Clinical manifestations
About 80% of patients are between 20 and 45 years of age, mostly young adults, with a male to female ratio of 1:2 to 4. The onset of the disease is slow, with patients experiencing prodromal symptoms such as fatigue, weight loss, poor appetite, low fever and numbness and tingling in the hands and feet for a few weeks to a few months. This is followed by pain and stiffness in a particular joint, and later by enlargement of the joint and increasing pain. At the beginning, one or two joints may be involved, often in a wandering fashion. Later, symmetrical polyarthritis develops, with joint involvement often starting in the small joints of the distal extremities and later involving other joints. The proximal interphalangeal joints are the most frequently affected, with pyknosis, followed by metacarpophalangeal, toe, wrist, knee, elbow, ankle, shoulder, and hip joints. The stiffness of the joints in the morning with muscle aches and pains may be reduced with moderate activity. The degree and duration of stiffness is often consistent with the degree of disease activity and can be used as an estimation of the activity of the lesion. Due to the swelling and pain of the joint and the limitation of movement, the stiffness and atrophy of the muscles near the joint become more pronounced. Later, even if the acute inflammatory changes dissipate, the periarticular tissues become stiff due to the proliferation of fibrous tissue already in the joint. As the lesion progresses, the patient has irregular fever, a rapid pulse rate, and significant anemia. The diseased joints eventually become stiff and deformed, with the knees, elbows, fingers, and wrists fixed in a flexed position. The fingers often become subluxed laterally at the metacarpophalangeal joint, forming a characteristic ulnar deviation deformity, and the patient requires assistance in daily life. Patients who have more joint involvement are in pain because they cannot move from the mattress all day long.
About 10%-30% of the patients have subcutaneous nodules, hard as rubber, in the joint protrusions, such as the eminence of the upper limb, the wrist and the ankle of the lower limb. Subcutaneous nodules are not easily absorbed, and the presence of subcutaneous nodules often indicates that the disease is in a severe active stage.
In addition, a small number of patients (about 10%) have lymph nodes and splenomegaly during the active phase of the disease. Ocular sclerositis and keratoconjunctivitis may be present. Cardiac involvement with clinical manifestations is less common and is found in about 35% according to autopsy, mainly affecting the mitral valve and causing valvular lesions. Patients with lung disease present in various forms, pleurisy, diffuse interstitial lung fibrosis, rheumatoid pneumoconiosis. Peripheral neuropathy and chronic calf ulcers, amyloidosis, etc. are also occasionally found.
There is no uniform standard for assessing the functional status of patients with rheumatoid arthritis, but the following classification is easily accepted.
Class I: The patient’s ability to perform normal activities without any limitation.
Grade II: Moderate limitation but still adaptable.
Grade III: Severe limitation, unable to perform most daily tasks or activities.
Grade IV: Loss of mobility to bed, or wheelchair use only.
Diagnosis of rheumatoid arthritis
Internationally, the American College of Rheumatology 1985 diagnostic criteria were revised in 1987 to remove the damaging tests and the less specific joint pain and tenderness, and to be more stringent about morning stiffness and joint swelling. However, rheumatoid arthritis in China is less severe than in Western countries, and the first and second criteria are not always met by our patients, so we can be flexible.
The following are introduced.
1. Morning stiffness for at least 1 hour (≥6 weeks).
2. Swelling of 3 or more joints (≥6 weeks).
3. Swelling of the wrist, metacarpophalangeal joint or proximal interphalangeal joint (≥6 weeks).
4. Symmetrical arthrogryposis (≥6 weeks).
5. subcutaneous nodules. 6. hand radiographic changes.
7. Positive rheumatoid factor (titer > 1:32).
The diagnosis of rheumatoid arthritis requires four or more criteria. The sensitivity is 93% and specificity is 90%, both better than the 1958 criteria (sensitivity 92%, specificity 85%).
Treatment of rheumatoid arthritis
Rheumatoid arthritis There is no specific treatment for rheumatoid arthritis so far, but it is still stuck in the treatment of inflammation and sequelae, taking a comprehensive treatment, most patients can get some effect. The current treatment aims to: (1) control inflammation of joints and other tissues to relieve symptoms; (2) maintain joint function and prevent deformity; and (3) repair damaged joints to reduce pain and restore function.
(i) General therapy: Those with fever, swollen and painful joints and systemic symptoms should rest in bed until the symptoms basically disappear. After two weeks of improvement, activities should be gradually increased to avoid prolonged bed rest leading to joint disuse and even promoting joint ankylosis. Adequate protein and vitamins should be included in the diet, and small blood transfusions can be given to those with significant anemia.
(B) Drug treatment
1. Non-steroidal anti-inflammatory drugs (NSAIDS) are used for the first or mild cases, and their mechanism of action is mainly to inhibit cyclooxygenase so that the inhibition of prostaglandin production to achieve the effect of anti-inflammatory for pain relief. However, it cannot stop the natural process of rheumatoid arthritis lesions. This class of drugs because of the different metabolic pathways in the body, they can interact with each other is not advocated for joint application, and should pay attention to individualization.
(1) Salicylic acid preparations: anti-rheumatic, anti-inflammatory, antipyretic and analgesic. The dose is 2-4g per day, if the efficacy is not satisfactory, the dose can be increased at your discretion, sometimes 4-6g per day is needed to be effective. It is usually taken after meals or used together with acidulants, and enteric tablets can also be used to reduce gastrointestinal irritation.
(2) Indomethacin: an indole acetate derivative with anti-inflammatory, antipyretic and analgesic effects. Patients who cannot tolerate aspirin can switch to this drug at the usual dose of 25mg 2-3 times a day, and side effects are likely to occur when 100mg or more is used daily. Side effects include nausea, vomiting, diarrhea, gastric ulcer, headache, vertigo, mental depression, etc.
(3) Propionic acid derivatives: a class of drugs that can replace aspirin, including ibuprofen, (ibuprofen) naproxen (naoproxen) and fenbufne (fenbufne) have similar effects to aspirin, with similar efficacy and fewer digestive side effects. Commonly used dose: 1.2-2.4g of ibuprofen per day, divided into 3-4 doses, and 250mg of naproxen per dose, twice daily. Side effects include nausea, vomiting, diarrhea, peptic ulcer, gastrointestinal bleeding, headache and central nervous system disorders such as irritability.
(4) Anti-acid drugs: They are o-aminobenzoic acid derivatives and their effects are similar to those of aspirin. Anti-acid 250mg each time, 3 to 4 times a day. Clomid acid 200-400mg per time, 3 times a day. Side effects include gastrointestinal reactions, such as nausea, vomiting, diarrhea and loss of appetite. Occasionally, rash, renal impairment, headache, etc.
2. Gold preparations are currently recognized to have a positive effect on rheumatoid arthritis. Gold, sodium thiomalate myochrysin is commonly used. If there are no adverse reactions, 50mg per week will be administered thereafter. 300-700mg of the total amount will be effective for most patients, and 600-1000mg of the total amount will lead to stable improvement of the disease. Because of the possibility of relapse after discontinuation of the drug, the maintenance dosage is used abroad for many years, and the straight line is lifelong. The earlier the gold preparation is used, the more effective it is. The effect of gold preparations is slow, 3-6 months to take effect, should not be used with immunosuppressive or cytotoxic drugs. If the total amount of treatment process has reached 1000mg, and the disease does not improve, should stop the drug. The effect of oral gold preparation is similar to that of gold injection. Side effects include increased stool frequency, skin rash, stomatitis, tight damage, etc., which can be recovered after stopping the drug.
Oral gold preparations gold Norfen (Auranofin) is a hydroxyl compound of gold phosphide. The dose is 6mg once a day, 2-3 months after the beginning of the effect. It is more effective in patients with a short course of early disease. Side effects are lighter than injections, commonly diarrhea, but it is transient, remission rate is 62.8%.
3. Penicillamine is an amino acid drug containing sulfhydryl groups, the treatment of chronic rheumatoid arthritis has a certain effect. It can selectively inhibit certain immune cells to reduce IgG and IgM. Side effects include thrombocytopenia, leukopenia, proteinuria, allergic rash, loss of appetite, optic neuritis, muscle weakness, increased transaminases, etc. Dosage 250mg per day orally for the first month and 250mg per time twice daily for the second month. No significant effect third month 250mg each time three times a day. Total dose up to 750mg per time is the maximum dose. Most of the clinical symptoms improve within 3 months, after the improvement of symptoms with a small dose maintenance, the course of treatment is about one year.
4. Chloroquine has some anti-rheumatic effect, but the effect is very slow, often 6 weeks to 6 months to reach the maximum effect. It can be used as an adjunct to salicylic acid preparations or decreasing corticosteroid doses. 250-500 mg per dose orally twice daily. Gastrointestinal reactions such as nausea, vomiting and loss of appetite are common during the course of treatment. Long-term application should be careful of retinal degeneration and optic nerve atrophy, etc.
5. Levamisole can reduce pain and shorten the duration of joint stiffness. The dose is 50mg once daily for the first strike, 50mg twice daily for the second week, and 50mg three times daily for the third week. Side effects include vertigo, nausea, allergic rash, hypotony, drowsiness, granulocytopenia, thrombocytopenia, hepatic impairment, proteinuria, etc.
6. Immunosuppressants For patients with severe rheumatoid arthritis in whom other drugs are ineffective, in cases of discontinuation or in patients with hormone reduction, azathioprine is commonly used at 50 mg twice to three times daily. Cyclophosphamide 50 mg twice daily. The dosage is gradually reduced after improvement of special symptoms or laboratory tests. The maintenance dose is 1/2 to 2/3 of the original therapeutic dose and is used continuously for 3 to 6 months. Side effects include bone marrow suppression, decreased white blood cells and platelets, hepatotoxic damage and gastrointestinal reactions, alopecia, amenorrhea, hemorrhagic bladder inflammation, etc.
Methotrexate (MTX) has immunosuppressive and anti-inflammatory effects, can lower blood sedimentation, improve bone erosion, 5-15mg per week intramuscularly or orally, 3 months as a course. Side effects include anorexia, nausea, vomiting, stomatitis, alopecia, leukopenia or thrombocytopenia, drug-interstitial pneumonia with rash. May be another palliative drug of choice after gold and penicillamine.
7. adrenocorticosteroids adrenocorticosteroids on joint swelling and pain, control inflammation, anti-inflammatory and pain relief effect is rapid, but the effect is not lasting, the cause and pathogenesis of the disease has no effect. Once the drug is discontinued for a short period of time, relapse occurs. There is no improvement on RF, blood sedimentation and anemia. Long-term application can lead to serious side effects, so it is not used as a routine treatment, limited to severe vasculitis caused by extra-articular damage and affect the function of vital organs, such as eye complications that may cause the risk of blindness, central nervous system lesions, heart block, joints with persistent active synovitis, etc. can be applied for a short time, or by NSAIDS, penicillamine and other treatment effect is not good, heavy symptoms, affecting daily life In addition to the original drugs, small doses of corticosteroids can be added. The dose of corticosteroids can be increased as appropriate. After the symptoms are controlled, the dose should be gradually reduced to the minimum maintenance amount.
Hydrogen prednisone acetate suspension can be used as local intra-articular injection for certain single large joint intractable lesions, 25-50mg per intra-articular injection, to prevent intra-articular infection and bone destruction. De-inflammation and suxamethasone tebutate is a long-acting corticosteroid suitable for intra-articular administration, with a single dose of 10mg and 30mg for the knee joint.
8. Leigongteng has good efficacy after years of clinical application and experimental research in China. It has non-steroidal anti-inflammatory effect and immunosuppressive or cytotoxic effect, which can improve the symptoms and make the blood sedimentation and RF potency decrease. 60mg/d of Radix Polygoni, 1-4 weeks can show clinical effect. Side effects include menstrual disorders and menopause in women, reduced sperm count in men, skin rash, leukocyte and platelet reduction, abdominal pain and diarrhea. It can be eliminated after discontinuation of the drug.
Kunming Shanghang, similar in action to Leigongtang, 2 to 3 tablets each time, 3 times a day. The course of treatment is more than 3 to 6 months. Side effects Dizziness, dry mouth, sore throat, loss of appetite, abdominal pain, amenorrhea.
9. Other treatments Thymidine, plasma removal therapy, etc. have yet to be explored.
(iii) Physical therapy The purpose is to use heat therapy to increase local blood circulation, relax muscles, achieve anti-inflammatory, swelling and analgesic effects, while using exercise to maintain and improve joint function. Physical therapy methods include the following: hot water bag, hot bath, wax bath, infrared ray, etc. Physical therapy is followed by massage to improve local circulation and relax muscle spasm.
The purpose of exercise is to preserve the function of joint movement and to strengthen the strength and endurance of muscles. In the acute stage, after the symptoms have subsided, as long as the patient can tolerate it, he/she should make active or passive joint exercise activities regularly at an early stage.
(iv) Surgical treatment Previously, it was thought that surgery was only applicable to advanced deformity cases. At present, early synovectomy can be tried for those who have only one or two joints that are heavily damaged and where salicylate treatment is ineffective. In the later stage, the lesion is stationary and the joint has obvious deformity, osteotomy correction is feasible, and joint ankylosis or destruction can be done as arthroplasty or artificial joint replacement. For weight-bearing joints, joint fusion can be performed.
Generally speaking, most of the patients recover better if they are treated actively and comprehensively at an early stage. If only a few joints are involved and the systemic symptoms are mild, or if the joints involved are not symmetrically distributed, the disease is often short-lived, and about 10% to 20% of patients become disabled due to untimely treatment. The disease does not directly cause death, but severe advanced cases can die from secondary infection.
Other treatment methods will not be discussed, but here is a brief description of surgical treatment.
Indications and contraindications for surgery
At present, there is a lack of curative treatment for rheumatoid arthritis. Treatment should be tailored to the location, stage of development, and severity of the disease, taking into account the patient’s age, health status, and requirements for living conditions. The treatment of rheumatoid arthritis is comprehensive and includes psychological, physical, pharmacological, surgical and rehabilitation treatments. Surgery is an important measure for rheumatoid arthritis of the hand and should be given sufficient attention. However, it is not the only treatment method, and should be combined with physical, drug and other treatment methods. Good rehabilitation is also needed after surgery to ensure the effect of surgery.
Indications: (1) anti-rheumatoid drug treatment for at least six months, inflammation does not subside; (2) nerve compression symptoms are obvious; (3) tendon facing rupture or has been ruptured; (4) persistent synovitis with persistent pain; (5) hand deformity or joint instability resulting in functional impairment; (6) painful rheumatoid nodules.
Contraindications: (1) those with severe cardiopulmonary disease; (2) those with quiescent rheumatoid lesions, with insignificant symptoms and patients who are already well adapted; (3) those undergoing immunosuppressive therapy. Joint surgery
(1) Synovectomy remains the most common and important procedure. Timely removal of the diseased synovium can prevent devastating late sequelae, and even in more advanced stages, synovectomy can prevent further deterioration of the joint lesion and reduce pain.
(2) Articular capsule and ligament folding to address laxity of the joint capsule and ligaments due to inflammatory synovial exudation on the capsule and ligament overextension.
(3) Capsular and ligamentoplasty for reconstruction of the joint capsule and ligaments in the event of rupture or deficiency.
(4) tendon fixation, which is used to achieve joint stability when neither capsule folding nor plication can be applied. For example, tendon strips are applied to the flexor side of the proximal interphalangeal joint to prevent hyperextension of the proximal interphalangeal joint and to correct goose neck deformity.
(5) Arthroplasty, which can be performed by placing autologous tissue between the joints or by artificial joint replacement.
(6) Arthrofusion, which is applied when joint stability is required or when arthroplasty is not effective, such as the metacarpophalangeal and interphalangeal joints of the thumb.