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The disease most often affects the small joints of the knees, hands, ankles and ankles, leading to destruction of the joints and disruption of their function. Without timely treatment, rheumatoid arthritis can cause serious complications, including disability.
Rheumatoid arthritis is an autoimmune disease, that is, associated with a malfunction of the immune system. In arthritis, immune cells mistakenly mistake joint cells for foreign elements - viruses, bacteria - and try to destroy them. This process continues for years..
Often the disease begins with damage to the knee joint. At the beginning of the disease, the patient feels weak, unwell, loses appetite, loses weight, and the temperature can rise to 37-39 degrees. In this case, joint problems fade into the background or are completely absent. As the disease develops, more and more joints are involved in the process, and after treatment of exacerbations, the joints become less mobile and deformed.
Over time, symptoms associated with damage to internal organs and systems appear: lungs, heart, blood vessels, kidneys, eyes, salivary glands. With rheumatoid polyarthritis, dense subcutaneous nodules often form.
The main signs of rheumatoid arthritis are:
The following symptoms can warn of the disease:
The main cause of the disease is autoimmune inflammation. Under the influence of genetic factors and infection (presumably viral), immune complexes are formed in the body, which are deposited in tissues and, above all, in the cartilage tissue of the joints. Further, inflammation develops in the places of deposition. The onset of the disease can be triggered by:
Relatives of patients with rheumatoid arthritis are susceptible to the disease. Notably, breastfeeding for two years reduces the risk of rheumatoid arthritis in women by half.
There are two main forms of the disease:
Rheumatoid arthritis is easy to diagnose if many joints are deformed. But in the initial stages, it is quite difficult to identify the disease due to the variety of symptoms.
The signs of the disease are similar to those of rheumatism and arthrosis. However, a specialist can easily distinguish rheumatoid arthritis. It is different from rheumatism in that the pain and swelling in the joints can last longer - for years. Difference from arthrosis: with arthritis, pain after exercise decreases, not increases.
Damage to the joints leads to fairly rapid disability of patients, loss of the ability not only to work, but also to care for themselves independently. The prognosis depends on the degree of damage to internal organs, especially the kidneys.
Unfortunately, there is no prevention for rheumatoid arthritis. However, you can reduce the rate of progression of the disease and prevent complications if you follow certain rules. First of all, it is necessary to regularly take basic therapy drugs under the supervision of the attending physician, to avoid hypothermia and infections.
At the first symptoms, you should immediately consult a doctor. It is important to start treatment at an early stage so that joint destruction can be avoided.
Doctors at the Health Workshop clinics in St. Petersburg can easily distinguish rheumatoid arthritis from other diseases. Our doctor will ask you in detail about your symptoms and make the correct diagnosis using a comprehensive study. We use the following diagnostic methods:
Doctors at our clinic treat the disease using conservative methods. Conservative treatment relieves pain and inflammation in the joints and heals the body.
We treat the patient individually. The doctor prescribes a course of procedures taking into account the stage of the disease and the characteristics of the patient’s body. Treatment takes from 3 to 6 weeks, procedures need to be completed 2-3 times a week. The course includes at least 5 different procedures from the list:
A course of treatment for rheumatoid arthritis at the Health Workshop clinics in St. Petersburg stops the progression of the disease, reduces pain and inflammation of the joints, and improves their mobility. The doctor will advise the patient what to do next for recovery and prevention of the disease.
In rheumatoid arthritis, proper nutrition plays an important role. Diet will not cure the disease, but it will help reduce pain. Doctors at the Health Workshop advise eating more fruits, berries, nuts, and vegetables - except tomatoes, potatoes, peppers and eggplants.
Eat less white bread, pasta and sugar, drink at least 1.5 liters of water per day. Include rapeseed oil, flax and pumpkin seeds in your personal menu. It is better to avoid cakes, snacks, crackers, caffeine, alcohol and cigarettes.
Doctors at the Health Workshop recommend for the purpose of prevention:
For rheumatoid arthritis, it is useful to do the following exercises:
Before performing therapeutic exercises, consult your doctor. Do the exercises for 30 minutes 5 days a week. If severe pain occurs during gymnastics, stop exercising.
How to start living without pain and worries
or call us at +7 (812) 309-82-03
Telephone consultation
A medical consultant will ask about your symptoms, select a suitable doctor, tell you about the cost of procedures and make an appointment for an initial appointment.
The doctor will examine and question you. If you already have the results of MRI, ultrasound and x-rays, he will analyze the images and make a diagnosis. If not, he will write out the necessary directions.
During the course of treatment, repeated appointments with the attending physician are unlimited and free.
Maintain your results after completing the course of treatment.
The doctor will give you a manual with personal recommendations for daily exercise. Try to exercise regularly to prevent the pain from returning.
Free preventive examination
After 3 months we will call and invite you for a free inspection.
The doctor will ask about your health and, if necessary, recommend diagnostic and supportive procedures.
The “Health Workshop” employs doctors of the highest, first and second categories. Our specialists have from 5 to 40 years of experience in treating diseases of the spine and joints. The doctor draws up a course of treatment, taking into account the patient’s profession and lifestyle, previous injuries and operations. Orthopedists and neurologists of the clinic regularly take advanced training courses and study professional literature.
Panfilova Nadezhda Iovovna
Gabdrakhmanov Rustam Fanilievich
Lisina Elena Arkadyevna
Karpukhina Valentina Ivanovna
Maslenin Maxim Igorevich
Khislavskaya Elena Vladimirovna
Charin Yuri Konstantinovich
Zhartanov Oleg Alekseevich
Kustova Marina Leonidovna
Savelyev Viktor Anatolievich
Egorov Vladimir Leonidovich
Bogoslovsky Sergey Ivanovich
Kryukov Alexander Sergeevich
Belyaev Evgeniy Mikhailovich
Cherkashin Gennady Vasilievich
years is the average length of service of our doctors
Over the years, our doctors have relieved pain from 60,000 patients. But even now we highly appreciate every positive review and sincere words of gratitude.
I would like to express my gratitude to Dr. A.A. Kryzhanovsky. for good treatment, I would really like to see him again. Also to my attending physician Savelyev V.A. for their attentive and responsible attitude towards their patients. And, of course, I would like to highlight chiropractor S.N. Paronko. for his wonderful hands. I will definitely recommend it to all my friends and, of course, will come back again. Thank you!
Alekseeva Svetlana Nikolaevna, 69 years old
I sincerely thank the attending physician Savelyev V.A. for high professionalism, effective treatment, correct, friendly attitude, patience. Many thanks also to Paronko S.N. for help and recommendations, Bogdanova T.G. for physical therapy classes, detailed explanations, recommendations and responsiveness. I would like to express my gratitude to all the doctors and nurses who carried out various procedures in accordance with the prescribed treatment, as well as the administrators on duty and the consultant. Thank you very much everyone! You help a lot!
Khaikina Rosa Ilyinichna, 85 years old
I, Elektrona Viktorovna, am very grateful to the Health Workshop clinic for the assistance provided. I heard nothing but kind words and respectful attitude from all employees. Thank you, dear employees, for your sensitive and kind attitude towards us, your patients.
Litvikova Elektrona Viktorovna, 87 years old
I completed the full course of treatment and was very satisfied, as all my complaints and pain were a thing of the past. All procedures were carried out quickly and efficiently. The team is very attentive, caring, responsive, and goes along with all the patient’s requests and wishes. I thank everyone for the help they provided me, since nowhere else could I have received such treatment so quickly. I especially thank my attending physician E.V. Khislavskaya. I wish you all good luck in your difficult work. Thank you very much!
Ryabova Antonina Nikolaevna
I, Alexander Sergeevich Naumov, took a course of back and cervical massage with Oleg Vladimirovich in February - March 2018. I have had many massages in my life, but they all pale in comparison to the massages of this specialist! There is no fuss or excess in his movements. His hands seem to know and feel what the patient’s back and neck are asking for. His hands are strong and hot. Real healing energy emanates from them. Oleg Vladimirovich’s massages bring incredible pleasure and relief. Relief after his massages against the backdrop of 40 years of torment with back pain - it looks like magic! I express my deep gratitude to Oleg Vladimirovich! Thank you!
Naumov Alexander Sergeevich
I contacted the Health Workshop clinic at the beginning of January 2017: for 3 months I had been suffering from pain in my legs, I had difficulty walking, every movement caused pain. I had an appointment with neurologist Valentina Ivanovna Karpukhina, a wonderful doctor, who immediately correctly diagnosed me and prescribed procedures. At first I didn’t believe in the success of the treatment, but as soon as I started doing reflexology procedures (needles), getting injections from the wonderful doctors Vladimir Yuryevich and Mikhail Vladimirovich, I immediately felt that the pain was disappearing, and later I began doing manual therapy from the very attentive osteopath Felix Sergeevich, who directed all his efforts to make me feel better with each of his procedures, gave advice and recommendations. Every time I came to the clinic with the greatest pleasure, since all the procedures were painless, everyone: from doctors and nurses to consultants at the reception, were very attentive and friendly. Many thanks to all the doctors - they are really interested in the patient’s recovery, they do everything with their souls. I recommend this clinic to everyone, because no amount of money can buy health, but here everything is in a complex, at a convenient time. All procedures are combined and have already been worked out for this disease. I will only contact you here.
Shustova Angela Zavkievna, 48 years old
Many thanks to the staff of the medical clinic for their warm, responsive attitude and willingness to help. Special thanks to Renat Azgarovich and Oleg Alekseevich for the attentiveness and effectiveness of my treatment. Thanks to Svetlana, Ekaterina, Alexandra - kind, smiling and sensitive workers. I really liked the clinic: warm, cozy, professional.
Yugapova Galina Viktorovna, 70 years old
Very professional, friendly and attentive. Many thanks to all the staff of the clinic, especially E.V. Khislavskaya, A.A. Kabaylov, S.N. Gubernatorov.
Shishova Natalya Yurievna, 67 years old
Thanks to the clinic staff for their conscientious work, attention and kindness. I express special gratitude to chiropractor Sergei Nikolaevich Paronko, ozone therapist Alexandra Anatolyevna Shkarupa and attending neurologist Rustam Fanilievich Gabdrakhmanov.
I wish the entire team of the clinic health and happiness, creative success.
Svitnev Vladimir Evgenievich, 79 years old
Many thanks to all the doctors and staff of the Health Workshop!
Shalikova N.F., 84 years old
I thank the Health Workshop team for the treatment they provided me. Especially to the individually treating doctors Angel Ankhelevich Kabailov, Sergei Nikolaevich Paronko, Yuri Konstantinovich Charin and Vadim Anatolyevich Pak. Good health and success in your work to everyone. I would like to note the good work of the young consultants. They are very polite and attentive.
Demidenko T.G., 86 years old
I express my sincere gratitude to Yuri Konstantinovich Charin for his competence, attention and conscientiousness in his work and treatment of the patient. I wish Charin Yu.K. health and success at work.
Shalnev Alexander Stepanovich, 70 years old
I am grateful to the team of the Health Workshop clinic for their attention and kindness to patients. The treatment had a positive effect. Thank you!
Maksimova G.G., 54 years old
I express my heartfelt gratitude to the Health Workshop team, personally to Dr. Sergei Nikolaevich Paronko for his professional attitude, for his golden hands that heal us and prolong our healthy life. At Dr. Paronko S.N. I was treated 2010-2012-2017, when the clinic was located on Polyustrovsky Prospekt and the treatment result was excellent. I wish him good health for the benefit of us patients.
Antipenko Vera Fedorovna
I express my deep gratitude to Dr. Rustam Fanilievich for the treatment he prescribed for me and for his attention, thank you for the medical care.
I would also like to note all the medical staff, they are very attentive. Having arrived at the clinic along the wall, today I leave as a full-fledged person! Thank you for being.
Demyanchuk Liliya Edwardovna, 55 years old
I, Ivanova N.V., am undergoing treatment at the Health Workshop clinic. I would like to express my gratitude to the massage therapist Dmitry Vyacheslavovich Nikolsky. An excellent specialist, he does massage very well. Feels the body. I am very grateful, thank you very much.
I thank the team for their professionalism and sensitive attitude. Personal thanks to chiropractor Kirill Valerievich Podnesinsky. I wish you further success in your noble activities.
Bukina Alina Evgenievna, 64 years old
I express my deep gratitude to the entire team and wish them to be just as kind and attentive. I am satisfied with the treatment.
Plich Lyudmila Mikhailovna, 83 years old
I thank all the employees of the Health Workshop for their exceptionally warm and attentive attitude. Special thanks to the physical therapy doctor Igor Vasilievich Panin. This is a very qualified, attentive doctor who helped me a lot. I want to come to this wonderful institution again and again.
Byailina L.Ya., 80 years old
In your clinic I gained strength, communicated with smart, tactful people. A little bit about yourself. Despite my scoliosis, oddly enough, I didn’t do much back work and did exercises irregularly. My lifestyle is quite active - I walk quite a bit, go to the countryside.
At the center I receive support and guidance. A high service culture and the opportunities provided are valuable.
I thank the doctors and nurses for their understanding and their efforts. Especially the attending physician Elena Vladimirovna Khislavskaya. The prescribed procedures only benefit me. The pressure is normal. And this is great, given my tendency to hypotension. Exercise therapy doctor Igor Vasilievich Panin proved to me that physical education is the only salvation in my situation
Doctors Kiryanova O.Yu., Kryzhanovsky A.A., Pak V.A. - these are professionals who are not indifferent to the problem.
The nurses are very attentive. I wish you success in your noble cause, and that there are fewer neglected and elderly patients like me.
from 2800 rub. 2520 rub.
Arthritis is a general diagnosis that refers to any inflammation of a joint, infectious or non-infectious.
1. Arthritis is not a joint disease!
From the point of view of Eastern medicine, inflammation, or arthritis, is only an external manifestation of a disease in the joints, and not its essence. Therefore, arthritis is often accompanied by other symptoms (skin, neurotic, etc.). In the Tibetan medical treatise “Chzhud-Shi” it is written that diseases only appear in the joints, but begin in the depths of the body.
2. Arthritis is related to hormones
Eastern medicine claims that all joint problems, including arthritis, are associated with an imbalance of the Bad Kan system. This is a fundamental system involving hormonal regulation. Therefore, usually joint diseases are somehow related to hormones.
3. Arthritis – a disease of the lymphatic system
The Bad-kan system includes the lymphatic system. When Bad Kan is imbalanced, the lymph nodes create blockages in the path of immune cells. As a result, these cells cannot enter the joint and do their job in arthritis - suppress infection and inflammation.
On the other hand, the Bad Kan system is responsible for immunity. Therefore, arthritis of the joints is associated either with a lack of immunity or with its failure when immune cells attack the body’s own tissues – the joints. This is how autoimmune arthritis develops, in particular rheumatoid arthritis.
4. Arthritis is a metabolic disease
Inflammatory diseases are usually perceived in isolation. Meanwhile, they are closely related to all life processes. In particular, local immunity, the lack of which provokes inflammation of the joints, depends on the absorption of food and the balance of heat and cold in the body. Therefore, arthritis is usually accompanied by metabolic disorders.
Facts about us
Short-term relief of symptoms is not at all what treatment in “Tibet” is all about. We eliminate the cause of arthritis. This requires a completely different treatment than non-steroidal drugs (NSAIDs) or hormonal injections. When treating arthritis, we use methods aimed not so much at the symptoms, but at restoring the balance of the body, natural immunity and normal processes in the joints.
(treatment of acute symptoms of arthritis, drawing up a plan and regimen for the use of acupuncture and herbal medicines)
First of all, pain and inflammation are relieved. For this purpose, acupuncture treatment is used - the doctor painlessly inserts thin needles into special bioactive points in the joint area.
In the treatment of arthritis, pharmacopuncture is also used - the administration of a small amount of homeopathic medicines.
In order to determine how to treat arthritis in this particular case, the Tibet clinic performs a comprehensive diagnosis. First, the consultant doctor asks the patient in detail about the medical history, the circumstances of the onset and exacerbation of symptoms. Since joint diseases, including arthritis, are mainly related to an imbalance of the Bad Kan system, the doctor asks about the patient's diet and lifestyle to determine the root cause of the problem. This will be needed in treatment.
This is followed by an external examination (not only of the joint itself, but also of the skin, tongue, lymph nodes), which is supplemented by meridian diagnostics. By palpating bioactive points, the doctor determines the presence of congestion on the meridians of the body, as well as dysfunction of internal organs. The doctor pays special attention to the organs that affect the Bad-kan system - the kidneys, liver, pancreas, thyroid gland. Next, pulse diagnostics is carried out, which provides information about the internal organs. Since arthritis is only an outward manifestation of internal problems in the body, the doctor must determine the nature and extent of these problems in order to prescribe treatment.
If additional information is needed, before treating arthritis, the patient is prescribed an MRI of the joint and/or laboratory tests. Having combined and analyzed joint diagnostic data, the doctor draws up a scheme and treatment plan for arthritis and prescribes herbal medicines.
A 51-year-old woman came to the Tibet clinic with complaints of pain, morning stiffness and stiffness in the left and right knee joints. An external examination revealed signs of inflammation - redness and swelling of the joints. The survey identified associated symptoms: nighttime tingling and numbness in the hand, morning stiffness in the wrists, irritability, hot flashes, sweating, headaches, fatigue, sleep disturbance, and palpitations. Increased appetite led to an excess of the normal body mass index (92 kg with a height of 171 cm). Based on the diagnosis, grade 2 arthritis of the knee joints was determined against the background of menopausal syndrome.
The joints were treated, which included 11 sessions of basic anti-inflammatory procedures and a course of herbal medicine. According to the results of treatment, joint pain has practically disappeared, mobility has improved, and stiffness in the joints has disappeared. Hot flashes became less intense, attacks of tachycardia passed, and sleep improved. Hormonal status has improved. Weight decreased by 6 kg.
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(treatment of inflammation, elimination of symptoms and causes of arthritis)
To relieve inflammation and relieve swelling in arthritis of the joints, the Tibet Clinic uses acupuncture. Painless insertion of hair-thin needles into bioactive points has an anti-inflammatory and anti-edematous effect. In addition, this procedure promotes the drainage of accumulated fluid from the joint area.
Acupuncture on distant bioactive points of the meridians of the kidneys, liver and other internal organs helps improve their functioning, on which blood supply, nutrition of the joints and processes of renewal (regeneration) of articular tissues depend.
Manual therapy helps relieve the sore joint. This method is not used in all cases, but in some it is useful to speed up healing.
With the help of acupressure, the doctor eliminates muscle spasm, which usually accompanies joint inflammation and pain. In the treatment of arthritis, this procedure is used only after acute inflammation has resolved. Massage treatment stimulates joint restoration and improves the delivery of healing components of herbal remedies to the site of inflammation. When the joint is inflamed, it plays a lesser role and has more restrictions than with arthrosis. However, the use of massage is justified by complex techniques, of which it is an essential part.
Treatment of joints with massage has a lymphatic drainage effect, improves the functioning of the lymphatic system, and helps reduce inflammation.
Tibetan herbal remedies have anti-inflammatory, immunomodulatory and chondroprotective effects, improve metabolism and increase the body's energy, and improve the digestion process. Treatment of joints with herbal medicine is prescribed as an individual course and accompanies treatment with procedures.
Since arthritis means inflammation, direct heating of the joint is not used in the treatment of arthritis. Instead, moxotherapy sessions are conducted at distant bioactive points. Treatment with a wormwood cigar improves metabolic processes in the body, stimulates the immune system, accelerates recovery processes and promotes the outflow of accumulated fluid from the joint.
Depending on the cause of the arthritis, treatment is given to eliminate it. For gouty arthritis, measures are taken to improve the functioning of the urinary system, kidneys, and metabolic processes. When treating articular psoriasis, a systemic restoration of the body’s balance is necessary; for reactive and rheumatoid arthritis, a targeted effect on the immune system is necessary. In the case of spondyloarthritis, treatment is directed to the spine.
The combination of a targeted effect (on the joint) and a general effect on the body helps not only eliminate the symptoms of arthritis, but also treat it at the level of the cause. Why us?
Treatment of arthritis in “Tibet” is a course that includes from 6-7 to 10-11 or more complex treatment sessions, each of which consists of several treatment procedures.
The combination of procedures, duration and intensity of exposure in the treatment of arthritis are determined in all cases individually so as to achieve the maximum therapeutic effect, based on the specific causes and factors of the development of the disease.
As a rule, the duration of a complex session is 1.5 hours. It includes acupuncture, acupressure, moxotherapy and additional procedures (as indicated). Additional procedures at the Tibet Clinic for arthritis include manual therapy, Su-jok, tsubo therapy, laser therapy, electropuncture, kinesiology, and hirudotherapy.
To increase the effectiveness of arthritis treatment, individual nutritional correction is carried out. In addition, an individual course of physical therapy may be recommended to be performed independently or with the participation of a doctor.
The effectiveness of arthritis treatment in Tibet exceeds 90%:
pain, redness, swelling and other signs of joint inflammation disappear or significantly decrease,
stiffness and stiffness of the joint disappear, ease and range of motion in the joint are restored, its size decreases,
the body’s defenses increase, chronic inflammatory processes go away,
prevents or reduces the risk of arthritis complications,
digestion and metabolism improves.
Specific treatment results depend on the type of arthritis, its stage, duration and cause of the disease. In some cases it is possible to cure arthritis or achieve remission, in others it is possible to significantly reduce the symptoms of the disease and reduce the risk of its complications.
Ultimately, the use of oriental medicine in the Tibet clinic pays off for all treatable arthritis.
Case from practice
A 57-year-old man came to the clinic with complaints of shoulder pain. External examination showed swelling, limited mobility, redness and increased temperature in the shoulder joint. Movements in the shoulder were accompanied by creaking. Pain in the joint occurred both during physical activity and at night, at rest. Based on MRI data and eastern diagnostics, grade 2 arthritis of the shoulder joint was determined.
After complex treatment of arthritis, which included 10 sessions of procedures while taking Tibetan herbal remedies, the signs of inflammation disappeared. Mobility in the joint has improved, and night pain in the joint has stopped. Daytime pain during physical activity became less intense, which corresponded to the transition of arthritis from 2nd to 1st degree. A control MRI image showed positive dynamics of joint restoration. A repeated course of treatment was carried out 6 months later, after which the pain in the joint practically ceased, and the range of motion in the shoulder was completely restored. Follow-up showed no recurrence of inflammation.
Treatment of joint arthritis in Tibet is an opportunity to use all the benefits of oriental medicine.
1. No side effects.
Treatment in “Tibet” relieves inflammation, swelling and pain in the joint no less effectively than non-steroidal or hormonal drugs. However, unlike the latter, this treatment does not have side effects and is not addictive, which makes it completely safe. Methods of oriental reflexology, physiotherapy and herbal medicine have virtually no contraindications, which allows them to be used in the treatment of arthritis not only in middle age, but also in childhood and old age.
2. Long-term results.
Treatment in “Tibet” does not just eliminate the symptoms of inflammation, it affects the cause of arthritis, restoring the balance of the body. If you follow medical recommendations, the results of treatment will be maintained and even increased for a long time after the end of the course of procedures and herbal medicine.
3. Elimination of hidden causes of joint disease.
Along with inflammation in the joints, treatment of arthritis in “Tibet” also eliminates other foci of chronic inflammation in the body (including hidden), improves immunity, and has a positive effect on all types of metabolic processes.
1. Can arthritis be treated in the same way as arthrosis?
Arthritis and arthrosis are completely different diseases, so they need to be treated differently. For example, with arthrosis it is useful to warm up the joint, but with arthritis this can lead to increased inflammation. Therefore, there are no universal remedies “for joint pain” or “for joint diseases”!
2. Are there safe ointments that help with arthritis?
Any ointments, tablets or injections of non-steroidal, and especially hormonal drugs have side effects. The same applies to cytostatics and antibiotics. These remedies affect the symptoms of arthritis, but leave the cause of the disease unaffected. The inflammatory process continues to develop, which creates a high risk of complications. This is one of the main dangers of symptomatic remedies for arthritis - time is lost for full treatment, and in many cases the doctor has to deal with already advanced arthritis.
3. Can warm compresses be used for arthritis?
Natural warming compresses are based on the action of capsaicin, a substance found in hot peppers. The feeling of warmth is created due to the dilation of blood vessels, blood flow and improved blood circulation in the joint area. This is a subjective feeling. In reality, the joint does not heat up, so there is no cause for concern. The analgesic effect of such patches is achieved by inhibiting the sensitivity of nerve endings. Such warming patches are classified as symptomatic therapy. Essentially, they only alleviate the symptoms of arthritis and cannot replace full-fledged treatment.
c) biopsy of the synovial membrane (hypertrophy and increase in the number of villi, proliferation of integumentary synovial cells, fibrin deposition on the surface of the synovium, foci of necrosis)
d) study of synovial fluid (in RA – turbid, viscosity is reduced, the number of cells per μl is 5-25 thousand, neutrophils > 75%, mononuclear cells < 25%, ragocytes are present - neutrophils with inclusions in the cytoplasm of the Russian Federation, their shape resembles a mulberry, total protein 40-60 g/l, glucose 0.5-3.5 mmol/l, LDH > 300 units, RF detected)
Diagnostic criteria for RA:
To make a diagnosis of RA, at least 4 of the following criteria must be present:
1. morning stiffness for more than 1 hour
2. arthritis? 3 joints (polyarthritis)
3. arthritis of the joints of the hands
4. symmetrical arthritis
5. rheumatoid nodes
6. rheumatoid factor
7. characteristic radiographic changes
These symptoms must last for at least 6 weeks because... sometimes other arthritis can present the same way.
1. Treatment should be permanent (lifelong), complex (medication + physiotherapeutic + sanatorium-resort + surgical according to indications), individual, staged.
2. Drug therapy:
A. Basic therapy (slow-acting drugs):
— Arava (leflunamide) (1st place in effectiveness, used for > 5 years)
— methotrexate (2nd place in effectiveness, used for > 20 years)
- gold preparations (tauredon) (3rd place in effectiveness, used for > 60 years)
— sulfasalazine (4th place in effectiveness, used > 50 years)
— D-penicillamine (5th most effective, used > 40 years)
— azathioprine (6th place in effectiveness, used > 30 years)
— aminoquinoline drugs (plaquenil) (7th place in effectiveness, used for > 40 years);
All these drugs are effective in 40% of cases, in 30% there are side effects, in another 30% there is no effect; On average, the effect of basic therapy occurs after 2 months (Arava - 1 month). It is possible to combine basic drugs (methotrexate + sulfasalazine + plaquenil, etc.), but only if they are pathogenetic compatible.
B. Anti-inflammatory therapy:
1) NSAIDs: traditional, classic (indomethacin, diclofenac 75-150 mg/day in 2-3 doses, ibuprofen 1.2-3.2 g/day in 3-4 doses, etc.) and selective COX-2 inhibitors ( fewer side effects: meloxicam/movalis 7.5-15 mg/day, nimesulide/nimesil/nise 100 mg/day in 2 doses, celecoxib/celebrex)
— any drug can be prescribed, usually they start with the classic ones; if there are contraindications (gastric and duodenal ulcers, hypertension, kidney disease), selective COX-2 inhibitors are indicated (they are not started with them due to the higher cost of these drugs)
- if there is no effect, the drug is changed (effectiveness is assessed after 5-7 days of use)
- main side effect: damage to the gastrointestinal tract in the form of dyspepsia or ulcers (stomach, 12pcs, intestines); if ulcers are at risk, proton pump inhibitors (omeprazole) can be used
2) GKS – can be used
a) orally in small doses: 5-7.5 mg of prednisolone
b) IV in the form of pulse therapy - only in the presence of systemic manifestations (except for renal amyloidosis)
c) intra-articularly (not > 3 times/year) – for synovitis: diprospan (betamethasone), depo-medrol (methylprednisolone), kenalog (triamcinolone)
Each patient should be prescribed at least 2 drugs (1 from A, 1 from B), but there may be more. Only 20% of patients manage to achieve remission of the disease (on some basic drug); for the second time it is no longer effective. All RA patients have the right to free outpatient treatment, but not all drugs are included in the order (no arava: $100 a month or gold drugs: $70 a month).
Current trends in the treatment of RA - anti-TNF ? -therapy : Etanercept (Immunex, Enbrel) - a soluble dimer of the TNF?-receptor combined with IgG 1 (s.c. 2.5 mg 2 times a week), Infliximab (Remicade) - a monoclonal antibody against TNF? (iv drip after 8 weeks); the cost of a year's course of treatment is $10,000-12,000; these drugs are highly effective, because stop the progression of RA.
3. Physiotherapeutic treatment - should be aimed at reducing pain and inflammation, thermal procedures (mud, ozokerite, paraffin) are not allowed, electrotherapy, laser therapy, balneotherapy are allowed.
4. Sanatorium-resort treatment : the sanatoriums “Radon” (Dyatlovsky district of the Grodno region), “Pridneprovsky” (Rogachevsky district) are recommended; "Them. Lenin" (Bobruisk)
5. Surgical treatment:
a) synovectomy – causes attenuation of the process only for 2-3 years, i.e. temporarily; currently
not used, because causes secondary arthritis
b) joint replacement (hip, knee and smaller)
6. Rehabilitation : changing the stereotype of motor activity to prevent joint deformation; orthopedic aids that keep the joint in the correct position; physical therapy, physical therapy, sanatorium-resort treatment.
Rheumatoid arthritis (RA) is a chronic connective tissue systemic disease characterized by progressive damage to predominantly peripheral (small) joints, such as erosive-destructive polyarthritis.
The etiology of this disease is currently not clearly established. However, it is known that this disease develops when a person has a genetic predisposition. It is believed that there is an inheritance of a defect in the immune system. Deficiency of the T-suppressor system provokes the occurrence of deterministic autoimmune processes. A hereditary etiological factor activates the development of the body's immune response. Joint damage begins with the occurrence of an inflammatory process in the synovial membrane, followed by its infiltration by plasma cells, T-lymphocytes and macrophages. When macrophages interact with helper cells (T-lymphocytes), the latter are activated, which leads to increased proliferation of B-lymphocytes and their further differentiation to plasma cells, which in turn produce altered IgG, which is perceived by the immune system as a foreign agent. The reaction of the lymph nodes, spleen and synovium to altered IgG is the production of specific antibodies - rheumatoid factors (IgM, A, G). As a result of the interaction of rheumatoid factor with a foreign agent, the formation of immune complexes occurs, which are phagocytosed by synovial macrophages and neutrophils. During the process of phagocytosis, inflammatory mediators and lysosomal enzymes are released, developing inflammatory and destructive changes in cartilage and synovium.
The clinical symptoms of rheumatoid arthritis can be pronounced, or they can subside and even temporarily completely disappear (during remission).
With carefully collected anamnestic data, it is possible to identify the presence of a prodromal period of the disease, the duration of which can vary from several weeks to several months. In the prodromal period, the patient complains of: increased fatigue, loss of appetite, weight loss, sweating, periodic arthralgia, 30% of patients complain of morning stiffness.
Depending on the severity, the following types of rheumatoid arthritis are distinguished: monoarthritis, polyarthritis, oligoarthritis. Depending on the presence of a specific rheumatoid factor in the blood serum: seropositive (RF “+”), seronegative (RF “-”).
The onset of the disease, as a rule, is subacute in nature, characterized by moderate pain in the joints during movement, stiffness of the joints in the morning, pain on palpation and the presence of hyperemia around. Only in some cases does this disease begin acutely - the body temperature rises sharply and for no reason, a feeling of chills appears, the lymph nodes become enlarged, and patients complain of sharp, intense pain in the joints.
The main diagnostic clinical sign is articular syndrome. Most often, joints are affected symmetrically on both sides. Let's consider the clinical manifestations of lesions of various joints and other organs and systems:
joints of the hand: most often the proximal interphalangeal, wrist and II-III metacarpophalangeal joints are involved in the pathological process. There is swelling and pain when moving. The spindle-shaped appearance of the fingers is a consequence of the inflammatory process in the proximal interphalangeal joints. The patient is unable to clench his hand into a fist. As the disease progresses, the hand becomes deformed like a “walrus fin” (characterized by deviation of the fingers towards the ulna), “swan neck” (formation of contracture of the metacarpophalangeal joints), “button loop” (flexion in the area of the metacarpophalangeal joints) and extension of the distal interphalangeal joints);
wrist joints: presence of pain, swelling, gradual development of ankylosis;
wrist joints: swelling, pain, ankylosis - a fairly rare phenomenon;
Tenosynovitis may develop - damage to the tendon sheaths of the hand. Tenosynovitis is accompanied by the so-called carpal tunnel syndrome, which is characterized by impaired sensitivity of the thumb, middle and index fingers with impaired motor function, pain that tends to spread to the elbow area;
elbow joints: intense pain, limited mobility during flexion and extension;
shoulder joints: swelling, pain on palpation, limited mobility. Sometimes swelling develops in the armpit and anterolateral area of the shoulder;
knee joints: their damage is characterized not only by swelling and pain, but also by the presence of effusion in the joint itself. Flexion contracture gradually develops;
joints of the foot: most often the metatarsophalangeal joints of the II, III, IV fingers are involved in the process. Swelling develops, pain progresses when walking and jumping, the foot becomes deformed like “hallux valgus”;
Muscles are often involved in the pathological process. Muscle tissue gradually atrophies, which is accompanied by a decrease in its strength and tone;
with a long course of rheumatoid arthritis, thinning and dryness of the skin, the appearance of subcutaneous hemorrhages are observed, the trophism of the nails is disrupted (as a result - fragility, longitudinal striations);
the appearance of rheumatoid nodules, which are most often localized subcutaneously. They are fairly dense, mobile and painless connective tissue formations;
damage to the cardiovascular system is characterized by the appearance of such pathological conditions as: myocarditis, pericarditis, in isolated cases, cardiac defects are formed;
polyneuropathy: the distal parts of the nerve trunks are mainly affected. There is a violation of sensitivity, a feeling of numbness and burning in the extremities;
possible lung damage - pleurisy, fibrosing diffuse alveolitis;
Kidney damage is represented by amyloidosis and glomerulonephritis.
The main diagnostic indicators of rheumatoid arthritis are: the presence of osteoporosis, marginal abnormalities of the articular surfaces, subluxations on the radiograph; hypochromic anemia and persistent acceleration of ESR in the general blood test; positive rheumatoid factor in diagnostic titers and increased acute phase parameters in biochemical blood tests; the presence of ragocytosis, rheumatoid factor and inflammatory type of changes in the synovial fluid during joint puncture (arthrocentesis).
Diagnostic criteria for rheumatoid arthritis
American Rheumatological Association (ARA), 1987.
Morning stiffness of joints and periarticular tissues lasting at least 1 hour.
Arthritis of 3 or more articular areas (swelling of periarticular soft tissues or the presence of effusion in the joint cavity (but not osteophytes), as determined by a doctor). 14 articular zones are taken into account on the right and left: proximal interphalangeal, metacarpophalangeal, wrist, elbow, knee, ankle and metatarsophalangeal.
Arthritis of the hand joints (swelling of at least one of the following joints: wrist, metacarpophalangeal, proximal interphalangeal).
Symmetrical arthritis (simultaneous damage to the same articular zones on the right and left - proximal interphalangeal, metacarpophalangeal or metatarsophalangeal).
Rheumatoid nodules (subcutaneous nodules localized on the extensor surface of the forearm near the elbow joint or in the area of other joints).
Rheumatoid factor in blood serum (in healthy people it is determined in less than 5% of cases).
X-ray changes (changes typical for rheumatoid arthritis on the X-ray of the hands and wrist joints - erosions or uneven decalcification (osteoporosis of the hand) in the affected joints or directly on adjacent joints).
The diagnosis is made if 4 out of 7 criteria are met. Criteria 1 - 4 must be present for at least 6 weeks.
The designations classic, definite, and probable are not used.
orthopedic treatment, rehabilitation.
Based on the pathogenesis of the disease, it becomes obvious that it is possible to effectively influence the development of the disease at two levels:
Anti-inflammatory therapy itself (NSAIDs) can produce a clinical effect (pain relief, reduction of stiffness) very quickly - within 1-2 hours, however, with the help of such treatment it is almost impossible to completely stop the symptoms of active rheumatoid arthritis and, apparently, it has no effect at all on the development of destructive processes in tissues.
Orthopedic treatment, including orthotics and surgical correction of joint deformities, as well as rehabilitation measures (physical therapy, etc.) are of particular importance, mainly in the later stages of the disease, to maintain functional ability and improve the patient’s quality of life.
The main goals of treatment for RA are relief of disease symptoms, achieving clinical remission or at least low disease activity;
improving the quality of life of patients, maintaining their ability to work.
It must be kept in mind that treatment goals may vary significantly depending on the duration of the disease. At an early stage of the disease, i.e., with a disease duration of 6–12 months, achieving clinical remission is a very realistic goal, as well as inhibiting the development of erosions in the joints. With the help of modern methods of active drug therapy, it is possible to achieve remission in 40–50% of patients; the absence of the appearance of new erosions according to radiography and magnetic resonance imaging has also been shown in a significant number of patients with a follow-up period of 1–2 years.
With long-term rheumatoid arthritis, especially with insufficiently active therapy in the first years of the disease, achieving complete remission is theoretically also possible, but the likelihood of this is much lower. The same can be said about the possibility of stopping the progression of destruction in joints that have already been significantly destroyed over several years of illness. Therefore, with advanced rheumatoid arthritis, the role of rehabilitation measures and orthopedic surgery increases. In addition, in the later stages of the disease, long-term basic maintenance therapy can be used for secondary prevention of complications of the disease, such as systemic manifestations (vasculitis, etc.), secondary amyloidosis.
Basic therapy for rheumatoid arthritis. DMARDs (synonyms: disease-modifying antirheumatic drugs, slow-acting drugs) are the main component of the treatment of rheumatoid arthritis and, in the absence of contraindications, should be prescribed to every patient with this diagnosis. It is especially important to prescribe DMARDs as quickly as possible (immediately after diagnosis) at an early stage, when there is a limited period of time (several months from the onset of symptoms) to achieve the best long-term results - the so-called “therapeutic window”.
Persistence of the clinical effect, including its persistence after discontinuation of the drug.
The ability to delay the development of the erosive process in joints.
Slow development of a clinically significant effect (usually within 1–3 months from the start of treatment).
DMARDs differ significantly in their mechanism of action and features of use.
DMARDs can be roughly divided into first-line and second-line drugs. First-line drugs have the best balance of effectiveness (reliably suppress both clinical symptoms and the progression of the erosive process in the joints) and tolerability, and therefore are prescribed to most patients.
Methotrexate is the “gold standard” for the treatment of rheumatoid arthritis. Recommended doses of 7.5–25 mg per week are individualized by gradual increases of 2.5 mg every 2–4 weeks until a good clinical response is achieved or intolerance occurs. The drug is given orally (weekly for two consecutive days in 3-4 divided doses every 12 hours). In case of unsatisfactory tolerability of methotrexate when taken orally due to dyspepsia and other complaints associated with the gastrointestinal tract (GIT), the drug can be prescribed parenterally (one IM or IV injection per week).
Leflunomide (Arava). Standard treatment regimen: 100 mg orally per day for 3 days, then 20 mg/day continuously. If there is a risk of intolerance to the drug (old age, liver disease, etc.), treatment can be started with a dose of 20 mg/day. It is comparable in effectiveness to methotrexate and has slightly better tolerability. There is evidence of higher effectiveness of leflunomide in relation to the quality of life of patients, especially in early rheumatoid arthritis. The cost of treatment with leflunomide is quite high, so it is often prescribed when there are contraindications to the use of methotrexate, its ineffectiveness or intolerance, but it can also be used as the first basic drug.
Second-line DMARDs are used much less frequently due to lower clinical efficacy and/or greater toxicity. They are prescribed, as a rule, when first-line DMARDs are ineffective or intolerable.
If monotherapy with any basic drug is insufficiently effective, a combination basic therapy regimen, i.e., a combination of two or three DMARDs, can be chosen. The following combinations have proven themselves to be the most effective:
methotrexate + sulfasalazine + hydroxychloroquine.
In combination regimens, drugs are usually used in moderate dosages. A number of clinical studies have demonstrated the superiority of combination basic therapy over monotherapy, but the higher effectiveness of combination regimens is not considered strictly proven. Combination DMARDs are associated with a moderate increase in side effects.
Biological drugs in the treatment of rheumatoid arthritis. The term biological drugs (from English biologics) is used in relation to drugs produced using biotechnology and carrying out targeted (“point”) blocking of key moments of inflammation using antibodies or soluble receptors to cytokines, as well as other biologically active molecules. Thus, biological products have nothing to do with “dietary supplements.” Due to the large number of “target molecules” that can potentially suppress immune inflammation, a number of drugs from this group have been developed and several more are undergoing clinical trials.
The main biological drugs registered in the world for the treatment of rheumatoid arthritis include:
rituximab (acts on CD 20 (B lymphocytes));
Rheumatoid arthritis is a disease that has been the focus of attention of rheumatologists around the world for decades. This is due to the great medical and social significance of this disease. Its prevalence reaches 0.5–2% of the total population in industrialized countries [1, 2]. Patients with rheumatoid arthritis experience a decrease in life expectancy compared to the general population by 3–7 years [3]. It is difficult to overestimate the colossal damage caused by this disease to society due to the early disability of patients, which, in the absence of timely active therapy, can occur in the first 5 years from the onset of the disease.
Rheumatoid arthritis is a chronic inflammatory disease of unknown etiology, which is characterized by damage to peripheral synovial joints and periarticular tissues, accompanied by autoimmune disorders and can lead to destruction of articular cartilage and bone, as well as systemic inflammatory changes.
The pathogenesis of the disease is very complex and largely insufficiently studied. Despite this, by now some key points in the development of rheumatoid inflammation are well known, which determine the main methods of therapeutic treatment for it (Fig. 1). The development of chronic inflammation in this case is associated with the activation and proliferation of immunocompetent cells (macrophages, T- and B-lymphocytes), which is accompanied by the release of cellular mediators - cytokines, growth factors, adhesion molecules, as well as the synthesis of autoantibodies (for example, anticitrullinated antibodies) and the formation immune complexes (rheumatoid factors). These processes lead to the formation of new capillary vessels (angiogenesis) and the proliferation of connective tissue in the synovial membrane, to the activation of cyclooxygenase-2 (COX-2) with an increase in the synthesis of prostaglandins and the development of an inflammatory reaction, to the release of proteolytic enzymes, activation of osteoclasts, and as a result - to the destruction of normal joint tissues and the occurrence of deformities.
Treatment of rheumatoid arthritis
non-drug therapy methods;
suppressing excessive activity of the immune system;
blocking the production of inflammatory mediators, primarily prostaglandins.
Since, in addition to inflammation itself, activation of the immune system is accompanied by many other pathological processes, the effect at the first level is significantly deeper and more effective than at the second. Drug immunosuppression is the mainstay of treatment for rheumatoid arthritis. Immunosuppressive drugs used to treat this disease include disease-modifying anti-inflammatory drugs (DMARDs), biological agents, and glucocorticosteroids. At the second level, non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticosteroids act.
In general, immunosuppressive therapy is accompanied by a slower development of the clinical effect (in a broad framework - from several days in the case of biological therapy to several months in the case of some DMARDs), which at the same time can be very pronounced (up to the development of clinical remission) and persistent, and is also characterized by inhibition of joint destruction.
Glucocorticosteroids have both immunosuppressive and direct anti-inflammatory effects, so clinical improvement can develop quickly (within a few hours when administered intravenously or intra-articularly). There is evidence of suppression of the progression of the erosive process in joints during long-term therapy with low doses of glucocorticosteroids and their positive effect on the functional status of the patient. At the same time, it is well known from practice that prescribing only glucocorticosteroids, without other immunosuppressive drugs (DMARDs), rarely provides an opportunity to effectively control the course of the disease.
Non-drug methods of treating rheumatoid arthritis (physiotherapy, balneotherapy, diet therapy, acupuncture, etc.) are additional methods that can slightly improve the patient’s well-being and functional status, but do not relieve symptoms and significantly influence joint destruction.
The main goals of treatment for RA are [2, 6]:
relief of disease symptoms, achievement of clinical remission or at least low disease activity;
inhibition of the progression of structural changes in joints and corresponding functional disorders;
It must be kept in mind that treatment goals may vary significantly depending on the duration of the disease. At an early stage of the disease, i.e., with a disease duration of 6–12 months, achieving clinical remission is a very realistic goal, as well as inhibiting the development of erosions in the joints. With the help of modern methods of active drug therapy, it is possible to achieve remission in 40–50% of patients [4, 5], and the absence of the appearance of new erosions according to radiography [7] and magnetic resonance imaging [8] has also been shown in a significant number of patients with a follow-up duration of 1 -2 years.
Basic therapy for rheumatoid arthritis. DMARDs (synonyms: disease-modifying antirheumatic drugs, slow-acting drugs) are the main component of the treatment of rheumatoid arthritis and, in the absence of contraindications, should be prescribed to every patient with this diagnosis [9]. It is especially important to prescribe DMARDs as quickly as possible (immediately after diagnosis) at an early stage, when there is a limited period of time (several months from the onset of symptoms) to achieve the best long-term results - the so-called “therapeutic window” [10].
Classic DMARDs have the following properties.
The ability to suppress the activity and proliferation of immunocompetent cells (immunosuppression), as well as the proliferation of synoviocytes and fibroblasts, which is accompanied by a pronounced decrease in the clinical and laboratory activity of RA.
Ability to induce clinical remission.
DMARDs differ significantly in their mechanism of action and features of use. The main parameters characterizing DMARDs are presented in Table 1.
First-line DMARDs include the following.
Sulfasalazine. In clinical trials, it was not inferior in effectiveness to other DMARDs, but clinical practice shows that sulfasalazine usually provides sufficient control over the course of the disease in cases of moderate and low activity of rheumatoid arthritis.
DMARDs can cause significant improvement (good clinical response) in approximately 60% of patients. Due to the slow development of the clinical effect, the prescription of DMARDs for periods of less than 6 months is not recommended. The duration of treatment is determined individually; the typical duration of a “course” of treatment with one drug (in case of a satisfactory response to therapy) is 2–3 years or more. Most clinical recommendations suggest indefinite use of maintenance dosages of DMARDs to maintain the achieved improvement.
infliximab, adalimumab, etanercept (act on tumor necrosis factor (TNF-?);
anakinra (acts on interleukin-1);
abatasept (affects CD 80, CD 86, CD 28).
Biological drugs are characterized by a pronounced clinical effect and reliably proven inhibition of joint destruction. These signs allow biological drugs to be classified as DMARDs. At the same time, a feature of the group is the rapid (often within a few days) development of significant improvement, which combines biological therapy with intensive care methods. A characteristic feature of biological agents is the potentiation of the effect in combination with DMARDs, primarily methotrexate. Due to its high effectiveness in rheumatoid arthritis, including in patients resistant to conventional therapy, biological therapy has now moved to second place (after DMARDs) in the treatment of this disease.
The negative aspects of biological therapy include:
inhibition of anti-infective and (potentially) anti-tumor immunity;
the risk of developing allergic reactions and inducing autoimmune syndromes due to the fact that biological drugs are proteins in their chemical structure;
high cost of treatment.
Biological therapies are indicated if treatment with DMARDs (such as methotrexate) is not adequate due to lack of effectiveness or poor tolerability.
One of the most important target molecules is TNF-a, which has many pro-inflammatory biological effects and contributes to the persistence of the inflammatory process in the synovium, destruction of cartilage and bone tissue through a direct effect on synovial fibroblasts, chondrocytes and osteoclasts. TNF blockers? are the most widely used biological agents in the world.
A drug from this group, infliximab (Remicade), which is a chimeric monoclonal antibody to TNF-?, has been registered in Russia. The drug is usually prescribed in combination with methotrexate. In patients with insufficient effectiveness of therapy with medium and high doses of methotrexate, infliximab significantly improves the response to treatment and functional indicators, and also leads to a significant inhibition of the progression of joint space narrowing and the development of the erosive process.
The indication for the use of infliximab in combination with methotrexate is the ineffectiveness of one or more DMARDs used at full dose (primarily methotrexate), with the persistence of high inflammatory activity (five or more swollen joints, erythrocyte sedimentation rate (ESR) more than 30 mm/h, C-reactive protein (CRP) more than 20 mg/l). In early rheumatoid arthritis with high inflammatory activity and a rapid increase in structural disorders in the joints, combination therapy with methotrexate and infliximab can be prescribed immediately.
Before prescribing infliximab, a screening examination for tuberculosis (chest x-ray, tuberculin test) is required. Recommended regimen: initial dose of 3 mg/kg of the patient’s body weight intravenously, then 3 mg/kg of body weight after 2, 6 and 8 weeks, then 3 mg/kg of body weight every 8 weeks, if the dose is insufficiently effective may increase up to 10 mg/kg body weight. The duration of treatment is determined individually, usually at least 1 year. After discontinuation of infliximab, maintenance therapy with methotrexate is continued. It should be kept in mind that re-administration of infliximab after completion of treatment with this drug is associated with an increased likelihood of delayed-type hypersensitivity reactions.
The second drug registered in our country for biological therapy is rituximab (Mabthera). The action of rituximab is aimed at suppressing B lymphocytes, which are not only the key cells responsible for the synthesis of autoantibodies, but also perform important regulatory functions in the early stages of immune reactions. The drug has pronounced clinical efficacy, including in patients who do not respond sufficiently to infliximab therapy.
For the treatment of rheumatoid arthritis, the drug is used at a dose of 2000 mg per course (two infusions of 1000 mg, each with an interval of 2 weeks). Rituximab is administered intravenously slowly; infusion in a hospital setting is recommended with the possibility of precise control over the rate of administration. To prevent infusion reactions, it is advisable to pre-administer methylprednisolone 100 mg. If necessary, a second course of rituximab infusions can be performed after 6–12 months.
According to European clinical guidelines, it is advisable to prescribe rituximab in cases of ineffectiveness or impossibility of infliximab therapy. The possibility of using rituximab as the first biological drug is currently the subject of research.
Glucocorticosteroids. Glucocorticosteroids have a multifaceted anti-inflammatory effect due to the blockade of the synthesis of proinflammatory cytokines and prostaglandins, as well as inhibition of proliferation due to their effect on the genetic apparatus of cells. Glucocorticosteroids have a rapid and pronounced dose-dependent effect on the clinical and laboratory manifestations of inflammation. The use of glucocorticosteroids is fraught with the development of undesirable reactions, the frequency of which also increases with increasing doses of the drug (steroid osteoporosis, drug-induced Itsenko-Cushing syndrome, damage to the gastrointestinal mucosa). These drugs alone in most cases cannot provide complete control over the course of rheumatoid arthritis and must be prescribed together with DMARDs.
Glucocorticosteroids for this disease are used systemically and locally. For systemic use, the main method of treatment is the administration of low doses orally (prednisolone - up to 10 mg/day, methylprednisolone - up to 8 mg/day) for a long period with high inflammatory activity, polyarticular lesions, and insufficient effectiveness of DMARDs.
Medium and high doses of glucocorticosteroids orally (15 mg/day or more, usually 30-40 mg/day in terms of prednisolone), as well as pulse therapy with glucocorticosteroids - intravenous administration of high doses of methylprednisolone (250-1000 mg) or dexamethasone (40-1000 mg). 120 mg) can be used to treat severe systemic manifestations of rheumatoid arthritis (effusive serositis, hemolytic anemia, cutaneous vasculitis, fever, etc.), as well as some special forms of the disease. The duration of treatment is determined by the time required to relieve symptoms and is usually 4–6 weeks, after which a gradual stepwise dose reduction is carried out with a transition to treatment with low doses of glucocorticosteroids.
Glucocorticosteroids in medium and high doses, pulse therapy, apparently, do not have an independent effect on the course of rheumatoid arthritis and the development of the erosive process in the joints.
For local therapy, drugs are used in microcrystalline form, prescribed in the form of intra-articular and periarticular injections: betamethasone, triamsinolone, methylprednisolone, hydrocortisone.
Glucocorticosteroids for local use have a pronounced anti-inflammatory effect, mainly at the injection site, and in some cases - a systemic effect. Recommended daily doses are: 7 mg for betamethasone, 40 mg for triamsinolone and methylprednisolone, 125 mg for hydrocortisone. This dose (in total) can be used for intra-articular injection into one large (knee) joint, two medium-sized joints (elbows, ankles, etc.), 4-5 small joints (metacarpophalangeal, etc.), or for periarticular administration of the drug at 3–4 points.
The effect after a single injection usually occurs within 1–3 days and lasts for 2–4 weeks if well tolerated.
In this regard, it is not advisable to prescribe repeated injections of glucocorticosteroids into one joint earlier than after 3-4 weeks. Carrying out a course of several intra-articular injections into the same joint has no therapeutic meaning and is fraught with complications (local osteoporosis, increased destruction of cartilage, osteonecrosis, suppuration). Due to the increased risk of osteonecrosis, intra-articular injection of glucocorticosteroids into the hip joint is generally not recommended.
Glucocorticosteroids for local use are prescribed as an additional method for relieving exacerbations of rheumatoid arthritis and cannot serve as a replacement for systemic therapy.
NSAIDs. The importance of NSAIDs in the treatment of rheumatoid arthritis has decreased significantly in recent years due to the emergence of new effective pathogenetic therapy regimens. The anti-inflammatory effect of NSAIDs is achieved by suppressing the activity of COX, or selectively COX-2, and thereby reducing the synthesis of prostaglandins. Thus, NSAIDs act on the final link of rheumatoid inflammation.
The effect of NSAIDs in rheumatoid arthritis is to reduce the severity of symptoms of the disease (pain, stiffness, swelling of the joints). NSAIDs have an analgesic, anti-inflammatory, and antipyretic effect, but have little effect on laboratory parameters of inflammation. In the vast majority of cases, NSAIDs are not able to significantly change the course of the disease. Their prescription as the only antirheumatic drug for a definite diagnosis of rheumatoid arthritis is currently considered a mistake. However, NSAIDs are the mainstay of symptomatic therapy for this disease and in most cases are prescribed in combination with DMARDs.