Special Planning: Rheumatism and Immunity 365 Q
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This issue is written by Lei Lingyan
Attending physician of Hebei Provincial Maternal and Child Health Hospital
Highlights of this issue
1. What to do if you have been diagnosed with rheumatoid arthritis
2. General treatment and medication for rheumatoid arthritis
▍Introduction
Rheumatoid arthritis (RA) is considered to be "an immortal cancer", after the diagnosis, many people have lost confidence in treatment, outpatient clinics can see many patients whose joints have been deformed, seriously affecting the quality of life, most of them have not received effective and formal treatment at the beginning of the disease, in fact, after formal treatment and selection of the right treatment plan, most of the rheumatoid arthritis patients can be controlled, like normal people work and live. So, how is rheumatoid arthritis treated?
▍General treatment
Proper rest, physiotherapy, topical medication, correct joint movement and muscle exercise play an important role in relieving symptoms and improving joint function.
▍Medication
Commonly used drugs for the treatment of RA include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologics, glucocorticoids, and targeted synthetic DMARDs.
(1)非甾体类抗炎药(NSAIDs)
It is the most commonly used and most effective adjuvant treatment for rheumatoid arthritis, and can play a dual role as an anti-inflammatory and analgesic. At present, commonly used non-steroidal anti-inflammatory drugs include diclofenac sodium, celecoxib, etoricoxib, meloxicam, indomethacin, ibuprofen, fenpidex, naproxen, etc., and the drug selection should be individualized, with as little dose and short course of treatment as possible, and the combination of 2 or more NSAIDs should be avoided.
(2)改善病情的抗风湿药物(DMARDs)
This class of drugs has a slow effect, and it takes about 1-6 months for obvious improvement of clinical symptoms, so it is also called slow-acting antirheumatic drugs. These drugs do not have significant analgesic and anti-inflammatory effects, but they can delay or control the progression of the disease and should be used early.
Commonly used DMARDs are the following:
(1) Methotrexate is currently the most commonly used DMARDs drug, most rheumatologists take it as the initial treatment, common adverse reactions include nausea, stomatitis, diarrhea, hair loss, rash and liver damage, a few bone marrow suppression, and occasional pulmonary interstitial lesions.
(2) Sulfasalazine can be used alone for short-duration and mild-symptomatic RA, or in combination with other DMARDs for the treatment of patients with a longer course of disease and moderate and severe disease, and the initial and gradual increase of low-dose dose can help reduce adverse reactions. The main adverse reactions include nausea, vomiting, abdominal pain, diarrhea, rash, increased aminotransferases and decreased spermatozoa.
(3) Leflunomide is increasing in the treatment of RA, according to the condition can be a single drug or a combination of drugs, the main adverse reactions are diarrhea, itching, hypertension, increased liver enzymes, rash, hair loss and leukocyte decline, etc., because of the teratogenic effect, so pregnant women are prohibited.
(4) Antimalarial drugs include hydroxychloroquine and chloroquine, which can be used for patients with a shorter course of disease and milder disease, the former has fewer adverse reactions, but the fundus should be examined once a year before and during treatment to monitor the retinal damage that the drug may cause, chloroquine is cheaper, but eye damage and heart-related adverse reactions are more common than the former.
(5) Azathioprine can be used alone or in combination with other drugs, mainly used in severe RA patients, and neutropenia due to bone marrow suppression is the most common complication.
(6) Compared with other immunosuppressive drugs, the main advantage of cyclosporine is that there is little bone marrow suppression, and it can be used for RA patients with severe disease or long course of disease and adverse prognostic factors. The main adverse reactions were hypertension, liver and kidney toxicity, gastrointestinal reactions, gingival hyperplasia and hirsutism.
(7) Cyclophosphamide is rarely used for RA, and can be tried as appropriate for severe patients when other drugs are ineffective.
(8) Tripterygium wilfordii is effective in relieving joint swelling and pain, and the main adverse reaction is gonadal inhibition, which leads to male infertility and female amenorrhea, so it is mostly used in elderly patients.
(9) The total glycosides of Paeonia alba are suitable for patients with mild symptoms or combined with other drugs, and its adverse reactions are few, mainly including abdominal pain, diarrhea, loss of appetite, etc.
(10) Eratimod is a relatively new DMARDs, but it is increasingly widely used, oral, the recommended dose is 25mg, twice a day, and gastrointestinal adverse reactions need to be monitored.
Others, such as penicillamine, gold preparation, and Sinomenine, are currently less clinically used because of their adverse reactions.
(3) Glucocorticoids
Low-dose corticosteroids are advocated as adjunctive therapy for symptomatic control, and recent evidence suggests that low-dose corticosteroid therapy can delay the progression of bone destruction. The principle of hormone therapy for RA is a small dose, short course, and the use of corticosteroids must be accompanied by DMARDs. During hormone therapy, calcium and vitamin D supplements should be given to prevent osteoporosis.
(4) Biological agents
It is a new type of drug for the treatment of RA, and is favored by many rheumatologists and patients because of its fast onset of action and much less side effects than DMARDs drugs. Biologics that can treat RA mainly include:
(1) Tumor necrosis factor (TNF)-a antagonist
It is the earliest biologics for the treatment of RA, including YISAIPU, etanercept, adalimumab, infliximab, golimumab, certolizumab, etc. Compared with traditional DMARDs drugs, tumor necrosis factor (TNF)-a antagonists are characterized by rapid onset, obvious inhibition of bone destruction, and good overall patient tolerance. The use of TNF-a antagonists in Chinese RA patients should be aware of the risk of hepatitis B virus replication and tuberculosis resurgence.
(2) IL-1 antagonist Anakinra is a recombinant IL-1 antagonist, and is currently the only IL-1 antagonist approved for the treatment of RA. However, it has a relatively weak effect on RA compared to other biologics.
(3) IL-6 antagonists currently on the market include tocilizumab and salibrumab, which are mainly used for patients with moderate to severe RA and active RA patients with poor efficacy against TNF-a antagonists. Common adverse reactions are infection, dyslipidemia, etc.
(4) The representative drug of anti-CD20 monoclonal antibody is rituximab, which is mainly used for active RA with poor efficacy of TNF-a antagonists. Although it has been used abroad for many years, on the mainland, there are no indications for the treatment of rheumatoid arthritis.
(5) T cell costimulatory signal inhibitor (CTLA4-Ig) is represented by abatacept, which is mainly used for the treatment of patients with severe disease or poor response to TNF-a antagonists. The risk of serious infection may be less than that of other biologics, but the risk of tumors is slightly increased.
(5) JAK inhibitors are targeted synthetic DMARDs drugs, and the JAK inhibitors currently approved for the treatment of RA include tofacitinib and baricitinib. All are oral preparations, easy to use, and the risk of infection should be paid attention to during use.
In recent years, with the development of rheumatology and immunology, new therapeutic drugs have gradually increased, providing more choices for the majority of patients.
In short, although rheumatoid arthritis cannot be cured at present, early diagnosis and early treatment can greatly improve the clinical symptoms and prognosis of patients.
Experts of this issue
Dr. Lei Lingyan
- Attending physician of Hebei Provincial Maternal and Child Health Hospital
- He graduated from Hebei Medical University with a bachelor's degree and a master's degree
- He has worked in the Department of Rheumatology and Immunology of the Second Hospital of Hebei Medical University for 13 years
- Since January 2024, he has been working in Hebei Provincial Maternal and Child Health Hospital
- In 2015, he studied musculoskeletal ultrasound at Peking University First Hospital
- He specializes in the clinical diagnosis and treatment of common rheumatological diseases such as systemic lupus erythematosus, Sjögren's syndrome, rheumatoid arthritis, inflammatory myopathy, spondyloarthritis, gout, antiphospholipid syndrome, osteoarthritis, etc., as well as musculoskeletal ultrasound diagnosis
- During the 2020 novel coronavirus epidemic, he was awarded the title of "Advanced Individual in Anti-epidemic"
- He has published several papers in professional journals, undertaken and participated in a number of projects of the Provincial Department of Health and the Department of Education, and participated in the compilation of 1 book
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