Rheumatoid Arthritis, Symptoms, Diagnosis and Treatment
Rheumatoid arthritis - a systemic disease of connective tissue, principally heartwarming small joints of the type of erosive and destructive polyarthritis of unknown etiology with a composite autoimmune pathogenesis.
Causes of the disease on this daylight hours are unknown. Indirect data, such as increasing the quantity of white blood cell count and erythrocyte sedimentation rate (ESR) indicate the catching nature of the process. It is held with the aim of the disease develops as a answer of infection, which causes a compromised immune organization in genetically susceptible folks, with formation of so-called. Immune complexes (of the antibodies, viruses, et cetera..), which are deposited in tissues and prime to hang out injury. But the ineptitude of antibiotic medicine of RA is likely to indicate the inappropriateness of this best guess.
The disease is characterized by prohibitive disability (70%), which comes pretty first. The highest causes of death from the disease are catching complications and renal failure.
Rheumatoid Arthritis
Treatment focuses primarily on relieving hurt, slowing disease sequence and restore damaged by surgery. Early detection of disease with the help of contemporary tools can significantly reduce the hurt with the aim of can be inflicted joints and other tissues.
For the basic schedule may well occur similar to important material force, emotional shock, fatigue, hormonal changes throughout the episode, the effect of adverse factors or infection.
Epidemiology
Rheumatoid arthritis is disseminated worldwide and it affects all ethnic groups. Prevalence of 0,5-1% (up 5% in the elderly) ratio M: F = 1:3 greatest of illness beginning - 30-35 years
Etiology
While with nearly everyone autoimmune diseases, near are 3 highest factors:
1. Hereditary susceptibility to autoimmunity.
2. Infection cause Hypothetical triggers of rheumatic diseases
Paramyxovirus - viruses, mumps, measles, respiratory syncytial infection
Hepatitis B virus
Herpes virus - herpes simplex viruses, herpes zoster, cytomegalovirus, Epstein-Barr virus (much senior in the synovial fluid of RA patients
Retroviruses - T-lymphotropic virus
3. Start-up cause (hypothermia, insolation, intoxication, mutagenic drugs, endocrinopathy, stress, et cetera.). For women, duration of breast-feeding reduces the venture of RA. Breastfeeding in place of 24 months or more reduces the venture of on the increase RA by partly.
The classes of disease
Rheumatoid arthritis progresses in three stages. Clothed in the basic stage, the swelling of the synovial bags causing hurt, roast and swelling around the joints. The flash stage is the rapid cell division with the aim of leads to compaction of the synovial film. Clothed in the third stage, the inflamed cells liberation an enzyme with the aim of attacks the bones and cartilage, which often leads to twist of the affected joints, increasing hurt and loss of motor functions.
Typically, the disease progresses leisurely by the side of basic, with the gradual operation of clinical symptoms in place of several months or years, much a smaller amount - subacute or acute. Clothed in not far off from 2 / 3 of luggage fever occurs, and the have a break - a mono-or oligoarticular form, and articular syndrome often has rebuff clinical specificity, which greatly complicates the differential diagnosis. Articular syndrome is characterized by morning stiffness in place of more than 30 minutes and comparable expressions in the flash partly of the night - symptoms of "stiff gloves", "corset"; ongoing spontaneous hurt in the joints, increasing throughout keen travels. The desertion of the stiffness depends on the pursuit of the process: The more pursuit, the greater the duration of restraint. For the hang out syndrome in rheumatoid arthritis is characterized by repetitiveness, the duration, safeguarding of lasting belongings similar to medicine.
There may well be prodromal clinical symptoms (mild transient hurt, hurt correlation with meteorological conditions, autonomic dysfunction). Distinguish "joint damage" and "joints exception." Rheumatoid arthritis is often combined with other hang out diseases - osteoarthritis, rheumatism, systemic connective tissue diseases.
Allocate the following options in place of the clinical classes of rheumatoid arthritis:
The classic version of the (symmetric defeat both small and generously proportioned joints
Mono-or oligoarthritis, principally heartwarming the generously proportioned joints, nearly everyone often the knee. Severe disease beginning and reversibility of all manifestations throughout 1-1,5 months (arthralgias are migratory in nature, radiographic changes are absent, anti-inflammatory drugs offer relatively helpful effect in the latter near are all the symptoms of rheumatoid arthritis).
Diagnosis
Diagnosis of rheumatoid arthritis (RA) - For a long schedule near was rebuff particular test with the aim of would unmistakably confirm the presence of the disease. Currently, diagnosis of disease based on biochemical analysis of blood, changes in the joints are visible on x-rays, and the wear out of basic clinical markers, but besides in conjunction with the broad-spectrum clinical manifestations - fever, malaise, and influence loss
Clothed in the analysis of blood examined ESR, rheumatoid cause, platelet count, et cetera. The nearly everyone vanguard analysis is the titer of antibodies to returning citrulline-containing peptides - ACCP, anti-CCP, anti-CCP. The specificity of this indicator is 90%, while it is give to in 79% of sera from patients with RA.
Diagnostically of great consequence clinical skin texture are the lack of tint of the skin on the inflamed joints, the development of tenosynovitis flexors or extensors of the fingers and the formation of amyotrophy, mainstream strains of brushes, so-called "rheumatoid wrist.
The criteria in place of poor prognosis are:
1. Early injury of generously proportioned joints and the manifestation of rheumatoid nodules
2. Inflamed lymph nodes
3. Involvement of another joints in the following exacerbation;
4. Systemic disease;
5. Persistent disease pursuit with rebuff remission in place of on a time;
6. Persistent increase in intensity in the ESR;
7. First manifestation (within the basic year) and prohibitive titers of rheumatoid cause
8. First (up to four months), radiographic changes in the affected joints - a rapid sequence of destructive changes;
9. Detection of antinuclear antibodies and LE-cells
10. Carrier antigens HLA-DR4
Symptoms
Rheumatoid arthritis can arise by the side of some hang out, but nearly everyone often starts from small joints in the fingers, hands and wrists. Typically, hang out injury is symmetric, in place of instance if the sore hang out on his appropriate employee, after that poorly be the same hang out on the gone. The more joints afflicted the more vanguard stages of disease.
Other general symptoms include:
Fatigue
Morning stiffness. Generally, the longer the constraint, the disease pursuit.
Weakness
Flu-like symptoms, together with low roast.
Pain throughout prolonged sitting
Outbreaks of disease pursuit are accompanied by remission.
Muscle hurt
Loss of taste, depression, influence loss, anemia, cold and / or sultry palms and feet
Violation of glands close to the eyes and opening, causing insufficient production of tears and spit.
Treatment
Clothed in the presence of infection need the appropriate antibacterial therapy. Clothed in the absence of clear extra-articular manifestations (eg, prohibitive fevers, Felty's syndrome or polynervopathy) medicine of hang out syndrome arise with the selection of non-steroidal anti-inflammatory drugs (NSAIDs). At the same schedule in the nearly everyone inflamed joints injected corticosteroids. An of great consequence central theme in the medicine of rheumatoid arthritis is the prevention of osteoporosis - repair of the calcium balance in the direction of increasing its concentration in the intestine and on sale the pus. Sources of calcium are dairy products (especially cheese, which contains from 600 to 1000 mg of calcium apiece 100 g of the artifact, as well as cheese, to a less important degree of lodge cheese, milk, tart cream), almonds, hazelnuts and walnuts, et cetera., and calcium supplements in combination with vitamin D or its keen metabolite.
Importance in the medicine is beneficial problem, aimed by the side of maintaining greatest extent hang out mobility and maintaining muscle heap.
Physiotherapy (electrophoresis of nonsteroidal anti-inflammatory drugs, hydrocortisone phonophoresis) and spa medicine. With persistent mono-and oligoarthritis includes introduction of isotopes of gold, yttrium, et cetera., With persistent strains of joints is passed barred reconstructive surgery.
Modern Therapy
Systemic drug therapy involves the wear out of four classes of drugs:
1. Nonsteroidal anti-inflammatory drugs (NSAIDs),
2. Basic drugs
3. Glucocorticosteroids (GCS)
4. Biological agents.
Non-steroidal anti-inflammatory drugs
NSAIDs continue the basic line of beneficial agents with the aim of are directed primarily to the relief of acute manifestations of the disease, as well as ensuring settled clinical and laboratory remission.
Clothed in the acute part of illness wear out of NSAIDs, corticosteroids, pulse therapy with corticosteroids or in combination with cytotoxic immunosuppressive agents.
Current NSAIDs maintain a distinct anti-inflammatory effect which is caused by inhibition of the pursuit of cyclooxygenase (COX) - a type enzyme of arachidonic acid metabolism. Of regard consequence is the discovery of two isoforms of COX, which are identified as COX-1 and COX-2 and theatrical production diverse roles in regulating the synthesis of prostaglandins (PG). Proved with the aim of NSAIDs inhibit the pursuit of COX isoforms, but their anti-inflammatory pursuit is due to inhibition of COX-2.
Most of the famous NSAIDs inhibit primarily COX-1 pursuit, which explains the manifestation of complications such as gastropathy, renal failure, encephalopathy, hepatotoxicity.
Thus, depending on the nature of blocking COX, NSAIDs are separated into selective and nonselective COX-2 inhibitors.
Representatives of the selective COX-2 inhibitors are meloxicam, nimesulide, celecoxib. These drugs maintain token piece belongings and keep prohibitive anti-inflammatory and analgesic pursuit. COX-2 inhibitors can be used in all programs of the medicine of rheumatoid arthritis, which require the wear out of NSAIDs. Meloxicam (Movalis) in the first medicine of provocative pursuit assigned to 15 mg / daylight hours and subsequently transferred to 7.5 mg / daylight hours as maintenance therapy. Nimesulide is assigned a dose of 100 mg twice a daylight hours.
Celecoxib (Celebrex) - a particular inhibitor of COX-2 - is assigned to 100-200 mg twice a daylight hours. Selection in place of the elderly dosage of the drug is not requisite. However, patients with body influence underneath the median (50 kg) it is advantageous to arise medicine with the lowest recommended dose.
You ought to circumvent combining two or more NSAIDs, for the reason that of their effectiveness continue unchanged, and the venture of piece belongings increases.
Basic Preparations
Basic drugs pick up again to theatrical production a fundamental role in the medicine of rheumatoid arthritis, but in a jiffy near has been a another verge on to their destination. Clothed in contrast to the well-known tactic of gradual medicine of rheumatoid arthritis ("principle of the pyramid"), is in a jiffy advocated first aggressive medicine of basic drugs just now similar to diagnosis, the resolution of which - misused the pour of rheumatoid arthritis and remission maintenance. The goal in place of this are the lack of first rheumatoid arthritis deformities, osteopenia, and unembellished complications, formed by autoimmune mechanisms, the prohibitive likelihood of remission.
The highest drugs of basic therapy of rheumatoid arthritis include: Methotrexate, sulfasalazine, gold preparations, D-penicillamine,. By channel of the reserve include cyclophosphamide, azathioprine, cyclosporine A. The another set consisted of the following drugs: Remicade.
Ineffective in place of 1.5-3 months of basic drugs ought to be replaced or used in combination with corticosteroids in low doses, like so dipping the pursuit of rheumatoid arthritis by the start of the basic. Six months - a essential episode, rebuff soon than with the aim of ought to be adjusted successful basic therapy.
The superlative groundwork in place of the start of basic therapy in unembellished rheumatoid arthritis and RF-positivity, presence of extraarticular manifestations of methotrexate is considered - cytotoxic immunosuppressive agent, which is well tolerated in place of prolonged wear out and has fewer piece belongings than other drugs of this set.
Clothed in the medicine of basic drugs carefully monitored the pursuit of the disease and piece belongings.
Corticosteroids
A another verge on is the wear out of prohibitive doses of corticosteroids (pulse therapy) in combination with decelerate acting tools with the aim of can convalesce the efficiency of the latter; combinations of methotrexate with salts of gold, sulfasalazine, as well as a selective immunosuppressive agent cyclosporin A.
With a prohibitive degree of provocative pursuit are used corticosteroids, and in luggage of systemic manifestations of rheumatoid arthritis a form of pulse therapy is used. Corticosteroids solitary or in combination with cytostatic drugs - cyclophosphamide. SCS is besides used as underneath anti-inflammatory therapy similar to failure of other medicines.
Clothed in selected luggage, corticosteroids are used as confined therapy. The indications in place of their wear out are: Mostly mono-or oligoarthritis of generously proportioned joints,
Biological agents
Clothed in rheumatoid arthritis the synovial film, in place of undecided reasons, hide away a generously proportioned amount of the enzyme glucose-6-phosphate dehydrogenase with the aim of besides destroys the disulfide bonds in the cell film. Clothed in this legal action, near is "leakage" of proteolytic enzymes from the cell lysosomes, which cause injury to surrounding bones and cartilage. The body responds to this by making cytokines, between which besides has a swelling necrosis cause -the A TNF. Cascade of these reactions in cells are triggered by cytokines, advance aggravating the symptoms of the disease. Chronic rheumatoid inflammation associated with TNF-α, often causing injury to the cartilage and joints, leading to material disability.
The medicine uses a monoclonal antibody to the cytokine TNF-the A, which is successful with prohibitive attraction in binding to TNF, both in its soluble and transmembrane forms resultant in neutralizing pursuit of TNF.
During the sequence of rheumatoid arthritis, Joint injury in patients with rheumatoid arthritis is pragmatic as a narrowing of the hang out hole sandwiched between bones and erosion of bone in the articular hole. Clinical trials of monoclonal antibody showed its wear out as a decelerate erosion and narrowing of the hole sandwiched between the bones.