Rheumatoid arthritis

Rheumatoid arthritis is characterized mainly by chronic progressive inflammation of many joints of the extremities.

Pathogenesis: usually the circulation in the blood of immune complexes, the development in connection with this of the vasculitis of the synovium and other organs. This leads to the development of persistent arthritis and destruction of the joint, as well as the occurrence in a number of cases of systemic damage to connective tissue and vessels. Antigens can be antigens of bacterial, viral and even parasitogenic origin.

Symptoms, course. The disease manifests itself as persistent arthritis (usually paliarthritis) with early and preferred involvement of wrist, metacarpophalangeal, proximal interphalangeal joints of brushes and pseudophalangeal joints. Any joints of the extremities can be affected. Characteristic of the morning stiffness, pain, swelling of the joints, hyperthermia of the tissues above them (skin color changes), symmetry of arthritis. Typically, a gradual onset of the disease with wave-like fluctuations in the severity of symptoms (sometimes even more or less prolonged remissions are noted at the beginning of the disease), slow but steady progression of arthritis, involvement of all new joints. Sometimes rheumatoid arthritis begins and for a relatively long time can manifest monoarthritis of a large, often knee joint. There is also a variant of the acute onset of the disease, in which, in addition to joint damage, high fever and extra-articular manifestations (serosites, carditis hepatolienal syndrome, lymphadenopathy, etc.) are noted.

The unfolded stage of the disease is characterized by deforming, destructive (roentgenologically) arthritis. Typical deformations of the metacarpophalangeal (flexural contractions, subluxations), proximal interphalangeal (flexion contractures) and wrist joints - the deviation of the brush to the outside (the so-called rheumatoid brush) and the pseudophalangeal joints (the hammer-shaped form of the fingers, their subluxations, flat feet, hallux valgus, The concept of rheumatoid foot.In some joints, inflammatory or fibro-proliferative changes may predominate.More changes in joints are of a mixed nature.

Extra-articular (systemic) manifestations of rheumatoid arthritis are relatively infrequent, mainly with seropositive (in rheumatoid factor) form of the disease, expressed and generalized articular syndrome; Their frequency increases with the progression of the disease. They include subcutaneous (rheumatoid) nodules, which are more often located in the elbow joint area, serosites - usually moderately pronounced adhesive plecha (percha) pleura and pericarditis; Lymphadenopathy, peripheral neuropathy - asymmetric lesion of the distal nerve trunks with sensitivity disorders, rarely motor disorders; Cutaneous vasculitis, more often manifested by pinpoint necrosis of the skin in the nail bed area, etc. Clinical signs of internal organ damage (carditis pneumonitis, etc.) are rarely noted. In 10-15% of patients, amyloidosis develops with a predominant kidney damage, which is characterized by gradually increasing proteinuria, nephrotic syndrome, and later renal failure. Rheumatoid arthritis, which, in addition to the typical joint damage, is characterized by silenomegaly and leukopenia, is called Felgie's syndrome.

The indicators of laboratory research are nonspecific. In 70 - 80% of patients in the blood serum, a rheumatoid factor is detected, this form of the disease is called seropositive. From the very beginning of the disease, as a rule, there is an increase in ESR, levels of fibrinogen, (2-globulins, C-reactive protein in the blood, and a decrease in hemoglobin.

Radiographically, there are 4 stages of rheumatoid arthritis: I stage (initial) - only periarticular osteoporosis; II stage - osteoporosis + narrowing of the joint space; III stage - osteoporosis + narrowing of the joint gap + bone erosion; IV stage - a combination of symptoms of stage III and ankylase of the joint. In the past, x-ray changes in rheumatoid arthritis appear in the joints of the hands and metatarsophalangeal joints. Treatment. In the presence of an infection or suspected of it (tuberculosis, iersiniosis, etc.), therapy with an appropriate antibacterial drug is necessary. In the absence of bright extra-articular manifestations (for example, high fever, Felty syndrome or palyneuropathy), the treatment of joint syndrome begins with the selection of non-steroidal anti-inflammatory drugs: indamethacin (75-150 mg / day), orthophene (75-50 mg / day), naproxen (500 - 750 mg / day), less often ibuprofen (1 - 2 g / day); They are used for a long time (not courses), for years. Simultaneously, corticosteroid preparations (hydrocortisone, metipred, kenalog) are injected into the most inflamed joints. The immunocomplex nature of the disease makes it possible to show the courses of parathyroidism, which in most cases gives a pronounced effect. The inconsistency of the results of this therapy is an indication of the addition of the so-called basic drugs: crisanol (34 mg of gold contained in 2 ml of 5% or in 1 ml of 10% solution of the drug 1 time Per week), 0-penicillamine (coulenyl, methylcapatase, 300 750 mg / day), deligil (0.25 g / day) or sulfasalazine (2 g / day). These drugs are slow, so should be used for at least 6 months, and with a clear positive effect, treatment with them necessarily continues for years to come.

Corticosteroids are administered orally in the absence of bright extra-articular manifestations as rarely as possible, usually only with severe pain in joints that are not obstructed by non-steroidal anti-inflammatory agents and intra-articular corticosteroids, in small doses (not more than 10 mg / day of prednisolone), for a short period of time and in combination with Basic means, which allow to reduce the dose of hormones and completely abolish them. Corticosteroids (prednisolone 20-30 mg / day, sometimes up to 60 mg / day or in the form of pulse therapy: metipred iv in 1 g for 3 days) are absolutely indicated in the presence of high fever, generalized rheumatoid vasculitis. Immunosuppressants (chlorbutin 6-8 mg / day, azathioprine 100-150 mg / day, cyclophosphamide 100-150 mg / day, methotrexate 2.5-7.5 mg / day for one day of each week) are the drugs of choice in the presence of bright extra-articular manifestations (Polyneuropathy, generalized vasculitis, etc.), and in other cases they are used only if all previous therapy is ineffective. The use of basic remedies for rheumatoid arthritis should be carried out under the constant supervision of a doctor who knows all aspects of the action of these drugs.

Of great importance in the treatment is therapeutic exercise, aimed at maintaining maximum mobility of the joints and maintaining muscle mass.

Physiotherapeutic procedures (electrophoresis of non-steroidal anti-inflammatory drugs, hydrocortisone phonophoresis, dimexide applications) and sanatorium treatment have an auxiliary significance and are used only with a slight arthritis.

With persistent mono- and oligoarthritis, a synovectomy is performed either by introducing into the joint isotopes of gold, yttrium, etc., or surgically. With persistent deformations of the joints, reconstructive operations are performed.