There is no specific therapy for rheumatoid arthritis so far, and it still stays in the treatment of inflammation and sequelae. Most patients can get certain curative effect after comprehensive treatment. At present, the purpose of treatment is: ① to control the inflammation of joints and other tissues and relieve symptoms; ② Maintain joint function and prevent deformity; ③ Repair damaged joints, relieve pain and restore function.
(a) general treatment of fever, joint swelling and pain, systemic symptoms should be bed rest until the symptoms basically disappear. After two weeks of improvement, you should gradually increase your activities to avoid joint disuse and even promote joint stiffness after long-term bed rest. Protein and various vitamins in the diet should be sufficient, and those with obvious anemia can receive a small amount of blood transfusion. If there are chronic diseases such as tonsillitis, it should be removed as soon as the patient's health permits.
(2) drug therapy
1. Non-steroidal anti-inflammatory drugs are used in primary or mild cases, and their mechanism of action is mainly to inhibit cyclooxygenase to inhibit prostaglandin production, thus achieving anti-inflammatory and analgesic effects. But it can't stop the natural process of rheumatoid arthritis. Because of different metabolic pathways in the body, these drugs can interact with each other. Joint application is not recommended, and individualization is emphasized.
⑴ Salicylic acid preparation: anti-rheumatic, anti-inflammatory, antipyretic and analgesic. The dosage is 2 ~ 4g per day. If the curative effect is not ideal, the dosage can be increased appropriately, sometimes 4 ~ 6g per day is effective. Generally taken after meals or combined with antacids, enteric-coated tablets can also be used to reduce gastrointestinal irritation.
⑵ Indomethacin is a derivative of indoleacetic acid, which has anti-inflammatory, antipyretic and analgesic effects. If patients can't stand aspirin, they can switch to this medicine. The usual dosage is 25mg 2 ~ 3 times a day, and it is easy to produce side effects when it exceeds 100mg a day. Side effects include nausea, vomiting, diarrhea, gastric ulcer, headache, dizziness and depression.
⑶ Propionic acid derivatives: They are a kind of drugs that can replace aspirin, including ibuprofen, naoproxen and fenbufen. They have similar effects with aspirin, similar curative effects and little side effects in digestive tract. Commonly used dosage: ibuprofen 65438+ 0.2 ~ 2.4g daily, 3 ~ 4 times, naproxen 250mg each time, twice a day. Side effects include nausea, vomiting, diarrhea, peptic ulcer, gastrointestinal bleeding, headache and central nervous system disorder.
⑷ antacids: o-aminobenzoic acid derivatives, which are similar to aspirin. 250 mg of antacid each time, 3 ~ 4 times a day. Chlormequat chloride is 200 ~ 400 mg each time, three times a day. Side effects include gastrointestinal reactions, such as nausea, vomiting, diarrhea and loss of appetite. Occasionally rash, renal function damage, headache, etc.
2. At present, gold preparation is considered to have a positive effect on rheumatoid arthritis. Gold (sodium thiomalate myosin) is commonly used. Usage 10mg intramuscular injection in the first week, 25mg in the second week. If there are no adverse reactions, 50 mg per week in the future. When the total dose reaches 300 ~ 700 mg, most patients begin to take effect, and when the total dose reaches 600 ~ 1000 mg, the condition can be steadily improved. The maintenance capacity is 50 mg per month. Because of the possibility of recurrence after stopping taking drugs, the useful maintenance amount abroad has been for many years, and it is taken directly for life. The earlier the gold preparation is used, the more effective it will be. Gold preparation takes effect slowly and takes 3 ~ 6 months to take effect, so it is not suitable to be used with immunosuppressants or cytotoxic drugs. If the total amount has reached 1000mg during the treatment period, and the condition is still not improved, the drug should be stopped. The effect of oral gold preparation is similar to that of injection gold. Side effects include increased stool frequency, rash, stomatitis, tension injury, etc. , can be recovered after stopping the drug.
Auranofin, an oral gold preparation, is a hydroxyl compound of gold phosphide. The dosage is 6mg once a day, and it will take effect after 2 ~ 3 months. Patients with short early course of disease have better curative effect. The side effect is lighter than that of injection, and diarrhea is common, but it is transient and the effective rate is 62.8%.
3. Penicillamine is an amino acid drug containing sulfhydryl group, which has certain curative effect on chronic rheumatoid arthritis. It can selectively inhibit some immune cells and reduce IgG and IgM. Side effects include thrombocytopenia, leukopenia, proteinuria, allergic skin rash's disease, anorexia, optic neuritis, myasthenia and elevated transaminase. Usage: Take 250mg orally every day in the first month and 250mg every time in the second month, twice a day. There was no obvious effect in the third month, 250mg each time, three times a day. The maximum dose is 750mg each time. Most clinical symptoms get better within 3 months, and the symptoms are maintained in a small dose after improvement, and the course of treatment is about one year.
4. Chloroquine has certain anti-rheumatic effect, but the effect is very slow, and it usually takes 6 weeks to 6 months to reach the maximum effect. It can be used as salicylic acid preparation or auxiliary medicine to reduce the dose of corticosteroids. 250~500mg orally each time, twice a day. Many gastrointestinal reactions such as nausea, vomiting and loss of appetite often occur during the treatment. Long-term application should pay attention to retinal degeneration and optic atrophy.
5. Levamisole can relieve pain and shorten the time of joint stiffness. The dosage is 50mg for the first time, once a day 1 time, 50mg twice a day in the second week, 50mg three times a day in the third week. Side effects include dizziness, nausea, allergic skin rash, decreased vision, lethargy, neutropenia, thrombocytopenia, liver function damage, proteinuria, etc.
6. Immunosuppressants are suitable for patients with severe rheumatoid arthritis who are ineffective in other drugs. Azathioprine is often used for patients who stop taking drugs or have hormone deficiency, 50mg each time, 2 ~ 3 times a day. Cyclophosphamide 50mg each time, twice a day. After special symptoms or laboratory tests are improved, gradually reduce the amount. The maintenance dose is 65438+ 0/2 ~ 2/3 of the original therapeutic dose. Continuous use for 3 ~ 6 months. Side effects include bone marrow suppression, leukopenia and thrombocytopenia, hepatotoxic damage and digestive tract reaction, alopecia, amenorrhea, hemorrhagic ophthalmia and so on.
Methotrexate (MTX) has immunosuppressive and anti-inflammatory effects, and can reduce erythrocyte sedimentation rate and improve bone erosion. Intramuscular injection or oral administration of 5 ~ 15 mg per week, with 3 months as a course of treatment. Side effects include anorexia, nausea, vomiting, stomatitis, alopecia, leukopenia or thrombocytopenia, drug-induced interstitial pneumonia and rash. It may become another palliative drug after gold and penicillamine.
7. Adrenocortical hormone Adrenocortical hormone has a rapid effect on joint swelling and pain, controlling inflammation, diminishing inflammation and relieving pain, but its effect is not lasting and has no effect on etiology and pathogenesis. Once the drug is stopped, the short-term fairy will relapse. Radio frequency, ESR and anemia did not improve. Long-term application can lead to serious side effects, so it is not used as routine treatment, and it is only used by people with severe vasculitis and affecting the function of important organs. For example, eye complications may lead to blindness, central nervous system diseases, heart block, synovitis with persistent joint activity, etc. Can be used for a short time, or after treatment with NSAIDS, penicillamine, etc. , the effect is not good and the symptoms are serious, affecting daily life. On the basis of the original drug, a small dose of corticosteroids can be added. If not, you can increase it as appropriate. After the symptoms are controlled, it should be gradually reduced to the minimum maintenance.
Prednisone acetate suspension can be used for local intra-articular injection, which is suitable for some difficult diseases of a single big joint, with 25 ~ 50mg intra-articular injection each time to prevent intra-articular infection and bone destruction. Triamcinolone acetonide acetate is a long-acting corticosteroid suitable for intra-articular administration, with a single dose of 10mg and a knee joint of 30mg.
8. After many years of clinical application and experimental research in China, tripterygium wilfordii has a good effect. It has non-steroidal anti-inflammatory, immunosuppressive or cytotoxic effects, and can improve symptoms and reduce ESR and RF titer. Tripterygium wilfordii polyglycoside 60mg/d, 1 ~ 4 weeks can have clinical effect. Side effects include irregular menstruation and menopause in women, decreased sperm count in men, rash, leukopenia and thrombocytopenia, abdominal pain and diarrhea. It can be eliminated after drug withdrawal.
Tripterygium wilfordii has a similar effect, 2 ~ 3 tablets each time, 3 times a day. The course of treatment is more than 3 to 6 months. Side effects: dizziness, dry mouth, sore throat, anorexia, abdominal pain, amenorrhea.
9. Other therapies such as thymosin and plasma exchange have yet to be explored.
(3) The purpose of physiotherapy is to increase local blood circulation and relax muscles by hyperthermia, so as to achieve the effects of diminishing inflammation, reducing swelling and relieving pain. At the same time, exercise is used to maintain and enhance joint function. There are several physical therapy methods: hot water bag, hot water bath, wax bath, infrared ray and so on. Massage after physical therapy to improve local circulation and relax muscle spasm.
The purpose of exercise is to preserve the activity function of joints and enhance the strength and endurance of muscles. After the symptoms in the acute phase are relieved and subsided, as long as patients can tolerate it, they should do active or passive joint exercises regularly in the early stage.
(4) Surgical treatment In the past, it was always thought that surgery was only suitable for cases of late deformity. At present, only 1 ~ 2 joint is seriously damaged, and those who are ineffective in salicylate treatment can try early synovectomy. Osteotomy is feasible for cases with static lesions and obvious joint deformities in the later stage. Arthroplasty and artificial joint replacement can be used for cases with stiff or damaged joints. Weight-bearing joints can be used for joint fusion and so on.
Generally speaking, given active comprehensive treatment in the early stage, most of them recover well. Acute attack is better than slow attack, and male is better than female. Only a few joints are involved, but the systemic symptoms are mild, or the joints are asymmetrical, the course of disease is often short, and about 10% ~ 20% patients are disabled due to untimely treatment. This disease does not directly lead to death, but serious advanced cases can die of secondary infection.
Etiology of rheumatoid arthritis
It's not completely clear yet. Rheumatoid arthritis is a disease closely related to environment, cell, virus, heredity, sex hormones and neuropsychiatric state.
The experimental study of (1) bacterial factors shows that the existence of peptidoglycan in group A streptococcus and bacterial wall may be a persistent irritant of RA. Group A streptococcus exists in the body for a long time and becomes a persistent antigen, which stimulates the body to produce antibodies and causes immunopathological damage. The animal model of arthritis made by mycoplasma is similar to human RA, but it does not produce rheumatoid factor (RF) specific to human RA. Bacteria or bacterial antigens have never been found in joint fluid and synovial tissue of RA patients, suggesting that bacteria may be related to the pathogenesis of RA, but there is no direct evidence.
(2) The relationship between virus factor RA and virus, especially EB virus, is one of the concerns of scholars at home and abroad. Studies have shown that arthritis caused by EB virus infection is different from RA, and RA patients have a stronger response to EB virus than normal people. Antibodies against Epstein-Barr virus membrane antigen appeared in serum and synovial fluid of RA patients, but so far, no antibodies against Epstein-Barr virus nuclear antigen or shell antigen were found in serum of RA patients.
(3) Genetic factors The incidence of this disease is relatively high in some families. In the population survey, it was found that human leukocyte antigen (HLA)-DR 4 was associated with RF positive patients. HLA study found that DW 4 is related to the pathogenesis of RA, and 70% of patients are HLA-DW 4 positive, and patients have susceptibility genes for this point, so heredity may play an important role in the pathogenesis.
(4) The study of sex hormones shows that the incidence ratio of male to female in RA is 65,438+0 ∶ 2 ~ 4, and the illness during pregnancy is alleviated, and the incidence of women taking contraceptives is reduced. Animal model shows that LEW/n female rats are highly sensitive to arthritis, while male rats have a low incidence of arthritis. After castration or treatment with β-estradiol, the incidence of arthritis in male rats is the same as that in female rats, indicating that sex hormones play a certain role in the pathogenesis of RA. Cold, humidity, fatigue, malnutrition, trauma, mental factors, etc. It is often the inducing factor of this disease, but most patients often have no obvious inducing factors to check.