In 2017, the first Russian biological drug will enter the pharmaceutical market, intended for the treatment of severe forms of rheumatoid arthritis, for which standard therapy has proven powerless.

About 1% of the inhabitants of our planet know firsthand about rheumatoid arthritis. Severe joint pain, accompanied by inflammation and subsequent destruction of joints and bones, is what awaits every sick person.

Normally, our body fights against foreign agents: bacteria, viruses. But if disturbances occur in the immune system, the body begins to produce antibodies to its own cells and organs. So, with rheumatoid arthritis, antibodies begin to work against their own structural elements joint: synovial membrane, articular surfaces, cartilage, bone.

Rheumatoid arthritis can begin with symptoms such as malaise, weakness, low-grade fever, decreased appetite, weight loss, and stiffness in the morning. Stiffness is manifested by difficulty in the first movements immediately after the period of awakening and limitation of movements in one, and more often in several joints. As the disease progresses, even the most familiar housework becomes a challenge. Symptoms worsen over weeks, months, and even years. Recognizing the onset of the disease is difficult. Often the doctor is dealing with an already progressive disease. Actually, inflammation begins, as a rule, in the small joints of the hands and feet, affects symmetrical joints, and spreads over time to the elbows, shoulders, knees and other joints. Inflammation in the joints is accompanied by the accumulation of synovial fluid in them, which is externally manifested by swelling and pain. The disease is chronic in nature with periods of exacerbations.

The new drug is also effective for severe chronic inflammatory bowel diseases, ankylosing spondylitis and psoriasis. This is a bioanalogue of the imported biological drug Remicade (infliximab). It was completely created in Russia: from the substance to the finished dosage form. The total investment of the domestic company BIOCAD in the development will be about $15 million. According to experts, the addition of infliximab to standard therapy for rheumatoid arthritis and other diseases mentioned above can achieve remission in almost 50% of patients who were not helped by standard treatment. However, in Russia, only about 10% of patients with rheumatoid arthritis receive biological drugs, including infliximab. In 2014, according to Headway, the state purchased 75,000 vials of infliximab. This volume is enough for 2800 patients with rheumatoid arthritis. However, the real need is much higher. According to experts, there are about 140,000-150,000 patients in Russia. Today, the weighted average market price for one 100 mg package of infliximab is about 40,000 rubles. For one infusion (injection), the patient needs an average of four bottles. And over the course of a year, the patient must receive nine such infusions. As a result, the cost of annual treatment for just one patient is almost 1.5 million rubles. And if there are 150,000 such patients, then the amount turns out to be unaffordable for the healthcare system. In Europe, they are now actively implementing a strategy to replace expensive and inaccessible original biological drugs with biosimilars. According to Datamonitor, the global market for this class of drugs grows by 18-20% annually. The cost of biosimilars is much lower, and in terms of quality and effectiveness, subject to the necessary European standards, they are not inferior to original drugs. Russian companies from Novaya Pharma follow the same approach. Thus, the domestic biosimilar of infliximab produced by BIOCAD will cost at least 15% less than the registered price of the original drug. As a result, the state will be able to significantly increase the volume of purchases of infliximab and more Russian patients will receive the modern drug. The transition to domestically produced biosimilars is the most effective way to get rid of import dependence. And now there is a turning point towards Russian pharmaceutical companies. Thus, the share of domestic drugs in the volume of purchases under the most expensive state program “7 high-cost nosologies” in value terms increases every year. In 2012 it was only 9%, and in 2014 it was already 27%. Three times the growth. Experts expect that a biosimilar of infliximab will occupy at least 50% of the current market volume.

“The domestic medicine will be completely produced in Russia: from the substance to the finished dosage form,” says general manager BIOCAD company Dmitry Morozov. “Therefore, its price will not depend on currency fluctuations and the geopolitical situation.”

A biosimilar of infliximab is currently undergoing an international multicenter clinical trial among patients with ankylosing spondylitis. The trial design was built in accordance with the recommendations of the European Medicines Agency (EMA) for clinical trials of biosimilars of monoclonal antibody drugs. An analysis of the equivalence of the biosimilar to the original imported drug will be carried out in terms of safety, efficacy, pharmacokinetics and immunogenicity. The study will last two years and will be carried out in Russia, Belarus and Ukraine. The trial will involve the largest medical centers: Research Institute of Rheumatology named after V.A. Nasonova RAMS (Moscow), North-Western State Medical University named after I.I. Mechnikov (St. Petersburg), Research Institute of Clinical Immunology" of the Siberian Branch of the Russian Academy of Medical Sciences (Novosibirsk) and a number of other accredited regional research centers. The progress of the study is presented in more detail on the website of the U.S. International Clinical Trials Registry. National Institutes of Health number NCT02359903. ETH Zurich specialists, working on the problem of rheumatoid arthritis, have developed a new drug that was tested on experimental animals - mice. Scientists managed to completely rid them of the disease.

The active ingredients of the medicine are two components. One of them is interleukin-4. This substance is an immune agent that is found in the body. In case of damage to cartilage and bone tissue by rheumatoid arthritis, interleukin-4 acts as their protector. The second component is an antibody that binds to the protein of the inflamed tissue.

Thanks to the antibody, interleukin-4 is delivered directly to tissues affected by rheumatoid arthritis, which not only allows for the most effective impact on the site of inflammation, but also reduces the risk of side effects. The effect of the mixture was studied both separately and in combination with dexamethasone. The drugs were administered when the first signs of the disease appeared in mice.

In the case of “isolated” use of drugs, the disease developed noticeably more slowly. With combined treatment, the work of rodents returned to normal. immune system and all the symptoms of rheumatoid arthritis disappeared within a few days. Scientists hope that clinical trials will take place in humans this year.

To diagnose rheumatoid arthritis, a complex of symptoms is assessed. These are both clinical symptoms and laboratory indicators. In the blood of most patients, rheumatoid factor and inflammatory factors are determined: C-reactive protein, accelerated ESR. To diagnose the disease, both ultrasound and x-ray examination joints.

If the disease is not recognized and treated, it inevitably leads to immobility and disability. The disease can be brought under control, pain can be reduced, the processes of inflammation and joint destruction can be stopped, and exacerbations and complications can be prevented.

A rheumatologist will be able to select individual therapy that is adequate for a given patient. You should know that therapy for rheumatoid arthritis is divided into basic and symptomatic. Symptomatic therapy helps to quickly relieve inflammation and pain. But basic therapy is extremely important, which affects the pathogenesis of the disease, blocks autoimmune disorders, prevents destruction of joints, and slows down the progression of the disease. Basic therapy should be long-term and should be carried out under the supervision of a physician. And although there is no universal remedy yet to help completely get rid of the disease, new groups of drugs have now appeared that are used in basic therapy and have a positive effect.

A patient with rheumatoid arthritis also needs to learn appropriate motor activity, rational load on the hands. Be sure to engage in physical therapy and exercise. Calcium and vitamin D3 supplements, as well as chondroprotectors, are auxiliary in treatment. There is no special diet for patients with rheumatoid arthritis, but you need to pay attention to your diet. You should limit sweets, flour, fatty, smoked foods, and reorient yourself to dairy products, cereals, vegetables, fruits, and fish. Foods rich in omega-3 acids are beneficial. These are fatty fish (salmon, trout, salmon), vegetable oils.

Rheumatoid arthritis belongs to systemic diseases that affect connective tissue. This is a chronic infectious-inflammatory process that primarily affects the synovial membrane of peripheral joints. The disease is progressive and over time can lead to complete immobility of the joint. This is also an autoimmune pathology, in which the defense system does not distinguish its own cells from foreign ones and begins to act aggressively towards native microorganisms.

Treatments for rheumatoid arthritis include:

• orthopedic treatment;
• medicines;
• physical education;
• rehabilitation;
• lifestyle change.

An integrated approach is used, which involves:

1. carrying out basic therapy;

2. taking several types of anti-inflammatory drugs;

3. mechanical, physical, physiotherapeutic and local treatment;

4. changes in diet.

Use of medications

Main directions:

• blocking the production of mediators that provoke inflammatory processes;
• suppression of immune system activity.

Drugs from the following list are used to treat rheumatoid arthritis in traditional therapy:

1. Anti-inflammatory - NSAIDs, which include Diclofenac sodium, Ibuprofen and Naproxen. These medications suppress the activity of COX, relieving pain and symptoms of inflammation.

2. Basic or modifiers of the course of the disease. Their action is designed for the future. They are not capable of quick results. The effect of their use becomes noticeable after about a month. These include gold salts, antimalarial, antimicrobial drugs such as Sulfasalazine, as well as cytostatics and D-penicillamine.

3. Complex drugs selectively inhibit COX-2, reducing the side effects of NSAIDs, for example, Meloxicam. These include those that eliminate inflammation and generally influence the development of the disease - Tenidap.

4. Glucocorticoids for oral administration in small doses relieve inflammation and prevent destructive processes in the bones. Similar medications, but for intra-articular administration, quickly eliminate inflammation where system tools can't help. These include Prednisolone and Dexamethasone.

Treatment of arthritis in any category of patients usually begins with the prescription of NSAIDs. This is done if the disease occurs in an intra-articular form with average or minimal activity. If an aggressive course of the disease is noted, then preference should be given to cytotoxic immunosuppressants.

The new generation of drugs includes:

• synthetic basic anti-inflammatory drugs;
• taking glucocorticoids;
• non-steroidal anti-inflammatory drugs;
• antibacterial therapy.

New methods will be effective only if an integrated approach is used. Medicines are selected individually, doctors take into account contraindications for each individual patient.

Latest technologies

New generation drugs that are used today to treat arthritis can be divided into two main groups:

• anti-inflammatory;
• basic.

Anti-inflammatory drugs are intended to quickly eliminate pain syndrome in the affected joints and other signs of the disease. This treatment is symptomatic. Basic drugs are designed to slow down the spread of the pathological process and gradually transfer it into a state of remission. Such medications have the ability to suppress the aggression of the immune system and directly influence the mechanism of disease development.

The outdated ones, which worked slowly and had many side effects, were replaced by a new generation of drugs - biological agents. The effects of these genetically engineered drugs are based on the principle of suppressing the production of cytokines by cells. They are the ones responsible for development inflammatory process and the occurrence of erosive lesions of articular tissue. The main advantage of biological agents is that they affect only one group of components of the immune system, without interfering with all other mechanisms. They allow you to get a positive result much faster, about a few weeks after you start taking it, and their effect is more pronounced.

New genetic engineering products also include products with monoclonal antibodies to the surface receptors of B-lymphocytes. It is these cells that are responsible for the inflammatory processes and joint destruction that occur in rheumatoid arthritis. That is, medications suppress the production of cytokines at the earliest stage of their formation.

Description of drugs

Products based on biological agents are divided into several types, depending on their mechanism of action. The new generation list includes:

• Suppressing interleukin-1. These include the famous Kinneret, whose second name is Anakinra.
• TNF blockers or beta blockers. Remicade (Infliximab), Enbrel (Etanercept) and Humira (Adalimumab) have proven themselves well.
• Interfering with the work of B-lymphocytes - Rituxan (Rituximab).
• Medicines that suppress the activation of immune T cells - Orence (Abatacept).

1. Kinneret.

This is a new biological medicine that helps treat severe arthritis. The mechanism of action is based on the inhibition of a special signaling protein called interleukin-1, which is responsible for activating the inflammatory process in joint tissue.

2. Remicade.

Refers to fast-acting basic drugs. It is used for active and severe progressive forms of rheumatoid arthritis. Remicade is a chimeric compound based on hybrid human and mouse IgG1 monoclonal antibodies. They begin to use it after other basic means have proven ineffective. It is also necessary to be careful before taking it to find out whether all infections in the patient have been cured. Otherwise, they may worsen, leading to the development of sepsis. During Remicade therapy, it is necessary to simultaneously treat with antihistamines.

3. Enbrel.

It is a cytokine inhibitor that stimulates pathological processes. Its use allows you to achieve stable remission in the treatment of autoimmune diseases by suppressing inflammation.

4. Humira.

It is a selective immunosuppressant based on a recombinant monoclonal antibody, the amino acid sequence of which is completely identical to human IgG1. The drug treats moderate and severe forms. It is usually combined with other basic anti-inflammatory drugs.

5. Rituxan.

Contains antibodies that reduce the number of lymphocytes that provoke the inflammatory process. The description says that the medicine does not affect the functions of the human immune system. Taking the medication allows you to achieve stable remission.

6. Orentia.

It is a selective modulator of T-cell costimulation. It blocks T-lymphocytes and is used if the body resists the action of drugs belonging to basic monotherapy.

Today, even in the most severe cases, one can expect, if not a complete recovery, then a significant improvement. Medicines used to treat arthritis help restore joint function in whole or in part. Studies have shown that approximately a third of patients taking biological agents experience sustained remission.

Today, doctors cannot clearly say what causes rheumatoid arthritis, and what factor is the most important.

Scientists and doctors in many countries are studying the synovial fluid of the joints, and developing new methods for treating this disease that meet the medical standard.

It is known that rheumatoid arthritis affects the synovial membrane that surrounds the joint, and its properties are completely disrupted. This disease is autoimmune and has a chronic form.

Treatment of rheumatoid arthritis must be carried out comprehensively, using medications. The doctor selects them based on the reasons that caused the joint disease, its severity, and also in order to prevent its exacerbation in the future.

The main purpose of prescribing medications is to reduce the progression of arthritis and, if possible, restore the functioning of the patient's joints.

Medications

Treatment of rheumatoid arthritis is carried out with the following types of drugs:

• anti-inflammatory;
• basic;
• complex;
• glucocorticoids taken orally;
• glucocorticoids injected into the joints.

Anti-inflammatory drugs include non-steroidal drugs, the intake of which suppresses the activity of special enzymes, the main function of which is the synthesis of arachidonic acid.

Among the drugs, the most commonly used ones can be identified: diclofenac sodium, ibuprofen, piroxicam, naproxen, all of which form the standard of treatment at the initial stage.

The actions of basic drugs are aimed at eliminating the manifestation of the disease in the future and the occurrence of complications. Their reception is not intended for several weeks.

After a course of taking the drugs, the patient will feel the effect. Such drugs include:

1. gold salts,
2. antimalarial drugs,
3. sulfasalazine.

Complex drugs are taken to produce selective COX-2 inhibitors by the body, as well as to reduce the inflammatory effect and to modify the course of the disease; they must exclude rheumatoid factor.

Glucocorticoids taken orally reduce the intensity of the inflammatory process and reduce the likelihood of changes in the structure of joints and bone tissue due to the disease.

Drugs injected into joints provide fast action, which is aimed locally at the joint to relieve inflammation and pain. The standard here could be in the form of an injection into knee joint, as an example.

Drug therapy begins with taking non-steroidal anti-inflammatory drugs (NSAIDs), these can be either tablets or. They are used to reduce the manifestation of a disease that is mild or moderate in severity. The dose of these medications is selected based on a number of features.

When selecting a dose, factors such as:

1. patient's age,
2. individual tolerance of the drug,
3. severity of the disease.

In severe cases of the disease and its extra-articular manifestations, the doctor may recommend taking cytotoxic immunosuppressants, which also take into account the rheumatoid factor.

Description and properties of drugs

Methotrexate

Patients taking methotrexate note a positive factor - the rapid action of the drug. The effect of taking the medication was noted within 1.5-2 months from the start of the course. Methotrexant has a low level of toxicity, is easy to use, and has a low cost, the latter also important factor its choice by patients.

This drug is generally well tolerated by patients and causes virtually no side effects. To achieve the effect, it is enough to use 10 ml of the medicine once a week.

Important! Methotrexate should not be taken simultaneously with drugs that have an anti-inflammatory effect.

On the day you take methotrexate, you must stop the dose of the anti-inflammatory drug.

Gold salts

Treatment of rheumatoid arthritis with drugs containing gold ions has been used for many decades. The first information about this method of treatment appeared in the late 20s of the last century.

The most commonly used medications for treating arthritis include:

• auronafin;
• aurothiomalate;
• Tauredon.

These drugs are recommended for patients with the initial stage of the disease or in cases where arthritis progresses quite quickly. Medicines containing gold help cope with the symptoms of the disease and restore joint mobility. It is eliminated to some extent, and rheumatoid factor can be said to be the “golden” standard in treatment.”

For a long time, medicines containing gold were leaders in the treatment of rheumatoid arthritis; they were truly accepted as the standard.

Only after the advent of methotrexate did they somewhat lose their popularity. But at the same time, many patients prefer these drugs, which have a wide spectrum of action, and their effectiveness plays an important role.

In addition, gold-based medications are used to relieve pain caused by bone erosion if rheumatoid factor is increased in the blood. Their action is quite effective in the treatment of seropositive arthritis.

In seronegative arthritis, when the rheumatoid factor is normal, treatment with such drugs may be ineffective.

The positive properties of gold-based drugs include high antibacterial and antifungal properties, which reduce the manifestations of gastric ulcers and fight gastritis.

These medications are used in the treatment oncological diseases and chronic infections.

Cytostatics

Previously, medications and immunosuppressants such as Arava, Remicade, and cyclophosphamide were used in the treatment of cancer. Later, rheumatologists began to use them in their practice to alleviate the condition of rheumatic and psoriatic arthritis.

Although about 80% of patients note a positive effect from taking such medications, they should be used with extreme caution, only after consulting a doctor. Such medications have a number of serious side effects, which, if the dosage is incorrect, can lead to irreversible consequences.

In small doses, under strict medical supervision, use medicinal product recommended for patients with severe rheumatoid arthritis that progresses rapidly.

The drug Arava has a good effect in the treatment of artiritis. This effect is comparable to that of Methotrexate and Sulfasalazine. Patients notice the first signs of improvement after two months of taking the medicine.

Afterwards, an increase in the cumulative effect is possible, which lasts up to 6 months.

Remicade

This medication is one of the latest developments in the treatment of rheumatoid arthritis. Among the positive properties of Remicade, the speed and effectiveness of action are noted.

This medicine is used when the dosage of the medicine needs to be reduced, because of side effects that occur, or when it is not working properly. internal organs. This drug can be used effectively in severe cases of the disease.

Despite the high effectiveness of the drug, it must be used in strictly limited doses, since Remicade very often causes severe adverse reactions in patients, for example, allergies. Another disadvantage is its high cost.

There are a number of contraindications to the use of the drug. These include:

• the presence of obvious or hidden infectious processes in the patient;
• pregnancy;
• breastfeeding.

There are many other medications whose composition and effect are the same as Remicade or Methotrexate. But doctors advise using them only in extreme cases, as they have severe side effects and are very difficult for patients to tolerate.

Such drugs can be prescribed only when previously prescribed drugs do not provide the required effect.

Antimalarial drugs

Studies of antimalarial drugs have shown that they not only successfully treat fever, but are also able to reduce the activity of developing rheumatoid arthritis, taking into account the fact that this is the initial factor.

These drugs, when used for a long time, reduce pain in the joints. In order for the pain to decrease or completely disappear, the course of taking antimalarial drugs ranges from 6 months to a year.

The main disadvantage of treatment with these drugs can be considered the duration of the course. These medications are the weakest of the entire list of drugs used to treat arthritis. However, despite this, these drugs are well tolerated by patients and have virtually no side effects.

Doctors identify the following antimalarial drugs that may be prescribed for the treatment of arthritis:

• delagil;
• chloroquine;
• Plaquenil;
• hingamin.

Some doctors consider treatment with antimalarial drugs to be ineffective. This is explained by the fact that there are a large number of modern drugs that can relieve joint pain in a short time.

After all, anti-malaria drugs will have an effect only after a few months. Until the effect is achieved, the patient will suffer from pain and discomfort.

It is effective to prescribe this type of medication for mild arthritis. In such cases, there is no need to prescribe stronger medications to the patient to treat this disease.

Sulfonamides

Medicines of this type are used in the basic treatment of rheumatoid arthritis. Sulfonamides are classified as antimicrobial drugs. The most commonly used drugs are sulfasalazine and salazopyridazine.

These medications are more effective than anti-malaria drugs, but are inferior to gold-based drugs and methotrexate.

It has been established that sulfonamides are well tolerated by patients and have virtually no adverse reactions. Such medications are recommended for use in the treatment of rheumatoid arthritis in children.

To achieve a sustainable effect, the course of treatment with this drug must be at least 3 months.

For treatment and further prevention of the disease, doctors recommend taking these medications for a period of 6-12 months.

D-penicillamine

Medicines of this type, which include trolovol, distamine, artamine, are prescribed to the patient in the following cases:

• gold-based drugs and methotrexone are not effective in treating the disease;
• the patient has an allergic reaction to other drugs for the treatment of rheumatoid arthritis;
• other drugs have severe side effects;

D-penicillamine has a good effect in the treatment of arthritis, but is highly toxic. This is the main reason why doctors prescribe it in extreme cases when all other treatments have been tried. This drug is prescribed when complications occur that affect the functioning of certain internal organs.

Diet and alternative treatments

A good effect in the treatment of rheumatoid arthritis is achieved by following a diet, as well as medical spa procedures such as mud baths, body wraps and treatment with leeches.

Diet for the treatment of arthritis

When researching foods that may cause arthritis flare-ups, doctors name dairy products, wheat, some vegetables, fruits and citrus fruits, meat and corn. Doctors note that there is a direct relationship between what the patient eats and the disease, which is why it is so important.

To avoid the development of the disease or its exacerbation, patients are advised to reduce the consumption of these products, and later completely abandon them. The diet should be rich in fish or seafood, pearl barley and buckwheat.

Eating food should be divided into 5-6 meals. The best way preparing steamed dishes for patients suffering from joint pain.

Sanatorium treatment

Treatment of rheumatoid arthritis in a sanatorium is its final stage. Sanatorium procedures improve general condition body, metabolism and joint condition.

In most cases, sanatorium treatment is preferable as a means of preventing exacerbations of the disease or maintaining health for people with a disability group for this type of disease.

Baths in the treatment of rheumatoid arthritis

One of the types of sanatorium treatment of the musculoskeletal system is baths with hydrogen sulfide.

It has been proven that taking such baths stimulates blood circulation, restoration of cartilage, and also activates metabolic processes in tissues and the body as a whole.

A good therapeutic effect is also observed when using baths with other components.

1. Radon baths have proven themselves in the treatment of rheumatoid arthritis. Depending on the concentration of this substance, baths are divided into weak, medium and weak. After the first procedure, patients noted a decrease in pain and improved motor activity. This effect persists even for several hours after the procedure.
2. Baths with salt. Their action is based on an effect that irritates skin receptors. Such baths help to activate the functioning of the body's systems, which in turn leads to the restoration of some body functions. After taking salt baths, the formation of new blood vessels is observed, through which oxygen is supplied to the affected areas.
3. Baths with iodine and bromine. Basically, such baths are recommended for patients with diseases thyroid gland. They also help reduce nervous tension.

Mud wraps

To relieve inflammation in the treatment of rheumatoid arthritis, mud applications are widely used. Due to the fact that they may have some side effects associated with the impact on the heart, circulatory system and lungs, wraps are done under the supervision of a doctor.

Time and concentration are calculated individually for each patient. A good effect is observed after applications with silt, ozokerite or peat mud.

Even in ancient times, leeches were used to treat rheumatoid arthritis. Their saliva contains substances such as analgesics and anesthetics, as well as hirudin, which reduces the degree of blood clotting.

When using leeches for treatment, it is possible to reduce the dose of medication, which in turn reduces side effects on the body.

Physical education for arthrosis

Moderate physical exercise has a positive effect at all stages of the disease. Physical therapy is recommended both in remission and during exacerbation. Contraindications for physical education are:

• third degree of the disease, which is characterized severe pain and the presence of purulent fluid in the joint;
• concomitant diseases such as pneumonia, pleurisy, nephritis and others;
• infectious diseases and acute conditions in diseases of internal organs.

The physical therapy exercise regimen is developed taking into account individual characteristics and severity of the disease. The exercises should be performed by the patient smoothly and effortlessly so that they do not cause pain.

Exercise therapy for arthrosis is divided into three periods:

1. Preparatory period. It usually lasts several days. During this period of time, the patient learns to perform exercises correctly and control breathing during exercise therapy.
2. The main stage of classes. This stage is designed for 1.5-2 weeks. Classes last 30-40 minutes. The exercises used help the patient strengthen the muscles and increase the range of motion of the limb.
3. The final stage of physical therapy. It is designed for several days. It is performed by the patient after discharge to consolidate the results obtained.

When treating arthrosis in pregnant women, it is necessary to prescribe therapy with extreme caution. If possible, you should stop using anti-inflammatory drugs. In some cases, the use of plaquenil is allowed.

Such drugs, such as metatrexate and leflunomide, are discontinued at the stage of pregnancy planning, for both men and women. This is due to the fact that the body must be cleansed of the components contained in the drug so as not to affect the health of the unborn child.

• cytostatics, due to their effect on the immune system. If their use is mandatory, then it is necessary to stop feeding the baby breast milk;
• preparations containing gold salts affect the functioning of internal organs and can provoke an allergic reaction;
• The use of drugs that reduce blood viscosity is not recommended for women with heart and vascular diseases.

Treatment of children is carried out only under the strict supervision of a doctor in a hospital or sanatorium after a thorough examination.

Possible complications of rheumatoid arthrosis

During the treatment of rheumatoid arthrosis, various types of complications may occur, such as fluid in the tendons and skin or eye abnormalities.

The resulting abnormalities on the skin are characterized by the development of systemic lupus or rheumatoid nodules. Their main foci are located in the neck, shoulders and forearms. Another complication is vasculitis, which leads to inflammation of blood vessels and the formation of difficult-to-heal ulcers on the skin.

When eye abnormalities occur, the sclera is affected and eyeball. In some cases, this can lead to complete or partial loss of vision. Mostly complications lead to frequent conjunctivitis, the appearance of a constant feeling of pain in the eyes.

It is the most common pathology of joint tissue in people of any age. According to the World Health Organization (WHO), the number of people suffering from rheumatoid arthritis on earth reaches 1%, which is 64 million people. As a result of the high risk of disability associated with this pathology, active development new generation drugs for the treatment of rheumatoid arthritis.

Treatment is aimed at increasing the patient's performance.

The etiology of this pathology still remains unknown to science. The prospects for complete recovery of patients are doubtful. Thanks to the recent discovery of the role of the immune mechanism in the development of rheumatoid arthritis, treatment has become more effective. The main goals of rheumatoid arthritis treatment are:

• symptomatic assistance to the patient (reducing pain, increasing performance);
• preventing further destruction of the joint;
• attempts to achieve an inactive form of arthritis;
• prolonging the patient's life.

In addition to the tasks, it is necessary to follow a diet (limit the consumption of sweets and starchy foods), and begin taking prescribed medications immediately after diagnosis. Additionally, resort to general strengthening methods of treatment: exercise therapy, physiotherapy, massage, sparing the joints, and, if necessary, use surgical interventions.

Important! Compliance with all of the above points will allow you to stop the pathological process at the detected level of development and prevent its progression.

All drugs used in the treatment of rheumatoid arthritis are divided into:

1. Cytotoxic.
2. Noncytotoxic.

The choice of medication depends on the degree of activity of the process, as well as on the effectiveness and presence of side effects identified during treatment.

Important! If the substance is not suitable, the doctor changes it to another and so on until a therapeutic effect is achieved.

The standard initial treatment for rheumatoid arthritis is a combination of the drugs Methotrexate and Leflunomide. The effectiveness of Methotrexate is determined 5-9 weeks after the start of treatment. The positive effect directly depends on the dose. This medicine has been used for years. The therapeutic benefit of taking Leflunomide develops after 3-5 months.

Efficiency this drug will appear no earlier than after 3 months.

If side effects occur, change medications to:

• Azathioprine belongs to the group of immunosuppressants. Effective after 3-5 months;
• Cyclophosphamide is an immunosuppressant. The result develops after 3-5 months;
• Cyclosporine is a selective immunosuppressant. The result is better when combined with other medications. With monotherapy, the effectiveness reaches 30-35%.

In addition to immunosuppressants, gold (aurotherapy) is used in the treatment of rheumatoid arthritis. The use of gold preparations is based on the assumption of the infectious nature of the pathological process. Aurotherapy is prescribed to all patients with a similar diagnosis. Distinctive feature is to quickly achieve results: subsiding pain, reducing the activity of the pathological process and slowing down the rate of destruction of joints. The most common gold preparation is Aurothiomalate.

Important! If there are contraindications to immunosuppressants, aurotherapy becomes the basic therapy.

Treatment with new generation drugs

Actemra is a new generation drug for the treatment of RA.

Types of newest drugs:

• new generation immunosuppressants;
• biological agents.

To date, developed the latest drugs in the field of treatment of rheumatoid arthritis. These drugs also belong to the group of immunosuppressants, but their effects are more selective and gentle on the immune system.

In addition to immunosuppressants, biological agents are being actively developed. By blocking individual parts of the immune system, biological agents prevent the production of destructive factors.

List of new generation drugs for the treatment of rheumatoid arthritis:

1. New generation immunosuppressants.
   • Tofacitinib (Yaquinus). The product is available in tablet form and is used in combination with the drug Methotrexate. The effectiveness of monotherapy is extremely low.
   • Tocilizumab (Actemra). The drug is released in vials and is used for intravenous administration. Due to its property of blocking the activation of cellular immunity, it helps reduce the rate of joint destruction.
   • Rituximab (MabThera). Vials of 100 and 500 mg are packaged in individual boxes. The drug is administered through a vein. The therapeutic effect is based on blocking specific components of humoral immunity.
2. Biological agents.
   • "Enbrel";
   • "Humira";
   • "Kinneret";
   • "Orencia";
   • Remicade.

The drugs Enbrel and Humira were the first in the group of biological agents. The mechanism of their effectiveness is based on blocking tumor necrosis factor. In the absence of positive dynamics while taking these drugs, Remicade, Orenzia, and Kineret are prescribed. Data Action dosage forms based on preventing the production of anti-inflammatory cytokines.

Conclusion

Newer drugs to treat rheumatoid arthritis have fewer side effects. The effectiveness of these dosage forms has been established experimentally. However, until the exact cause of rheumatoid arthritis is discovered, it is not worth talking about 100% effectiveness of these remedies.

Modern methods of treating patients with rheumatoid arthritis

Rheumatoid arthritis is a disease that has been the focus of attention of rheumatologists around the world for decades. This is due to the great medical and social significance of this disease. Its prevalence reaches 0.5–2% of total number population in industrialized countries. Patients with rheumatoid arthritis experience a decrease in life expectancy compared to the general population by 3–7 years. It is difficult to overestimate the colossal damage caused by this disease to society due to the early disability of patients, which, in the absence of timely active therapy, can occur in the first 5 years from the onset of the disease.

Rheumatoid arthritis is a chronic inflammatory disease of unknown etiology, which is characterized by damage to peripheral synovial joints and periarticular tissues, accompanied by autoimmune disorders and can lead to destruction of articular cartilage and bone, as well as systemic inflammatory changes.

The pathogenesis of the disease is very complex and largely insufficiently studied. Despite this, by now some key points in the development of rheumatoid inflammation are well known, which determine the main methods of therapeutic action on it.
The development of chronic inflammation in this case is associated with the activation and proliferation of immunocompetent cells (macrophages, T- and B-lymphocytes), which is accompanied by the release of cellular mediators - cytokines, growth factors, adhesion molecules, as well as the synthesis of autoantibodies (for example, anticitrullinated antibodies) and the formation immune complexes (rheumatoid factors). These processes lead to the formation of new capillary vessels (angiogenesis) and proliferation connective tissue in the synovium, to the activation of cyclooxygenase-2 (COX-2) with an increase in the synthesis of prostaglandins and the development of an inflammatory reaction, to the release of proteolytic enzymes, activation of osteoclasts, and as a result - to the destruction of normal joint tissues and the occurrence of deformities.

Treatment of rheumatoid arthritis

Treatment includes:
drug therapy;
non-drug therapies;
orthopedic treatment, rehabilitation.

Based on the pathogenesis of the disease, it becomes obvious that it is possible to effectively influence the development of the disease at two levels:
suppressing excessive activity of the immune system;
blocking the production of inflammatory mediators, primarily prostaglandins.

Since, in addition to inflammation itself, activation of the immune system is accompanied by many other pathological processes, the effect at the first level is significantly deeper and more effective than at the second. Drug immunosuppression is the mainstay of treatment for rheumatoid arthritis. Immunosuppressive drugs used to treat this disease include disease-modifying anti-inflammatory drugs (DMARDs), biological agents, and glucocorticosteroids. At the second level, non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticosteroids act.

In general, immunosuppressive therapy is accompanied by a slower development of clinical effect (in a broad framework - from several days in the case of biological therapy to several months in the case of some DMARDs), which at the same time can be very pronounced (up to the development of clinical remission) and persistent, and is also characterized by inhibition of joint destruction.

Anti-inflammatory therapy itself (NSAIDs) can produce a clinical effect (pain relief, reduction of stiffness) very quickly - within 1-2 hours, however, with the help of such treatment it is almost impossible to completely stop the symptoms of active rheumatoid arthritis and, apparently, it has no effect at all on the development of destructive processes in tissues.

Glucocorticosteroids have both immunosuppressive and direct anti-inflammatory effects, so clinical improvement can develop quickly (within a few hours when administered intravenously or intra-articularly). There is evidence of suppression of the progression of the erosive process in joints during long-term therapy with low doses of glucocorticosteroids and their positive effect on the functional status of the patient. At the same time, it is well known from practice that prescribing only glucocorticosteroids, without other immunosuppressive drugs (DMARDs), rarely provides an opportunity to effectively control the course of the disease.

Non-drug methods of treating rheumatoid arthritis (physiotherapy, balneotherapy, diet therapy, acupuncture, etc.) are additional methods that can slightly improve the patient’s well-being and functional status, but do not relieve symptoms and significantly influence joint destruction.

Orthopedic treatment, including orthotics and surgical correction of joint deformities, as well as rehabilitation measures ( physical therapy etc.) are of particular importance mainly in the later stages of the disease to maintain functional ability and improve the patient’s quality of life.

The main goals of treatment for RA are:
relief of disease symptoms, achievement of clinical remission or at least low disease activity;
inhibition of the progression of structural changes in joints and corresponding functional disorders;
improving the quality of life of patients, maintaining their ability to work.

It must be kept in mind that treatment goals may vary significantly depending on the duration of the disease. At an early stage of the disease, i.e., with a disease duration of 6–12 months, achieving clinical remission is a very realistic goal, as well as inhibiting the development of erosions in the joints. By using modern methods active drug therapy can achieve remission in 40–50% of patients; the absence of the appearance of new erosions according to radiography and magnetic resonance imaging is also shown in a significant number of patients with a follow-up period of 1–2 years.

With long-term rheumatoid arthritis, especially with insufficiently active therapy in the first years of the disease, achieving complete remission is theoretically also possible, but the likelihood of this is much lower. The same can be said about the possibility of stopping the progression of destruction in joints that have already been significantly destroyed over several years of illness. Therefore, with advanced rheumatoid arthritis, the role of rehabilitation measures and orthopedic surgery increases. In addition, in the later stages of the disease, long-term maintenance basic therapy can be used for secondary prevention of complications of the disease, such as systemic manifestations (vasculitis, etc.), secondary amyloidosis.

Basic therapy for rheumatoid arthritis. DMARDs (synonyms: disease-modifying antirheumatic drugs, slow-acting drugs) are the main component of the treatment of rheumatoid arthritis and, in the absence of contraindications, should be prescribed to every patient with this diagnosis. It is especially important to prescribe DMARDs as quickly as possible (immediately after diagnosis) at an early stage, when there is a limited period of time (several months from the onset of symptoms) to achieve the best long-term results - the so-called “therapeutic window”.

Classic DMARDs have the following properties.
The ability to suppress the activity and proliferation of immunocompetent cells (immunosuppression), as well as the proliferation of synoviocytes and fibroblasts, which is accompanied by a pronounced decrease in the clinical and laboratory activity of RA.
Persistence of the clinical effect, including its persistence after discontinuation of the drug.
The ability to delay the development of the erosive process in joints.
Ability to induce clinical remission.
Slow development of a clinically significant effect (usually within 1–3 months from the start of treatment).

DMARDs differ significantly from each other in their mechanism of action and features of use. The main parameters characterizing DMARDs are presented in Table 1.
DMARDs can be roughly divided into first-line and second-line drugs. First-line drugs have the best balance of effectiveness (reliably suppress both clinical symptoms and the progression of the erosive process in the joints) and tolerability, and therefore are prescribed to most patients.

First-line DMARDs include the following.
Methotrexate is the “gold standard” for the treatment of rheumatoid arthritis. Recommended doses are 7.5–25 mg per week and are adjusted individually by gradual increases of 2.5 mg every 2–4 weeks until a good clinical response is achieved or intolerance occurs. The drug is given orally (weekly for two consecutive days in 3-4 divided doses every 12 hours). In case of unsatisfactory tolerability of methotrexate when taken orally due to dyspepsia and other complaints associated with the gastrointestinal tract (GIT), the drug can be prescribed parenterally (one IM or IV injection per week).

Leflunomide (Arava). Standard treatment regimen: 100 mg orally per day for 3 days, then 20 mg/day continuously. If there is a risk of intolerance to the drug (old age, liver disease, etc.), treatment can be started with a dose of 20 mg/day.
It is comparable in effectiveness to methotrexate and has slightly better tolerability.
There is evidence of higher effectiveness of leflunomide in relation to the quality of life of patients, especially in early rheumatoid arthritis. The cost of treatment with leflunomide is quite high, so it is often prescribed when there are contraindications to the use of methotrexate, its ineffectiveness or intolerance, but it can also be used as the first basic drug.

Sulfasalazine. In clinical trials, it was not inferior in effectiveness to other DMARDs, however clinical practice shows that sulfasalazine usually provides sufficient control over the course of the disease with moderate and low activity of rheumatoid arthritis.

Second line DMARDs are used much less frequently due to lower clinical effectiveness and/or greater toxicity. They are prescribed, as a rule, when first-line DMARDs are ineffective or intolerable.

DMARDs can cause significant improvement (good clinical response) in approximately 60% of patients. Due to the slow development of the clinical effect, the prescription of DMARDs for periods of less than 6 months is not recommended. The duration of treatment is determined individually; the typical duration of a “course” of treatment with one drug (in case of a satisfactory response to therapy) is 2–3 years or more. Most clinical recommendations suggest indefinite use of maintenance dosages of DMARDs to maintain the achieved improvement.

If monotherapy with any basic drug is insufficiently effective, a regimen may be chosen combination basic therapy, i.e. a combination of two or three DMARDs. The following combinations have proven themselves to be the most effective:
methotrexate + leflunomide;
methotrexate + cyclosporine;
methotrexate + sulfasalazine;
methotrexate + sulfasalazine + hydroxychloroquine.

In combination regimens, drugs are usually used in moderate dosages. A number of clinical studies have demonstrated the superiority of combination basic therapy over monotherapy, but the higher effectiveness of combination regimens is not considered strictly proven. Combination DMARDs are associated with a moderate increase in side effects.

Biological drugs in the treatment of rheumatoid arthritis. The term biological drugs (from the English biologics) is used in relation to drugs produced using biotechnology and carrying out targeted (“point”) blocking of key moments of inflammation using antibodies or soluble receptors to cytokines, as well as other biologically active molecules. Thus, biological products have nothing to do with “dietary supplements.” Due to the large number of “target molecules” that can potentially suppress immune inflammation, a number of medicines Several other drugs from this group are undergoing clinical trials.

The main biological drugs registered in the world for the treatment of rheumatoid arthritis include:
infliximab, adalimumab, etanercept(acts on tumor necrosis factor (TNF);
rituximab (acts on CD 20 (B lymphocytes));
anakinra (acts on interleukin-1);
abatasept (affects CD 80, CD 86, CD 28).

Biological drugs are characterized by a pronounced clinical effect and reliably proven inhibition of joint destruction. These signs allow biological drugs to be classified as DMARDs. At the same time, a feature of the group is the rapid (often within a few days) development of significant improvement, which combines biological therapy with intensive care methods. A characteristic feature of biological agents is the potentiation of the effect in combination with DMARDs, primarily methotrexate. Due to its high effectiveness in rheumatoid arthritis, including in patients resistant to conventional therapy, biological therapy has now moved to second place (after DMARDs) in the treatment of this disease.

TO negative aspects biological therapies include:
inhibition of anti-infective and (potentially) anti-tumor immunity;
the risk of developing allergic reactions and inducing autoimmune syndromes due to the fact that biological drugs are proteins in their chemical structure;
high cost of treatment.

Biological therapies are indicated if treatment with DMARDs (such as methotrexate) is not adequate due to lack of effectiveness or poor tolerability.

One of the most important target molecules is TNF, which has many proinflammatory biological effects and contributes to the persistence of the inflammatory process in the synovium, destruction of cartilage and bone tissue through a direct effect on synovial fibroblasts, chondrocytes and osteoclasts. TNF blockers are the most widely used biological agents in the world.

A drug from this group is registered in Russia infliximab (Remicade), which is a chimeric monoclonal antibody to TNF. The drug is usually prescribed in combination with methotrexate.
In patients with insufficient effectiveness of therapy with medium and high doses of methotrexate, infliximab significantly improves the response to treatment and functional indicators, and also leads to a significant inhibition of the progression of joint space narrowing and the development of the erosive process.

The indication for the use of infliximab in combination with methotrexate is the ineffectiveness of one or more DMARDs used at full dose (primarily methotrexate), with the persistence of high inflammatory activity (five or more swollen joints, erythrocyte sedimentation rate (ESR) more than 30 mm/h, C-reactive protein (CRP) more than 20 mg/l). In early rheumatoid arthritis with high inflammatory activity and a rapid increase in structural disorders in the joints, combination therapy with methotrexate and infliximab can be prescribed immediately.

Before prescribing infliximab, a screening examination for tuberculosis is required (radiography chest, tuberculin test). Recommended regimen: initial dose of 3 mg/kg of the patient’s body weight intravenously, then 3 mg/kg of body weight after 2, 6 and 8 weeks, then 3 mg/kg of body weight every 8 weeks, if the dose is insufficiently effective may increase up to 10 mg/kg body weight.
The duration of treatment is determined individually, usually at least 1 year. After discontinuation of infliximab, maintenance therapy with methotrexate continues. It should be borne in mind that re-administration of infliximab after completion of treatment with this drug is associated with an increased likelihood of delayed-type hypersensitivity reactions.

The second drug for biological therapy registered in our country is rituximab (mabthera). The action of rituximab is aimed at suppressing B lymphocytes, which are not only the key cells responsible for the synthesis of autoantibodies, but also perform important regulatory functions in the early stages of immune reactions. The drug has pronounced clinical efficacy, including in patients who do not respond sufficiently to infliximab therapy.

For the treatment of rheumatoid arthritis, the drug is used at a dose of 2000 mg per course (two infusions of 1000 mg, each with an interval of 2 weeks). Rituximab is administered intravenously slowly; infusion in a hospital setting is recommended with the possibility of precise control over the rate of administration. To prevent infusion reactions, it is advisable to pre-administer methylprednisolone 100 mg. If necessary, a second course of rituximab infusions can be performed after 6–12 months.

According to European clinical guidelines, it is advisable to prescribe rituximab in cases of ineffectiveness or impossibility of infliximab therapy. The possibility of using rituximab as the first biological drug is currently the subject of research.

Glucocorticosteroids. Glucocorticosteroids have a multifaceted anti-inflammatory effect due to the blockade of the synthesis of proinflammatory cytokines and prostaglandins, as well as inhibition of proliferation due to their effect on the genetic apparatus of cells. Glucocorticosteroids have a rapid and pronounced dose-dependent effect on the clinical and laboratory manifestations of inflammation. The use of glucocorticosteroids is fraught with the development of undesirable reactions, the frequency of which also increases with increasing doses of the drug (steroid osteoporosis, drug-induced Itsenko-Cushing syndrome, damage to the gastrointestinal mucosa). These drugs alone in most cases cannot provide complete control over the course of rheumatoid arthritis and must be prescribed together with DMARDs.

Glucocorticosteroids for this disease are used systemically and locally. For systemic use, the main method of treatment is the administration of low doses orally (prednisolone - up to 10 mg/day, methylprednisolone - up to 8 mg/day) for long period with high inflammatory activity, polyarticular lesions, insufficient effectiveness of DMARDs.

Medium and high doses of glucocorticosteroids orally (15 mg/day or more, usually 30–40 mg/day in terms of prednisolone), as well as pulse therapy with glucocorticosteroids - intravenous administration of high doses of methylprednisolone (250–1000 mg) or dexamethasone (40–1000 mg) 120 mg) can be used to treat severe systemic manifestations of rheumatoid arthritis (effusive serositis, hemolytic anemia, cutaneous vasculitis, fever, etc.), as well as some special forms of the disease. The duration of treatment is determined by the time required to relieve symptoms and is usually 4–6 weeks, after which a gradual stepwise dose reduction is carried out with a transition to treatment with low doses of glucocorticosteroids.

Glucocorticosteroids in the middle and high doses, pulse therapy apparently does not have an independent effect on the course of rheumatoid arthritis and the development of the erosive process in the joints.

For local therapy, drugs are used in microcrystalline form, prescribed in the form of intra-articular and periarticular injections: betamethasone, triamsinolone, methylprednisolone, hydrocortisone.

Glucocorticosteroids for local use have a pronounced anti-inflammatory effect, mainly at the injection site, and in some cases - a systemic effect. Recommended daily doses are: 7 mg for betamethasone, 40 mg for triamsinolone and methylprednisolone, 125 mg for hydrocortisone. This dose (in total) can be used for intra-articular injection into one large (knee) joint, two medium-sized joints (elbows, ankles, etc.), 4-5 small joints (metacarpophalangeal, etc.), or for periarticular administration of the drug at 3–4 points.

The effect after a single injection usually occurs within 1–3 days and lasts for 2–4 weeks if well tolerated.

In this regard, it is not advisable to prescribe repeated injections of glucocorticosteroids into one joint earlier than after 3–4 weeks. Carrying out a course of several intra-articular injections into the same joint has no therapeutic meaning and is fraught with complications (local osteoporosis, increased destruction of cartilage, osteonecrosis, suppuration). Due to the increased risk of developing osteonecrosis, intra-articular injection of glucocorticosteroids into hip joint Overall not recommended.

Glucocorticosteroids for local use are prescribed as an additional method for relieving exacerbations of rheumatoid arthritis and cannot serve as a replacement for systemic therapy.

NSAIDs. The importance of NSAIDs in the treatment of rheumatoid arthritis recent years decreased significantly due to the emergence of new effective pathogenetic therapy regimens. The anti-inflammatory effect of NSAIDs is achieved by suppressing the activity of COX, or selectively COX-2, and thereby reducing the synthesis of prostaglandins. Thus, NSAIDs act on the final link of rheumatoid inflammation.

The effect of NSAIDs in rheumatoid arthritis is to reduce the severity of symptoms of the disease (pain, stiffness, swelling of the joints). NSAIDs have an analgesic, anti-inflammatory, and antipyretic effect, but have little effect on laboratory parameters of inflammation. In the vast majority of cases, NSAIDs are not able to significantly change the course of the disease. Their prescription as the only antirheumatic drug for a definite diagnosis of rheumatoid arthritis is currently considered a mistake. However, NSAIDs are the mainstay of symptomatic therapy for this disease and in most cases are prescribed in combination with DMARDs.

Along with the therapeutic effect, all NSAIDs, including selective ones (COX-2 inhibitors), are capable of causing erosive and ulcerative lesions of the gastrointestinal tract (primarily its upper parts - “NSAID gastropathy”) with possible complications(bleeding, perforation, etc.), as well as nephrotoxic and other undesirable reactions.

Basic characteristic features, which must be taken into account when prescribing NSAIDs, are as follows.
There are no significant differences between NSAIDs in terms of effectiveness (for most drugs, the effect is proportional to the dose up to the maximum recommended).
There are significant differences in tolerability between different NSAIDs, especially with regard to gastrointestinal involvement.
Frequency unwanted effects usually proportional to the dose of NSAID.
In patients with an increased risk of developing NSAID-associated gastrointestinal lesions, the risk can be reduced by concurrent administration of proton pump blockers and misoprostol.

There is individual sensitivity to various NSAIDs in terms of both effectiveness and tolerability of treatment. Doses of NSAIDs for rheumatoid arthritis correspond to standard doses. The duration of NSAID treatment is determined individually and depends on the patient’s need for symptomatic therapy. If there is a good response to DMARD therapy, the NSAID drug may be discontinued.

The most commonly used NSAIDs for rheumatoid arthritis include:
diclofenac (50–150 mg/day);
nimesulide (200–400 mg/day);
celecoxib (200–400 mg/day);
meloxicam (7.5–15 mg/day);
ibuprofen (800–2400 mg/day);
lornoxicam (8–12 mg/day).

Selective NSAIDs, while not significantly different in effectiveness from non-selective ones, are less likely to cause NSAID gastropathy and serious adverse reactions from the gastrointestinal tract, although they do not exclude the development of these complications. A number of clinical studies have demonstrated an increased likelihood of developing severe vascular pathology (myocardial infarction, stroke) in patients receiving drugs from the coxib group, and therefore the possibility of treatment with celecoxib should be discussed with particular caution in patients with coronary artery disease and other serious cardiovascular pathologies.

Additional drug treatments. As a symptomatic analgesic (or an additional analgesic if NSAIDs are insufficiently effective), paracetamol (acetaminophen) can be used at a dose of 500–1500 mg/day, which has relatively low toxicity. For local symptomatic therapy, NSAIDs are used in the form of gels and ointments, as well as dimethyl sulfoxide in the form of a 30–50% aqueous solution in the form of applications. In the presence of osteoporosis, appropriate treatment with calcium, vitamin D3, bisphosphonates, and calcitonin is indicated.

General principles of management of patients with RA

A patient diagnosed with rheumatoid arthritis should be prescribed a drug from the DMARD group, which, with a good clinical effect, can be used as the only method of therapy. Other medicinal products used as needed.

The patient should be informed about the nature of his disease, course, prognosis, the need for long-term complex treatment, as well as possible adverse reactions and a treatment monitoring scheme, unfavorable combinations with other drugs (in particular alcohol), possible activation of foci of chronic infection during treatment , the advisability of temporarily discontinuing immunosuppressive drugs in the event of acute infectious diseases, the need for contraception during treatment.

Therapy for rheumatoid arthritis should be prescribed by a rheumatologist and carried out under his supervision. Treatment with biological drugs can only be carried out under the supervision of a rheumatologist who has sufficient knowledge and experience to carry it out. Therapy is long-term and involves periodic monitoring of disease activity and assessment of response to therapy.

Monitoring disease activity and response to therapy includes assessment of joint status indicators (number of painful and swollen joints, etc.), acute phase blood parameters (ESR, CRP), assessment of pain and disease activity using a visual analog scale, assessment functional activity the patient in daily activities using the Russian version of the Health Questionnaire (HAQ). There are internationally recognized methods for quantifying treatment response using the European League Against Rheumatism (EULAR) DAS (Disease Activity Score) index and the American College of Rheumatology (ACR) criteria. In addition, the safety of the therapy administered to the patient should be monitored (in accordance with both the formulary and existing clinical guidelines). Due to the fact that the erosive process can develop even with low inflammatory activity, in addition to assessing the activity of the disease and response to therapy, radiography of the joints is mandatory. The progression of destructive changes in the joints is assessed by standard radiography of the hands and feet using the radiological classification of the stages of rheumatoid arthritis, quantitative methods using the Sharp and Larsen indices. In order to monitor the patient's condition, examinations are recommended to be carried out at certain intervals.

Treatment of treatment-resistant RA

It is advisable to consider a patient resistant to treatment if there is ineffectiveness (lack of 20% improvement in the main indicators) of at least two standard DMARDs in sufficiently high doses (methotrexate - 15–20 mg/week, sulfasalazine - 2000 mg/day, leflunomide - 20 mg/day) . Failure can be primary or secondary (occurring after a period of satisfactory response to therapy or when the drug is re-prescribed). There are the following ways to overcome resistance to therapy:
prescription of biological drugs (infliximab, rituximab);
prescription of glucocorticosteroids;
use of combination basic therapy;
use of second-line DMARDs (cyclosporine, etc.).

From the point of view of long-term results in relation to functional impairment, quality of life and its duration, the optimal treatment strategy for rheumatoid arthritis is long-term treatment with DMARDs with a systematic change in the regimen of their use as needed.

Medical rehabilitation program
Treatment of joint diseases is carried out accordingly, taking into account the period of the disease. In the acute period of the disease, treatment of arthritis is based on the principles of maintaining rest for the diseased joint. Pro-
noli gaya treatment by position, heat and ultraviolet irradiation are used to reduce pain in the affected joints. In the subacute stage, in order to preserve the functions of diseased joints, comprehensive physical rehabilitation is indicated: treatment with position, therapeutic massage, therapeutic exercises in combination with physiotherapeutic procedures (Ural irradiation, thermal procedures, hydrogen sulfide baths). In the chronic process, comprehensive physical rehabilitation includes therapeutic massage, therapeutic exercises, balneotherapy (hydrogen sulfide, radon baths), mud therapy in combination with sanatorium conditions.

The entire system of physical rehabilitation is divided into 3 stages: in a hospital: in a sanatorium or clinic; at home.
In the process of physical rehabilitation, the following tasks are set:
impact on the affected joints in order to develop their mobility and prevent further dysfunction;
strengthening the muscular system and increasing its performance;
improving blood circulation in joints, combating muscle atrophy;
counteracting the negative effects of bed rest (stimulating the functions of blood circulation, breathing, increasing metabolism);
reducing pain by adapting the affected joints to dosed physical activity;
rehabilitation of physical performance.

Stage I of physical rehabilitation in the hospital refers to the beginning of the subacute period of the disease (pronounced exudative phenomena - swelling, painful contractures, limitation of movements, deformation varying degrees, muscle atrophy). In the first period, passive exercises are used for sore joints. They should not be accompanied by pain or severe defensive reaction in the form of reflex muscle tension. Passive movements should be preceded by a therapeutic massage to relax the muscles.
During the second period of physical rehabilitation at this stage, with a decrease in exudative phenomena, the patient can make the first active movements in the diseased joints in the most comfortable positions. Active and passive exercises are used, as well as passive exercises using a healthy limb to increase the range of motion, exercises with apparatus.
Before performing the exercises, a therapeutic massage is performed, and physiotherapeutic procedures are applied (Ural irradiation, paraffin baths, ozokerite).

Stage II of physical rehabilitation in a sanatorium or clinic, it is prescribed when there are no inflammatory phenomena in the affected joints, but there are still some restrictions on movement. Special exercises are aimed at stretching the ligaments of the affected joints and strengthening the muscles, especially the extensors. Therapeutic gymnastics classes are carried out in the initial standing position, active exercises are used for sick and healthy joints.
The complex of physical rehabilitation at this stage includes mud therapy ( Staraya Russa) or balneotherapy (Matsesta, etc.).
These procedures are used before doing therapeutic exercises. Self-execution by patients physical exercise is mandatory to ensure the best effect.

III stage of physical rehabilitation refers to the period of convalescence, has a preventive value and is carried out in a clinic or at home. The main task of this stage is to maintain and preserve the achieved movements in the joints. Without systematic training, movement in the affected joints may gradually deteriorate. Patients engage in a developed set of exercises depending on the affected joints.
For young and middle-aged people, skiing, short rowing, and swimming (water temperature 28 - 29 ° C) can be recommended. games of tennis, volleyball. Elderly persons are only allowed to walk.

Vocational Rehabilitation Program

RA, mild form(mainly articular or combined, with deforming osteoarthritis; grade I-II activity; I-II stage process; dysfunction of joints I-II degrees.

Significant physical and neuropsychic stress. Moderate constant physical stress, prolonged walking and standing, prescribed pace of work, forced body position; unfavorable microclimatic conditions (low and high temperatures, high humidity, drafts), exposure to toxic substances, frequent and long business trips.

Moderate RA (recurrent course, activity II degree; II stage of the process with dysfunction of joints II degree; articular-visceral, combined form with severe dysfunction of organs).

Against
Significant and moderate physical and neuropsychic stress, prolonged walking and standing, prescribed pace of work, forced body position; unfavorable microclimatic conditions (low and high temperatures, high humidity, drafts), exposure to toxic substances, frequent and long business trips. Vocational training disabled people with RA require the use of auxiliary technical means - special furniture, height-adjustable chairs and tables, devices for holding objects, hand supports, etc.

RA, mild form
Conditions and nature of work shown. Work with minor physical (1) and moderate neuropsychic stress (2) in comfortable (1) sanitary and hygienic conditions.
The weight of the lifted and moved load for women is up to 3 kg, for men - up to 5 kg; when alternating with other work for women - up to 5 kg, for men - up to 12 kg. The working position is free. It is allowed to bend the body up to 50 times per shift. The duration of concentrated observation is up to 50% of the shift time with the number of observation objects up to 10, signal density up to 175 per hour. Work according to schedule with the possibility of correction. Solving alternative problems according to instructions.
Highly qualified persons creative work possible active search information when there is a lack of it. Day shift work no more than 8 hours. Shortened working hours (week) are possible.

RA, moderate severity
Conditions and nature of work shown.
Minor physical and mental stress (1). Optimal sanitary and hygienic conditions (1). Work without lifting heavy objects, without walking.
The working position is comfortable and free. Solution simple tasks. Work according to an individual schedule, with a shortened working day in specially created conditions (special enterprise, special workshop, specially equipped workplace; at home).

Range of available professions: proofreader, photographer, archivist, engineer, speech therapist, researcher, economist, statistician.
For disabled people with damage to the upper and lower extremities, a special workplace must be equipped with special work furniture, devices for moving objects, holding objects, with an expanded workplace area for moving in a wheelchair, etc.

Social rehabilitation program
People with disabilities due to RA need information and consultation of the disabled person and his family, adaptation training for the disabled person and his family in “life with a disability,” training in personal care, social independence, use of technical means of rehabilitation, assistance in solving personal problems, adaptation of housing (installation of handrails, laying non-slip floors, removing thresholds).

Rehabilitation technical means required:
for movement (canes, crutches, axillary crutches, three-legged canes, walking, indoor wheelchairs, etc.);
means for preparing food and drinks (means for cutting, chopping and dosing, for cleaning products, a food preparation machine, means for cooking and frying, etc.);
household cleaning products (vacuum cleaners, carpet cleaners, squeezing machine, etc.);
functional bed, bedside table, bed rails;
railings and handrails;
. openers and closes of doors, windows, curtains;
means for dressing and undressing;
means for performing natural needs (toilet seats, toilet armrests, etc.);
means for washing, bathing and showering (bath/shower chairs, anti-slip bath mats; washcloths, sponges, brushes, soap dispensers with a handle);
special dishes for food.