Rheumatoid arthritis

The reasons

Symptoms of Rheumatoid Arthritis

Diagnostics

Rheumatoid Arthritis Treatment

Rheumatoid arthritis is an inflammatory disease characterized by symmetrical lesions of the joints and inflammation of the internal organs.

The reasons

The cause of rheumatoid arthritis is unknown. Various viruses, bacteria, trauma, allergies , heredity, and other factors can serve as probable causes . 

The frequency of occurrence is 1% in the general population. The prevailing age is 22–55 years. The predominant gender is female (3: 1).

Symptoms of Rheumatoid Arthritis

Common symptoms

  • Fatigue
  • Slight increase in body temperature
  • Swollen lymph nodes
  • Slimming

Joint damage

Symmetry of joint damage is an important feature of rheumatoid arthritis (for example, right and left elbow joints or right and left knee joints are affected)

  • Morning stiffness of joints longer than 1 hour
  • Rheumatoid hand: deformations like “boutonniere”, “swan neck”, “hands with lorgnet”
  • Rheumatoid foot: 1 finger deformity
  • Rheumatoid knee: Baker’s cyst, flexion deformities
  • Cervical spine: subluxation of the atlanto-axial joint
  • Cricoid joint: coarseness of voice, violation of swallowing.

Damage to periarticular tissues

Tendosinovitis in the area of ​​the wrist joint and hand (inflammation of the tendon, characterized by swelling, pain and a distinct creak during movement).

Bursitis , especially in the elbow joint.

The defeat of the ligament apparatus with the development of increased mobility and deformities.

Muscle damage: muscle atrophy, often drug-induced (steroid, as well as on the background of taking penicillamine or aminoquinoline derivatives).

Systemic manifestations

Rheumatoid nodules are dense subcutaneous lesions, in typical cases localized in areas often undergoing traumatization (for example, in the area of ​​the olecranon, on the extensor surface of the forearm). Very rarely found in the internal organs (eg, in the lungs). Observed in 20–50% of patients.

Anemia due to slower iron metabolism caused by impaired liver function; platelet count reduction 

Felty’s syndrome, including a decrease in blood neutrophils , an enlarged spleen, 

Still’s Syndrome:

  • fever 39 ° C and above for one or more weeks;
  • joint pain 2 weeks or more;
  • salmon-colored spotted rash that appears during fever.

Sjogren syndrome – dryness of the mucous membrane of the eyes, mouth. 

Also, in rheumatoid arthritis, signs of osteoporosis (this is a bone loss) and amyloidosis may appear.   

Frequent are ulcers on the skin of the legs, inflammation of the arteries.

Diagnostics

In general, and biochemical analysis of blood:

  • anemia,
  • increased ESR,
  • increasing the content of C-reactive protein.

The articular fluid is cloudy, with low viscosity, the number of leukocytes and neutrophils is increased.

Rheumatoid factor (antibodies to immunoglobulins of class M) is positive in 70–90% of cases.

Urinalysis: protein in the urine. 

Increased creatinine , serum urea (evaluation of renal function, the necessary stage of selection and control of treatment). 

Criteria for the diagnosis of rheumatoid arthritis of the American Rheumatological Association (1987). Having at least 4 of the following symptoms:

  • morning stiffness more than 1 hour;
  • arthritis of 3 or more joints;
  • arthritis of the joints of the hands;
  • symmetric arthritis;
  • rheumatoid nodules;
  • positive rheumatoid factor ; 
  • radiological changes.

Rheumatoid Arthritis Treatment

Drug therapy includes the use of three groups of drugs:

Nonsteroidal anti-inflammatory drugs

Representatives of nonsteroidal anti-inflammatory drugs are

  • meloxicam
  • nimesulide
  • celecoxib.

These drugs have a minimal side effect and retain a high anti-inflammatory and analgesic activity.

Meloxicam (moval) at the beginning of treatment with the activity of the inflammatory process is prescribed at 15 mg / day, and later on it goes to 7.5 mg / day. as maintenance therapy.

Nimesulide is prescribed in a dose of 100 mg twice a day.

Celecoxib (Celebrex) is administered 100–200 mg twice a day.

For older people, the selection of the dosage of the drug is not required. However, in patients with a body weight below average (50 kg), it is desirable to begin treatment with the lowest recommended dose.

A combination of two or more nonsteroidal anti-inflammatory drugs should be avoided, since their effectiveness remains unchanged and the risk of side effects increases.

Basic drugs

Basic drugs are recommended immediately after diagnosis.

The main drugs of basic therapy for rheumatoid arthritis are:

  • methotrexate,
  • sulphazalazine,
  • D-penicillamine,
  • aminoquinoline preparations
  • cyclophosphamide,
  • azathioprine
  • cyclosporin A (sandimmune),
  • remikeid (infliximab),
  • enbrel (etanercept),
  • systemic enzyme therapy drugs (wobenzym, phlogenzyme),
  • leflunomide (arava) and others.

Basic preparations that are ineffective for 1.5–3 months should be replaced or their combinations used with hormones in small doses, which can reduce the activity of rheumatoid arthritis.

Six months is a critical period, no later than which an effective basic therapy should be selected.

In the course of treatment with basic drugs, the disease activity and side effects are carefully monitored.

The use of high doses of hormones (pulse therapy) in combination with slow-acting agents allows to increase the effectiveness of the latter.

In therapy, systemic enzyme therapy is used, most commonly the drug Wobenzym.

The drug has anti-inflammatory, immunomodulatory and secondarily analgesic effect. This allows it to be widely used for rheumatoid arthritis in combination with nonsteroidal anti-inflammatory drugs, basic drugs, hormones.

Assign 7-10 tablets 3 times a day 30 minutes before meals; Tablets are washed down with a glass of water, without chewing. Maintenance therapy – 3-5 tablets 3 times a day.

Glucocorticosteroids (hormones)

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With a high degree of inflammation activity, hormones are used, and in cases of systemic manifestations of rheumatoid arthritis – in the form of pulse therapy (hormones alone or in combination with a cytostatic agent – cyclophosphamide), without systemic manifestations – in the form of a course treatment.

Hormones are also used as a supportive anti-inflammatory therapy with the ineffectiveness of other drugs.

In some cases, hormones are used as local therapy. The drug of choice is diprospan, which has a prolonged effect.

Ointments, creams, gels based on nonsteroidal anti-inflammatory drugs (ibuprofen, piroxicam, ketoprofen, diclofenac) are used in the form of applications on inflamed joints.

To enhance the anti-inflammatory effect, applications of the above-mentioned ointment forms of drugs are combined with applications of dimethyl sulfoxide solution at a dilution of 1: 2–1: 4.

Moderate disease activity with insufficient efficacy of other treatment methods requires the administration of hormones at low maintenance doses (5–7.5 mg per equivalent of prednisolone) in combination with other drugs, primarily with systemic enzyme therapy drugs (3-5 tablets 3 times / day).

Additional therapy

In the absence of a response to standard drug treatment in patients with high activity of rheumatoid arthritis, plasmapheresis and lymphocytepheresis are used. 

An important point in the treatment of rheumatoid arthritis is the prevention of osteoporosis – the restoration of impaired calcium balance in the direction of increasing its absorption in the intestine and reducing excretion from the body.

To do this, apply a diet with a high content of calcium.  

Sources of calcium are dairy products (especially hard varieties of cheese, as well as processed cheese; to a lesser extent, cottage cheese, milk, sour cream), almonds, hazelnuts and walnuts, etc., as well as calcium preparations in combination with vitamin D or its active metabolites.

The drug that can be attributed to the basic anti-osteoporotic drugs is miacalcium. It is available for intramuscular administration of 100 ME and as a nasal spray; appointed by the scheme in conjunction with calcium preparations (calcitonin) and vitamin D derivatives.

Laser therapy is also used to treat rheumatoid arthritis. Especially in severe exacerbations of rheumatoid arthritis in recent years, extracorporeal treatment methods (primarily hemosorption and plasmapheresis) have been widely used.

Laser therapy is especially indicated at an early stage of the process. The course is not more than 15 procedures.

In order to reduce pain and eliminate spasm of periarticular tissues, cryotherapy is used (cold treatment), for a course of 10–20 procedures.

In order to influence allergic processes, improve tissue nutrition and eliminate inflammation, other physical methods of treatment are also used.

In the early stage of rheumatoid arthritis, ultraviolet irradiation of the affected joints, electrophoresis of dimethyl sulfoxide, calcium, and salicylates is recommended.  

With the appearance of more persistent changes in the joints and in the absence of signs of high activity, phonophoresis of hydrocortisone, magnetic therapy, and impulse currents are prescribed.

Physical therapy and massage are prescribed to all patients with the aim of relieving muscle spasm, the most rapid restoration of joint function.

All patients with rheumatoid arthritis should be systematically monitored and examined by a rheumatologist.

Patients with a slowly progressive course without damage to internal organs should appear at a rheumatologist 1 time in 3 months. If there is a lesion of the internal organs, patients are examined by a rheumatologist once every 2–4 weeks.

Spa treatment of patients with rheumatoid arthritis is recommended annually outside the acute phase.

In case of a benign course of the process without marked changes in the joints, the use of radioactive baths in Tskaltubo and Belokurikha is shown; with a typical progressive process – treatment with hydrogen sulfide baths in Sochi, Sernovodsk, Pyatigorsk, Kemeri; with severe deformities and contractures – treatment with mud applications in Evpatoria, Saki, Pyatigorsk, Odessa.

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