Rheumatoid arthritis clinical guidelines. We talk in detail

Rheumatoid arthritis is a systemic chronic form of inflammation of the joints, in which the immune system destroys not only the synovial membrane, but also other connective tissues (including internal organs). It occurs 3 times more often in women, and also affects up to 5% of the population after 60 years.

Treatment of the disease is complex and almost always lifelong, and any doctor selects a treatment regimen based on clinical recommendations generally accepted by physicians.

To begin with, we will briefly talk about how the standard examination is carried out and what additional examination methods help make an accurate diagnosis.

Laboratory tests

If RA is suspected, a rheumatologist prescribes the following tests:

• blood and urine (general clinical);
• stool for occult blood;
• on the activity of liver enzymes (ALT and AST);
• for the presence of C-reactive protein (abbr. CRP) and rheumatoid factor (abbr. RF);
• to the ACDC level;
• biochemical blood test (determination of total protein, urea, triglycerides, cholesterol, bilirubin, creatinine, glucose);
• blood microreaction (precipitation reaction) to detect syphilis.

If the patient comes for the first time, then they are also examined for the presence of sexually transmitted infections using enzyme-linked immunosorbent assay (ELISA) - chlamydia, trichomoniasis, gonorrhea. Treat identified STDs before prescribing arthritis therapy.

Additionally, during a hospital stay, tests are taken for hepatitis, HIV infection, daily proteinuria and a biopsy for protein metabolism disorders (amyloidosis).

Hardware Research

Of the instrumental methods in diagnosing and monitoring the course of RA, the following are used:

• radiography of the hands every year, pelvic joints and other joints as indicated;
• FGDS (fibrogastroduodenoscopy) – examination of the intestinal and gastric mucosa;
• Ultrasound of the kidneys and abdominal organs;
• chest fluorography;

Additionally, they may prescribe ECHO-CG and computed tomography of the chest area.

American League of Rheumatology Diagnostic Criteria

They are generally accepted and used by doctors in all countries:

• damage to three or more joints;
• stiffness in the morning;
• symmetrical inflammation of the joints;
• damage to the hands;
• increased levels of RF in the blood;
• the presence of subcutaneous rheumatoid nodules;
• changes on the x-ray – osteoporosis of bones near the joints, the presence of cysts, erosions.

To make a diagnosis, at least 4 of the 7 listed criteria must be found.

Extra-articular manifestations

It is also necessary to pay attention to changes outside the joints, which often signal the active development of rheumatoid arthritis:

• Malaise, fatigue, weight loss, low-grade fever (may occur in the early stages).
• From the heart and blood vessels: vasculitis, atherosclerosis, pericarditis, valvular granulomatosis.
• Subcutaneous nodules, slight tissue necrosis near the nail bed, thickening of the skin.
• From the eyes: scleritis, ulcerative keratopathy, keratoconjunctivitis, scleromalacia.
• Damage to nervous tissue: myelitis of the cervical region, neuropathy, mononeuritis.
• Nephritis, amyloidosis, renal vasculitis.
• Anemia, neutropenia, thrombocytosis.

With severe infectious diseases and heart damage, the prognosis of rheumatoid arthritis is significantly worsened.

Rheumatoid arthritis is incurable. Therefore, the main goal of treatment is to achieve complete remission or at least reduce the frequency of relapses.

General tactics of drug treatment

The drug therapy regimen for RA is based on several rules. Firstly, the sooner the use of basic drugs (DMARDs) begins, the more successful the treatment will be.

Factors of unfavorable development of the disease must be taken into account - increased erythrocyte sedimentation rate and C-reactive protein, high RF values, rapid destruction of joints. In such situations, the drug of choice is the cytostatic drug Methotrexate. It is started at 7.5 mg per week, increasing the dosage to 25 mg/week over 3 months.

Important! The activity of treatment with basic drugs should be especially high if more than six months have passed between the first symptoms and the start of therapy.

Finally, the effectiveness of therapeutic measures is assessed through systematic laboratory and instrumental studies. Treatment of a patient with RA should be as individual as possible; if necessary, specialists from other fields are involved.

Non-drug therapy

In addition to medications, auxiliary treatment methods are of great importance. First of all, this is physical therapy:

• laser exposure;
• thermal procedures (applications with clay, paraffin, ozokerite, heating with salt, special devices);
• cryotherapy for pain relief;
• electrophoresis with medications;
• ultrasound.

• bed rest and hospitalization;
• taking penicillin antibiotics for 14 days;
• anti-inflammatory drugs (GCS Prednisolone up to 40 mg per day in tablets; when started in the first days of illness, heart disease can be avoided);
• if joint pain is severe, then NSAIDs are additionally used;
• if there is no effect from GCS, weak immunosuppressants are prescribed (Delagil, Plaquenil).

Acute rheumatism is treated for at least 8 weeks, subacute – 2 times longer.

Juvenile rheumatoid arthritis in children: treatment of the systemic form

The systemic variety has distinctive features:

• occurs before age 16;
• chronic joint damage;
• two-week fever;
• splenomegaly (enlarged spleen) and/or hepatomegaly (enlarged liver);
• transient erythematous rash;
• lymphadenopathy.

Standard therapy is not always effective for the systemic form of JA. It includes NSAIDs, intravenous infusion of immunoglobulin, oral corticosteroids and cytostatics. Today, doctors are looking for new methods of treating such arthritis, and biological agents, in particular Actemra (Tocilizumab), have become an effective solution to the problem. According to research, a positive result of therapy is observed in 98% of patients (according to the Russian Medical Journal No. 30 of November 13, 2012).

Useful video

Doctors talk about the complications of rheumatoid arthritis in the program “About the Most Important Thing.”

Conclusion

Rheumatoid arthritis requires long-term treatment and careful selection of medications. The basis of therapy is basic drugs, NSAIDs, glucocorticosteroids and, if necessary, biological drugs. The treatment regimen is chosen only by a specialist in accordance with generally accepted clinical recommendations.

About the article

Over the past decade, the management of patients with rheumatoid arthritis (RA) has changed radically, which is due, on the one hand, to the emergence of new highly effective medications, and on the other, to the development of standardized algorithms that determine the choice of therapeutic tactics in each specific case. The basis of these recommendations is the treatment strategy to achieve the goal. It was developed by experts taking into account the results of scientific research of recent decades and includes the basic principles of RA treatment. Experts believe that the goal of treatment for RA should be remission or low disease activity. The treatment-to-goal strategy requires that until the treatment goal (remission or low inflammatory activity) is achieved, activity level should be assessed monthly using one of the summary indices. The therapy carried out taking into account these results must be adjusted at least once every 3 months. If the patient persistently maintains low activity or remission, then the status can be assessed less frequently - approximately once every 6 months. The achieved treatment goal must be continuously maintained in the future.

Key words: rheumatoid arthritis, treatment, glucocorticoids, basic anti-inflammatory drugs, genetically engineered biological drugs, non-steroidal anti-inflammatory drugs, activity, remission, methotrexate, nimesulide, tumor necrosis factor inhibitors, tofacitinib.

For citation: Olyunin Yu.A., Nikishina N.Yu. Rheumatoid arthritis. Modern treatment algorithms // Breast cancer. 2016. No. 26. S. 1765-1771

Modern treatment algorithms of rheumatoid arthritis Olyunin Yu.A., Nikishina N.Yu. V.A. Nasonova Research Institute of Rheumatology, Moscow Treatment approach to rheumatoid arthritis (RA) has undergone dramatic changes in the last decade as a result of the development of novel effective medications and standard algorithms which determine treatment choice in individual cases. These recommendations are based on the “treat-to-target” strategy which was developed on the basis of recent findings and includes major principles of RA treatment. According to the experts, RA treatment goal is the remission or low disease activity. “Treat-to-target” strategy means that disease activity should be measured monthly using one of the RA activity indices until treatment goal (i.e., remission or low inflam-matory activity) is achieved. The prescribed treatment should be corrected at least every 3 months (or every 6 months in stable low disease activity or remission). The achieved treatment goal should be maintained permanently.

Key words: rheumatoid arthritis, treatment, glucocorticoids, disease-modifying anti-rheumatic drugs, engineered biological agents, non-steroidal anti-inflammatory drugs, activity, remission, methotrexate, nimesulide, tumor necrosis factor inhibitors, tofacitinib.

For citation: Olyunin Yu.A., Nikishina N.Yu. Modern treatment algorithms of rheumatoid arthritis // RMJ. 2016. No. 26. P. 1765–1771.

The article presents modern algorithms for the treatment of rheumatoid arthritis

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The article discusses the problem of lumbar pain and chronic pelvic pain syndrome

The article is devoted to the issues of choosing the optimal non-steroidal anti-inflammatory drug.

Rheumatology is a specialization of internal medicine that deals with the diagnosis and treatment of rheumatic diseases.

The European League Against Rheumatism (EULAR) has released new recommendations for the treatment of rheumatoid arthritis (RA), focusing on the use of traditional disease-modifying drugs (DMARDs), biologics and biosimilars, as well as targeted synthetic drugs such as Jak (Janus kinase) inhibitors.

“The 2016 update to the EULAR guideline is based on the most recent research in the treatment of RA and the discussions of a large, wide-ranging international working group. These recommendations synthesize current thinking about approaching the treatment of RA into a set of comprehensive principles and recommendations,” writes Josef S. Smolen, MD, Chairman of the Department of Rheumatology at the Medical University of Vienna in the Annals of Rheumatic Diseases.

The guidelines were last updated in 2013, and since then there have been several new approved treatments and refinements in therapeutic strategies and clinical outcome assessment, which in turn prompted the task force to provide an update on these principles and recommendations.

“EULAR experts tend to develop fairly simple guidelines that are very practical, without some of the levels of detail often found in ACR and other group guidelines,” Saag noted in an interview with MedPage Today. “The recommendations are few and simple, and this really reflects the process that EULAR uses, which is a mixture of systematic review, evidence synthesis and expert consensus.”

General principles

The four fundamental principles underlying treatment are that:

• RA management should rely on shared decision-making between the patient and the rheumatologist;
• treatment decisions should be based on activity, injury, comorbidities, and safety;
• rheumatologists play a leading role in the management of patients with RA;
• The high individual, medical and social costs of RA should be taken into account.

• Treatment with conventional disease-modifying drugs (DMARDs) should be started as soon as the diagnosis of RA is established;
• Treatment should be aimed at achieving the goal of sustained remission or low disease activity in each patient.

These recommendations are based on a large body of evidence showing that early intervention and treatment approach can dramatically change the course of RA. In general, significant improvement should be evident within 3 months, with a treatment goal within 6 months.

Communication with the patient to clarify and agree on the goal of treatment and the means to achieve this goal is of paramount importance.

Traditional disease-modifying drugs ( DMARD ) and others:

The next group of recommendations focuses on specific treatments, starting with methotrexate, that should be included in the initial strategy. Based on its effectiveness, safety (especially with folic acid), the possibility of individualizing the dose and route of administration, as well as relatively low costs, methotrexate continues to be the main (first) drug for the treatment of patients with RA, both as monotherapy and in combination with other drugs.

However, for patients with contraindications or intolerance to methotrexate, initial treatment may include or sulfasalazine , or leflunomide . Alternative DMARDs may be used if the patient does not have adverse prognostic factors such as a large number of swollen joints, seropositivity, or high acute phase blood counts.

Regarding glucocorticoids: the working group advised that consideration be given to use when traditional DMARDs are initiated or changed and should be discontinued as quickly as clinically feasible, most commonly within 3 months.

The guidelines then addressed issues related to biologic therapies or targeted synthetic DMARDs, indicating that they are options after avoiding the first conventional DMARD in patients with poor prognostic factors. However, the authors note that the biologic agents currently favored are the tumor necrosis factor inhibitors (anti-TNF), abatacept (Orencia), the interleukin-6 blocker Tocilizumab (Actemra), and the anti-B cell agent Rituximab (MabThera).

The recommendations also note that Other options include Sarilumab, Clazakizumab and Sirukumab, as well as Tofacitinib ( Xeljanz ) and other Janus kinase inhibitors such as baricitinib.

Besides, biosimilars should be preferred if they are indeed significantly cheaper than other targeted agents.

If treatment with biologics or targeted agents fails, another biologic or targeted agent may be considered, and if the failed biologic was a TNF inhibitor, either another TNF inhibitor or an agent with a different mechanism of action may be tried. However, it is unclear whether a second Janus kinase (Jak) inhibitor or IL-6 blocker might be useful after failure of the first.

Look ahead

Finally, the guidelines considered the possibility of tapering therapy if patients are in persistent remission. For example, once glucocorticoids are discontinued, tapering biologic therapy could be considered, especially if the patient is also receiving a traditional DMARD. This taper may involve reducing the dose or increasing the interval between doses.

Tapering traditional DMARDs could also be considered, although many members of the task force believed that therapy with these drugs should not be stopped.

The task force has also developed a number of research priorities that will be reviewed over the next few years, including:

• Can induction therapy with a biologic + methotrexate followed by withdrawal of the biologic lead to sustained remission?
• Can predictors of response to various biological and targeted synthetic therapies be identified?
• What impact do traditional DMARDs, biologics, and targeted synthetic drugs have on cardiovascular outcomes?

Translation and adaptation: Miroslava Kulik

International standard for the treatment of rheumatoid arthritis

The international standard for the treatment of rheumatoid arthritis is a single protocol developed in 2013 for the diagnosis and treatment of the disease. This document includes a detailed description of the pathology and a mandatory list of actions of the attending physician in one or another of its forms. The document describes in detail treatment depending on the form and stage of rheumatoid arthritis, as well as the doctor’s actions in the presence of complications that arise during the long course of the disease.

General standards for diagnosis and treatment of the disease

Every year the number of people suffering from rheumatoid arthritis increases. Patients do not always seek medical help for various reasons. Based on the results of past years, the official numbers of patients in Russia are about 300 thousand patients suffering from this disease. To count patients who did not seek help, this figure must be multiplied by 100.

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To make a diagnosis, the patient must undergo an examination as directed by a doctor. The basis for its appointment is the patient’s complaints, as well as the results of the initial examination. The doctor makes a preliminary diagnosis, which usually does not indicate the stage of development of the disease and systemic manifestations of rheumatoid arthritis. A more detailed diagnosis is made after tests, as well as after an instrumental examination of the patient.

Standards of diagnostic approach for rheumatoid arthritis:

• Manifestation of symptoms;
• The results of the external examination of the patient - determination of the number of inflamed joints, the degree of their damage, the presence of complications from other organs;
• Laboratory tests confirming arthritis;
• The presence of characteristic signs of the disease during instrumental examination (especially with radiography or MRI).

After confirming the disease, the doctor will select the appropriate therapy. Rheumatoid arthritis is incurable, but with timely treatment it is possible to stop the progression of the disease, as well as restore those changes in the joints that are still reversible. Determining the treatment method for rheumatoid arthritis directly depends on the stage of the identified pathology, as well as the presence of complications and the likelihood of an unfavorable prognosis.

The standards describe the main objectives of the treatment of rheumatoid arthritis:

• Relieving pain and inflammation - under this condition, the destruction of connective tissue slows down;
• Restoration of joint tissue that has not undergone severe destruction - a number of changes are still reversible, and the administration of a course of certain medications contributes to partial recovery.

Guided by the standard, therapy for rheumatoid arthritis is divided into 2 types:

• Symptomatic – is not a treatment for the disease, but is aimed at relieving symptoms, alleviating the suffering of the patient;
• Basic – provides complete or partial remission, restores joint tissue as much as possible.

Clinical protocol for rheumatoid arthritis

Initially, there were no specific standards for examining patients with this pathology, and the classification varied even in Russia, the CIS and Western countries. Rheumatoid arthritis is a worldwide problem, which forced rheumatologists to publish a single document - the “International Protocol for Rheumatid Arthritis.” In Russia, it was approved on December 12, 2013 under the version “MZ RK - 2013”. After adoption, uniform standards for treating the disease were developed, which significantly reduced the rate of complications and facilitated the exchange of experience between clinicians from different countries.

The clinical protocol for rheumatoid arthritis includes the following sections:

• A brief description of the disease, including codes for the types of arthritis according to ICD-10. This significantly saves the doctor’s time to make a diagnosis;
• Detailed classification of pathology;
• Diagnostics;
• Differential diagnosis – allows you to exclude diseases with similar symptoms;
• Standards of treatment.

This protocol is intended for healthcare professionals. Patients can use it as an introduction.

Diagnostic approach according to the standard

The protocol specifies mandatory diagnostic measures carried out for suspected rheumatoid arthritis, which are divided into two large groups:

• Diagnostic appointments before hospitalization are necessary for a preliminary examination of the patient in order to recognize the disease and its complications that threaten the patient’s condition. In this case, the goal is not to differentiate from other diseases - this will be dealt with by doctors during hospitalization;
• A list of diagnostic methods carried out in a hospital - in this case, the patient undergoes a full examination to determine the degree of activity of the process, identify the form and stage of the pathology, and is also examined for the presence of all possible complications. At this stage, a differential diagnosis with similar pathologies is carried out to eliminate errors.

Basic diagnostic methods described in the protocol

According to the standard, the following results are of greatest value:

• Blood tests - increased ESR and leukocytosis with a shift to the left, increased C-reactive protein and a number of enzymes. Also a sign of pathology is an increase in globulin levels and a decrease in albumin;
• Immunological examination - detection of rheumatoid factor and cryoglobulins;
• X-ray examination - reduction of the articular cavity, signs of damage and destruction of cartilage.

Diagnostic criteria

The American League of Rheumatology has proposed the following criteria to prove rheumatoid arthritis:

• Joint stiffness or difficulty moving for at least an hour;
• The presence of arthritis of 3 or more joints;
• Inflammation of small joints of the upper limb;
• The same lesion on the right and left;
• Presence of rheumatoid nodules;
• Detection of rheumatoid factor in blood serum;
• X-ray signs of this disease.

Rheumatoid arthritis is confirmed if 4 of the criteria described above are identified. The first four must be consistently registered for 1.5 months.

An international standard for diagnosing rheumatoid arthritis was proposed in 2010 by the European League Against Rheumatic Diseases. The essence of the standard is that each diagnostic criterion corresponds to a certain number of points, which are ultimately summed up. If during the examination their number is 6 or more, a diagnosis of rheumatoid arthritis is made. These criteria are presented in the table below:

Clinical recommendations for rheumatoid arthritis: specifics of diagnosis, treatment

Rheumatoid arthritis is a serious disease that attracts the attention of doctors from different countries. The lack of clarity of the causes of occurrence, the severity of the course, and the complexity of healing determine the importance of the cooperation of doctors in the study of the disease. Clinical recommendations are developed by the Association of Rheumatologists with the aim of developing a unified scheme for identifying the disease, developing treatment options, and using modern medications.

Rheumatoid arthritis is described in clinical guidelines as a chronic disease. The disease causes an autoimmune response of the body - a striking change in the protective reaction caused by an unclear reason. According to ICD 10, manifestations of rheumatoid arthritis are coded M05-M06 (belong to the class of inflammatory pathologies).

Patients are characterized by a severe pathological condition that occurs differently in different stages. Clinical recommendations consider several periods of illness:

1. Ultra-early period (up to six months of disease development).
2. Early period (from six months to a year).
3. Expanded period (from one to two years).
4. Late period (from two years of disease existence).

Early detection of the disease increases the chances of stopping the pathological process. Medical staff recommend seeking help immediately after finding suspicious negative symptoms.

The clinic of rheumatoid arthritis is marked by the following manifestations:

• inflammation of the joints (damage to the joints of the hands is common);
• feeling of stiffness in movements, especially after waking up;
• elevated temperature;
• permanent weakness;
• high sweating;
• decreased appetite;
• the appearance of subcutaneous nodules.

A distinctive feature of the disease is the manifestation of symmetry of the inflamed joints. For example, inflammation on the right leg is accompanied by a similar lesion on the left limb. Consult a doctor immediately if you have symmetrical lesions!

Examinations of patients using X-rays show the presence of several stages:

• stage No. 1 shows a slight decrease in bone density in the periarticular area;
• stage No. 2 marks the expansion of the bone lesion, the appearance of gaps, and initial signs of bone deformation;
• stage No. 3 reveals severe osteoporosis, accompanied by pronounced deformations of bone tissue, joint dislocations;
• Stage No. 4 highlights bright bone lesions, joint joint disorders, and growths on the joints.

An important condition for correct classification is the professionalism of medical staff. An experienced doctor will correctly classify the disease, highlight the degree of development of the disease, and clarify the symptoms.

Remember - distrust of the doctor hinders the effectiveness of treatment. If there is no contact with a medical professional, you should seek treatment from another specialist.

Basic principles of disease diagnosis

It is quite difficult to make a correct medical opinion. Doctors are guided by the following principles for diagnosing a disease:

1. There are no unique characteristics of the disease. You should not expect specific manifestations of rheumatoid arthritis. It is important to realize that the doctor’s suspicions should definitely be confirmed by reliable research (for example, x-rays, laboratory methods).
2. The final medical opinion is made by a rheumatologist. The therapist must refer the patient for a rheumatological consultation if there are suspicious symptoms (prolonged feeling of stiffness, swelling of the joint area).
3. If in doubt, it is worth holding a consultation of specialists to help provide the correct medical opinion.
4. It is important to remember the need to analyze the possibility of the manifestation of other diseases. The doctor needs to study all possible illnesses that have similar symptoms.

Important! If a joint is inflamed, do not expect changes in other joints! Do not delay contacting a doctor, wasting time. Early treatment (preferably before six months of illness) will provide a chance to fully preserve the quality of life of patients.

Differential diagnosis of pathology based on clinical recommendations

The doctor's diagnosis of rheumatoid arthritis according to clinical recommendations is carried out comprehensively in several areas. The basis for the medical report is the classification criteria described in the clinical guidelines. When examined by a doctor, the following symptoms are alarming:

• the patient complains of various pains in the joint area;
• patients are characterized by morning stiffness (it is difficult for patients to move their joints for about half an hour);
• the affected areas are swollen;
• the inflammatory process bothers the patient for at least two weeks.

Employees evaluate joint damage using a five-point system. A unit is assigned in a situation of inflammation of 2 to 10 large joints, the maximum 5 points are received by a patient with many inflamed joints (at least 10 large joints, at least one small).

Remember - the disease strikes slowly. The development of the disease is characterized by a slow increase in pain over several months. Patients are pleased by the absence of significant symptoms, but this symptom is an alarming signal for the doctor. Be sure to monitor the intensity of negative symptoms, the frequency of pain, and the strength of painful sensations.

Instrumental diagnostics allows you to clarify the medical conclusion by performing the following procedures:

1. X-rays allow you to see changes in the joints. The doctor examines the condition of the joint spaces, analyzes the presence of joint dislocations (subluxations), studies bone density, sees cysts, and diagnoses the presence of erosive lesions. Research is used for the initial analysis of the disease. Further, patients are recommended to repeat this examination procedure annually.
2. Magnetic resonance imaging is more sensitive compared to x-rays. MRI reveals inflammatory processes in the synovial membranes, erosive bone lesions, and connective tissue lesions (surrounding the joints).
3. Ultrasound diagnostics makes it possible to discern pathological changes in the joints. The medical professional is able to see erosions, affected areas of connective tissue, proliferation of the synovial membrane, and the presence of pathological effusions (places of fluid accumulation). The results of ultrasound diagnostics demonstrate the boundaries of the affected area and allow you to track the intensity of inflammation.

Instrumental examinations complement the diagnosis. However, it is unlawful to issue a medical report based on the results of this diagnosis. The presence of the disease must be confirmed by laboratory tests!

Laboratory methods are of great importance for an accurate medical conclusion:

• Blood test for antibodies against citrullinated cyclic peptide (CCCP). This method allows you to diagnose diseases at an early stage. Analysis of the ACCP allows you to confirm the medical report, identify the form of the disease, and analyze the course. Through analysis, medical staff predict the rate at which the disease will progress. Normally, the content of specific antibodies does not exceed 20 IU/ml. Elevated levels are a cause for concern. Often, positive test results precede the manifestation of negative symptoms.
• A test for the presence of rheumatoid factor helps diagnose the disease. In the absence of disease, the indicators are zero or not higher than 14 IU/ml (indicators are the same for minors, adults, and the elderly).
• Tests for the presence of viruses in the body (tests for HIV infection, for various types of hepatitis).

ACCP tests and a test for the presence of rheumatoid factor are taken from the patient’s vein. It is recommended to contact the laboratory in the morning and not eat before taking tests. The day before visiting the laboratory technicians, it is unacceptable to eat fatty foods or smoked products. Blood serum can clot, depriving the patient of correct results.

Current trends in disease treatment

Having heard about the incurability of the disease, patients feel emptiness, anxiety, and hopelessness. You should not succumb to depression - medical staff will help you overcome the disease. Traditionally, chronic rheumatoid arthritis is pacified through comprehensive treatment:

1. Basic anti-inflammatory drugs help stop inflammatory processes in patients. Among the drugs in this category, Methotrexate tablets are popular. If tolerance is insufficient, doctors prescribe Leflunomide. Treatment with Sulfasalazine is also acceptable. Patients leave positive reviews about the effectiveness of gold preparations.
2. Non-steroidal anti-inflammatory drugs significantly improve the well-being of patients by reducing pain. Ibuprofen, Ketonal, Dicloberl actively help patients. Severe disease situations require prescription of Ketorolac. The doctor considers each situation individually, choosing the optimal combination of medications suitable for a particular patient.
3. Glucocorticoids help suppress atypical reactions of the body, allowing the symptoms of the disease to subside. Dexamethasone and Prednisone are actively used. Hormonal therapy is used with extreme caution when treating minors, for fear of disrupting the development of children's bodies. For adult patients, drugs of this series are prescribed in situations where the lack of results from previous treatment has been confirmed.

The most difficult thing in treating a disease is selecting effective medications. It is impossible to predict the effect of a drug on a specific patient. Doctors are forced to observe the effect of the medicine for about three months (the minimum time is about a month). The absence of the expected result forces you to change the dose of medications or completely change the drug.

The use of genetic engineering is recognized as a new method in rheumatology. This group of drugs represents genetic engineering developments that suppress atypical reactions of the body.

Infliximab injections give hope for the recovery of patients. Remicade is the only drug containing this substance. Infliximad is a synthesis of human and mouse DNA, which makes it possible to contact negative factors, neutralize immune responses, and extinguish atypical reactions. The end result is the elimination of rheumatoid arthritis. Clear benefits of Remicade:

• quick effect (obvious improvements occur in a couple of days);
• high effectiveness (suppression of the disease development mechanism);
• duration of positive results (patients forget about an unpleasant diagnosis for several years);
• efficiency even in difficult situations.

Disadvantages of using infliximab in the complex treatment of rheumatoid arthritis:

1. The need to stay under IV drips (the medicine is administered in a course).
2. A variety of side effects (the likelihood of nausea, headaches, cardiac dysfunction, allergic manifestations, and other negative reactions).
3. Extremely high price (patients will have to pay about $400 for 100 milligrams of the drug).

Lack of funds for treatment is not a reason to be sad. When conducting experiments, medical staff offer patients a free cure. There are opportunities to get into experimental groups and take part in testing new drugs. It is important to follow the news, actively study modern forums, and apply for trial studies.

Biological drugs are another novelty in the fight against disease. The main effect of the drug is due to the establishment of specific bonds with protein molecules that suppress atypical reactions of the body. Clinical guidelines for rheumatoid arthritis advocate the use of new biological agents to treat the disease. Among this group of medicines are:

• Humira contains the active ingredient adalimumab, which stops tumor necrosis factor. For adult patients, the drug is injected into the abdomen and thighs;
• Kineret (anakinra) is used subcutaneously, blocking interleukin-1 protein;
• Etanercept stimulates the reproduction of white blood cells. The medicine is injected subcutaneously into adults, minors, and elderly patients.

Using several biological drugs at once is a big mistake. It is unacceptable to consider drugs harmless, mix different types, or prescribe independent treatment. Be treated only under the supervision of medical staff!

Rheumatoid arthritis is an extremely complex disease that requires careful treatment. Final healing is impossible, but modern clinical recommendations make it possible to extinguish the manifestations of the disease, minimize negative consequences, and allow patients to enjoy life.

Standard for the treatment of rheumatoid arthritis (international)

Arthritis is a chronic disease that cannot be completely cured. Medicines, surgery and exercise constitute the international standard of care for rheumatoid arthritis.

Taken together, these measures will help the patient control or minimize unpleasant symptoms. They will also prevent further joint damage from rheumatoid arthritis.

Diagnostics

No test alone can confirm the diagnosis of rheumatoid arthritis. The new international treatment standard and protocol aims to diagnose arthritis in its early stages. At this time, it is important to obtain maximum information about specific markers in the blood, to notice the slightest deformation of the rheumatoid joints during a hardware examination.

Only a comprehensive examination will show the presence of rheumatoid arthritis in a patient.

The laboratory test will look at a complete blood count, which:

1. Measures the number of each cell type (white blood cells, platelets, etc.).
2. Detects specific antibodies (rheumatoid factor and/or anticyclic citrullinated peptide).
3. Determines erythrocyte sedimentation rate and C-reactive protein level.
4. Measures the level of electrolytes (calcium, magnesium, potassium).

Synovial fluid is also analyzed - with rheumatoid arthritis, its quantity and quality changes. There is too much of it, the number of leukocytes increases. Fluid is withdrawn from the patient's rheumatoid joint (usually the knee) with a special needle. A level of indicators above normal does not yet confirm the diagnosis of rheumatoid arthritis, but in combination with other markers it helps in diagnosis.

Important! Initially, the deformations may not be visible. But this does not mean that there is no arthritis. It is necessary to take into account the data of laboratory tests in order to give the patient a definitive diagnosis for diseased joints.

Hardware examination includes:

1. Visual inspection of the rheumatoid joint for redness, swelling, and checking mobility.
2. Magnetic resonance imaging is used for early detection of bone erosion in the initial diagnosis of rheumatoid arthritis.
3. An ultrasound examines the internal structure of a joint with rheumatoid arthritis and looks for abnormal fluid accumulation in the soft tissue around it.
4. Damage and inflammation of the joints at an early stage, if present, is very difficult to examine. Therefore, X-rays are prescribed to patients to monitor the progression of rheumatoid arthritis.
5. Arthroscopy examines the inside of the rheumatoid joint using
   a narrow tube with a camera at the end. It will be additional
   a method for detecting signs of joint inflammation.

Treatment

Any disease is easier to prevent than to cure. Standards of treatment adopted by the international medical community are aimed at controlling joint inflammation. Timely diagnosis will help speed up remission and prevent further damage to joints and bones from rheumatoid arthritis.

Medication

Nonsteroidal anti-inflammatory drugs reduce the clinical manifestations of rheumatoid arthritis:

1. Ibuprofen – relieves pain and relieves joint inflammation during exacerbation; it should be taken for rheumatoid pain of mild to moderate intensity. Contraindicated for diseases of the gastrointestinal tract, allergies, dysfunction of the heart, liver, kidneys, and hematopoietic disorders. Adults take tablets once or twice a day, but no more than 6 tablets per day.
2. Naproxen is a gel that relieves swelling and hyperemia of rheumatoid joints. Prescribed to relieve symptoms and as a prevention of degenerative changes. Contraindicated for women during pregnancy, breastfeeding, allergies or open wounds on the skin. The gel is applied to the affected areas 4-5 times a day.
3. Celecoxib – indicated for symptomatic relief. Not recommended for pregnant women and after childbirth, during heart surgery, allergies. Capsules of 100 mg are taken orally 2 times a day, the dose can be increased to 400 mg per day.

Corticosteroids and non-biological inhibitors of rheumatoid joint inflammation slow the progression of arthritis:

1. Methotrexate is prescribed for acute and severe forms of rheumatoid arthritis, when other drugs are powerless. Doctors call it the “gold standard” of treatment. Contraindications – dysfunction of the kidneys, liver, stomach, chronic infections. Injections are administered inside a vein or muscle, dosage ranges from 7.5 mg to 25 mg per week.
2. Methylprednisolone is part of systemic therapy for arthritis. Not recommended for patients with tuberculosis, diabetes, arterial hypertension, glaucoma, stomach ulcers and osteoporosis, as well as pregnant women. Available in powder form for injection, injected into a vein or muscle. The dose is prescribed by the doctor; it can range from 10 to 500 mg per day.
3. Sulfasalazine is indicated when no non-steroidal drug against rheumatoid arthritis helps. The tablets are not recommended for use by pregnant, lactating women, with systemic forms of juvenile rheumatoid arthritis, patients with bronchial asthma, kidney or liver failure. The course can last six months, 1.5-3 g of the drug is taken per day.
4. Leflunomide is a basic medication for exacerbation of joint inflammation. Contraindicated in severe immunodeficiency and infections, renal and pulmonary failure, anemia. For the first 3 days, the patient takes 5 tablets daily, then 10-20 mg per day.
5. Humira (adalimumab) - normalizes inflammatory processes in the synovial fluid of rheumatoid joints and prevents the destruction of joint tissue. Indicated for high erythrocyte sedimentation rate and high levels of C-reactive protein. Contraindicated for tuberculosis, other infections, heart failure. Once every 1-2 weeks an injection is given with a dose of 40 mg.

Surgical

Surgery to restore joints affected by rheumatoid arthritis returns them to normal functioning, reduces pain, and corrects deformity.

Depending on the characteristics of the patient (year of birth, concomitant pathologies, body weight) and the stage of arthritis, the doctor decides on the advisability of surgery. The location of the affected areas and the effectiveness of previously carried out conservative treatment are also important.

Advice! The doctor needs to carefully study the medical history, and the patient needs to reduce body weight and give up bad habits (smoking). Then there will be fewer complications, and the positive effect will exceed the possible negative consequences.

The surgical approach to treating rheumatoid arthritis includes several procedures:

1. Synovectomy. Indicated for patients with inflammation of the synovial membrane of the joints of the upper and lower extremities and skeleton. During the intervention it is removed, but not forever. After some time, the membrane can regenerate and become inflamed again. Then re-excision is required.
2. Prosthetics. It is most often performed on the hip and knee joints using conventional or minimally invasive surgery. Surgery is prescribed if the disease progresses rapidly and conservative methods are not effective. A rheumatoid arthritis patient's joint is removed and replaced with an implant.
   artificial made of plastic and metal. They can last 10–15 years. Afterwards, repeated surgery of the joint is indicated, which may not have such a positive effect as the first time.
3. Arthrodesis. It is prescribed to patients who are not suitable for total rheumatoid joint replacement for various reasons. This is a more gentle procedure that can straighten the joint and relieve pain. The bones of the area affected by rheumatoid arthritis are fused together. They are securely fixed, helping to stabilize the joint.

Immobility, suppuration, swelling and tenderness are possible complications for patients as a result of surgery. Symptomatic therapy and postoperative observation will help to cope with them.

Physical activity

If surgery is the last option for joint treatment, then physical therapy becomes necessary. With regular exercise, the muscles around the joints affected by rheumatoid arthritis become stronger. And the discomfort in patients goes away over time. Pain in the joints, if any, is first relieved.

To begin with, it is recommended to take walks - from half an hour to an hour and a half several times a week. Gradually, this regimen will become the norm, and the patient’s rheumatoid joints will adapt. Then you can start intense training.

Important! If after training you still feel severe pain or discomfort, then the load was too great. The patient needs to reduce their intensity next time or give the body more time to get used to them.

There are several types of exercises you can do.

They all relieve pain and help joints with rheumatoid arthritis move better:

1. Stretching.
2. Flexion and extension of joints.
3. Circular rotations and swings.

Allocate 20-30 minutes for training 5 times a week. Every day you can divide a block of classes into small segments of 5-10 minutes, taking breaks of several hours between them. They also increase the intensity. When the patient's muscles are weak, it is difficult for them to receive a large load at once. Over time, walking and exercise become faster and more intense.

Water sports - swimming, aerobics - have a positive effect on joints with rheumatoid arthritis. Yoga is also shown. Many patients actively use such exercises as rehabilitation. It is advisable for them to be managed by an experienced rehabilitation specialist.

You may be interested in the following article: “Arthritis of the knee joint.”

Diet

Diet alone will not cure rheumatoid arthritis. But it guarantees a reduction in joint inflammation and prevents the manifestation of many symptoms. There is no specific diet for patients with rheumatoid arthritis.

Can be eaten for joint inflammation:

1. Vegetables (white cabbage, Brussels sprouts, broccoli), spinach, chard.
2. Fruits and berries (cherries, raspberries, blueberries, pomegranates), citrus fruits (orange, grapefruit).
3. Fish (herring, salmon, mackerel, trout) and fish oil.
4. Extra virgin olive oil.
5. Eggs.
6. Whole grains.
7. Beans, beans, nuts.
8. Ginger, turmeric.
9. Skim milk.
10. Green tea.

The following should not be added to the patient’s diet so as not to provoke a relapse of rheumatoid arthritis of the joints:

1. Red meat.
2. High fat dairy products.
3. Pasta.
4. Oils – corn, sunflower, soybean.
5. Alcohol.

The amount of salt consumed by a patient with joint inflammation should not exceed 1.5 grams per day. Sugar should also be reduced, because it provokes inflammation in arthritis.

In rheumatoid arthritis, significant improvement was noted in those patients who switched to a vegetarian diet. If the patient is sensitive to gluten or dairy products, the doctor may recommend a paleo diet.

International standards for the treatment of rheumatoid arthritis

Rheumatoid arthritis has become widespread in the last 10 years. Every year the number of cases increases from 3 to 4%. The international standard for the treatment of rheumatoid arthritis is intended to reduce the number of complications.

Limbs affected by rheumatoid arthritis

Etiology of the disease

Rheumatoid arthritis is considered a systemic disease that affects connective tissue and supporting connective tissue. The disease has not been fully studied. Experts have put forward a hypothesis about a hereditary predisposition to the pathological condition.

Women over 45 years of age are more susceptible to the disease. Out of 10 cases, only one is affected by a man. The pathological process affects small joints in the feet and hands. If rheumatoid arthritis is not treated promptly, the supporting connective tissue is destroyed. The patient may lose his ability to work, and even become disabled.

Goals of therapy

Treatment of rheumatoid arthritis is aimed at achieving several goals:

1. Reducing pain, swelling, and other clinical manifestations of pathology.
2. Preventing deformation and destruction of bone and cartilage tissue, preserving the functional characteristics of the joint, reducing the likelihood of disability, improving the quality of life of patients.

The pathological process is characterized by serious complications. Therefore, therapeutic measures and diagnostics for a long time caused discussions at international congresses and congresses of specialists. Thanks to the many years of experience and qualifications of medical staff, an international protocol for the treatment of the rheumatoid process, as well as the diagnosis of arthritis, was approved.

Only a doctor will make the correct diagnosis and prescribe effective treatment

Diagnostic tests

If it is necessary to make an accurate diagnosis, you need to take into account symptoms, test results and instrumental studies.

To correctly take into account the signs of the disease, the College of Rheumatologists of America in 1987 released criteria characteristic of this process:

• signs of inflammation - swelling, pain, increased temperature at the local level in 3 or more joints;
• symmetry of pathological lesions of small diarthrosis;
• movements are constrained, especially after waking up for an hour;
• the joints of the hand are affected;
• Rheumatoid nodules are noticeable near diarthrosis;
• rheumatoid factor is detected in blood plasma without fibrinogen;
• characteristic signs are narrowing of the gap of diarthrosis, erosions, and at an advanced stage - ankylosis.

The standards for diagnosing rheumatoid arthritis provide for establishing a diagnosis if at least 4 points of the protocol are present. This scale allows you to diagnose the type of disease - seropositive or seronegative. It is determined by the presence or absence of ACCP or rheumatoid factor in the blood.

Laboratory tests are also included in the standards for diagnosing arthritis:

1. General blood test. Rheumatoid arthritis is characterized by high levels of ESR, as well as C-reactive protein, and neutropenia.
2. General urine examination. Indicators may not be outside the normal range.
3. Biochemistry of blood. The study allows you to obtain accurate information about the condition of the kidneys and liver, as they may be affected by the pathological process.
4. Rheumatoid factor (RF) and ACCP. They are characteristic indicators for the pathological process. But their absence does not mean that the patient is healthy.
5. X-ray in direct projection.
6. To identify contraindications to the use of medications, differential diagnosis is carried out.
7. Fluorographic examination of the chest.

Main symptoms of reactive arthritis

In 2010, several indicators were developed to diagnose arthritis. Each criterion is assigned a score. The survey is conducted only by a doctor. If, after the survey, the score is 6 or higher, international standards allow you to confirm the diagnosis.

Treatment of rheumatoid arthritis should be comprehensive. The earlier therapeutic measures are started, the less likely there are complications and destruction of diarthrosis. Alcoholic drinks and smoking are contraindicated for the patient. It is recommended to avoid stressful situations and hypothermia. Physical therapy is mandatory. Exercises are selected for each patient separately. It is recommended to wear arch supports and special splints.

Standard treatment

In medical practice, standards for the treatment of arthritis are applied, from which it is possible to deviate only if the patient has contraindications. The international community of doctors uses:

• anti-inflammatory drugs without steroids;
• glucocorticosteroids;
• basic anti-inflammatory drugs.

These groups of medications eliminate pain, inflammation, and prevent destructive processes in cartilage.

Anti-inflammatory drugs without steroids

Medicines reduce and completely stop pain. All medications can be purchased at the pharmacy without a doctor's prescription. But at an advanced stage and with a pronounced pathological process, these drugs have low effectiveness.

It is not recommended to use the drugs for gastritis, ulcerative lesions or duodenitis. Due to the effect on the gastrointestinal mucosa, selective anti-inflammatory drugs without steroids are used - Nimesulide, Meloxicam.

Meloxicam is a drug, a non-steroidal anti-inflammatory drug from the oxicam group

Basic anti-inflammatory drugs

They are the main group of drugs for treating the disease. In the absence of contraindications, it is prescribed after the diagnosis has been clarified.

• influence the mechanism of development of the disease;
• prevent the destruction of cartilage tissue and diarthrosis bones;
• provide stable remission;
• the clinical effect is noticeable after a month of taking the drug.

Classification of basic anti-inflammatory drugs (DMARDs):

1. By origin - synthetic and biological origin.
2. By use – rows I and II.

I series DMARDs, if there are no contraindications, are prescribed immediately upon diagnosis. The drugs are considered the most effective and are easily tolerated by patients. These are Arava, Methotrexate and Sulfasalazine.

Methotrexate is considered the “gold standard” in the treatment of the disease. Eliminates swelling and has an immunosuppressive effect. If you are allergic to one of the components, have a low number of leukocytes and platelets, pregnancy, kidney or liver failure, use is contraindicated. The initial daily dosage is individual and varies between 7.5-25 mg. Then it gradually increases until a positive effect is achieved or symptoms of intolerance to the components appear. Available in the form of tablets or injections. The doctor prescribes injections for patients with gastrointestinal pathologies. Methotrexate therapy should be supplemented with vitamin B9 (at a dosage of at least 5 mg).

Leflunomide is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis and psoriatic arthritis.

"Arava" or "Leflunomide". For the first 3 days, take 100 mg, then the dosage is reduced to 20 mg per day daily. The drug is contraindicated in case of pregnancy and excessive sensitivity to the components. Provides stable remission over a long period of time.

"Sulfsalazine." It is highly effective at the beginning of the development of the disease. Contraindicated in breastfeeding, anemia, liver and kidney failure, pregnancy, individual intolerance to components.

II line DMARDs – gold preparations in the form of injections. They are resorted to in case of ineffectiveness or intolerance of first-line remedies.

Negative consequences of basic treatment:

• damage to the digestive tract;
• skin rash and itching;
• blood pressure is increased;
• swelling;
• decreased body resistance to infections.

Therefore, only a doctor should prescribe therapeutic measures.

Before starting treatment, you must consult a rheumatologist.

Glucocorticosteroids

These include hormones produced by the adrenal cortex. Glucocorticosteroids eliminate inflammation in a short period of time. Quickly relieve pain and swelling. Due to systemic use, they are characterized by many negative consequences. To minimize unwanted effects, corticosteroids are injected into the joint. But such therapy is used only during exacerbation.

They are not used independently, as they reduce clinical manifestations and do not eliminate the cause of the disease. Used in combination with BPPV.

Early diagnostic measures will allow timely initiation of therapeutic measures. This will help prevent destructive processes and progression of the disease. Standards for the treatment of rheumatoid arthritis allow us to use many years of experience of internationally qualified specialists to make therapy effective.

Arthritis is one of the most serious diseases that causes destructive and painful consequences in the patient’s body. Stiffness and pain in the joints affected by the disease do not allow a person to perform seemingly simple tasks around the house or taking care of himself: sometimes even heating dinner or putting on socks becomes a difficult task that requires effort and can quickly tire.

The seriousness of the disease, of course, requires constant treatment, including many different medications and drugs, and in emergency cases - with osteoarthritis of the hip and knee joints - very strong painkillers.

In addition to medications, doctors strongly recommend that patients monitor their own weight, perform special complexes of therapeutic exercises, and visit a massage therapist. Paying attention to a healthy diet, maintaining a healthy weight, and improving your physical health is also important to prevent cardiovascular disease, which is directly related to diseases such as lupus and rheumatoid arthritis.

1. - Movement is mandatory! Don't allow yourself to sit at the table for more than a quarter of an hour in one position! Be sure to get up and do a little warm-up. Don't forget about this while sitting watching TV or reading a book!

2. - Avoid sudden movements and forces that create additional stress on arthritic joints. For example, if you have pain in the joints of your hands, do not try at all costs, overcoming the pain, to unscrew, for example, a tightly screwed lid on a jar. Purchase special household tools that will make your efforts easier.

3. - Use your power! Build strength in healthy muscles and joints. For example, in order not to “worry” your fingers and wrist in vain, learn to open massive doors using your shoulder or the back of your hand. To reduce the load on the affected knee or hip when walking up steps, use your stronger leg as the lead when going up, and your weaker leg when going down.

4. — Simplify your everyday life! For example, to get rid of constant ironing, purchase clothes made from material that does not require ironing. In order not to carry funds and household items from room to room, purchase several identical sets, assigning them a place in the kitchen, bathroom, and toilet. Furniture on casters allows you to move it easily and effortlessly when cleaning.

5. — Take advantage of the achievements of scientific and technological progress that make life easier! For example, in the kitchen, electric can openers are useful, and best of all, a full-fledged food processor with numerous functions. A dishwasher wouldn't hurt. In stores you can find many devices that help you avoid unnecessary painful movements when cleaning your apartment or preparing food.

6. - Secure the apartment! Take care of the bathroom first. If you have arthritis, it would be useful to mount a handrail and lay a soft rubberized mat to prevent possible slipping and falling to the floor. It is advisable, if the room allows, to place a chair under the shower for those who suffer from arthritis of the lower extremities.

7. — Don’t avoid help! Of course, it is very important for an adult to maintain their own independence, which seriously affects self-esteem and comfort in life. But independence at any cost, at the cost of loss of health, leads to disaster. Enlist the support of family and friends who can take on some of your everyday problems.

Rheumatoid arthritis is an autoimmune disease in which an inflammatory process occurs in the connective cartilage tissue and affects the joints.

Statistics say that 1% of the entire population suffers from the disease, and this is no less than 58 million people.

The pathogenesis of rheumatoid arthritis disease is worth considering in more detail.

Etiology of the disease

Today, the etiology of rheumatoid arthritis is not yet fully understood. However, there are two options for the occurrence of the disease:

1. Hereditary factor.
2. Infectious pathologies.

Hereditary causes are due to the patient’s genetic predisposition to damage the body’s immune system. A direct connection has been proven between the onset of the disease and the presence of special HLA antigens in the patient.

In addition to destroying the immune system, these antigens alter the body's normal response to infectious agents. HLAs block the body's defense system, its immune ability to resist, and allow the disease to “settle” in the body.

The hypothesis of a genetic predisposition to the development of pathology is confirmed by the fact that rheumatoid arthritis is often observed among close relatives and twins.

Infectious etiology. Modern medicine has data on several infectious agents that can trigger the appearance of rheumatoid arthritis. They are viruses:

• hepatitis B;
• Epstein-Barr;
• measles;
• rubella;
• mumps;
• herpes;
• retroviruses.

And this list is not complete. Today, doctors are actively discussing the role of microbacteria in the development of pathology. Microbacteria are capable of expressing stress proteins that are causative agents of rheumatoid arthritis.

The following categories of people are at risk for arthritis:

1. patients over 45 years of age;
2. women;
3. people whose close relatives suffer from arthritis;
4. antigen carriers;
5. those patients who have colds of the nasopharynx and bone defects.

Pathogenesis

The pathogenesis of rheumatoid arthritis is based on autoimmune processes that are disrupted at the genetic level. First, the articular membrane is damaged, then the disease becomes proliferative. Next, damage and deformation of cartilage and bone tissue begin.

In the synovial fluid, the concentration of collagen degradation products increases. The influence of these factors leads to the formation of immune complexes. After this, the mechanism of phagocytosis of immune complexes is triggered, which provokes the development of rheumatoid arthritis.

The appearance of immune complexes gives rise to platelet aggregation, promotes the formation of microthrombi, and causes pathological changes in the blood microcirculation system.

Immune complexes that damage joints cause inflammation. The pathogenesis of rheumatoid arthritis determines its clinical picture.

Clinic of the disease

The main clinical manifestation of the disease is articular syndrome. Typically, with rheumatoid arthritis, joint damage occurs symmetrically on both sides.

The onset of the disease most often coincides with cold weather conditions and those periods when physiological changes occur in the patient’s body. In addition, arthritis can begin after an injury, infection, stress or hypothermia.

Before the first signs of the disease appear, it is in a prodromal period, which can last several weeks or even months.

Main symptoms of arthritis:

• weight loss;
• weakness;
• loss of appetite;
• increased sweating;
• morning stiffness;

• low-grade body temperature.

Most often, the onset of the disease is characterized as subacute. But there is also an acute picture of the pathology: sharp pain appears in the joints and muscles, significant morning stiffness and fever are observed.

If rheumatoid arthritis develops gradually, the changes are subtle, and subsequent progression of joint damage does not impair their functionality.

The following symptoms are typical for the initial stage of the disease:

• inflammation and swelling of adjacent tissues;
• predominance of exudative processes in joints;
• limitation of joint mobility;
• pain when touching the affected joints;
• over the joints the skin is hyperemic and hot to the touch.

As the disease progresses, fibrous changes are observed in the joint capsule, ligaments and tendons. These degenerative processes lead to deformities, contractures and dislocations of the joints.

There is limited mobility in the joints. Over time, the disease can lead to complete loss of their function. First of all, diarthrosis of the hand suffers: carpal, phalangeal and interphalangeal.

1. The diseased joints begin to swell.
2. Mobility is limited.
3. There is pain when moving.

If the inflammatory process affects the interphalangeal joints, the patient’s fingers acquire a spindle-shaped shape. The hand of a person suffering from this type of arthrosis cannot bend into a fist. The interosseous spaces collapse, muscle atrophy develops. Eventually, the entire brush becomes deformed.

Deformation of the hand can lead to the fingers becoming shorter, one phalanx growing into the other, and contracture developing in the joints.

The constant progression of the disease leads to impaired sensitivity and the occurrence of paresis of the fingers, as a result of which they lose mobility.

• Pain may occur in the forearm, which will spread to the elbow joint.
• Damage to the tendons of the hand and fingers is observed.
• Rheumatoid arthritis can cause lesions of the radioulnar joint, which is manifested by intense pain when bending the wrist, often with subluxation and damage to the ulna.
• If the elbow joint is affected, limb movement is limited, the patient feels pain, and contracture develops.
• The ulnar nerve may be pinched, which provokes paresis of the corresponding area.
• Damage to the shoulder joint is characterized by inflammation of the collarbone and humerus, chest and neck, and muscles of the shoulder girdle.
• Changes may occur in the knee, ankle, and foot bones.
• With long-term and severe arthritis, lesions can develop in the hip joint. The inflammatory process is manifested by pain, limitation of movements, the hip is fixed in a bent position. A severe complication of the disease can appear as ischemic necrosis of the femoral head.
• The spinal column is rarely affected. This can happen with a long course of the disease. The cervical spine suffers, inflammation covers the atlanto-axial joint. Pain occurs in the neck area and movement is noticeably limited.
• Damage to the jaw joint typically results in pain and limited mouth opening, which makes eating difficult.

Damage to any joints is accompanied by stiffness in the morning and limited mobility. These factors lead to the fact that it becomes difficult for the patient to take care of himself; he cannot wash himself, comb his hair, get dressed, or hold cutlery in his hand.

Often people suffering from rheumatoid arthritis lose their ability to work and become disabled.

Damage to other organs and systems

• Respiratory system: pleurisy.
• Cardiovascular system: vasculitis, pericarditis, atherosclerosis, heart valve damage.
• Nervous system: neuropathy, myelitis, mononeuritis.
• Skin: hypotrophy and hypertrophy of joints, rheumatoid nodes, vasculitis.
• Kidneys: nephritis, amyloidosis.
• Organs of vision: scleritis, conjunctivitis.
• Circulatory system: anemia, thrombocytosis.

The course of rheumatoid arthritis can occur in one of the following ways:

1. Classic option. Large and small joints are affected.
2. Oligoarthritis. Large joints suffer.
3. Arthritis with pseudoseptic syndrome. Fever appears, anemia develops, and weight loss is observed.
4. Felty's syndrome. Combination of extra-articular lesions with polyarthritis.
5. Articular-visceral form.

Diagnosis and treatment

Diagnosis of rheumatoid arthritis is currently carried out on the basis of a blood test, x-ray of the affected joints, and symptoms characteristic of this pathology. The blood is examined for ESR, platelet count, rheumatic factor.

The most effective is considered to be the titer of antibodies to citrulline-containing cyclic peptide - ACCP.

Treatment of rheumatoid arthritis depends entirely on the symptoms of the disease.

• If an infection is present, the doctor will prescribe antibiotic therapy.
• Joints in the absence of extra-articular manifestations should be treated with non-steroidal anti-inflammatory drugs.
• Corticosteroids are injected directly into the joint.
• Doctors prescribe basic medications and plasmapheresis courses to patients.

Treatment of rheumatoid arthritis is a rather long process, which often takes years. It is very important to prevent osteoporosis in a timely manner. The patient's calcium balance in the body must be restored. To do this, the patient is prescribed a diet rich in this substance. The diet must include milk, cottage cheese, cheese, and walnuts.

The patient must perform daily therapeutic exercises. The selection of exercises is carried out so that muscle mass is preserved in the joint area, and the joints themselves do not lose their mobility.

Paraffin therapy, mud therapy, electrophoresis, and phonophoresis are prescribed as physiotherapeutic procedures. If the disease is in remission, sanatorium treatment is indicated.

Severe joint deformation requires surgical intervention, during which the joint is reconstructed and its functionality is restored.

Drug therapy consists of the use of the following groups of drugs:

1. basic drugs;
2. non-steroidal anti-inflammatory drugs;
3. immunological agents;
4. glucocorticosteroids.

Treatment with basic drugs slows the progression of the disease and brings about remission. Due to the fact that there are no significant joint deformities at the early stage of rheumatoid arthritis, basic therapy is most effective and plays an important role in the complex treatment of the pathology.

The most popular means of basic therapy are gold preparations, cyclosporine, methotrexate, and aminoquinoline drugs. If the prescriptions do not provide the expected effect, the doctor selects a combination of medications that should replace the previous therapy.

Nonsteroidal anti-inflammatory ointments and medications for rheumatoid arthritis are very effective. They provide antiviral and antibacterial effects.

Glucocorticosteroids should be prescribed in combination with slow-acting drugs. Current treatment methods involve the use of monoclonal antibodies, which slow the progression of the disease.

For each patient, treatment is prescribed individually. The duration of arthritis, the degree of joint damage, and the presence of concomitant diseases are taken into account. The patient must strictly follow all the doctor’s recommendations; only under this condition will the therapy bring results.

In accordance with the recommendations of the European League Against Rheumatism, Methotrexate is prescribed for rheumatoid arthritis immediately after diagnosis. Experts from the American College of Rheumatology also suggest using the “gold standard” treatment for systemic disease first. The drug meets the principles of the “Treat to Target - T2T” program, which was developed in 2008 by representatives of 25 countries in Europe, North and Latin America, Australia and Japan. It includes strategic therapeutic approaches that provide the best results in the treatment of pathology.

Description of the drug Methotrexate

Methotrexate is a cytostatic drug from the group of antimetabolites, folic acid antagonists. Cytostatics are antitumor drugs that disrupt the processes of growth and development of tissues, including malignant ones. They negatively affect the mechanism of cell division and restoration. Rapidly dividing cells, including bone marrow cells, are most sensitive to cytostatics. Due to this property, cytotoxic drugs are used to treat autoimmune diseases. By inhibiting the formation of leukocytes in the hematopoietic tissue of the bone marrow, they suppress the immune system.

Immunosuppressive therapy is the mainstay of treatment for rheumatoid arthritis, as the disease is autoimmune. With autoimmune pathologies, the body's defenses begin to fight against its own cells, destroying healthy joints, tissues and organs. Immunosuppressive therapy stops the development of symptoms and inhibits destructive processes in the joints. Cytostatics inhibit the growth of connective tissue in the joint, which gradually destroys cartilage and subchondral bones (adjacent to the joint, covered with cartilage tissue).

The action of Methotrexate is based on blocking dihydrofolate reductase (an enzyme that breaks down folic acid). The drug disrupts the synthesis of thymidine monophosphate from dioxyuridine monophosphate, blocking the formation of DNA, RNA and proteins. It prevents cells from entering the S period (the phase of synthesis of a daughter DNA molecule on the matrix of a parent DNA molecule).

Methotrexate is a first-line drug used in the basic treatment of rheumatoid arthritis. It suppresses the production of not only immunocompetent cells, but also synoviocytes (cells of the synovial membrane) and fibroblasts (the main cells of connective tissues). Inhibiting the proliferation of these cells helps prevent deformation and inflammation of the joint. Methotrexate stops bone erosions that occur as a result of the attack of actively growing tissues of the synovial membrane of the joint.

Methotrexate for rheumatoid arthritis allows you to achieve stable remission. The clinical effect persists even after its discontinuation.

Toxicity of Methotrexate

Methotrexate is the most toxic folic acid antagonist. Due to impaired methylation of deoxyuridine monophosphate, it accumulates and is partially converted into deoxyuridine triphosphate. Deoxyuridine triphosphate is concentrated in the cell and incorporated into DNA, causing the synthesis of defective DNA. In it, thymidine is partially replaced by uridine. As a result of pathological processes, megaloblastic anemia develops.

Megaloblastic anemia is a condition in which the body is deficient in vitamin B12 and folic acid. Folic acid (along with iron) takes part in the synthesis of red blood cells. These blood cells play an important role in hematopoiesis and the functioning of the entire body.

With a lack of folic acid, red blood cells that change in shape and size are formed. They are called megaloblasts. Megaloblastic anemia causes oxygen starvation in the body. If the pathological condition is observed for a long time, it leads to degeneration of the nervous system.

When treated with Methotrexate, adverse reactions characteristic of megaloblastic anemia occur. The hematopoietic function is inhibited. If recommended doses are exceeded, the following occurs:

• nausea;
• vomit;
• diarrhea.

If the drug is not discontinued in the presence of such symptoms, serious diseases of the digestive tract develop. Renal tubular acidosis (reduced urinary excretion of acids) and cortical blindness (impaired vision) are sometimes observed.

Methotrexate practically does not break down in the body. It is distributed in biological fluids and 80–90% is excreted unchanged by the kidneys. If kidney function is impaired, the drug accumulates in the blood. Its high concentrations can cause kidney damage.

With long-term treatment, liver cirrhosis and osteoporosis may develop (especially in childhood). While taking Methotrexate, the following occurs:

• dermatitis;
• stomatitis;
• sensitivity to light;
• skin hyperpigmentation;
• photophobia;
• furunculosis;
• conjunctivitis;
• lacrimation;
• fever.

Alopecia (hair loss) and pneumonitis (an atypical inflammatory process in the lungs) are extremely rare consequences of Methotrexate therapy.

Studies have confirmed the connection between the occurrence of side effects during treatment with Methotrexate and a lack of folic acid in the body. During the treatment of rheumatoid arthritis, cellular folate reserves rapidly decrease. At the same time, an increase in homocysteine ​​concentration is observed. Homocysteine ​​is an amino acid formed during the metabolism of methionine. The breakdown of homocysteine ​​requires adequate levels of folic acid. With its deficiency, the level of homocysteine ​​in the blood increases critically. Its high concentration increases the risk of atherosclerotic vascular damage and accelerates thrombus formation.

A large increase in homocysteine ​​concentration is due to the tendency for its accumulation in patients with rheumatoid arthritis. Treatment with Methotrexate enhances the negative process, especially at the stage when achieving a therapeutic effect requires increasing doses of the drug.

The administration of folic acid during Methotrexate therapy can reduce dangerous homocysteine ​​levels and reduce the likelihood of developing undesirable consequences. It helps reduce the risk of developing critical conditions in patients who have concomitant cardiovascular diseases.

Treatment with folic acid allows you to avoid other adverse reactions that occur during treatment with Methotrexate. If it is prescribed immediately after the start of a course of therapy with the basic drug or during the first 6 months of treatment, the incidence of gastrointestinal disorders is reduced by 70%. Folic acid helps minimize the risk of developing diseases of the mucous membranes and alopecia.

Folic acid for rheumatoid arthritis is taken daily throughout the entire period of treatment with Methotrexate. The dosage of the drug is selected by the doctor individually. The exception is the day you take Methotrexate.

The daily dose can be taken the next morning. This will make it possible to stop adverse reactions at the earliest stages of their development. In addition, a folic acid regimen may be prescribed, in which a weekly dose of folic acid is drunk once a week. The drug should be taken no earlier than 12 hours after taking Methotrexate.

Methotrexate therapy for rheumatoid arthritis

Treatment of rheumatoid arthritis with Methotrexate is sometimes started even before the diagnosis is confirmed, especially in cases where the pathology is rapidly progressing. The longer the disease develops, the higher the likelihood of disability and death of the patient. Therefore, the activity of the rheumatoid process must be slowed down as soon as possible.

As a rule, a one-time weekly injection of moderate doses of the drug allows you to achieve the desired result within 1-1.5 months after the start of treatment. In some cases, double or triple doses of the drug are necessary to produce and maintain the desired clinical effect.

Since complete remission occurs extremely rarely, treatment is continued for a long time. The minimum course of treatment lasts six months. In 60% of cases it is possible to obtain the required clinical result. To consolidate it, monotherapy is continued for 2-3 years. With long-term use, the effectiveness of Methotrexate does not decrease.

The drug cannot be stopped abruptly. Stopping treatment may cause an exacerbation of the disease. If it is necessary to adjust the dose downward, do this gradually.

If monotherapy does not have the desired effect on the pathological process, Methotrexate is combined with one or two drugs of basic therapy. The best treatment results were observed after using a combination of Methotrexate and Leflunomide. Leflunomide (Arava) has a similar effect. If you take both drugs, they will enhance each other's effects.

A persistent positive result is provided by therapy with Methotrexate in combination with Cyclosporine or Sulfasalazine. The sulfanilamide drug Sulfasalazine helps to achieve a significant improvement in the well-being of patients in whom the disease develops slowly.

When the pathology is difficult to treat, the doctor prescribes a combination of 3 drugs: Methotrexate, Sulfasalazine and Hydroxychloroquine. When using combination regimens, average dosages of drugs are prescribed.

During treatment with Methotrexate and for 6 months after its discontinuation, it is necessary to use reliable methods of contraception. The medication negatively affects the development of the fetus and can cause spontaneous abortion. In men, there is a decrease in sperm count.

Treatment of psoriatic arthritis

Psoriatic arthritis is a chronic systemic disease associated with psoriasis. Psoriatic arthritis is diagnosed in 13-47% of patients with psoriasis. Numerous studies have confirmed the autoimmune nature of the inflammatory process in the joints. Therefore, basic therapy drugs are most often used to treat it. They allow you to slow down the progression of pathology and achieve positive changes that are unattainable with other treatment methods.

The modifying properties of Methotrexate in psoriatic arthritis are beyond doubt. They have been proven by many years of experience. The drug demonstrates an optimal balance of effectiveness and tolerability compared to other cytostatic drugs.

Methotrexate for psoriatic arthritis is used not only to slow down destructive processes in the joints, but also to reduce dermatological manifestations. The medication is the drug of choice in the treatment of generalized exudative, erythrodermic and pustular psoriatic arthritis. It helps alleviate the condition of patients suffering from the most severe forms of dermatosis.

The treatment program is developed individually by the doctor. Begin therapy with small or medium doses. Injections are given weekly. If there is no result, the dosage can be doubled. After the appearance of a stable therapeutic effect, the dose is reduced. Methotrexate can be taken not only parenterally, but also orally.

A significant improvement in the condition of patients occurs within 3-4 weeks after the first dose of the drug. By the end of the second month, all indicators of articular syndrome decrease by 2-3 times. Methotrexate therapy demonstrates excellent results in relation to skin manifestations. In almost all patients, the progressive stage of psoriasis stops. Such a high effectiveness of the drug is due not only to its immunosuppressive effect, but also to its anti-inflammatory effect.

Over 6 months of therapy, positive dynamics of dermatosis develops in 90% of patients, as evidenced by numerous reviews. Almost every fifth patient managed to achieve complete remission of the articular syndrome.