Rheumatism - a systemic disease of ligament, mainly affecting small joints of the type of erosive and destructive polyarthritis of unknown etiology that has a complex autoimmune pathogenesis.
Causes of the illness for this day are unknown. Indirect data, for instance increasing the amount of white blood cell count and erythrocyte sedimentation rate (ESR) indicate the infectious nature with the process. It truly is thought that the illness develops caused by infection, that causes a compromised body's defence mechanism in genetically susceptible individuals, with formation of so-called. immune complexes (with the antibodies, viruses, etc..), which can be deposited in tissues and bring about joint damage. However the ineffectiveness of antibiotic therapy for RA will indicate the incorrectness in this assumption.
The ailment is seen as an high disability (70%), which comes pretty early. The primary factors behind death on the disease are infectious complications and renal failure.
Treatment focuses on relieving pain, slowing disease progression and restore damaged by surgery. Early detection of disease by making use of modern tools can significantly limit the harm that can be inflicted joints along with other tissues.
The very first time may occur after heavy physical exertion, emotional shock, fatigue, hormonal changes during the period, the impact of adverse factors or infection.
Epidemiology
Rheumatoid arthritis symptoms is distributed worldwide plus it affects all ethnic groups. Prevalence of 0,5-1% (up 5% inside elderly) ratio M: F = 1:3 peak of illness onset - 30-35 years
Etiology
As with most autoimmune diseases, there are 3 main factors:
1. Hereditary inclination towards autoimmunity.
2. Infection factor 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 (higher in the synovial fluid of RA patients
* Retroviruses - T-lymphotropic virus
3. Start-up factor (hypothermia, insolation, intoxication, mutagenic drugs, endocrinopathy, stress, etc.). For female, duration of breast-feeding reduces the risk of RA. Breastfeeding for 24 months or more cuts down on risk of developing RA by half.
The path of disease
Rheumatism progresses in three stages. Inside first stage, the swelling from the synovial bags causing pain, heat and swelling around the joints. The 2nd stage may be the rapid cell division that leads to compaction with the synovial membrane. Within the third stage, the inflamed cells release an enzyme that attacks the bones and cartilage, which frequently brings about deformation of the affected joints, increasing pain and decrease in motor functions.
Typically, the illness progresses slowly to begin with, with the gradual deployment of clinical symptoms for a lot of entire time, a lesser amount of - subacute or acute. Within Two-thirds of cases fever occurs, and also the rest - a mono-or oligoarticular form, and articular syndrome often doesn't have clinical specificity, which greatly complicates the differential diagnosis. Articular syndrome is seen as an morning stiffness for over Thirty minutes and other expressions inside the second half of the night - signs of "stiff gloves", "corset"; ongoing spontaneous pain inside the joints, increasing during active movements. The disappearance on the stiffness depends upon the game on the process: the greater activity, greater the duration of restraint. With the joint syndrome in rheumatoid arthritis symptoms is characterized by monotony, the duration, preservation of residual effects after treatment.
There could be prodromal clinical symptoms (mild transient pain, pain relationship with meteorological conditions, autonomic dysfunction). Distinguish "joint damage" and "joints exception." Rheumatoid arthritis is frequently coupled with other joint diseases - osteoarthritis, rheumatism, systemic connective tissue diseases.
Allocate the subsequent choices for the clinical length of rheumatoid arthritis:
* The classic version with the (symmetric defeat both small and large joints
* Mono-or oligoarthritis, mainly affecting the large joints, quite often the knee. Severe disease onset and reversibility off manifestations during 1-1,5 months (arthralgias are migratory anyway, radiographic changes are absent, anti-inflammatory drugs offer relatively positive effect in the latter you'll find every one of the signs and symptoms of rheumatoid arthritis symptoms).
Diagnosis
Diagnosis of rheumatoid arthritis symptoms (RA) - For a long time there was no specific test that might unambiguously confirm the presence from the disease . Currently, proper diagnosis of disease depending on biochemical analysis of blood, modifications to the joints are visible on x-rays, plus the utilization of basic clinical markers, but additionally with the general clinical manifestations - fever, malaise, and weight reduction
In the analysis of blood examined ESR, rheumatoid factor, platelet count, etc. By far the most advanced analysis is the titer of antibodies to cyclic citrulline-containing peptides - ACCP, anti-CCP, anti-CCP. The specificity on this indicator is 90%, though it may be contained in 79% of sera from patients with RA.
Diagnostically important clinical features are definitely the lack of discoloration on the skin on the inflamed joints, the creation of tenosynovitis flexors or extensors on the fingers and also the formation of amyotrophy, typical strains of brushes, so-called "rheumatoid wrist.
The criteria for poor prognosis are:
* Early harm to large joints along with the appearance of rheumatoid nodules
* swollen lymph nodes
* involvement of recent joints in the subsequent exacerbation;
* systemic disease;
* persistent disease activity without the need of remission for over a year;
* persistent increase in the ESR;
* early appearance (inside the newbie) and high titers of rheumatoid factor
* early (up to four months), radiographic alterations in the affected joints - an instant advancement of destructive changes;
* Detection of antinuclear antibodies and LE-cells
* Carrier antigens HLA-DR4
Symptoms
Rheumatoid arthritis may start at any joint, most often starts from small joints inside fingers, wrists. Typically, joint damage is symmetric, as an example when the sore joint on his right hand, then ill function as the same joint around the left. A lot more joints afflicted a lot more advanced stages of disease.
* Other common symptoms include:
* Fatigue
* Morning stiffness. Generally, the longer the constraint, the ailment activity.
* Weakness
* Flu-like symptoms, including low heat.
* Pain during prolonged sitting
* Outbreaks of disease activity are accompanied by remission.
* Muscle pain
* Lack of appetite, depression, weight-loss, anemia, cold and sweaty palms and feet
* Violation of glands close to the eyes and mouth, causing insufficient production of tears and saliva.
Treatment
Within the presence of infection need the appropriate antibacterial therapy. In the absence of bright extraarticular manifestations (eg, high fevers, Felty's syndrome or polynervopathy) management of joint syndrome start with picking a non-steroidal anti-inflammatory drugs (NSAIDs). While doing so in the most inflamed joints injected corticosteroids. An important part of the treating arthritis rheumatoid will be the prevention of osteoporosis - restoration from the calcium balance on the way to increasing its absorption from the intestine and reducedthe excretion. Types of calcium are dairy foods (especially cheese, containing from 600 to 1000 mg of calcium per 100 g on the product, together with cheese, to your lesser level of some kinds of cheese, milk, sour cream), almonds, hazelnuts and walnuts, etc., and calcium supplements in combination with vitamin D or its active metabolite.
Importance from the therapy for this is therapeutic exercise, directed at maintaining maximum joint mobility tweaking muscle tissue.
Physiotherapy (electrophoresis of nonsteroidal anti-inflammatory drugs, hydrocortisone phonophoresis) and spa treatment. With persistent mono-and oligoarthritis includes introduction of isotopes of gold, yttrium, etc., With persistent strains of joints is carried out reconstructive surgery.
Modern Therapy
Systemic drug therapy involves the using 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 remain the primary line of therapeutic agents which can be directed primarily towards the relief of acute manifestations of the disease, in addition to ensuring stable clinical and laboratory remission.
In the acute phase of illness using NSAIDs, corticosteroids, pulse therapy with corticosteroids or even in combination with cytotoxic immunosuppressive agents.
Current NSAIDs use a marked anti-inflammatory effect which can be attributable to inhibition from the activity of cyclooxygenase (COX) - an important enzyme of arachidonic acid metabolism. Of particular interest could be the discovery of two isoforms of COX, which can be identified as COX-1 and COX-2 and play different roles in regulating the synthesis of prostaglandins (PG). Proved that NSAIDs inhibit the game of COX isoforms, however their anti-inflammatory activity is due to inhibition of COX-2.
Many of the known NSAIDs inhibit primarily COX-1 activity, which explains the appearance of complications for example gastropathy, renal failure, encephalopathy, hepatotoxicity.
Thus, depending on the nature of blocking COX, NSAIDs are split into selective and nonselective COX-2 inhibitors.
Representatives in the selective COX-2 inhibitors are meloxicam, nimesulide, celecoxib. These drugs have minimal unwanted side effects and retain high anti-inflammatory and analgesic activity. COX-2 inhibitors may be used in every programs from the treatments for rheumatoid arthritis, which require the using NSAIDs. Meloxicam (Movalis) in early management of inflammatory activity allotted to 15 mg / day and subsequently utilized in 7.5 mg / day as maintenance therapy. Nimesulide is assigned a dose of 100 mg 2 times a day.
Celecoxib (Celebrex) - a specific inhibitor of COX-2 - is a member of 100-200 mg twice a day. Selection to the elderly dosage with the drug is not required. However, patients with weight below the median (50 kg) it truly is desirable to begin treatment while using lowest recommended dose.
It is best to avoid combining two or more NSAIDs, due to their effectiveness remain unchanged, along with the risk of unwanted side effects increases.
Basic Preparations
Basic drugs continue to play a pivotal role within the therapy for rheumatoid arthritis symptoms symptoms, but now there is a different method of their destination. Not like the well-known tactic of gradual treatment of rheumatoid arthritis symptoms symptoms ("principle in the pyramid"), has become advocated early aggressive therapy for basic drugs soon after diagnosis, the purpose of which - changed the flow of rheumatoid arthritis and remission maintenance. The real reason for this will be the not enough early rheumatism deformities, osteopenia, and severe complications, formed by autoimmune mechanisms, our prime probability of remission.
The leading drugs of basic therapy of rheumatoid arthritis include: methotrexate, sulfasalazine, gold preparations, D-penicillamine,. By using the reserve include cyclophosphamide, azathioprine, cyclosporine A . The revolutionary group was comprised of the subsequent drugs: Remicade.
Ineffective for 1.5-3 months of basic drugs needs to be replaced or used in combination with corticosteroids in low doses, thus lowering the activity of rheumatoid arthritis symptoms ahead of the start of the first. Half a year - a critical period, no later than that needs to be adjusted effective basic therapy.
The very best preparation for the start of basic therapy in severe rheumatoid arthritis and RF-positivity, presence of extraarticular manifestations of methotrexate is recognized as - cytotoxic immunosuppressive agent, which can be well tolerated for prolonged use and contains fewer unwanted effects than other drugs of the group .
From the treatments for basic drugs carefully monitored the experience on the disease and unwanted effects.
Corticosteroids
A different approach is the use of high doses of corticosteroids (pulse therapy) in combination with slow acting tools that can improve efficiency on the latter; mixtures of methotrexate with salts of gold, sulfasalazine, or a selective immunosuppressive agent cyclosporin A.
Having a high penetration of inflammatory activity are utilized corticosteroids, and in cases of systemic manifestations of rheumatism a kind of pulse remedies are used. Corticosteroids only or perhaps in combination with cytostatic drugs - cyclophosphamide. SCS can be used as supporting anti-inflammatory therapy after failure of other medicines.
In some cases, corticosteroids are employed as local therapy. The indications for his or her use are: mostly mono-or oligoarthritis of huge joints,
Biological agents
In rheumatism the synovial membrane , for unclear reasons, secrete a great deal of the enzyme glucose-6-phosphate dehydrogenase that also destroys the disulfide bonds inside cell membrane. In cases like this, there may be "leakage" of proteolytic enzymes in the cell lysosomes, which can damage surrounding bones and cartilage. The body responds to this by causing cytokines , among which includes a tumor necrosis factor -the A TNF . Cascade of those reactions in cells are triggered by cytokines, further aggravating the the signs of the condition. Chronic rheumatoid inflammation associated with TNF-a, often causing problems for the cartilage and joints, resulting in physical disability.
Treatments utilizes a monoclonal antibody towards cytokine TNF-the A , that is effective with good affinity in binding to TNF, at its soluble and transmembrane forms producing neutralizing activity of TNF .
Over the continuing development of rheumatism, Joint damage in patients with arthritis rheumatoid is observed to be a narrowing in the joint space between bones and erosion of bone from the articular space. Clinical trials of monoclonal antibody showed its use being a slow erosion and narrowing in the space between your bones.
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