中轴脊柱关节炎诊疗进展专家讲座.pptx

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level,中轴脊柱关节炎诊疗进展,中轴脊柱关节炎诊疗进展,第1页,内容,中轴脊柱关节炎（,axSpA,）疾病负担,疾病活动度监测在,axSpA,目标治疗中意义,axSpA,预后原因研究进展,中轴脊柱关节炎诊疗进展,第2页,axSpA,自然病程,中轴脊柱关节炎诊疗进展,第3页,中轴脊柱关节炎诊疗进展,第4页,AS,和,nr-axSpA,：同一症候群或不一样疾病？,ESPERANZA,队列研究,研究目标：,在早期疾病队列中，描述和比较满足,ASAS,标准,nr-axSpA,和,AS,患者特征；并对两组,axSpA,患者（临床、影像学）特征进行比较。,研究方法和结果：,EsPeranza,队列：,45,岁,以下症状连续,3-24,个月：炎症性背痛,(IBP),或非对称性关节炎或脊柱,/,关节痛，伴,1,个,SpA,特征,满足,ASAS axSpA,标准患者,N=291,筛选,两组人口统计学和临床特征，疾病活动指数,BASDAI,，,CRP,，,BASMI,和,BASFI,比较,影像学诊疗组,N=194(67%),，,(44%axSpA-nr,及,56%EA),临床诊疗组,N=97(33%),AS,组更高：男性百分比，医生评价,VAS,，,BASMI,nr-axSpA,组更高：腹泻,/,泌尿生殖系统症状,AS,和,nr-axSpA,疼痛，,CRP,，疾病活动度，功效状态水平相当,影像学诊疗组患者生理功效障碍较多,Hernandez-Sanz A,et al.Presented at EULAR.THU0066,中轴脊柱关节炎诊疗进展,第5页,nr-axSpA,与,AS,在疾病早期临床特征类似，,AS,患者更多见男性及活动受限,临床诊疗组N=97(33%),影像学诊疗组 N=194(67%),P,值,(,临床,vs,影像,),整体,nr-axSpA,AS(N=109),P,值,(nr-axSpA VS,as,）,男性,64(66.0),127(65.5),46(54.1),81(74.3),0.01,0.9,外周关节炎,25(25.8),28(14.4),9(10.6),19(17.4),0.2,0.02,起止点炎,36(37.1),21(10.8),11(12.9),10(9.2),0.4,0.001,指,/,趾炎,10(10.3),6(3.1),2(2.4),4(3.7),0.6,0.01,眼葡萄膜炎,12(12.4),11(5.7),4(4.7),7(6.4),0.6,0.046,腹泻、宫颈炎、尿道炎,8(8.2),3(1.5),3(3.5),0,0.048,0.01,家族史,45(46.4),56(28.9),25(29.4),31(28.4),0.8,0.01,HLA-B27,97(100),122(62.9),49(58.3),73(67.6),0.2,0.001,CRP(mg/L),10.916.4,10.814.6,9.813.8,11.515.3,0.4,0.9,VAS(0-10),医生评价,2.52.1,3.12.2,2.72.1,3.42.2,0.047,0.5,VAS(0-10),患者评价,4.12.6,4.22.7,4.32.9,4.12.6,0.7,0.5,BASDAI,3.82.2,3.82.3,3.72.1,4.02.4,0.4,0.8,BASFI,2.02.0,2.52.4,2.32.4,2.72.5,0.3,0.02,BASMI,1.21.0,1.61.3,1.21.2,1.81.4,0.01,0.1,Hernandez-Sanz A,et al.Presented at EULAR.THU0066,中轴脊柱关节炎诊疗进展,第6页,nr-axSpA,疾病活动度与,AS,相当,GESPIC,和,Kiltz,为登记研究；,ATLAS,、,ABILITY-1,和,Haibel,为临床,RCT,入组标准对疾病活动度有要求,1.Rudwaleit.Arthritis Rheum.:60(3)717-27.2.Kiltz et al.FRI0529.3.van der Heijde et al.Arthritis Rheum.;54(7):2136-46.4.Sieper et al.ACR.Tues2486A.5.Haibel et al.Arthritis Rheum.;58(7):1981-91.,GESPIC,1,Kiltz,2,ATLAS,3,ABILITY-1,4,Haibel,5,中轴脊柱关节炎诊疗进展,第7页,Jacobsson LT,et al.EULAR,Paris,#THU0096,中轴脊柱关节炎诊疗进展,第8页,nr-axSpA,和,AS,患者,2,年内临床疾病进程类似,GESPIC,队列研究,Poddubnyy D,et al.Presented at EULAR.THU0071,分析德国脊柱炎起始队列,(GESPIC)188,名,axSpA,患者（,90 nr-axSpA,，,98 AS,）,2,年内疾病负担及病情进展；,2,年内允许接收,NSAIDs,治疗（,NSAIDs,评分：,33.728.0 vs 34.228.4,，,P=0.9,），剔除接收,TNFi,治疗者；,nr-axSpA,和,AS,在,2,年内疾病进程类似（,NSAIDs,治疗）,AS,高,CRP,和较差脊柱活动度提醒更高炎症和更严重结构破坏,中轴脊柱关节炎诊疗进展,第9页,早期,axSpA,疾病活动度和工作能力、生活质量相关：,SPACE,队列研究,研究目标：,在早期,axSpA,患者中，评定疾病活动度和工作能力、健康相关生 活质量,(HRQoL),关联研究方法：,SPACE(N=345),队列：慢性背痛,(3,个月,2,年，起病,45,岁,),满足,ASAS,标准,axSpA,患者,(n=131),筛选,评定,ASDAS,、,BASDAI,BASFI,SF-36,WPAI,ASDAS3.5,极高度活动,评定,Roeterink A,et al.Presented at EULAR.FRI0109,中轴脊柱关节炎诊疗进展,第10页,高疾病活动度影响早期,axSpA,患者生活质量,及工作能力,*：,P,0.001,；*：,P=0.02,；*：,P=0.97,PCS,：（,SF-36,中）躯体组分评分；,MCS,：（,SF-36,中）情感组分评分；,WPAI,：工作效率和活动损害调研,PCS,和,MCS,在普通人群中平均值：,5010,平均,PCS,和,MCS,得分,平均工作效率障碍,(%),*,*,*,*,*,普通人群平均值,*,*,*,*,*,*,*,*,*,*,ASDAS,*,*,Roeterink A,et al.Presented at EULAR.FRI0109,*,*,*,-2SD,ASDAS,临床缓解应作为早期,axSpA,治疗目标,中轴脊柱关节炎诊疗进展,第11页,大规模队列研究，,axSpA,和慢性下背痛患者,工作能力差异,研究目标：,评定,axSpA(AS,和,nr-axSpA),和非特异性慢性下背部痛（,CLBP,）患者工作能力差异,CaFaSpA 2,横截面研究，纳入,579,名,18-45,岁,CLBP,患者，,采取,ASAS,分类标准，评定伎俩：,Roland Morris,功效障碍调查表,(RMDQ),，,BASDAI,和,ASDAS,，,WPAI,Van Hoeven L,et al.Presented at EULAR.THU0097,AS,(n=24),nr-axSpA,(n=71),CLBP,(n=484),男性,no.(%),6(25%),30(42%),202(42%),年纪,38.6 5.8,36.8 6.6,37.3 6.5,下背部疼痛连续时间 (年),9.3 9.9,96 7.4,9.2 7.7,RMDQ,11.1 6.8,7.0 5.3,8.0 6.1,BASDAI,4.9 2.1,3.9 2.1,4.2 2.3,ASDAS,2.8 0.9,2.2 0.8,2.3 0.9,中轴脊柱关节炎诊疗进展,第12页,AS,较,nr-axSpA,和,CLBP,缺勤率和带病出勤率更高,Van Hoeven L,et al.Presented at EULAR.THU0097,中轴脊柱关节炎诊疗进展,第13页,AS,患者,BASDAI,越高，工作能力越差,W P,Maksymowych et al.Presented at EULAR.,更轻易失业：,2.56,倍,更可能出现活动力损害：,16.45,倍,更可能缺勤：,2.66,倍,更可能出现工作能力损害：,6.96,倍,OR,（,odds ratio,）：高活动度,vs,低活动度,;WPAI:Work Productivity and Activity Impairment questionnaire;WLQ-25:,Work Limitations Questionnaire;WALS:,Workplace Activity Limitations Scale,多国多中心，真实世界，,成年,AS,患者,（,n=555,）疾病负担在线调研（,PROSE-AS,）,标准化病情评定工具：,BASDAI,WPAIWLQ-25,WALS,高度活动,vs,低度活动,中轴脊柱关节炎诊疗进展,第14页,Jakobsen AK,et al.EULAR,Paris,#THU0095,中轴脊柱关节炎诊疗进展,第15页,结论（,1,）,在疾病早期阶段，,nr-axSpA,与,AS,疾病负担及病情进展类似,疾病活动显著影响,axSpA,患者生活质量及工作能力，提醒早期治疗和控制病情活动在改进预后方面主要作用,中轴脊柱关节炎诊疗进展,第16页,内容,中轴脊柱关节炎（,axSpA,）疾病负担,疾病活动度监测在,axSpA,目标治疗中意义,axSpA,预后原因研究进展,中轴脊柱关节炎诊疗进展,第17页,SpA,目标治疗,基于疾病活动度调整改疗,假如缓解未能保持则调整改疗,维持缓解,维持低疾病活动度,替换目标,主要目标,缓解,活动性,SpA,低疾病活动度,基于疾病活动度,调整改疗,使用临床疾病活动度和急性期反应物指标,假如低疾病活动度未能保持,则调整改疗,使用临床疾病活动度和急性期反应物指标,中轴型脊柱关节炎、外周型脊柱关节病炎或银屑病关节炎,Smolen JS,et al.Ann Rheum Dis;73:616,中轴脊柱关节炎诊疗进展,第18页,怎样定义,ax,SpA,临床缓解？,CRP,和,/,或,ESR,正常,BASDAI,评分,4,，无,EAMs,，急性期反应物正常,1,ASDAS,疾病不活动（,1.32,ASAS,缓解,3,MRI,炎症减轻或消失，并伴随相关临床缓解,:,在一项加拿大,AS,研究中，,MRI,脊柱炎症评分改进与,CRP,降低相关，但,MRI,评分与患者汇报结局,(BASDAI,BASMI),无相关性,4,ABILITY-1,中取得了相同结果,5,对于关节外肌肉骨骼疾病缓解，如起止点炎或指（趾）炎，没有明确定义,6,1,Zochling J,Braun J.Clin Exp Rheumatol;24(6 Suppl.43):S88S92;,2,Machado P,et al.Ann Rheum Dis;70:4753;,3,Anderson JJ,et al.Arthritis Rheum;44:18761886;,4,Lambert RG,et al.Arthritis Rheum;56:40054014;,5,van der Heijde et al.ACR:Abstract OP1801;,6,Smolen JS,et al.Ann Rheum Dis;73:616,阿达木单抗在中国获批适应症为类风湿关节炎和强直性脊柱炎,中轴脊柱关节炎诊疗进展,第19页,www.asas-group.org/,中轴脊柱关节炎诊疗进展,第20页,ax,SpA,疾病活动度和目标治疗监测工具：,BASDAI versus ASDAS,1,Spoorenberg A.Rheumatology;44:789795;,2,Machado P,van der Heijde D.Curr Opin Rheumatol;23:339345;,3,Machado P,et al.Ann Rheum Dis;70:4753;,4,van der Heijde D,et al.Ann Rheum Dis;68:18111818;,5,Smolen JS,et al.Ann Rheum Dis;73:616,BASDAI,ASDAS,仅包含患者汇报衡量指标1,结合了患者汇报指标和急性期反应物两方面原因2,病情定义和改进临界值选择较主观1,病情定义和改进临界值经过验证3,未依据相对主要性对单个临床表现进行加权处理2,能区分不一样疾病活动度水平患者，区分病情改变水平不一样患者4,未能反应医师对疾病观点2,从患者和医师角度反应疾病活动度1,不能解释所评定变量冗余2,不过，影响急性期反应物伴发疾病可能影响疾病活动度评定5,ASDAS,既反应患者和医师主观感受，又涵盖炎症客观标志物，,因而可能更适合用于临床实践,中轴脊柱关节炎诊疗进展,第21页,活动性,ax,SpA,患者较非活动者接收愈加频繁病情监测,A,bbvie,GMA global survey on axial SpA monitoring and treatment goals,(GMA Rheumatology,data on file),应答者人数,(n=36),活动性,ax,SpA,监测指标,非活动性,ax,SpA,监测指标,应答者人数,(n=33),中轴脊柱关节炎诊疗进展,第22页,AS,疾病活动度增加是否会促进放射学进展？,1,Poddubnyy D,et al.Arthritis Rheum;64:13881389;,2,Kroon F,et al.Ann Rheum Dis;71:16231629;,3,Ramiro S,et al.Ann Rheum Dis 7 May E-pub,ASDAS,，强直性脊柱炎疾病活动性评分；,BASDAI,，,Bath,强直性脊柱炎疾病活动性指数；,CRP,C,反应蛋白；,ESR,，红细胞沉降率；,PRO,患者汇报结局,评定,AS,疾病活动度和放射学进展，需要：,长久，,纵向研究,疾病活动度衡量指标包含,PROs,和,APRs,AS,12,年纵向研究：,ASDAS,与病情进展相关,3,APRs,：,CRP,和,ESR,AS,放射学进展,横断面研究,（,4,年）,1,2,患者汇报结局,（,PROs,）,AS,放射学进展,无相关性,1,中轴脊柱关节炎诊疗进展,第23页,高疾病活动度与,axSpA,脊柱放射学进展相关,纳入德国,GESPIC,队列,177,名,axSpA,患者（,100,名,AS,，,77,名,nr-axSpA,）,疾病活动度与骨赘形成关联,变量,OR,95%CI,ASDAS,时间平均值,2.64,1.504.64,ASDAS,调整,CRP,时间平均值,2.16,1.134.11,调整基线骨赘及吸烟状态,1.91,0.993.69,CRP,1.08,1.041.12,BASDAI,1.19,0.961.46,病程,10,年,axSpA,患者中，,ASDAS,连续高水平与放射学进展相关，且不受,CRP,影响,Poddubnyy D,et al.Presented at EULAR.FRI0113,中轴脊柱关节炎诊疗进展,第24页,ASDAS,较,BASDAI,能更佳捕捉放射学进展改变,采取ASDAS连续评分模型 a,采取BASDAI连续评分和CRP模型a,变量,多变量回归模型,(95%CI),(n=183),多变量回归模型,(95%CI),(n=184),既往,mSASSS(072),1.03(1.011.05),1.03(1.011.05),ASDAS,0.72(0.411.04),BASDAI(010),0.21(0.060.37),CRP(mg/L),0.02(0.000.04),模型QIC,5439,5665,a,模型含有时间滞后（,2,年时间滞后）和自动回归性,（即,2,年前调整,mSASSS,）；,反应,2,年内,mSASSS,单位进展；,未纳入模型中；,QIC,，独立性模型标准下类似,-,可能性,BASDAI,和,CRP,结合模型也显示与放射学进展相关,采取,ASDAS,作为一个连续评分模型，其,QIC,最低，表明,ASDAS,能够最正确捕捉放射学评分变异性,Ramiro S,et al.EULAR,Paris,#THU0102,中轴脊柱关节炎诊疗进展,第25页,AS,抗,TNF,治疗：,ASAS,部分缓解及长久疗效,*,不一样研究：不宜进行,头对头直接比较,PR,部分缓解,Patients(%),Patients(%),英利昔单抗,(5,年,),1,Patients(%),阿达木单抗（,5,年）,3,1,Heldmann F,et al.Arthritis Rheum;60(Suppl.10):520;,2,Davis J,et al.Ann Rheum Dis;67:346352;,3,Sieper J,et al.Ann Rheum Dis;71:700706;,依那西普（第,192,周）,2,中轴脊柱关节炎诊疗进展,第26页,axSpA,抗,TNF,治疗：,早期应答预示更加好长久治疗反应,第,12,周时到达,ASDAS ID,和,ASAS PR AS,患者中阿,达木单抗治疗,1,和,5,年后到达长久缓解最强预测原因,1,早期缓解患者与,12,周时未到达缓解患者相比，阿,达木单抗治疗,1,和,5,年后到达缓解 可能性高,10,倍,(p0.001),1,1,Sieper Jet al.Ann Rheum Dis;71:700706;,2,van der Heijde D,et al.EULAR:Abstract SAT0338,类似地，,基线时含有极高疾病活动度且第,12,周时未到达,ASDAS,临床主要改进中轴,SpA,患者中，仅,3%(1/30),在,CZP,治疗,48,周时到达,ASDAS,疾病非活动目标,2,Wk 12 ASDAS ID,Wk 12 ASDAS MI,Wk 12 ASAS PR,Wk 12 ASAS20,Wk 12 ASAS40,基线,韧带骨赘,病程,基线异常,CRP,0.01,0.1,1,10,100,0.01,0.1,1,10,100,第,1,年,ASAS PR,第,1,年,ASDAS ID,Wk 12 ASDAS ID,Wk 12 ASDAS MI,Wk 12 ASAS PR,Wk 12 ASAS20,Wk 12 ASAS40,基线,韧带骨赘,病程,基线异常,CRP,BL,baseline,阿达木单抗在中国获批适应症为类风湿关节炎和强直性脊柱炎,中轴脊柱关节炎诊疗进展,第27页,抗,TNF,治疗,AS,：,12,至,24,周可取得最大改进,1,van der Heijde D,et al.Arthritis Rheum;54:21362143;,2,Smolen JS,et al.,Ann Rheum Dis;73:616,阿达木单抗,1,:ASAS40,抚慰剂,(n=107),阿达木单抗,(n=208),*p0.05;,*p0.001 vs,抚慰剂,Patients with AS(%),因而，中轴,SpA,最长,6,个月目标治疗似乎是适当,2,阿达木单抗在中国获批适应症为类风湿关节炎和强直性脊柱炎,中轴脊柱关节炎诊疗进展,第28页,结论（,2,）,临床缓解和低疾病活动度是,ax,SpA,关键治疗目标,ASDAS,用于,ax,SpA,疾病活动度监测，不但结合了患者和医师视角，而且包含急性期反应物客观指标,抗,TNF,治疗,12,周到达,ASDAS/ASAS,应答预示更加好长久治疗反应,高疾病活动度与,AS放射学进展纵向相关,中轴脊柱关节炎诊疗进展,第29页,内容,中轴脊柱关节炎（,axSpA,）疾病负担,疾病活动度监测在,axSpA,目标治疗中意义,axSpA,预后原因研究进展,中轴脊柱关节炎诊疗进展,第30页,诊疗：,14-3-3,本身抗体是,AS,新型血清学标志,14-3-3,：正常状态下于细胞内广泛表示,RA,患者体内，,14-3-3,细胞外表示诱发本身抗体反应，,14-3-3,在,RA,诊疗中含有较高敏感性和特异性,AS,患者体内，,14-3-3,本身抗体水平可经过检测其,N-,末端,Pan 1,表位为依据,Maksymowych W,et al.Presented at EULARTHU0105,结论：,AS,患者体内,14-3-3,本身抗体水平升高，而非,14-3-3,本身,116,例符合修订纽约标准,AS,患者，检测血清,14-3-3,Pan 1 AAb,肽,(Pan 1),表示，并和,106,例对照组比较。,中轴脊柱关节炎诊疗进展,第31页,敏感度为,72%,，特异度为,82%,Maksymowych W,et al.Presented at EULAR.THU0105,14-3-3,本身抗体与,SIJ,炎症相关，,并可预测,2,年放射学进展,原因,Pearson,（,r,）,P,值,SIJ,炎症,0.44,0.0001,CRP,0.23,0.02,基线,mSASSS,0.18,0.05,mSASSS,0.34,0.001,MMP-3,-0.07,0.62(ns),ROC,曲线下面积,0.8611,标准误差,0.02412,95%CI 0.8139-0.9084,P,值：,0.0001,中轴脊柱关节炎诊疗进展,第32页,预后：,吸烟是否影响病活动度和放射学进展相关性？,OASIS,患者（,127,例）,(71%,男性，平均年纪,41,岁，平均症状连续时间,18,年，,82%HLA-B27,阳性,),随访,12,年，每六个月进行一次临床,(ASDAS-CRP),和影像学,(mSASSS),评定,评定,ASDAS-CRP,和影像学损害相关性,评定基线吸烟状态是否影响,ASDAS-CRP,与影像学进展之间相关性,Ramiro S,et al.Presented at EULAR.THU0103,分类,评价效应,多变量回归分析模型,(95%CI)*,吸烟状态,非吸烟患者ASDAS(n=78),0.35(0.04;0.65),吸烟患者ASDAS (n=49),1.94(1.00;2.87),5.5,倍,吸烟使疾病活动度对影像学影响增加超出,5,倍,中轴脊柱关节炎诊疗进展,第33页,与女性非吸烟者相比，,男性吸烟者中这种影响则增至,13.4,倍,不一样亚组对,ASDAS,造成影像学损伤百分比,百分比,Ramiro S,et al.Presented at EULAR.THU0103,中轴脊柱关节炎诊疗进展,第34页,职业是否影响病活动度对韧带骨赘形成影响？,目标：,调查评定职业劳力性活动和社会经济学状态是否以及怎样影响,AS,疾病活动度和影像学损害长久相关性。,方法和结果：,OASIS,N=154,随访,12,年,每年,2,次评定：,mSASSS,ASDAS-CRP,使用,GEE,分析,ASDAS,和影像学进展相关性,:,以职业劳力性、受教育程度、基线月收入、基线全家月收入等作为变量，吸烟作为协变量,结论：在,AS,患者中，劳力性职业性活动可增强疾病活动度对影像学进展不利影响。,Ramiro S,et al.Presented at EULAR.OP0262,中轴脊柱关节炎诊疗进展,第35页,体力劳动增强疾病活动度对影像学进展,不利影响,2,年,mSASSS,增值,Ramiro S,et al.Presented at EULAR.OP0262,P,值,（交互作用）,2,年,mSASSS,增值,(95%CI),职业,蓝领,(n=65),0.014,1.19(0.58;1.79),白领,(n=71),0.20(-0.23;0.64),吸烟,吸烟,(n=49),0.001,1.94(1.00;2.87),非吸烟,(n=78),0.35(0.04;0.65),教育,非大学,(n=167),0.364,0.74(0.41;1.07),大学,(n=14),-0.18(-1.91,1.55),个人月收入,1588(n=105),0.059,0.93(0.45,1.41),1588(n=56),0.14(-0.21,0.50),家庭月收入,3176(n=90),0.445,0.49(0.09,0.89),3176(n=21),0.15(-0.35,0.65),基于时滞性（,2,年滞后期）及自回归模型。影像学进展以,2,年间,ASDAS,每增加,1,单位，对应,mSASSS,增加值来表示。,蓝领工人中，,ASDAS,每增加,1,分，,2,年,mSASSS,增加,1.19,，而白领工人只增加,0.20,一定程度上可解释为社会经济学差异所致，吸烟可能也是部分原因,中轴脊柱关节炎诊疗进展,第36页,治疗：,显微镜下肠道炎症与启用,TNF,抑制剂关系,GIANT,队列，前瞻性，观察性队列研究,63,例符合,ASAS,分类标准新诊疗且未接收,TNF,抑制剂,SpA,患者：,51,例,axSpA(23,例,AS,和,28,例,nr-axSpA),，,12,例,pSpA,基线时行回结肠镜检评定是否存在显微镜下肠炎，随访,18,个月,风湿病科医师盲法决定是否启用,TNF,抑制剂,Cypers H,et al.Presented at EULAR.OP0159,50%,合并亚临床肠道炎症,6%,在,5,年内发展为,CD,中轴脊柱关节炎诊疗进展,第37页,显微镜下肠炎是,SpA,患者启用,TNF,抑制剂预测原因,合并镜下肠炎,SpA,患者更早、更多启用,TNF,抑制剂,镜下肠炎（,+,）,镜下肠炎（,-,）,使用,TNF,抑制剂患者百分比（,%,）,Cypers H,et al.Presented at EULAR.OP0159,未应用,抗,TNF,应用,抗,TNF,P,值,基线,CRP(mg/dl),0.64,(0-1.6),0.75,(0-2.6),0.037,镜下肠炎,(,急,/,慢性,),14(38.9%),18(66.7%),0.042,中轴脊柱关节炎诊疗进展,第38页,结论（,3,）,许多生物标志物可预测中轴SpA,脊柱,放射,学,进展，即使数据仅限于群体水平、横断面分析,14-3-3,自体抗体肽和,AS,骶髂关节炎显著相关，且其基线表示为,2,年,mSASSS,进展预测因子,吸烟、体力劳动职业可增强疾病活动度对影像学进展不利影响,SpA,显微镜下肠炎、基线,CRP,高水平与启用,TNF,抑制剂相关,中轴脊柱关节炎诊疗进展,第39页,Thank You,！,中轴脊柱关节炎诊疗进展,第40页,