Rheumatoid arthritis (RA) is a systemic autoimmune disease with erosive arthritis as its main manifestation. RA can occur at any age, with a peak incidence at the age of 30 to 50.
The prevalence of RA in mainland China is about 0.20%~0.36%. The disease manifests as symmetric, persistent polyarthritis with involvement of small joints, mainly in the hands and wrists. The pathology is characterized by chronic inflammation of the synovial membrane, formation of vascular opacities, and destruction of articular cartilage and bone, which can eventually lead to joint deformity and loss of function. In addition, patients may have systemic manifestations such as fever and fatigue. Rheumatoid factor (RF) and anti-cyclic citrullinated polypeptide (CCP) antibodies may be present in the serum.
I. Treatment principles
The principles of early treatment, combination of drugs and individualized treatment are emphasized.
II. Treatment methods
The aim of RA treatment is to control the disease and improve joint function and prognosis.
1.General treatment
Emphasize the concept of patient education and overall standardized treatment. Proper rest, physiotherapy, physical therapy, topical medication, proper joint activities and muscle exercises play an important role in relieving symptoms and improving joint function.
2.Drug therapy
Drugs commonly used in the treatment of RA include non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), biological agents, glucocorticoids and botanicals.
(1) Non-steroidal anti-inflammatory drugs (NSAIDs)
They have anti-inflammatory, analgesic, antipyretic and anti-swelling effects by inhibiting cyclooxygenase activity and reducing prostaglandin synthesis. They play an important role in relieving patients’ joint swelling and pain and improving systemic symptoms. The main adverse effects of NSAIDs include gastrointestinal symptoms, hepatic and renal impairment, and a possible increase in cardiovascular adverse events.
①Focus on individualization of type, dose and dosage form
(2) Use the lowest effective dose and short duration of treatment as possible
③Generally use one NSAIDs drug first, and then switch to another agent when there is no obvious effect for a few days to a week, avoid using two or more NSAIDs at the same time
④Patients with a history of peptic ulcer should use selective COX-2 inhibitors (e.g., cibotropic) or other NSAIDs plus proton pump inhibitors
⑤ The elderly may use NSAIDs with a short half-life or smaller doses
(6) NSAIDs should be used with caution in people with high cardiovascular risk, and acetaminophen or naproxen should be recommended if needed
(7) NSAIDs should be used with caution in patients with renal insufficiency
(8) Pay attention to regular monitoring of blood and liver and kidney functions
NSAIDs topical preparations (such as diclofenac diethylamine emulsion, capsaicin ointment, etc.) and plant ointments have a certain effect on relieving joint swelling and pain, with fewer adverse reactions.
(2) Disease improving anti-rheumatic drugs (DMARDs)
These drugs work slowly, and it takes about 1~6 months for clinical symptoms to improve, so they are also called slow-acting anti-rheumatic drugs. These drugs do not have obvious pain relief and anti-inflammatory effects, but can slow down or control the progression of the disease. For patients with rheumatoid arthritis, early application of DMARDs should be emphasized, and those with severe disease, multiple joint involvement, extra-articular manifestations or early joint destruction and other poor prognostic factors should consider the combination of the following DMARDs commonly used in the treatment of RA.
①Methotrexate (MTX)
It is a synthetic antagonist of folic acid and has strong anti-inflammatory and anti-immune effects. It is effective when administered orally, intramuscularly, intra-articularly or intravenously, and is given once a week. Commonly used dose 7.5-20mg/w.
Toxic side effects: gastrointestinal reactions, hepatotoxicity, hematopoietic inhibition, hair loss, etc. Regularly check blood and liver function.
②Sulfasalazine (SASP)
It is a compound of 5-aminosalicylic acid and sulfapyridine, which has both anti-rheumatic and anti-inflammatory effects. It is used for patients with short duration and mild RA, or in combination with longer duration and moderate and severe disease. Generally, it takes 4-8 weeks to take effect, and the dosage is gradually increased from small doses to reduce adverse effects. The main adverse reactions include rash, nausea, abdominal pain, diarrhea, abnormal liver enzymes, hematocrit, and seminal fluid reduction, most of which are mild. Use with caution if you are allergic to sulfonamide.
③Leflunomide (LEF)
It is an isozole immunomodulator with anti-proliferative activity. Its mechanism of action is mainly to inhibit the activity of dihydroorotic acid dehydrogenase, thus affecting the pyrimidine synthesis of activated lymphocytes. In vitro and in vivo tests have shown that it has anti-inflammatory effects. The in vivo activity of leflunomide is mainly produced through its active metabolites. 10mg-20mg/d is mainly used in patients with longer duration of disease, more severe disease and poor prognostic factors. Major adverse effects diarrhea, pruritus, hypertension, elevated liver enzymes, rash, alopecia.
④Anti-malarials
Including chloroquine, hydroxychloroquine can patients with milder disease. Used alone for shorter duration of disease, for severe disease or those with poor prognostic factors should be combined with other DMARDs. The drug has a slow onset of action, with effects seen in 2 to 3 months after administration. It is administered as hydroxychloroquine 200 mg/d, bid, and chloroquine 250 mg/d, qd. The former has fewer adverse effects, but the fundus should be examined once a year before and during treatment to detect possible retinal damage caused by the drug.
⑤ Azathioprine (AZA)
This product has anti-rheumatic effects, which may be related to its immunosuppressive effects, but the mechanism remains unclear. In addition, it has anti-inflammatory activity because it can inhibit the release of macrophage braking factor from lymphocytes during the late stage of immune response and suppress the local tissue inflammation. Commonly used dose is 1~2mg/(kg.d), generally 100~150mg/d. It is mainly used for RA patients with severe disease. Adverse effects include nausea, vomiting, alopecia, rash, liver damage, bone marrow suppression, possible damage to the reproductive system, and occasionally teratogenic. Regular blood tests and liver function should be performed during the drug administration.
(6) Cyclophosphamide (CYC)
CYC is rarely used in RA, and can be tried in severe cases when remission is difficult with multiple drug therapy. The main adverse reactions are gastrointestinal reactions. Alopecia, bone marrow suppression, liver damage, hemorrhagic cystitis, gonadal suppression, etc.
(3) Biological agents
Biological agents that can treat RA mainly include tumor necrosis factor (TNF)-a antagonists, interleukin 1 (IL-1) and interleukin 6 (IL-6) antagonists, anti-CD20 monoclonal antibodies, and T-cell co-stimulatory signaling inhibitors.
The commonly used (TNF)-a antagonists mainly include etanercept, infliximab, and adalimumab. Compared with traditional DMARDs, their main features are rapid onset of action, significant inhibition of bone destruction, and good overall patient tolerability. The recommended dose and usage of etanercept is 25 mg/dose,; or 50 mg/dose once a week. The recommended dose of infliximab for RA is 3 mgkg/dose, once each at 0, 2, and 6 weeks, and once every 4-8 weeks thereafter. The recommended dose of adalimumab for RA is 40 mgkg/dose, injected subcutaneously twice a week. These drugs can have injection site reactions or infusion reactions, may increase the risk of infection and tumors, and occasionally drug-induced lupus-like syndrome as well as demyelinating lesions. Tuberculosis screening should be performed prior to drug administration to exclude active infections and tumors.
(4) Glucocorticoids
Glucocorticoids rapidly improve joint swelling and pain and systemic symptoms. In patients with severe RA with cardiopulmonary or neurological involvement, short-acting hormones can be given in doses that depend on the severity of the disease. Small doses of hormones (prednisone 7.5 mg/d) are only indicated for a small number of patients with RA. Hormones can be used in the following conditions.
①Severe RA with extra-articular manifestations such as vasculitis;
②Patients with RA who cannot tolerate NSAIDs as a “bridge” treatment;
③Patients with RA in whom other treatments are not effective
(iv) Indications for local hormone therapy (e.g., intra-articular injection)
The principles of hormone therapy for RA are low dose, short course of treatment, and the simultaneous application of DMARDs; during hormone therapy, calcium and vitamin D should be supplemented to prevent osteoporosis; intra-articular injection of hormone is beneficial to reduce arthritic symptoms, but too frequent joint puncture may increase the risk of infection and steroid crystal arthritis may occur.
(5) Botanical preparations
Effective in relieving joint swelling and pain. Commonly used drugs Lei Gong Deng and Bai Shao total glucoside.
(1) Radix Rehmanniae commonly used dose 30-60 mg/d, divided into 3 times after meals. The main adverse effects are gonadal rash, hyperpigmentation, nail softening, hair loss, headache, poor appetite, nausea, vomiting, abdominal pain, diarrhea, bone marrow suppression, elevated liver enzymes and elevated blood creatinine.
②Total peony glucoside Commonly used dose 600mg, 2~3 times daily. Adverse reactions are rare, mainly abdominal pain, diarrhea, poor appetite, etc.
3.Surgical treatment
If the condition of RA patients cannot be controlled after regular medical treatment, surgery can be considered to relieve pain, correct deformity and improve the quality of life. However, surgery cannot cure RA, so drug treatment is still needed after surgery. Commonly used surgeries include synovectomy, artificial joint replacement, joint fusion and soft tissue repair.
4.Other treatments
Including autologous liver cell transplantation, T-cell vaccine and mesenchymal stem cell therapy may be effective in the remission of RA, but only for a small number of patients, and the indications must be strictly controlled, and further clinical research is still needed.
Third, common care problems
1. Pain: chronic inflammatory response; degenerative joint degeneration.
2, joint stiffness: inflammatory response related to the active phase of the disease; secondary to joint degeneration caused by long-standing inflammation.
3.Somatic mobility disorders: associated with joint pain, stiffness and mobility disorders
4.Self-care deficits: related to pain, stiffness, fatigue, psychological factors, altered joint function, and muscle weakness.
5.Risk of disuse syndrome: related to joint pain, destruction of deformity caused in dysfunction.
6.Predictable sadness: related to the disease is not cured for a long time, joint dysfunction affects the quality of life.
7, lack of knowledge: patients have not received relevant education related to.
8.Activity intolerance: related to chronic inflammation, anemia, and activity disorders.
9.Nutritional disorders: lower than the body’s needs Related to chronic inflammation, anemia, application of anti-rheumatic drugs and other gastrointestinal reactions.
IV. Nursing goals
To reduce or disappear pain, promote functional recovery and improve self-care ability.
V. Nursing routine
1.Implement the general nursing routine of rheumatology.
2.Patients with obvious joint swelling and pain in the acute stage and heavy systemic symptoms should rest in bed, and should not sleep on soft mattresses or have high pillows; patients in remission should carry out functional exercise in time to avoid joint disuse.
3.Balanced diet, give adequate amount of protein, vitamins, nutrient-rich light and easy to digest food, avoid spicy and stimulating food.
4, pay attention to the joint warmth, avoid moisture, cold to aggravate the joint symptoms.
5.Symptom care.
(1) Assess the patient’s joint pain site, degree and mobility; assess the site, time and relationship with activity of morning stiffness and the impact on life.
(2) Joint pain: give non-steroidal anti-inflammatory drugs as prescribed by the doctor, and analgesics in severe cases, supplemented by massage, thermal hydrotherapy, wax therapy, etc. to reduce pain; for knee pain, put a small pillow under the knee to keep the knee in an extended position; if necessary, give a support frame to avoid pressure on the lower limbs; also instruct the patient to use relaxation methods such as listening to music to reduce pain.
(3) Joint stiffness: instruct the patient to take a 15-minute warm bath or local hot compress in the morning, exercise the joints after bathing, and avoid long periods of inactivity; pay attention to warmth during sleep, and wear elastic gloves on the hands to reduce the symptoms of hand stiffness in the morning.
(4) For those who have deformed joints, limited activities and cannot completely take care of themselves, do well in life care to increase comfort. Cultivate the patient’s awareness of self-care, and provide assistance only when necessary, and provide auxiliary tools.
(5) Observe the damage to other organs outside the joints.
6. Observation of disease
Pay attention to joint swelling and pain, activity, self-care, joint symptoms, peri-articular skin lesions, anemia, etc.
7.Medication observation
The commonly used non-steroidal anti-inflammatory drugs are easy to cause gastrointestinal reactions, so they should be taken after meals; for patients who apply immunosuppressive drugs, pay attention to whether there are uncomfortable symptoms such as nausea and vomiting. Instruct the patient to take the medication as prescribed by the doctor and not to increase or decrease the dosage at will. Check liver and kidney function, blood and stool routine plus occult blood as prescribed by the doctor.
8.Health education
Explain to patients and family members the causes, triggers, treatment methods, common drugs and self-care methods of RA.
VI. Health guidance
1.Psychological guidance
Instruct the patient to keep a relaxed mood and be optimistic about the disease, and cite some cases of improvement to eliminate the patient’s tension and negative emotions and enhance treatment confidence.
2.Dietary guidance
High vitamin and high protein diet should be given.
3.Guidance on activity and rest
If the patient’s condition permits, carry out functional exercises of the joints as soon as possible, including finger grasping exercises, wrist, elbow, knee and hip flexion and extension exercises. For joints that are already ankylosed, strenuous and excessive exercise is prohibited. During the recovery period, short, repeated and quantitative exercises should be used, and adequate rest should be taken after the exercises. Instruct patients and family members to insist on limb and body massage and heat therapy to improve blood circulation and prevent muscle atrophy.
4.Medication guidance
Instruct the patient to strictly follow the medical prescriptions for regular medication, not to stop, change or increase or decrease the amount of medication at will inform the method of medication and common adverse reactions.
5.Advise the time and place of follow-up examination and the importance of regular review, and seek medical attention in time to avoid damage to important organs in case of recurrence; avoid triggering factors such as infection, cold, humidity and overwork.