Rheumatoid arthritis (RA) is one of the more common autoimmune diseases, with a multijoint, symmetrical presentation. RA is a heterogeneous disease, most often seen in middle-aged women, with a basic pathological change of synovitis, which varies greatly in severity and prognosis. Severe cases can eventually lead to joint deformity and loss of function.
Clinical manifestations.
The severity of clinical manifestations of RA can range from mild, transient arthritis to acute polyarthritis and systemic multi-organ involvement.
(i) Joint manifestations.
The typical pathogenesis is gradually increasing pain, stiffness and swelling of small joints, with involvement of the proximal interphalangeal joints, metacarpophalangeal joints, wrists, knees and feet joints of both hands being more common. In some patients, the hip and temporomandibular joints may be involved, and even the cervical spine and cricoid cartilage may be involved. In some patients (about 1/3), the disease starts with weakness, weight loss, myalgia, and morning stiffness. In the late stage of the disease, “swan neck” deformity (proximal interphalangeal joint hyperextension causing distal interphalangeal joint flexion) and “button flower” deformity (proximal interphalangeal flexion and distal interphalangeal joint hyperextension), and even metacarpophalangeal joint subluxation and ulnar deviation of the fingers can be seen.
(B) Extra-articular manifestations.
Skin Raynaud’s phenomenon, erythema, purpura and rheumatoid nodules are associated with vascular infarction, skin ulcers and severe infections; rheumatoid nodules are mostly seen at the skin pressure and forearm extension, which can assist in the diagnosis. Ocular manifestations include painful scleritis that can lead to scleral softening. Lymph nodes Enlargement may be seen, and in some patients, generalized lymph node enlargement. Pulmonary Pleurisy, pleural effusion, pulmonary rheumatoid nodules, diffuse interstitial fibrosis and fibroalveolitis may be seen. Heart Pericarditis (20%), endocarditis and myocarditis are rare. Renal Mostly secondary to drug use, glomerulonephritis, occasionally amyloidosis. Nervous system Carpal tunnel syndrome, multiple peripheral neuropathies. Hematologic system Microcytic hypochromic anemia may be present. Diagnostic criteria.
The diagnostic criteria for RA have changed several times, from the American Rheumatism Association’s diagnostic criteria in 1958, to the simplified New York criteria, to the revised criteria of the American College of Rheumatology in 1987, and currently the most recent diagnostic criteria proposed at the 2009 ACR meeting.
A patient is diagnosed with RA if he or she has a score of 6 or more according to the following criteria
1. Involved joints.
1 medium to large joint (0 points).
2-10 medium to large joints (1 point)
1-3 small joints (2 points).
4-10 small joints (3 points).
More than 10 small joints (5 points).
2. Serology.
Negative for RF and anti-citrullinated synthetic protein antibodies (0 points).
One of them is low potency positive, i.e. above the upper limit of normal, but not above 3 times the upper limit of normal (2 points).
At least one of them is highly potent positive, i.e. potency exceeds 3 times the upper limit of normal (3 points).
3. Duration of synovitis.
Less than 6 weeks (0 points).
6 weeks or longer (1 point).
4, Acute phase reactants.
CRP and ESR are normal (0 points).
Elevated CRP or ESR (1 point).
Treatment.
The goal of treatment is to improve quality of life, relieve joint symptoms, and achieve complete remission of the disease as early as possible. Emphasis is placed on early detection, early treatment, combination of drugs, and avoidance of disabling and surgical interventions as much as possible.
(i) Non-steroidal anti-inflammatory drugs (NSAIDs).
Inhibit cyclooxygenase activity and reduce prostaglandin synthesis thereby acting as an anti-inflammatory, analgesic, anti-swelling and antipyretic agent. Commonly used drugs include meloxicam, fenbendazole, nimesulide, diclofenac, ibuprofen, etc. The combination of drugs is not advocated, not to increase the therapeutic effect of the side effects will be more prominent, including nephrotoxicity and gastrointestinal side effects.
(B) improve the condition of drugs (DMARDs).
1.Methotrexate (MTX) 7.5-15mg/w, 4-6 weeks onset of action. Adverse effects: gastrointestinal tract, leukopenia and thrombocytopenia, liver function impairment, rash, etc.
2.Leflunomide (LEF) 10-20mg/d, adverse reactions: hypertension, elevated liver enzymes, hair loss, diarrhea, pruritus and transient leukocyte drop.
3.Hydroxychloroquine (HCQ) 200-400mg/d Adverse effects: may accumulate in the retina, fundus examination is required before use, pay attention to changes in vision, other dizziness, headache, rash, tinnitus and cardiac arrhythmia, etc.
4.Reglanoside 20mg Tid Adverse reactions: diarrhea, rash, leukocyte and platelet reduction, menstrual disorders or menopause in women, sperm reduction in men, etc.
5.Lyuzosulfapyridine 0.25g Bid orally, if no adverse reactions, increase 0.25g every 5 days to 1-2g/d after 1-2 months, adverse reactions are white blood cell or platelet reduction.
(iii) Glucocorticoid.
It can rapidly relieve joint pain and swelling, and can play a “bridge” role before DMARDs take effect. The overall principle is small doses and short courses of treatment.
(iv) Biological agents.
Anti-tumor necrosis factor-α, anti-CD20 antibody, IL-1 inhibitor, anti-interleukin-6 receptor monoclonal antibody, CTLA-4 inhibitor, can better stop the progression of bone erosion. Adverse effects: include injection site reactions and, rarely, increased risk of serious infections, including recurrence of tuberculosis, deep fungal infections, etc.