Treatment of senile rheumatoid arthritis
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic aggressive joint disease. As the disease progresses, the synovial membrane, spine and bone destruction gradually appear, eventually to joint deformity and even disability.
In China, the disease of RA is 0.
34%, elderly RA accounted for about 40% of the total number of patients, of which 20% of patients after the age of 60, is senile RA (elderly rheumatoid arthritis, EORA).
With the aging of the age population, the number of patients with EORA and young adults who migrate to the elderly has gradually increased.
The clinical manifestations of elderly RA patients, with the characteristics of the disease and the drug itself, how to properly apply anti-rheumatic drugs after diagnosis and choose appropriate treatment to control the disease and improve the prognosis are important topics for clinicians.
Multiple studies have shown that patients with EORA usually have more acute onset, have higher disease activity, and have more disability and mortality than RA patients with young adults.
However, often due to the diagnosis is not timely, the medication is not standardized and other reasons lead to the patient’s condition prolonged, and even disabled.
Clinically, for patients with EORA, the principles of treatment for early, combination, and individualized regimens must be developed.
Once diagnosed, treatment should be treated as soon as possible.
In the application of first-line non-steroidal anti-inflammatory drugs (NSAIDs) to relieve joint swelling and systemic symptoms, timely combined with slow-acting anti-rheumatic drugs (SAARDs) or remission of anti-rheumatic drugs (DMARDs) to control the development of the disease.
Due to the special constitution of the elderly, it is necessary to select individualized treatment options for patients with good therapeutic effects and no obvious adverse reactions.
First, the application of anti-rheumatic drugs to alleviate symptoms.
Non-steroidal anti-inflammatory drugs, non-steroidal anti-inflammatory drugs (NSAIDs), are the main drugs for relieving symptoms such as swelling and pain in RA joints, such as diclofenac, meloxicam and the like.
These drugs are mainly effective in relieving the symptoms of RA, and they work faster.
However, elderly patients with long-term application of NSAIDs are more likely to cause insulin dysfunction, bleeding, tinnitus and other adverse reactions, and the incidence of renal damage is also higher than that of young adults.
In addition, it may cause sodium water retention, induce and aggravate heart failure.
Therefore, elderly patients should be more careful when using NSAIDs.
After starting the drug, the blood, liver and kidney function and other indicators should be regularly monitored, and adverse reactions should be adjusted in time to adjust the medication.
It is a better choice to use a gastric mucosal protective agent such as an H2 receptor antagonist, a proton pump inhibitor or a prostaglandin preparation in elderly RA patients.
In addition, the application of two oral NSAIDs at the same time has fewer advantages and disadvantages and should be avoided.
The therapeutic effects of celecoxib, rofecoxib, COX189 and etoxoxib and other COX2 inhibitors are comparable to those of non-selective NSAIDs, while digestive tract adverse reactions are reduced and are used in large numbers in elderly patients.
In elderly patients, there are significant increases in underlying diseases such as cardiovascular and cerebrovascular diseases requiring antiplatelet therapy, and small doses of aspirin should be used if necessary.
Hormones For elderly patients with acute onset of symptoms, opposite to the extra-articular manifestations or rheumatic polymyalgia, hormones can be used as the first choice. Sedation can quickly control symptoms, and hormones can be gradually reduced or replaced as the condition improves.
Small doses of hormone may be a safer first-line drug in elderly patients with NSAIDs causing gastrointestinal adverse effects or kidney damage.
It is generally believed that in the absence of contraindications, the addition of small doses of hormone (prednisone ≤ 10 mg) is safe and effective.
Individual patients may need to apply prednisone 15-30 mg / day for a short period of time, and should be reduced as soon as possible after symptom relief.
However, the application of hormones requires the use of DMARDs in combination to achieve complete control of the disease.
In addition, hormones can lead to a reduction in bone mass and increase the risk of fracture. For elderly patients with osteoporosis, potential adverse effects of hormone therapy should be noted.
It is recommended to give 1500mg / d calcium and 400-800IU vitamin D to prevent osteoporosis and dilated osteonecrosis.
For patients with long-term joint effusion, the joint cavity puncture and local injection of Debaosong or triamcinolone acetonide can be used to promote the control of permeation, but the local injection of the hormone is repeated within 3 months.
Second, the application of anti-rheumatic drugs to alleviate the disease.
Early treatment Currently, the internationally recognized window of RA treatment is 3 months, that is, the treatment of DMARDs begins within 3 months of onset.
The American College of Rheumatology (ACR) 2002 TR Treatment Guidelines recommend the best time to treat DMARDs within 3 months.
Studies have shown that patients who are treated early with DMARDs have a prognosis with significant complications after 3-6 months of treatment.
This principle also applies to patients with EORA.
Timely and rational application of DMARDs can completely relieve the condition of most patients.
2.Combination therapy Clinically, some patients with mild RA may be relieved by treatment with a DMARD.
However, most of these patients, especially those with high titers of autoantibodies in the serum, are more frequently repeated.
Therefore, while paying attention to avoid adverse drug reactions, patients with RA must be given a sufficient amount of DMARDs in combination with the treatment of the foot, in order to reduce the autoantibody titer in the patient’s serum and effectively control the condition.
Clinical studies have shown that the combined treatment of DMARDs is clearly a single drug.
Combinations commonly used at home and abroad include methotrexate (MTX) + sulfasalthiophene (SSZ), MTX + hydroxychlorothiophene (HCQ), SSZ + HCQ and MTX + SSZ + HCQ.
The combined therapeutic effects of DMARDs such as cyclosporin, penicillamine, azathioprine and gold preparations are also combined with a single treatment.
The new immunosuppressant leflunomide has synergistic effects with MTX, SSZ and HCQ, which can significantly relieve the patient’s condition.
The therapeutic effect of Pavlin in this disease has been confirmed.
The drug is safe and has a certain hepatoprotective effect. Combination with drugs such as MTX and SSZ may be a better choice for the treatment of elderly RA.
In addition, recent clinical observations indicate that biologic agents such as Etanercept and Infliximab have a good therapeutic effect on refractory RA in combination with MTX.
The DMARDs and treatment methods in the ACR recommended guidelines for treatment in 2002 are shown in the attached table.
Among them, the recommended dose of MTX was 7 from the 1996 RA treatment guidelines.
Increase 5-15mg / w to 7.
5-20mg / w, but for elderly patients, due to decreased glomerular clearance rate, MTX is delayed from the kidneys, and excessive doses may cause adverse drug reactions, such as gastrointestinal symptoms, liver damage, and bone marrow suppression.
Therefore, it is recommended to give a small dose of 5mg / w, about 2 months, if there is no adverse reaction, then increase the dose to 7.
5mg / w.
Long-term application of anti-dose MTX can lead to pulmonary fibrosis, especially in elderly patients. Pulmonary changes should be noted before and during the replacement.
Glennas et al reported that auranofin treatment of EORA is effective and safe, and only a small number of patients discontinued due to adverse effects such as poor efficacy or diarrhea.
It is generally believed that the adverse reactions of hydroxychlorofluoroquine in elderly patients do not exceed 6mg / kg / d, which is a safer drug, but the impact of ophthalmic toxicity on elderly patients needs further study.
The sedative methazine has similar ocular toxicity to hydroxychloroquine and should be avoided.
Older people taking SSZ are prone to gastrointestinal reactions, and those with malnutrition are prone to folate deficiency.
Penicillamine is used in elderly patients with a high incidence of rash and dysgeusia, and should be noted.
Cyclosporin is not recommended for use in elderly patients because of its obvious nephrotoxicity and its poor efficacy in single administration.
Enazepam and other biological agents such as infliximab have been used abroad for clinical purposes, but complications of adverse reactions in elderly patients, such as severe infection, induced lupus and possible potential tumorigenic effects, should be carefully applied[9, 10].
At present, there is little control study on the therapeutic effect and safety evaluation of DMARDs in patients with EORA and young adults with prolonged onset to elderly patients. Further clinical research is necessary.
DMARDs and their doses of DMARDs in the 2002 ACR RA Treatment Guide were dosed with hydroxychloroquine 0.
2, bid sulfasalamide 1.
0, bid or Tid methotrexate 7.
5-20mg / w Ai Ruohua 20mg / d or 10mg / d etanercept 25mg, 2 / w infliximab 3-10mg / 4-8w minocycline 0.
1, bid cyclocycline 2.
5-4mg / kg / d immunoadsorption 1 / W × 12 azathioprine 50-150mg / d penicillamine 250-750mg / d gold preparation 3mg, bid 3.
Long-term remission of individualized treatment regimens and reduction of adverse events are dependent on the individualization of RA treatment regimens.
For elderly patients, it is not possible to simply develop a good adverse drug reaction, and not to be treated for fear of adverse reactions.
The key to the problem is how to reduce the occurrence of adverse reactions and how to deal with them in a timely and correct manner.
Therefore, the choice of individualized treatment regimens with good efficacy without significant adverse reactions is fundamental to control the disease and improve the prognosis of RA.
Due to the reduction of liver metabolic function and glomerular clearance rate in the elderly, the changes in pharmacokinetics, the presence of comorbidities and various concomitant drug interactions make the selection of treatment options more difficult.
The above factors should be fully considered when selecting a combination regimen and determining the dose of the drug.
In addition, the choice of individualized programs should pay special attention to the individual differences of patients, such as the application of SSZ to those who have a history of allergies to sulfa drugs.
In the process of determining individualized treatment options, patients can usually be treated with COX2 inhibitors or small doses of hormones with less adverse reactions to relieve symptoms. A DMARDs is added to regularly monitor blood, urine and liver and kidney functions.In the absence of adverse reactions, the dose is gradually increased until a small dose of the drug is maintained.
In the case of a DMARDs tolerated, one or two DMARDs may be added depending on the condition until the symptoms are significantly relieved and the serum autoantibody titer is decreased.Then, consider replacing DMARDs with maintenance, treatment with one or two DMARDs, or even complete remission, with hormone or COX2 inhibitors being gradually reduced or discontinued.
Third, immunopurification treatment immunoadsorption, nuclear cell clearance and plasma exchange and other immunopurification treatments are effective in the treatment of refractory RA.
These treatments are indicated for patients with refractory RA who are ineffective in treatment and have high titers or multiple autoantibodies in serum.
At the same time, it should be assisted in combination with two or more DMARDs in order to achieve long-term relief of the disease.
In elderly patients, hypertension, coronary heart disease and other cardiovascular complications, hemodynamic disorder, prone to hypotension and arrhythmia and other adverse reactions during the immunopurification process.
Therefore, the indications must be strictly controlled, and during the treatment, the patient’s blood pressure, heart rate, and adverse reactions should be detected and treated in a timely manner.
Fourth, surgery and joint cavity injection of synovectomy and repeated synovectomy for long-term synovitis long-term unhealed effect is obvious, and is beneficial to relieve systemic symptoms.
Joint replacement can be considered in elderly patients with joint deformity.
In addition, hyaluronic acid injection in the joint cavity improves the joint activity pain, rest pain, joint swelling, walking distance pain in elderly patients, and has good safety.
V. Treatment of comorbidities Some elderly patients with RA have cardiovascular and cerebrovascular diseases and diabetes.
The presence of these comorbidities often affects patient compliance with RA treatment and drug selection and efficacy.
Therefore, actively treating comorbidities and improving the overall physique of patients is of great significance for increasing drug compliance and improving overall patient prognosis and quality of life.
Sixth, supportive care and patient education research shows that the levels of antioxidant micronutrients such as selenium and vitamin E in the serum of RA patients are reduced.
A recent study pointed out that supplementation with antioxidant micronutrients, especially beta-cryptoxanthin and zinc, as well as eating more fruits and vegetables, is beneficial for the treatment of RA.
Vitamin A, E and other supplements have a certain effect on improving the body’s over-oxidation disorder and preventing cardiovascular disease in RA patients.
In addition, it has been suggested that inhalation of fish oil in patients with RA can be achieved by relieving joint symptoms.
In elderly patients, malnutrition and the lack of trace elements are more common, and proper supplementation of certain nutrients may be beneficial to the improvement of joint symptoms.
In addition to good nutritional support, proper rest and functional exercise, as well as daily guidance, are important for the protection of joint function in elderly RA patients.
Patients should be encouraged to perform appropriate non-weight-bearing activities to ensure that joint mobility is maintained.
Elderly patients often have osteoarthritis and osteoporosis, and care should be taken to avoid excessive joint exercise leading to joint damage.
In addition, elderly patients due to physical weakness, joint activity disorders, decreased self-care ability, often lead to psychological depression, can not actively cooperate with drug treatment and joint function exercise, can significantly affect the therapeutic effect of RA.
It is of great significance for elderly patients to patiently and meticulously carry out disease education and rehabilitation guidance to eliminate psychological barriers of patients, and to effectively control the condition and improve joint function.
In summary, after the early, combined, individualized and standardized treatment, the condition of most elderly RA patients can be completely relieved.
The patient’s joint function and quality of life can be improved.