Rheumatoid arthritis (rheumatoid arthritis) is a chronic inflammatory disease of multiple joints with peripheral symmetry, and may be associated with extra-articular systemic damage. The pathology is synovitis of the joints, with joint deformities when cartilage and bone are involved. 70% of patients have rheumatoid factor in the serum. It is an autoimmune disease.
The prevalence of this disease in our population is 0.34% to 0.32%, which is lower than the 1% to 2% of whites in Europe and America. This disease is one of the main causes of labor loss and disability in our population.
Clinical manifestations
The age of onset of the disease is from 20 to 60 years old, with about 45 years old being the most common. Female patients are about 2 to 3 times more common than male patients.
Most patients have a slow onset, with a period of weakness, general malaise, fever, and poor circulation before the appearance of obvious joint symptoms.
I. Joint manifestations
(A) Morning stiffness
The diseased joints appear stiff for a longer period of time (half to several hours) after resting, like a glue-like sensation. It occurs in more than 95% of patients with rheumatoid arthritis. The duration of morning stiffness is proportional to the degree of joint inflammation, and it is often used as one of the indicators of the activity of the disease. Arthritis of other etiologies may also present with morning stiffness, but it is less pronounced than in this disease.
(ii) Pain and pressure pain
Arthralgia is often the earliest joint symptom and is most often seen in the wrist, metacarpophalangeal, and proximal phalangeal joints, followed by the toes, knees, ankles, elbows, and tendons. It is mostly symmetrical and persistent, but sometimes mild and sometimes severe. The painful joints are often accompanied by pressure pain.
(C) Arthrosis
Mostly caused by fluid accumulation in the joint cavity or soft tissue inflammation around the joint. Longer duration of the disease may cause swelling due to hypertrophy of the synovial membrane after chronic inflammation. All affected joints can be swollen, and the common sites are wrist, metacarpophalangeal, proximal phalangeal and knee joints, also mostly symmetrical.
(iv) Joint deformity
Most often seen in more advanced patients. Due to the destruction of cartilage and subchondral bone by the villi of synovitis, the deformity of fibrous or bony ankylosis of the joint is caused, and due to the damage of the muscle girdle and ligament around the joint, the joint cannot be kept in the normal position, and the subluxation of the finger joint, such as ulnar deviation and swan neck-like deformity, occurs. The atrophy and spasm of the muscles around the joint aggravate the deformity.
(E) Joint dysfunction
Painful swelling and deformity of the joints cause joint dysfunction. The American College of Rheumatology classifies the degree to which the disease affects the ability to live in four levels.
Grade I: Able to perform daily activities and tasks as usual.
Grade II Able to perform normal activities of daily living and certain occupational tasks, but limited in participation in other activities.
Grade III: Can perform general daily living activities, but has limitations in participating in certain occupational work or other activities.
Grade IV The ability to perform daily activities and participate in work is limited.
In conclusion, the arthritis of this disease has the following characteristics: it is a symmetric polyarthritis that mainly involves small joints, especially the hand joints. The disease is chronic and recurrent, and progressively worsens if not treated appropriately. The degree and speed of exacerbation varies widely among individuals.
II. Extra-articular manifestations
(A) Rheumatoid nodules
It is a more specific skin manifestation of the disease, appearing in 20%-30% of patients, mostly located in the subcutaneous part of the joint prominence and pressure areas, such as the forearm extension, elbow hawk prominence near the occiput, Achilles tendon, etc.. The nodules vary in size, ranging from a few millimeters to several centimeters in diameter, are hard, non-pressure, and symmetrically distributed. Its presence indicates the activity of the disease.
(ii) Rheumatoid vasculitis
It can be present in either system of the patient. Small vasculitis appearing under the nails or at the ends of the fingers is observed on examination, and rarely causes ischemic necrosis of local tissues. In the eye, it causes sclerositis, and in severe cases, vision is affected by scleral softening.
(C) Lung
1. Interstitial lung lesions
It is the most common pulmonary lesion and is seen in about 20% of patients. Although there are lung function abnormalities but often clinically asymptomatic, sometimes can be detected by lung x-ray. Only a few develop chronic fibrous alveolitis.
2. Nodule-like changes
The appearance of single or multiple nodules in the lungs is a manifestation of rheumatoid nodules in the lungs. The nodules may sometimes liquefy and form cavities after coughing up.
3.Pleurisy
Seen in about 10% of patients. Unilateral or bilateral small amount of pleural fluid, occasionally a large amount of pleural fluid. The pleural fluid is exudative and has a very low sugar content.
(iv) Pericarditis
It is the most common manifestation of cardiac involvement. Small amounts of pericardial effusion are seen in about 30% by echocardiography and mostly do not cause clinical symptoms.
(v) Gastrointestinal tract
Patients may have epigastric discomfort, stomach pain, nausea, poor appetite, or even black stool, but all are related to the use of anti-rheumatic drugs. Rarely caused by rheumatoid arthritis itself.
(vi) Kidney
Vasculitis in this disease rarely involves the kidneys. If there are abnormalities in the urine, kidney damage caused by anti-rheumatic drugs should be considered. Amyloidosis can also be complicated by long-term rheumatoid arthritis.
(vii) Nervous system
1. Spinal cord compression
All are caused by rheumatoid lesions of the cervical spine synovial joints. It manifests as gradual abnormal sensation and weakening of strength in both hands, hyperactive tendon reflexes, and pathological reflexes of order.
2. Peripheral nerve compression due to synovitis, such as carpal tunnel syndrome due to compression of the median nerve at the wrist joint. Polyneuritis mononeuritis, on the other hand, is caused by ischemic lesions of small vasculitis.
(H) Hematologic system
The disease presents with low hemoglobin microcytic anemia. Felty’s syndrome is a rheumatoid arthritis with splenomegaly neutropenia, and in some cases, both anemia and thrombocytopenia.
(ix) dry syndrome
About 30%-40% of patients with this disease have this syndrome. The symptoms of dry mouth and dry eyes are not obvious, but dry keratoconjunctivitis and dry mouth must be confirmed by various tests. The following factors affect the prognosis of rheumatoid arthritis.
①The natural course of the disease varies from patient to patient, with a few (about 10%) resolving on their own after a short-term episode without sequelae. Another minority (about 15%) go into significant destruction of the articular bone in a very short period of 1 to 2 years. The majority of patients have alternating episodes of remission with mild to severe joint deformity and functional impairment;
The early and late treatment and the reasonableness of the treatment plan should be treated as early as possible in the early stages of the disease, because arthritis is still reversible at that time, but the destruction of articular cartilage is often irreversible. People with persistent polyarticular pain, RF (ten), early X-ray bone destruction, extra-articular symptoms such as subcutaneous nodules, and HLA-DR4 or DRl should be treated early and aggressively with a combination regimen.
Among the causes of death related to this disease are: systemic vasculitis, infection, amyloidosis, etc.
Measures to prevent this disease. The objectives of treatment of this disease are to.
① Reduce or eliminate the patient’s joint swelling and pain, pressure pain, morning stiffness or extra-articular symptoms caused by arthritis;
②Control the development of the disease, prevent and reduce the destruction of joints and bones, achieve a longer period of clinical remission, and maintain the function of the affected joints as much as possible;
③Promote the repair of damaged joints and bones. In order to achieve the above objectives, early diagnosis and early and reasonable treatment are extremely important.
The treatment measures include: general treatment, drug treatment, and surgical treatment, among which drug treatment is the most important.
I. General treatment
It includes rest, joint braking (acute good period), joint function exercise (recovery period), physical therapy, etc. Bed rest is only suitable for patients in the acute stage, fever and internal organ involvement.
Second, drug treatment
According to the role, anti-rheumatoid arthritis drugs can be divided into: anti-rheumatic drugs to improve the symptoms and anti-rheumatic drugs to control the disease. The latter drugs are still being explored and tested, and the following is a description of the former drugs.
Anti-rheumatic drugs to improve symptoms are divided into non-steroidal anti-inflammatory drugs, slow-acting anti-rheumatic drugs, adrenal corticosteroids, etc.
(I) Non-steroidal anti-inflammatory drugs
By inhibiting cyclooxygenase to reduce the metabolism of arachidonic acid into prostaglandins, prostacyclin, thromboxane and other inflammatory mediators, thus improving the inflammatory phenomena such as congestion and exudation of synovial membrane, and achieving the purpose of controlling joint swelling and pain. It is an indispensable and non-specific symptomatic drug for the treatment of this disease. There are many varieties of these drugs with different structures, different pharmacokinetics and different dosages, but they have the following common features.
①All are oral drugs;
②All of them are acid compounds except for some;
③Since the synthesis of prostate in the gastric mucosa is also inhibited, gastrointestinal adverse reactions such as gastric discomfort, stomach pain, nausea, acid reflux, and even gastric mucosal bleeding occur after administration;
(iv) Interstitial renal damage may occur after prolonged use of these drugs.
(C) adrenocorticosteroids
This drug has a powerful anti-inflammatory effect and can bring about rapid and significant improvement in arthritis symptoms, but because it cannot control the disease at all, it, like NSAIDs, can cause symptoms to recur when the drug is discontinued. Long-term use of corticosteroids results in dependence that is difficult to discontinue and the development of many adverse effects. This drug is indicated for patients with extra-articular symptoms or when the arthritis is significant and cannot be controlled by NSAIDs or when slow-acting drugs have not yet taken effect. The daily dose of prednisone (prednisone) is 30-40 mg, decreasing after the symptoms are controlled, and is maintained at 10 mg daily. Gradually replace with non-steroidal drugs.
(iv) Experimental treatment
Including some biological agents such as gamma interferon, anti-TNFa antibodies, monoclonal antibodies against T lymphocytes and their receptors, etc. Promising to block the pathogenesis of rheumatoid arthritis to control the disease, the efficacy remains to be seen. Other treatments such as plasma exchange, de-lymphocyte drainage, and radiation therapy are applied to some refractory and severe patients.
The choice of drugs and the regimen applied depend on the activity, severity and progression of the patient’s disease. If more than 20 joints are involved, joint bone destruction occurs within 2 years of disease onset, RF titers remain high, and extra-articular symptoms are present, a combination therapy program should be used as early as possible; this includes the combination of more than one slow-acting anti-rheumatic drug and non-steroidal anti-inflammatory drugs.
Third, surgical treatment
Including joint replacement and synovectomy. The former is suitable for joints with more advanced deformity and loss of normal function. This surgery is currently only applicable to large joints, and the surgery cannot improve the condition of rheumatoid arthritis itself. Synovectomy can provide some relief, but the disease tends to recur when the synovium grows again.