc\u00edch \u00fa\u010dink\u016f. <\/p>\n
– O\u010dek\u00e1v\u00e1te p\u0159\u00edchod nov\u00e9ho l\u00e9ku pro l\u00e9\u010dbu RA a kdy? V \u010dem m\u00e1 spo\u010d\u00edvat jeho p\u0159\u00ednos? <\/p>\n
Ano, v roce 2017 by m\u011bly roz\u0161\u00ed\u0159it l\u00e9\u010debn\u00e9 mo\u017enosti nov\u00e9 l\u00e9ky, je\u017e pat\u0159\u00ed do skupiny tzv. c\u00edlen\u00fdch syntetick\u00fdch p\u0159\u00edpravk\u016f. Jedn\u00e1 se o inhibitory Janus kin\u00e1zy, l\u00e9ky blokuj\u00edc\u00ed nitrobun\u011b\u010dn\u00e9 signalizace, kter\u00e9 navozuj\u00ed zv\u00fd\u0161enou z\u00e1n\u011btlivou aktivitu. Jejich \u00fa\u010dinnost je podobn\u00e1 biologick\u00e9 terapii, dokonce jsou \u00fa\u010dinn\u00e9, i pokud jsou pod\u00e1v\u00e1ny samostatn\u011b, tj. bez MTX, a nespornou v\u00fdhodou m\u016f\u017ee b\u00fdt jejich peror\u00e1ln\u00ed pod\u00e1v\u00e1n\u00ed. <\/p>\n
– Musej\u00ed v\u0161ichni pacienti u\u017e\u00edvat l\u00e9ky do\u017eivotn\u011b? <\/p>\n
Ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f ano, pouze u mal\u00e9ho po\u010dtu pacient\u016f (asi deset procent) m\u016f\u017ee b\u00fdt terapie zcela ukon\u010dena, ani\u017e by do\u0161lo ke vzplanut\u00ed choroby. Nicm\u00e9n\u011b u pacient\u016f v dlouhodob\u00e9 remisi je vhodn\u011bj\u0161\u00ed redukovat d\u00e1vky l\u00e9k\u016f. O redukci l\u00e9\u010dby by se m\u011blo za\u010d\u00edt uva\u017eovat u pacient\u016f, kte\u0159\u00ed spl\u0148uj\u00ed krit\u00e9ria remise po dobu \u0161esti m\u011bs\u00edc\u016f. Jako prvn\u00ed z l\u00e9k\u016f by m\u011bly b\u00fdt vysazeny glukokortikoidy, a to z d\u016fvodu jejich ne\u017e\u00e1douc\u00edch \u00fa\u010dink\u016f. N\u00e1sledovat m\u016f\u017ee redukce d\u00e1vek nebo prodlou\u017een\u00ed d\u00e1vkovac\u00edho intervalu biologick\u00e9ho l\u00e9ku, eventu\u00e1ln\u011b jeho \u00fapln\u00e9 vysazen\u00ed. Udr\u017een\u00ed remise nebo n\u00edzk\u00e9 aktivity po \u00fapln\u00e9m vysazen\u00ed biologick\u00e9ho l\u00e9ku je pravd\u011bpodobn\u011bj\u0161\u00ed u \u010dasn\u00e9 RA. Redukce d\u00e1vky syntetick\u00e9ho DMARD (nap\u0159. MTX) se prov\u00e1d\u00ed a\u017e jako posledn\u00ed. Poznatky o d\u016fsledc\u00edch redukce d\u00e1vek \u010di \u00fapln\u00e9ho p\u0159eru\u0161en\u00ed l\u00e9\u010dby syntetick\u00fdmi DMARD jsou omezen\u00e9. P\u0159edev\u0161\u00edm u pacient\u016f s d\u00e9letrvaj\u00edc\u00edm onemocn\u011bn\u00edm je \u0161ance na udr\u017een\u00ed dlouhodob\u00e9 remise bez l\u00e9\u010dby konven\u010dn\u00edmi syntetick\u00fdmi DMARD mal\u00e1.<\/p>\n
Medical Tribune<\/p>\n","protected":false},"excerpt":{"rendered":"
Biologickou l\u00e9\u010dbu dost\u00e1v\u00e1 v \u010cesku odhadem jen pouh\u00fdch p\u011bt procent pacient\u016f s revmatoidn\u00ed artritidou. Ve vysp\u011bl\u00fdch zem\u00edch je ov\u0161em po\u010det takto l\u00e9\u010den\u00fdch dvakr\u00e1t a\u017e p\u011btkr\u00e1t […]<\/a><\/p>\n<\/div>","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[],"class_list":["post-27084","post","type-post","status-publish","format-standard","hentry","category-zpravy"],"_links":{"self":[{"href":"https:\/\/www.invarena.cz\/index.php?rest_route=\/wp\/v2\/posts\/27084","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.invarena.cz\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.invarena.cz\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.invarena.cz\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.invarena.cz\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=27084"}],"version-history":[{"count":0,"href":"https:\/\/www.invarena.cz\/index.php?rest_route=\/wp\/v2\/posts\/27084\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.invarena.cz\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=27084"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.invarena.cz\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=27084"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.invarena.cz\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=27084"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}