RA患者小腿及足部溃疡发生率呈上升趋势

华盛顿——基于美国明尼苏达州Olmstead人群的一项回顾性队列研究表明，在类风湿性关节炎(RA)患者中，小腿及足部溃疡的发生率约为每年1%。在过去几年内这一发生率已经翻倍。


Eric L. Matteson
 
美国梅奥医院风湿病科的Adlene Jebakumar博士在美国风湿病学会(ACR)2012年会上报告称，该研究队列共纳入了1980~2007年接诊的813例RA患者，他们均符合1987年美国风湿病学会制定的RA诊断标准。其中，66%类风湿因子阳性，53%合并侵蚀性关节病，33%存在类风湿结节，这些都是重症RA的指征。

这项研究的总随访期为9,771人年，随访期间共有125例患者发生171次小腿和(或)足部溃疡。这不包括因动物咬伤、手术、烧伤、活检、蜂窝组织炎、嵌甲、趾甲拔除、擦伤、异物或带状疱疹导致的溃疡。

患者首次出现溃疡的平均年龄为73.5岁，女性占74%。踝关节与膝关节之间的区域是溃疡最高发的部位(58次溃疡发作，34%)，其次是足尖(46次溃疡发作，27%)。主要病因为受压(62次溃疡发作，36%)或外伤(49次溃疡发作，27%)。另外22次溃疡发作为缺血性(13%)，还有2次为血管炎性(1%)。

在1995~2007年确诊为RA的患者中，小腿及足部溃疡的发生率高于1980~1994年确诊的RA患者[危险比(HR)：2.03；P<0.001]。小腿及足部溃疡愈合的中位时间为30天。在这171次溃疡发作中共有10次(6%)导致了截肢。校正年龄、性别和年代后，在RA患者中小腿及足部溃疡与死亡率增加相关(HR：2.42；P<0.001)。

在RA患者中，下肢溃疡的危险因素包括年龄(每增加10年的HR为1.90；P<0.001)；目前吸烟(HR：1.51；P=0.048)；糖尿病 (HR：1.65；P=0.015)；冠心病或心衰 (HR：1.56；P<0.035)；存在类风湿结节(HR：1.64；P=0.010)；3次检测均显示ESR ≥ 60 mm/h(HR：1.78；P=0.022)；静脉血栓栓塞(HR：2.08；P=0.014)；以及重度关节炎表现(HR：1.67；P=0.048)。

梅奥医院风湿病科主任Eric L. Matteson博士在接受采访时说，RA患者出现小腿及足部溃疡并不令人吃惊。“下肢溃疡的确是RA患者的一大问题，因为这类患者的心血管疾病和外周动脉疾病的发生率较高。许多溃疡都是因为循环差造成的。此外，有时用于治疗RA患者的长期大剂量类固醇也可能与溃疡发作有关。”他还补充道，在老年患者中这一情况更加严重，因为老年人往往会因为RA相关性下肢疼痛而不愿活动。

Matteson博士指出：“预防下肢溃疡的最佳策略就是控制好RA。”在溃疡出现早期，即溃疡面积还很小时就开始治疗也很重要，因此务必嘱咐患者及早就医，切忌等到溃疡面积扩大到难以愈合时才去看医生。此外，溃疡的预防可能是“听起来容易做起来难”，Matteson博士建议：“应尽量让患者保持活动。”

Jebakumar博士和Matteson博士声明无相关经济利益冲突。

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By: SALLY KOCH KUBETIN, Internal Medicine News Digital Network

WASHINGTON – Ulcers of the lower leg and foot occurred at an incidence of 1% per year among people with rheumatoid arthritis, with the rate having doubled over the last few years, according to findings from a retrospective assessment of a population-based incidence cohort in Olmstead County, Minn.

The study cohort all met the 1987 American College of Rheumatology criteria for rheumatoid arthritis (RA) in 1980-2007. The cohort included 813 people with RA, said Dr. Adlene Jebakumar during her presentation at the annual meeting of the American College of Rheumatology. Of these, 66% were positive for rheumatoid factor, 53% had erosive joint disease, and 33% had rheumatoid nodules, all markers of severe disease.

During 9,771 total person-years of follow-up, there were 171 episodes of leg and/or foot ulcers in 125 of these people. These cases did not include ulcers resulting from animal bites, surgery, burns, biopsy, cellulitis, ingrown toenails, toenail removal, abrasion, foreign body, or herpes zoster.

Patients’ mean age at first ulcer onset was 73.5 years, and 74% were female.

The area between the ankle and knee was the most common location for ulcers (58 ulcers, 34%), followed by the tips of the toes (46 ulcers, 27%).

The major etiology was pressure (62 ulcers, 36%) or trauma (49 ulcers, 27%). Another 22 ulcers (13%) were ischemic, and 2 (1%) were vasculitic, reported Dr. Jebakumar of the division of rheumatology at the Mayo Clinic in Rochester, Minn.

The incidence of lower leg and foot ulcers was higher among patients diagnosed with RA in 1995-2007, compared with those diagnosed in 1980-1994 (hazard ratio, 2.03; P less than .001). The median time for the lower leg and foot ulcers to heal was 30 days. Ten (6%) of 171 episodes led to amputation. Lower leg and foot ulcers in RA were associated with increased mortality (HR, 2.42; P less than .001), adjusted for age, sex, and calendar year.

The risk factors for lower extremity ulcers in RA were age (HR, 1.90/10-year increase; P less than .001); current smoking (HR, 1.51; P = .048); diabetes mellitus (HR, 1.65; P =.015); coronary heart disease or heart failure (HR, 1.56; P less than .035); presence of rheumatoid nodules (HR, 1.64; P = .010); ESR of 60 mm/hr or greater on three occasions (HR, 1.78; P = .022); venous thromboembolism (HR, 2.08; P = .014); and severe extra-articular manifestations (HR, 1.67; P = .048). The patients on corticosteroid therapy accounted for 79 (46%) of 171 ulcer episodes.

Dr. Eric L. Matteson said in an interview that the incidence of leg and foot ulcers in RA patients should not come as a surprise. "Leg ulcers are a real big problem in RA because these patients have increased cardiovascular disease and peripheral artery disease. Lots of ulcers are due to poor circulation. And long-term high-dose steroids sometimes used to treat RA patients may contribute to that."

The situation is made worse in elderly patients who become sedentary in response to lower-extremity RA-related pain, he added.

"The best prevention of lower extremity ulcers is to have RA under control," said Dr. Matteson, chair of the department of rheumatology at the Mayo Clinic. And treat ulcers early in their course, when they are small, he noted, adding that patients need to be told to seek care early rather than wait until the ulcers have become large and harder to heal.

Another important aspect of prevention is harder to do than it sounds: "Keep patients active," Dr. Matteson advised.

Dr. Jebakumar and Dr. Matteson reported having no relevant financial conflicts of interest.