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类风湿性关节炎

  • 类风湿性关节炎
  • 病因 基因与环境因素
  • 症状
    • 关节发热、肿胀和疼痛
    • 休息后恶化
  • 并发症
    • 可能导致低红血球细胞、肺部炎症、和心脏炎症。
    • 可能会发烧和缺乏活力。
  • 治疗
    • 主要针对改善疼痛、减少发炎以及改善全身机能。
    • 适当的休息及运动、使用夹板及背带或辅具等皆能帮助治疗改善。
    • 使用止痛剂、类固醇、非类固醇抗发炎药物来缓解症状
    • 疾病调节抗风湿药物(DMARD,包括羟氯喹、氨甲蝶呤等)亦可用来控制减缓病程,通常是在其他疗程对病人无效时才会使用到此类药物,然而此类药物相较于其他疗程也可能对病人造成较大的副作用。
  • 阶段
    • initiation phase (due to non-specific inflammation)
    • amplification phase (due to T cell activation)
    • chronic inflammatory phase, with tissue injury resulting from the cytokines, IL–1, TNF-alpha and IL–6
  • 参考

处理#

生活习惯#

  • 规律的运动能维持肌肉力量和生理机能
    • 目前暂无证据表明运动对长期治疗有害
  • Moderate effects have been found for aerobic exercises and resistance training on cardiovascular fitness and muscle strength in RA.
  • 专业的康复治理师能对病情有所帮助

药物抑制#

  • Disease-modifying antirheumatic drugs (DMARDs) are the primary treatment for RA.

  • DMARD 抗风湿药

  • 药物主要能改善症状、减轻关节损伤、提升整体机能

  • 主要药物 methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, TNF-alpha inhibitors (certolizumab, infliximab and etanercept), abatacept, and anakinra. Rituximab and tocilizumab are monoclonal antibodies and are also DMARDs.

  • Hydroxychloroquine - 羟氯喹

    • 毒性最轻 - considered effective in the moderate RA treatment
  • 最常用的是 methotrexate - 其次是 sulfasalazine and leflunomide

  • Leflunomide is effective when used from 6–12 months, with similar effectiveness to methotrexate when used for 2 years.

  • Sulfasalazine also appears to be most effective in the short-term treatment of rheumatoid arthritis.

Sodium aurothiomalate (gold) and cyclosporin are less commonly used due to more common adverse effects. However, cyclosporin was found to be effective in the progressive RA when used up to one year.

Agents may be used in combinations however, people may experience greater side effects.[8][92] Methotrexate is the most important and useful DMARD and is usually the first treatment.

  • 药物共用则会导致额更多的副作用
  • Methotrexate 最为重要,通常用于初次治疗。
  • A combined approach with methotrexate and biologics improves ACR50, HAQ scores and RA remission rates.
  • Triple therapy consisting of methotrexate, sulfasalazine and hydroxychloroquine may also effectively control disease activity.
  • 应定期监测不良反应的毒性,包括胃肠道,血液,肺和肝
  • 服用叶酸可以减轻恶心,呕吐或腹痛等副作用。

2015 年 Cochrane 发现 rituximab 配合 methotrexate 能更有效的改善病情。效果比单独使用 methotrexate 更好

Rituximab works by decreasing levels of B-cells (immune cell that is involved in inflammation). People taking rituximab had improved pain, function, reduced disease activity and reduced joint damage based on x-ray images. After 6 months, 21% more people had improvement in their symptoms using rituximab and methotrexate.

抗炎镇痛药#

  • Glucocorticoids can be used in the short term and at the lowest dose possible for flare-ups and while waiting for slow-onset drugs to take effect.
  • Combination of glucocorticoids and conventional therapy has shown a decrease in rate of erosion of bones. Steroids may be injected into affected joints during the initial period of RA, prior to the use of DMARDs or oral steroids.

手术#

  • 主要针对受影响的手指、手、手腕
  • 当药物无效的时候可能需要滑膜切除来避免疼痛或肌腱破裂
  • 受影响的关节可以就行关节替换,例如膝

理疗#

  • 药物治疗通常需要配合理疗 - 冷热、电子刺激、水疗
  • 理疗可有效改善心血管健康,肌肉力量并维持长期的积极生活方式。
  • 根据公共卫生建议进行体育锻炼应该成为 RA 和其他关节炎疾病患者标准治疗的组成部分。

替代药物#

疫苗接种#

患有 RA 的人感染和死亡的风险增加,建议接种疫苗可以降低这些风险。应每年接种灭活的流感疫苗。对于 65 岁以下的人应接种两次肺炎球菌疫苗,对于 65 岁以上的人应接种一次。 减毒的带状疱疹疫苗应在 60 岁以后服用一次,但不建议使用肿瘤坏死因子 α 受体阻滞剂的患者服用。