Rheumatoid arthritis disease code. Chronic disease - rheumatoid arthritis. Make an appointment through the app! Fast and convenient any time of the day

When a person notices certain symptoms, he almost immediately runs to the clinic. After undergoing diagnostics and tests, the doctor makes a diagnosis of rheumatoid arthritis.

In general, disease activity begins about a year or two after its onset. The disease is characterized by the manifestation of general symptoms, such as inflammation in the joints and discomfort in the morning.

But rheumatoid arthritis is a disease that has many subtypes.

Classification according to ICD-10

According to the International Classification of Diseases, 10th revision, rheumatoid arthritis is classified as seropositive and seronegative. These two types also have their own classification and each subtype of the disease has its own code.

Seronegative RA, ICD-10 code – M-06.0:

• Still's disease in adults – M-06.1;
• bursitis – M-06.2;
• rheumatoid nodule – M-06.3;
• inflammatory polyarthropathy – M-06.4;
• other specified RA – M-06.8;
• seronegative RA, unspecified – M-06.9.

Seropositive RA, ICD-10 code – M-05:

• Felty syndrome – M-05.0;
• rheumatoid lung disease – M-05.1;
• vasculitis – M-05.2;
• rheumatoid arthritis with involvement of other organs and systems – M-05.3;
• other seropositive RA – M-05.8;
• unspecified RA – M-05.9.

Historical development of rheumatoid arthritis

History says that arthritis and similar diseases were known to our ancestors.

The history of ancient times names Papyrus Ebers as the first person who named the health condition that is similar to rheumatoid arthritis.

The history of Egypt determines that rheumatoid arthritis was a leading disease in this country.

The history of India names the symptoms by which the disease can be identified: painful manifestations, swelling and limitation in movement.

History 1858: B Garrod names the causes that distinguish rheumatoid arthritis, osteoarthritis and gout.

History of the Far East: in case of illness, acupuncture is used as treatment.

History of 1880: the publication known at that time defines the chronic course of the disease, the effect on the tendon sheath, and the inflammatory process.

The famous figure Hippocrates used willow extracts to relieve pain during illness.

1929 story: Leroux names the drug salicylic acid as a relief for arthritis pain.

Diagnosis of the disease

The definition and diagnosis of the disease is based on indicators such as the criteria for rheumatoid arthritis. These include:

• discomfort in the joints and periarticular tissues after sleep, which is typical in the morning. As a rule, the activity of such pain lasts for one hour;
• arthritis activity manifests itself in three or more joint areas;
• The disease is typical for the joints in the hands. A tumor process is observed in one of the joints: wrist, metacarpophalangeal, proximal interphalangeal;
• symmetrical form of the disease. The inflammatory process begins in similar joint areas on both sides.
• the appearance of rheumatoid nodules;
• clinical tests reveal the presence of rheumatoid factor in the blood;
• presence of changes on the X-ray image: erosion.

The diagnosis of the disease is considered confirmed if four of the above symptoms are identified, the activity of which should be observed for six weeks.

Tests to help clarify the diagnosis

As a rule, when diagnosing a disease, the doctor prescribes the following tests:

Laboratory tests that contribute to the correct diagnosis. Clinical tests. These include a clinical blood test, which helps determine how much hemoglobin is reduced in the patient’s body.

Clinical tests are not the decisive link in making a diagnosis, but thanks to them they can determine how complex the course of the disease is.

Biochemical tests. These include a biochemical blood test that can determine the presence or absence of rheumatoid factor and C-reactive protein.

Determination of erythrocyte sedimentation rate. The speed can be normal or increased. An increased rate means that there is an inflammatory process in the human body, an exacerbation of the disease, or a severe course.

X-ray examination. When the disease is just beginning, x-rays will not show any visible changes. You can only notice excess joint fluid and swelling. But not only x-rays and tests can show such symptoms. They can also be seen during direct examination by a doctor. With the active development of arthritis, an x-ray will be able to show the presence of specific signs: erosion, reduction of joint spaces, ankylosis.

Analysis for the presence of antibodies to cyclic peptide. This analysis is the most reliable in modern medicine. Thanks to it, rheumatoid arthritis can be detected in 80% of diagnostic cases.

Juvenile (youthful) type of rheumatoid arthritis

The juvenile type of rheumatoid arthritis is a rheumatic disease that appears before the child (adolescent) is 16 years of age.

As a rule, in medicine there is no clear answer to why a disease occurs. People with a genetic predisposition are at risk.

The juvenile type of rheumatoid arthritis has the following symptoms, such as swelling in the joints, a feeling of stiffness, pain, and it is also noted that the disease affects the eyes.

Photophobia, conjunctival infections, glaucoma, and kerotopathy appear. The juvenile type of rheumatoid arthritis manifests itself with an increase in temperature.

Diagnosis of the disease includes all the same methods used for adult patients.

As a rule, with adequate treatment, the juvenile type of rheumatoid arthritis can be overcome in 50% of cases. How long it will take for treatment and what medications need to be taken can only be determined by the attending physician.

Biological agents as a method of treatment

Biological agents are proteins that are genetically engineered. Human genes were taken as the basis.

This method of treatment is aimed at suppressing inflammation in the disease. What differences do biological agents have without causing side effects? Proteins affect a number of special components of human immunity, while eliminating further complications.

Despite the fewer side effects, they still exist. Thus, there is an increase in body temperature and the occurrence of infectious diseases. In addition to such mild side effects, an exacerbation of an existing chronic disease is possible.

There are not so much recommendations as a ban on the use of biological agents in the case of sclerosis and chronic heart failure. The use of such agents should only be in the presence of a physician. Application is carried out by intravenous administration. It is prohibited to administer the drug during pregnancy.

Disability due to rheumatoid arthritis

Disability is determined taking into account the following factors:

• degree of illness;
• course of the disease;
• existing exacerbations and remissions during the last year;
• leading physician's prognosis;
• the patient's ability to provide for himself.

Disability due to illness has two subsections: disability from childhood (before adulthood) and general disability (after adulthood).

There are 3 disability groups:

1. Placed in case of mild or moderate course of the disease. A person can serve himself and move around.
2. Placed in moderate or severe cases of the disease. The person requires care, can partially care for himself, and has limited mobility.
3. Placed in case of severe disease. There is no independent movement. A person cannot serve himself. Requires constant care.

Psychosomatics

The psychosomatics of the disease determines the interaction of rheumatoid arthritis (ICD-10 code) with the psychological state of the patient. Thus, mental influence on the course of the disease can completely change it.

In the case of different disorders, psychosomatics will also be different. That is why individual psychological diagnostics are required.

Psychosomatics is characterized by the following factors, such as the feeling that a person is the center of all affairs and concerns, and in childhood such people are raised by certain methods. They are characterized by hyper-conscientiousness and external compliance, self-sacrifice and excessive need for physical activity.

Psychosomatics is one of the main reasons for the development of the disease.

Drug treatment of rheumatoid arthritis

What medications does the doctor prescribe to treat the disease? As a rule, the use of traditional anti-inflammatory drugs helps reduce pain, swelling, and increase the functioning of joints.

How much of the drug is required to treat rheumatoid arthritis? As a rule, a reduced dose is used.

It is also possible to use analgesics, which also help relieve pain.

Common medications in the treatment of arthritis

Today, medicine has a lot of medications that help treat rheumatoid arthritis (ICD-10 code). These include:

Sulfasalazine

Sulfasalazine is prohibited in some American countries. In our country, Sulfasalazine is the safest drug that can slow down the development of the disease.

Please note that Sulfasalazine can cause a number of side effects. Thus, it is prohibited to use the drug Sulfasalazine if you are hypersensitive.

As a rule, the drug Sulfasalazine is started at 500 mg/day, and after 14 days the dose is increased. The maintenance dose is 2 g/day.

Sulfasalazine is divided into two doses per day. For children, Sulfasalazine is divided into four doses.

As a rule, the effectiveness of the drug Sulfasalazine comes at the beginning - end of the third month of treatment. Sulfasalazine can cause the following negative effects: nausea, loss of appetite, agranulocytosis.

Methotrexate

Methotrexate is widely used in oncology. Thus, thanks to it, the division of cancer cells is inhibited. But Methotrexate has also found its use in rheumatoid arthritis.

Only a doctor can prescribe the correct dosage of Methotrexate.

Basically, Methotrexate leads to improvement 6 months after its use. It must be remembered that the frequency of taking Methotrexate promotes rapid treatment.

Wobenzym

The drug Wobenzym helps to reduce side effects, as well as reduce the dosage of basic medications. Wobenzym also helps reduce the dosage of non-steroidal anti-inflammatory drugs.

The drug Wobenzym can be prescribed by a doctor for mild illness. Wobenzym is also prescribed for contraindications to treatment with immunosuppressive therapy.

Metipred

Metypred belongs to the group of corticosteroids. In other words, Metypred is referred to as methylprednisolone.

In the case of rheumatoid arthritis, Metypred helps eliminate painful manifestations, as well as improve the general condition of the disease.

Metypred has its side effects. That is why this drug must be used as prescribed by a doctor.

Turmeric

Turmeric is not a medicine at all, but rather a folk method of treatment.

Turmeric is popularly known as a seasoning for many dishes. In addition to this property, turmeric is famous for its medicinal properties. Thus, turmeric helps relieve painful symptoms, as well as swelling in the inflamed joint.

Preparing a medicinal mixture is not at all difficult. To do this, you need to mix crushed turmeric and olive oil in equal parts. Take the miracle mixture in the amount of 2 teaspoons with food.

Turmeric is useful as a seasoning, which must be added to food at least 2 times in 7 days.

And the most important rule is that unauthorized treatment will only worsen the course of the disease.

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 drugs
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: duration of the disease is 2 years or more + pronounced destruction of small (III-IV X-ray stage) and large joints, the 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 processes (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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The World Health Organization (WHO) has developed a special medical coding for the diagnosis and definition of medical diseases. ICD 10 code is the coding of the international classification of diseases, 10th revision, as of January 2007.

Classification of arthritis according to ICD 10

Today, there are 21 classes of diseases, each of which contains subclasses with codes for 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.”

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.

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.

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

Symptoms of reactive arthritis

A characteristic feature of the course of the disease is the symmetry of joint damage

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.

1. Inflammation of the mucous membrane of the eyes occurs (conjunctivitis may develop).
2. Pain in the joints becomes increasingly stronger, while motor activity decreases. Noticeable redness and swelling appear in the infected areas.
3. The organs of the genitourinary system become inflamed.

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.

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

Diagnosis and treatment 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.

Treatment of reactive arthritis must begin 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.

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.

To prevent reactive arthritis from developing into a chronic form, timely treatment is necessary. Only the attending physician should make decisions about whether a patient should take certain medications. Self-medication is unacceptable.

An important point in preventive measures associated with reactive arthritis is to prevent infectious infection of bone tissue. To do this, you need to adhere to basic rules of personal hygiene. Avoid intestinal infections, wash your hands before eating and after using the toilet, and use individual cutlery. Please note the need for heat treatment of food products before consumption.

Using a condom during sexual intercourse will protect you from genitourinary infections. Having a regular sexual partner will reduce the risk of the disease. All of the above methods will help prevent the disease.

It is easier to prevent a disease than to treat it. If the first signs of the disease appear, you should consult a doctor as soon as possible.

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.

At-risk groups

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.

General symptoms

• weakness;
• pale skin;
• shortness of breath with any exertion;
• poor appetite.

The general symptoms are partly due to, and it occurs because the amount of bone marrow in which blood cells are formed decreases.

Characteristics

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

Since the disease simultaneously brings pain and deprives mobility, patients often begin. 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 in the joint decreases, they become fragile and break easily. In severe cases, osteoporosis of the entire skeleton develops.

In addition, it 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, it 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 juvenile rheumatoid arthritis).

Diagnostics

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.

Health care

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 there are only mild symptoms, they 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. First, or is prescribed. If the symptoms do not go away, gold compounds are prescribed, or. 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.

Precautionary measures

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.

The question of where to perform the operation arises for everyone who has decided to replace a joint. It is better to entrust your joints to private medical institutions; their only drawback is the high cost of the procedure.

To perform endoprosthetics, the following is required:

• maximum sterility in the operating room and throughout the clinic;
• the latest high-quality equipment;
• disposable consumables;
• high-quality endoprostheses;
• experienced specialists.

State clinics occupy old buildings dating back to the last century. Repairs there are carried out every 10 years, but is this enough to maintain sterility? Another problem of government agencies is old equipment, which reduces the quality of the operation.

Preoperative preparation and surgery.

Sometimes a patient, having learned about the need for hip replacement, is determined exclusively to undergo surgical intervention abroad. So to speak, there are no comrades according to taste. Everyone makes their own choice.

In this case, we can advise you to send a request to clinics in Germany and Israel. These countries are quite good at conducting such operations. Abroad, you are a foreign citizen who has come to receive treatment, so local quotas do not apply to you.

Above we calculated the approximate cost of hip replacement in Russia. For some, this price may seem exorbitant. Not every person is able to pay that much. Understanding this situation, our state has developed a quota, due to which it is possible to replace the hip joint.

The causes of the development of a pathological process in the hip joint can be various deforming diseases or injuries. Most often, people over 55 years of age and professional athletes need prosthetics.

Failure to see a doctor in a timely manner or attempts to cure the disease on your own only worsen its course. The patient is unable to move normally and even sit. All this is accompanied by severe pain and negatively affects a person’s physiological state and psychological background.

Hip replacement is prescribed when conservative methods have not given the desired result, the disease continues to progress, aggravating the pathological process, and increases the chances of disability. A person constantly experiences severe pain that cannot be relieved by medications, which only confirms the process of destruction of the hip joint.

Arthroplasty is the most effective method of treating diseases of the musculoskeletal system, and often the only one. The preparatory stage begins after the doctor prescribes a replacement and the patient makes a decision.

The coordinating doctor will tell you in detail; he will also help you choose a prosthesis and recommend the appropriate one. After clarifying all the nuances, you need to communicate with other specialists, determine possible risks and consequences.

You will need to consult an anesthesiologist to determine the type of anesthesia. It is important to detect a possible allergic reaction to anesthesia in time. Preparation begins with a series of diagnostic tests approximately 5 days before surgery.

1. Consultation, examination by specialists (rheumatologist, orthopedist).
2. X-ray examination, MRI of the joint.
3. Visit to specialized specialists (cardiologist, anesthesiologist, gynecologist/urologist).
4. Laboratory tests: detailed, general blood test, diagnostics of coagulation.
5. Ultrasound examination of the heart, cardiography.
6. 4-8 weeks in advance, you need to start attending physical therapy procedures to strengthen the ligamentous apparatus in order to quickly adapt to the prosthesis.

If the diagnosis does not reveal any contraindications, a date for surgery is set. In about a few days, the patient arrives at the clinic, where endoprosthetics will be performed. The procedure is performed with painkillers under general or spinal anesthesia - this is the name given to the introduction of an anesthetic into the subarachnoid space using a puncture.

With the latter type of anesthesia, the patient remains conscious and can observe the progress of the operation. How long does it take to install an implant? The duration of the manipulation ranges from one to several hours. After cutting the soft tissues and muscles of the thigh, the doctor removes the affected joint and then installs an endoprosthesis.

1. Diseases of the cardiovascular and bronchial-pulmonary systems in the stage of decompensation
2. The presence of a focus of purulent infection in the body (tonsillitis, carious teeth, chronic sinusitis and otitis, pustular skin diseases)
3. Psychiatric or neuromuscular disorders that increase the risk of various disorders and disorders in the postoperative period
4. Active or latent infection in the hip joint less than 3 months old
5. Skeletal immaturity
6. Acute vascular diseases of the lower extremities (thrombophlebitis, thromboembolism)

To perform this type of operation, an operating room of the 1st degree of cleanliness is required, which is not provided in all hospitals. Our Clinic guarantees compliance with these requirements. The duration of the operation is from 1 to 3 hours.

Operations are performed under combined anesthesia (epidural or spinal with intravenous support). The operation is accompanied by blood loss of about 500 ml, which in 50% of patients requires intraoperative and postoperative blood transfusion.

Highly qualified ECSTO specialists in most cases perform endoprosthesis surgery using a minimally invasive method, which involves the use of small incisions (from 6 cm) to access the hip joint.

This technique allows for minimal blood loss during surgery, provides a good cosmetic effect, reduces postoperative pain, and reduces recovery time and hospital stay after surgery.

READ ALSO: Osteoarthritis of the hip joint, stage 2 treatment

At the ECSTO Clinic there are no age restrictions for hip replacement; the clinic’s specialists have extensive experience in the surgical treatment of elderly patients. If necessary, the patient is prepared for surgery by several specialists - a cardiologist, a neurologist, and other specialists.

When surgically treating elderly patients, additional parameters are taken into account when choosing an endoprosthesis. Elderly patients are fitted with endoprostheses with a large head diameter to eliminate the risk of dislocation after surgery, even with weakened muscles.

The endoprosthesis replacement procedure takes from half an hour to several hours and is performed under general or spinal anesthesia (in this case, the patient is given intravenous sleeping pills). To prevent thromboembolic complications, the patient is given anticoagulants on the eve of surgery.

After surgery, the patient is in the recovery room, where specialists monitor his condition around the clock. If the patient’s condition is stable, after some time he is transferred to a regular ward. As a rule, after a week the patient can leave the clinic on his own.

Is it possible to perform a joint replacement in Moscow as efficiently as possible and at the lowest cost? Investigation of the Big City Doctors project

More recently, an operation to replace various joints in Moscow could be done under a quota. Since 2014, quotas for the treatment of most diseases have been abolished, except for very rare ones and those that require repeated surgical intervention due to doctor error.

1. You need a large package of certificates and documents to apply for a quota.
2. If you are lucky and your application is accepted, you may be offered surgery in any clinic in Russia.
3. You cannot choose a surgeon based on recommendations.
4. The endoprosthesis will be installed from those available at the clinic's disposal, most often these are domestically produced products.

You can get a joint replacement free of charge through an individual rehabilitation program. To do this you need:

1. Choose a clinic and doctor.
2. Prepare documents for participation in the program.
3. Select an implant and buy it from the manufacturer.
4. Have surgery.
5. Get your money back for purchasing a prosthesis after a few weeks.

The only drawback is that you buy the desired type of endoprosthesis yourself. All expenses for hospital stay, services of a surgeon, anesthesiologist, and other expenses are paid by the state.

Endoprosthetics at the Pirogov Clinic, the leader of the rating, is performed by specialists who daily carry out similar operations on all joints in the human body. Go to the official website of the organization, in the reviews section - patients speak positively about this medical institution, staff and leading surgeons.

The clinic is equipped with the latest equipment. Employees follow innovative developments in the medical industry, attend conferences and lectures to improve their skills. If a new technology for minimally invasive treatment of joints has appeared in the world, it is already being practiced here.

Prices are much lower than European, Turkish or Israeli. Here we are always happy to accommodate the patient halfway.

The Smolensk Endoprosthetics Clinic is a state institution equipped to world standards. 5 modern operating rooms have the latest equipment allowing for extremely difficult neurosurgical operations, and post-operative intensive care wards are ready to receive patients at any time of the day.

Until recently, joint replacement in Moscow was carried out using quotas for high-tech surgery, which were allocated by the state. To be more precise, hip replacement was carried out at the expense of quotas until 2014.

Since 2014, quotas for most such operations have been abolished, with the exception of some systemic diseases, for example, systemic lupus erythematosus or for iatrogenic reasons (doctors’ error during primary replacement).

In most cases, there are simply no quotas for hip replacement. The picture is the same with knee replacement, but since 2015. Joint replacement operations are expensive and most citizens cannot afford to pay both the cost of the endoprosthesis and the cost of the operation itself.

It was planned that joint replacement operations would be carried out at the expense of the compulsory medical insurance policy, but for now this period is transitional and, often, there is misunderstanding and confusion on the part of hospitals and doctors.

The presence of any of the above indications is the basis for surgery to replace a joint or part thereof.

Head of the department, traumatologist-orthopedist

Medical experience 30 years Qualification category Highest Academic degree Candidate of Medical Sciences, Doctor of Medical Sciences

Address of the State Clinical Hospital named after. S.P. Botkin

Moscow, 2nd Botkinsky pr-d, 5, 22nd building, sector “B”, 7th floor Telephones

Professor, Doctor of Medical Sciences, doctor of the highest category. He has been the head of the Center since 2006 and has extensive experience in treating orthopedic and trauma patients. During the year he performs more than 500 operations on primary and revision endoprosthetics of the hip, knee and shoulder joints using the most modern technologies

The Moscow City Center for Bone and Joint Replacement is a unique structural unit in the Moscow healthcare system. The center was founded by Professor Movshovich I.A. in 1989

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At that time, hip replacement was considered a unique operation. 15 years ago at the State Clinical Hospital named after. S.P. Botkin performed no more than 30 hip replacements per year. Currently, the Endoprosthetics Center performs more than 1 thousand procedures annually.

hip replacements, about 700 knee replacement operations. Today, the most complex high-tech operations for revision endoprosthetics of the hip and knee joints have become routine for the Center, while in the early 2000s no more than 5–7 of them were performed annually.

The Center employs 5 doctors, three of them are doctors of the highest category, one is a candidate of medical sciences, and the Center’s staff includes 7 nurses.

The Center's profile is the treatment of patients with diseases and injuries of the joints of the upper and lower extremities, periprosthetic fractures.

• Total hip replacement using the most modern coatings and implant designs, the most wear-resistant friction pairs;
• Unipolar hip replacement (in elderly patients with femoral neck fractures);
• Total knee replacement, including routine use of computer navigation;
• Total shoulder arthroplasty;
• Organ-saving operations on the joints of the upper and lower extremities;
• Revision hip replacement;
• Revision knee replacement;
• Osteosynthesis of periprosthetic fractures of the femur, tibia, humerus, and pelvis.

The endoprosthetics center is equipped with the latest equipment to carry out high-tech operations according to the most modern standards. We use computer navigation for knee and hip replacements.

80% of knee replacements are performed using navigation technology. Currently, the clinic has accumulated unique experience in performing 1.2 thousand total knee replacements using computer navigation.

Knee replacement using navigation equipment

We perform hip and knee replacement using minimally invasive methods. This technique was introduced in our clinic more than 10 years ago and is successfully used and developed. The technique allows endoprosthetics to be performed without significant muscle damage, which, in turn, makes it possible to more quickly restore limb function.

Recently, along with the increase in primary endoprosthetics operations, the number of revision operations to replace unstable hip and knee joints has also increased. These operations are unique because

each of them is individual. Here we have developed and implemented our own instruments and technologies into clinical practice, and received patents. The use of shoulder arthroplasty for injuries and chronic diseases of the shoulder joint is also expanding. All this allows patients to get rid of pain and return to an active life.

In revision surgery, we use the most modern materials, we use only proven endoprostheses produced by companies that occupy a leading position in the world in terms of product quality. The endoprostheses installed in the clinic are equipped with the most modern friction pairs.

The equipment of the clinic allows performing operations of any complexity. In this case, low-traumatic techniques are used, both in relation to soft tissues (minimally invasive approaches) and in relation to bones (components of endoprostheses that ensure minimal damage to bone tissue).

In addition to using the most modern world developments in their practice, the clinic’s specialists themselves create and implement new techniques. The clinic's staff defended 24 patents for inventions and utility models related to both new treatment methods and new surgical instruments.

The center has a clinical base of the Department of Traumatology, Orthopedics and Disaster Surgery of the First Moscow State Medical University. THEM. Sechenov. The head of the Center is a professor in this department.

Weekly in the consultative and diagnostic clinic at the City Clinical Hospital named after. S.P. Botkin undergoes a commission of about 30 patients to determine indications for joint replacement. Every year, about 2 thousand patients undergo inpatient treatment at the Center.

Hip replacement is a surgical procedure during which a damaged joint is replaced with an artificial implant that replicates the anatomical shape of a healthy joint.

The purpose of this operation is to restore the lost function of the limb, relieve pain, and, as a result, return to a normal, active lifestyle. With subtotal (unipolar) arthroplasty, only the femoral articular surface is replaced, while total (complete) arthroplasty involves replacing the entire joint with an endoprosthesis.

Hip replacement surgery costs from RUB 103,000. Conducted by candidates of medical sciences and professors. The latest equipment and tools are used. Implants of both domestic and foreign production are installed.

In fact, a person always wants to reduce his financial costs, especially those related to medical services. So, private medical institutions with quotas practically do not work, but by contacting a municipal hospital, a valid option appears to replace a joint at low cost, that is, get a quota.

The small costs associated with hip replacement will only include the purchase of the prosthesis itself. The rest, that is, anesthesia, a separate room or bed, food, testing, everything will be paid for from the state budget.