Rheumatoid arthritis: treatment

Treatment of rheumatoid arthritis is performed by a rheumatologist, since the functional state of patients under the supervision of a doctor 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, side effects of the drugs used. If appropriate symptoms appear, the patient should immediately stop taking the drug and consult a doctor.

When choosing a treatment, it is necessary to take into account risk factors for a poor prognosis and the duration of the period between the onset of symptoms and the start of DMARDs.

The following are considered factors of unfavorable prognosis that necessitate more active treatment:

• Seropositivity for RF and anti-CCL antibodies at the onset of the disease.
• High inflammatory activity.
• Involvement of many joints in the pathological process.
• Development of extra-articular manifestations.
• Increased ESR and CRP levels.
• Detection of specific HLA DR alleles (0101, 0401, 0404/0408, 1402).
• Detection of erosions in joints at the onset of the disease.
• Young or old age of onset of the disease.
• Poor socio-economic living conditions.

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

The effectiveness of rheumatoid arthritis treatment is assessed using standardized indices, such as the American College of Rheumatology improvement criteria, the dynamics of the DAS28 index (every 3 months, recommendations of the European League Against Rheumatism), the patient's functional ability (HAQ) (every 6 months), the progression of joint destruction according to radiography using the Sharp or Larsen methods (every year).

Currently, treatment of rheumatoid arthritis is considered effective if it allows achieving clinical improvement of at least ACR70 level or remission.

To assess improvement according to the American College of Rheumatology criteria, the following should be considered.

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

• Number of swollen joints (the severity of synovitis is determined by counting the number of painful joints and the number of painful and swollen joints).
• General activity (according to the doctor).
• General activity (according to the patient) (the patient evaluates activity using a visual analogue scale with extreme points: “complete lack of activity” and “maximum possible activity”),
• Joint pain.
• Disability Assessment Questionnaire (HAQ).
• Changes in ESR and CRP levels.

ACR20, ACR50, ACR70 indicate 20, 50 and 70% improvement in at least five of the seven listed indicators (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: maintenance of five of the following six signs for at least 2 months).

• Morning stiffness less than 15 min.
• No discomfort.
• No joint pain.
• No pain in joints when moving.
• No swelling of joints.
• ESR less than 50 mm/h in women and <20 mm/h in men.

According to the criteria of the European League Against Rheumatism.

• The DAS28 index value is less than 2.6.

According to FDA criteria.

• Clinical remission according to the criteria of the American College of Rheumatology and the absence of progression of joint destruction according to radiological signs (according to the Larsen or Sharp index) for 6 months without taking DMARDs (remission).
• Clinical remission according to the criteria of the American College of Rheumatology and the absence of progression of joint destruction according to radiological signs (according to the Larsen or Sharp index) for 6 months during treatment with DMARDs (complete clinical remission).
• Improvement in ACR70 levels for at least 6 subsequent months (clinical effect).
• Inflammatory activity usually correlates with the development of joint destruction, but in some patients, against the background of treatment with standard DMARDs, progression of the erosive process in the joints is observed even with low inflammatory activity and even during the period of clinical remission.

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

Indications for hospitalization

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

• To clarify the diagnosis and assess the prognosis.
• For selection of DMARDs at the beginning and throughout the course of the disease.
• In case of exacerbation of RA.
• In the development of severe systemic manifestations of RA.
• In case of intercurrent disease, septic arthritis or other severe complications of the disease or drug therapy.

What are the goals of rheumatoid arthritis treatment?

• Suppression of arthritis symptoms and extra-articular manifestations.
• Prevention of destruction, dysfunction and deformation of joints.
• Maintaining (improving) the quality of life of patients.
• Achieving remission of the disease.
• Reducing the risk of developing comorbid diseases.
• Increase in life expectancy (to the population level).

Non-drug treatment for rheumatoid arthritis

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

In the absence of serious joint deformations, patients continue to work, but significant physical activity is contraindicated. Patients should avoid factors that can potentially provoke an exacerbation of the disease (intercurrent infections, stress, etc.). It is recommended to stop smoking and limit alcohol consumption.

Maintaining an ideal body weight helps reduce the load on joints and reduce the risk of death and osteoporosis. To do this, you need to follow a balanced diet, including food with a high content of polyunsaturated fatty acids (fish oil, olive oil), fruits, vegetables. Eating these products potentially reduces the intensity of inflammation.

Patient education programs (changing the stereotype of motor activity) are of great importance. Physical therapy, special exercises (1-2 times a week) aimed at strengthening muscle strength, physiotherapeutic methods (with moderate RA activity). Orthopedic methods are aimed at preventing and correcting typical joint deformations and instability of the cervical spine.

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

Throughout the entire period of the disease, active prevention and treatment of concomitant diseases, primarily 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 the correction of persistent joint deformities.

Drug treatment of rheumatoid arthritis

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

A fundamentally new direction in drug treatment of rheumatoid arthritis has become the formation of the concept of "window of opportunity". Window of opportunity is a period of time at the onset of the disease when treatment with DMARDs has the maximum anti-inflammatory and anti-destructive effect and improves the prognosis.

It has been established that patients who started receiving DMARDs early do not have an increased risk of premature death, unlike RA patients who did not receive DMARDs. The prognosis in patients with severe RA treated with DMARDs at the onset of the disease is the same as in patients with a more favorable course of the disease. It is noteworthy that treatment with DMARDs and, especially, TNF-a inhibitors can significantly reduce mortality from cardiovascular causes, as well as slow the development of osteoporosis, which leads to bone fractures.

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

• NNPV:
  • non-selective;
  • selective.
• Glucocorticosteroids.
• BPVP.
• Synthetic drugs.
• Biological preparations.

The basis of treatment is considered to be drug therapy with DMARDs. Treatment of rheumatoid arthritis should be started as early as possible, preferably within the first 3 months from the onset of the disease. Therapy should be as active and flexible as possible with changes (if necessary) in the treatment regimen depending on the dynamics of clinical symptoms and laboratory signs of inflammation. When choosing DMARDs, it is necessary to take into account risk factors.

Nonsteroidal anti-inflammatory drugs

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

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

Treatment of rheumatoid arthritis with NSAIDs must be combined with the administration of DMARDs, since the frequency of remission development with NSAID monotherapy is significantly lower than with treatment with any DMARD.

Glucocorticoids

The use of low-dose GCs (prednisolone <10 mg/day) allows effective control of clinical manifestations of RA associated with joint inflammation. Early rheumatoid arthritis treatment with glucocorticosteroids (in combination with DMARDs) has a more pronounced clinical effect (according to the criteria of the American College of Rheumatology) and more often leads to the development of stable remission than monotherapy with DMARDs. GCs can potentially enhance the effect of DMARDs in slowing the progression of joint destruction in early RA. Moreover, the effect of GCs persists after their use is stopped.

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

When prescribing GC for RA, it should be remembered that their use 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 effects (for example, severe damage to the gastrointestinal tract, penis and other organs) occur less frequently than when treating with NSAIDs and NSAIDs. In addition, effective preventive measures have been developed to prevent some undesirable effects (for example, glucocorticoid osteoporosis).

Indications for the use of low doses of GC.

• Suppression of joint inflammation before the onset of action of DMARDs (“bridge” therapy).
• Suppression of joint inflammation during exacerbation of the disease or development of complications of DMARD treatment.
• Ineffectiveness of NSAIDs and DMARDs.
• Contraindications to the use of NSAIDs (for example, in elderly people with a history of ulcers and/or impaired functions of the liver).
• Achieving remission in some types of RA (for example, in seronegative RA in the elderly, resembling polymyalgia rheumatica).

Medium and high oral doses of GC (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 (exudative serositis, hemolytic anemia, cutaneous vasculitis, fever, etc.), as well as special forms of the disease (Felty's syndrome, Still's syndrome in adults). The duration of treatment is determined by the time required to suppress symptoms. The course is usually 4-6 weeks, after which the dose is gradually reduced and treatment with low doses of GC is switched to.

Routine use of GC in RA is not recommended. Drugs of this group should be prescribed by a rheumatologist.

Pulse therapy of GC is used in patients with severe systemic manifestations of RA. This method allows achieving rapid (within 24 hours), but short-term suppression of joint inflammation activity.

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

Local (intra-articular) administration of GC in combination with DMARDs effectively suppresses joint inflammation at the onset of the disease or during an exacerbation of the process, but does not affect the progression of joint destruction. General recommendations should be followed when conducting local therapy.

Biological therapy

In patients with persistent and/or erosive arthritis, treatment of rheumatoid arthritis with DMARDs should be started as early as possible (within 3 months from the onset of disease symptoms), even if they do not formally meet the diagnostic criteria for RA (undifferentiated arthritis). Early treatment with DMARDs improves the patient's condition and slows down the progression of joint destruction. Late administration of DMARDs (3-6 months from the onset of the disease) reduces the effectiveness of ionotherapy. The longer the duration of the disease, the lower the effectiveness of DMARDs. In undifferentiated arthritis, the administration of methotrexate reduces the risk of transformation of the disease into definitive RA, especially in patients whose blood contains anti-CCP antibodies.

During treatment, it is necessary to carefully assess the dynamics of disease activity (DAS index) at least once every 3 months. Correct selection of DMARDs depending on disease activity significantly increases the effectiveness of treatment for early RA.

DMARDs should be continued even if the disease activity decreases and remission is achieved, since drug withdrawal often leads to exacerbation and progression of destructive changes in the joints. When remission is achieved, the DMARD dose can be reduced if this does not result in an exacerbation.

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

The efficacy and toxicity of DMARDs may be affected by other drugs. These interactions should be taken into account when administering treatment.

Women of childbearing potential taking DMARDs should use contraception and carefully plan pregnancy, as these drugs should be used with particular caution during pregnancy and lactation.

[ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ]

Combination treatment of rheumatoid arthritis with DMARDs

There are three main treatment regimens used.

• Monotherapy followed by the administration of one or more DMARDs (over 8-12 weeks) while maintaining the activity of the process (step-up).
• Combination therapy with subsequent transfer to monotherapy (after 3-12 months) when the activity of the process is suppressed (step-down).
• Combination therapy throughout the entire period of the disease.
• Methotrexate is considered the main drug in combination therapy.

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Biological drugs

Despite the fact that treatment with standard DMARDs in the most effective and tolerable doses starting from the earliest stage of the disease can improve the immediate (symptom relief) and remote (reduced risk of disability) prognosis in many patients, the results of RA treatment are generally unsatisfactory. Treatment of rheumatoid arthritis with standard DMARDs has certain limitations and disadvantages. These include difficulties in predicting the effectiveness and toxicity of DMARDs, the rarity of achieving disease remission (even with early treatment), and the development of exacerbation after stopping the drug. Against the background of DMARD treatment, joint destruction can progress, despite a decrease in the inflammatory activity of the disease and even the development of remission. These drugs often cause side effects that limit the possibility of using these drugs in doses necessary for achieving a stable clinical effect.

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

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

The main indications for prescribing TNF-a inhibitors (infliximab and adalimumab) are considered to be inefficiency (preservation of inflammatory activity) or intolerance to methotrexate (as well as leflunomide) in the most effective and tolerable dose. There are data, which, however, require further confirmation, on the effectiveness of combined therapy with infliximab and leflunomide in patients with insufficient effectiveness of ionotherapy with leflunomide. It should be especially emphasized that, despite the fact that combined therapy with methotrexate and TNF-a inhibitors is highly effective (compared to standard DMARDs), this type of treatment does not help more than 30% of patients, and only in 50% of cases can complete or partial remission be achieved. In addition, after completion of the course, patients with RA, as a rule, experience an exacerbation. All of this taken together, as well as the fact that the use of TNF-a inhibitors can contribute to the development of severe side effects (the addition of tuberculosis, opportunistic infections and other diseases), served as the basis for the use of rituximab for the treatment of RA.

Treatment of rheumatoid arthritis depends to some extent on both the duration and 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 arthritis symptoms) no erosions are detected in the joints (in most patients), while the probability of developing clinical remission is high. Quite often, patients do not have a sufficient number of RA criteria, and the disease is classified as undifferentiated arthritis. It should be emphasized that patients with undifferentiated arthritis have a high frequency (13-55%) of spontaneous remissions (disappearance of symptoms without treatment). In this case, the development of spontaneous remission is associated with the absence of anti-CCP antibodies. At the same time, in patients with reliable early RA, spontaneous remissions are rare (in 10% of cases), while in this group of patients, anti-CCP antibodies are also not detected. As already noted, the administration of methotrexate to patients with anti-CCP-positive undifferentiated arthritis significantly reduces the risk of its transformation into reliable RA. There is evidence that in patients with early RA, when markers of an unfavorable prognosis are identified, it is advisable to begin treatment with the prescription of combination therapy with methotrexate and infliximab.

The advanced stage is usually observed when the disease lasts more than 12 months. It is characterized in most cases by the typical clinical picture of RA, gradual development of the erosive process in the joints and progression of functional disorders.

The vast majority of patients require continuous treatment of rheumatoid arthritis with effective doses of DMARDs even at low disease activity. It is often necessary to change DMARDs, prescribe combined treatment of rheumatoid arthritis, including the use of biological agents. To prevent exacerbations, NSAIDs, GC for systemic and local use can be re-prescribed.

Late stage manifestations are usually observed when the disease lasts more than 5 years (sometimes less). Late stage RA is characterized by significant destruction of small (X-ray stage III-IV) and large joints with severe impairment of their functions, development of complications (tunnel syndromes, aseptic bone necrosis, secondary amyloidosis). In this case, inflammatory activity may subside. Due to persistent joint deformation, mechanical pain, the role of orthotics and orthopedic methods in the treatment of RA at this stage increases. Patients should be regularly examined to actively identify complications of the disease (in particular, secondary amyloidosis).

It is reasonable to consider a patient resistant to treatment if treatment with at least two standard DMARDs in the maximum recommended doses (methotrexate 15-20 mg/week, sulfasalazine 2 g/day, leflunomide 20 mg/day) was ineffective (lack of 20 and 50% improvement according to the criteria of the American College of Rheumatology). Ineffectiveness can be primary and secondary (occurring after a period of satisfactory response to therapy or when the drug is re-administered). To overcome resistance, low doses of GCs, combination therapy with standard DMARDs and biological agents are used, and in case of ineffectiveness or detection of contraindications to their use, second-line DMARDs are used.

[ 18 ], [ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ]

Treatment of Felty's syndrome

Special criteria have been developed to assess the effectiveness of treatment for Felty's syndrome.

Criteria for good treatment effectiveness.

• An increase in the number of granulocytes to 2000/mm3 or more.
• Reduction in 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's syndrome are parenteral gold salts, and if methotrexate (leflunomide and cyclosporine) is ineffective. The tactics of their use are the same as for other forms of RA. Monotherapy with GC (more than 30 mg / day) leads only to temporary correction of granulocytopenia, which recurs after reducing the dose of the drug, and an increased risk of infectious complications. Patients with agranulocytosis are prescribed pulse therapy with GC according to the usual scheme. Data on rapid normalization of the granulocyte level against the background of the use of granulocyte-macrophage or granulocyte colony-stimulating factors have been obtained. However, their administration is accompanied by side effects (leukocytoclastic vasculitis, anemia, thrombocytopenia, bone pain) and exacerbations 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 mcg/kg per day) in combination with a short course of GC (prednisolone at a dose of 0.3-0.5 mg/kg). In severe neutropenia (less than 0.2x 109/l), treatment with granulocyte-macrophage colony-stimulating factor is carried out for a long time at the minimum effective dose necessary to maintain the number of neutrophils >1000/mm3.

Although splenectomy results in rapid (within hours) correction of hematological disorders, it is currently recommended only for patients resistant to standard therapy. This is due to the fact that a quarter of patients experience recurrent granulocytopenia, and 26-60% of patients experience recurrent infectious complications.

Blood transfusion is not recommended except in cases of very severe anemia associated with cardiovascular risk. The effectiveness of epoetin beta (erythropoietin) has not been proven. It is recommended to use it only before surgery (if necessary).

Treatment of amyloidosis

There is evidence of some clinical efficacy of cyclophosphamide, chlorambucil, GC and especially infliximab.

Treatment of infectious complications

RA is characterized by an increased risk of infectious complications localized in bones, joints, the respiratory system, and soft tissues. In addition, many drugs used to treat the disease (NSAIDs, DMARDs, and especially GCs) can increase the risk of 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 considered to be:

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

Patients with RA are highly susceptible to developing septic arthritis. The characteristics of septic arthritis in RA include involvement of multiple joints and a typical course in patients receiving glucocorticosteroids.

Treatment of cardiovascular complications in patients with RA (including undifferentiated arthritis) has a higher risk of developing cardiovascular diseases (acute MI, stroke), so they should undergo an examination to assess the risk of developing this pathology.

Treatment of osteoporosis

Osteoporosis is a common complication of RA. Osteoporosis can be associated with both the inflammatory activity of the disease itself and physical activity impairment, as well as with treatment, primarily GC. Osteoporosis prevention should be carried out in the following categories of patients:

• receiving GC;
• with a history of non-traumatic skeletal fractures;
• over 65 years old.

In patients with risk factors for osteoporosis and receiving GC, BMD should be determined annually.

The main drugs for the prevention and treatment of osteoporosis, including glucocorticoid osteoporosis, are bisphosphonates. In case of intolerance to bisphosphonates, strontium ranelagh can be used. Calcitonin (200 IU/day) is indicated for severe pain associated with compression fractures of the vertebrae. All patients are prescribed combination therapy with calcium (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 correcting functional disorders at a late stage of the disease. Application at an early stage of RA in the vast majority of cases is inappropriate due to the wide possibilities of drug therapy. At an advanced stage of the disease, the need for surgical treatment is determined individually when establishing indications.

Indications for surgery

• Nerve compression due to synovitis or tenosynovitis.
• Threatened or accomplished rupture of the tendon.
• Atlantoaxial subluxation accompanied by the appearance of neurological symptoms.
• Deformations that make it difficult to perform simple everyday activities.
• Severe ankylosis or dislocation of the lower jaw.
• The occurrence of bursitis, which impairs the patient's ability to work, as well as rheumatic nodules, which tend to ulcerate.

Relative indications for surgery.

• Drug-resistant synovitis, tenosynovitis or bursitis.
• Severe pain in the joints.
• Significant limitation of movement in the joint.
• Severe joint deformation.

Endoprosthetics is the main method of treatment for deformations of the hip and knee joints, as well as the joints of the fingers. Synovectomy (recently performed mainly in small joints) and tenosynovectomy are also used. Arthroscopic synovectomy is becoming more widespread, but the long-term results have not yet been studied. Bone resections and arthroplasty (used mainly on the joints of the table) are performed. Arthrodesis can be the method of choice for severe deformation of the ankle, first metatarsophalangeal and wrist joints.

What should a patient know about rheumatoid arthritis treatment?

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

Drug therapy is considered the main method of treating RA. This is the only way to slow down the development of the inflammatory process and maintain mobility in the joints. Other treatment methods: physiotherapy, diet, exercise therapy are of secondary importance and are not able to have a significant impact on the course of the disease.

The treatment of RA is based on the use of DMARDs. These include a large number of drugs with various chemical structures 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. A 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. Biological drugs include infliximab, rituximab, adalimumab.

Rheumatoid arthritis treatment usually begins with methotrexate or leflunomide. Biological agents (infliximab, adalimumab and rituximab) are usually added to these drugs when ionotherapy is ineffective. GCs can provide a rapid anti-inflammatory effect. NSAIDs are an important component of RA treatment, as they can reduce pain and stiffness in the joints. The most commonly used are diclofenac, nimesulide, meloxicam, ketoprofen, celecoxib.

Rheumatoid arthritis treatment with drugs can give very good results, but requires careful monitoring. Monitoring should be carried out by a qualified rheumatologist and the patient himself. The patient must visit the doctor at least once every 3 months at the beginning of treatment. In addition to examination, blood tests are prescribed, an X-ray examination of the joints is carried out annually to assess the course of the disease. It is necessary to remember the restrictions associated with treatment against the background of methotrexate and leflunomide therapy not

Approximate periods of incapacity for work

Temporary disability may occur with RA with moderate and high activity and persist for the period of development of the clinical effect of drug treatment. Patients lose their ability to work and become disabled due to joint dysfunction during the first 5 years of the disease in 50% of cases. With a disease duration of more than 15 years, 80% of patients are recognized as disabled in groups I and II.

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

[ 24 ], [ 25 ], [ 26 ]

Forecast

And at the end of the 20th century, on average, about half of the patients lost their ability to work during the first 10 years; by the 15th year of the disease, approximately 80% of patients became disabled of groups I and II. In patients with RA, a decrease in life expectancy was observed compared to the general population by 5-10 years. The most common causes of death were cardiovascular diseases (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. Fatal outcomes due to secondary amyloidosis were often observed. concomitant infections (pneumonia, suppuration of soft tissues, etc.).

Modern active treatment, especially at an early stage of rheumatoid arthritis, allows to significantly improve the results in maintaining working capacity, achieve clinical remission in 40-50% of patients, and bring life expectancy to the population level.

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