Rheumatoid arthritis: treatment

Treatment of rheumatoid arthritis is performed by a rheumatologist, since the functional state of patients under medical supervision is better, and the use of modern methods of pharmacotherapy of rheumatoid arthritis requires special knowledge. It is necessary to inform patients about the nature of the disease, the side effects of the drugs used. If symptoms appear, the patient should immediately stop taking the medication and consult a doctor.

When choosing a treatment, it is necessary to take into account the risk factors of an unfavorable prognosis and the duration of the period between the onset of symptoms and the onset of BPVP administration.

Among the factors of unfavorable prognosis, which necessitate more active treatment, include the following:

• Seroposigivnost in the RF and anti-TsTSL antibodies in the debut of the disease.
• High inflammatory activity.
• Involvement in the pathological process of many joints.
• Development of extra-articular manifestations.
• Increased ESR and CRP.
• Detection of certain alleles of HLA DR (0101, 0401, 0404/0408, 1402).
• Detection of erosion in the joints in the debut of the disease.
• Young or old age of the onset of the disease.
• Bad socio-economic conditions of life.

If the duration of the disease is more than 6 months, treatment should be more active. If risk factors for an unfavorable prognosis are identified, consider taking methotrexate (an initial dose of 7.5 mg / week) with fast (for about 3 months) dose increase to 20-25 mg / week.

The efficacy of treating rheumatoid arthritis is assessed using standardized indices such as the American College of Rheumatology improvement criteria, the dynamics of the DAS28 index (every 3 months of the recommendations of the European Antirheumatic League), the functional capacity of the patient (HAQ) (every 6 months), the progression of joint destruction according to data Radiography with the use of the methods of Sharp or Larsen (every year).

Currently, the treatment of rheumatoid arthritis is considered effective, allowing to achieve clinical improvement no less than the level of ACR70 or remission.

In order to assess the improvement according to the criteria of the American College of Rheumatologists, the following should be considered.

The number of painful joints (the severity of synovitis is determined by counting the number of painful and the number of painful and swollen joints).

• The number of swollen joints (the severity of synovitis is determined by counting the number of painful and the number of painful and swollen joints).
• General activity (according to the doctor).
• Overall activity (according to the patient) (the patient evaluates the activity on a visual analogue scale with extreme points: "complete absence of activity" and "maximum possible activity"),
• Pain in the joints.
• The disability index (HAQ).
• Change in ESR, level of CRP.

ACR20, ACR50, ACR70 indicate a 20, 50 and 70% improvement in at least five of the seven indicators (the improvement of the first two is considered mandatory).

Characteristics of remission in rheumatoid arthritis

According to the criteria of the American College of Rheumatology (clinical remission: preservation of five of the following six signs for at least 2 months).

• Morning stiffness less than 15 min.
• There is no indisposition.
• There is no pain in the joints.
• There is no pain in the joints when moving.
• There is no swelling of the joints.
• ESR less than 50 mm / h in women and <20 mm / h in men.

According to the criteria of the European Antirheumatic League.

• The value of the DAS28 index is less than 2.6.

According to the FDA criteria.

• Clinical remission according to the criteria of the American College of Rheumatology and the absence of progression of the destruction of the joints according to roentgenological signs (Larsen or Sharpe index) for 6 months without taking BPAI (remission).
• Clinical remission according to the criteria of the American College of Rheumatology and the absence of progression of the destruction of the joints according to roentgenological signs (Larsen or Sharp index) for 6 months against the background of treatment with BPA (complete clinical remission).
• Improve the level of ACR70 for at least 6 consecutive months (clinical effect).
• Inflammation activity usually correlates with the development of joint destruction, however, in some patients, the progression of the erosive process in the joints is observed even with the use of standard MBPI in the case of low inflammatory activity, and even during the period of clinical remission.

[1], [2], [3], [4], [5], [6], [7], [8]

Indications for hospitalization

Patients are hospitalized in the rheumatology department in the following cases.

• To clarify the diagnosis and estimate the prognosis.
• For the selection of BPVP at the beginning and throughout the course of the disease.
• With an exacerbation of RA.
• With the development of severe systemic manifestations of RA.
• If there is an intercurrent disease, septic arthritis or other serious complications of the disease or drug therapy.

What are the objectives of treating rheumatoid arthritis?

• Suppression of symptoms of arthritis and extra-articular manifestations.
• Prevention of destruction, dysfunction and joint deformity.
• Preservation (improvement) of patients' quality of life.
• Achievement of remission of the disease.
• Reducing the risk of comorbid disease.
• Increase in life expectancy (to the population level).

Non-medicamentous treatment of rheumatoid arthritis

At the heart of the treatment of rheumatoid arthritis is a multidisciplinary approach based on the use of non-pharmacological and pharmacological methods, involving specialists in other medical specialties (orthopedists, physiotherapists, cardiologists, neurologists, psychologists, etc.).

In the absence of serious deformations of the joints, patients continue to work, but they are contraindicated in significant physical activities. Patients should avoid factors that could potentially provoke an exacerbation of the disease (intercurrent infections, stress, etc.). It is recommended to stop smoking and limit the intake of alcohol.

Maintaining an ideal body weight helps reduce the burden on joints and reduce the risk of death and development of osteoporosis. To do this, you must follow a balanced diet, including foods high in polyunsaturated fatty acids (fish oil, olive oil), fruits, vegetables. The use of these products potentially reduces the intensity of inflammation.

Important programs are the training of patients (changing the stereotype of motor activity). LFK, special exercises (1-2 times a week), aimed at strengthening muscle strength, physiotherapy methods (with moderate activity of the RA). Orthopedic methods are aimed at the prevention and correction of typical joint deformities and instability of the cervical spine.

Sanatorium treatment of rheumatoid arthritis is recommended only for patients with minimal RA activity or in remission.

Throughout the period of the disease, active prevention and treatment of concomitant diseases, especially cardiovascular pathology, is necessary.

It should be especially emphasized that non-drug treatment of rheumatoid arthritis has a moderate and short-term effect. The effect on the progression of the disease has not been proven. The described measures increase the effectiveness of symptomatic therapy and help in correcting permanent joint deformities.

Medicamentous treatment of rheumatoid arthritis

The last decades were marked by significant progress in deciphering the pathogenetic mechanisms of the development of the RA. It is no accident that this disease is considered as a kind of model of chronic inflammatory disease of man. The study of RA acquires a general medical value, as it creates prerequisites for improving the pharmacotherapy of many other human diseases (atherosclerosis, type 2 diabetes, osteoporosis), the development of which is also associated with chronic inflammation.

A fundamentally new direction in the medical treatment of rheumatoid arthritis was the formation of the concept of a "window of opportunity". The window of opportunity is a period of time in the debut of the disease, when the treatment with BPD has the maximum anti-inflammatory and antidestructive effect and improves the prognosis.

It was established that patients who started to receive DMAP early did not observe an increase in the risk of premature death in contrast to RA patients who did not receive BGIV. The prognosis in patients with severe RA treated with DMARD at the onset of the disease is the same as in patients with a more favorable variant of the course of the disease. It is noteworthy that treatment with DMAP and, in particular, with TNF-α inhibitors, significantly reduces mortality from cardiovascular causes. As well as inhibit the development of osteoporosis, which leads to fractures of the bones of the skeleton.

The following groups of drugs are used to treat rheumatoid arthritis.

• NNPV:
  • nonselective;
  • selective.
• Glucocorticosteroids.
• DMAP.
• Synthetic preparations.
• Biological preparations.

The basis of the treatment is considered drug therapy BDVP. Treatment of rheumatoid arthritis should be started as early as possible, preferably within the first 3 months of the onset of the disease. Therapy should be as active and flexible as possible, with a change in the treatment regimen, if necessary, depending on the dynamics of clinical symptoms and laboratory signs of inflammation. When choosing a BPO, risk factors must be considered.

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs have a direct anti-inflammatory effect.

The purpose of prescribing NSAIDs in RA is to relieve the symptoms of the disease (pain, stiffness, swelling of the joints). NSAIDs do not affect the activity of inflammation, can not affect the course of the disease and the progression of joint destruction. Nevertheless, NSAIDs are considered the main means for symptomatic treatment of RA and a first-line agent when administered in conjunction with BPVP.

Treatment of rheumatoid arthritis NSAIDs must necessarily be combined with the appointment of BPVP, since often the development of remission against the background of monotherapy with NSAIDs is significantly lower than when treated with any BPA.

Glcocorticoids

The use of HA in low doses (prednisolone <10 mg / day) can effectively control the clinical manifestations of RA associated with inflammation of the joints. Early rheumatoid arthritis treatment with glucocorticosteroids (in combination with BPVP) has a more pronounced clinical effect (according to the criteria of the American College of Rheumatology) and the bowl leads to the development of persistent remission than the monotherapy of BGIV. HA can potentially increase the effect of DPOI on slowing the progression of joint destruction in early RA. In this case, the HA effect is preserved after the completion of their reception.

In rheumatoid arthritis, glucocorticosteroids should not be used as monotherapy. They must be used in combination with DMAP. In the absence of specific indications, the dose of a glucocorticosteroid should not exceed 10 mg / day (in terms of prednisolone).

When appointing HA in RA, it should be remembered that their administration leads to the development of a large number of side effects. Side effects are more often observed with inadequate use of drugs (long-term use of high doses). It should be borne in mind that some side affects (for example, severe lesions of the gastrointestinal tract, foam and other organs) occur less frequently than when treating NSAIDs and NSAIDs. In addition, effective prevention measures have been developed to prevent some unwanted effects (eg, glucocorticoid osteoporosis).

Indications for the appointment of low doses of HA.

• Suppression of inflammation of the joints before the onset of action of the BPVP ("bridge" -therapy).
• Suppression of joint inflammation with exacerbation of the disease or development of complications in the treatment of BPD.
• Ineffectiveness of NSAIDs and DMARD.
• Contraindications to the appointment of NSAIDs (for example, in elderly people with a "ulcerative" anamnesis and / or impaired functions).
• Achievement of remission in some variants of RA (for example, with seronegative RA in elderly people, reminiscent of rheumatic polyalgia).

Medium and high doses of HA inside (15 mg per day or more, usually 30-40 mg per day in terms of prednisolone) are used to treat severe systemic manifestations of RA (exudate serositis, hemolytic anemia, cutaneous vasculitis, fever, etc.), and special forms of the disease (Felty syndrome, Still's syndrome in adults). The duration of treatment is determined by the time needed to suppress symptoms. The course is usually 4-6 weeks, after which gradually reduce the dose and switch to treatment with low doses of HA.

Routine use of HA in RA is not recommended. Prescribe drugs or a group of this should a rheumatologist.

Pulse therapy of HA is used in patients with severe systemic manifestations of RA. This method allows you to achieve rapid (within 24 hours), but a short-term suppression of inflammation of the joints.

Since the positive effect of the pulse therapy of HA on the progression of joint destruction and prognosis is not proven, their use (without special indications) is not recommended.

Local (intra-articular) administration of HA in combination with the use of BPOI effectively suppresses inflammation of the joints at the onset of the disease or during exacerbation of the process, but does not affect the progression of joint destruction. When conducting local therapy, general recommendations should be observed.

Biological Therapy

In patients with persistent and / or erosive arthritis, the treatment of rheumatoid arthritis of BPVP should be started as early as possible (within 3 months of the onset of symptoms of the disease), even if they formally do not meet the diagnostic criteria of RA (undifferentiated arthritis). Early swings in the treatment of BPO improves the patient's condition and slows the progression of joint destruction. Later, the appointment of BPO (after 3-6 months from the onset of the disease) decreases the effectiveness of ionotherapy. The longer the duration of the disease, the lower the efficacy of DMARD. With undifferentiated arthritis, the appointment of methotrexate reduces the risk of transformation of the disease into a reliable RA, especially in patients whose blood is detected by anti-CCP antibodies.

Against the backdrop of treatment, it is necessary to carefully evaluate the dynamics of disease activity (DAS index) at least once every 3 months. A correct selection of the BPOA, depending on the activity of the disease, significantly improves the effectiveness of treatment in early RA.

The intake of DMB should be continued even with a decrease in the activity of the disease and the achievement of remission, since the withdrawal of the drug often leads to an aggravation and progression of destructive changes in the joints. When the remission is achieved, it is possible to reduce the dose of DPOI, if there is no exacerbation.

The main drugs (first-line drugs) for the treatment of rheumatoid arthritis are methotrexate, leflunomide, sulfasalazine, hydroxychloroquine. Other DMBs (azathioprine, cyclosporine, penicillamine, cyclophosphamide, chlorambucil) are rarely used, primarily because of side effects and lack of reliable data on their effect on the progression of joint damage. Potential indications for their appointment are considered ineffectiveness of other BPVP or contraindications to their appointment.

The efficacy and toxicity of DMARD may be affected by other drugs. These interactions should be taken into account during the treatment.

Women of childbearing age who take BPAI should use contraception and carefully plan pregnancy, since these drugs should be used with extreme caution during pregnancy and lactation

[9], [10], [11], [12], [13], [14], [15], [16]

Combined treatment of rheumatoid arthritis BPVP

Apply three basic treatment regimens.

• Monotherapy with the subsequent appointment of one or more DMAP (for 8-12 weeks) while maintaining the activity of the process (step-up).
• Combination therapy with the subsequent transfer to monotherapy (after 3-12 months) with the suppression of the activity of the process (step-down).
• Combination therapy for the entire period of the disease.
• The main drug in the combination therapy is methotrexate.

[17], [18]

Biological preparations

Despite the fact that treatment with standard DMAP in the most effective and tolerated doses from the earliest period of the disease allows improving the immediate (symptom relief) and the long-term (risk reduction of the disability) prognosis in many patients, the results of RA treatment are generally unsatisfactory. Treatment of rheumatoid arthritis with standard BPVP has certain limitations and disadvantages. These include the difficulties of predicting the efficacy and toxicity of BPHP, the rarity of achieving remission of the disease (even with the early appointment of treatment), the development of exacerbation after stopping the intake of medications. Against the background of the treatment of benign prostatic hyperplasia, the destruction of the joints can progress, despite the reduction in the inflammatory activity of the disease and even the development of remission. These drugs often cause adverse reactions that limit the use of these drugs at doses necessary to achieve a persistent clinical effect.

This is a serious stimulus for improving approaches to pharmacotherapy in the RA. New methods should be based on knowledge about the fundamental mechanisms of development of rheumatoid inflammation and on modern medical technologies. The most significant achievement of rheumatology in the last decade is the introduction into the clinical practice of a group of drugs that are united by a common term "biologicals", or, more precisely, biological modifiers of the immune response. Unlike traditional HDL and HA, which are characterized by nonspecific anti-inflammatory and (or) immunosuppressive effects, biological agents have a more selective effect on the humoral and cellular components of the inflammatory cascade.

Currently, 3 registered drugs belonging to the class of biological agents are successfully used. These are inhibitors of TNF-a (infliximab, adalimumab) and an inhibitor of B cell activation (rituximab). They are characterized by all the beneficial properties inherent in BPO (suppression of inflammatory activity, inhibition of joint destruction, possible induction of remission), but the effect usually occurs much more quickly (within 4 weeks and sometimes immediately after infusion) and is much more pronounced in including in relation to inhibition of joint destruction.

The main indications for the appointment of inhibitors of TNF-a (infliximab and adalimumab) are considered ineffectiveness (the maintenance of inflammatory activity) or intolerance of methotrexate (as well as leflunomide) in the most effective and tolerated dose. There are data that require, however, further confirmation of the effectiveness of combination therapy with infliximab and leflunomide in patients with insufficient leflunomide ionotherapy. It should be specially emphasized that, although combined therapy with methotrexate and TNF-a inhibitors is highly effective (compared to standard BPVP), more than 30% of patients do not benefit from this type of treatment, and only 50% of cases can achieve complete or partial remission . In addition, after completion of the course, patients with RA tend to have an exacerbation. All this taken together, as well as the fact that the use of TNF-α inhibitors can contribute to the development of severe side effects (adherence to tuberculosis, opportunistic infections and other diseases), served as the basis for the use of rituximab for RA treatment.

The treatment of rheumatoid arthritis depends to a certain extent on the duration and the stage of the disease, although the goals and general principles of therapy do not differ significantly.

At the early stage of the disease (the first 3-6 months from the onset of symptoms of arthritis), erosions and joints are not detected (in most patients), with a high probability of developing clinical remission. Often, patients do not detect a sufficient number of RA criteria, and the disease is classified as undifferentiated arthritis. It should be emphasized that in patients with undifferentiated arthritis a high frequency (13-55%) of development of spontaneous remissions is observed (the disappearance of symptoms without treatment). In this case, the development of spontaneous remission is associated with the lack of anti-CCP antibodies. At the same time, spontaneous remissions are observed rarely in patients with a reliable early RA (in 10% of cases), while this group of patients also do not show anti-CCP antibodies. As already noted, the appointment of methotrexate to patients with anti-CCP-positive undifferentiated arthritis significantly reduces the risk of its transformation into a reliable RA. There is information that in patients (early RA, when markers of unfavorable prognosis are identified, treatment should be started with the appointment of combined therapy with methotrexate and inflixmann.

An extended stage is usually observed with a disease duration of more than 12 months. It is typical in most cases of a typical clinical picture of RA, the gradual development of an erosive process in the joints and the progression of functional disorders.

The vast majority of patients need continuous treatment of rheumatoid arthritis with effective doses of BPVP even with low disease activity. It often happens that it is necessary to change the BPD, prescribe a combined treatment of rheumatoid arthritis, including using biological agents. To prevent exacerbations, you can re-appoint NSAIDs, HA for systemic and local use.

Late stage manifestations are usually observed with a disease duration of more than 5 years (sometimes less). For the late stage of RA is characterized by a significant destruction of small (X-ray stage III-IV) and large joints with severe impairment of their functions, the development of complications (tunnel syndromes, aseptic necrosis of bones, secondary amyloidosis). At the same time, inflammatory activity can subside. In connection with the stable deformation of the joints, mechanical pains, the role of orthosis and orthopedic methods in the treatment of RA at this stage is increasing. Patients should be examined regularly to actively detect complications of the disease (in particular, secondary amyloidosis).

It is advisable to treat the patient as resistant to treatment as a treatment with at least two standard DMARD at the recommended maximum doses (methotrexate 15-20 mg / week sulfasalazine at 2 g / day, leflunomide 20 mg / day) was ineffective (20% and 50% according to the criteria of the American College of Rheumatology). Inefficiency can be primary and secondary (occurring after a period of satisfactory response to therapy or with a repeated prescription of the drug). To overcome resistance use low doses of HA, combined therapy with standard DMPP and biological agents, and in case of ineffectiveness or detection of contraindications to their use, second-order BPD is used.

[19], [20], [21], [22], [23], [24],

Treatment of Felty Syndrome

To assess the effectiveness of treatment Felty syndrome developed special criteria.

Criteria for good treatment effectiveness.

• Increase in the number of granulocytes up to 2000 / mm3 and more.
• Reducing the incidence of infectious complications by at least 50%.
• Reduction in the incidence of skin ulcers by at least 50%.

The main drugs for the treatment of Felty syndrome are parenteral gold salts, with ineffectiveness of methotrexate (leflunomide and cyclosporine). The tactics of their application are the same as in other forms of RA. Monotherapy GK (more than 30 mg / day) leads only to a temporary correction of granulocytopenia, which recurs after a reduction in the dose of the drug, and an increased risk of developing infectious complications. Patients with agranulocytosis are prescribed a pulse-therapy of HA according to the usual scheme. Data on the rapid normalization of granulocyte levels against granulocyte-macrophagal or granulocyte colony-stimulating factors have been obtained. However, their administration is accompanied by side effects (leukocytoclastic vasculitis, anemia, thrombocytopenia, bone pain) and exacerbation of RA. To reduce the risk of side effects, it is recommended to start treatment with a low dose of granulocyte-macrophage colony-stimulating factor (3 μg / kg / day) in combination with a short course of HA (prednisolone in a dose of 0.3-0.5 mg / kg). In severe neutropenia (less than 0.2 x 109 / L), treatment with granulocyte-macrophagic colony-stimulating factor is carried out for a long time in the minimally effective dose necessary to maintain the number of neutrophils> 1000 / mm3.

Although splenectomy leads to rapid (within a few hours) correction of hematological abnormalities, currently it is recommended to be performed only in patients resistant to standard therapy. This is due to the fact that a quarter of patients observe recurrence of granulocytopenia, and 26-60% of patients have recurrence of infectious complications.

Conduct blood transfusion is not recommended except for cases of very severe anemia associated with cardiovascular risk. The efficacy of epoetin beta (erythropoietin) has not been proven. It is recommended to be used only before surgical operations (if necessary).

Treatment of amyloidosis

There are data on the clinical efficacy of cyclophosphamide, chlorambucil, HA, and especially infliximab.

Treatment of infectious complications

RA is characterized by an increased risk of developing infectious complications with localization in the bones, joints, respiratory system and soft tissues. In addition, many drugs used to treat the disease (NSAIDs, DMBs and especially HA) may increase the risk of developing infectious complications. This dictates the need for careful monitoring and active early treatment of infectious complications.

Risk factors for the development of infections in RA are:

• elderly age;
• extra-articular manifestations;
• leukopenia;
• comorbid diseases, including chronic lung diseases and diabetes mellitus;
• treatment of HA.

Patients With RA are very susceptible to the development of septic arthritis. The peculiarities of septic arthritis in RA include the damage of several joints and the typical course in patients receiving glucocorticosteroids.

Treatment of cardiovascular complications in patients with RA (including undifferentiated arthritis) is higher than the risk of developing cardiovascular diseases (acute myocardial infarction, stroke), so they should undergo a screening to assess the risk of this pathology.

Treatment of osteoporosis

Osteoporosis is a frequent complication of RA. Osteoporosis can be associated with both the inflammatory activity of the disease itself and the violation of physical activity, and with treatment, in the first place GC. Prevention of osteoporosis should be carried out in the following categories of patients:

• receiving HA;
• with nontraumatic fractures of the bones of the skeleton in the anamnesis;
• over 65 years of age.

In patients who have risk factors for the development of osteoporosis and receiving HA, an IPC definition is required annually.

The main drugs for the prevention and treatment of osteoporosis, including glucocorticoid, are bisphosphonates. With intolerance to bisphosphonates, strontium ranelag can be used. Calcitonin (200 IU / day) is indicated for severe pain associated with vertebral compression fractures. All patients are prescribed combined therapy with calcium preparations (1.5 mg / day) and cholecalciferol (vitamin D) (800 IU / day).

Surgical treatment of rheumatoid arthritis

Surgical treatment of rheumatoid arthritis is considered the main method of correction of functional disorders in the late stage of the disease. Application in the early stage of the RA in the vast majority of cases is impractical due to the wide possibilities of drug therapy. In the advanced stage of the disease, the need for surgical treatment is determined individually when establishing the indications.

Indications for operation

• Nerve compression due to synovitis or tenosynovitis.
• Threatening or complete rupture of the tendon.
• Atlanto-axial subluxation, accompanied by the appearance of neurological symptoms.
• Deformations that make it difficult to perform simple daily activities.
• Heavy ankylosis or dislocation of the lower jaw.
• The emergence of bursitis, disrupting the patient's working capacity, as well as rheumatic nodules, which tend to ulcerate.

Relative indications for surgery.

• Resistant to drug therapy synovitis, tenosynovitis or bursitis.
• Expressed pain in the joints.
• Significant restriction of movement in the joint.
• Severe deformity of the joints.

Endoprosthetics - the main method of treatment for deformities of the hip and knee joints, as well as the finger joints of the hand. Apply also a synovectomy (recently carried out mainly in small joints) and tenosynovectomy. Arthroscopic synovectomy is becoming more common, however, long-term results have not yet been studied. Perform bone resections, arthroplasty (used mainly on the joints table). Artrodesis can be a method of choice for severe deformities of the ankle first metatarsophalangeal and wrist joints.

What should a patient know about the treatment of rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease. Its length is characterized by the development of erosive arthritis and systemic damage to internal organs. Symptoms usually are persistent and progressively progress in the absence of treatment.

Medical therapy is considered the main method of RA treatment. This is the only way to slow down the development of the inflammatory process and keep mobility in the joints. Other methods of treatment: physiotherapy, diet, exercise therapy have an auxiliary value and are not capable of having a significant effect on the course of the disease.

At the heart of RA treatment is the use of DMAP. They include a large number of drugs that differ in chemical structure and pharmacological properties, such as methotrexate, leflunomide, sulfasalazine, etc. They are united by the ability to suppress inflammation and (or) pathological activation of the immune system to a greater or lesser extent and through various mechanisms. The new method of treating RA is the use of so-called biological agents. Biological agents (not to be confused with biologically active additives) are protein molecules that selectively affect individual substances or groups of cells involved in the process of chronic inflammation. To biological preparations carry infliximab, rituximab, adalimumab.

Rheumatoid arthritis treatment usually begins with the appointment of methotrexate or leflunomide. Biological agents (infliximab, adalimumab and rituximab), as a rule, are added to these drugs with insufficient ionotherapy efficiency. A rapid anti-inflammatory effect can give a HA. NSAIDs are an important component of RA treatment, as they can reduce joint pain and stiffness. The most commonly used diclofenac, nimesulide, meloxicam, ketoprofen, celecoxib.

Rheumatoid arthritis medication treatment can give very good results, but requires careful monitoring. Control should be carried out by a qualified rheumatologist and the patient himself. The patient should visit the doctor at least once every 3 months at the beginning of treatment. In addition to the examination, blood tests are prescribed, and an X-ray examination of the joints is performed annually to assess the course of the disease. It should be remembered about the limitations of treatment with methotrexate and leflunomide therapy

Approximate terms of incapacity for work

Temporary disability can occur with RA with moderate and high activity and persist for the period of development of clinical effect from drug treatment. Patients lose their ability to work and go to disability due to the violation of joint function during the first 5 years of the disease in 50% of cases. If the duration of the disease is more than 15 years, 80% of patients are recognized as disabled by groups I and II.

Early active treatment of rheumatoid arthritis, including the use of biological agents, can significantly reduce the time of temporary disability and the number of disabled patients.

[25], [26], [27],

Forecast

And the end of XX century. On average, about half of the patients lost their ability to work during the first 10 years, by the year 15 of the disease, about 80% of the patients had become disabled in groups I and II. In RA patients, a decrease in life expectancy compared to the general population for 5-10 years was observed. The most common causes of death were cardiovascular disease (stroke, acute myocardial infarction), the occurrence of which is associated with the intensive development of atherosclerosis and a tendency to thrombosis due to chronic immune inflammation. Often observed lethal outcomes due to secondary amyloidosis. Concomitant infections (pneumonia, suppuration of soft tissues, etc.).

Modern active treatment, especially at the early stage of rheumatoid arthritis, can significantly improve the results of retention of work capacity, achieve clinical remission in 40-50% of patients, bring the expected life expectancy to the population level.

[28], [29], [30], [31], [32], [33], [34]