Treatment methods for rheumatoid arthritis: basic therapy, anti-inflammatory drugs of different groups, methods of physical and mechanical influence on the immune system, local treatment, physiotherapeutic treatment, diet.
* The main treatment for rheumatoid arthritis is the so-called basic drugs . Therefore, it is with basic drugs that we will begin our conversation about methods of treating arthritis.
It is believed that basic drugs act on the basis of the disease, its “basis”. These drugs are used with an eye to the future, counting on their ability to interrupt the development of the disease. But you need to keep in mind that, unlike anti-inflammatory drugs and hormones, basic drugs do not provide an immediate positive effect, that is, they do not eliminate the symptoms of the disease in the first days and weeks of their use. As a rule, basic drugs can take effect no sooner than after a month - and this is their significant drawback.
In addition, practically no basic drug is capable of providing a guaranteed 100% result. That is, many of the basic drugs slow down the development of arthritis and provide improvement over time, but how pronounced this improvement will be cannot be predicted in advance by even the most experienced rheumatologist. Therefore, the correct selection of basic therapy largely depends not only on the doctor’s experience, but also on his intuition. Nevertheless, any basic drug has its own characteristic advantages and disadvantages, and we will now talk about them.
Currently, five groups of drugs are most often used as basic therapy: gold salts, antimalarial drugs, the antimicrobial drug sulfasalazine, D-penicillamine and cytostatics .
Gold preparations ( auranofin and aurothiomalate, also known as crizanol, myocrisin, tauredon, etc.) have been used to treat rheumatoid arthritis for more than 75 years. They were first used for this purpose back in 1929.
Until recently, gold preparations were the most popular group of basic drugs among rheumatologists for the treatment of rheumatoid arthritis. But recently, with the advent of such a medicine as methotrexate, they were assigned to the group of “second-line” drugs and began to be used somewhat less frequently - mainly due to the fact that methotrexate is more convenient to use, is better tolerated by patients and is less likely to cause adverse reactions. However, for those patients who are not suitable for methotrexate, it is quite possible to prescribe gold preparations - of course, in the absence of obvious contraindications.
It has been noticed that gold preparations help better those patients whose disease has recently begun, that is, they are useful in the initial stages of rheumatoid arthritis. At the same time, it is believed that gold preparations help especially well those patients whose disease progresses quickly, there are sharp pains in the joints and many hours of morning stiffness, rheumatoid nodules appear early, especially if the patient is not helped well by non-steroidal anti-inflammatory drugs.
In addition, gold preparations are recommended for those who have early onset of bone erosions (on x-ray) and high levels of RF - rheumatoid factor in the blood. That is, gold preparations mainly help with seropositive rheumatoid arthritis , and much worse with seronegative arthritis, when no increase in rheumatoid factor is found in the blood.
In case of seropositive rheumatoid arthritis, long-term administration of gold preparations can significantly slow down the progression of disease symptoms and the destruction of articular cartilage, slow down the formation of bone cysts and erosions (usur), and also often improves bone mineralization. In a few patients, even healing of bone erosions (usur) inside the affected bones of the hands and feet was observed.
In addition, gold preparations help well with a number of serious complications of rheumatoid arthritis - Felty's syndrome and the so-called dry syndrome (Sjögren's syndrome), although in the latter case gold preparations treat only the joint manifestations of the disease, and not the dry syndrome itself. Gold is also indicated for juvenile rheumatoid arthritis, that is, for the childhood version of classic seropositive rheumatoid arthritis.
Gold preparations have other additional benefits. Unlike methotrexate and other immunosuppressants, they can be used for concomitant chronic infections and cancer (including those suffered in the past). In addition, it turned out that gold preparations have antibacterial and antifungal effects, and are also able to suppress the causative agent of stomach ulcers and gastritis - the bacterium Helicobacter pylori.
In general, gold preparations provide significant relief to approximately 70-80% of patients. The first positive changes can be seen already 2-3 months after the start of treatment, and the best result should be expected six months to a year from the start of aurotherapy (the complete absence of the therapeutic effect of gold preparations after 4-5 months of therapy indicates the inappropriateness of their further use).
It is believed that the greatest therapeutic effect from aurotherapy is achieved after the patient receives a dose of medicines containing a total of one gram (1000 mg) of pure gold. In previous years, treatment was stopped when this equivalent was reached. However, in some patients, after some time, the disease worsened again, and repeated administration of gold preparations no longer brought relief. Alas, only one course of “golden” treatment is effective. Repeating it after a break rarely benefits the patient. That is why, in our time, the initial use of “golden drugs” is continued indefinitely, literally for years - unless, of course, the patient develops adverse reactions to gold and does not experience any complications associated with taking these medications.
Side effects of gold drugs. Unfortunately, more than a third of patients may experience complications during treatment with gold preparations. Moreover, what is unusual is that immediately after the appearance of adverse reactions and complications, patients often experience a persistent improvement in the condition of the joints, which, as a rule, persists even after discontinuation of the drug. But complications most often disappear soon after stopping taking gold-containing medications.
The most common complication of aurotherapy is “golden” dermatitis in the form of a rash of pink spots and small pink blisters, often accompanied by itching, and an increase in the level of eosinophils in blood tests. This dermatitis usually goes away within a few days after stopping treatment with gold preparations (especially when antiallergic drugs are prescribed simultaneously), but in rare cases it lasts for months.
When golden dermatitis occurs, it must be taken into account that its manifestations are especially intensified by exposure to sunlight. Sometimes the skin takes on a brownish tint; very rarely, deposits of gold particles in the skin may occur - with the appearance of bluish spots. In some patients, the manifestations of golden dermatitis are almost indistinguishable from eczema, pityriasis rosea and lichen planus, which leads to errors in the diagnosis of these conditions. And very rarely, in advanced cases, if gold preparations were not stopped on time (when a rash appeared), patients developed areas of skin necrosis.
In addition to gold dermatitis, in some cases, patients taking gold preparations may experience inflammation of the mucous membranes of the mouth, vagina, or conjunctiva of the eyes. Ulcers in the mouth may appear, and the throat or intestines may become inflamed. In some cases, during treatment with gold preparations, non-infectious hepatitis and jaundice developed, which quickly disappeared after stopping the drug and prescribing prednisolone.
One of the most severe side complications of aurotherapy is kidney damage with the development of so-called “golden” nephropathy, which under unfavorable conditions can lead to “paralysis” of kidney activity. Most rheumatologists believe that to avoid nephropathy, gold medications should be stopped (at least temporarily) if a patient repeatedly shows red blood cells and protein (or traces thereof) on urine tests.
The listed side effects often make themselves felt already in the first months of treatment. Therefore, in order not to miss the so-called “golden” complications, the patient needs to regularly examine his skin for the appearance of unusual rashes. And doctors observing the patient should send him for blood and urine tests at least once a month, and periodically monitor the condition of his oral mucosa. If ulcers or rashes appear in the mouth, if a skin rash occurs, if protein or red blood cells appear repeatedly in a urine test, if the number of platelets, leukocytes, neutrophils, red blood cells decreases in blood tests and a sharp decrease in hemoglobin, as well as at the first signs of other complications, treatment Gold preparations should be stopped.
Despite some weaknesses (very slow development of the therapeutic effect, frequent side effects), gold compounds, which turned out to be the first long-acting anti-rheumatoid drugs, still remain one of the best, and, according to some authors, the best basic drugs for the treatment of rheumatoid arthritis.
Cytostatic drugs, or so-called immunosuppressants ( methotrexate, Arava, Remicade, azathioprine, cyclophosphamide, chlorbutin, cyclosporine , and others), were borrowed by rheumatologists from oncologists. According to most modern rheumatologists, cytostatics are the best group of basic drugs for the treatment of not only rheumatoid, but also psoriatic arthritis.
In oncology, these drugs are used to inhibit cell division, including cancer cells. Moreover, cytostatics are prescribed to cancer patients in huge doses, which leads to a large number of complications. In this regard, both doctors and patients are very wary of the use of cytostatics, fearing severe side effects.
However, when it comes to the use of these drugs in the treatment of arthritis, the danger is clearly exaggerated, because in arthrology, cytostatics are used in significantly lower doses than in oncology. Doses of cytostatics in the treatment of arthritis are approximately 5-20 times less than the doses used in the treatment of tumors! Such small amounts of immunosuppressive drugs rarely cause side effects, but the therapeutic effect is often significant. The use of cytostatics helps at least 70-80% of patients, and the drugs bring the greatest benefit to those suffering from a rapidly progressing severe form of rheumatoid arthritis.
Side effects are possible in 15-20% of patients and are rarely severe. Most often these are allergic rashes, a sensation of “goosebumps” on the skin, upset stool and moderate urination problems. All these manifestations usually disappear immediately after stopping the drugs. Other side effects, which can be learned from the drug leaflet, occur infrequently when taking “anti-arthritic doses” of cytostatics.
However, in order to avoid complications, it is necessary to monitor the condition of the patient taking immunosuppressants. Once a month you need to examine your urine, and most importantly, do a blood test taken from your finger once every two weeks in order to notice in time a possible inhibition of hematopoiesis. Once every three months it is necessary to check “liver parameters” in blood taken from a vein. If everything is in order and the patient easily tolerates cytostatic therapy, you can expect a clear improvement in well-being within 2-4 weeks after the start of treatment.
Currently, rheumatologists most often use 3 cytostatic drugs to treat rheumatoid arthritis:
Methotrexate is perhaps the best of the best basic drugs for the treatment of rheumatoid and psoriatic arthritis. Today it is considered the “drug of choice” for these diseases. For the basic treatment of rheumatoid arthritis, methotrexate is taken only once (10 mg) per week. For the first time, a specific day is chosen, say, Monday, and from then on, throughout the entire course of treatment, methotrexate is taken only on Mondays. The therapeutic effect usually appears within 5-6 weeks from the start of taking methotrexate and usually reaches its maximum within six months to a year.
Attention! On the day of taking methotrexate, it is advisable to avoid using non-steroidal anti-inflammatory drugs. On all other days, anti-inflammatory drugs can be used safely.
Arava, or leflunomide , is a relatively new, promising basic drug. Arava is considered to be as effective and tolerable as methotrexate and sulfasalazine. Although, according to my observations, it is still tolerated somewhat worse than methotrexate.
In general, Arava is recommended for patients whose arthritis is very active and for those who do not tolerate methotrexate well. And arava is sometimes prescribed to those patients for whom methotrexate helps little - since it happens that sometimes arava helps patients for whom methotrexate was ineffective (and vice versa, it often happens that methotrexate helps a patient well, but arava does not). The therapeutic effect usually appears 4-6 weeks from the start of taking Arava and can increase over 4-6 months.
Remicade , also known as infliximab , is a new fast-acting and quite effective basic drug. It is used in cases where other basic drugs, in particular methotrexate, do not provide the desired effect. Remicade is also used in cases where it is necessary to reduce the dose of corticosteroid hormones taken, or when arthritis is very active. Unfortunately, Remicade is still very expensive. However, despite the high cost, the use of Remicade is slowly gaining momentum - due to the fact that Remicade acts faster than many other basic drugs.
However, Remicade must be used with great caution. Very often, it is more difficult for patients to tolerate than Arava or methotrexate, and more often produces side effects.
Before starting treatment with Remicade, it is necessary to identify and treat all the patient's infections, including hidden ones, and treat all abscesses. After all, if this is not done, the use of Remicade can provoke a severe exacerbation of untreated infectious processes, up to the development of sepsis. In addition, during treatment with Remicade, it is recommended to use antiallergic drugs to prevent possible allergic reactions (they happen quite often). Even during treatment, it is necessary to use reliable methods of contraception in order to prevent pregnancy - Remicade is strictly contraindicated for pregnant women and nursing mothers (you should refrain from breastfeeding during therapy). Breastfeeding is allowed no earlier than 6 months after the end of Remicade treatment!
Other cytostatic drugs, such as azathioprine (Imuran), chlorobutin, cyclophosphamide (Endoxan) and cyclosporine (Imusporin, Consupren, Sandimmune, Ecoral), are rarely used for rheumatoid arthritis, since they are much more difficult to tolerate by patients than methotrexate, Arava and Remicade and much more often give various side effects. Due to the “severity” of the listed drugs, their poor tolerability and high frequency of side effects, these drugs are used only in extreme cases, when other basic drugs are ineffective.
The antimalarial drugs delagil (also known as chloroquine, resoquine, hingamine) and plaquenil (also known as hydroxychloroquine, hydrochlorine) have long been used by infectious disease specialists to treat tropical fever (malaria). However, in the 20th century. Rheumatologists also paid attention to them. They noticed that with very long-term use, delagil and plaquenil are able to influence the activity of the rheumatoid process, gradually reducing inflammation in the joints.
Unfortunately, over time it turned out that these drugs act very slowly: the therapeutic effect develops only after six months to a year of continuous use of the medicine. The effectiveness of delagil and plaquenil also turned out to be low. These are the weakest of all modern basic drugs. Their only advantage is good tolerability and a small number of side effects.
Although the effectiveness of these drugs is not very high and they act slowly, we are forced to use them to this day, since we feel a relative shortage of anti-rheumatoid drugs. After all, sometimes situations arise when other basic remedies are tried unsuccessfully and canceled due to ineffectiveness or severe side effects. Then it is necessary to use delagil and plaquenil, which are weak but still have a specific anti-arthritic effect.
Well, in addition, one cannot help but mention the force of inertia, which often prompts rheumatologists even today to recommend antimalarial drugs. Apparently, the outdated and established rule thirty years ago is working, which prescribes that patients with rheumatoid arthritis should first be prescribed Delagil or Plaquenil, then gold or D-penicillamine, and, inevitably, hormones. The concept is clearly outdated, and was controversial before. From my point of view, with actively progressing rheumatoid arthritis, waiting for Delagil or Plaquenil to work (and this is a period of six to twelve months), without even trying to use stronger basic drugs, is simply criminal.
When it is known that gold salts or methotrexate will work within a month or two, to put it mildly, it is absurd to condemn the patient to long suffering while waiting for the therapeutic effect of antimalarials. Nevertheless, some rheumatologists are still guided by outdated textbooks, and first of all prescribe delagil or plaquenil to patients.
According to the majority of leading modern rheumatologists, basic therapy should begin with antimalarial drugs only when rheumatoid arthritis is very mild, and there is no need for stronger drugs that have a better therapeutic effect, but can provoke numerous side effects. Indeed, unlike them, antimalarial drugs are practically harmless. Only in rare cases, with long-term use, delagil or plaquenil can provoke the development of adverse reactions.
Sulfasalazine and salazopyridazine are antimicrobial drugs successfully used in the basic therapy of rheumatoid arthritis. In terms of the potency of the therapeutic effect, sulfonamides are quite slightly inferior to the drugs gold and methotrexate, quite comparable in effectiveness to D-penicillamine, and clearly superior in potency to drugs such as delagil and plaquenil.
The main advantage of sulfonamides over other basic drugs is their good tolerability - sulfasalazine and salazopyridazine have almost no complications even with long-term use. With long-term use, side effects develop in only 10-20% of patients, and these side effects are almost never severe.
The only thing that detracts from the advantages of sulfonamide drugs is the slow development of their therapeutic effect. Some improvement in the condition during treatment with sulfonamides is usually observed only after three months of therapy, and the “peak form” is reached 6-12 months after the start of treatment.
D-penicillamine (also known as cuprenil, trolovol, metalcaptase, distamine, artamine) is usually prescribed in cases where therapy with gold and methotrexate does not bring relief to the patient, or when these drugs have to be discontinued due to adverse reactions. However, D-penicillamine, which is only slightly inferior in effectiveness to gold drugs and methotrexate, is a rather toxic drug that causes complications much more often - when using D-penicillamine, adverse reactions occur in 30-40% of cases, and they occur more often with seropositive rheumatoid arthritis than with seronegative (approximately 50% in the first case versus 25-30% in the second). It is because of the severe side effects that I try to prescribe D-penicillamine to my patients very, very rarely, only when absolutely necessary.
You may ask: if D-penicillamine is such a "heavy" drug, why do doctors still continue to prescribe it? The fact is that sometimes other basic drugs turn out to be ineffective, or they have to be canceled due to side effects, and the rheumatologist simply has no choice. You cannot leave a patient without help when the doctor has a strong drug in his arsenal, even if the risk of side effects is quite high. In the end, when the first signs of complications caused by taking D-penicillamine appear, you can stop this drug and eliminate the unpleasant phenomena quite quickly. In addition, there are cases when D-penicillamine should be prescribed first, for example, if arthritis has caused rheumatoid complications in the lungs or heart. It also helps a lot with such a complication of rheumatoid arthritis as amyloidosis.
If the drug is well tolerated and there are no contraindications, treatment with D-penicillamine is continued for up to 3-5 years. Then you can take a break for 1-2 years and continue treatment with D-penicillamine again for another 3-4 years. Fortunately, unlike gold preparations, this medicine does not lose its effectiveness even after a break in treatment. Although it must be borne in mind that in 10% of patients who take D-penicillamine for a long time and feel an improvement in their condition, an exacerbation of the disease may then occur - the so-called phenomenon of “secondary ineffectiveness” appears.
So, there are 5 groups of basic drugs to combat rheumatoid arthritis. They all have their advantages, and, unfortunately, their disadvantages, which we have just discussed. The most common question that patients ask about basic therapy and which is often discussed by patients on the Internet concerns the potential harm of basic drugs. Thus, one of the amateur “specialists”, who clearly does not understand the problem, declared with indignation on one of the Internet forums: “What kind of medicines do doctors prescribe if they have so many side effects - they cure one thing, and cripple another?”
Indeed, how great is the desire of some narrow-minded people to see in everything almost a conspiracy of doctors. But maybe they are right, and we really don’t need to prescribe the patient any medications in general, and basic drugs in particular? Let him get sick and suffer?
If we discard the idle speculations of narrow-minded critics, the facts look like this: according to numerous observations of scientists and doctors (and according to my observations too), the later a patient is prescribed basic therapy, the worse it is for him - the disease is much more severe, with numerous complications, and more often ends in fatal outcome. And vice versa, if basic drugs are prescribed to the patient on time, in the first months of the disease, we are often able to achieve a significant improvement in the patient’s well-being, and sometimes it is even possible to completely interrupt the development of the disease.
Although, of course, the selection of basic therapy is a serious matter. And we must take into account the possibility of side effects. Therefore, the attending physician, as they say, must constantly keep his “finger on the pulse” and regularly monitor the patient’s condition. It is also advisable that the patient be as informed as possible about what complications the medication taken may cause, and inform the doctor about any alarming reactions. It was with the goal of giving you maximum information about the medications you are taking and their possible adverse reactions that I wrote this chapter.
But still: which basic drug should be preferred in each specific case? Only your treating rheumatologist can answer this question. Only he knows (in any case, he should know) when and what basic remedy should be used for a particular patient. Although the disadvantage of basic drugs is precisely that it is difficult for doctors to predict with 100% certainty whether the medicine will give the desired therapeutic effect. The answer to this question can be obtained only after a month or two from the start of using the drug. And if the drug does not work, then you have to change it and again wait a couple of months for the result.
Thus, it sometimes takes from 4 to 6 months to select basic therapy. The period is, of course, extremely long for a sick person, but we have to accept it - we have no other choice. But we can try to improve the patient's condition during this "waiting period" using methods of physical and mechanical influence on the immune system, using anti-inflammatory drugs, and using local effects on the joints. We will talk about them further.
As a first aid remedy for joint pain, “classical” non-steroidal anti-inflammatory drugs are most often used - diclofenac, ibuprofen, ketoprofen, piroxicam, indomethacin, butadione, etc. Non-steroidal anti-inflammatory drugs for rheumatoid arthritis effectively reduce inflammation in the joints and reduce pain.
Without a doubt, these drugs can significantly make the patient’s life easier, but it is impossible to cure rheumatoid arthritis with non-steroidal anti-inflammatory drugs. They are not used to cure arthritis, but to temporarily reduce inflammation and pain in the joint. That is, they cannot stop the development of the disease, but are used exclusively symptomatically. And as soon as the patient stops taking them, the disease gradually returns.
However, since it is very difficult for a person suffering from rheumatoid arthritis to do without non-steroidal anti-inflammatory drugs, and it takes a long time to take NSAIDs for arthritis, let's talk about how best to use them.
Treatment should begin with the least toxic drugs. That is, those that are quickly absorbed and easily excreted from the body. Such drugs include diclofenac, ibuprofen, ketoprofen and their derivatives, as well as the selective anti-inflammatory drug movalis. Indomethacin, piroxicam, ketorolac and their analogues take longer to be eliminated from the body, are considered more “heavy” drugs, so they try to prescribe them less frequently, mainly to those patients who have a lower risk of developing side effects from the kidneys, cardiovascular system and stomach. In addition, given that indomethacin can cause the development of mental disorders in older people, it is prescribed, as a rule, only to young or middle-aged patients.
The second selection criterion is the effectiveness of the drug. Typically, the therapeutic effect from the use of non-steroidal anti-inflammatory drugs develops quickly, during the first three to seven days of treatment. If during this time there is no improvement from taking the anti-inflammatory drug used, it must be changed to another.
At the same time, diclofenac is considered one of the most effective anti-inflammatory drugs. True, many patients, and even doctors, are put off by the overly detailed summary of the drug. Especially the part where all possible complications and side effects to the medicine are punctually listed. Most people who read the summary think that they will definitely experience all of the listed complications. Meanwhile, diclofenac is no more harmful than aspirin, which many people drink without thinking about it. It’s just that the summary for diclofenac is written more honestly and in more detail. But the listed side effects do not occur in all people, even for years taking diclofenac or its analogues.
Selective anti-inflammatory drugs - the drug movalis - were developed to reduce the number of side effects with long-term use of the drug. For rheumatoid arthritis, Movalis is almost as effective as other non-steroidal anti-inflammatory drugs, it eliminates inflammation and pain well, but has a minimum of contraindications and is much less likely to cause adverse reactions, especially from the gastrointestinal tract. You can drink it for a long time, in courses from several weeks to several months and even years (of course, only under the supervision of a doctor).
Movalis is easy to use - one tablet of the drug or a suppository is enough for the whole day, that is, it needs to be taken once a day: in the morning or at night. And for the most acute cases, an injection form of movalis has been developed for intramuscular administration.
In situations where we need to quickly stop an attack of intense joint pain, we can use Movalis in injection form for the first 5-7 days, and then switch to taking similar tablets, which the patient will need to take for a long time in the future.
To provide quick help to those suffering from rheumatoid arthritis, many doctors, especially foreign ones, in addition to non-steroidal anti-inflammatory drugs, do not hesitate to prescribe anti-inflammatory corticosteroid hormones: prednisolone (aka Medopred), triamcinolol (aka Kenalog, Polcortolone, triamsinolol, Kenacort), dexamethasone, methylprednisolone (aka aka metypred, medrol, depo-medrol), betamethasone (aka diprospan, flosteron, celeston).
Among our doctors, there are two polarly different views on the use of hormonal corticosteroid drugs. Some doctors clearly welcome their use for medicinal purposes, while others completely reject and ignore them. As a result, patients who try to keep up with the trends of “medical fashion” are completely perplexed: are such hormones useful for arthritis or harmful, can they be used or not? Well, let's think together.
On the one hand, the use of such hormones almost always leads to a clear improvement in the patient’s condition. Joint pain immediately decreases, morning stiffness disappears, weakness and chills disappear or decrease. Naturally, such a quick result makes any patient feel grateful to the doctor. And in the conditions of paid medicine, this gratitude is often supported financially - for such relief the patient is willing to pay money, considerable money at that - which is the main incentive for Western and modern paid medicine.
Unfortunately, patients taking corticosteroid hormones are often unaware that they are receiving a fairly powerful blow to all body systems. After all, corticosteroids are stress hormones. And as long as the patient takes such hormones, he feels good. But as soon as they are canceled or the dose is reduced, the disease will literally attack the person with double or triple force.
You may ask: maybe then it’s worth not canceling hormones, but continuing to take them constantly? No, this is not an option. The fact that over time corticosteroids no longer relieve pain as well as at the beginning of their use is not so bad. The worst thing is that the side effects from their use gradually “accumulate”.
There are many such side effects - corticosteroids contribute to the development of the Itsenko-Cushing symptom complex, in which sodium and water are retained in the body with the possible appearance of edema and increased blood pressure. In addition, such hormones increase blood sugar levels leading to the development of diabetes, promote weight gain, reduce immunity, provoke stomach and duodenal ulcers in some patients, and increase the risk of blood clots. With long-term use of corticosteroids, acne, a moon-shaped face, menstrual irregularities, and the development of hemorrhagic pancreatitis may occur. Some patients develop reactions from the nervous system: insomnia, euphoria, agitation (in some cases even with the development of psychosis), and seizures similar to epilepsy. In addition, with long-term use, medicinal corticosteroids suppress the body's production of its natural hormones.
As a result, sooner or later there comes a time when, due to side effects, the patient is forced to stop taking corticosteroid hormones. But this is not so easy to do. The body can no longer cope without the supply of corticosteroids from the outside, and a rapid reduction in their dose leads to a sharp deterioration in well-being and exacerbation of joint pain. Therefore, the dose of hormones consumed must be reduced gradually, a few milligrams per week. And their final cancellation is delayed for several months. But even with such a gradual reduction in the dose of hormones, the process is rarely painless for the body.
So, before prescribing hormone therapy to a patient, the doctor must weigh three times whether such treatment will cause more harm or benefit. From my point of view, hormones should be prescribed only when arthritis is highly active, when inflammatory indicators are “off the charts” (for example, an increase in ESR, or ROE, above 40 mm/hour, with a strong increase in the levels of C-reactive protein, seromucoid and other indicators ), especially if the inflammation is not controlled by non-steroidal anti-inflammatory drugs, and is accompanied by severe pain and weakness of the patient.
And, of course, hormones should definitely be prescribed for the development of a number of so-called systemic complications of arthritis - Felty's syndrome, Still's syndrome, polymyalgia rheumatica, etc. That is, on the one hand, the doctor does not have the right to prescribe hormones to everyone, but he should not refuse their use in cases where they are really needed. Indeed, in some situations, the use of hormones can, without exaggeration, save the patient’s life. Therefore, the issue of their use must be approached very carefully, and, naturally, it is also necessary to take into account the presence of contraindications to hormonal treatment.
During this procedure, lymph is removed from the thoracic lymphatic duct through a drainage apparatus. The resulting lymph is placed in a centrifuge, and the cellular sediment is separated from the lymph using a centrifuge. Then the liquid part of the purified lymph is returned to the lymphatic duct through drainage. In this way, the lymph is released and cleansed from the products of inflammation and cell breakdown, and from elements of the vital activity of harmful microorganisms. The therapeutic effect occurs 1-2 weeks after long-term operation of the drainage. However, a few weeks after removal of the drainage, relapses of the disease very often occur, and this is why drainage of the thoracic lymphatic duct for the treatment of arthritis is now used quite rarely.
During lymphocytophoresis, two types of blood cells—lymphocytes and monocytes—are slowly removed from the circulating blood using a centrifuge. In 1 minute it is possible to purify 50-75 ml of blood, while in 4 hours of the procedure about 11-13x1010 lymphocytes are removed. As a result, the “reactivity” of the blood decreases and the degree of inflammation decreases. This technique is simpler than drainage of the thoracic lymphatic duct and is easier to tolerate by patients. But it requires expensive equipment, and therefore the price of the procedure is high. In addition, lymphocytophoresis also gives a very short-term and shallow positive effect (only a few weeks). Therefore, the method is not widely used and is used infrequently.
During plasmaphoresis, large volumes of blood plasma containing rheumatoid factor, immune complexes, inflammatory mediators and other pathological impurities are mechanically removed. At the same time, donor plasma or albumin is injected into the patient’s bloodstream. In order to obtain a full therapeutic effect, a large amount of plasma is removed in one session lasting more than 5 hours: about 40 ml of plasma for each kilogram of the patient’s body weight. The course of treatment includes 15-20 procedures over 6 weeks.
As a result of the procedure, there is a significant decrease in the amount of immunoglobulins, ESR or ROE, and other elements of inflammation; there is a clear improvement in the patient's condition. Thanks to this effect of the procedure, plasmaphoresis can be successfully used both as an adjuvant therapy to the use of basic drugs, and “in standby mode” while the basic therapy has not yet had time to take effect. However, some complications may occur during the procedure. Fluid retention in the body may occur, swelling may appear, and the amount of potassium and hemoglobin in the blood may decrease.
The second disadvantage of plasmaphoresis is the relatively high cost of the procedure. Considering that a patient requires at least 15 procedures per course of treatment, such therapy often requires very large material costs. And, again, the effect of the procedure is not very durable - without concomitant treatment, the patient’s body returns to its “original state” after a few months. Therefore, ideally, plasmaphoresis should be prescribed to the patient only as part of complex therapy, in combination with basic drugs.
The technique consists of sequential irradiation of lymphoid tissue (lymph nodes, spleen, thymus) with doses up to 150-220 rad. The method was first used in 1980. After a course of treatment (up to 4000 rads per course), patients with rheumatoid arthritis note a clear improvement in their condition, which in some cases allows them to reduce the amount of corticosteroid hormones and non-steroidal anti-inflammatory drugs taken, and in some cases even cancel them altogether. The period of improvement after the procedure lasts from 1 to 2 years. But in some cases, during treatment or after irradiation, patients experience some complications: nausea, weakness, a decrease in the number of leukocytes in the blood, and sometimes other side effects.
Most often, drugs of corticosteroid hormones are injected into the joint for arthritis: Kenalog, Diprospan, hydrocortisone, Flosterone, Celeston, Metypred, Depo-Medrol. Corticosteroids are good because they quickly and effectively suppress pain and inflammation due to swelling and swelling of the joint. It is the speed with which the therapeutic effect is achieved that is the reason why corticosteroid injections have gained particular popularity among doctors.
The introduction of corticosteroid hormones into the joint helps the patient survive a period of particularly acute inflammation of individual joints. Such intra-articular injections can significantly make life easier for the patient, even in particularly severe cases of rheumatoid arthritis. But usually the therapeutic effect of the injection lasts only 3-4 weeks. Then the inflammation begins to gradually increase again.
That is, such injections are in no way a panacea. Moreover, they cannot be done too often - otherwise the hormones will begin to have a negative effect on the entire body. Therefore, the intervals between such procedures should be at least 7-10 days. And in total, it is undesirable to give more than 5-8 hormonal injections to one joint, even at large intervals. After all, too frequent administration of hormones provokes disruption of the structure of the joint ligaments and surrounding muscles, gradually causing “looseness” of the joint and destruction of cartilage.
This method has a mild anti-inflammatory effect for rheumatoid arthritis. Laser therapy is used both as a separate method of treating rheumatoid arthritis and in combination with basic therapy.
There are two ways to influence a patient’s body with laser radiation. In the acute phase of rheumatoid arthritis, the laser does not irradiate the patient’s joints, but the area of the cubital vein - that is, the radiation affects the blood circulating inside the body. It is believed that after irradiating blood with a laser, various positive changes occur in the body: immunity is normalized, blood supply to organs and tissues is improved, any inflammation is reduced and foci of infection are suppressed.
In the chronic phase of the disease (when blood tests and body temperature are normal), the laser is applied directly to the joints of a patient with rheumatoid arthritis. This is done provided that the patient has normal tests and body temperature. Improvement after laser therapy is observed in 80% of patients, although at the beginning of the course of treatment there is a short-term exacerbation of the disease.
In general, the most favorable results are observed in patients with a sluggish, mild form of rheumatoid arthritis. In severe forms of the disease, laser is ineffective. The course of treatment consists of 15-20 procedures performed every other day.
Contraindications to the use of laser are tumor diseases, blood diseases, hyperfunction of the thyroid gland, infectious diseases, physical exhaustion, bleeding, myocardial infarction, stroke, tuberculosis, cirrhosis of the liver, hypertensive crisis.
Cryotherapy is one of the best local methods of treating rheumatoid, psoriatic and reactive arthritis, as well as ankylosing spondylitis. Cryotherapy has been successfully used in both the acute and chronic phases of rheumatoid arthritis. This treatment is practically harmless and has almost no contraindications, but requires regularity. Improvement after cryotherapy is observed in more than 80% of patients with rheumatoid arthritis.
There are two main hardware methods of cryotherapy: dry cryotherapy (exposure to ultra-low temperature air, in particular the use of cryosaunas), and “liquid cryotherapy” - exposure of the body to a jet of liquid nitrogen.
With “liquid cryotherapy,” a pressurized stream of liquid nitrogen is directed onto the affected joints or back; the nitrogen instantly evaporates and quickly cools the affected area. As a result of this procedure, it is possible to achieve a pronounced response from the body and the affected joints - inflammation and swelling of the joints are reduced, blood circulation and metabolism are improved, and pain is reduced. The course of treatment includes 8-12 procedures performed daily or every other day.
When used correctly, cryotherapy with liquid nitrogen has almost no contraindications and can be used even to treat elderly, debilitated patients. It cannot be used only for Raynaud's syndrome, some arrhythmias, and immediately immediately after a heart attack or stroke.
During dry cryotherapy, the undressed patient is placed for a very short time in a special room - a cryosauna, where very cold air is supplied. Dry cryotherapy has a lesser local effect on individual inflamed joints of the patient, but, like liquid cryotherapy, it has a good effect on the general condition of patients with rheumatoid arthritis - especially when the patient has a large group of joints inflamed at once. However, other things being equal, dry cryotherapy in commercial medical centers usually costs much more than liquid cryotherapy, since it requires more complex and expensive equipment.
Medicinal ointments and creams are often advertised as guaranteeing cure for joint diseases. However, for arthritis, medicinal ointments can bring only slight relief to the patient. Usually, for rheumatoid arthritis, ointments based on non-steroidal anti-inflammatory substances (indomethacin, butadione, dollit, voltaren-gel, fastum-gel, etc.) are used. Unfortunately, they do not act as effectively as we would like - after all, the skin allows no more than 5-7% of the active substance to pass through, and this is clearly not enough to develop a full anti-inflammatory effect. But these ointments almost never cause the side effects that occur from the internal use of non-steroidal anti-inflammatory drugs. That is, they are practically harmless.
Massage and any physiotherapeutic procedures, with the exception of cryotherapy and laser, for rheumatoid arthritis are carried out only when the exacerbation of arthritis has passed and blood counts return to normal. After all, physiotherapy and massage have a stimulating effect on the body, which is useful for arthrosis, but with arthritis it can increase inflammation of the joints. Therefore, physiotherapy and massage are done exclusively when the body temperature is normal, blood tests are good and in the absence of redness and swelling of the joints (redness and swelling indicate the accumulation of pathological “inflammatory” fluid in the joint).
Let me emphasize once again: massage and almost any physiotherapeutic procedures, with the exception of cryotherapy and laser, are absolutely contraindicated in cases of moderate and high activity of rheumatoid arthritis, while noticeable inflammation of the joints continues! And only after the exacerbation has been eliminated, you can move on to gentle massage and physiotherapy in order to improve blood circulation in diseased joints, reduce their deformation and increase their mobility.
For this purpose, infrared irradiation, diathermy, UHF, paraffin, ozokerite and therapeutic mud applications are used. These types of physiotherapy promote muscle relaxation and eliminate joint contractures, and improve nutrition for diseased joints. Phonophoresis with medications (for example, hydrocortisone) has also been successfully used. Phonophoresis has a mild anti-inflammatory effect on the patient’s joints.
X-ray therapy is used somewhat less frequently for rheumatoid arthritis. The method involves exposing the affected joints to small doses of x-rays. Small doses of radiation have a pronounced analgesic and anti-inflammatory effect and do not cause serious complications. Sometimes radiotherapy is used to enhance the anti-inflammatory effect of basic drugs, even with active rheumatoid arthritis.
Diet for rheumatoid arthritis is one of the important components of treatment. In some patients, there is a clear relationship between the activity of inflammation and the tolerance of certain foods. Exacerbation of arthritis occurs when eating foods that “allergize” the body, and their abolition leads to an improvement in the condition. Most often, according to some scientists, the exacerbation of the inflammatory process in rheumatoid arthritis is facilitated by eating corn, wheat, pork, citrus fruits, oatmeal, rye, milk and dairy products. This means that all these foods should be limited or excluded, if possible, from the diet of a patient with rheumatoid arthritis. It is recommended to consume fish, fish oil and other seafood, as well as vegetables, fruits, chicken eggs, pearl barley and buckwheat. Meals should be small and frequent, 5-6 times a day.
It is advisable to steam food. Try to reduce your salt intake and eat fried or smoked foods as little as possible. Some scientists recommend that patients suffering from rheumatoid arthritis generally switch to diet No. 10 (see Chapter 1).
Article by Dr. Evdokimenko© for the book “Arthritis”, published in 2003.
People with rheumatoid arthritis use medications daily to combat pain and swelling and prevent joint erosion. Newer drugs can also provide long-term remission of the disease.
Advances in medications are welcome news for millions of people with rheumatoid arthritis and offer a real chance of controlling the disease. Currently, the drugs are much more effective than their predecessors. Their number is constantly increasing, but they differ somewhat in action. If one drug doesn't work, there are many other options.
Choosing a drug for rheumatoid arthritis
Traditional anti-inflammatory drugs reduce pain, improve daily functioning, reduce joint swelling and tenderness, and increase range of motion.
But that's not all. Over the past two decades, drugs used to suppress an overactive immune system have become the mainstay of treatment for rheumatoid arthritis. Disease-modifying antirheumatic drugs (DMARDs) can stop the progression of rheumatoid arthritis by suppressing or modifying the immune system that damages joints.
Some drugs in this class are traditionally used to treat other diseases, such as cancer and inflammatory bowel disease, and to prevent organ transplant rejection. Currently, they are also used in the treatment of rheumatoid arthritis. This uses a reduced dose of drugs used in chemotherapy, such as methotrexate. The range of side effects of these drugs is comparatively lower than in the treatment of cancer.
DMARDs are used as an aggressive treatment in the early stages of the disease. Doctors prescribe DMARDs immediately after diagnosis, increasing the dose to achieve a therapeutic effect as quickly as possible. However, DMARDs are not suitable for all patients. In other cases, the capabilities of new biological agents are used.
Biological agents: a new step in the treatment of rheumatoid arthritis
A newer class of antirheumatic drugs—biologic agents—promise significant benefits for more rheumatoid arthritis patients. These drugs can prevent and slow down joint erosion, and even provide long-term remission of the disease, since they act directly on the immune system - a significant factor in the development of rheumatoid arthritis.
Biological agents such as Embrel, Humira, Kinneret, Orentia and Remicade are approved by the US Food and Drug Administration for the treatment of rheumatoid arthritis. They suppress the function of cells and cytokines produced by the immune system, which cause inflammation and joint erosion.
Cytokine blocking drugs specifically target these components of the immune system. Each agent has its own characteristics of action.
Biological agents may be used in combination with DMARDs such as methotrexate.
A biological agent such as Rituxan exclusively blocks immunocytes called CD20-positive B cells. B cells are thought to cause the inflammation that is a hallmark of rheumatoid arthritis. Rituxan is intended for patients who have not improved with anti-tumor necrosis factor (TNF) medications such as Enbrel and Remicade.
The number of people with RA who can maintain functional activity and prevent disability with the help of biological agents is constantly increasing.
Even if other medications are ineffective, biological agents can alleviate symptoms and maintain functional activity, preventing further joint erosion.
Pros and cons of using medications to treat rheumatoid arthritis
We offer a brief description of the features of various drugs used in the treatment of rheumatoid arthritis.
Anti-inflammatory painkillers
These drugs are used by almost all people suffering from various forms of arthritis. There are many types of medications available to help reduce joint swelling, stiffness, and pain. However, they do not stop the progression of the disease.
Traditional non-steroidal anti-inflammatory drugs (NSAIDs), such as Motrin and Aleve, can cause stomach upset. Celebrex is a new generation anti-inflammatory drug that causes fewer gastrointestinal complications and is also effective in reducing pain and inflammation.
All prescription anti-inflammatory drugs, including Celebrex, carry FDA warnings about the risk of heart attacks and strokes, and potentially life-threatening gastrointestinal bleeding. However, these drugs are extremely effective treatments for rheumatoid arthritis. Patients and doctors should discuss the benefits and side effects of these drugs. Controlling risk factors such as cholesterol and blood pressure can reduce the risk of heart attacks and strokes.
Analgesics act solely to relieve pain. They do not have an anti-inflammatory effect, but help control pain. Most often, patients tend to take an over-the-counter drug, Acetaminophen (Tylenol). There are also prescription painkillers and drugs that have narcotic properties. Narcotics are used to relieve acute pain when other medications have failed. Caution: There is a possibility of developing dependence on narcotic drugs, they can cause constipation, problems urinating, and also produce excessive sedation.