What do you think is the biggest harm of rheumatoid arthritis? It is estimated that many patients will answer: joint swelling and pain! Joint swelling and pain are indeed typical symptoms of rheumatoid arthritis, but they are only the tip of the iceberg of rheumatoid harm. Some patients in order to make the joints feel better, use hormones as soon as the disease occurs, and the joint swelling and pain are alleviated, but they will face many hidden dangers such as continuous development of the disease and adverse hormonal reactions! Today, Dr. Zhao will take you to see what harm the abuse of hormones will cause to rheumatoid arthritis patients!
<h1 class="pgc-h-arrow-right" data-track="2" can > glucocorticoids help patients control pain in the long term? </h1>
The main effect of glucocorticoids on rheumatoid arthritis is anti-inflammatory and immunosuppressive, but immunosuppression is related to the application of doses, and the use of glucocorticoids in large doses is rare, and is generally used when there are severe systemic symptoms, so we mainly look at its anti-inflammatory effect.
The anti-inflammatory mechanism of glucocorticoids is relatively clear. In patients with rheumatoid arthritis, autoimmune abnormalities lead to inflammation of synovial cells, inflamed synovial cells secrete phospholipase A2, catalyzing phospholipid hydrolysis to produce arachidonic acid, arachidonic acid under the catalysis of epoxygenase (COX) to produce inflammatory mediator prostaglandins, glucocorticoids mainly by inhibiting the synthesis of prostaglandins to achieve anti-inflammatory effects.
For patients with rheumatoid arthritis, it can reduce the permeability of capillaries, inhibit inflammatory infiltrates and exudations, and resolve the edema of the interstitial cells, thereby alleviating joint swelling and pain. Glucocorticoids act quickly, often within a few hours of taking the drug, the joint pain is relieved, the joint stiffness is reduced, and after about 1 week, the joint swelling and pain can be significantly improved, and the condition can be greatly improved after 1 to 2 months. The use of small doses of glucocorticoids also has a certain effect on delaying joint destruction.
Because of its immediate anti-swelling and analgesic effect, some patients will take glucocorticoids privately in order to alleviate pain, hoping to be able to control pain all the time, not to mention the harm of drug abuse, in fact, glucocorticoids do not have a long-term role in controlling pain.
A study by British scholars quantifying the analgesic effect of hormonal system therapy on RA showed that oral glucocorticoids have an analgesic effect on rheumatoid arthritis, but the effect is most significant in the short term after starting treatment, and after 3 months of medication, clinically significant analgesic effect may not be achieved. That is to say, the analgesic effect of glucocorticoids decreases with the extension of the medication time, and it does not always help the patient to control the pain, and other drugs need to be used to help the patient reduce long-term pain!
<h1 class="pgc-h-arrow-right" data-track="38" > the use of glucocorticoids should be vigilant against adverse reactions, especially cardiovascular risk and osteoporosis risk</h1>
Glucocorticoids are known for their adverse reactions, common adverse reactions include: hyperinvestia, weight gain, full moon face, buffalo back, hirsutism, acne, ecchymosis, gastric and duodenal ulcers, gastrointestinal bleeding, secondary infections, hypertension, diabetes, aseptic osteonecrosis, osteoporosis and so on. The two things that worry patients the most are the following:
01 / Cardiovascular risk of glucocorticoids
The cardiovascular safety of glucocorticoids in patients with rheumatoid arthritis has been controversial and may be related to the dose and duration of the hormone. This is reflected in three aspects:
Single-day dose – A study in the United States showed an increased risk of cardiovascular events when the dose of the hormone ≥5 mg, while the risk was not increased at a dose of 0 to 4 mg of the hormone.
Cumulative dose – the risk of cardiovascular events increased when the patient's cumulative hormonal dose > 751 mg in the first 6 months, and did not increase the risk at a lower cumulative dose.
Duration of administration – The risk of cardiovascular events increased with more than 81 days of hormone use in the first 6 months, and the risk did not increase if it did not exceed 81 days.
In patients with rheumatoid arthritis who have not previously used hormones, daily doses of hormones ≥5 mg, higher cumulative doses and longer duration of administration of hormones for the past 6 months and 1 year increase the risk of cardiovascular events! Prednisone ≤ 4 mg/day, low cumulative dose, and short duration of use were not associated with cardiovascular event risk.
02 / Risk of osteoporosis and fracture of glucocorticoids
Rheumatoid arthritis patients are more likely to be in women aged 30 to 50 years, the patients themselves may belong to the high incidence of osteoporosis, the impact of the disease will increase the risk of osteoporosis, the use of glucocorticoids will make the bones worse!
Causes of glucocorticoid secondary osteoporosis include:
Directly damage the function of osteoblasts, osteocytes and osteoclasts, mainly bone formation defects;
This leads to decreased bone reconstruction function, decreased repair ability after bone micro-injury, increased bone fragility, and is prone to fractures and bone necrosis;
Promotes excessive secretion of parathyroid hormone, causing secondary hyperparathyroidism;
Direct or indirect antagonism to gonadal function, inhibition of bone formation of gonadal hormones and growth hormones;
Causes muscle atrophy and muscle weakness, the stress of the bones meets a decrease, reduces bone formation;
Decreased calcium assorption and tubular reabsorption, and the emergence of negative calcium balance promotes secondary hyperparathyroidism.
Bone mass begins to be lost after a few weeks of glucocorticoid therapy, and bone mass is lost rapidly in the first few months, reaching 5% to 15% per year, and the incidence of osteoporosis is as high as 30% to 50% in patients who have received glucocorticoid therapy for more than 1 year. Therefore, patients with rheumatoid arthritis treated with glucocorticoids should do a good job of bone density monitoring, and calcium and vitamin D supplementation can be supplemented under the guidance of doctors to prevent osteoporosis.
A recent European study showed that current oral treatment with low-dose glucocorticoids (≤ 7.5 mg prednisolone/day) was not associated with the overall risk of osteoporotic fractures, but was associated with an increased risk of clinical vertebral fractures, both short-term and long-term. Therefore, patients should be more cautious about using glucocorticoids, especially the single-day dose.
<h1 class="pgc-h-arrow-right" data-track="39" > the application of glucocorticoids should be in line with the indications, and the correct choice of drug types and doses</h1>
The correct use of glucocorticoids is recommended for patients with rheumatoid arthritis when controlling whether the patient meets the indications and generally meets the following conditions:
There are serious extra-articular manifestations, such as vasculitis, myocarditis, pericardial effusion, interstitial pneumonia, central nervous system and eye lesions, Ferti syndrome, etc.
When treatment with other drugs is ineffective, the condition is severe or more severe.
When slow-acting antirheumatic drugs have not yet taken effect, as a transitional therapy, glucocorticoids are gradually reduced when slow-acting drugs take effect.
There are many types of glucocorticoids, and not all of them are suitable for rheumatism treatment.
Short-acting hormones - natural hormones, weak anti-inflammatory effect, shorter duration of action, mainly used for alternative treatment of adrenal insufficiency, including cortisone, hydrocortisone. Includes cortisone, hydrocortisone.
Medium-acting hormone - anti-inflammatory effect and half-life centered, better than short-acting hormone effect, less than long-acting hormone side effects, clinically often used for rheumatism, autoimmune diseases, immunosuppressive therapy and other treatments, including prednisone, prednisolone, methylprednisolone, triamcinolone acetonide.
Long-acting hormone - strong anti-inflammatory effect, long time of action, but the adverse reactions are also large, not suitable for long-term medication, generally as a temporary medication, such as allergies, closure therapy, etc., including dexamethasone, betamethasone and so on.
Suitable for patients with rheumatoid arthritis, the use of moderate-acting hormones, some patients oral dexamethasone to relieve pain, which is actually a hormone abuse.
Surveys have shown that in patients with more than 2 years of medical history, more than 30% of patients who have long-term unreasonable use of large doses of hormones and long-acting hormones, and up to 80% of those who have used hormones irrationally, which shows how common hormone abuse is, and the harm caused to patients cannot be ignored!
In short, patients with rheumatoid arthritis must use glucocorticoids under the guidance of a specialist, and ordinary patients should be applied in short-term small doses, taking prednisone as an example, the daily dose should be ≤ 7.5 mg, but if possible, it is still necessary to reduce the dose to a minimum as soon as possible, or even as low as 2.5 mg per day. For patients with severe disease with cardiac, pulmonary, or neurologic involvement, this high dose should be used decisively. In addition, patients should be monitored for adverse reactions during glucocorticoids.