Other rheumatoid arthritis according to ICD 10. Rheumatoid arthritis seronegative ICD. The need to create a unified classification

Rheumatism according to ICD 10 is an autoimmune disease associated with the appearance of circulating immune complexes after contact of the body with group A hemolytic streptococcus. It develops due to the congenital similarity of the antigenic structure of connective tissue and streptococcus, affecting the valve apparatus of the heart, large joints and the central nervous system. It is divided into forms of the disease with and without the formation of heart defects.

This pathology can occur after a sore throat. In modern times, rheumatism is much less common; the massive use of antibiotics prevents the development of autoimmune processes.

The incidence of the disease in developed countries among the adult population is up to 0.9%, and in childhood - at least 0.6%. When rheumatism develops from a young age to adulthood (30-40), about 80-90% do not survive.

According to the ICD 10 registry, rheumatism is a systemic autoimmune disease. Its classification is based on damage to the joints, heart valves, central nervous system, stages and severity of the disease.

For a complete list of this pathology, the International Classification of Diseases, 10th revision, is used. According to ICD-10, each disease has its own coding. The rheumatism code begins with the Latin letter I, which means all diseases of the circulatory system. The code for rheumatism and rheumatic fever is found under the numbers 00 - 09.

Acute rheumatic fever (ARF - rheumatism code according to ICD 10 I00-I02).

I 00 Rheumatic fever without influence on heart disease.

I 01 Rheumatic fever with influence on the occurrence of heart disease.

I01.0 pericarditis;

I01.1 endocarditis;

I01.2 myocarditis;

I01.8 other acute rheumatic heart diseases.

I 02 Chorea.

Chronic rheumatic heart disease (code I05-I09):

I 05 Rheumatic diseases of the mitral valve.

I05.0 mitral stenosis;

I05.1 mitral insufficiency;

I05.2 mitral stenosis with mitral insufficiency.

I 06 Rheumatic diseases of the aortic valves.

I 07 Rheumatic diseases of the tricuspid valve.

I 08 Multiple valve lesions.

I 09 Other rheumatic heart lesions.

I09.0 Rheumatic myocarditis;

I09.1 chronic endocarditis, valvulitis;

I09.2 chronic pericarditis.

Classification of rheumatism

Clinicians and theorists distinguish two forms of rheumatism - active and inactive. Some distinguish between progressive, waning and relapsing phases. This pathology can be in a chronic stage with the involvement of the valve apparatus and myocardium. Palindromic (recurrent) rheumatism was described back in 1891.

In medicine, rheumatism is classified according to two criteria: clinical manifestations and the degree of disease activity.

Clinical manifestations of acute rheumatic fever:

Classification of rheumatisms by degree of activity:

First degree. The minimum degree, which has mild symptoms. Characterized by minor or no symptoms.

Second degree or average degree in activity. May occur in conjunction with fever and carditis. It is characterized by an increase in ESR, leukocytes and a number of other blood test parameters.

Third degree (maximum). It is characterized by the appearance of fever with fluid effusion in the cavity (polyarthritis, serositis). In the biochemical analysis, the content of inflammatory proteins (CRP, a-globulins, seromucoid) and enzymes was sharply increased.

When diagnosed, the central nervous system, heart, joints and other organs are affected. Professors often characterize the disease with the expression “rheumatism kisses the brain, licks the joints and bites the heart.”

This disease is quite difficult to treat, but with proper and timely examination and treatment, complete recovery occurs.

Causes and risk factors

The main cause of this disease is infection with group A bacteria; only beta-hemolytic streptococcus contains a rheumatogenous factor, which determines the development of rheumatism. The second reason is considered to be the similarity of antigens of the microbe and cartilage tissue. Taken together, these reasons can cause the development of autoaggression of the immune system against the connective tissue of the body.

Risk factors for developing rheumatic disease:

• the presence of a characteristic streptococcus that causes hemolysis (provoking factor);
• genetic predisposition of immune status;
• inflammatory factors.

Course and prognosis of the disease

Rheumatism occurs in 3 stages:

1. Autoimmune (in which the appearance of antigen-antibody immune compounds and the production of autoantibodies occurs).
2. Vascular (pathology of the microvasculature and blood coagulation system, leading to the formation of blood clots).
3. Inflammatory (exudative reactions of connective tissue).

Course of ARF and rheumatism:

In 75% of patients, attacks of rheumatism subside within no more than 6 weeks; in 95% of patients, complete recovery occurs within 12 weeks. And only in 5% the course of the disease can exceed six months. Such patients are characterized by all clinical manifestations in a severe and advanced form. The frequency of exacerbations depends on the degree of re-infection with the bacterium, the presence of damage to the cardiovascular system and the duration of the remission stage.

Carditis develops in almost all patients. In the absence of rough murmurs over the apex of the heart, a favorable prognosis for rheumatism should be judged.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Rheumatoid arthritis, unspecified (M06.9)

Rheumatology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013

Rheumatoid arthritis (RA)- an autoimmune rheumatic disease of unknown etiology, characterized by chronic erosive arthritis (synovitis) and systemic damage to internal organs.

I. INTRODUCTORY PART

Protocol name: Rheumatoid arthritis
Protocol code:

ICD-10 codes:
M05 Seropositive rheumatoid arthritis;
M06 Other rheumatoid arthritis;
M05.0 Felty's syndrome;
M05.1 Rheumatoid lung disease;
M05.2 Rheumatoid vasculitis;
M05.3 Rheumatoid arthritis involving other organs and systems;
M06.0 Seronegative rheumatoid arthritis;
M06.1 Still's disease in adults;
M06.9 Rheumatoid arthritis, unspecified.

Abbreviations used in the protocol:
ARR - Association of Rheumatologists of Russia
ACCP - antibodies to cyclic citrullinated peptide
DMARDs - basic anti-inflammatory drugs
VAS - Visual Analog Scale
GIBP - genetically engineered biological products
GK - glucocorticoids
Gastrointestinal tract - gastrointestinal tract
STDs - sexually transmitted diseases
LS - medicines
MTX - methotrexate
MRI - magnetic resonance imaging
NSAIDs - non-steroidal anti-inflammatory drugs
GHS - general health status
RA - rheumatoid arthritis
RF - rheumatoid factor
CRP - C-reactive protein
Ultrasound - ultrasound examination
FC - functional class
NPV - number of swollen joints
COX - cyclooxygenase
FGDS - fibrogastroduodenoscopy
ECG - electrocardiogram
ECHO KG - echocardiogram

Date of development of the protocol: 2013
Patient category: patients with RA
Protocol users: rheumatologists, therapists, general practitioners.

Classification

Clinical classification

Working classification of rheumatoid arthritis (ARR, 2007)

Main diagnosis:
1. Rheumatoid arthritis, seropositive (M05.8).
2. Seronegative rheumatoid arthritis (M06.0).

Special clinical forms of rheumatoid arthritis
1. Felty's syndrome (M05.0);
2. Still's disease developed in adults (M06.1).
3. Probable rheumatoid arthritis (M05.9, M06.4, M06.9).

Clinical stage:
1. Very early stage: duration of illness<6 мес..
2. Early stage: disease duration 6 months - 1 year.
3. Advanced stage: disease duration >1 year in the presence of typical RA symptoms.
4. Late stage: disease duration of 2 years or more + pronounced destruction of small (III-IV X-ray stage) and large joints, presence of complications.

Disease activity level:
1. 0 - remission (DAS28<2,6).
2. Low (DAS28=2.6-3.2).
3. II - average (DAS28=3.3-5.1).
4. III - high (DAS28>5.1).

Extra-articular (systemic) signs:
1. Rheumatoid nodules.
2. Cutaneous vasculitis (ulcerative-necrotizing vasculitis, nail bed infarctions, digital arteritis, livedoangiitis).
3. Neuropathy (mononeuritis, polyneuropathy).
4. Pleurisy (dry, effusion), pericarditis (dry, effusion).
5. Sjögren's syndrome.
6. Eye damage (scleritis, episcleritis, retinal vasculitis).

Instrumental characteristics.
The presence or absence of erosions [according to radiography, magnetic resonance imaging (MRI), ultrasound (ultrasound)]:
- non-erosive;
- erosive.

X-ray stage (according to Steinbrocker):
I - periarticular osteoporosis;
II - periarticular osteoporosis + narrowing of the joint space, there may be single erosions;
III - signs of the previous stage + multiple erosions + subluxations in the joints;
IV - signs of previous stages + bone ankylosis.

Additional immunological characteristic - antibodies to cyclic citrullinated peptide (ACCP):
1. Anti-CCP - present (+).
2. Anti-CCP - absent (-).

Functional class (FC):
Class I - the possibilities of self-service, non-professional and professional activities are fully preserved.
Class II - opportunities for self-service, non-professional occupation are preserved, opportunities for engaging in professional activities are limited.
Class III - self-service opportunities are preserved, opportunities for non-professional and professional activities are limited.
Class IV - self-service opportunities for non-professional and professional activities are limited.

Complications:
1. Secondary systemic amyloidosis.
2. Secondary osteoarthritis
3. Osteoporosis (systemic)
4. Osteonecrosis
5. Tunnel syndromes (carpal tunnel syndrome, compression syndromes of the ulnar and tibial nerves).
6. Subluxation in the atlantoaxial joint, incl. with myelopathy, instability of the cervical spine
7. Atherosclerosis

Comments

To the section “Main diagnosis”. Seropositivity and seronegativity are determined by a test for rheumatoid factor (RF), which must be carried out using a reliable quantitative or semi-quantitative test (latex test, enzyme immunoassay, immunonephelometric method),

To the heading “Disease activity”. Assessment of activity in accordance with modern requirements is carried out using the index - DAS28, which evaluates pain and swelling of 28 joints: DAS 28 = 0.56. √ (BBS) + 0.28. √ (NPV)+ 0.70 .Ln (ESR)+0.014 ESHR, where NPV is the number of painful joints out of 28; NPS - number of swollen joints; Ln - natural logarithm; General health status or general assessment of disease activity according to the patient using a Visual Analog Scale (VAS).
A DAS28 value >5.1 corresponds to high disease activity; DAS<3,2 - умеренной/ низкой активности; значение DAS< 2,6 - соответствует ремиссии. Вычисление DAS 28 проводить с помощью специальных калькуляторов.

To the heading “Instrumental characteristics”.
Modified stages of RA according to Steinbrocker:
Stage I- periarticular osteoporosis, single small cyst-like clearings of bone tissue (cysts) in the subchondral part of the articular surface of the bone;
Stage 2A - periarticular osteoporosis, multiple cysts, narrowing of joint spaces;
Stage 2B - stage 2A symptoms of varying severity and single erosions of the articular surfaces (5 or less erosions);
Stage 3 - stage 2A symptoms of varying severity and multiple erosions (6 or more erosions), subluxations and dislocations of joints;
Stage 4 - symptoms of stage 3 and ankylosis of the joints.
To the heading “Functional class”. Description of characteristics. Self-care - dressing, eating, personal care, etc. Non-professional activities - creativity and/or recreation and professional activities - work, study, housekeeping - are desirable for the patient, specific to gender and age.

Flow options:
According to the nature of progression of joint destruction and extra-articular (systemic) manifestations, the course of RA is variable:
- Long-term spontaneous clinical remission (< 10%).
- Intermittent course (15-30%): periodically occurring complete or partial remission (spontaneous or treatment-induced), followed by exacerbation involving previously unaffected joints.
- Progressive course (60-75%): increasing destruction of joints, damage to new joints, development of extra-articular (systemic) manifestations.
- Rapidly progressive course (10-20%): constantly high disease activity, severe extra-articular (systemic) manifestations.

Special clinical forms
- Felty's syndrome is a symptom complex that includes severe destructive joint damage with persistent leukopenia with neutropenia, thrombocytopenia, splenomegaly; systemic extra-articular manifestations (rheumatoid nodules, polyneuropathy, chronic trophic ulcers of the legs, pulmonary fibrosis, Sjogren's syndrome), high risk of infectious and inflammatory complications.
- Adult Still's disease is a unique form of RA, characterized by severe, rapidly progressive articular syndrome in combination with generalized lymphadenopathy, maculopapular rash, high laboratory activity, significant weight loss, prolonged fever of remitting, intermittent or septic nature, seronegativity for RF and ANF.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures before planned hospitalization

Laboratory research:
1. General blood test
2. General urine test
3. Microreaction
4. Fecal occult blood test
5. Activity of liver enzymes (ALT, AST)
6. Contents of creatinine, urea, total protein, glucose, bilirubin, cholesterol
7. Content of C-reactive protein (CRP), rheumatoid factor
8. Antibodies to cyclic citrullinated peptide (ACCP)
9. Upon initial diagnosis - ELISA for STDs (chlamydia, gonorrhea, trichomonas), if the result is positive, preliminary sanitation of the source of infection is required before hospitalization

Instrumental examination:
1. X-ray of the OGK; FLG;ECG
2. X-ray of the hands - annually
3. X-ray of the pelvic bones (detection of aseptic necrosis of the femoral head) and other joints - according to indications
4. FGDS
5. Ultrasound of the abdominal organs

List of additional diagnostic measures (according to indications):
1. Markers of hepatitis B, C and HIV viruses
2. Daily proteinuria;
3. ECHO-KG
4. Biopsy for amyloidosis
5. CT scan of the thoracic segment

List of basic diagnostic measures in the hospital
1. CBC, expanded with platelets
2. Coagulogram
3. CRP, RF, ACCP, protein fractions, creatinine, triglycerides, lipoproteins, ALT, AST, thymol test
4. EchoCG
5. Ultrasound of the abdominal organs and kidneys
6. R-graphy brushes

List of additional diagnostic measures in the hospital:
1. FGDS according to indications
2. R-graphy of the pelvic bones and other joints - according to indications
3. R-graph of OGK - according to indications
4. Urinalysis according to Nechiporenko - according to indications
5. Densitometry according to indications
6. Determination of Ca, alkaline phosphatase
7. Feces for occult blood
8. Ultrasound of joints - according to indications
9. Consultation with narrow specialists - according to indications
10. Analysis of synovial fluid

Diagnostic criteria for RA.

To make a diagnosis of RA, a rheumatologist must use the American League of Rheumatology criteria (1997).

American League of Rheumatology Criteria (1997).
Morning stiffness is stiffness in the morning in the joints or periarticular tissues, lasting at least 1 hour, existing for 6 weeks.
Arthritis of 3 or more joints - swelling of the periarticular soft tissues or the presence of fluid in the joint cavity, diagnosed by a doctor in at least 3 joints.
Arthritis of the joints of the hands is swelling of at least one of the following groups of joints: wrist, metatarsophalangeal and proximal interphalangeal.
Symmetrical arthritis - bilateral damage to the joints (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal).
Rheumatoid nodules are subcutaneous nodules (diagnosed by a doctor), localized mainly on protruding areas of the body, extensor surfaces or in periarticular areas (on the extensor surface of the forearm, near the elbow joint, in the area of ​​other joints).
RF - detection of elevated titers in blood serum by any standardized method.
X-ray changes typical of RA: erosions or periarticular osteoporosis, bone decalcification (cysts), localized in the wrist joints, hand joints and most pronounced in clinically affected joints.
The diagnosis of RA is made when at least 4 of 7 criteria are met, and criteria 1 to 4 must be maintained for at least 6 weeks.
For the new diagnostic criteria, four groups of parameters were selected, and each parameter, based on multivariate static analysis, received a score; with a score of 6 or more, a definite diagnosis of RA is established.
It is necessary to collect information about concomitant pathology, previous therapy, and the presence of bad habits.

Complaints and anamnesis
Start options
Characterized by a variety of options for the onset of the disease. In most cases, the disease begins with polyarthritis; less often, manifestations of arthritis can be moderately expressed, and arthralgia, morning stiffness in the joints, deterioration in general condition, weakness, weight loss, low-grade fever, lymphadenopathy predominate, which may precede clinically significant joint damage.

Symmetrical polyarthritis with gradual(over several months) increasing pain and stiffness, mainly in the small joints of the hands (in half of the cases).

Acute polyarthritis with predominant damage to the joints of the hands and feet, severe morning stiffness (usually accompanied by the early appearance of RF in the blood).

Mono-, oligoarthritis of the knee or shoulder joints with subsequent rapid involvement of small joints of the hands and feet in the process.

Acute monoarthritis of large joints, resembling septic or microcrystalline arthritis.

Acute oligo- or polyarthritis with severe systemic phenomena (febrile fever, lymphadenopathy, hepatosplenomegaly) are more often observed in young patients (reminiscent of Still's disease in adults).

"Palindromic rheumatism": multiple recurrent attacks of acute symmetrical polyarthritis of the joints of the hands, less often of the knee and elbow joints; last several hours or days and end with complete recovery.

Recurrent bursitis and tenosynovitis, especially often in the area of ​​the wrist joints.

Acute polyarthritis in the elderly: multiple lesions of small and large joints, severe pain, diffuse swelling and limited mobility. It is called “RSPE syndrome” (Remitting Seronegative symmetric synovitis with Pitting Edema).

Generalized myalgia: stiffness, depression, bilateral carpal tunnel syndrome, weight loss (usually develops in old age and resembles polymyalgia rheumatica); characteristic clinical signs of RA develop later.

Physical examination

Joint damage
The most characteristic manifestations at the onset of the disease:
- pain (during palpation and movement) and swelling (associated with effusion into the joint cavity) of the affected joints;
- weakening of hand compression force;
- morning stiffness in the joints (duration depends on the severity of synovitis);
- rheumatoid nodules (rare).

The most characteristic manifestations in the advanced and final stages of the disease:
- Brushes: ulnar deviation of the metacarpophalangeal joints, usually developing 1-5 years from the onset of the disease; lesions of the fingers of the hands in the “boutonniere” type (flexion in the proximal interphalangeal joints) or “swan neck” (hyperextension in the proximal interphalangeal joints); “lornette” type deformation of the hand.
- Knee joints: flexion and valgus deformity, Baker's cyst.
- Feet: subluxation of the heads of the metatarsophalangeal joints, lateral deviation, deformation of the big toe.
- Cervical spine: subluxations in the area of ​​the atlantoaxial joint, occasionally complicated by compression of the spinal cord or vertebral artery.
- Cricoid-arytenoid joint: deepening of the voice, shortness of breath, dysphagia, recurrent bronchitis.
- Ligamentous apparatus and synovial bursae: tenosynovitis in the area of ​​the wrist and hand; bursitis, most often in the elbow joint; synovial cyst on the back of the knee joint (Baker's cyst).

Extra-articular manifestations
Sometimes the following may prevail in the clinical picture:
- Constitutional symptoms: generalized weakness, malaise, weight loss (up to cachexia), low-grade fever.
- The cardiovascular system: pericarditis, vasculitis, granulomatous heart valve disease (very rare), early development of atherosclerosis.
- Lungs:pleurisy, interstitial lung disease, bronchiolitis obliterans, rheumatoid nodules in the lungs (Kaplan syndrome).
- Leather:rheumatoid nodules, thickening and hypotrophy of the skin; digital arteritis (rarely with the development of gangrene of the fingers), microinfarctions in the nail bed, livedo reticularis.
- Nervous system:compression neuropathy, symmetric sensory-motor neuropathy, multiple mononeuritis (vasculitis), cervical myelitis.
- Muscles:generalized amyotrophy.
- Eyes:dry keratoconjunctivitis, episcleritis, scleritis, scleromalacia, peripheral ulcerative keratopathy.
- Kidneys:amyloidosis, vasculitis, nephritis (rare).
- Blood system: anemia, thrombocytosis, neutropenia.

Cardiovascular and severe infectious complications are risk factors for poor prognosis.

Laboratory research
Goals of laboratory examination
- confirmation of diagnosis;
- exclusion of other diseases;
- assessment of disease activity;
- forecast assessment;
- assessment of the effectiveness of therapy;
- identification of complications (both the disease itself and side effects of the therapy).

Clinical significance of laboratory tests
General blood analysis:
- leukocytosis/thrombocytosis/eosinophilia - severe RA with extra-articular (systemic) manifestations; combined with high RF titers; may be associated with GC treatment.
- persistent neutropenia - exclude Felty's syndrome.
- anemia (Нь< 130 г/л у мужчин и 120 г/л у женщин) - активность заболевания; исключить желудочное или кишечное кровотечение.
- increase in ESR and CRP - differential diagnosis of RA from non-inflammatory joint diseases; assessment of inflammation activity, therapy effectiveness; predicting the risk of progression of joint destruction.

Biochemical research:
- a decrease in albumin correlates with the severity of the disease.
- An increase in creatinine is often associated with nephrotoxicity of NSAIDs and/or DMARDs.
- increase in the level of liver enzymes - disease activity; hepatotoxicity of NSAIDs and DMARDs; liver damage associated with carriage of hepatitis B and C viruses.
- hyperglycemia - glucocorticoid therapy.
- dyslipidemia - glucocorticoid therapy; inflammatory activity (decreased concentrations of high-density lipoprotein cholesterol, increased concentrations of low-density lipoprotein cholesterol).

Immunological study:
- increase in RF titers (70-90% of patients), high titers correlate with the severity, progression of joint destruction and the development of systemic manifestations;
- an increase in anti-CCP titers is a more “specific” marker of RA than RF;
- increase in ANF titers (30-40% of patients) - in severe RA;
- HLA-DR4 (DRB1*0401 allele) is a marker of severe RA and poor prognosis.

In the synovial fluid in RA, there is a decrease in viscosity, a loose mucin clot, leukocytosis (more than 6x109/l); neutrophilia (25-90%).

In the pleural fluid, the inflammatory type is determined: protein >3 g/l, glucose<5 ммоль/л, лактатдегидрогеназа >1000 U/ml, pH 7.0; RF titers > 1:320, complement reduced; cytosis - cells 5000 mm3 (lymphocytes, neutrophils, eosinophils).

Instrumental studies
X-ray examination of joints:
Confirmation of the diagnosis of RA, stage and assessment of the progression of destruction of the joints of the hands and feet.
Changes characteristic of RA in other joints (at least in the early stages of the disease) are not observed.

X-ray of the chest organs indicated for identifying rheumatoid lesions of the respiratory system and concomitant lesions of the lungs (tuberculosis COPD, etc.).

Magnetic resonance imaging (MRI):
- a more sensitive (than radiography) method for detecting joint damage at the onset of RA.
- early diagnosis of osteonecrosis.

Doppler ultrasonography: a more sensitive (than radiography) method for detecting joint damage at the onset of RA.

High resolution computed tomography: diagnosis of lung damage.

Echocardiography: diagnosis of rheumatoid pericarditis, myocarditis and coronary artery disease-related heart damage.

Dual-energy X-ray absorptiometry

Diagnosis of osteoporosis in the presence of risk factors:
- age (women >50 years, men >60 years).
- disease activity (persistent increase in CRP >20 mg/l or ESR >20 mm/h).
- functional status (Steinbroker score >3 or HAQ score>1.25).
- body mass<60 кг.
- taking GK.
- sensitivity (3 out of 5 criteria) for diagnosing osteoporosis in RA is 76% in women, 83% in men, and specificity is 54% and 50%, respectively.

Arthroscopy indicated for the differential diagnosis of RA with villous-nodular synovitis, osteoarthritis, and traumatic joint damage.

Biopsy indicated for suspected amyloidosis.

Indications for consultation with specialists:
- Orthopedic traumatologist - to resolve the issue of surgical intervention.
- Oculist - in case of damage to the organs of vision.

Differential diagnosis

Differential diagnosis It is often performed with diseases such as osteoarthritis and rheumatic fever (Table 1).

Table 1. Clinical and laboratory characteristics of rheumatoid arthritis, rheumatoid arthritis and osteoarthritis

At the onset of RA, joint damage (and some other clinical manifestations) is similar to joint damage in other rheumatic and non-rheumatic diseases.

Osteoarthritis. Minor swelling of soft tissues, involvement of the distal interphalangeal joints, absence of severe morning stiffness, increased severity of pain towards the end of the day.

Systemic lupus erythematosus. Symmetrical damage to the small joints of the hands, wrists and knees. Arthritis is non-deforming (with the exception of Jaccoud's arthritis); there may be soft tissue swelling, but intra-articular effusion is minimal; high titers of ANF (however, up to 30% of RA patients have ANF), rarely - low titers of RF; X-rays show no bone erosions.

Gout. The diagnosis is made based on the identification of crystals in the synovial fluid or tophi with characteristic negative birefringence under polarizing microscopy. In the chronic form, there may be symmetrical damage to the small joints of the hands and feet with the presence of tophi; subcortical erosions are possible on radiographs.

Psoriatic arthritis. Monoarthritis, asymmetric oligoarthritis, symmetric polyarthritis, mutilating arthritis, lesions of the axial skeleton. Frequent damage to the distal interphalangeal joints, fusiform swelling of the fingers, changes in the skin and nails characteristic of psoriasis.

Ankylosing spondylitis. Asymmetric mono-, oligoarthritis of large joints (hip, knee, shoulder), spinal column, sacroiliac joints; peripheral joints may be involved; HLA-B27 expression.

Reactive arthritis. Arthritis is oligoarticular and asymmetric, with predominant involvement of the lower extremities, HLA-B27 expression. Caused by infection with various microorganisms (Chlamydia, Escherichia coli, Salmonella, Campylobacter, Yersinia and etc.); Reiter's syndrome: urethritis, conjunctivitis and arthritis; the presence of pain in the heel areas with the development of enthesitis, keratoderma on the palms and soles and circular balanitis.

Bacterial endocarditis. Damage to large joints; fever with leukocytosis; heart murmurs; A blood culture test is mandatory in all patients with fever and polyarthritis.

Rheumatic fever. Migratory oligoarthritis with predominant damage to large joints, carditis, subcutaneous nodules, chorea, ring-shaped erythema, fever. Specific (for streptococci) serological reactions.

Septic arthritis. Usually monoarticular, but can also be oligoarticular; with predominant damage to large joints; may be migratory. Blood culture, aspiration of fluid from the joint cavity with a study of cellular composition, Gram staining and culture; RA patients may also have septic arthritis.

Viral arthritis. Morning stiffness with symmetrical damage to the joints of the hands and wrist joints is characteristic; RF and viral exanthema can be detected. In most cases, it resolves spontaneously within 4-6 weeks (with the exception of arthritis associated with parvovirus infection).

Systemic scleroderma. Raynaud's phenomenon and skin thickening; rarely arthritis, usually arthralgia, can be detected; limitation of range of motion associated with the attachment of the skin to the underlying fascia.

Idiopathic inflammatory myopathies. Arthritis with severe synovitis is rarely found. Muscle inflammation, characterized by proximal muscle weakness, increased levels of CPK and aldolase, arthralgia and myalgia, and pathological changes in the electromyogram.

Mixed connective tissue disease. In 60-70% of cases, arthritis can be deforming and erosive. Characteristic features of SLE, systemic scleroderma and myositis; ATs to ribonucleoprotein are characteristic.

Lyme disease. In the early stages - erythema migrans and cardiovascular pathology, in the later stages - intermittent mono- or oligoarthritis (in 15% of patients it can be chronic and erosive), encephalopathy and neuropathy; 5% of healthy people have a positive reaction to Lyme borreliosis.

Polymyalgia rheumatica. Diffuse pain and morning stiffness in axial joints and proximal muscle groups; swelling of the joints is detected less frequently; pronounced ESR; rarely occurs before the age of 50 years. Pronounced response to glucocorticoid therapy; in 10-15% it is combined with giant cell arteritis.

Behçet's disease. Differential diagnosis with scleritis in RA.

Amyloidosis. Periarticular amyloid deposition; there may be effusion into the joint cavity. Congo red staining of aspirated joint fluid.

Hemochromatosis. Enlargement of the bone structures of the 2nd and 3rd metacarpophalangeal joints; increased serum iron and ferritin levels with decreased transferrin-binding capacity; X-rays may reveal chondrocalcinosis. Diagnosed by liver biopsy.

Sarcoidosis. Chronic granulomatous disease, in 10-15% accompanied by chronic symmetrical polyarthritis.

Hypertrophic osteoarthropathy. Oligoarthritis of the knee, ankle and wrist joints; periosteal new bone formation; deep and aching pain. “Drumsticks”, connection with pulmonary disease, pain in the limbs in a certain position.

Multicentric reticulohistiocytosis. Dermatoarthritis, periungual papules, painful destructive polyarthritis. Characteristic changes during biopsy of the affected skin area.

Familial Mediterranean fever. Recurrent attacks of acute synovitis (mono- or oligoarticular) of large joints, associated with fever, pleurisy and peritonitis.

Relapsing polychondritis. Widespread progressive inflammation and destruction of cartilage and connective tissue; migrating asymmetric and non-erosive arthritis of small and large joints; inflammation and deformation of the cartilage of the auricle.

Fibromyalgia. Widespread musculoskeletal pain and stiffness, paresthesia, unproductive sleep, fatigue, multiple symmetrical “trigger” points (presence of 11 out of 18 is sufficient for diagnosis); laboratory tests and joint examination - without pathology.

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Treatment

Treatment tactics for patients with RA

RECOMMENDATIONS FOR TREATMENT OF PATIENTS WITH RHEUMATOID ARTHRITIS
According to modern standards, treatment of RA should be based on the following basic principles:
The main goal is to achieve complete (or at least partial) remission.

To achieve this goal:
1. Treatment with DMARDs should begin as early as possible;
2. Treatment should be as active as possible with changes (if necessary) in the treatment regimen for 2-6 months;
3. When choosing therapy, you must consider:
- risk factors for poor prognosis, which include high RF titers, increased ESR and CRP, rapid development of joint destruction
- duration of the period between the onset of symptoms and the start of DMARD therapy:
a) if it is more than 6 months, therapy should be more active;
b) in the presence of risk factors, the drug of choice is methotrexate (initial dose 7.5 mg/week) with a rapid (over about 3 months) dose increase to 20-25 mg/week;
c) the effectiveness of therapy should be assessed using standardized clinical and radiological criteria.

The use of non-pharmacological and pharmacological methods, the involvement of specialists from other specialties (orthopedists, physiotherapists, cardiologists, neurologists, psychologists, etc.); Treatment of patients should be carried out by rheumatologists and be as individualized as possible depending on clinical manifestations and activity.

Non-drug treatment
1. Avoid factors that could potentially provoke an exacerbation of the disease (intercurrent infections, stress, etc.).

2. Quitting smoking and drinking alcohol:
- smoking may play a role in the development and progression of RA;
- an association was identified between the number of cigarettes smoked and RF positivity, erosive changes in the joints and the appearance of rheumatoid nodules, as well as lung damage (in men).

3. Maintaining ideal body weight.

4. A balanced diet, including foods high in polyunsaturated fatty acids (fish oil, olive oil, etc.), fruits, vegetables:
- Potentially suppresses inflammation;
- reduces the risk of cardiovascular complications.

5. Patient education (changing the stereotype of physical activity, etc.)

6. Physical therapy (1-2 times a week)

7. Physiotherapy: heat or cold procedures, ultrasound, laser therapy (for moderate RA activity)

8. Orthopedic benefits (prevention and correction of typical joint deformities and instability of the cervical spine, wrist splints, neck corset, insoles, orthopedic shoes)

9. Sanatorium-resort treatment is indicated only for patients in remission.

10. Throughout the course of the disease, active prevention and treatment of concomitant diseases are necessary.

Drug treatment

Basic provisions
To reduce joint pain, all patients are prescribed NSAIDs
- NSAIDs have a good symptomatic (analgesic) effect
- NSAIDs do not affect the progression of joint destruction

Treatment of RA is based on the use DMARDs
- Treatment of RA with the use of DMARDs should be started as early as possible, preferably within 3 months from the onset of symptoms of the disease
- early initiation of DMARD treatment improves function and slows the progression of joint destruction
- “late” administration of DMARDs (3-6 months from the onset of the disease) is associated with a decrease in the effectiveness of DMARD monotherapy
- the longer the duration of the disease, the lower the effectiveness of DMARDs.
The effectiveness of therapy should be assessed using standardized methods

Nonsteroidal anti-inflammatory drugs (NSAIDs)
Key points:
1. NSAIDs are more effective than paracetamol.
2. Treatment with NSAIDs should be carried out in combination with active DMARD therapy.
3. The incidence of remission during NSAID monotherapy is very low (2.3%).

In the general population of RA patients, NSAIDs in equivalent doses do not differ significantly in effectiveness, but they differ in the frequency of side effects:
- since the effectiveness of NSAIDs can vary significantly in individual patients, individual selection of the most effective NSAID for each patient is necessary
- selection of an effective dose of NSAIDs is carried out within 14 days.

Do not exceed the recommended dose of NSAIDs and COX-2 inhibitors: this usually leads to increased toxicity, but not the effectiveness of treatment.
It is recommended to begin treatment with the administration of the safest NSAIDs (short T1/2, no accumulation) and at the minimum effective dose.
You should not take 2 or more different NSAIDs at the same time (with the exception of low-dose aspirin).
Inhibitors (selective) COX-2 are not inferior in effectiveness to standard (non-selective) NSAIDs.

When choosing an NSAID, the following factors must be taken into account:
- safety (presence and nature of risk factors for side effects);
- presence of concomitant diseases;
- the nature of interaction with other drugs taken by the patient;
- price.

All NSAIDs (as well as selective COX-2 inhibitors) are more likely to cause gastrointestinal, renal, and cardiovascular side effects than placebo.
Selective COX-2 inhibitors are less likely to cause gastrointestinal damage than standard NSAIDs.
If there is a history of severe gastrointestinal damage, antiulcer therapy using proton pump inhibitors (omeprazole) is necessary.

Although an increase in the risk of thrombosis during treatment with COX-2 inhibitors (with the exception of rofecoxib) has not been proven, the following steps must be taken before a final decision on their cardiovascular safety is made:
- inform doctors and patients in detail about the potential cardiovascular side effects of all drugs that have the characteristics of COX-2 inhibitors;
- prescribe them with extreme caution in patients at risk of cardiovascular complications;
- conduct careful monitoring of cardiovascular complications (especially arterial hypertension) throughout the entire period of taking the drugs;
- do not exceed recommended doses.

When administered parenterally and rectally, NSAIDs reduce the severity of symptomatic gastroenterological side effects, but do not reduce the risk of severe complications (perforation, bleeding).
In patients with risk factors for NSAID gastropathy, treatment should begin with COX-2 inhibitors (meloxicam, nimesulide).

Risk factors for the development of NSAID gastropathy include the following:
- age over 65 years;
- history of severe gastrointestinal damage (ulcers, bleeding, perforation);
- concomitant diseases (cardiovascular pathology, etc.);
- taking high doses of NSAIDs;
- combined use of several NSAIDs (including low doses of aspirin);
- taking GC and anticoagulants;
- infection Helicobacter pylori.
Celecoxib should not be prescribed to patients with a history of allergy to sulfonamides or cotrimaxozole.

Recommended doses of NSAIDs: lornoxicam 8 mg. 16 mg/day in 2 divided doses, diclofenac 75-150 mg/day in 2 divided doses; ibuprofen 1200-2400 mg/day in 3-4 doses; indomethacin 50-200 mg/day in 2-4 doses (max. 200 mg); ketoprofen 100-400 mg/day in 3-4 doses; aceclofenac 200 mg in 2 doses; meloxicam 7.5-15 mg/day in 1 dose; piroxicam 20 - 20 mg/day in 1 dose; etoricoxib 120 - 240 mg/day in 1-2 doses; etodolac 600 - 1200 mg/day in 3 - 4 doses.

Note. When treating with diclofenac, concentrations of aspartate aminotransferase and alanine aminotransferase should be determined 8 weeks after the start of treatment. When taking angiotensin-converting enzyme (ACE) inhibitors together, serum creatinine should be determined every 3 weeks.

Glucocorticoids (GC)
Key points:
1. GCs (methylprednisolone 4 mg) in some cases slow down the progression of joint destruction.
2. The effectiveness/cost ratio of GCs is better than that of NSAIDs.
3. In the absence of special indications, the dose of GC should not exceed 8 mg/day in terms of methylprednisolone and 10 mg in terms of prednisolone.
4. HA should be used only in combination with DMARDs.

Most of the side effects of GC are an inevitable consequence of GC therapy:
- develop more often with long-term use of high doses of GC;
- some side effects develop less frequently than with the treatment of NSAIDs and DMARDs (for example, severe damage to the gastrointestinal tract);
- prevention and treatment of some side effects (for example, glucocorticoid osteoporosis) are possible.

Indications for prescribing low doses of GC:
- suppression of joint inflammation before the onset of DMARD action.
- suppression of joint inflammation during exacerbation of the disease or the development of complications of DMARD therapy.
- ineffectiveness of NSAIDs and DMARDs.
- contraindications to the use of NSAIDs (for example, in elderly people with a history of peptic ulcers and/or impaired renal function).
- achieving remission in some types of RA (for example, with seronegative RA in the elderly, reminiscent of polymyalgia rheumatica).

For rheumatoid arthritis, glucocorticoids should only be prescribed by a rheumatologist!

Pulse therapy HA(Methylprednisolone 250 mg):
severe systemic manifestations of RA at a dose of 1000 mg-3000 mg per course.
- used in patients with severe systemic manifestations of RA;
- sometimes allows you to achieve rapid (within 24 hours), but short-term suppression of the activity of inflammation of the joints;
- since the positive effect of GC pulse therapy on the progression of joint destruction and prognosis has not been proven, use (without special indications) is not recommended.

Local (intra-articular) therapy(betamethasone):
Key points:
- used to suppress arthritis at the onset of the disease or exacerbations of synovitis in one or more joints, improving joint function;
- leads only to temporary improvement;
- the effect on the progression of joint destruction has not been proven.
Recommendations:
- repeated injections into the same joint no more than 3 times a year;
- use sterile materials and instruments;
- rinse the joint before administering drugs;
- avoid putting stress on the joint for 24 hours after the injection.

Basic anti-inflammatory drugs (DMARDs)

Basic provisions
To achieve the goal, it is necessary to early prescribe DMARDs to all RA patients, regardless of the stage and degree of treatment activity, taking into account concomitant diseases and contraindications, long-term continuous, active treatment with changes (if necessary) in the regimen for 2-6 months, constant monitoring of therapy tolerability , informing patients about the nature of the disease, the side effects of the drugs used and, if appropriate symptoms appear, the need to immediately stop taking them and consult a doctor. When choosing therapy, it is necessary to take into account risk factors for poor prognosis (high titers of RF and/or ACCP, increased ESR and CRP, rapid development of joint destruction).

Methotrexate (MTX):
1. Drug of choice (“gold standard”) for “seropositive” active RA.
2. Compared to other DMARDs, it has the best efficacy/toxicity ratio.
3. Treatment interruption is more often associated with drug toxicity than with the lack of effect.
4. The main drug for combination therapy of DMARDs.
5. Treatment with methotrexate (compared to treatment with other DMARDs) is associated with a reduced risk of mortality, including cardiovascular mortality

Recommendations for use:
1. Methotrexate is prescribed once a week (orally or parenterally); more frequent use may lead to the development of acute and chronic toxic reactions.
2. Fractional doses at 12-hour intervals (in the morning and evening hours).
3. If there is no effect when taken orally (or if toxic reactions develop from the gastrointestinal tract), switch to parenteral administration (im or subcutaneous):
- the lack of effect when taking methotrexate orally may be due to low absorption in the gastrointestinal tract;
- the initial dose of methotrexate is 7.5 mg/week, and in elderly people and with impaired renal function 5 mg/week;
- do not administer to patients with renal failure;
- do not prescribe to patients with severe lung damage.
4. Efficacy and toxicity are assessed after approximately 4 weeks; with normal tolerability, the dose of methotrexate is increased by 2.5-5 mg per week.
5. The clinical effectiveness of methotrexate is dose dependent in the range from 7.5 to 25 mg/week. Taking a dose of more than 25-30 mg/week is not advisable (increased effect has not been proven).
6. To reduce the severity of side effects, if necessary, it is recommended:
- use short-acting NSAIDs;
- avoid prescribing acetylsalicylic acid (and, if possible, diclofenac);
- on the day of taking methotrexate, replace NSAIDs with GCs in low doses;
- take methotrexate in the evening;
- reduce the dose of NSAIDs before and/or after taking methotrexate;
- switch to taking another NSAID;
- in case of insufficient effectiveness and tolerability (non-severe adverse reactions) of oral MTX, it is advisable to prescribe a parenteral (subcutaneous) form of the drug;
- prescribe antiemetics;
- take folic acid at a dose of 5-10 mg/week after taking methotrexate (taking folic acid reduces the risk of developing gastroenterological and hepatic side effects and cytopenia);
- exclude alcohol intake (increases the toxicity of methotrexate), substances and foods containing caffeine (reduces the effectiveness of methotrexate);
- exclude taking drugs with antifolate activity (primarily cotrimoxazole).
- in case of an overdose of methotrexate (or the development of acute hematological side effects), it is recommended to take folic acid (15 mg every 6 hours), 2-8 doses depending on the dose of methotrexate.

Main side effects: infections, gastrointestinal and liver damage, stomatitis, alopecia, hematological (cytopenia), sometimes myelosuppression, hypersensitivity pneumonitis.

Sulfasalazine 500 mg- an important component of combination therapy for patients with RA or in the presence of a contraindication to the use of MT.
Recommendations for use.
1. Typically used dose in adults is 2 g (1.5-3 g, 40 mg/kg/day) 1 g 2 times daily with food:
- 1st week - 500 mg
- 2nd week - 1000 mg
- 3rd week - 1500 mg
- 4th week - 2000 mg.
2. If a sore throat, mouth ulcers, fever, severe weakness, bleeding, or skin itching occurs, patients should immediately discontinue the drug on their own.

Main side effects: damage to the gastrointestinal tract (GIT), dizziness, headaches, weakness, irritability, liver dysfunction, leukopenia, hemolytic anemia, thrombocytopenia, rash, sometimes myelosuppression, oligospermia.

The drug Leflunomide:
1. It is not inferior in effectiveness to sulfasalazine and methotrexate.
2. It is superior to methotrexate and sulfasalazine in terms of its effect on the quality of life of patients.
3. The incidence of side effects is lower than that of other DMARDs.
Main indication for use: insufficient effectiveness or poor tolerability of methotrexate.

Recommendations for use
1. 100 mg/day for 3 days (“saturating” dose), then 20 mg/day.
2. When using a “saturating” dose, the risk of treatment interruption increases due to the development of side effects; Careful monitoring of adverse reactions is required.
3. Currently, most experts recommend starting treatment with leflunomide at a dose starting at 20 mg/day (or even 10 mg/day); It is recommended to compensate for the slow increase in clinical effect by intensifying concomitant therapy (for example, low doses of GCs).

Main side effects: cytopenia, liver and gastrointestinal damage, destabilization of blood pressure, sometimes myelosuppression.

4-Aminoquinoline derivatives:
1. Inferior to other DMARDs in clinical effectiveness.
2. They do not slow down the progression of joint destruction.
3. Positively affect the lipid profile.
4. Chloroquine is more likely to cause side effects than hydroxychloroquine.
5. Potential indications for use:
- early stage, low activity, absence of risk factors for poor prognosis
- undifferentiated polyarthritis, if it is impossible to exclude the onset of a systemic connective tissue disease.

Recommendations for use:
1. Do not exceed the daily dose: hydroxychloroquine 400 mg (6.5 mg/kg), chloroquine 200 mg (4 mg/kg).
2. Conduct ophthalmological monitoring before prescribing aminoquinoline derivatives and every 3 months during treatment:
- asking the patient about visual disorders;
- fundus examination (pigmentation);
- study of visual fields.
3. Do not administer to patients with uncontrolled arterial hypertension and diabetic retinopathy.
4. Do not use simultaneously with drugs that have an affinity for melanin (phenothiazines, rifampicin).
5. Explain to the patient the need for self-monitoring of visual impairment.
6. Recommend wearing protective glasses in sunny weather (regardless of the season).

Note: Reduce dose for liver and kidney diseases.
Main side effects: retinopathy, neuromyopathy, itching, diarrhea.

Cyclosporine:
Recommended for use when other DMARDs are ineffective. At the same time, cyclosporine is characterized by a high frequency of side effects and a high frequency of unwanted drug interactions. Take 75-500 mg orally 2 times a day (<5 мг/кг/сут.).
Indications: RA is severe forms of active course in cases where classical DMARDs are ineffective or their use is impossible.

Main side effects: increased blood pressure, impaired renal function, headaches, tremors, hirsutism, infections, nausea/vomiting, diarrhea, dyspepsia, gum hyperplasia. If the creatinine level increases by more than 30%, it is necessary to reduce the drug dose by 0.5-1.0 mg/kg/day for 1 month. If the creatinine level decreases by 30%, continue drug treatment, and if the increase remains 30%, stop treatment.

Azathioprine, D-penicillamine, cyclophosphamide, chlorambucil.
Potential indication: ineffectiveness of other DMARDs or contraindications to their use.

Combination therapy of DMARDs.
There are 3 main options for combination therapy: start treatment with monotherapy followed by one or more DMARDs (for 8-12 weeks) while maintaining the activity of the process ; begin treatment with combination therapy, followed by transfer to monotherapy (after 3-12 months) if the activity of the process is suppressed, combination therapy is carried out throughout the entire period of the disease. In patients with severe RA, treatment should begin with combination therapy, and in patients with moderate activity - with monotherapy, followed by transfer to combination therapy if treatment is insufficiently effective.
Combinations of DMARDs without signs of poor prognosis:
- MTX and hydroxychloroquine - with long duration of RA and low activity;
- MT and leflunomide - with an average duration (≥ 6 months), the presence of poor prognosis factors;
- MTX and sulfasalazine - for any duration of RA, high activity, signs of poor prognosis;
- MTX + hydroxychloroquine + sulfasalazine - in the presence of poor prognosis factors and with moderate/high disease activity, regardless of the duration of the disease.

Genetically engineered biological products
For the treatment of RA, GEBDs are used, which include TNF-α inhibitors (etanercept, infliximab, golimumab), the anti-B cell drug rituximab (RTM) and the interleukin 6 receptor blocker tocilizumab (TCZ).
Indications:
- patients with RA who do not respond sufficiently to MT and/or other synthetic DMARDs, with moderate/high activity of RA in patients with signs of poor prognosis: high disease activity, RF + /ACCP +, early appearance of erosions, rapid progression (appearance of more than 2 erosions for 12 months even with a decrease in activity);
- persistence of moderate/high activity or poor tolerability of therapy with at least two standard DMARDs, one of which should be MTX for 6 months and more or less 6 months if it is necessary to discontinue DMARDs due to the development of side effects (but usually not less than 2 months);
- the presence of moderate/high RA activity or an increase in titers of serological tests (RF + /ACCP +) must be confirmed in the process of 2-fold determination within 1 month.

Contraindications:
- pregnancy and lactation;
- severe infections (sepsis, abscess, tuberculosis and other opportunistic infections, septic arthritis of non-prosthetic joints during the previous 12 months, HIV infection, hepatitis B and C, etc.);
- heart failure III-IV functional class (NYHA);
- history of demyelinating diseases of the nervous system;
- age less than 18 years (the decision is individual for each case).

Treatment of DMARDs in adult patients with severe active RA in case of ineffectiveness or intolerance to other DMARDs can begin with inhibition of tumor necrosis factor (etanercept, infliximab).

Etanercept is prescribed to adults for the treatment of moderate to severe active rheumatoid arthritis in combination with methotrexate, when the response to disease-modifying anti-inflammatory drugs (DMARDs), including methotrexate, was inadequate.
Etanercept may be prescribed as monotherapy in cases of ineffectiveness or intolerance to methotrexate. Etanercept is indicated for the treatment of severe, active and progressive rheumatoid arthritis in adults who have not previously received methotrexate therapy.
Treatment with etanercept should be prescribed and supervised by a physician experienced in the diagnosis and treatment of rheumatoid arthritis.
Etanercept in the form of a ready-made solution is used for patients weighing more than 62.5 kg. In patients weighing less than 62.5 kg, lyophilisate should be used to prepare the solution.
The recommended dose is 25 mg etanercept twice a week with an interval of 3-4 days. An alternative dose is 50 mg once weekly.
Etanercept therapy should be continued until remission is achieved, usually no more than 24 weeks. Administration of the drug should be discontinued if, after 12 weeks of treatment, no positive dynamics of symptoms are observed.
If it is necessary to re-prescribe etanercept, the duration of treatment indicated above should be observed. The recommended dose is 25 mg twice weekly or 50 mg once weekly.
The duration of therapy in some patients may exceed 24 weeks.
Elderly patients (65 years and older)
There is no need to adjust either the dose or route of administration.

Contraindications
- hypersensitivity to etanercept or any other component of the dosage form;
- sepsis or risk of sepsis;
- active infection, including chronic or localized infections (including tuberculosis);
- pregnancy and lactation period;
- patients weighing less than 62.5 kg.
Carefully:
- Demyelinating diseases, congestive heart failure, immunodeficiency states, blood dyscrasia, diseases predisposing to the development or activation of infections (diabetes mellitus, hepatitis, etc.).

Infliximab prescribed in accordance with the dose and frequency of administration, in combination with Treatment of GEBD in adult patients with severe active RA in case of ineffectiveness or intolerance of other DMARDs, you can begin with inhibition of tumor necrosis factor (infliximab). Infliximab is prescribed in accordance with the dose and frequency of administration, in combination with MTX.
Infliximab at the rate of 3 mg/kg body weight according to the regimen. It is used in combination with MT when it is insufficiently effective, and less often with other DMARDs. Effective in patients with insufficient “response” to MTX in early and late RA. Relatively safe in carriers of the hepatitis C virus. Side effects requiring interruption of treatment occur less frequently than during treatment with other DMARDs.
Before infliximab is prescribed, all patients should be screened for mycobacterial infection according to current national guidelines

Indications:
- lack of effect (“unacceptably high disease activity”) during treatment with methotrexate at the most effective and tolerable dose (up to 20 mg/week) for 3 months or other DMARDs
- 5 or more swollen joints
- increase in ESR more than 30 mm/h or CRP more than 20 mg/l.
- activity corresponds to DAS>3.2
- ineffectiveness of other DMARDs (if there are contraindications for prescribing methotrexate)
- nThe need to reduce the dose of GC.
- if there are contraindications to the use of standard DMARDs, infliximab can be used as the first DMARD.

Infliximab is prescribed in accordance with the dose and frequency of administration, in combination with methotrexate. Infliximab therapy is continued only if adequate response is observed 6 months after the start of therapy. The effect is considered adequate if there is a decrease in the disease activity score (DAS28) by 1, 2 points or more. Monitor treatment with DAS28 assessment every 6 months.

Contraindications:
- severe infectious diseases (sepsis, septic arthritis, pyelonephritis, osteomyelitis, tuberculosis and fungal infections, HIV, hepatitis B and C, etc.); - malignant neoplasms;
- pregnancy and lactation.

Recommendations for use:

- intravenous infusion at a dose of 3 mg/kg, infusion duration - 2 hours;
- 2 and 6 weeks after the first administration, additional infusions of 3 mg/kg each are prescribed, then the administration is repeated every 8 weeks;
- repeated administration of infliximab 2-4 years after the previous injection may lead to the development of delayed-type hypersensitivity reactions;
- patients with RA who have signs of possible latent tuberculosis (history of tuberculosis or changes on chest x-ray) should be given recommendations for preventive anti-tuberculosis therapy, in accordance with current national recommendations, before starting HIBT;
- When clinically warranted, patients with RA should be evaluated for possible tumors. If a malignant tumor is detected, treatment with anti-TNF drugs should be stopped.

Golimumab used in combination with MT. Golimumab is effective in patients who have not previously received MTX, in patients with an insufficient “response” to MTX in early and late RA, as well as in patients who do not respond to other TNF-alpha inhibitors. It is applied subcutaneously.
Before prescribing golimumab, all patients should be assessed for active infectious diseases (including tuberculosis) in accordance with current national recommendations.

Indications:
Golimumab in combination with methotrexate (MTX) is indicated for use in
quality:
- treatment of moderate and severe active rheumatoid arthritis in adults who have an unsatisfactory response to DMARD therapy, including MTX;
- treatment of severe, active and progressive rheumatoid arthritis in adults who have not previously received MTX therapy.
Golimumab in combination with MTX has been shown to reduce the incidence of progression of joint pathology, as demonstrated by radiography, and improve their functional status
Golimumab is prescribed in accordance with the dose and frequency of administration, in combination with MTX. Golimumab therapy is continued only if adequate response is observed 6 months after initiation of therapy. The effect is considered adequate if there is a decrease in the Disease Activity Score (DAS28) of 1.2 points or more. Monitor treatment with DAS28 assessment every 6 months.

Contraindications:
- hypersensitivity to the active substance or any excipients;
- active tuberculosis (TB) or other severe infections, such as sepsis and opportunistic infections;
- moderate or severe heart failure (NYHA class III/IV) .

Recommendations for use:
- treatment is carried out under the supervision of a rheumatologist with experience in diagnosing and treating RA;
- Golimumab at a dose of 50 mg is administered subcutaneously once a month, on the same day of the month;
- Golimumab in patients with RA should be used in combination with MTX;
- in patients weighing more than 100 kg who have not achieved a satisfactory clinical response after administration of 3-4 doses of the drug, increasing the dose of golimumab to 100 mg once a month may be considered.

Patients with RA who have evidence of possible latent tuberculosis (history of tuberculosis or changes on chest x-ray) should be advised on preventive anti-tuberculosis therapy, in accordance with current national recommendations, before starting TB therapy.
When clinically warranted, patients with RA should be evaluated for possible tumors. If a malignant tumor is detected, treatment with anti-TNF drugs should be stopped.

Rituximab. Therapy is considered as a treatment option for adult patients with severe active RA, with insufficient effectiveness, intolerance to TNF-a inhibitors or with contraindications to their use (history of tuberculosis, lymphoproliferative tumors), as well as with rheumatoid vasculitis or signs of poor prognosis (high RF titers, increase in ACCP concentration, increase in ESR and CRP concentration, rapid development of destruction in joints) within 3-6 months from the start of therapy. Rituximab is prescribed in accordance with the dose and frequency of administration (at least every 6 months), in combination with methotrexate. Treatment with rituximab is continued if adequate response is observed after initiation of therapy and if this response is maintained after re-administration of rituximab after at least 6 months. The effect is considered adequate if there is a decrease in the Disease Activity Score (DAS28) of 1.2 points or more.

Tocilizumab. It is used for RA duration of more than 6 months, high disease activity, and signs of poor prognosis (RF+, ACCP+, presence of multiple erosions, rapid progression). Tocilizumab is prescribed in accordance with the dose and frequency of administration (once a month) as monotherapy or in combination with DMARDs in patients with moderate to severe rheumatoid arthritis. Leads to persistent objective clinical improvement and increase in the quality of life of patients. Treatment in monotherapy or in combination with methotrexate should be continued if an adequate effect is observed 4 months after the start of therapy. The effect is considered adequate if there is a decrease in the Disease Activity Score (DAS28) of 1.2 points or more. With intravenous administration of tocilizumab, serum levels of acute inflammatory markers such as C-reactive protein and amyloid-A, as well as erythrocyte sedimentation rate, are reduced. Hemoglobin levels increase as tocilizumab reduces the effect of IL-6 on hepcidin production, resulting in increased iron availability. The greatest effect is observed in patients with rheumatoid arthritis with concomitant anemia. Along with the inhibition of factors in the acute phase of inflammation, treatment with tocilizumab is accompanied by a decrease in the number of platelets within normal values.

Indications for use:
- rheumatoid arthritis of moderate or high activity in monotherapy or as part of complex therapy (methotrexate, basic anti-inflammatory drugs), including to prevent the progression of radiologically proven joint destruction.
- systemic juvenile idiopathic arthritis in monotherapy or in combination with methotrextate in children over 2 years of age.

Directions for use and dosage: The recommended dose for adults is 8 mg/kg body weight once every 4 weeks as an intravenous infusion over 1 hour. Tocilizumab is used as monotherapy or in combination with methotrexate and/or other basic therapy drugs.
Recommended doses in children:
- Body weight less than 30 kg: 12 mg/kg every 2 weeks
- Body weight 30 kg or more: 8 mg/kg every 2 weeks

Contraindications:
- hypersensitivity to tocilizumab or other components of the drug,
- acute infectious diseases and chronic infections in the acute stage,
- neutropenia (absolute number of neutrophils less than 0.5*109/l),
- thrombocytopenia (platelet count less than 50*109/l),
- increase in ALT/AST levels more than 5 times compared to normal (more than 5N),
- pregnancy and lactation period,
- children under 2 years of age.

Recommendations for the treatment of anemia
Anemia due to chronic inflammation - intensify DMARD therapy, prescribe GC (0.5-1 mg/kg per day).
Macrocytic - vitamin B12 and folic acid.
Iron deficiency - iron supplements.
Hemolytic - GK (60 mg/day); if ineffective within 2 weeks, azathioprine 50-150 mg/day.
Blood transfusions are recommended except for very severe anemia, which is associated with a risk of cardiovascular complications.

Felty's syndrome:
- the main drugs are MT, the tactics of use are the same as for other forms of RA;
- GC monotherapy (>30 mg/day) leads only to temporary correction of granulocytopenia, which recurs after a reduction in the GC dose.
In patients with agranulocytosis, the use of GC pulse therapy according to the usual regimen is indicated.

Recommendations for the treatment of extra-articular manifestations of RA:
Pericarditis or pleurisy - GC (1 mg/kg) + DMARDs.
Interstitial lung disease - GC (1 - 1.5 mg/kg) + cyclosporine A or cyclophosphamide; Avoid prescribing methotrexate.
Isolated digital arteritis - symptomatic vascular therapy.
Systemic rheumatoid vasculitis - intermittent pulse therapy with cyclophosphamide (5 mg/kg/day) and methylprednisolone (1 g/day) every 2 weeks. for 6 weeks, followed by lengthening the interval between administrations; maintenance therapy - azathioprine; in the presence of cryoglobulinemia and severe manifestations of vasculitis, plasmapheresis is advisable.
Cutaneous vasculitis - methotrexate or azathioprine.

Surgical intervention
Indications for emergency or emergency surgery:
- Nerve compression due to synovitis or tenosynovitis
- Impending or actual tendon rupture
- Atlantoaxial subluxation, accompanied by neurological symptoms
- Deformations that make it difficult to perform simple daily activities
- Severe ankylosis or dislocation of the lower jaw
- The presence 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 syndrome
- Significant limitation of movements in the joint
- Severe joint deformation.

Main types of surgical treatment:
- joint prosthetics,
- synovectomy,
- arthrodesis.

Recommendations for perioperative patient management:
1. Acetylsalicylic acid(risk of bleeding) - cancel 7-10 days before surgery;
2. Non-selective NSAIDs(risk of bleeding) - cancel 1-4 days in advance (depending on T1/2 of the drug);
3. COX-2 inhibitors can not be canceled (there is no risk of bleeding).
4. Glucocorticoids(risk of adrenal insufficiency):
- minor surgery: 25 mg hydrocortisone or 5 mg methylprednisolone IV on the day of surgery;
- average surgery - 50-75 mg hydrocortisone or 10-15 mg methylprednisolone IV on the day of surgery and rapid withdrawal within 1-2 days before the usual dose,
- major surgery: 20-30 mg methylprednisolone IV on the day of the procedure; rapid withdrawal within 1-2 days before the usual dose;
- critical condition - 50 mg hydrocortisone IV every 6 hours.
5. Methotrexate - cancel if the following factors exist:
- elderly age;
- renal failure;
- uncontrolled diabetes mellitus;
- severe damage to the liver and lungs;
- taking GC > 10 mg/day.
Continue taking the same dose 2 weeks after surgery.
6. Sulfasalazine and azathioprine - discontinue 1 day before surgery, resume taking 3 days after surgery.
7. Hydroxychloroquine can't be cancelled.
8. Infliximab You can not cancel it or cancel it a week before surgery and resume taking it 1-2 weeks after surgery.

Preventive actions: smoking cessation, especially for first-degree relatives of patients with anti-CCP positive RA.

Prevention of tuberculosis infection: preliminary screening of patients can reduce the risk of developing tuberculosis during treatment with infliximab; All patients before starting treatment with infliximab and those already receiving treatment should undergo an x-ray examination of the lungs and consult a phthisiatrician; if the skin test is positive (reaction >0.5 cm), an x-ray examination of the lungs should be performed. In the absence of radiological changes, treatment with isoniazid (300 mg) and vitamin B6 should be carried out for 9 months, after 1 month. Infliximab may be prescribed; in case of a positive skin test and the presence of typical signs of tuberculosis or calcified mediastinal lymph nodes, at least 3 months of therapy with isoniazid and vitamin B6 must be carried out before prescribing infliximab. When prescribing isoniazid in patients over 50 years of age, a dynamic study of liver enzymes is necessary.

Further management
All patients with RA are subject to dispensary observation:
- promptly recognize the onset of exacerbation of the disease and correct therapy;
- recognition of complications of drug therapy;
- non-compliance with recommendations and independent interruption of treatment are independent factors of unfavorable prognosis of the disease;
- careful monitoring of clinical and laboratory activity of RA and prevention of side effects of drug therapy;
- visit a rheumatologist at least 2 times every 3 months.
Every 3 months: general blood and urine tests, biochemical blood test.
Annually: lipid profile study (to prevent atherosclerosis), densitometry (diagnosis of osteoporosis), radiography of the pelvic bones (detection of aseptic necrosis of the femoral head).

Management of patients with RA during pregnancy and breastfeeding:
- Avoid taking NSAIDs, especially in the second and third trimesters of pregnancy.
- Avoid taking DMARDs.
- You can continue treatment with GC in minimally effective doses.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods: achieving clinical and laboratory remission.
In assessing the treatment of patients with RA, it is recommended to use the criteria of the European League of Rheumatology (Table 9), according to which (%) improvements in the following parameters are recorded: heart rate; NPV; Improvement in any 3 of the following 5 parameters: patient's global assessment of disease activity; general assessment of disease activity by the physician; patient assessment of pain; Health Assessment Questionnaire (HAQ); ESR or CRP.

Table 9. European League of Rheumatology Response to Therapy Criteria

The minimum degree of improvement is considered to be an effect corresponding to a 20% improvement. According to the recommendations of the American College of Rheumatology, achieving an effect below 50% improvement (up to 20%) requires adjustment of therapy in the form of changing the dose of DMARDs or adding a second drug.
When treating DMARDs, possible treatment outcomes include:
1. Reducing activity to low or achieving remission;
2. Reduced activity without reaching a low level;
3. Minimal or no improvement.
With option 1, treatment continues without changes; in case of the 2nd - you need to change DMARDs if the degree of improvement in activity parameters does not exceed 40-50% or join a DMARD if there is a 50% improvement in another DMARD or GEBD; at the 3rd - discontinuation of the drug, selection of another DMARD.

Hospitalization

Indications for hospitalization:
1. Clarification of diagnosis and assessment of prognosis
2. Selection of DMARDs at the beginning and throughout the course of the disease.
3. RA articular-visceral form of high activity, exacerbation of the disease.
4. Development of intercurrent infection, septic arthritis or other severe complications of the disease or drug therapy.

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Rheumatology, Ed. ON THE. Shostak, 2012 2. Hip replacement, Zagorodniy N.V., 2011 3. Clinical recommendations. Rheumatology. 2nd edition, corrected and expanded / ed. E.L. Nasonova. - M.: GEOTAR-Media, 2010. - 738 p. 4. Karateev D.E., Olyunin Yu.A., Luchikhina E.L. New classification criteria for rheumatoid arthritis ACR/EULAR 2010 - a step forward towards early diagnosis // Scientific and Practical Rheumatology, 2011, No. 1, pp. 10-15. 5. Diagnosis and treatment in rheumatology. Problematic approach, Pyle K., Kennedy L. Translation from English. / Ed. ON THE. Shostak, 2011 6. Smolen J.S., Landewe R., Breedveld F.C. et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. AnnRheumDis, 2010; 69:964–75. 7. Nasonov E.L. New approaches to pharmacotherapy of rheumatoid arthritis: prospects for the use of tocilizumab (monoclonal antibodies to the interleukin-6 receptor). Ter Arch 2010;5:64–71. 8. Clinical recommendations. Rheumatology. 2nd ed., S.L. Nasonova, 2010 9. Nasonov E.L. Use of tocilizumab (Actemra) for rheumatoid arthritis. Nauch-praktichrevmatol 2009; 3(Add):18–35. 10. Van Vollenhoven R.F. Treatment of rheumatoid arthritis: state of the art 2009. Nat Rev Rheumatol 2009;5:531–41. 11. Karateev A.E., Yakhno N.N., Lazebnik L.B. etc. Use of non-steroidal anti-inflammatory drugs. Clinical recommendations. M.: IMA-PRESS, 2009. 12. Rheumatology: national manual / ed. E.L. Nasonova, V.A. Nasonova. - M.: GEOTAR-Media, 2008. - 720 p. 13. Emery P., Keystone E., Tony H.-P. et al. IL-6 receptor inhibition with tocilizumab improves treatment outcomes in patients with rheumatoid arthritis refractory to anti-TNF biologics: results from a 24-week multicenter randomized placebo-controlled trial. 14. West S.J. - Secrets of Rheumatology, 2008 15. AnnRheumDis 2008;67:1516–23. 16. Rational pharmacotherapy of rheumatic diseases: Compendium/ Nasonova V.A., Nasonov E.L., Alekperov R.T., Alekseeva L.I. and etc.; Under general ed. V.A. Nasonova, E.L. Nasonova. – M.: Literra, 2007. – 448 p. 17. Nam J.L., Winthrop K.L., van Vollenhoven R.F. et al. Current evidence for the management of rheumatoid arthritis with biological disease-modifying antirheumatic drugs: a systemic literature rewires informing the EULAR recommendations for the management of RA. 18. Nasonov E.L. Use of tocilizumab (Actemra) for rheumatoid arthritis. Scientific and Practical Rheumatology, 2009; 3(Add. ):18–35. 19. Vorontsov I.M., Ivanov R.S. - Juvenile chronic arthritis and rheumatoid arthritis in adults, 2007. 20. Belousov Yu.B. - Rational pharmacotherapy of rheumatic diseases, 2005. 21. Clinical rheumatology. Guide for practitioners. Ed. IN AND. Mazurova - St. Petersburg. Folio, 2001.- P.116 22. Paul Emery et al. “Golimumab, a human monoclonal antibody to tumor necrosis factor alpha administered by subcutaneous injection every four weeks to patients with active rheumatoid arthritis not previously treated with methotrexate,” ARTHRITIS & RHEUMATISM, Vol. 60, No. 8, August 2009, pp. 2272–2283 , DOI 10.1002/art.24638 23. Mark C. Genovese et al. “The Effect of Golimumab Therapy on Patient-Reported Outcomes in Rheumatoid Arthritis: Results from the GO-FORWARD Study,” J Rheumatol first issue April 15, 2012, DOI: 10.3899/jrheum.111195 24. Josef S Smolen “Golimumab therapy in patients with active rheumatoid arthritis after treatment with tumor necrosis factor inhibitors (GO-AFTER study): a multicentre, randomized, double-blind, placebo-controlled phase III trial,” Lancet 2009; 374:210–21

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers
1. Togizbaev G.A. - Doctor of Medical Sciences, chief freelance rheumatologist of the Ministry of Health of the Republic of Kazakhstan, head of the Department of Rheumatology, AGIUV
2. Kushekbaeva A.E. - Candidate of Medical Sciences, Associate Professor of the Department of Rheumatology, ASIUV
3. Aubakirova B.A. - chief freelance rheumatologist in Astana
4. Sarsenbayuly M.S. - chief freelance rheumatologist of the East Kazakhstan region
5. Omarbekova Zh.E. - chief freelance rheumatologist of Semey
6. Nurgalieva S.M. - chief freelance rheumatologist of the West Kazakhstan region
7. Kuanyshbaeva Z.T. - chief freelance rheumatologist of Pavlodar region

Reviewer:
Seisenbaev A.Sh. Doctor of Medical Sciences, Professor, Head of the Rheumatology Module of the Kazakh National Medical University named after S.D. Asfendiyarova

Disclosure of no conflict of interest: absent.

Conditions for reviewing the protocol: availability of new diagnostic and treatment methods, deterioration of treatment results associated with the use of this protocol

Attached files

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​Tags:​

​Tactics of application​

Classification of arthritis according to ICD 10

​(by presence of RF): seropositive, seronegative ​

​The distinction is made according to the following types of etiological connection: a) direct infection of the joint, in which microorganisms invade synovial tissue and microbial antigens are detected in the joint; b) indirect infection, which can be of two types: “reactive arthropathy”, when microbial infection of the body is established, but neither microorganisms nor antigens are detected in the joint; and “post-infectious arthropathy,” in which the microbial antigen is present, but recovery of the organism is incomplete and there is no evidence of local proliferation of the microorganism.

​Cyclophosphamide (200 mg ampoules), endoxan - 50 mg tablets​

​physiotherapeutic procedures;​

Symptoms of reactive arthritis

​Swelling​

​Second degree - the pain intensifies, the limitation of motor activity is such that it leads to a decrease in working capacity and limitation of self-care.​

1. The symptom complex of the disease included: symmetrical damage to the joints, the formation of deformities, contractures and ankylosis in them; development of anemia, enlargement of lymph nodes, liver and spleen, sometimes the presence of febrile fever and pericarditis. Subsequently, in the 30-40s of the last century, numerous observations and descriptions of Still's syndrome revealed many similarities between rheumatoid arthritis in adults and children, both in clinical manifestations and in the nature of the course of the disease. However, rheumatoid arthritis in children was still different from the disease with the same name in adults. In this regard, in 1946, two American researchers Koss and Boots proposed the term “juvenile (adolescent) rheumatoid arthritis.” The nosological isolation of juvenile rheumatoid arthritis and adult rheumatoid arthritis was subsequently confirmed by immunogenetic studies.​
2. This type of rheumatoid arthritis includes Still and Visseler-Fanconi syndrome. Still's syndrome is most often diagnosed in preschool children. It has the following features:​
3. ​Juvenile rheumatoid arthritis is a pathology that develops in children and adolescents under 16 years of age, which can affect not only joints, but also other organs. A doctor can make a similar diagnosis if a child has arthritis that lasts more than 6 weeks. The disease does not occur very often. International statistics say that JRA is detected in 0.05-0.6% of children. Children under 2 years of age suffer from this disease extremely rarely. There are gender differences in incidence rates among children. Arthritis is diagnosed more often in girls. The disease is steadily progressing.​

​NSAIDs Patients at risk of developing gastropathy and gastrointestinal bleeding (age over 75 years, history of gastrointestinal ulcers, simultaneous use of low doses of acetylsalicylic acid and GC, smoking) can be prescribed selective or specific inhibitors of COX-2 or (subject to high individual effectiveness) non-selective COX inhibitors in combination with misoprostol 200 mcg 2-3 times / day or proton pump inhibitors (omeprazole 20-40 mg / day) In patients with impaired renal function, treatment with NSAIDs should be carried out with extreme caution. If there is a risk of thrombosis, patients receiving selective COX-2 inhibitors, should simultaneously continue taking small doses of acetylsalicylic acid.​

Diagnosis and treatment of the disease

​Downstream:​

​Alkylating cytostatic; forms alkyl radicals with DNA, RNA and proteins, disrupting their function; has an antiproliferative effect.​

​Severe swelling from the very beginning of the disease​

​In the third degree - inability to self-care, significant loss of mobility in the joint(s).​

​What causes juvenile rheumatoid arthritis?​

MoiSustav.ru

Learning to live with a diagnosis according to ICD 10 - rheumatoid polyarthritis

​acute onset;​

Causes and symptoms of rheumatoid polyarthritis

​If treatment is not started in the early stages, there is a high risk that the child will become disabled.​

​The World Health Organization (WHO) has developed a special medical coding for the diagnosis and definition of medical diseases. ICD 10 code - coding of the international classification of diseases of the 10th revision as of January 2007.​

​GK Systemic use. It is recommended to use low (< 10 мг/сут) дозы ГК, что позволяет адекватно « контролировать» ревматоидное воспаление, но должно обязательно сочетаться с базисной терапией Локальная терапия ГК имеет вспомогательное значение. Предназначена для купирования активного синовита в 1 или нескольких суставах. Повторные инъекции ГК в один и тот же сустав необходимо производить не чаще 1 раза в 3 мес. Противопоказания к проведению локальной терапии: гнойный​ ​rapidly progressive, slowly progressive (assessment of the rate of development of destructive changes in the joint during long-term observation) ​

​Staphylococcal arthritis and polyarthritis​

How to treat rheumatoid polyarthritis?

RA with systemic manifestations (vasculitis, nephropathy).

​massage;​

Edema appears when inflammation occurs

​Based on the nature of its occurrence in medicine, several forms of arthritis are distinguished:

The pathogenesis of juvenile rheumatoid arthritis has been intensively studied in recent years. The development of the disease is based on the activation of both cellular and humoral immunity.​

​moderate fever;​

​The primary incidence rate ranges from 6 to 19 cases per 100 thousand children. It is important that the health prognosis largely depends on the age at which the disease began. The older the child, the worse the prognosis. A type of rheumatoid arthritis is Still's disease. The disease is very severe, with severe fever, articular syndrome, damage to the lymphatic system and sore throat. This pathology also occurs in adults.

​Today, there are 21 classes of diseases, each of which contains subclasses with codes of diseases and conditions. Rheumatoid arthritis ICD 10 belongs to class XIII "Diseases of the musculoskeletal system and connective tissue." Subclass M 05-M 14 “Inflammatory processes of polyarthropathy.”​

Rheumatoid arthritis: treated with traditional methods

​arthritis​

​By activity:​

​200 mg IM 2-3 times a week until a total dose of 6-8 g per course is reached; combined pulse therapy; endoxan at a dose of 100-150 mg/day, maintenance dose – 50 mg/day.​ ​methods of operative surgery (injections into the joint cavity).​

artrozmed.ru

Etiology and treatment of juvenile rheumatoid arthritis

​Redness of the joint​

Features of the disease

​reactive - a complication that occurs with untreated (undertreated) infections;​ ​Pathogenesis of juvenile chronic arthritis​

​polyarthritis involving small joints;​

Etiological factors

​Juvenile arthritis can occur for a variety of reasons. The exact reason has not yet been established.​

​Reactive arthritis of the knee is the most common rheumatic disease. The disease is characterized by a non-purulent inflammatory formation in the bone structure. In some cases, the disease occurs as a response to infectious diseases of the gastrointestinal tract (GIT), urinary tract and reproductive system.​

• ​, unspecified nature​
• ​I - low, II - moderate, III - high activity ​
• ​Pneumococcal arthritis and polyarthritis​
• ​Hemorrhagic cystitis, myelosuppression, activation of foci of infection.​
• ​The medications prescribed are NSAIDs, cytostatics, hormonal agents, antibiotics, etc. The range of medications directly depends on the type and etiology of arthritis. Table 2 shows treatment regimens for rheumatoid arthritis.​
• ​Yes, but it may not happen right away​
• ​rheumatoid - is a consequence of rheumatic diseases;​

The main clinical manifestation of the disease is arthritis. Pathological changes in the joint are characterized by pain, swelling, deformation and limitation of movement, increased skin temperature over the joints. In children, large and medium-sized joints are most often affected, in particular, knees, ankles, wrists, elbows, hips, and less commonly, small joints of the hand. Typical for juvenile rheumatoid arthritis is damage to the cervical spine and maxillotemporal joints, which leads to underdevelopment of the lower, and in some cases, the upper jaw and the formation of the so-called “bird jaw.”

Forms of the disease

​enlarged and painful lymph nodes;​

​Possible etiological factors are the following:​

• ​The development of arthritis occurs a month after infection, but the provocative infection that caused this disease is in the human body and does not manifest itself. Men over 45 years of age are at greatest risk. Sexually transmitted infections (gonorrhea, chlamydia and others) can contribute to the progression of the disease. Women are less likely to suffer from this disease.​
• ​arthritis​
• ​X-ray stage:​

Clinical symptoms

Chlorbutin (leukeran) – tablets of 2 and 5 mg

• ​Drug​
• ​Yes, but in the later stages there may not be any redness​
• ​acute - develops after bruises, fractures, severe physical exertion;​
• ​Symptoms of juvenile chronic arthritis​
• ​hepatosplenomegaly;​

​presence of a viral or bacterial infection;​

​If the carrier of the infection enters the body through food, reactive arthritis can develop equally in both men and women.​

• ​, any skin changes near the puncture site, joint tuberculosis, tabes of the spinal cord, aseptic bone necrosis, intra-articular fracture, joint subluxation. The following drugs are used (the full dose of drugs is injected into large joints, 50% into medium-sized joints, and 25% into small joints): Methylprednisolone 40 mg Hydrocortisone 125 mg Betamethasone in the form of injections (celeston, flosterone, diprospan) Pulse therapy methylprednisolone leads to a rapid but short-term effect (3–12 weeks); not affecting the rate of progression of the process. In order to prevent osteoporosis, persons receiving GCs are prescribed calcium preparations (1500 mg/day) and cholecalciferol (400–800 IU/day), and in the absence of their effectiveness, bisphosphonates and calcitonin (see Osteoporosis). ​
• ​I - periarticular osteoporosis, II - the same + narrowing of the interarticular spaces + single erosions, III - the same + multiple erosions, IV - the same + ankylosis H​
• ​Other streptococcal arthritis and polyarthritis​
• ​Alkylating cytostatic; forms alkyl radicals with DNA, RNA and proteins, disrupting their function; has an antiproliferative effect
• ​Principle of operation​

​Symptoms of intoxication​

Other manifestations

​infectious - caused by viruses or fungal infections that enter the joint with the bloodstream, or through a non-sterile surgical instrument, often leading to the development of purulent inflammation of the knee joint;​

• In the systemic version of juvenile rheumatoid arthritis, leukocytosis (up to 30-50 thousand leukocytes) with a neutrophilic shift to the left (up to 25-30% of band leukocytes, sometimes up to myelocytes), an increase in ESR to 50-80 mm/h, hypochromic anemia, thrombocytosis, increased concentrations of C-reactive protein, IgM and IgG in the blood serum.​
• ​anemia;​
• ​traumatic injury to the joint;​
• A characteristic feature of the course of the disease is the symmetry of joint damage
• ​Basic therapy​
• ​availability of functional ability:​

• ​High RA activity with systemic manifestations, generalized lymphadenopathy, splenomegaly.​
• ​Principle of operation​
• Observed in cases of autoimmune nature of the disease
• Reiter's syndrome is a type of reactive arthritis;
• ​Diagnosis of juvenile chronic arthritis​
• ​myocardial damage;​
• ​increased insolation;​
• ​Reactive arthritis has an acute form. In the first week, the patient experiences fever, gastrointestinal (GIT) disorders, acute intestinal malaise, and general weakness. Subsequently, the symptoms of arthritis progress and are of a classic nature. At this stage of development, the disease can be divided into 3 types.
• ​Basic therapy should be prescribed to all patients with definite RA.​

​0 - preserved, I - professional ability preserved, II - professional ability lost, III - ability to self-service lost.​

Diagnostic measures

​Arthritis and polyarthritis caused by other specified bacterial pathogens. If necessary, identify the bacterial agent, use an additional code (​

​6-8 mg/day, maintenance dose – 2-4 mg/day.​

• ​Assignment schemes​
• ​No​
• ​arthritis due to ankylosing spondylitis, gout (uncommon);​
• ​Suppression of the inflammatory and immunological activity of the process.​

​polyserositis;​

​hypothermia;​

​Inflammation of the mucous membrane of the eyes occurs (conjunctivitis may develop).​

Treatment tactics

​ The “gold standard” of basic therapy for RA remains methotrexate, which has the best efficacy/toxicity ratio. Prescribed to patients with active RA or those with risk factors for poor prognosis (see above) at a dose of 7.5–15 mg per week. The onset of effect is 1–2 months. Side effects of methotrexate include hepatotoxicity and myelosuppression, so monitoring of blood flow and transaminases should be performed monthly. An increase in the level of liver enzymes is a signal to reduce the dose of the drug or completely discontinue it. A persistent increase in liver enzyme levels after discontinuation of the drug is an indication for liver biopsy. Taking into account the antifolate mechanism of action, folic acid 1 mg/day is indicated, with the exception of days of methotrexate use.​

​Frequency - 1% in the general population. The predominant age is 22–55 years. The predominant gender is female (3:1). Incidence: 23.4 per 100,000 population in 2001​

​Myelosuppression.​

​Possible side effects​

SpinaZdorov.ru

Juvenile rheumatoid arthritis

​Symptoms of “seized joint”​

​psoriatic arthritis (occurs in 10-40% of patients with psoriasis)​

ICD-10 code

• ​Relief of systemic manifestations and articular syndrome.​
• ​increasing ESR in the UAC.​
• ​ingestion of protein components into the body;
• ​Pain in the joints becomes increasingly stronger, while motor activity decreases. Noticeable redness and swelling appear in the infected areas.
• Hydroxychloroquine (200 mg twice a day or 6 mg/kg/day) is a common component of combination therapy for active, especially “early” RA. Hydroxychloroquine monotherapy does not slow radiological progression. The onset of effect is 2–6 months. Long-term treatment requires an annual ophthalmological examination and visual field examination.
• ​unknown. Various exogenous (viral proteins, bacterial superantigens, etc.), endogenous (type II collagen, stress proteins, etc.) and nonspecific (trauma, infection, allergy) factors can act as “arthritisogenic”.
• ​Due to the fact that the RA treatment regimens indicated in the table are not always effective, several combinations of basic agents are used in practice, among which the most widely used combinations of methotrexate with sulfasalazine, methotrexate and delagil. Currently, the most promising treatment regimen is one in which methotrexate is combined with anticytokines.​

Epidemiology of juvenile chronic arthritis

​Quinoline drugs (delagil - 0.25 g tablets)​

Classification of juvenile chronic arthritis

Reiter's syndrome (according to ICD-10 code 02.3) can develop in two forms - sporadic (causative agent - C. Trachomatis) and epidemic (Shigella, Yersinia, Salmonella).

​Preservation of the functional ability of the joints.​

Causes of juvenile chronic arthritis

In the subacute course of the disease, the symptoms are less pronounced. First, one joint is affected. Most often it is the ankle or knee joint. It can affect one joint or several. In the oligoarticular form of the disease, 2-4 joints are affected. There may be no pain syndrome. During a medical examination, swelling and dysfunction of the joint are determined. Movement of a sick child is difficult. The liver and spleen are of normal size. The subacute course is more favorable and responds better to therapy.​

​hereditary predisposition;​

The organs of the genitourinary system become inflamed.

Pathogenesis of juvenile chronic arthritis

​ Sulfasalazine is especially indicated for seronegative RA, when differential diagnosis with seronegative spondyloarthropathy is difficult. The starting dose is 0.5 g/day with a gradual increase in dose to 2–3 g/day in 2 divided doses after meals. Taking into account the myelotoxicity of the drug with its long-term use, it is necessary to monitor the blood flow every 2–4 weeks for the first 2 months, then every 3 months.​

​70% of RA patients have HLA - DR4 Ag, the pathogenetic significance of which is associated with the presence of a rheumatoid epitope (section b - chain of the HLA - DR4 molecule with a characteristic amino acid sequence from position 67 to 74). The effect of “gene dose”, that is, the quantitative-qualitative relationship between the genotype and clinical manifestations, is discussed. The combination of HLA - Dw4 (DR b10401) and HLA - Dw14 (DR b1*0404) significantly increases the risk of developing RA. On the contrary, the presence of antigen protectors, for example HLA - DR5 (DR b1*1101), HLA - DR2 (DR b1*1501), HLA DR3 (DR b1*0301) significantly reduces the likelihood of developing RA.​

Symptoms of juvenile chronic arthritis

​In medical practice, there are often cases of lack of effect from treatment (for example, with reactive arthritis, inflammation does not go away even when taking antibiotics in combination with NSAIDs), when patients continue to have disease activity and rapid progression of joint deformities.​

Diagnosis of juvenile chronic arthritis

​Stabilization of lysosomal membranes, inhibition of neutrophil phagocytosis and chemotaxis, inhibition of cytokine synthesis.​

Treatment goals for juvenile chronic arthritis

• The clinical picture differs from other types of arthritis, since concomitant signs of the disease are lesions of the mucous membranes of the oral cavity, prostatitis (in men), vaginitis and cervicitis (in women). A common symptom is inflammation of the eyes (conjunctivitis, iridocyclitis), which manifests itself in redness of the sclera, the appearance of purulent discharge, and swelling of the eyelids.​
• ​Preventing or slowing down the destruction of joints and disability of patients.​
• ​It is necessary to know not only the causes and symptoms of juvenile rheumatoid arthritis, but also methods for diagnosing it. In the early stages of the disease, symptoms may be mild, so making a diagnosis is often difficult.​
• ​Impaired functioning of the immune system.​
• ​Initially, the disease may affect only one knee joint, but later it can spread to other joints. The pronounced clinical manifestations can be minor or very strong depending on the person’s immune system. In the future, rheumatoid polyarthritis may develop, which affects the larger joints of the lower extremities and toes. Back pain occurs in the most severe form of the disease.​
• ​ Leflunomide is a new cytostatic drug with an antimetabolic mechanism of action, developed specifically for the treatment of RA. Used at a dose of 10–20 mg/day. The effect develops after 4–12 weeks. Toxicity monitoring involves monitoring liver enzymes and TBC levels.​
• ​The basis of the pathological process in RA is generalized immunologically caused inflammation. In the early stages of the disease, Ag - specific activation of CD4+ - T - lymphocytes is detected in combination with hyperproduction of pro-inflammatory cytokines (tumor necrosis factor, IL - 1, IL - 6, IL - 8, etc. .) against the background of a deficiency of anti-inflammatory mediators (IL - 4, soluble antagonist of IL - 1). IL-1 plays an important role in the development of erosions. IL - 6 stimulates B - lymphocytes to synthesize RF, and hepatocytes - to synthesize proteins of the acute phase of inflammation (C - reactive protein, etc.). TNF-a causes the development of fever, pain, cachexia, is important in the development of synovitis (it promotes the migration of leukocytes into the joint cavity by enhancing the expression of adhesion molecules, stimulates the production of other cytokines, induces procoagulant properties of the endothelium), and also stimulates the growth of pannus (granulation tissue , penetrating into cartilage from synovial tissue and destroying it). An important prerequisite is the weakening of the endogenous synthesis of GC hormones. In the later stages of RA, in conditions of chronic inflammation, tumor-like processes are activated, caused by somatic mutation of fibroblast-like synovial cells and apoptosis defects.​

Forecast

​Doctors draw a conclusion about the need to change the therapy program if the patient has been treated for six months using at least three basic drugs.​

​Initial stage of RA.​

​Laboratory research methods​

Arthritis of the knee joint should be differentiated from other pathological processes, the most common of which are arthrosis and bursitis. An experienced specialist can easily distinguish bursitis, which is an inflammation in the synovial bursa, from arthritis at the first appointment.​

​Achieving remission.​

Prevention of juvenile chronic arthritis

​The main diagnostic methods are:​

ilive.com.ua

Causes, symptoms, diagnosis and treatment of knee arthritis

Of the viral infections, the most dangerous are those caused by the Epstein-Barr virus, parvovirus and retroviruses. The mechanism of disease development is associated with autoimmune disorders. When exposed to any unfavorable factor, special immunoglobulins are formed in the child’s body. In response to this, rheumatoid factor is synthesized. Joint damage occurs. In this case, the synovial membranes and blood vessels, cartilage tissue are affected. Not only joints, but also the marginal parts of bones (epiphyses) can be destroyed. The resulting circulating immune complexes are carried through the blood vessels to various organs. In this case, there is a risk of developing multiple organ failure.​

Etiology

In rare cases, the disease can affect the central nervous system and cause complications in the cardiovascular system.

​ Gold salts (for example, sodium aurothiomalate) are used to treat seropositive RA. Test dose 10 mg IM, then 25 mg weekly, then 50 mg weekly. As the total dose of 1000 mg is reached, they gradually switch to a maintenance regimen of 50 mg once every 2–4 weeks. The effect develops after 3–6 months. Side effects include myelosuppression, thrombocytopenia, stomatitis, proteinuria, therefore OAC and OAM are recommended to be performed once every 2 weeks.​

​Evidence of the ineffectiveness of therapy is the negative dynamics of laboratory tests and the persistence of the focus of inflammation. In this case, you need an alternative solution on how to treat knee arthritis. Medical statistics confirm the positive dynamics when using pulse therapy using hormonal drugs (methylprednisolone intravenously, isotonic solution for three days - three courses are repeated after one month). Methylprednisolone is prescribed with caution in combination with cyclophosphamide due to the high toxicity of the drugs.​

​Table 2 per day for the first 2-4 weeks, then 1 tablet. per day for a long time.​

Arthritis in children

​Detect changes​

​Firstly, with bursitis, the mobility of the knee is slightly limited, and secondly, the area of ​​articular inflammation has clear contours. By palpation, the doctor quickly determines the boundaries of the inflammatory focus. As for arthrosis, differentiation is more difficult, since these diseases, which have completely different etiologies, have many similar symptoms.​

​Improving the quality of life of patients.​

​collecting anamnesis;​

Symptoms of the disease

​Classification of JRA according to ICD 10 takes into account the type of joint damage. There are polyarthritis and oligoarthritis. ICD 10 divides arthritis into acute and subacute. There is a classification that takes into account the clinical symptoms of the disease.​

​Today, to confirm whether a patient really has reactive arthritis, a whole range of laboratory tests is needed. Various specialists are involved in examining the patient. It is necessary to undergo an examination by a gynecologist, urologist and therapist. The attending physician will indicate the need for examination by other medical specialists. After collecting the results of laboratory tests, medical history data, and identifying clinical manifestations, the use of certain drugs is prescribed.​

​ Cyclosporine is rarely used in the treatment of RA, only in cases of refractoriness to other drugs. The dose is 2.5–4 mg/kg/day. The effect develops after 2–4 months. Side effects are serious: arterial hypertension, impaired renal function.​

​General symptoms:​

​Pyogenic arthritis, unspecified. Infectious arthritis NOS

Degrees of dysfunction

A new direction in the treatment of rheumatoid arthritis is therapy that involves the use of so-called biological agents. The action of the drugs is based on the inhibition of the synthesis of cytokines (TNF-α and IL-1β).​

​Dyspeptic symptoms, skin itching, dizziness, leukopenia, retinal damage.​

​Does not reveal specific deviations​

​Arthrosis is a degenerative process in cartilage and bone tissue that occurs due to metabolic disorders and is not associated with an inflammatory component. The main group of patients are elderly people (by the age of 60, most people are diagnosed with dystrophic changes in the joints).​

Types of arthritis

​Minimize side effects of therapy.​

• ​external examination of the child;​
• In this case, the following forms of juvenile arthritis are distinguished:
• It is necessary to begin treatment of reactive arthritis with the destruction of the infectious focus, that is, the causative agents of the original disease. To do this, you need to undergo a comprehensive examination of the whole body. After identifying the pathogen, sensitivity to drugs is determined. A bacterial infection is treated with antibiotics.​
• ​ Azathioprine is used in a dose of 50–150 mg/day. The effect develops after 2–3 months. Laboratory monitoring is required (CBC every 2 weeks, then every 1–3 months).​
• ​fatigue, low-grade fever, lymphadenopathy, weight loss. 2.​
• ​Excluded: arthropathy due to sarcoidosis (​
• ​It has been reliably established that in 60% of patients with active rheumatoid joint syndrome, even with the third degree of the disease, there is a decrease (or absence) in the progression of articular changes during maintenance therapy with Remicade. However, the use of this form of treatment is justified if basic therapy does not produce the expected effect.​

​Sulfonamide drugs (sulfasalazine, salazopyridazine) - 500 mg tablets

​Instrumental research methods​

Differential diagnosis

​Arthritis is always inflammation, which over time, as the disease progresses (if it is autoimmune in nature), spreads to the entire body. That is why there are many accompanying signs of autoimmune arthritis - fever, low-grade fever, headache, and general malaise. With rheumatoid arthritis, the cardiovascular system is seriously affected.

​Treatment of juvenile chronic arthritis​

​laboratory research;​

​articular;​

The use of antibacterial drugs is recommended at the initial, most acute stage of the disease. In the future, their use becomes less effective. In some cases, symptomatic treatment is prescribed, in which non-steroidal drugs are used, for example, ibuprofen. “Anti-cytokine” therapy for RA is based on the suppression of the main pro-inflammatory cytokines: TNF-a and IL-1. Infliximab, registered in Russia, is a monoclonal antibody to TNF - a. Infliximab is used at a dose of 3 mg/kg IV every 2, 6, and then every 8 weeks. The onset of effect ranges from several days to 4 months.​ ​Joint syndrome ​

Diagnosis of knee arthritis

​The mortality rate for juvenile arthritis is low. Most deaths are associated with the development of amyloidosis or infectious complications in patients with systemic juvenile rheumatoid arthritis, often resulting from long-term glucocorticoid therapy. In secondary amyloidosis, the prognosis is determined by the possibility and success of treatment of the underlying disease.​

​Treatment is carried out only after diagnosis. It is necessary to exclude diseases such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis, Reiter's syndrome, systemic lupus erythematosus, tumor, and ankylosing spondylitis. In the presence of rheumatic diseases in children, treatment should be comprehensive.​

​involvement of joints in the process;

The 10th International Classification of Diseases (ICD 10) lists types of pathologies of joints and connective tissues under the codes M05 (seropositive), M06 (seronegative) and M08 (juvenile) rheumatoid arthritis. Rheumatoid polyarthritis, which in the ICD is coded M13.0, like other arthritis, is classified depending on the presence of rheumatoid factor in the blood.​

​Long-term outpatient observation.​

​Tendosynovitis in the area of ​​the wrist joint and hand Bursitis, especially in the area of ​​the elbow joint Damage to the ligamentous apparatus with the development of hypermobility and deformities Muscle damage: muscle atrophy, myopathies, often medicinal (steroids, as well as while taking penicillamine or aminoquinoline derivatives). 4.​

​* Meningococcal arthritis (​

​Balneological therapy is a very effective procedure in a comprehensive treatment program for knee arthritis. However, this direction of rehabilitation is indicated for those patients who do not have serious diseases of the cardiovascular system, neoplasms of a malignant nature, and have not previously had a heart attack or stroke. All procedures using medicinal biological components are prescribed with great caution.​

​Inhibition of the functional activity of macrophages and neutrophils, inhibition of the production of immunoglobulins and RF.​

​Drug treatment​

​Arthritis​

Treatment

​Due to the fact that the etiology of juvenile rheumatoid arthritis is unknown, primary prevention is not carried out.​

​Treatment of juvenile rheumatoid arthritis includes limiting physical activity, avoiding sun exposure, using NSAIDs to eliminate pain and inflammation, immunosuppressants, exercise therapy, and physiotherapy.​

• ​slight increase in body temperature;​
• ​Polyarthritis is understood as systemic multiple lesions of the joints, in which not only almost all types of joints become inflamed and destroyed, simultaneously or sequentially, but also other organ systems. Sometimes the result of an advanced form of polyarthritis can be disability. Rheumatoid polyarthritis can act as an independent disease as an infectious nonspecific rheumatoid polyarthritis, and sometimes it is a consequence of other diseases - sepsis, gout, rheumatism. Even those with bad teeth should be wary of the disease, but the word “dentistry” is unacceptable in the lexicon.​
• Observation is carried out jointly with a specialist - a rheumatologist and a local (family) doctor. The competence of a rheumatologist includes making a diagnosis, choosing treatment tactics, teaching the patient the correct regimen, and performing intra-articular manipulations. General practitioners are responsible for organizing the systematic management of the patient; they also carry out clinical monitoring. During each visit, the patient is assessed: the severity of joint pain on a 100-point scale, the duration of morning stiffness in minutes, the duration of malaise, the number of swollen and painful joints, and functional activity.​
• ​Systemic manifestations ​
• ​A39.8​

​Since there are many types of arthritis and joint pathologies, it is necessary to consult a doctor when the first signs of the disease appear. The sooner the causes of the inflammatory process are determined, the greater the chance of curing the disease completely.​

​Age group​

​The disease is not limited by age, but middle-aged women are diagnosed with this diagnosis somewhat more often than representatives of the stronger half. The exception is infectious reactive arthritis, which is diagnosed mainly in men aged 20-40 years (more than 85% of patients with reactive arthritis are carriers of the HLA-B27 antigen).

​Depending on the type of classification, the disease has the following names: juvenile arthritis (ICD-10), juvenile idiopathic arthritis (ILAR), juvenile chronic arthritis (EULAR), juvenile rheumatoid arthritis (ACR).​

​The process often involves joints in the cervical spine. Joint syndrome is characterized by:

New techniques

​This disease is difficult to treat. The only thing patients can hope for is long-term remission, when the hospital does not become a second home. In the early stages this can often be achieved, but in most cases the symptoms recur and even worsen.​

​Assess and calculate the degree of improvement (20%, 50%, 70%) using indicators: count of swollen joints; count of painful joints; at least 3 out of 5 indicators; overall assessment of activity according to the patient; overall assessment of activity according to the doctor; assessment of pain by the patient; acute phase blood parameters (ESR, CRP) disability (quantified using standardized questionnaires).​

​arthritis​

​arthritis​

​Arthritis and physical activity. Gordon N.F.​

Rehabilitation programs

​Suppression of collagen synthesis, inhibition of the activity of T-helper type I and B-lymphocytes, destruction of the CEC​

Knee arthritis can be diagnosed at home by carefully studying the symptoms of the disease. Regardless of the etiology, symptoms such as swelling, redness in the joint area, general malaise, and external signs of deformation of the joint tissue appear.

​No restrictions (any age)​

​It is worth taking a closer look at rheumatoid arthritis (RA), which is an autoimmune disease of unknown etiology. The disease is a common pathology - approximately 1% of the population suffers. Cases of self-healing are very rare; 75% of patients experience stable remission; in 2% of patients the disease leads to disability.​

​M08. Juvenile arthritis.​

​stiffness in the morning lasting up to 1 hour or more;

1. The goal of therapy for rheumatoid polyarthritis is to reduce rheumatic pain, reduce inflammation, improve joint mobility and prevent complete immobility of the patient. The basic principles that guide any clinic treating rheumatoid arthritis are complexity and consistency. Spa treatment through therapeutic mud has proven itself well.​
2. ​Rehabilitation​
3. ​American Rheumatological Association (1987) ​

SpinaZdorov.ru

ICD 10. Class XIII (M00-M25) | Medical practice - modern medicine of diseases, their diagnosis, etiology, pathogenesis and methods of treating diseases

​peripheral joints and systemic inflammatory damage to internal organs.​

​2 Shoulder Humerus Elbow joint bone​

​High clinical and laboratory activity of RA​

​However, you should not wonder how to treat arthritis of the knee joint on your own, especially using dubious traditional healing recipes. This can lead to irreversible consequences. The decision on how to treat knee arthritis is made only after a comprehensive examination.​

​As a rule, over 50-60 years old​

​With this disease, the inner surface of the joints (cartilage, ligaments, bones) is destroyed and replaced with scar tissue. The rate of development of rheumatoid arthritis varies - from several months to several years. Features of the clinical picture of one or another type of inflammation of the joints make it possible to suspect the disease and prescribe the necessary examinations to confirm the diagnosis. In accordance with ICD-10, RA is classified as seropositive (code M05), seronegative (code M06), juvenile (code MO8)

​M08.0. Adolescent (juvenile) rheumatoid arthritis (sero-positive or seronegative).​

​swelling in the joint area;​

The first stage is the suppression of the autoimmune process, which actually leads to tissue destruction, pain, and loss of ability to move. This is followed by anti-inflammatory treatment, complete cleansing of the body from toxic metabolic products. During the period of remission, blood circulation is restored, joint performance is increased, and metabolism is normalized. All these stages combine both medication and physiotherapeutic treatment methods.​

INFECTIOUS ARTHROPATHIES (M00-M03)

Exercise therapy plays an important role. Sanatorium-resort treatment is recommended during periods of minimal activity or remission. To correct deformities, orthoses are used - individual orthopedic devices made of thermoplastic, worn at night.​ ​At least 4 of the following Morning stiffness > 1 hour ​​Code according to the international classification of diseases ICD-10:​ ​3 Forearm, radius, wrist joint - bone, ulna​​The initial dose is 250 mg/day with a gradual increase to 500-1000 mg/day; maintenance dose – 150-250 mg/day

M00 Pyogenic arthritis

​Doctors must determine the nature of the disease in order to prescribe adequate treatment. Referrals for laboratory and instrumental studies are given by orthopedic traumatologists, surgeons, and rheumatologists. The treatment regimen is developed by a specialized specialist (this can be a phthisiatrician, dermatologist-venereologist, cardiologist and other doctors).​ ​Nature of the process​ ​Some types of arthritis only affect children and adolescents, so they should be classified separately.​​M08.1. Adolescent (juvenile) ankydosing spondylitis.​ ​soreness;​​The basic treatment is to suppress the autoimmune process through the following drugs: methotrexate, sulfasalazine and leflunomide. In terms of minimizing side effects, the latter differs; this should be taken into account from the position that all of them require long-term (at least six months) use.​ ​Features in pregnant women​​Arthritis​ ​M06-​​4 Hand Wrist, Joints between these fingers, bones, metacarpus ​Skin rash, dyspepsia, cholestatic hepatitis, myelosuppression​​The first stage to determine the disease (according to ICD 10) is a visual examination and medical history.​ ​Acute or chronic​​Juvenile rheumatoid arthritis (ICD-10 code M08) affects children after bacterial and viral infections. As a rule, one knee or other large joint becomes inflamed. The child experiences pain with any movement and swelling in the joint area. Children limp and have difficulty getting up in the morning. Without treatment, joint deformation gradually develops, which can no longer be corrected.​

​M08.2. Adolescent (juvenile) arthritis with systemic onset.​ ​change in gait;​ Nonsteroidal anti-inflammatory drugs (NSAIDs) also have an analgesic effect. But they should also be used for a long time, so the doctor must choose the one that is best tolerated by the patient. Among non-steroids, diclofenac, ibuprofen, and nimesulide are widely used. All of them affect the gastrointestinal tract to a greater or lesser extent. Pregnancy improves the course of RA, but after delivery there is always a relapse due to hyperprolactinemia. It is undesirable to use NSAIDs in the first trimester of pregnancy and 2 weeks before birth (in the first trimester there is a risk of a teratogenic effect, before childbirth there is a risk of developing weakness in labor, bleeding, and early closure of the ductus arteriosus in the fetus). Gold salts and immunosuppressants are contraindicated for pregnant women. There is evidence of the relative safety of the use of aminoquinoline drugs and sulfasalazine, however, the expected effect should be weighed against the possible risk.​ ​3 joints or more ​

​Other rheumatoid arthritis​​5 Pelvic Gluteal Hip joint, region and hip region, sacroiliac, femoral joint, bone, pelvis​ ​Methotrexate (2.5 mg tablets, 5 mg ampoules)​​The second stage is laboratory blood tests (with inflammation, an increase in ESR, leukocytosis, the inflammatory marker CRP, and other specific reactions are observed).​

medpractik.ru

Rheumatoid arthritis, Diseases and treatment with folk remedies and medicines. Description, application and healing properties of herbs, alternative medicine

Origin of systemic disease

In ICD 10, rheumatoid arthritis is listed under code M06. The basis for the occurrence of the disease is the abnormal functioning of the immune system of the patient’s body. The body consists of cells whose functions are based on protecting the immune system. Protective cells begin to be produced after an infection, but instead of destroying the microorganisms that caused the infectious disease, they begin to attack healthy cells, destroying them. Damage to the cartilage tissue of the joints begins, which leads to irreversible destruction in the patient’s body.

The ICD 10 codification is necessary only for doctors; not many patients understand and understand it. Why is this necessary? Let's say a patient is admitted to the hospital with acute pain, and his attending physician is not available. Taking a card that says rheumatoid arthritis code M06 according to ICD 10, the medical staff knows the patient’s medical history, why the pain is severe, and how to act in this or that case. This is why classification is important for doctors.

Healthcare has provided for all the nuances in advance, even if they are minor, but it is very convenient, especially for hospital staff. After all, the patient is not always able to explain what he is sick with.

Types of diseases of the musculoskeletal system

Rheumatoid arthritis comes in several types:

There are cases where people with identical symptoms are classified into different categories of the disease. The nature of the course is different, the degrees of the disease can also be different, but the signs are the same.

The clinical picture of the disease is largely similar in all varieties. The main types of symptoms for all classifications of the disease:

Arthritis ICD 10 is a classification of diseases according to generally accepted international standards, the last 10 reviews, in which arthritis is divided into groups according to etiology, course and associated ailments and symptoms.

For patients, in fact, this division into classes will mean nothing, but for doctors this classification is very important. This list is intended primarily for medical workers. When making a diagnosis, ordering tests and determining subsequent therapy, it is important to follow generally accepted standards and designations.

Arthritis code icd 10

For example, the inscription “arthritis of the joints ICD 10” indicates that the patient has a disease of the musculoskeletal system and changes in the connective tissue of the joints. Therefore, according to the generally accepted worldwide classification of diseases, it is assigned a specific code and number in the category.

This is also necessary for medical personnel to ensure that there are no errors in data processing and reporting. This classification is used all over the world. This is convenient when maintaining documentation electronically on a computer.

Rheumatoid arthritis according to ICD 10 is designated M06, but there are also separate subtypes:

Rheumatoid arthritis according to ICD 10 in patients

Symptoms of reactive arthritis ICD 10

Such arthritis can be classified as gouty arthritis according to ICD 10. This will happen if the medical history and tests reveal:

If there is a correct diagnosis by a qualified specialist, the prognosis for a speedy recovery is always high.

Medicine's fight against ICD 10 arthritis and advances in treatment

Reports and other paperwork have not been canceled, so this ordering of diseases simplifies the work of medical personnel. Now healthcare workers have more time to spend with patients who need it. ICD has reduced and simplified business in the medical sector.

For the patient, it does not matter, in fact, what is written in the medical records, what subtype of the disease was identified in him. It is much more important for a person who comes to the hospital with problems in the body to receive adequate advice, prescriptions, and instructions.

International practice of disease classification has met all expectations. It has become easier for doctors to treat. In very developed countries of the world this has been used for a long time. In the post-Soviet space, this process occurs only partially. Poor funding of the medical sector is the reason that most hospitals are not equipped with computers.

But it is always better to stay away from medical institutions and not experience all the modern delights of medical care. The rules remain unchanged, compliance with which will protect you from all kinds of arthritis, rheumatism and gout.

You need to take care of your body and spirit, adhere to a balanced diet, strengthen your body, strengthen your immune system, beware of psychological and physical stress, and exercise in moderation. In this case, no diseases according to the generally accepted worldwide classification will be terrible.

Classification and ICD-10 codes of arthritis of the knee joint

Classification, incidence rate

In ICD-10, arthritis has a code from M00 to M25. The exact code is determined depending on the underlying cause of the disease. The international classification of diseases identifies various forms of arthritis. Knee joints are affected very often. There are 3 forms of this pathology:

The incidence rate of arthritis is 9.5 cases per 1000 people. The risk group includes women aged 40 to 50 years. The knee joint allows flexion of the lower limbs at the knee, which facilitates movement. In severe cases, if not treated promptly, knee arthritis can cause disability. This disease should not be confused with deforming osteoarthritis. Arthritis most often develops against the background of another disease of infectious etiology.

This disease can occur in acute, subacute and chronic forms. In the first case, purulent inflammation of the knee joint may develop. In the chronic course of the disease, cartilage tissue suffers. Possible development of ankylosis and contractures. The joint becomes deformed, making it difficult to move the limb. The knee joint may be affected in isolation or polyarthritis may occur.

Why does inflammation occur?

An experienced doctor must know not only the code of the disease, but also the causes of its occurrence. Knee arthritis occurs for the following reasons:

• against the background of circulatory disorders;
• against the background of infectious diseases;
• against the background of injuries.

The most commonly diagnosed disease is rheumatoid arthritis. The exact cause of its occurrence has not been established. Possible provoking factors: infectious diseases (rubella, herpes, hepatitis), genetic predisposition, environmental factors (stress, occupational hazards, intoxication of the body). Arthritis can be primary or secondary. Primary inflammation is caused by injury, infection, and decreased immunity. Often the knee joint becomes inflamed due to gonorrhea, tuberculosis, and dysentery. Secondary forms of the disease develop against the background of blood diseases, sarcoidosis, and osteomyelitis.

Clinical manifestations

Symptoms of inflammation of the knee joint are few. The most commonly observed symptoms are:

• pain syndrome;
• soreness in one or both knees;
• swelling;
• knee deformity;
• rapid fatigue while walking;
• stiffness in the limbs;
• local increase in body temperature;
• redness.

The severity of pain depends on the stage of the disease. The pain most often intensifies in the evening and in the morning. In severe cases, the pain bothers a person at night, making it difficult to sleep normally. Knee deformity does not occur immediately. Bone or cartilaginous growths (exostoses) may be observed.

Characteristics of rheumatoid arthritis

According to ICD-10, arthritis is rheumatoid. This pathology occurs in 1-2% of the population. The disease is of an autoimmune nature. At the same time, against the background of exposure to provoking factors, cells of the immune system begin to attack the joint tissue, causing inflammation. Rheumatoid arthritis often develops after suffering from measles, mumps, or herpes. The symptoms are not specific. In rheumatoid arthritis, extra-articular manifestations are often observed. These include the formation of rheumatoid nodes, weight loss, myocarditis, pleurisy, and kidney damage.

The juvenile form of the disease occurs in children and adolescents. One of its varieties is Still's disease. With Still's disease, not only the joints are affected, but also the organ of vision. In this situation, the development of iridocyclitis and cataracts is possible. Rheumatoid arthritis is dangerous due to its possible complications. These include anemia, renal amyloidosis, changes in blood counts (decrease in leukocytes and platelets), kidney and heart damage.

Diagnostic and therapeutic measures

Diagnosing knee arthritis is not difficult. The main method is x-ray examination. It is carried out in 2 projections. The x-ray reveals signs of osteoporosis, the presence of bone defects, and narrowing of the gap in the joint area. Sometimes dislocations or subluxations are found. This indicates a chronic inflammatory process. Other diagnostic methods include medical history, palpation of the knee, blood test, ultrasound of the knee joint, scintigraphy, tomography, arthroscopy.

The disease is treated with anti-inflammatory drugs.

The latter are steroidal and non-steroidal. The NSAID group includes Ibuprofen, Diclofenac, and Aspirin. The course of treatment with these medications is very long. Glucocorticoids are used only in severe cases. If the rheumatoid nature of the inflammation is identified, treatment may include plasmapheresis (blood purification). If anti-inflammatory drugs are ineffective, basic drugs are prescribed (Chloroquine, D-penicillamine).

In the remission phase, with mild inflammation, physical therapy can be performed. Electrophoresis and phonophoresis are used. For a speedy recovery, sanatorium treatment is recommended. If knee inflammation is caused by other diseases, specific therapy is prescribed.

Thus, ICD-10 arthritis of the knee joint in most cases is of an infectious or traumatic nature. Treatment must be carried out in the early stages, otherwise deformation of the joint is possible.

Bibliography

1. Russian Medical Journal - http://www.rmj.ru/;

2. Journal “Concilium Medicum” - http://con-med.ru/;

3. Magazine “Attending Physician” - http://www.lvrach.ru/;

4. Journal of Neurology and Psychiatry named after. S. S. Korsakova;

6. Electronic journal “Angiology” - http://www.angiologia.ru/;

8. Journal "Phlebology";

9. Vidal Directory of Medicines - http://www.vidal.ru/;

Does an ordinary patient need to know the ICD arthritis code? On the one hand, let doctors teach coding, prescribe medications and give them sick leave. On the other hand, you look at the card, and it’s written there incomprehensibly and in bad handwriting, so that if you understand the M25 or something similar, you’ll read everything else in the reference book. You can't figure it out without the code.

The main thing in this matter is not the codes, but the fact that the approaches to treatment depend on the type of arthritis. Rheumatoid - will affect the immune system, and if reactive - then the infection that caused the disease. If your knees hurt after an injury, they can only relieve the pain.

As a patient, I have been using the ICD codification for a long time. This document can be used to verify any assignment. You really need to have a reliable source, otherwise there is so much empty stuff on the Internet that you can choke.

M06.9 Rheumatoid arthritis, unspecified

Rheumatoid arthritis is a chronic disease in which the synovial membrane becomes inflamed, causing joints to lose mobility and become swollen. Gradually, inflammation destroys the ends of the bone and the cartilage covering the articular surfaces. The structure and function of the ligaments that give the joint strength are disrupted, and it begins to deform.

Most often, the disease affects several joints and usually begins on one of the small ones - the hand or foot. As a rule, the disease develops symmetrically. The inflammatory process may involve the eyes, lungs, heart and blood vessels. The disease usually develops slowly, but clinically manifests itself sharply.

Rheumatoid arthritis is an autoimmune disease, i.e. the synovial membrane, and in some cases other parts of the body are damaged by their own antibodies.

Women over 60 years of age are more likely to get sick, men - 3 times less often. The disease may be hereditary. Lifestyle doesn't matter.

Common symptoms are partly due to anemia, which occurs because the amount of bone marrow in which blood cells are made decreases.

• joints lose mobility, hurt and swell;
• characteristic nodules appear in areas under pressure (for example, on the elbows).

Because the disease is both painful and immobilizing, patients often become depressed. In women with rheumatoid arthritis, the condition may improve during pregnancy, but the attacks return after the birth of the child.

As the disease progresses, due to low mobility, the density of the bones connecting at the joint decreases, they become fragile and break easily. In severe cases, osteoporosis of the entire skeleton develops.

In addition, bursitis may develop, i.e. inflammation of the joint capsule. Swollen tissue in the wrist puts pressure on the median nerve, causing numbness, tingling, and pain in the fingers. If the walls of the arteries supplying blood to the fingers become inflamed, Raynaud's syndrome develops, in which, especially in the cold, the fingers begin to ache and turn white. Less commonly, the spleen and lymph nodes become enlarged. The heart sac, the pericardium, may become inflamed. In some cases, the whites of the eyes become inflamed.

It is typical for rheumatoid arthritis that attacks lasting from several weeks to several months are followed by relatively symptom-free periods. A similar form of arthritis, but with characteristic features, is observed in children (see).

Usually based on medical history and the results of a general examination of the patient. Blood tests are performed to confirm the presence of antibodies (the so-called rheumatoid factor) and determine the severity of inflammation. Bone and cartilage destruction is assessed by x-rays of the affected joints.

Rheumatoid arthritis is incurable. The doctor’s task is to take control of the symptoms of the disease and prevent the disease from progressing so that the joints do not deteriorate further. There are many medications, the choice of which depends on the severity and stage of development of the disease, the age of the patient and his general health.

If only mild symptoms are present, non-steroidal anti-inflammatory drugs will be prescribed. However, at the beginning of the disease, the doctor may prescribe stronger drugs that change its course. They should limit irreversible joint damage, but will have to be taken for several months before improvement occurs. Sulfasalazine or chloroquine is prescribed first. If symptoms persist, gold compounds, penicillamine, methotrexate or cyclosporine are prescribed. New drugs targeting tumor necrosis factor may also be used. Since all of these drugs are characterized by severe side effects, the patient must be under constant supervision.

For anemia, which often accompanies rheumatoid arthritis, the hormone erythropoietin is prescribed to improve the condition, which increases the formation of red blood cells.

To reduce stress on a particularly painful joint and prevent deformity, splints or braces will likely be recommended. To strengthen muscles and not lose joint mobility, gentle but regular physical exercise is suitable. For this purpose, physical therapy and/or occupational therapy is performed. To relieve pain, hydrotherapy and hot or cold heating pads are prescribed. If the pain is very severe, the doctor may give an intra-articular injection of corticosteroids. If the joint is very badly damaged, surgical implantation is performed, replacing it with a prosthesis.

Most people with rheumatoid arthritis are able to lead a normal life, but lifelong medication is required to manage symptoms. About 1 in 10 patients develop severe disability due to persistent bouts of the disease. To monitor the progression of the disease and response to treatment, you need to have your blood tested regularly. Sometimes the attacks gradually weaken and the disease runs its course, but in these cases some irreversible changes may remain.

Complete medical reference book/Trans. from English E. Makhiyanova and I. Dreval. - M.: AST, Astrel, 2006. - 1104 p.

ICD code 10 juvenile arthritis

ICD 10 juvenile arthritis

JUVENILE CHRONIC ARTHRITIS is:

JUVENILE CHRONIC ARTHRITIS honey.

Juvenile chronic arthritis (JCA) is a syndromic concept that includes several diseases with different etiologies.

Juvenile idiopathic arthritis - description, causes, symptoms (signs), diagnosis, treatment.

Juvenile idiopathic arthritis(JIA, juvenile rheumatoid arthritis, chronic juvenile arthritis) is a heterogeneous group of diseases united by a tendency towards a chronic progressive course. The term was proposed by the WHO Standing Committee on Pediatric Rheumatology (1994) to replace the previously used terms juvenile chronic and juvenile rheumatoid arthritis.

Statistical data. Incidence: 2–19 per 10,000 children per year. Boys and girls get sick equally often. Etiology unknown. Pathogenesis- see Rheumatoid Arthritis.

Genetic aspects. A high prevalence of Ag HLA was established - DRВ1*0801 and *1401 in patients with polyarthritis, HLA - DRВ1*0101 and 0801 in patients with oligoarthritis. The connection between Ag HLA - B27 and the development of arthritis with enthesopathy, as well as HLA - DRB1*0401 with RF - positive polyarthritis, has also been proven.

System option- arthritis with/or previous fever for at least 2 weeks in combination with two or more signs: fleeting, non-fixed erythematous rash, generalized enlargement of the lymph nodes, hepato-or splenomegaly, serositis. Description Age of onset of disease Characteristics of arthritis during the first 6 months of the disease oligoarthritis polyarthritis presence of arthritis only after 6 months of systemic disease Characteristics of arthritis after 6 months of disease oligoarthritis polyarthritis absence of arthritis after 6 months of systemic disease Traits of systemic disease after 6 months Presence of RF CRP level.

Juvenile rheumatoid arthritis

Depending on the type of classification, the disease has the following names: juvenile arthritis (ICD-10), juvenile idiopathic arthritis (ILAR), juvenile chronic arthritis (EULAR), juvenile rheumatoid arthritis (ACR).

Juvenile rheumatoid arthritis (JRA) is arthritis of unknown cause, lasting more than 6 weeks, developing in children under the age of 16 years when other joint pathology is excluded.

M08. Juvenile arthritis.

M08.0. Adolescent (juvenile) rheumatoid arthritis (sero-positive or seronegative). M08.1. Adolescent (juvenile) ankylosing spondylitis. M08.2. Adolescent (juvenile) arthritis with systemic onset. M08.3. Youthful (juvenile) polyarthritis (seronegative). M08.4. Pauciarticular juvenile (juvenile) arthritis. M08.8. Other juvenile arthritis. M08.9. Juvenile arthritis, unspecified.

JRA is one of the most common and most disabling rheumatic diseases that occurs in children. The incidence of JRA ranges from 2 to 16 people per 100,000 children under the age of 16 years. The prevalence of JRA in different countries is from 0.05 to 0.6%. The prevalence of JRA in children under 18 years of age in the Russian Federation is 62.3 per 100,000, primary incidence is 16.2 per 100,000. In adolescents, the prevalence of JRA is 116.4 per 100,000 (in children under 14 years of age - 45.8 per 100,000), primary incidence - 28.3 per 100,000 (in children under 14 years of age - 12.6 per 100,000). Girls are more likely to suffer from rheumatoid arthritis. The mortality rate is 0.5-1%.

Due to the fact that the etiology of JRA is unknown, primary prevention is not carried out.

472 JUVENILE RHEUMATOID ARTHRITIS

Three classifications of the disease are used: the American College of Rheumatology (ACR) JRA classification, the European League Against Rheumatism (EULAR) classification of juvenile chronic arthritis, and the International League of Associations of Rheumatology (ILAR) classification of juvenile idiopathic arthritis, which are presented in Table 21-1). Comparative characteristics of all classification criteria are presented in table. 21-2.

What is juvenile rheumatoid arthritis?

Juvenile rheumatoid arthritis was first described at the end of the last century by pediatricians Still and Shaffar, and was originally called Still-Chaffar disease. Juvenile rheumatoid arthritis is a chronic disease that develops only at an early age (before 16 years). The causes of the disease have not yet been clarified. It manifests itself with a wide range of symptoms, often involving internal organs, progresses quickly and often leads to disability of the patient. May influence growth and development processes. One of the most common rheumatic diseases in children (in different regions, the incidence ranges from 2 to 16 people per 100,000), girls are more often affected.

According to ICD 10 (International Classification of Diseases), a group of rheumatic diseases characteristic only of childhood is called juvenile arthritis, but names such as juvenile idiopathic arthritis or juvenile chronic arthritis may also appear in the literature. In some patients, this form of arthritis may be accompanied not only by joint damage, but also by inflammatory processes in other organs. Professor Alekseeva, who studied this disease, described in her scientific work the possible causes of the appearance and development of the disease.

Manifestations of the disease

There are three types of manifestations of the disease:

1. Systemic damage (Still's disease): fever, rash, damage to internal organs (myocardium, liver, kidneys).

2. Oligoarthritis (affects no more than 4 joints).

3. Polyarthritis (affects 5 or more joints, sometimes up to 20).

Arthritis can manifest itself in acute or subacute form. With the acute onset of the disease, the patient experiences multiple inflammations of the joints, which are accompanied by edema, swelling, deformities and severe pain. An increase in body temperature is typical, more often in the morning. A drop in temperature is accompanied by profuse sweating.

Deformation of limbs in sick children

Juvenile rheumatoid arthritis

• M08. Juvenile arthritis.
• M08.0. Adolescent (juvenile) rheumatoid arthritis (sero-positive or seronegative).
• M08.1. Juvenile (juvenile) ankydosing spondylitis.
• M08.2. Adolescent (juvenile) arthritis with systemic onset.
• M08.3. Youthful (juvenile) polyarthritis (seronegative).
• M08.4. Pauciarticular juvenile (juvenile) arthritis.
• M08.8. Other juvenile arthritis.
• M08.9. Juvenile arthritis, unspecified.

Epidemiology of juvenile chronic arthritis

Juvenile rheumatoid arthritis is one of the most common and most disabling rheumatic diseases found in children. The incidence of juvenile rheumatoid arthritis ranges from 2 to 16 people per 100,000 children under the age of 16 years. The prevalence of juvenile rheumatoid arthritis in different countries is from 0.05 to 0.6%. Girls are more likely to suffer from rheumatoid arthritis. The mortality rate is 0.5-1%.

Adolescents have a very unfavorable situation with rheumatoid arthritis, its prevalence is 116.4 per 100,000 (in children under 14 years of age - 45.8 per 100,000), primary incidence is 28.3 per 100,000 (in children under 14 years of age - 12.6 per 100,000).

Causes of juvenile chronic arthritis

Juvenile rheumatoid arthritis was first described at the end of the last century by two famous pediatricians: the Englishman Still and the Frenchman Shaffard. Over the following decades, this disease was referred to in the literature as Still-Chaffard disease.

The symptom complex of the disease included: symmetrical damage to the joints, the formation of deformities, contractures and ankylosis in them; development of anemia, enlargement of lymph nodes, liver and spleen, sometimes the presence of febrile fever and pericarditis. Subsequently, in the 30-40s of the last century, numerous observations and descriptions of Still's syndrome revealed many similarities between rheumatoid arthritis in adults and children, both in clinical manifestations and in the nature of the course of the disease. However, rheumatoid arthritis in children was still different from the disease with the same name in adults. In this regard, in 1946, two American researchers Koss and Boots proposed the term juvenile (youthful) rheumatoid arthritis. The nosological isolation of juvenile rheumatoid arthritis and adult rheumatoid arthritis was subsequently confirmed by immunogenetic studies.

Classification of juvenile chronic arthritis

Three classifications of the disease are used: the American College of Rheumatology (ACR) classification of juvenile rheumatoid arthritis, the European League Against Rheumatism (EULAR) classification of juvenile chronic arthritis, and the International League of Associations of Rheumatology (ILAR) classification of juvenile idiopathic arthritis.

Diagnosis of juvenile chronic arthritis

In the systemic version of juvenile rheumatoid arthritis, leukocytosis (up to 30-50 thousand leukocytes) with a neutrophilic shift to the left (up to 25-30% of band leukocytes, sometimes up to myelocytes), an increase in ESR to 50-80 mm/h, hypochromic anemia, thrombocytosis is often detected , increased concentrations of C-reactive protein, IgM and IgG in the blood serum.

Treatment goals for juvenile chronic arthritis

• Suppression of inflammatory and immunological activity of the process.
• Relief of systemic manifestations and articular syndrome.
• Preservation of the functional ability of joints.
• Preventing or slowing down the destruction of joints and disability of patients.
• Achieving remission.
• Improving the quality of life of patients.
• Minimizing side effects of therapy.

With the systemic variant of juvenile rheumatoid arthritis, 40-50% of children have a favorable prognosis; remission may occur lasting from several months to several years. However, an exacerbation of the disease can develop years after stable remission. In 1/3 of patients, a continuously relapsing course of the disease is observed. The most unfavorable prognosis is in children with persistent fever, thrombocytosis, and long-term corticosteroid therapy. 50% of patients develop severe destructive arthritis, 20% develop amyloidosis in adulthood, and 65% have severe functional impairment.

All children with early onset polyarticular seronegative juvenile arthritis have a poor prognosis. Adolescents with seropositive polyarthritis have a high risk of developing severe destructive arthritis and disability due to the musculoskeletal system.

In 40% of patients with early-onset oligoarthritis, destructive symmetrical polyarthritis develops. In patients with late onset, the disease may transform into ankylosing spondylitis. 15% of patients with uveitis may develop blindness.

An increase in the level of C-reactive protein, IgA, IgM, IgG is a reliable sign of an unfavorable prognosis for the development of joint destruction and secondary amyloidosis.

The mortality rate for juvenile arthritis is low. Most deaths are associated with the development of amyloidosis or infectious complications in patients with systemic juvenile rheumatoid arthritis, often resulting from long-term glucocorticoid therapy. In secondary amyloidosis, the prognosis is determined by the possibility and success of treatment of the underlying disease.

Elena Malysheva: A breakthrough in medicine! It is possible to restore joints completely in 1 course.

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Rheumatoid arthritis classification according to ICD 10

Classification and ICD-10 codes of forms of rheumatoid arthritis and its complications

Etiology and risk factors

The causes of the pathology have not been established today.

• Genetically determined predisposition to this disease. People over 50 years of age are at risk.
• The trigger for activation of the pathological process is hormonal disorders and excess weight. Mostly women get sick. Often they develop a serious autoimmune disease during pregnancy and postmenopause.
• Viral infections can provoke the occurrence of systemic illness. Bad habits affect the condition of the joints.
• Being in a forced position, prolonged static work.

A combination of various factors leads to the development of systemic inflammation.

Pathogenesis of systemic disease

Abnormal functioning of the immune system is the basis for the occurrence and progression of rheumatoid arthritis, which in ICD10 has code M06. The body has immune cells that are designed to protect the body. These antibodies are produced after an illness. However, instead of attacking bacteria and viruses, the blood cells misbehave.

For various reasons, immune complexes mistakenly begin to destroy the body's own cells and joints. Foci of lymphocytic infiltration occur in the tissues as abnormal immune cells migrate to the joint area. Damage and swelling of the articular membrane and cartilaginous tissue of the joints occurs. This leads to destruction of the body. In the absence of proper treatment, serious deformation of the arms and legs occurs over time.

Symptoms of rheumatoid arthritis

The classic picture of the disease is typical. There is a systemic inflammatory process in progress.

Rheumatoid arthritis has a progressive course. But sometimes there are remissions - periods of temporary improvement.

1. An early symptom is joint swelling, which is characteristic of inflammation of the joint capsule. This is the synovium of the joint.
2. At least three joints are affected. Patients suffer from bone tissue in the palms and lower jaw. Less commonly affected are the elbow and knee joints.
3. Stiffness in the hands in the morning disrupts daily life. The patient's joints do not function. He needs to move so that their work can be restored. This usually takes at least 30 minutes. The symmetry of the damage to the joints is characteristic.
4. Low-grade fever. Feeling very bad.
5. Damage to internal organs. The pathological process involves the lungs, heart, and kidneys. Heart attack, angina pectoris, and pleurisy occur more often in rheumatoid arthritis.
6. Every movement begins with a sharp pain, which greatly interferes with life.
7. Redness of the joint.

Types of joint inflammation

There are several types of arthritis:

8. Aching knees for a long time after heavy loads or injury is a symptom of traumatic arthritis.
9. Joint pain after ARVI is a sign of reactive arthritis.
10. The joint ache, and the patient suffers from psoriasis - most likely it is psoriatic arthritis.
11. If a child's joints are sore, this may indicate the development of juvenile arthritis.
1. Immobilization. High tendency to become disabled.
2. The disease provokes the development of osteoporosis. Bone tissue becomes looser and weaker. Possible fractures.
3. The results of clinical tests allow us to determine the disease.
4. Erythrocyte sedimentation rate is a very important indicator of the presence of inflammation. ESR values ​​above 30 mm/h in women, above 20 mm/h in men indicate the possibility of developing rheumatoid arthritis, which has code M06 in ICD10.
5. X-ray findings show specific changes in the joints.

Therapy for rheumatoid arthritis should begin immediately, without waiting for complications and irreversible consequences. Today there are international standards for the treatment of this pathology.

Basic principles of healing:

6. When choosing a treatment course, the specialist takes into account the duration of the disease and the characteristics of pain. In the early stages, active surveillance is established to monitor the patient's health status. The patient should regularly visit a rheumatologist and take the necessary tests. If necessary, a liver puncture is performed once a year to check its condition.
7. First, one drug is used. Basic antirheumatic drugs and non-steroidal anti-inflammatory drugs are used. Voltaren, Naproxen, Ibuprofen, Ortofen, Indomethacin can relieve inflammation.
8. If first-line drugs do not help, during the acute phase the doctor prescribes steroids - hormones. This allows you to keep the inflammatory process at a very low level.
9. To relieve the patient from constant steroid therapy, immunosuppressants are used as prescribed by the doctor. These drugs are disease modifying. They prevent abnormal immune cells from destroying body tissue. Most often, doctors prescribe Methotrexate, since its effectiveness has now been fully proven. Plaquenil is used as an immunosuppressant.
10. After achieving remission, the doctor recommends switching to a maintenance dose of drugs.
11. In severe cases, the patient has to have joints replaced and prostheses installed.

If you experience pain in the joints, you should consult a specialist. This serious disease cannot be neglected. If treated incorrectly, this pathology can cause many problems. Only intensive treatment can prevent complications and make life easier for patients.

5. Journal “Scientific and Practical Rheumatology”;

7. JOURNAL “ANGIOLOGY AND VASCULAR SURGERY”;

10. Directory of RLS drugs - http://www.rlsnet.ru/;

Classification of rheumatoid arthritis ICD 10

This disease is one of the pressing problems in medicine. Rheumatoid arthritis has an ICD-10 code: M05-M14. ICD 10 - international classification of diseases, 10th revision. This disease is characterized by inflammation of the joints and wear of cartilage tissue. Many patients complain of redness of the skin and itching in the affected area. Even doctors sometimes confuse arthrosis and arthritis. Essentially, these are completely different types of diseases. Arthrosis is rather an age-related degeneration of the joint cavities. Arthritis is an inflammatory process of the joints. Inactivity often leads to disability.

Rheumatoid arthritis is a terrible disease that affects not only older people, but also infants. This disease applies to all age categories. It's like an epidemic, it spares no one.

Lack of treatment leads to deformation of the area where rheumatoid arthritis is developed. Serious deformation does not go away without a trace; many symptoms begin that bother the patient. The joints swell and cause hellish discomfort. Cartilage and bone continue to deteriorate, threatening the patient with disability.

Patients with rheumatoid arthritis with ICD code 10

Why is it necessary to write coding on the patient’s card:

12. Taking the card, the doctor knows the patient’s complaints, what worries him most.

Rheumatoid arthritis, according to the 10th international classification, is a disease of the musculoskeletal system, which has many varieties. The international classification distinguishes the following codes for rheumatoid arthritis: M06.0, M06.1, M06.2, M06.3, M06.4, M06.8, M06.9. These are the main points into which the disease is divided. In fact, each type has several sub-items. In the ICD 10 system, rheumatoid arthritis has a code from M05 to M99.

If the disease is not treated, complications may arise:

13. disability;
14. development of osteoporosis;
15. fractures and other injuries;
16. immobilization.

Symptomatic manifestations of the disease

17. the joints cease to function properly, morning stiffness is observed, which significantly worsens the patient’s well-being;
18. the temperature in the affected area rises, the swelling is hot to the touch and your health worsens;
19. increased risk of heart attack;
20. acute pain;
21. swelling and redness of the articular surfaces.

The main symptom is the presence of an inflammatory process. Rheumatoid arthritis is a progressive disease with periods of temporary improvement.

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Arthritis code ICD 10: knee joint, treatment

This facilitates and improves the process of treating the patient. Thus, if the patient’s card indicates arthritis code according to ICD 10, then all medical staff, all employees of the institution will be able to provide adequate assistance, provide consultation that complies with the standards, and carry out all the laboratory tests and diagnostics necessary in this case .

There is no misunderstanding between the patient and the medical staff, since this designation already gives an understanding of the reasons for the person’s visit to the hospital. The patient will not be able to correctly, from a medical point of view, explain what he is sick with. And the entry in his medical documents - rheumatoid arthritis ICD 10 - will give an understanding of what health care workers faced in this case.

Patients with arthritis code ICD 10

List of diseases of the musculoskeletal system

The list of diseases of the musculoskeletal system and connective tissues according to ICD 10 revision looks something like this:

22. M00 Pyogenic arthritis
23. M03 Post-infectious and reactive arthropathy

This list can be continued up to M99. In turn, each paragraph is divided into subparagraphs.

24. M06.0 Seronegative rheumatoid arthritis
25. M06.1 Still's disease in adults
26. M06.3 Rheumatoid nodules
27. M06.8 Other specified rheumatoid arthritis

Sometimes, patients with the same diagnosis, for example, arthritis of the knee joint, are divided into different groups according to the ICD 10 revision.

Even with similar main signs of the disease:

28. pain sign
29. limited mobility
30. swelling and redness accompanying inflammation

After all, according to the classification, such patients are distributed according to individual indicators, the nature of the course and signs of the disease.

Such arthritis may be in the group of reactive arthritis according to ICD 10, if there are additional symptoms characteristic of this type of disease:

31. general metabolic disorders
32. renal dysfunction
33. malfunctions in the water-salt balance system
34. polyarthritis

Gouty arthritis according to ICD 10 and its symptoms

The main thing is to contact medical institutions in a timely manner, undergo all prescribed examinations, take all recommended tests and take prescribed medications strictly according to the regimen prescribed by the attending physician.

Illness is always a big problem for a person. When an illness is detected, the patient is not so much interested in the subgroup and type of the disease in the international classification of diseases as in the positive outcome.

Medicine is developing rapidly. This classification is an example of how doctors keep up with the times, improve their methods, and improve their approach to patient care.

Rheumatoid arthritis- a chronic inflammatory disease of connective tissue, characterized by its own immune response, of a systemic nature.

The causes of the disease are still unknown. Mostly large articular joints, which are located on the periphery of the body, are affected. In the structure of the joint, erosion and destruction of all tissue structures occur.

Populationally, 1% of the population suffers from rheumatoid arthritis. Women get sick 4 times more often than men. The disease occurs at any age, but most often at 40-50 years of age.

The main peak incidence occurs at 30-35 years of age.
After 1 year of illness, every 3-4 patients experience erosive changes in the joint apparatus, which causes a decrease in performance.

Causes of rheumatoid arthritis

In the modern world, medical science cannot give an exact answer about the cause of rheumatoid arthritis.
Risk factors are identified that, to one degree or another, can lead to changes in the autoimmune response to its own mediators.

Main risk factors:

1. Genetically mediated predisposition. Presence of specific antigens.
2. Congenital deformity musculoskeletal system.
3. Hormonal imbalance during pregnancy, taking oral contraceptives and breastfeeding. Postmenopause in women.
4. Toxic effects of nicotine on connective tissue (tobacco smoking).
5. Various infectious agents(mycobacteria, intestinal infections, toxins).
6. Non-specific agents(injuries, hypothermia, abortion).
7. Specific proteins produced during heat shock.

Triggers for the development of rheumatoid arthritis:

• Acute infectious diseases.
• The period of exacerbation of a chronic disease.
• Climate change.
• Puberty.
• Menopause.
• The period after childbirth.
• Injury.
• Stress reactions.

Types and codes of rheumatoid arthritis according to ICD-10

Rheumatoid arthritis- a multimodal disease and different variants of its manifestation are possible. The mechanism of formation and migration of the inflammatory process in the joints is unclear.

Main types

1. Articular form of rheumatoid arthritis:
   • M05.8 - other seropositive rheumatoid arthritis.
   • M06.0 - seronegative rheumatoid arthritis.
   • M08.0 - juvenile rheumatoid arthritis.
   • M08.1 - juvenile ankylosing spondylitis.
   • M08.3 - juvenile polyarthritis.
2. Rheumatoid arthritis involving internal organs or systemic lesions:
   • M05.0 - Felty's syndrome.
   • M05.1 - rheumatoid lung disease.
   • M05.2 - rheumatoid vasculitis.
   • M06.1 - Still's disease in adults.
   • M06.2 - rheumatoid bursitis.
   • M06.3 - rheumatoid nodule.
   • M06.4 - inflammatory polyarthropathy.
   • M08.2 - juvenile rheumatoid arthritis with systemic onset.
   • M35.0 - Sjögren's syndrome.

The presented disease encodings are used in the international classification of diseases

The assignment of one of the codes must be accompanied by a detailed study and on its basis the issue of detailing the disease according to ICD-10 is decided. Perhaps a combination of several encodings in one clinical case.

Degrees of the disease

Since rheumatoid arthritis is an independent nosological entity, there are degrees of progression of the process, which are based on a number of clinical and instrumental research methods.

These include:

1. Clinical stage.
2. Degrees of activity.
3. X-ray stage.
4. Functional class.

Clinical stage

It is established based on the time interval from the first manifestations of the disease.

• Very early stage- duration of the disease from the first manifestations, no more than 6 months.
• Early stage- duration from 6 months to a year.
• Expanded stage- the disease lasts more than 1 year, with the presence of clinical symptoms.
• Late stage- illness period of more than 2 years. Significant damage to small joints and symmetrical destruction of the main large joints with the formation of multiple erosions.

Disease activity level

• Low- clinical symptoms are scant, exacerbations up to 1 time per year.
• Moderate- pronounced clinical picture, exacerbation of pain syndrome up to 4 times a year. Damage to one target organ.
• High- constant pain syndrome. Impaired movement function. Complications from many physiological systems.
• Remission- absence of clinical signs of the disease.

Function class

Used to assess work activity and self-care functions. Necessary for assessing disease progression.

• Functional class 1- the ability to perform standard physical activity is preserved.
  Daily and professional activities are not impaired.
• Functional class 2- the ability to perform daily activities is preserved, but there is a limitation in the non-professional sphere.
• Functional class 3- the performance of everyday work is preserved, but there are restrictions in professional and non-professional areas.
• Functional class 4- persistent violations of self-care. Inability to perform professional activities.

Clinical picture

The symptoms of the disease consist of several variants of the course of rheumatoid arthritis.

• Classic version- multiple lesions of small joints of the hands and feet. It is symmetrical in nature.
• Monoarthritis- large joints are affected.
• Polyarthritis with damage to small and large joints, after an infectious disease.

With all variants of the onset of the disease, the occurrence of severe symptoms is noted, which is progressive over time.

Main symptoms:

• General weakness.
• Hyperhidrosis.
• Rarely, a rise in low-grade fever in the evening.
• Muscle weakness, up to malnutrition and atrophy.
• Morning stiffness in the small joints of the hands and large joints. Goes away after the start of physical activity.

As the process progresses, the joints become deformed. Persistent contractures and limited movement occur. Changes in the joints of the hand cause deformation like a walrus flipper.

Extra-articular changes may occur:

1. Heart damage with the development of rheumatic pericarditis.
2. Damage to blood vessels and internal organs.
3. Chronic inflammation of the muscular system.
4. Lung damage (interstitial pulmonary fibrosis).
5. Kidney damage (renal amyloidosis, glomerulonephritis).
6. Lymphadenopathy.
7. Systemic liver damage.
8. The occurrence of complications from the gastrointestinal tract.

Diagnostics

Diagnostic measures consist of four main types of research:

1. Anamnesis.
2. Physical examination.
3. Laboratory research.
4. Instrumental research methods.

Anamnesis

• Complaints.
• The moment of pain or stiffness in the joints.
• The degree of restriction of work activity.
• Recent infectious diseases.
• Allergy history.
• Heredity.

Physical examination

• Each joint is examined in detail.
• Mobility is assessed.
• Auscultation of the heart and brachycephalic arteries is performed.
• The skin is examined to assess its condition.

Laboratory research

• General blood analysis.
• Clinical blood test.
• General urine analysis.
• Biochemistry of blood.
• Lipid spectrum.

Instrumental research methods

• Radiography.
• CT scan.
• Magnetic resonance imaging.

The prescription and subsequent assessment of the diagnostic results should be carried out by a doctor.

Treatment of rheumatoid arthritis

Modern therapy consists of taking two main groups of drugs:

1. Fast-acting drugs (NSAIDs, glucocorticosteroids). They are designed for rapid pain relief and elimination of the inflammatory reaction in the joint. Do not affect the course of the disease.
2. Basic drugs (methotrexate, cuprenil, plaquenil, arava). They are able to delay the development of erosions and the occurrence of ankylosis. Thanks to these properties, they preserve the functionality of the joints.

Lifestyle modification is required, with a change in the motor pattern

New generation drugs

In the modern world, there are few new dosage forms to curb the progression of the disease.

Main groups of drugs:

• Aminoquinolines.
• Sulfonamides.
• Salts of gold.
• Cytostatic immunosuppressants.
• Biological modifiers of the immune response.

The choice of drug in the treatment of rheumatoid arthritis should be made only by the attending physician, under the control of clinical blood parameters and x-ray picture

Possible complications

Complications of the disease are usually associated with the involvement of internal organs and systems in the process.

The most common complications:

• Rheumatoid pericarditis.
• Amyloidosis of the kidneys.
• Intestinal amyloidosis.
• Seropositive keratoconjunctivitis.
• Osteoporosis.
• Increased bone fragility.

Complications mainly occur in the later stages of the disease.

Complications of long-term use of drug therapy:

1. Dysfunction of the gastrointestinal tract.
2. Hormonal imbalance.
3. Acute renal, liver failure.
4. Headache.
5. Nausea, vomiting.
6. Constipation, diarrhea.

If complications occur, you must urgently seek help from a diagnostic and treatment facility.

Prevention

Prevention consists of lifestyle modifications and constant use of medications.

Necessary:

• Avoid drafts.
• Wear warm clothes.
• Resume taking NSAIDs in stressful situations and irrational physical activity.

There are no strict rules in prevention. Neither method guarantees protection against the occurrence of rheumatoid arthritis.