Rheumatoid arthritis is an autoimmune disease of unknown etiology, mostly seen in middle-aged women, with a prevalence of about 0.33% in China, and according to the population of 68 million in Hunan Province, there are currently 224,000 patients in the province.
I. Clinical manifestations
Rheumatoid arthritis mainly manifests as symmetrical joint swelling and pain, especially in the second half of the night (after 1-2 o’clock) every night with unfavorable joint movement, and in the morning after waking up, it is difficult to wash face, brush teeth, dress and other activities. With time, the affected joints gradually develop from the common small joints of the wrist (mainly the proximal interphalangeal joints, metacarpophalangeal joints, and wrist joints) to all the large and small movable joints of the body;
In severe cases, the joints may become fibrous or bony ankylosis and lose function, making life unmanageable. In severe cases, rheumatoid nodules and visceral lesions such as heart, lung, kidney, peripheral nerve and eye may also appear.
II. Clinical types.
1, transient, mild oligoarthritis, sometimes can be used without drugs, accounting for about 10% of the total.
2, slowly developing polyarthritis, the disease can be controlled with drugs for about 1-2 years, and will recur after 2-5 years, accounting for about 30%.
3, progressive polyarthritis, about 2 years of drug treatment can be temporary relief, but can not stop the drug, once stopped, 3-6 months will be relapsed, accounting for about 30%.
4, the rapid development of polyarthritis, regular drug treatment can not control the disease, about 2 years of deterioration, generally about 5-10 years of joint disability, such patients account for about 30%.
Third, the etiology.
The cause of the disease is unclear, the current research on the existence of certain rheumatoid arthritis genes, such as HLADR4. At the same time, certain factors in the outside world, such as infection, environmental pollution and other conditions induced by the body’s internal immune disorders, resulting in the onset of the disease. This is why the number of patients with rheumatoid arthritis is increasing year by year.
IV. Examination
The high level of rheumatoid factor in the blood of 60-80% of patients, and the introduction of rheumatoid factor 3 subtypes and anti-cyclic citrullinated polypeptide (CCP) antibodies in our department, the first in the province, has greatly improved the accuracy of diagnosis. For some patients with early onset (within 3 months), when blood tests are often normal, MRI scans and ultrasound of joints have provided us with early and accurate diagnostic tools.
V. Treatment
Traditionally, people believe that rheumatoid arthritis is a chronic disease and that it is mainly treated slowly by traditional Chinese medicine, with the mentality of “it can’t be cured, it can’t die, it can be delayed. Any disease at an advanced stage, any more brilliant doctors, with the most advanced drugs, the effect is only so good, and the cost of joint replacement surgery at an advanced stage is even more forced patients on the “road of no return”, and ultimately brings a heavy economic and ideological burden to individuals and families. Therefore, doctors currently advocate “the earlier the better” for the treatment of rheumatoid arthritis, and once diagnosed, advocate the need for formal treatment, “sending charcoal in the snow, sending enough charcoal in the snow”.
(a) The traditional treatment of rheumatoid arthritis is divided into commonly used drugs, namely anti-inflammatory and analgesic drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), glucocorticoids and botanicals. The last 10 years abroad is the mainstream application of biological agents.
(1) Anti-inflammatory and analgesic drugs: including celecoxib, menoxicam, loxoprofen, ibuprofen, etc.. The main role is to improve the condition of drugs (DMARDs) before the effect of pain relief, symptom relief bridge, once the DMARDs after 3 months to take effect, this is the time for painkillers “retired”. Since these drugs have more or less gastrointestinal, renal and cardiac side effects, in general, physicians do not prescribe pain medication to patients for more than 3 months.
(2) Improving the condition of drugs: including methotrexate, leflunomide, hydroxychloroquine, salazosulfapyridine, penicillamine, jinnophine, azathioprine, cyclosporine, cyclophosphamide, etc.. These drugs play a role in relieving the disease by suppressing the abnormal immune function of the body, and are currently the long-term drugs of choice for most patients, as well as the drugs of choice for physicians. However, there are two problems: (1) because of the need for long-term use, about 5-10% of patients will still have toxic reactions to drugs, so they need to be “closely monitored”, regularly checked at the hospital, and timely adjustment of drug doses; (2) these drugs mainly suppress inflammatory reactions, and have no significant effect on rheumatoid bone destruction. Therefore, the phenomenon of “inflammation – bone destruction separation” will occur, which is the real reason why some long-term treatment patients do not have pain in the joints, but the joints are deformed.
(3) Glucocorticoids: This is the most common drug used by the majority of patients without formal treatment, and is also the “ancestral secret recipe” of “charlatans” for rheumatoid treatment, which works very quickly and is not expensive, and does not require frequent blood tests in hospitals. But with the use of drugs for a long time, the patient will find a round face, stomach, high blood pressure and blood sugar, although the hands and joints are good, but the legs can not walk, the original femoral head necrosis, and even some patients have gastrointestinal bleeding, shock, which is the Chinese Society of Rheumatology rheumatoid arthritis treatment guidelines in the position of hormones ranked at the bottom of the main reason.
(4) Botanicals: Chinese herbal medicine has unique advantages in the field of treating rheumatoid arthritis. Certain botanicals, such as lei gong teng, qing feng teng, strychnine, white peony, etc. do have partial therapeutic effects on some patients with rheumatoid arthritis, but the side effects of some herbal medicines are also quite significant. However, some Chinese herbal medicines are also quite side effects, such as the reproductive toxicity (the “son disinheritance” medicine) and hepatotoxicity of Lei Gong Vine, the cardiotoxicity and neurotoxicity of Strychnos. Our hospital has admitted a patient who had cardiac arrest after taking only one herbal medicine. Although the life was saved by active resuscitation, the expensive resuscitation cost was “more than worth it” in the end.
(5) Biological agents: Due to the development of biotechnology, genetic drugs have been applied on a large scale abroad. Such as: anti-TNF-α antibody (class gram), soluble TNF-α receptor fusion protein (Yicep), anti-CD20 antibody (Rituxan), etc.. Its advantages of strong targeting effect and controlling the continued progression of bone destruction make it a more desirable therapeutic drug at present, but it also has shortcomings, (i) it is expensive; (ii) there are case reports of induced tuberculosis abroad.
In conclusion, patients in the early stage, acute stage or with persistent disease activity should be “closely monitored” once every 1-3 months until the disease is under control. Patients in remission can be followed up every six months, and regular blood tests and liver and kidney functions should be performed according to the requirements of the treatment drugs to minimize the toxic side effects of the drugs.
DMARDs can control the progression of the disease, but cannot stop the development of bone destruction, and biological agents can stop the progression of bone destruction, but cannot really “cure” rheumatoid arthritis (the percentage of patients who stop taking DMARDs at 5 years is only 19% abroad). The proportion of patients who stop taking the drug at 5 years is only 19%). In our experience, long-term, very small doses of immunosuppressive therapy after remission of the disease may remain with the patient for a long time
(ii) Surgical treatment.
Patients with rheumatoid arthritis whose disease cannot be controlled after active formal or pharmacological treatment in internal medicine may be considered for surgery in order to prevent destruction of the joints, correct deformities, and improve quality of life. However, surgery does not cure rheumatoid arthritis, so postoperative medication is still required.
Commonly used surgeries include synovectomy, arthroplasty, joint fusion, soft tissue release or repair surgery.
(C) Psychological, rehabilitation and dietary treatment
(1) Psychological treatment.
Patients are eager for treatment, but are worried about the actual effect of drugs or adverse reactions; fear of disability, or already disabled and unable to take care of themselves to increase the economic burden of the family, all add to 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, in addition to active and reasonable drug treatment, psychological treatment of rheumatoid arthritis should be paid attention to. The selection of the treatment plan and the assessment of the efficacy should also be combined with the change of the patient’s psychiatric symptoms.
(2) Rehabilitation treatment.
In the acute stage, those with severe joint pain and systemic symptoms should rest in bed, pay attention to the position at rest to avoid pressure on the joint, and to maintain the functional position of the joint, short-term splint fixation (2-3 weeks) if necessary to prevent deformation. Passive and active joint mobility training is performed as the condition allows to prevent muscle atrophy.
During the remission period, more exercise is performed without fatiguing the patient , to restore physical strength, and under the guidance of a rehabilitation physician.
(3) Diet therapy.
RA dietary therapy is still in an immature stage, some foreign studies believe that cereals (wheat, cereals, oats, rye), milk, dairy products, tea, coffee, citrus fruits, etc. can aggravate the symptoms of rheumatoid arthritis patients. As for the folk saying that you can’t eat “hairy things”, there is no reliable research to confirm that we believe that a comprehensive, balanced and light diet is sufficient, and that too much “taboo” is unnecessary.