Definition of Scientific Terms
Chinese name: rheumatoid arthritis English name: rheumatoid arthritis Definition: arthritis due to autoimmune trigger. The disease is accompanied by the production of rheumatoid factor. Applied disciplines: Immunology primary discipline; immunopathology, clinical immunology secondary discipline; autoimmune disease secondary discipline.
Encyclopedia card
Rheumatoid arthritis, RA, is a systemic autoimmune disease characterized by chronic erosive arthritis. The lesions of rheumatoid arthritis are characterized by synovitis and the resulting destruction of joint cartilage and bone, ultimately leading to joint deformity.
Western medical name.
Rheumatoid arthritis
English Name.
Rheumatoid arthritis, RA
Affiliation: Department of
Internal Medicine – Immunology
Site of disease: Rheumatoid arthritis
Joints
Main symptoms.
Joint swelling and pain, morning stiffness, joint deformity
Primary cause.
Unknown cause
Most prevalent group.
30 to 50 years old
Infectiousness.
Non-infectious
Whether covered by medical insurance.
Yes
Contents
Disease DescriptionDisease ClassificationCausesPathogenesisPathologyClinical ManifestationsDiagnosisExpandDisease DescriptionDisease ClassificationCausesPathogenesisPathologyClinical ManifestationsDiagnosisExpand
Disease Profile
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic erosive arthritis. Rheumatoid arthritis is characterized by synovitis and the resulting destruction of articular cartilage and bone, ultimately leading to joint deformity. Without regular treatment, approximately 75% of patients become disabled within 3 years. The prevalence of rheumatoid arthritis is worldwide, ranging from 0.18% to 1.07% in different populations, with some racial differences in its development, with Indians being higher than Caucasians and Caucasians being higher than Yellow Asians. The total number of patients in China is more than 5 million. Rheumatoid arthritis can develop in all ages, with a peak age of about 30-50 years, and generally more women than men.
Disease classification
Rheumatoid arthritis is often classified according to the degree of urgency of onset or the site of involvement at the time of onset. According to the degree of urgency of onset, the disease can be classified into three categories: insidious, subacute and sudden onset; according to the number of joints involved at the time of onset, the disease can be classified into polyarticular, oligoarticular, monoarticular and extraarticular manifestations.
Causes
The causes of rheumatoid arthritis are still unclear, but are generally considered to be closely related to genetic, environmental, and infectious factors.
I. Genetic factors
The risk of developing rheumatoid arthritis among 1st degree relatives is 1 or 5 times higher than that of the general population. The results of twin studies show that genetic factors account for 50% to 60% of the various factors associated with rheumatoid arthritis. The susceptibility genes associated with the development of rheumatoid arthritis include HLA-DR, PADI4 and PTPN22.
Second, the infection factors
Certain viral and bacterial infections may act as initiating factors to initiate an immune response in individuals carrying susceptibility genes, leading to the development of rheumatoid arthritis. The pathogens associated with the development of rheumatoid arthritis include EBV, B19, influenza virus and Mycobacterium tuberculosis.
Three, sex hormones
The ratio of male to female rheumatoid arthritis incidence is 1:2 to 4, suggesting that sex hormones may be involved in the development of the disease. In addition, female rheumatoid arthritis patients in pregnancy can reduce the disease, 1-3 months after delivery easy to relapse, suggesting that the decline in progesterone levels or estrogen-progesterone imbalance may be related to the development of rheumatoid arthritis.
Fourth, other factors
Smoking, cold, trauma and mental stimulation may be related to the development of rheumatoid arthritis.
Pathogenesis
The pathogenesis of rheumatoid arthritis is not well understood, but there are several hypotheses about the pathogenesis of rheumatoid arthritis.
I. Molecular mimicry
The molecular mimicry hypothesis suggests that some components of the pathogen have similar antigenic epitopes to self-antigens, and that the resulting immune response against the pathogen may react against its own components, leading to self-tissue damage.
II. Epitope expansion
Epitope expansion refers to the expansion of the response of T cells or B cells to individual epitopes early in the immune response to other epitopes. In the very early stages of rheumatoid arthritis development, only a few antibodies may be detected in the body, and as the autoimmune response progresses, multiple autoantibodies gradually appear.
III. Ambiguous recognition
It has been found that the binding of HLA and antigen is not strict in structural specificity. The same antigen can be recognized by multiple HLA phenotypes, and the same HLA molecule can bind different antigens separately, a phenomenon that becomes ambiguous recognition. The development of rheumatoid arthritis may be caused by ambiguous recognition between T-cell receptors as well as HLA-DRB1, causing the development of HLA-DR4/1 or other class II HLA gene carriers.
Pathology
The main pathological change in rheumatoid arthritis is synovitis, which manifests as synovial hyperplasia and inflammatory cell infiltration. Synovial changes in rheumatoid arthritis can be divided into an inflammatory phase, a vascular opacity formation phase, and a fibrosis phase. Vascular opacity formation is an important pathological feature of the synovium in rheumatoid arthritis and plays an important role in the process of cartilage and bone destruction in rheumatoid arthritis. The main pathological basis of the extra-articular manifestations is vasculitis. The rheumatoid nodules are characterized by fibrinoid necrotic tissue in the center of the nodule, surrounded by a “grid” of histiocytes, fibroblasts and macrophages.
Clinical manifestations
The clinical manifestations of rheumatoid arthritis are diverse, most of them have a slow insidious onset, while a few have an acute onset and alternate between attacks and remissions [1].
I. Joint manifestations
The symptoms of rheumatoid arthritis involve joints with symmetrical, persistent joint swelling and pain, often accompanied by morning stiffness. The most commonly affected joints are the proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows and toe joints; at the same time, the cervical spine, temporomandibular joints, sternoclavicular and acromioclavicular joints can also be involved. In the middle and late stages, patients may have a “swan neck” of the fingers.
Second, extra-articular manifestations
1, rheumatoid nodules: mostly seen in the joint protrusion and often pressed, no obvious pressure pain, not easy to move. Rheumatoid nodules can also occur in the internal organs, pericardial surface, endocardium, central nervous system, lung tissue and sclera, etc.
2, vasculitis: can affect all types of blood vessels, with medium and small artery involvement being more common. It may manifest as gangrene of the fingertips, skin ulcers, peripheral neuropathy, sclerositis, etc.
3, heart: pericarditis, nonspecific heart valve inflammation, myocarditis.
4, pleura and lung: pleurisy, pulmonary interstitial fibrosis, pulmonary rheumatoid nodules, pulmonary hypertension.
5, kidney: membranous and thylakoid proliferative glomerulonephritis, interstitial nephritis, focal glomerulosclerosis, proliferative nephritis, IgA nephropathy and amyloidosis, etc.
6, the nervous system: sensory peripheral neuropathy, mixed peripheral neuropathy, multiple mononeuritis and embedded peripheral neuropathy.
7, hematopoietic system: patients with rheumatoid arthritis may develop orthocytic orthochromic anemia and elevated platelets during active disease.
Third, special types of rheumatoid arthritis
1, rheumatoid arthritis in the elderly: refers to the onset of rheumatoid arthritis after the age of 60. Compared with the younger onset of rheumatoid arthritis, rheumatoid arthritis in the elderly is more acute onset, often accompanied by systemic symptoms such as fever, weight loss and fatigue. Some patients may present with clinical manifestations similar to rheumatic polymyalgia. Proximal limb joints, especially shoulder joints, are more prominently involved, and rheumatoid nodules are less common. The disease activity is often higher, morning stiffness is more obvious, rheumatoid factor RF) is mostly negative.
2, seronegative rheumatoid arthritis: seronegative rheumatoid arthritis refers to rheumatoid factor and anti-citrullinated protein antibody ACPA are negative rheumatoid arthritis. Bone erosion and extra-articular manifestations are less severe than in patients with seropositive rheumatoid arthritis. Good response to treatment and good prognosis.
3, the return type rheumatism: also known as recurrent rheumatism, the disease is mostly seen between 30 and 60 years old, characterized by intermittent episodes of joint redness, swelling, heat and pain. Intermittent periods without any symptoms, attacks without a clear pattern. The disease recurs, but no significant joint damage occurs, and some patients may develop typical rheumatoid arthritis.
3, remitting seronegative symmetric synovitis with depressed edema syndrome: also known as RS3PE, mainly manifests as acute inflammation of the wrist, flexor tendon sheath and small joints of the hand, accompanied by depressible edema of the back of the hand. Rheumatoid factor is persistently negative, and there is a risk of neoplastic disease, poor response to a variety of non-steroidal anti-inflammatory drugs, short-term application of hormones can rapidly improve the symptoms, but there can still be sequelae, including flexion contracture of the wrist and fingers.
4, Felty syndrome: one of the systemic complications of patients with seropositive rheumatoid arthritis, the duration of the disease is more than 10 years, accounting for 2/3 of women, often accompanied by highly efficient rheumatoid factor. The main clinical manifestations are rheumatoid arthritis, leukopenia, anemia, thrombocytopenia, lymph node enlargement, splenomegaly, also accompanied by fever, fatigue, loss of appetite, weight loss and other systemic manifestations.
5. Adult Still’s disease: The disease is characterized by high fever, transient rash, arthritis as the main clinical manifestations, accompanied by enlarged liver, spleen and lymph nodes, and significantly increased white blood cells. Laboratory tests suggest that serum ferritin is significantly elevated, antinuclear antibodies and rheumatoid factor are often negative, and if rheumatoid factor is positive, it suggests the possible development of rheumatoid arthritis.
Diagnosis and differentiation
I. Auxiliary tests
1, routine examination:
1, blood routine: about 30% of patients with rheumatoid arthritis combined with anemia, mostly orthocytic orthochromic anemia. Platelets are elevated during the active phase of the disease. In a few cases, there is a decrease in white blood cells, such as Felty’s syndrome.
2. Acute phase reactants: Most patients with rheumatoid arthritis have increased sedimentation and elevated C-reactive protein during the active phase, which can return to normal when the disease is in remission.
2, autoantibodies:
1, rheumatoid factor RF: 75%-85% of patients have positive serum rheumatoid factor, and correlate with the disease and extra-articular manifestations.
2, anti-citrullinated protein antibodies ACPA: anti-citrullinated protein antibodies is a general term for a class of autoantibodies containing citrullinated epitopes, has a high sensitivity and specificity for the diagnosis of rheumatoid arthritis, and is closely related to the condition and prognosis of rheumatoid arthritis. The sensitivity and specificity of various anti-citrullinated protein antibodies to rheumatoid arthritis are shown in Table 1.
3, synovial fluid examination: the joint fluid of patients with rheumatoid arthritis is generally inflammatory in character, with total leukocyte count up to 10-10000×10/L and cell classification dominated by neutrophils.
4.Imaging examinations.
1.X-ray examination:Early X-ray shows swelling of soft tissues around the joints and osteoporosis near the joints; with the progress of the disease, joint surface destruction, joint space narrowing, joint fusion or dislocation may occur.
2, magnetic resonance imaging MRI: magnetic resonance imaging is better than X-ray in showing joint lesions, and has been increasingly used in the diagnosis of rheumatoid arthritis in recent years. Magnetic resonance imaging can show synovial thickening, bone marrow edema and mild joint surface erosion at the beginning of the inflammatory response of the joint, which is beneficial for the early diagnosis of rheumatoid arthritis.
3.Ultrasound: High-frequency ultrasound can clearly show the joint cavity, synovial membrane, bursa, joint cavity fluid, articular cartilage thickness and morphology, etc. Color Doppler flow imaging CDFI) and color Doppler energy map CDE) can visually detect the distribution of blood flow within the joint tissue and reflect the synovial membrane hyperplasia with high sensitivity. Ultrasonography can also dynamically determine the amount of joint fluid and the distance from the body surface, which can be used to guide joint puncture and treatment.
II. Disease diagnosis
To date [2-4], several international diagnostic and classification criteria for rheumatoid arthritis have been developed. In order to diagnose rheumatoid arthritis at an earlier stage, the American Rheumatism Association/European League Against Rheumatism developed a new classification standard for rheumatoid arthritis in 2010. 2012, the People’s Hospital of Peking University took the lead in proposing an ERA for early rheumatoid arthritis with the participation of 12 hospitals across China. The classification criteria are easier and more practical than the 2010 American Rheumatism Association/European League Against Rheumatism criteria.
1. Morning stiffness: stiffness in and around the joints that lasts at least 1 hour before maximum improvement is obtained Duration of disease ≥ 6 weeks)
2, arthritis in at least 3 or more joint areas: the physician observed at least 3 or more joint areas with 14 joint areas likely to be involved: bilateral proximal interphalangeal joints, metacarpophalangeal joints and wrist, elbow, knee, ankle and metatarsal phalangeal joints) with concurrent soft tissue swelling or effusion not purely bony hypertrophy) duration of disease ≥ 6 weeks).
3, arthritis of the hand joints: wrist, metacarpophalangeal or proximal interphalangeal joints at least 1 joint swelling disease duration ≥ 6 weeks).
4, symmetric arthritis: the same joint areas on both sides of the body are involved at the same time proximal interphalangeal joints, metacarpophalangeal joints and metatarsophalangeal joints when involved, not necessarily completely symmetrical) disease duration ≥ 6 weeks).
5, rheumatoid nodules: subcutaneous nodules observed by the physician on the extensor side of the joint, around the joint or at the site of bone prominence.
6, positive rheumatoid factor RF: the method used to detect serum rheumatoid factor in the normal population is less than 5% positive.
7, radiological changes: typical radiological changes of rheumatoid arthritis in the posterior-anterior phase of the hand and wrist, which must include bone erosion or definite osteoporosis in the involved joint and its adjacent areas.
Those meeting 4 or more of the above 7 items can be classified as rheumatoid arthritis.
2 2010 American Rheumatism Association/European League Against Rheumatism Classification Criteria: If there is at least one joint with clear clinical synovitis swelling that cannot be better explained by other diseases, the following scoring system can be applied and those with a score of 6 or more can be classified as rheumatoid arthritis.
A: Involved joints: Any swollen or tender joints found on examination that can be confirmed by imaging evidence of synovitis.
1 large joint 0 points: large joints refer to shoulder, elbow, hip, knee and ankle joints
1 point for 2 to 10 major joints
1~3 small joints with or without large joints 2 points: small joints refer to metacarpophalangeal joints, proximal interphalangeal joints, 2~5 metatarsophalangeal joints, interphalangeal joints of thumbs and wrist joints
4~10 small joints with or without large joints 3 points
More than 10 joints with at least one small joint 5 points: In this article, at least one affected joint must be a small joint; other joints may include any combination of large or additional small joints, such as other joints not specifically listed elsewhere temporomandibular joints, acromioclavicular joints, sternoclavicular joints
B: Serology requires at least 1 result for.
-negative rheumatoid factor and anti-citrullinated protein antibodies 0 points
-Rheumatoid factor and anti-citrullinated protein antibodies, at least one of which is low titer positive. 2 points
-Rheumatoid factor and anti-citrullinated protein antibodies, at least one high titer positive 3 points
C: Acute phase reactants require at least 1 result of.
-CRP and ESR both normal 0 points
- 1 point for abnormal CRP or ESR
D: Duration of symptoms.
-<6 weeks 0 points
-≥6 weeks 1 point
Note: Within A~D, take the highest score that the patient meets the condition. For example, if the patient has 5 small joints and 4 large joints involved, the score is 3.
3 The classification criteria for early rheumatoid arthritis introduced in China in 2012
1, morning stiffness ≥ 30 minutes
2, polyarthritis arthritis in at least 3 or more parts of 14 joint areas
3, hand arthritis wrist or metacarpophalangeal or proximal interphalangeal joints at least 1 arthritis
4, anti-CCP antibody positive
5.Positive rheumatoid factor
Those who meet 3 or more of the above 5 items can be classified as rheumatoid arthritis. Sensitivity 84,4%, specificity 87,4%
Differential diagnosis
In the diagnosis of rheumatoid arthritis, attention should be paid to differentiate from arthritis caused by osteoarthritis, gouty arthritis, reactive arthritis, psoriatic arthritis and other connective tissue diseases such as systemic lupus erythematosus, dry syndrome and scleroderma.
1, osteoarthritis: the age of onset is more than 40 years old, mainly involving the knee, spine and other weight-bearing joints. The joint pain worsens with activity, and there may be joint swelling and fluid accumulation. Osteoarthritis of the fingers is often misdiagnosed as rheumatoid arthritis, especially when Heberden nodes appear in the distal interphalangeal joints and Bouchard nodes in the proximal phalangeal joints, which are easily treated as synovitis. X-rays show narrowing of the joint space, labyrinthine hyperplasia of the joint edges or formation of bony warts.
2, gout: chronic gouty arthritis is similar to rheumatoid arthritis, gouty arthritis is mostly seen in middle-aged and elderly men, often with recurrent attacks, the preferred site is the unilateral first metatarsophalangeal joint or tarsal joint, can also invade the knee, ankle, elbow, wrist and hand joints, acute attacks usually have increased blood uric acid levels, chronic gouty arthritis can appear in the joints and auricles and other parts of the gouty stone.
3, psoriatic arthritis: psoriatic arthritis with involvement of the distal joints of the fingers or toes, can also appear joint deformities, but rheumatoid factor negative, and accompanied by psoriatic skin or nail lesions.
4, ankylosing spondylitis: this disease mainly invades the spine, but the surrounding joints can also be involved, especially the knee, ankle, hip as the first symptoms, need to be distinguished from rheumatoid arthritis. The disease has the following characteristics: young men are more common; mainly invade the sacroiliac joints and spine, peripheral joint involvement is mainly asymmetric joint involvement of the lower extremities, often with tendonitis; 90%-95% of patients are HLA-B27 positive; rheumatoid factor negative; X-ray changes of the sacroiliac joints and spine can help the diagnosis.
5, arthritis due to connective tissue disease: dry syndrome, systemic lupus erythematosus can have joint symptoms, and some patients are positive for rheumatoid factor, but they all have corresponding characteristic clinical manifestations and autoantibodies.
6, other atypical rheumatoid arthritis with single or few joints should be distinguished from infectious arthritis including tuberculosis infection, reactive arthritis and rheumatic fever.
Disease treatment
The goal of rheumatoid arthritis treatment is to control the disease and improve joint function and prognosis. The principles of early treatment, combination of drugs and individualized treatment should be emphasized. Treatment methods include general therapy, drug therapy and surgical and other treatments.
General treatment
Patient education and the concept of holistic and standardized treatment are emphasized. Appropriate rest, physical therapy, body therapy, topical medication, proper joint activities and muscle exercises play an important role in relieving symptoms and improving joint function.
Second, drug treatment
1, non-steroidal anti-inflammatory drugs NSAIDs): these drugs mainly through the inhibition of cyclooxygenase COX) activity, reduce prostaglandin synthesis and has anti-inflammatory, analgesic, antipyretic and reduce the role of joint swelling, is the most commonly used clinical rheumatoid arthritis treatment drugs. NSAIDs have an important role in relieving joint swelling and pain and improving systemic symptoms in patients. Their major adverse effects include gastrointestinal symptoms, liver and renal impairment, and possible increased cardiovascular adverse events.
According to the existing evidence-based medical evidence and expert consensus, the following points should be noted in the use of NSAIDs.
1, focus on the individualization of the type, dose and dosage form of NSAIDs.
2, as far as possible with the lowest effective amount, short course of treatment.
3, generally first choose a non-steroidal anti-inflammatory drugs. 3.Usually choose one kind of NSAID first. When there is no obvious effect for several days to 1 week, it should be increased to the full amount. If it is still ineffective, then switch to another preparation, avoid taking 2 or more NSAIDs at the same time.
4.For those who have a history of peptic ulcer, selective cyclooxygenase-2 inhibitors or other NSAIDs plus proton pump inhibitors are appropriate.
5, the elderly can use short half-life or smaller doses of non-steroidal anti-inflammatory drugs.
6, cardiovascular high-risk groups should be cautious in the selection of non-steroidal anti-inflammatory drugs, if necessary, can choose non-selective cyclooxygenase inhibitors class of non-steroidal anti-inflammatory drugs.
7, pay attention to regular monitoring of blood routine and liver and kidney function.
2, improve the condition of anti-rheumatic drugs DMARDs): the drugs are slower than non-steroidal anti-inflammatory drugs, about 1 to 6 months, so also known as slow-acting anti-rheumatic drugs SAARDs) these drugs can slow down or control the progress of the disease. Commonly used in the treatment of rheumatoid arthritis to improve the condition of anti-rheumatic drugs include the following.
1, Methotrexate (MTX): oral, intramuscular or intravenous injections are effective, given once a week. If necessary, it can be used in combination with other anti-rheumatic drugs to improve the condition. The commonly used dose is 7,5 to 20 mg/week. Common adverse reactions include nausea, stomatitis, diarrhea, alopecia, rash and hepatic damage, with a few cases of bone marrow suppression. Interstitial lung lesions are occasionally seen. Folic acid should be supplemented appropriately during the dosing period, and blood routine and liver function should be checked regularly.
2. Leflunomide (LEF): The dose is 10-20 mg/d orally. It is mainly used for patients with severe disease and poor prognostic factors. The main adverse effects include diarrhea, pruritus, hypertension, increased liver enzymes, rash, alopecia and decreased white blood cells. It is contraindicated in pregnant women because of its teratogenic effect. Regular blood tests and liver function should be conducted during the drug administration.
3, Salicylazosulfapyriding (SASP): can be used for short duration and mild rheumatoid arthritis alone, or combined with other anti-rheumatic drugs to improve the condition of patients with longer duration and moderate and severe disease. It usually takes effect after 4 to 8 weeks. Gradually increasing the dose from small doses helps to reduce adverse effects. It can be started at 250-500 mg orally three times a day, and then gradually increased to 750 mg three times a day. Major adverse reactions include nausea, vomiting, abdominal pain, diarrhea, rash, increased transaminases, and occasionally decreased leukocytes and platelets; use with caution if allergic to sulfonamide. Regular blood tests, liver function and kidney function should be performed during the drug administration.
4. Hydroxychloroquine (HCQ): It can be used alone for patients with short duration and mild disease. For severe disease or with poor prognosis should be combined with other anti-rheumatic drugs to improve the condition. The drug has a slow onset of action and is effective for 2 to 3 months after administration. It is administered as hydroxychloroquine 200 mg twice daily. A fundus examination should be performed once a year before and during treatment to monitor for possible retinal damage caused by the drug.
Early application of disease-modifying antirheumatic drugs should be clinically emphasized in patients with rheumatoid arthritis. The combination of two or more disease-modifying antirheumatic drugs should be considered in patients with severe disease, multiple joint involvement, extra-articular manifestations or early onset of joint destruction and other poor prognostic factors. The main combinations of methotrexate, leflunomide, hydroxychloroquine and salazosulfapyridine include any two or three combinations. According to the patient’s condition and individual situation, different combined medication methods should be selected.
3, biological agents: is currently the main drug to actively and effectively control inflammation, reduce bone destruction, reduce the amount of hormones and osteoporosis. Biological agents for the treatment of rheumatoid arthritis mainly include tumor necrosis factor TNF)-α antagonists, interleukin IL)-l and IL-6 antagonists, anti-CD20 monoclonal antibodies and T-cell co-stimulatory signal inhibitors.
1, tumor necrosis factor-α antagonists: this class of agents mainly includes etanercept), infliximab) and adalimumab). The main features of tumor necrosis factor-alpha antagonists are rapid onset of action, significant inhibition of bone destruction, and overall good patient tolerability compared to traditional disease-modifying antirheumatic drugs. These agents can have injection site reactions or infusion reactions, may have an increased risk of infection and tumors, and occasionally have 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.
2, interleukin-6 antagonist tocilizumab): mainly used for moderate to severe rheumatoid arthritis, and may be effective in patients who respond poorly to tumor necrosis factor-alpha antagonists. Common adverse reactions are infection, gastrointestinal symptoms, rash and headache.
3, interleukin-1 antagonist: anakinra) is currently the only IL-1 antagonist approved for the treatment of rheumatoid arthritis. The main adverse effects are dose-related injection site reactions and possible increase in the probability of infection.
4, anti-CD20 monoclonal antibody: rituximab) is mainly used for active rheumatoid arthritis in which tumor necrosis factor-alpha antagonists are ineffective. A common adverse effect is infusion reactions. Intravenous administration of glucocorticoids reduces the incidence and severity of infusion reactions. Other adverse reactions include hypertension, rash, pruritus, fever, nausea, arthralgia, etc., and may increase the probability of infection.
5. Cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin CTLA4-Ig:abciapabatacept) is used to treat patients with more severe disease or poor response to tumor necrosis factor-alpha antagonists. The main adverse effects are headache and nausea, and may increase the incidence of infection and tumors.
4.Glucocorticoids: Glucocorticoids can rapidly improve joint swelling and pain and systemic symptoms. In patients with severe rheumatoid arthritis with cardiac, pulmonary or neurological involvement, short-acting hormones can be given, and the dose depends on the severity of the disease. For joint lesions, if needed, usually a small dose of the hormone prednisone ≤ 7,5 mg/d) is only indicated for a small number of patients with rheumatoid arthritis.
Hormones can be used for the following conditions.
1, severe rheumatoid arthritis with extra-articular manifestations such as vasculitis.
2, rheumatoid arthritis patients who cannot tolerate NSAIDs as a “bridge” treatment.
3.Patients with rheumatoid arthritis in whom other treatment methods are not effective.
4.With local hormone therapy indications such as intra-articular injection. The principle of hormone therapy for rheumatoid arthritis is small doses and short courses of treatment. The use of hormones must be applied simultaneously to improve the condition of anti-rheumatic drugs. In the course of hormone therapy, calcium and vitamin D should be supplemented. joint cavity injection of hormone is beneficial to reduce the symptoms of arthritis, but too frequent joint cavity puncture may increase the risk of infection, and steroid crystal arthritis may occur.
5. Botanical preparations
1, thunderbolt: effective in relieving joint swelling and pain, whether to slow down joint destruction is still lack of research. Generally, 30-60 mg/d of tretinoin is given, divided into 3 doses after meals. The main adverse effect is gonadal suppression and is generally not used in patients of childbearing age. Other adverse reactions include skin rash, hyperpigmentation, nail softening, hair loss, headache, nausea, vomiting, abdominal pain, diarrhea, bone marrow suppression, elevated liver enzymes and elevated blood creatinine.
2, total peony glycosides: the common dose is 600mg, 2 to 3 times a day. Its adverse reactions are less, mainly abdominal pain, diarrhea, poor nausea, etc.
6, surgical treatment: rheumatoid arthritis patients after active medical formal treatment, the disease still can not be controlled, in order to correct the deformity, improve the quality of life can consider surgery. But surgery does not cure rheumatoid arthritis, so post-operative drug therapy is still required. Commonly used surgeries are synovectomy, artificial joint replacement, joint fusion and soft tissue repair.
7, other treatment: for a small number of standardized drug treatment is not effective, the serum has a high titer of autoantibodies, immunoglobulin significantly increased can be considered immune purification, such as plasma exchange or immunosorbent treatment. However, clinical emphasis should be placed on strict control of the indications and the combination of anti-rheumatic drugs to improve the condition and other treatment principles.
Prognosis of disease
The prognosis of patients with rheumatoid arthritis is related to the duration of the disease, the extent of the disease and the treatment. Patients with multiple joint involvement, heavy extra-articular manifestations, high titers of autoantibodies and HLA-DRI/DR4 positivity in the serum, and early bone destruction should be treated aggressively. Most patients with rheumatoid arthritis can go into clinical remission with standard medical treatment.
Disease prevention
There is no effective prevention method for rheumatoid arthritis, but early diagnosis and treatment are important to avoid delaying the disease. Once rheumatoid arthritis has been diagnosed, aggravating factors should be reduced or avoided.
Disease care
Patients with rheumatoid arthritis should quit smoking, avoid exposure to cold, and exercise appropriately to maximize and preserve the function of the affected joints and reduce the occurrence of disability. The changes in the disease should be closely monitored during the course of medication, and blood routine, liver and kidney functions should be regularly rechecked.