Rheumatoid arthritis (RA) is an autoimmune disease of unknown etiology, most commonly seen in middle-aged women. The main manifestation is symmetric, chronic, progressive polyarthritis. Chronic inflammation and hyperplasia of the synovial membrane form vascular opacities that invade articular cartilage, subchondral bone, ligaments and tendons, resulting in destruction of articular cartilage, bone and joint capsule, eventually leading to joint deformity and loss of function.
I. Symptoms and signs
The condition and course of the disease varies individually, ranging from transient, mild oligoarthritis to acute progressive polyarthritis. The most commonly affected joints are the proximal interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, knee, and toe joints; the cervical spine, temporomandibular, sternoclavicular, and acromioclavicular joints may also be involved, with limited motion; hip involvement is rare. Arthritis often presents with symmetric, persistent swelling and pressure pain, often accompanied by morning stiffness. The most common joint deformities are ankylosis of the wrist and elbow, subluxation of the metacarpophalangeal joints, ulnar deviation of the fingers, and a “swan neck” or button-like appearance. In severe cases, the joints are fibrous or bony ankylosis, and the muscles around the joints atrophy and spasm, resulting in loss of joint function, making life unmanageable. In addition to joint symptoms, rheumatoid nodules and visceral lesions such as heart, lung, kidney, peripheral nerve and eye may also appear.
Experimental examination
Most active patients have mild to moderate orthocytic anemia, mostly normal white blood cell count, sometimes eosinophils and platelets are seen, serum immunoglobulin IgG, IgM, IgA may be elevated, serum complement levels are mostly normal or mildly elevated, 60%-80% of patients have high levels of rheumatoid factor (RF), but RF positivity is also seen in chronic infections (hepatitis, tuberculosis, etc.), other connective tissue diseases and normal elderly people. Other autoantibodies such as anti-keratin antibodies (AKA), anti-perinuclear factor (APF) and anti-cyclic citrullinated polypeptide (CCP) have a high diagnostic specificity for rheumatoid arthritis, with a sensitivity of about 30%-40%.
X-ray examination
To clarify the diagnosis, stage and development of the disease, X-rays of both wrists and hands and/or feet should be taken at the beginning of the disease, as well as X-rays of other affected joints. early X-rays of RA show swelling of the soft tissues around the joints, mild osteoporosis near the joints, followed by joint space narrowing, joint destruction, joint dislocation or fusion.
IV. Diagnostic criteria.
1.Morning stiffness
Stiffness in and around the joint lasting at least 1 hour (duration of disease ≥ 6 weeks).
2.Arthritis in 3 or more regions of the joint site
The physician observes the involvement of 3 of the following 14 regions (left or right proximal interphalangeal joint, metacarpophalangeal joint, wrist, elbow, knee, ankle and metatarsophalangeal joint) with concurrent soft tissue swelling or effusion (not simple bone augmentation) (duration of disease ≥ 6 weeks).
3.Hand arthritis
Swelling of at least one joint in wrist, metacarpal or proximal interphalangeal arthritis (duration of disease ≥ 6 weeks).
4.Symmetric arthritis
Bilateral joint involvement (bilateral proximal interphalangeal joints, metacarpophalangeal joints and metatarsophalangeal joints may not be absolutely symmetrical) (duration of disease ≥ 6 weeks).
5.Rheumatoid nodules
The doctor observed subcutaneous nodules on the bony prominence, extensor surface or around the joint.
6.Positive rheumatoid factor
Any test method proves abnormal serum rheumatoid factor level, and the positive rate of the method in the normal population is less than 5%.
7.Radiological changes
Typical radiological changes of rheumatoid arthritis in the posterior-anterior phase of the hand and wrist: must include bone erosion or definite bone decalcification in the involved joint and its adjacent areas.
Rheumatoid arthritis can be diagnosed by meeting 4 or more of the above 7 criteria and excluding other arthritis
V. Treatment methods.
Current domestic and foreign applications of drugs, including plant drugs can not completely control joint destruction, but can only relieve pain, reduce or delay the development of inflammation. Commonly used drugs for the treatment of rheumatoid arthritis are non-steroidal anti-inflammatory drugs (NSAIDs), anti-rheumatic drugs to improve the condition (DMARDs), glucocorticoids and botanicals, as well as the current more popular biological agents.
1.NSAIDs: for example, Fotarine, Letson, Anti-inflammatory pain, Mupiroc, Celecoxib, etc.
2, improve the condition of anti-rheumatic drugs.
(1) Methotrexate (MTX) is effective when taken orally, intramuscularly or intravenously. Generally, it takes 2 to 3 months for the drug to take effect. Mostly used once a week to give the drug. The usual dose is 7.5-25 mg/week, and the dose can be increased at the discretion of individual patients with severe disease. Common adverse reactions include nausea, stomatitis, diarrhea, alopecia, rash, and rarely, bone marrow suppression, hearing impairment and interstitial lung changes. It can also cause miscarriage, malformation and affect fertility. Blood and liver function should be checked regularly during the drug administration.
(2) Salazosulfapyridine (SSZ) usually takes effect after 4-8 weeks. Gradual increase from small doses helps to reduce adverse reactions. Use: Start with 250-500 mg daily, then increase 500 mg weekly until 2.0 g daily, and increase to 3.0 g daily if the efficacy is not obvious. Major adverse reactions include nausea, vomiting, anorexia, dyspepsia, abdominal pain, diarrhea, rash, asymptomatic transaminase increase and reversible spermopenia, occasionally leukocyte and platelet reduction, and are contraindicated in cases of allergy to sulfonamide. Regular blood tests and liver function should be performed during the drug administration.
(3) Leflunomide (LEF): The dose is 10-20mg/day treatment. It usually takes 2 to 3 months to take effect. The main adverse effects include diarrhea, pruritus, hypertension, increased liver enzymes, skin rash, hair loss and transient leukocyte decline. Due to teratogenic effect, it is prohibited to be taken by pregnant women. Since leflunomide and MTX inhibit cell proliferation in different ways, the combination of the two drugs has a synergistic effect. Regular blood tests and liver function should be performed during the drug administration.
(4) Antimalarial drugs: there are two kinds of drugs, chloroquine (250mg/tablet) and hydroxychloroquine (100mg/tablet). The effect of this drug is slow, and it takes 3-4 months to reach the peak of efficacy after taking it, and it can be declared ineffective after at least 6 months. The dosage is 250mg/day for chloroquine and 200-400mg/day for hydroxychloroquine. This drug has accumulative effect and may precipitate in the pigment epithelium of the retina, causing retinal degeneration and leading to blindness. In addition, in order to prevent myocardial damage, electrocardiogram should be checked before and after the use of the drug. Patients with heart disease such as sinus node insufficiency, slow heart rate and conduction block should be prohibited. Other adverse reactions include dizziness, headache, and rash.
There are other classes of anti-rheumatic drugs.
3.Glucocorticoid
They can rapidly reduce joint pain and swelling. In patients with acute attacks of arthritis or severe disease with involvement of organs such as heart, lung, eye and nervous system, short-acting hormones can be given, and the dose is adjusted according to the severity of the disease. Small doses of glucocorticosteroids (prednisone 10 mg daily or equivalent) can relieve symptoms in most patients and serve as a “bridge” before the onset of DMARDs, or as a short-term measure when NSAIDs are unsatisfactory. DMARDs
4.Botanical preparations
(1) Radix et Rhizoma: Radix et Rhizoma polysaccharide 30-60mg/day, divided into 3 doses after meals. The main adverse effect is gonadal suppression, resulting in reduced sperm production male infertility and female amenorrhea. Other adverse reactions include rash, hyperpigmentation, mouth ulcers, nail softening, hair loss, dry mouth, palpitations, chest tightness, headache, insomnia, etc.
(2) Cytoxanine: Cytoxanine 20mg, taken orally before meals, 1-4 tablets each time, three times daily. Common adverse reactions include allergic reactions such as skin itching and rash, and leukopenia in a few patients.
(3) Total Paeoniae glycosides: The commonly used dose is 600mg, 2-3 times a day. Toxic side effects are small, its adverse reactions include increased number of stools, mild abdominal pain, poor appetite, etc.
5.Biological agents
Ixepro, classical gram, etc., the price is relatively expensive. The side effects are relatively few and may induce the onset of tuberculosis, hepatitis B.
DMARDs can slow down the progression of disease, but cannot cure rheumatoid arthritis, based on this, in order to prevent the relapse of the disease, in principle, do not stop the drug, but can also gradually reduce the amount of maintenance treatment according to the condition, until the final discontinuation.
VI. Prognosis
Most patients with rheumatoid arthritis have a prolonged course, and the disability rate for the first 2-3 years of rheumatoid arthritis is high, and if not treated early and reasonably, joint destruction can reach 70% within 3 years. Active and correct treatment can make more than 80% of rheumatoid arthritis patients in remission, only a few eventually disabled.