Rheumatoid arthritis

　　Although the etiology of rheumatoid arthritis is not yet clear, doctors generally believe that the disease may be caused by a combination of genetic factors and environmental factors. Some researchers believe that bacterial or viral infections can trigger the progression of the disease in patients with rheumatoid arthritis susceptible to genetic factors. However, to date, no specific infectious agent or microorganism has been found that can cause the disease.

　　Rheumatoid arthritis is a chronic systemic autoimmune disease, mainly manifested by synovitis of the joints. In addition to the harm of the disease itself, it will also cause many complications such as: pneumonia, rheumatoid arthritis is prone to cause a decrease in body resistance, the lungs are prone to bacterial and other infections, and pneumonia symptoms may occur; urinary system infection, the immune ability of patients with rheumatoid arthritis decreases, and urinary system infection is prone to occur; oral ulceration, which usually occurs after taking immunosuppressants; infectious diseases, which are also one of the complications of rheumatoid arthritis. Due to the decreased body's immune function, patients are more susceptible to infectious diseases when certain infectious diseases are spreading in society; Cushing's syndrome: if patients take hormones for a long time, they are often complicated with Cushing's syndrome due to the suppression of adrenal cortical function. Common symptoms include a full moon face, a water buffalo back, weight gain, etc. This is also a complication of rheumatoid arthritis.

　　The common symptoms of rheumatoid arthritis include joint swelling and pain, joint stiffness (especially after getting out of bed in the morning or after sitting for a long time), fatigue, etc. The progression of the disease in patients with rheumatoid arthritis varies from person to person. Some patients may slowly show joint symptoms over a few years, while other patients may progress rapidly. Some patients may enter a remission period after a period of onset.

　　Although rheumatoid arthritis is unpreventable, early treatment and reasonable exercise can have a certain preventive effect on disability. It is not yet clear whether non-smokers have a lower risk of developing rheumatoid arthritis, but smoking is closely related to the occurrence and development of rheumatoid arthritis. Appropriate exercise can also enhance the body's immunity and provide resistance to the body.

　　It is difficult to diagnose rheumatoid arthritis in the early stage. At present, there is no early specific diagnostic index, so doctors generally diagnose rheumatoid arthritis based on its related characteristics, such as: long morning stiffness, invasion of small joints, symmetrical distribution, rheumatoid nodules, etc.; blood routine, synovial fluid examination, magnetic resonance imaging, ultrasound, rheumatoid factor, erythrocyte sedimentation rate, C-reactive protein, X-ray changes, etc.

　　Balanced diet cannot treat rheumatoid arthritis, but it can alleviate symptoms. If a certain food causes your condition to worsen, such as joint 'red, swollen, hot, and painful', stop eating it first and observe whether the symptoms are relieved. After a period of time, eat this food again and observe whether the symptoms worsen. Once it is determined that a certain food will worsen symptoms, it is best to eat less of it. Eat less animal fat, which is extracted from animal fat, and its chemical composition is saturated fatty acids, which can increase the body's inflammatory response and is of no benefit to patients with rheumatoid arthritis. Eat more vegetables: they can improve arterial function and reduce the risk of cardiovascular events.

(One) Treatment

Rheumatoid arthritis has no effective treatment yet, and it is still停留在the treatment of inflammation and sequelae, taking comprehensive treatment, most patients can get certain efficacy. The purpose of current treatment is: ① Control the inflammation of joints and other tissues, relieve symptoms; ② Maintain joint function and prevent deformity; ③ Repair damaged joints to reduce pain and restore function.

(One) General therapy: Patients with fever, joint swelling and pain, and systemic symptoms should rest in bed until the symptoms are basically resolved. After two weeks of improvement in the condition, activities should be gradually increased to avoid prolonged bed rest leading to joint atrophy, or even promoting joint rigidity. The diet should be rich in protein and various vitamins. For those with significant anemia, small amounts of blood transfusion can be given. If there are chronic lesions such as tonsillitis, they should be removed as soon as possible under the condition that the patient's health status allows.

(Two) Drug treatment

1. Non-steroidal anti-inflammatory drugs (NSAIDs) are used for initial or mild cases, and their mechanism of action is mainly to inhibit the activity of cyclooxygenase, thereby inhibiting the formation of prostaglandins and achieving the effect of inflammation and pain relief. However, it cannot stop the natural process of rheumatoid arthritis. Due to different metabolic pathways in the body, there may be interactions between different drugs, and it is not recommended to use them together, and individualization should be noted.

⑴ Salicylate preparations: Can relieve rheumatism, inflammation, fever, and pain. The daily dose is 2-4g, and if the efficacy is not ideal, the dose can be increased appropriately. Sometimes, 4-6g per day is needed to be effective. Generally, it is taken after meals or with antacids to reduce gastrointestinal irritation, or enteric-coated tablets can be used to reduce gastrointestinal irritation.

⑵ Indomethacin: A derivative of indole acetic acid, with anti-inflammatory, antipyretic, and analgesic effects. Patients who cannot tolerate aspirin can switch to this drug. The common dosage is 25mg, taken 2-3 times a day, and it is easy to produce side effects when the daily dose is more than 100mg. Side effects include nausea, vomiting, diarrhea, gastric ulcer, headache, dizziness, and depression.

⑶ Propionic acid derivatives: A class of drugs that can replace aspirin, including ibuprofen, (ibuprofen) naproxen (naproxen) and fenbufen (fenbufen), with effects similar to aspirin, similar efficacy, and small gastrointestinal side effects. Common dosage: 1.2-2.4g of ibuprofen per day, taken 3-4 times, 250mg of naproxen per time, twice a day. Side effects include nausea, vomiting, diarrhea, peptic ulcer, gastrointestinal bleeding, headache, and central nervous system disorders such as irritability.

⑷ Non-steroidal anti-inflammatory drugs: Derivatives of o-aminobenzoic acid, their action is similar to aspirin. Antacids are 250mg, three to four times a day. Chloracetic acid is 200-400mg, three times a day. Side effects include gastrointestinal reactions, such as nausea, vomiting, diarrhea, and decreased appetite. Occasionally, there are rashes, renal function damage, headache, etc.

2. Gold preparations are currently recognized to have definite efficacy for rheumatoid arthritis. The commonly used gold sodium thiomalate is gold, sodium thiomalate myochrysin. The first week is 10mg intramuscular injection, the second week 25mg. If there are no adverse reactions, it is 50mg per week thereafter. Most patients start to see improvement when the total dose reaches 300-700mg, and the condition can be stabilized and improved when the total dose reaches 600-1000mg. The maintenance dose is 50mg per month. Due to the possibility of recurrence after discontinuation, some countries use the maintenance dose for many years, even lifelong. The earlier the gold preparation is used, the more significant the effect is. The action of gold preparations is slow, it takes 3-6 months to take effect, and they should not be used with immunosuppressants or cytotoxic drugs. If the total dose has reached 1000mg during the treatment process and the condition has not improved, the drug should be discontinued. The efficacy of oral gold preparations is similar to that of gold injections. Side effects include increased frequency of defecation, rash, stomatitis, and skin damage, etc., which can recover after discontinuation.

Oral gold preparation Auranofin is a hydroxyl compound of phosphine gold. The dosage is 6mg once a day, and it starts to take effect after 2-3 months. It is more effective for patients with a short disease course in the early stage. The side effects are milder than those of injectable agents, common symptoms are diarrhea, but they are transient, and the effective rate of relief is 62.8％.

3. Penicillamine is an amino acid drug containing a thiol group, which has a certain efficacy in the treatment of chronic rheumatoid arthritis. It can selectively inhibit certain immune cells to reduce IgG and IgM. Side effects include decreased platelets, decreased leukocytes, proteinuria, allergic skin rash, decreased appetite, optic neuritis, muscle weakness, and increased transaminases. The first month is taken orally 250mg daily, the second month 250mg twice a day. If there is no obvious effect in the third month, it is taken 250mg three times a day. The total dose per time reaches 750mg, which is the maximum dose. Most patients have improved clinical symptoms within 3 months, and after the symptoms improve, a small dose is maintained for about one year.

4. Chloroquine has a certain anti-rheumatic effect, but its onset is very slow, often taking 6 weeks to 6 months to achieve maximum efficacy. It can be used as an adjuvant drug when salicylate preparations or the dose of corticosteroids is decreased. The oral dose is 250-500mg, twice a day. There are often more gastrointestinal reactions during the course of treatment, such as nausea, vomiting, and decreased appetite. Long-term use requires attention to degenerative changes in the retina and optic atrophy, etc.

5. Levamisole can alleviate pain and shorten the duration of joint stiffness. The dosage is 50mg for the first dose, once a day, 50mg twice a day from the second week, 50mg three times a day from the third week. Side effects include dizziness, nausea, allergic skin rash, vision loss, drowsiness, decreased granulocytes, decreased platelets, liver function damage, and proteinuria, etc.

6. Immunosuppressants are used in patients with severe rheumatoid arthritis who are ineffective to other drugs. Commonly used in patients who discontinue medication or reduce the dose of hormones include azathioprine, 50mg each time, 2-3 times a day. Cyclophosphamide is 50mg each time, twice a day. After symptoms or laboratory tests show improvement, the dose should be gradually reduced. The maintenance dose is 1/2 to 2/3 of the original treatment dose. Continuous use for 3-6 months. Side effects include bone marrow suppression, decreased white blood cells and platelets, liver toxicity damage, gastrointestinal reactions, alopecia, amenorrhea, hemorrhagic conjunctivitis, etc.

Methotrexate (MTX) has immunosuppressive and anti-inflammatory effects, can reduce erythrocyte sedimentation rate, and improve bone erosion. It is administered intramuscularly or orally at 5-15mg per week, with a course of 3 months. Side effects include anorexia, nausea, vomiting, stomatitis, alopecia, decreased white blood cells or platelets, drug-induced interstitial pneumonia, and rash. It may become another therapeutic drug chosen after gold and penicillamine.

7. Adrenal cortical hormones Adrenal cortical hormones have a rapid effect on joint swelling and pain, controlling inflammation and relieving pain, but the effect is not lasting, and have no effect on the etiology and pathogenesis. Relapse occurs shortly after discontinuation of the drug. There is no improvement in RF, erythrocyte sedimentation rate, and anemia. Long-term use can lead to serious side effects, so it is not used as routine treatment, but is limited to patients with severe extrajoint damage caused by severe vasculitis affecting vital organ function, such as those with ocular complications at risk of blindness, central nervous system lesions, heart block, and persistent active synovitis in joints, which can be used for a short period of time, or on the basis of previous drugs, small doses of corticosteroids can be added if the treatment effect of NSAIDs, penicillamine, etc. is not good, symptoms are severe, and affect daily life. The dose can be increased appropriately if the effect is not significant. After symptom control, the dose should be gradually reduced to the minimum maintenance dose.

Hydrocortisone acetate suspension can be used for local joint cavity injection, suitable for some single large joint refractory lesions. Each joint cavity injection is 25-50mg, strictly prevent joint cavity infection and bone destruction. Triamcinolone acetonide, a long-acting corticosteroid suitable for intra-articular administration, is given in a dose of 10mg, and 30mg for the knee joint.

8. Raifuku藤 has been shown to have good efficacy through years of clinical application and experimental research in China. It has non-steroidal anti-inflammatory effects, as well as immunosuppressive or cytotoxic effects, which can improve symptoms, reduce the erythrocyte sedimentation rate and RF titer. Raifuku polyglycoside 60mg/d can produce clinical effects in 1-4 weeks. Side effects include menstrual irregularity and amenorrhea in women, decreased sperm count in men, rash, decreased white blood cells and platelets, abdominal pain, diarrhea, etc., which can be eliminated after discontinuation of the drug.

Kunming Shanhaitang, similar in action to Raifuku藤, take 2-3 pieces each time, 3 times a day. The course of treatment is more than 3-6 months. Side effects include dizziness, dry mouth, sore throat, decreased appetite, abdominal pain, amenorrhea.

9. Other treatments: Thymosin, plasma pheresis therapy, etc., are still to be explored.

(Three) Physical Therapy: The purpose is to increase local blood circulation with heat therapy, relax the muscles, achieve the effects of anti-inflammatory, decongestion, and analgesia, and at the same time, exercise is adopted to maintain and improve joint function. There are several methods of physical therapy: hot water bags, hot bath, paraffin bath, infrared rays, etc. After physical therapy, massage is also recommended to improve local circulation and relax muscle spasms.

The purpose of exercise is to preserve the activity of the joints, strengthen the strength and endurance of the muscles. After the symptoms of the acute stage are relieved and消退, as long as the patient can tolerate, it is necessary to perform active or passive joint exercise activities early and regularly.

(Four) Surgical Treatment: In the past, it was believed that surgical treatment was only suitable for late-stage deformed cases. Currently, early synovectomy can be tried for those with only 1-2 joints severely damaged and ineffective to salicylate treatment. For those with static lesions in the later stage and obvious joint deformities, osteotomy correction surgery, joint arthroplasty, or artificial joint replacement surgery can be performed. For weight-bearing joints, joint fusion surgery can be performed, etc.

The specific introduction is as follows:

(1) Synovectomy: Mainly used for metacarpophalangeal joints, wrist joints, and knee joints, etc., it can remove the diseased synovium. After synovectomy, the joint function should be gradually restored with the help of orthopedic devices.

(2) Joint lavage + arthroscopic synovectomy: In large joints, especially the knee joint, synovectomy can be performed under arthroscopy, and repeated lavage can be carried out at the same time to achieve the purpose of replacing the components of joint fluid and alleviating the symptoms of arthritis and improving joint function.

(3) Joint Osteotomy: For weight-bearing joints, especially the metatarsophalangeal joints of the foot, when claw toe deformity affects weight-bearing, metatarsal bone resection can be performed to form a new joint and achieve the purpose of improving weight-bearing function and relieving pain.

(4) Artificial Joint Replacement Surgery: For severe rheumatoid arthritis patients, when their hip or knee joint is severely damaged and cannot be repaired, artificial joint replacement surgery can be considered. This kind of situation is more common in elderly patients.

The following dietary formulas are provided for selection and application (for reference only, specific needs should be consulted with a doctor).

1, Spicy Pork Soup: 100 grams of lean pork, 90 grams of pepper root. Wash the lean pork clean and cut into pieces, wash the pepper root with water and wrap it in a gauze bag, seal it. Then put the pork, pepper root, scallion slices, ginger slices, and Sichuan pepper into a pot, add an appropriate amount of water, boil it with high heat first, then simmer it with low heat for 30 minutes until the meat is tender, remove the pepper root, eat the meat and drink the soup, take one dose per day. This formula has the functions of warming the meridians and dispelling cold, removing dampness and relieving pain, and is suitable for those with severe joint pain. It is prohibited for those with heat bi.

2, Guizao Congee: 10 grams of cinnamon, 50 grams of sticky rice, and appropriate amount of brown sugar. Grind the cinnamon into fine powder, wash the sticky rice clean, cook the congee as usual, and add the cinnamon powder and brown sugar when the congee is about to be done. Boil it 1-2 more times before serving. Eat it on an empty stomach while hot, take one dose per day, and 3-5 days make up one course of treatment. If effective, take 1-2 more courses. This formula has the effects of warming the meridians and dispelling cold, warming the stomach and relieving pain, and is suitable for cold bi. It is prohibited for those with heat syndrome and hyperactive fire due to Yin deficiency.

3. Herba Et Rhizoma Angelicae Sinensis Wine: 30 grams each of Herba Angelicae Sinensis, Eucommia ulmoides, Angelica sinensis, Ligusticum chuanxiong, Rehmannia glutinosa, and Salvia miltiorrhiza, 1000 milliliters of white wine. First, grind the above 6 herbs into fine powder, separately wrap them in gauze, put them into the white wine, cover and seal it, then place it next to the fire and simmer for 24 hours, wait until it cools down, and it can be drunk at any time. This recipe has the effects of tonifying the liver and kidney, strengthening the tendons and bones, and removing dampness and arthritis, and is suitable for those with kidney and liver deficiency, dampness and arthritis pain. It is contraindicated for those with early arthritis and hot bi.

4. Broccoli Root Wine: 50 grams of broccoli root and 50 grams of yellow wine. Wash the broccoli root clean, put it in a pot, add an appropriate amount of water, boil it with high heat first, then simmer it for 30 minutes with low heat, remove the dregs and take the juice, then pour it into the yellow wine for internal administration. Take it twice a day, for several days. This recipe has the effects of clearing heat and unblocking the meridians, and is suitable for those with obvious symptoms of hot bi, joint redness, swelling, and pain. It is contraindicated for those without joint redness.

5. Eggplant Root Wine: 90 grams of eggplant root (or white eggplant root), 500 milliliters of white wine. Wash the eggplant root clean, chop it up, wrap it in white gauze, seal it, then put the eggplant root into the white wine and soak for 3 days, then open the seal and drink it. Take 15 milliliters each time, 2-3 times a day, for 7-10 days. This recipe has the effects of clearing heat, removing wind, and removing dampness to unblock the meridians, and is suitable for symptoms such as hot bi, joint redness, swelling, heat, thirst, constipation, and fever. It is contraindicated for those without joint redness.

(II) Prognosis

Generally speaking, early and active comprehensive treatment is given, and the recovery is mostly good. Acute onset is better than chronic onset, and men are better than women, those who only involve a few joints and have mild systemic symptoms, or those whose joints are not symmetrically distributed, often have a short course of disease, about 10% to 20% of patients become disabled due to delayed treatment. The disease does not directly cause death, but severe late cases can die of secondary infection.