Overview
Rheumatoid arthritis (RA) is an autoimmune disease of unknown etiology, mostly seen in middle-aged women, with a prevalence of about 0.32-0.36% in China. The main manifestation is symmetrical, 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.
Clinical manifestations
The disease can vary from transient, mild oligoarthritis to acute progressive polyarthritis. The most commonly affected joints are the proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows, shoulders, knees and toes; the cervical spine, temporomandibular joints, sternoclavicular and acromioclavicular joints can also be involved, with restricted movement; 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 joint function is lost due to muscle atrophy and spasm around the joints, 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.
Laboratory tests]
Most active patients have mild to moderate orthocytic anemia, white blood cell count is mostly normal, 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 positive RF is also seen in chronic infections (hepatitis, tuberculosis, etc.) (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 high diagnostic specificity for rheumatoid arthritis.
X-ray examination]
In order to clarify the diagnosis, stage and development of the disease, both wrist joints and hands should be taken at the beginning of the disease.
Diagnostic points]
The diagnosis of rheumatoid arthritis mainly relies on clinical manifestations, autoantibodies and X-ray changes. Typical cases are not difficult to diagnose according to the 1987 American College of Rheumatology classification criteria (Table 2), but some atypical, early rheumatoid arthritis with monoarthritis as the first symptom is often misdiagnosed or missed. For these patients, in addition to blood and urine tests, blood sedimentation, C-reactive protein, rheumatoid factor and other tests, magnetic resonance imaging (MRI) can be done for early diagnosis. Patients with suspected rheumatoid arthritis should be regularly reviewed and closely followed up.
Treatment options
At present, the treatment of rheumatoid arthritis includes medication, surgical treatment and psychological rehabilitation treatment, etc.
1.Drug treatment
The current domestic and international application 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 divided into four categories, namely non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), glucocorticoids and botanical drugs.
2.Surgical treatment
Patients with rheumatoid arthritis can consider surgery to prevent joint destruction, correct deformities and improve the quality of life if the disease is still not controlled after active formal or drug treatment in internal medicine. However, surgery does not cure rheumatoid arthritis, so the post-operative drug treatment is still required. Commonly used surgeries include synovectomy, arthroplasty, soft tissue release or repair surgery, and joint fusion.
3.Psychological and rehabilitation treatment
Joint pain, fear of disability or already facing disability, inability to take care of themselves, economic loss, changes in family, friends and other relationships, the cessation of social and recreational activities and many other factors inevitably bring mental stress to patients with rheumatoid arthritis, who are eager for treatment, but are worried about adverse drug reactions or lack of confidence in the actual effects of drugs, which in turn increases the psychological burden of patients. Depression is the most common psychiatric symptom among patients with rheumatoid arthritis, and severe depression hinders the recovery of the disease. Therefore, along with active and rational drug therapy, attention should be paid to the psychological treatment of rheumatoid arthritis. In addition, the selection of the treatment plan and the evaluation of the efficacy should also take into account the changes in the patient’s psychiatric symptoms. In the acute stage, patients with severe joint pain and systemic symptoms should rest in bed, and pay attention to the resting position to avoid pressure on the joints as much as possible. Passive and active joint mobility training is carried out to prevent muscle atrophy as far as the condition allows. For patients in remission, exercise more often without making them feel fatigued, and restore physical strength, and treat under the guidance of physical rehabilitation physicians.
4.Other treatment
Biological agents such as anti-tumor necrosis factor-α (TNF-α) have been used abroad for the treatment of rheumatoid arthritis. Infliximab is a monoclonal antibody to TNF-α and Etanercept is a recombinant human soluble TNF-α receptor fusion protein. There is no clinical report of anti-TNF-α treatment for rheumatoid arthritis in China.
【Treatment strategy】.
In today’s world, where rheumatoid arthritis cannot be cured, it is our goal to prevent joint destruction, protect joint function, and maximize the quality of life of patients. Therefore, the timing of treatment is very important. Although NSAIDs and glucocorticoids can reduce symptoms, joint inflammation and destruction can still occur or progress. DMARDs, on the other hand, can improve and delay the disease and should be used early. Early aggressive and rational treatment with DMARDs is the key to reducing disability. It is important to note that drug selection should be consistent with the principles of safety, effectiveness, economy and simplicity.
The activity of the disease should be monitored in all patients. Patients with early, acute or persistent disease activity should be followed closely until the disease is controlled. Patients in remission can be followed up every six months, and at the same time, the corresponding indicators should be tested regularly according to the requirements of the therapeutic drugs. DMARDs can slow down the progression of disease, but they cannot cure rheumatoid arthritis, so in order to prevent recurrence of the disease, in principle, the drug should not be stopped, but the dosage can be gradually reduced to maintain the treatment until it is finally stopped.
Prognosis
Most patients with rheumatoid arthritis have a prolonged course, and the disability rate is high in the first 2-3 years of rheumatoid arthritis, and if not treated early and reasonably, joint destruction reaches 70% within 3 years. Active and correct treatment can lead to remission in more than 80% of patients with rheumatoid arthritis, with only a few eventually becoming disabled.
There are no accurate indicators to predict prognosis, but it is usually believed that: men have a better prognosis than women; those with late onset of disease have a better prognosis than those with early onset of disease; the number of joints involved at the onset of disease or with metatarsophalangeal joints involved, or the number of joints involved in the course of disease is greater than 20 has a poor prognosis; persistent high titer rheumatoid factor positivity, persistent increased blood sedimentation, increased C-reactive protein, and increased eosinophilia in the blood all indicate a poor prognosis; there are Severe peripheral symptoms (fever, anemia, malaise) and extra-articular manifestations (rheumatoid nodules, sclerositis, interstitial lung disease, pericardial disease, systemic vasculitis and other visceral injuries) have a poor prognosis; short-term hormone therapy is difficult to control symptoms or the maintenance dose of hormone cannot be reduced to less than 10 mg/day has a poor prognosis.