RCHD (Republican Center for Healthcare 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 the Development of Healthcare of the Ministry of Health of the Republic of Kazakhstan
No.23 on 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:
APP - Association of Rheumatologists of Russia
ACCP - antibodies to cyclic citrullinated peptide
DMARDs - basic anti-inflammatory drugs
YOUR - Visual Analogue Scale
GIBP - genetic engineering biological products
HA - glucocorticoids
Gastrointestinal tract - gastrointestinal tract
STDs - Sexually Transmitted Diseases
PP - medicines
MT - methotrexate
MRI - Magnetic Resonance Imaging
NSAIDs - non-steroidal anti-inflammatory drugs
NEO - General Health
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

Protocol development date: 2013
Patient category: patients with RA
Protocol users: rheumatologists, therapists, general practitioners.

Classification

Clinical classification

Working Classification of Rheumatoid Arthritis (APP, 2007)

The main diagnosis:
1. Seropositive rheumatoid arthritis (M05.8).
2. Seronegative rheumatoid arthritis (M06.0).

Special clinical forms rheumatoid arthritis
1. Felty's syndrome (M05.0);
2. Adult-onset Still's disease (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: the duration of the disease is 2 years or more + severe destruction of small (III-IV radiological stages) and large joints, the presence of complications.

The degree of disease activity:
1.0 - remission (DAS28<2,6).
2. Low (DAS28 = 2.6-3.2).
3. II - medium (DAS28 = 3.3-5.1).
4. III - high (DAS28> 5.1).

Extra-articular (systemic) signs:
1. Rheumatoid nodules.
2. Cutaneous vasculitis (necrotizing ulcerative vasculitis, nail bed infarctions, digital arteritis, livedo angiitis).
3. Neuropathy (mononeuritis, polyneuropathy).
4. Pleurisy (dry, effusion), pericarditis (dry, effusion).
5. Sjogren's syndrome.
6. Damage to the eyes (scleritis, episcleritis, retinal vasculitis).

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

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

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

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

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 of the atlanto-axial joint, incl. with myelopathy, instability of the cervical spine
7. Atherosclerosis

Comments (1)

To the heading "Basic diagnosis". Seropositivity and seronegativeness are determined by the test for rheumatoid factor (RF), which must be performed using a reliable quantitative or semi-quantitative test (latex test, enzyme immunoassay, immunonephelometric method),

To the heading "Disease activity". The assessment of activity in accordance with modern requirements is carried out using the index - DAS28, which assesses the pain and swelling of 28 joints: DAS 28 = 0.56. √ (CHBS) + 0.28. √ (NPV) + 0.70 .Ln (ESR) +0.014 OOSZ, where ChBS is the number of painful joints out of 28; NPV is the number of swollen joints; Ln - natural logarithm; VASD is the general state of health or a general assessment of the activity of the disease according to the patient's opinion according to the Visual Analogue Scale (VAS).
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 by Steinbroker:
Stage I- periarticular osteoporosis, single small cystic enlightenment of bone tissue (cysts) in the subchondral part of the articular surface of the bone;
Stage 2A - periarticular osteoporosis, multiple cysts, narrowing of the joint spaces;
Stage 2B - symptoms of stage 2A of varying severity and single erosion of articular surfaces (5 or less erosions);
Stage 3 - symptoms of stage 2A of varying severity and multiple erosions (6 or more erosions), subluxations and dislocations of the joints;
Stage 4 - symptoms of stage 3 and ankylosis of the joints.
Back to the heading "Functional class". Description of characteristics. Self-care - dressing, eating, grooming, etc. Non-professional activities - creativity and / or leisure and professional activities - work, study, housekeeping - are desirable for the patient, specific to gender and age.

Flow options:
By the nature of the 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%): intermittent complete or partial remission (spontaneous or treatment-induced), alternating with exacerbation with involvement of previously unaffected joints in the process.
- Progressive course (60-75%): an increase in joint destruction, damage to new joints, the development of extra-articular (systemic) manifestations.
- Rapidly progressive course (10-20%): constantly high activity of the disease, severe extra-articular (systemic) manifestations.

Special clinical forms
- Felty's syndrome - a symptom complex, including 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), a high risk of infectious and inflammatory complications.
- Adult Still's disease is a peculiar form of RA characterized by severe, rapidly progressing articular syndrome in combination with generalized lymphadenopathy, maculopapular rash, high laboratory activity, significant weight loss, prolonged remitting, intermittent or septic fever, seronegativeness according to RF and ANF.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

List of basic and additional diagnostic measures before planned hospitalization

Laboratory research:
1. Complete blood count
2. General urine analysis
3. Microreaction
4. Analysis of feces for occult blood
5. Activity of liver enzymes (ALT, AST)
6. Content 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. At the initial establishment of the diagnosis - ELISA for STDs (chlamydia, gonorrhea, Trichomonas), with a positive result, preliminary sanitation of the focus of infection is required before hospitalization

Instrumental examination:
1. Radiography 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 of the thoracic segment

The list of the main diagnostic measures in the hospital
1. KLA deployed with platelets
2. Coagulogram
3.CRP, RF, ACCP, protein fractions, creatinine, triglycerides, lipoproteins, ALT, AST, thymol test
4. EchoCG
5. Ultrasound of the abdominal cavity and kidneys
6.R-graphics of brushes

The 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. Analysis of urine 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 the joints - according to indications
9. Consultation of 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 criteria of the American League of Rheumatology (1997).

American League of Rheumatology Criteria (1997).
Morning stiffness - stiffness in the morning in the area of ​​the joints or periarticular tissues, lasting at least 1 hour, existing for 6 weeks.
Arthritis in 3 or more joints - swelling of the periarticular soft tissues or fluid in the joint cavity, as identified by a doctor in at least 3 joints.
Hand arthritis is swelling of at least one of the following groups of joints: the wrist, metatarsophalangeal, and proximal interphalangeal joints.
Symmetrical arthritis is a bilateral lesion of the joints (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal).
Rheumatoid nodules - subcutaneous nodules (established by a doctor), localized mainly on protruding parts 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 serum titers by any standardized method.
Radiological changes typical for RA: erosion or periarticular osteoporosis, decalcification of the bone (cysts), localized in the wrist joints, hand joints and are most pronounced in clinically affected joints.
A diagnosis of RA is made if at least 4 of 7 criteria are present, with criteria 1 through 4 being 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 point severity, with a total of 6 or more points, 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
A variety of options for the onset of the disease is characteristic. In most cases, the disease begins with polyarthritis, less often the manifestations of arthritis can be moderately expressed, and arthralgia, morning stiffness in the joints, deterioration of the general condition, weakness, weight loss, low-grade fever, lymphadenopathy, which may precede clinically pronounced joint damage, prevail.

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

Acute polyarthritis with a predominant lesion of the joints of the hands and feet, pronounced 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 in the process of small joints of the hands and feet.

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 (similar to Still's disease in adults).

"Palindromic rheumatism": multiple recurrent attacks of acute symmetric polyarthritis of the joints of the hands, less often of the knee and elbow joints; last for several hours or days and end in full 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 edema and limited mobility. Received the name "RSPE-syndrome" (Remitting Seronegative symmetric synovitis with Pitting Edema - remitting seronegative symmetric synovitis with "pillow-like" edema).

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

Physical examination

Joint damage
The most characteristic manifestations in the onset of the disease:
- pain (on palpation and movement) and swelling (associated with effusion into the joint cavity) of the affected joints;
- weakening of the force of compression of the hand;
- 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 after 1-5 years from the onset of the disease; damage to the fingers of the hands of the "boutonniere" type (flexion in the proximal interphalangeal joints) or "swan neck" (overextension in the proximal interphalangeal joints); deformation of the hand as a "lornette".
- Knee joints: flexion and hallux valgus, Baker's cyst.
- Feet: subluxation of the heads of the metatarsophalangeal joints, lateral deviation, deformity of the thumb.
- Cervical spine: subluxation in the area of ​​the atlantoaxial joint, sometimes complicated by compression spinal cord or vertebral artery.
- Cricoid-scary joint: coarsening of the voice, shortness of breath, dysphagia, recurrent bronchitis.
- Ligamentous apparatus and bursae: tendosynovitis in the area of ​​the wrist joint and hand; bursitis, more often in the area of ​​the elbow joint; a synovial cyst on the back of the knee joint (Baker's cyst).

Extra-articular manifestations
Sometimes they can prevail in the clinical picture:
- Constitutional symptoms: generalized weakness, malaise, weight loss (up to cachexia), subfebrile fever.
- The cardiovascular system: pericarditis, vasculitis, granulomatous lesions of the heart valves (very rare), early development of atherosclerosis.
- Lungs:pleurisy, interstitial lung disease, bronchiolitis obliterans, rheumatoid nodules in the lungs (Kaplan's syndrome).
- Leather:rheumatoid nodules, thickening and hypotrophy of the skin; digital arteritis (rarely with the development of gangrene of the fingers), microinfarctions in the area of ​​the nail bed, livedo mesh.
- Nervous system:compression neuropathy, symmetric sensory-motor neuropathy, multiple mononeuritis (vasculitis), cervical myelitis.
- Muscles:generalized amyotrophy.
- Eyes:keratoconjunctivitis dry, 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 a poor prognosis.

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

Clinical significance of laboratory tests
General blood analysis:
- leukocytosis / thrombocytosis / eosinophilia - severe course of RA with extra-articular (systemic) manifestations; are combined with high titles of the Russian Federation; may be associated with HA treatment.
- persistent neutropenia - exclude Felty's syndrome.
- anemia (Hb< 130 г/л у мужчин и 120 г/л у женщин) - активность заболевания; исключить желудочное или кишечное кровотечение.
- increased ESR and CRP - differential diagnosis of RA from non-inflammatory diseases of the joints; assessment of the activity of inflammation, the effectiveness of therapy; 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.
- an increase in the level of liver enzymes - the activity of the disease; hepatotoxicity of NSAIDs and DMARDs; liver damage associated with the carriage of hepatitis B and C viruses
- hyperglycemia - glucocorticoid therapy.
- dyslipidemia - glucocorticoid therapy; the activity of inflammation (a decrease in the concentration of high density lipoprotein cholesterol, an increase in the concentration of low density lipoprotein cholesterol).

Immunological examination:
- an 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 - a more "specific" marker of RA than RF;
- An increase in ANF titers (30-40% of patients) - in severe RA;
- HLA-DR4 (DRB1 * 0401 allele) - 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%).

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

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

Chest x-ray indicated for the detection of rheumatoid lesions of the respiratory system, and concomitant lung lesions (COPD tuberculosis, etc.).

Magnetic resonance imaging (MRI):
- a more sensitive (than X-ray) method for detecting joint lesions in the onset of RA.
- early diagnosis osteonecrosis.

Doppler ultrasonography: a more sensitive (than X-ray) method for detecting joint lesions in the onset of RA.

High resolution computed tomography: diagnosis of lung damage.

Echocardiography: diagnostics of rheumatoid pericarditis, myocarditis and coronary heart disease associated with heart disease.

Dual-energy X-ray absorptiometry

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

Arthroscopy shown for differential diagnosis RA with ville-nodular synovitis, osteoarthritis, traumatic joint damage.

Biopsy indicated for suspected amyloidosis.

Indications for specialist consultation:
- Traumatologist-orthopedist - to resolve the issue of surgical intervention.
- Oculist - in case of damage to the organs of vision.

Differential diagnosis

Differential diagnosis often performed with diseases such as osteoarthritis, 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. Slight swelling of the soft tissues, involvement of the distal interphalangeal joints, the absence of pronounced morning stiffness, an increase in the severity of pain by the end of the day.

Systemic lupus erythematosus. Symmetrical lesion of small joints of the hands, wrist and knee joints. Non-deforming arthritis (with the exception of Jaccoux arthritis); there may be soft tissue edema, but intra-articular effusion is minimal; high titers of ANF (however, up to 30% of RA patients have ANF), rarely - low titers of RF; on radiographs - the absence of bone erosion.

Gout. Diagnosis is by detection of crystals in synovial fluid or tophi with characteristic negative birefringence on polarizing microscopy. In the chronic form, there may be a symmetrical lesion of the small joints of the hands and feet with the presence of tofuses; possible subcortical erosion on radiographs.

Psoriatic arthritis. Monoarthritis, asymmetric oligoarthritis, symmetric polyarthritis, mutating arthritis, axial skeletal lesions. 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; possible involvement of peripheral joints; expression of HLA-B27.

Reactive arthritis. Arthritis oligoarticular and asymmetric, with a predominant lesion of the lower extremities, expression of HLA-B27. 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. The defeat of 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 involvement of large joints, carditis, subcutaneous nodules, chorea, annular erythema, fever. Specific (in relation to streptococci) serological reactions.

Septic arthritis. Usually monoarticular, but may be oligoarticular; with a predominant lesion of large joints; may be migratory. Blood culture, aspiration of fluid from the joint cavity with the study of cell composition, Gram stain and culture study; 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, viral exanthema can be detected. In most cases, spontaneously resolves within 4-6 weeks (with the exception of arthritis associated with parvovirus infection).

Systemic scleroderma. Raynaud's phenomenon and skin tightening; 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 rare. Inflammation of the muscles, characterized by proximal muscle weakness, increased levels of CPK and aldolase, arthralgias and myalgias, pathological changes on 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; AT to ribonucleoprotein is characteristic.

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

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

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

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

Hemochromatosis. Increase in bone structures of the 2nd and 3rd metacarpophalangeal joints; an increase in the level of iron and ferritin in serum with a decrease in transferrin-binding capacity; chondrocalcinosis can be detected on radiographs. Diagnosed by liver biopsy.

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

Hypertrophic osteoarthropathy. Oligoarthritis of the knee, ankle and wrist joints; periosteal neoplasm of bone; deep and aching pain. "Drumsticks", association 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.

Recurrent polychondritis. Widespread progressive inflammation and destruction of cartilage and connective tissue; migratory 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, paresthesias, unproductive sleep, fatigue, multiple symmetrical "trigger" points (11 out of 18 are sufficient for the diagnosis); laboratory research and examination of joints - without pathology.

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Treatment

Treatment tactics for patients with RA

TREATMENT RECOMMENDATIONS FOR PATIENTS WITH RHEUMATOID ARTHRITIS
According to modern standards, RA treatment 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 of DMARDs should be started as early as possible;
2. Treatment should be as active as possible with a change (if necessary) of the treatment regimen within 2-6 months;
3. When choosing a therapy, it is necessary to consider:
- risk factors for an unfavorable prognosis, which include high titers of RF, an increase in ESR and CRP, the rapid development of joint destruction
- the duration of the period between the onset of symptoms and the initiation 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 of 7.5 mg / week) with a rapid (within 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, neuropathologists, psychologists, etc.); treatment of patients should be carried out by rheumatologists, be as individualized as possible, depending on clinical manifestations and activity.

Drug-free treatment
1. Avoid factors that can potentially provoke an exacerbation of the disease (intercurrent infections, stress, etc.).

2. Quitting smoking and drinking alcohol:
- smoking can play a role in the development and progression of RA;
- an association was revealed between the number of cigarettes smoked and positivity in the RF, 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. Physiotherapy exercises (1-2 times a week)

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

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

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

10. Throughout the course of the disease, active prevention and treatment of concomitant diseases is required.

Drug treatment

Basic Provisions
All patients are prescribed NSAIDs to reduce joint pain
- NSAIDs have a good symptomatic (analgesic) effect
- NSAIDs do not affect the progression of joint destruction

RA treatment is based on the use of BPVP
- Treatment of RA with 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 helps to improve function and slow down the progression of joint destruction
- “late” prescription of DMARDs (3-6 months after the onset of the disease) is associated with a decrease in the effectiveness of DMARD monotherapy
- the longer the duration of the illness, the lower the effectiveness of DMARDs.
The effectiveness of therapy should be assessed using standardized methods.

Non-steroidal anti-inflammatory drugs (NSAIDs)
Key points:
1. NSAIDs are more effective than paracetamol.
2. Treatment of NSAIDs should be carried out in combination with active therapy with DMARDs.
3. The incidence of remission against the background of monotherapy with NSAIDs is very low (2.3%).

In the general population of RA patients, NSAIDs in equivalent doses do not significantly differ in their effectiveness, but differ in the frequency of side effects:
- since the effectiveness of NSAIDs in individual patients can vary significantly, an individual selection of the most effective NSAIDs 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 an increase in toxicity, but not the effectiveness of treatment.
It is recommended to start treatment with the appointment of the safest NSAIDs (short T1 / 2, no cumulation) and at the lowest effective dose.
Do 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 should be taken into account:
- safety (presence and nature of risk factors for side effects);
- the presence of concomitant diseases;
- the nature of the 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 inhibitors COX-2 is less likely to cause gastrointestinal damage than standard NSAIDs.
If there is a history of severe gastrointestinal lesions, 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 should be taken before the final decision on their cardiovascular safety:
- inform physicians 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;
- carry out careful monitoring of cardiovascular complications (especially arterial hypertension) throughout the duration of the drug intake;
- do not exceed the recommended dose.

With the parenteral and rectal routes of administration, NSAIDs reduce the severity of symptomatic gastroenterological side effects, but do not reduce the risk of developing severe complications (perforation, bleeding).
In patients with risk factors for NSAID gastropathy, treatment should be started with COX-2 inhibitors (meloxicam, nimesulide).

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

Recommended doses of NSAIDs: lornoxicam 8mg. 16 mg / day in 2 divided doses, diclofenac 75-150 mg / day in 2 doses; ibuprofen 1200-2400 mg / day in 3-4 divided 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 divided 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, the concentrations of aspartate aminotransferase and alanine aminotransferase should be determined 8 weeks after the start of treatment. With the joint administration of angiotensin-converting enzyme (ACE) inhibitors, serum creatinine must be determined every 3 weeks.

Glucocorticoids (GC)
Key points:
1. HA (methylprednisolone 4 mg) in some cases slows down the progression of joint destruction.
2. The efficacy / cost ratio of HA is better than that of NSAIDs.
3. In the absence of special indications, the dose of HA 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 inevitable consequences of GC therapy:
- more often develop with prolonged use of high doses of HA;
- some side effects develop less frequently than in the treatment of NSAIDs and DMARDs (for example, severe gastrointestinal damage);
- possible prevention and treatment of some side effects (for example, glucocorticoid osteoporosis).

Indications for prescribing low doses of BG:
- 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.
- the ineffectiveness of NSAIDs and DMARDs.
- contraindications to the appointment of NSAIDs (for example, in the elderly with a "ulcerative" history and / or impaired renal function).
- Achievement of remission in some variants of RA (for example, with seronegative RA in the elderly, resembling polymyalgia rheumatica).

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

HA pulse therapy(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 it allows to achieve a quick (within 24 hours), but short-term suppression of the activity of joint inflammation;
- since the positive effect of HA pulse therapy on the progression of joint destruction and prognosis has not been proven, the use (without special indications) is not recommended.

Local (intra-articular) therapy(betamethasone):
Key points:
- it is used to suppress arthritis at the onset of the disease or exacerbations of synovitis in one or more joints, to improve the function of the joints;
- 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 tools;
- flush the joint before the introduction of drugs;
- to exclude the load on the joint within 24 hours after the injection.

Basic anti-inflammatory drugs (DMARDs)

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

Methotrexate (MT):
1. Drug of choice ("gold standard") for "seropositive" active RA.
2. Compared with other DMARDs, it has the best efficacy / toxicity ratio.
3. Interruption of treatment is more often associated with drug toxicity than with no effect.
4. The main drug in the combination therapy of DMARDs.
5. Treatment with methotrexate (compared with treatment with other DMARDs) is associated with a reduced risk of mortality, including cardiovascular

Recommendations for use:
1. Methotrexate is prescribed once a week (orally or parenterally); more frequent use can lead to the development of acute and chronic toxic reactions.
2. Fractional reception with a 12-hour interval (in the morning and evening hours).
3. If there is no effect with oral administration (or with the development of toxic reactions from the gastrointestinal tract), switch to parenteral administration (IM or SC):
- the lack of effect with oral administration of methotrexate may be associated with low absorption in the gastrointestinal tract;
- the initial dose of methotrexate 7.5 mg / week, and in the elderly and with impaired renal function 5 mg / week;
- do not prescribe to patients with renal insufficiency;
- Do not prescribe to patients with severe lung damage.
4. Efficacy and toxicity are assessed after about 4 weeks; with normal tolerance, the dose of methotrexate is increased by 2.5-5 mg per week.
5. The clinical efficacy of methotrexate is dose-dependent, ranging from 7.5 to 25 mg / week. Reception in a dose of more than 25-30 mg / week is inappropriate (the increase in the effect has not been proven).
6. To reduce the severity of side effects, if necessary, it is recommended:
- use short-acting NSAIDs;
- avoid the appointment of acetylsalicylic acid (and, if possible, diclofenac);
- on the day of taking methotrexate, replace NSAIDs with HA 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 efficacy and tolerance (not severe HP) of oral MT, 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 the use of 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.

The main side effects are: infections, gastrointestinal tract and liver damage, stomatitis, alopecia, hematological (cytopenia), sometimes myelosuppression, hypersensitive pneumonitis.

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

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

Leflunomide drug:
1. In terms of effectiveness, it is not inferior to sulfasalazine and methotrexate.
2. Surpasses methotrexate and sulfas-lazine in terms of the effect on the quality of life of patients.
3. The incidence of side effects is lower than that of other DMARDs.
The main indication for the appointment: lack of effectiveness or poor tolerance 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 interruption of treatment due to the development of side effects increases; requires careful monitoring of adverse reactions.
3. Currently, most experts recommend starting treatment with leflunomide at a dose of 20 mg / day (or even 10 mg / day); a slow increase in the clinical effect is recommended to compensate for the intensification of concomitant therapy (for example, low doses of GC).

The main side effects are: cytopenia, liver and gastrointestinal tract damage, destabilization of blood pressure, sometimes myelosuppression.

4-aminoquinoline derivatives:
1. They are inferior in clinical efficacy to other DMARDs.
2. Do not slow down the progression of joint destruction.
3. Have a positive effect on 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 an unfavorable prognosis
- undifferentiated polyarthritis, if it is impossible to exclude the debut 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. To carry out ophthalmological control before the appointment of aminoquinoline derivatives and every 3 months during treatment:
- questioning the patient about visual disorders;
- examination of the fundus (pigmentation);
- study of visual fields.
3. Do not prescribe 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 impairments.
6. Recommend wearing goggles in sunny weather (regardless of the season).

Note: Reduce the dose for liver and kidney disease.
The main side effects are: retinopathy, neuromyopathy, itchy skin, diarrhea.

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

The main side effects are: increased blood pressure, impaired renal function, headaches, tremors, hirsutism, infections, nausea / vomiting, diarrhea, dyspepsia, gingival hyperplasia. With an increase in the level of creatinine by more than 30%, it is necessary to reduce the dose of drugs by 0.5-1.0 mg / kg / day for 1 month. If the creatinine level decreases by 30%, continue the drug treatment, and if the 30% increase is maintained, stop the treatment.

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

Combination therapy of DMARDs.
Three main options for combination therapy are used: start treatment with monotherapy, followed by the appointment of one or more DMARDs (within 8-12 weeks) while maintaining the activity of the process ; to start treatment with combination therapy followed by transfer to monotherapy (after 3-12 months) with suppression of the activity of the process, conducting combination therapy during the entire period of the disease. In patients with severe RA, treatment should be started with combination therapy, and in patients with moderate activity - with monotherapy, followed by transfer to combination therapy with insufficient treatment effectiveness.
Combinations of DMARDs without signs of poor prognosis:
- MT and hydroxychloroquine - with a long duration of RA and low activity;
- MT and leflunomide - with an average duration (≥ 6 months), the presence of factors of poor prognosis;
- MT and sulfasalazine - for any duration of RA, high activity, signs of poor prognosis;
- MT + hydroxychloroquine + sulfasalazine - in the presence of factors of poor prognosis and with moderate / high disease activity, regardless of the duration of the disease.

Genetically engineered biological products
For the treatment of RA, GIBPs are used, which include TNF-α inhibitors (etanercept, infliximab, golimumab), an anti-B cell drug - rituximab (RTM), and an interleukin 6 receptor blocker - tocilizumab (TCZ).
Indications:
- patients with RA, insufficiently responding to MT and / or other synthetic DMARDs, with moderate / high RA activity in patients with signs of poor prognosis: high disease activity, RF + / ACCP +, early onset 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 tolerance to therapy with at least two standard DMARDs, one of which should be MT for 6 months and more or less 6 months if it is necessary to cancel 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 serological test titers (RF + / ACCP +) should 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 (decision on each case is individual).

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

Etanercept is prescribed for adults in the treatment of moderate to severe active rheumatoid arthritis in combination with methotrexate, when the response to basic anti-inflammatory drugs (DMARDs), including methotrexate, was inadequate.
Etanercept can be given as monotherapy if methotrexate is ineffective or intolerant. Etanercept is indicated for the treatment of severe, active, and progressive rheumatoid arthritis in adults who have not previously received methotrexate therapy.
Etanercept treatment should be prescribed and monitored 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, a lyophilisate should be used to prepare a solution.
The recommended dose is 25 mg etanercept twice a week, 3-4 days apart. An alternative dose is 50 mg once a week.
Etanercept therapy should be continued until remission is achieved, usually no more than 24 weeks. The administration of the drug should be discontinued if, after 12 weeks of treatment, there are no positive dynamics of symptoms.
If it is necessary to re-prescribe etanercept, the duration of treatment indicated above should be observed. The recommended dose is 25 mg twice a week or 50 mg once a week.
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 the route of administration.

Contraindications
- hypersensitivity to etanercept or any other component of the dosage form;
- sepsis or the 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, states of immunodeficiency, blood dyscrasia, diseases that predispose to the development or activation of infections ( diabetes, hepatitis, etc.).

Infliximab it is prescribed in compliance with the dose and frequency of administration, in combination with Treatment of BAs in adult patients with severe active RA in case of ineffectiveness or intolerance to other DMARDs, one can start with inhibition of tumor necrosis factor (infliximab). Infliximab is prescribed in accordance with the dose and frequency of administration, in combination with MT.
Infliximab at the rate of 3 mg / kg of body weight according to the scheme. It is used in combination with MT with its insufficient effectiveness, less often with other DMARDs. It is effective in patients with insufficient "response" to MT 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 starting infliximab, all patients should be screened for mycobacterial infection in accordance with current national guidelines.

Indications:
- no effect ("unacceptably high disease activity") during treatment with methotrexate in the most effective and tolerable dose (up to 20 mg / week) for 3 months or other DMARDs
- 5 or more swollen joints
- an increase in ESR over 30 mm / h or CRP over 20 mg / l.
- activity corresponds to DAS> 3.2
- ineffectiveness of other DMARDs (if there are contraindications for the appointment of methotrexate)
- n The need for reductions in the HA dose.
- if there are contraindications to the appointment 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 an adequate effect 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. Monitoring of treatment with a 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, duration of infusion - 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;
- re-appointment 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 on prophylactic anti-tuberculosis therapy before starting HIBT, in accordance with current national recommendations;
- if there are clinical grounds, patients with RA should be examined for possible tumors. If a malignant tumor is detected, treatment with anti-TNF drugs should be discontinued.

Golimumab used in combination with MT. Golimumab is effective in patients who have not previously received MT, in patients with insufficient “response” to MT 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 screened for active infectious processes (including tuberculosis) in accordance with current national guidelines.

Indications:
Golimumab in combination with methotrexate (MT) is indicated for use in
quality:
- therapy of moderate to severe active rheumatoid arthritis in adults who have an unsatisfactory response to therapy with DMARDs, including MT;
- therapy of severe, active and progressive rheumatoid arthritis in adults who have not previously received MT therapy.
It was shown that golimumab in combination with MT reduces the rate of progression of joint pathology, which was demonstrated by X-ray, and improves their functional state.
Golimumab is prescribed in compliance with the dose and frequency of administration, in combination with MT. Golimumab therapy is continued only if an adequate effect 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) of 1.2 points or more. Monitoring of treatment with a 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 the diagnosis and treatment of RA;
- Golimumab at a dose of 50 mg is injected subcutaneously once a month, on the same day of the month;
- Golimumab in patients with RA must be used in combination with MT;
- in patients weighing more than 100 kg, in whom a satisfactory clinical response was not achieved after the administration of 3-4 doses of the drug, the issue of increasing the dose of golimumab to 100 mg once a month may be considered.

Patients with RA who have signs of possible latent tuberculosis (history of tuberculosis or changes on chest x-ray) should be given recommendations on prophylactic anti-tuberculosis therapy prior to starting HIBT, in accordance with current national guidelines.
If there are clinical grounds, patients with RA should be evaluated for possible tumors. If a malignant tumor is detected, treatment with anti-TNF drugs should be discontinued.

Rituximab. Therapy is considered as an option for the treatment of adult patients with severe active RA, with insufficient efficacy, intolerance to TNF-a inhibitors or having contraindications to their appointment (a history of tuberculosis, lymphoproliferative tumors), as well as with rheumatoid vasculitis or signs of a poor prognosis (high RF titers, an increase in the concentration of ACCP, an increase in ESR and CRP concentration, the rapid development of destruction in the 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. Rituximab therapy is continued if adequate response is observed after initiation of therapy and if this response is sustained after re-administration of rituximab for 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 when RA lasts more than 6 months, high disease activity, signs of poor prognosis (RF +, ACCP +, the presence of multiple erosions, rapid progression). Tocilizumab is prescribed in compliance with the dose and frequency of administration (1 time per month) in monotherapy or in combination with DMARDs in patients with moderate to severe rheumatoid arthritis. Leads to a stable objective clinical improvement and an increase in the quality of life of patients. Treatment in monotherapy regimen 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 in the blood serum, the level of markers of the acute inflammatory process, such as C-reactive protein and amyloid-A, decreases, as well as the erythrocyte sedimentation rate. Hemoglobin levels increase as tocilizumab reduces the effect of IL-6 on hepcidin production, which leads to increased iron availability. The greatest effect is observed in patients with rheumatoid arthritis with concomitant anemia. Along with the inhibition of the factors of the acute phase of inflammation, treatment with tocilizumab is accompanied by a decrease in the number of platelets within the normal range.

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

Method of administration 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 alone or in combination with methotrexate and / or other basic therapy drugs.
Recommended doses for 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 (the absolute number of neutrophils is less than 0.5 * 109 / l),
- thrombocytopenia (platelet count less than 50 * 109 / l),
- an increase in ALT / AST indicators by more than 5 times compared with the norm (more than 5N),
- pregnancy and lactation period,
- children under 2 years old.

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 preparations.
Hemolytic - HA (60 mg / day); if ineffective within 2 weeks - azathioprine 50-150 mg / day.
Blood transfusions are recommended except for very severe anemia associated with a risk of cardiovascular complications.

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

Recommendations for the treatment of extra-articular manifestations of RA:
Pericarditis or pleurisy - GC (1 mg / kg) + DMARDs.
Interstitial lung disease - HA (1 - 1.5 mg / kg) + cyclosporin A or cyclophosphamide; avoid the appointment of methotrexate.
Isolated digital arteritis is a symptomatic vascular therapy.
Systemic rheumatoid vasculitis - intermittent pulse therapy with cyclophosphamide (5 mg / kg / day) and methylprednisolone (1 g / day) every 2 weeks. within 6 weeks, followed by lengthening the interval between injections; 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 urgent surgery:
- Compression of a nerve due to synovitis or tendosynovitis
- Threatened or complete tendon rupture
- Atlantoaxial subluxation, accompanied by neurological symptoms
- Deformations that make it difficult to perform the simplest daily activities
- Severe ankylosis or dislocation of the lower jaw
- The presence of bursitis, disrupting the patient's performance, as well as rheumatic nodules, which tend to ulceration.

Relative indications for surgery
- Drug-resistant synovitis, tendosynovitis or bursitis
- Severe pain syndrome
- Significant limitation of movement in the joint
- Severe deformity of the joints.

Main types 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 in 1-4 days (depending on T1 / 2 drugs);
3. COX-2 inhibitors can not be canceled (there is no risk of bleeding).
4. Glucocorticoids(risk of adrenal cortex insufficiency):
- minor surgery: 25 mg hydrocortisone or 5 mg methylprednisolone IV on the day of surgery;
- medium surgery - 50-75 mg of hydrocortisone or 10-15 mg of methylprednisolone IV on the day of surgery and quick withdrawal within 1-2 days before the usual dose,
- major surgery: 20-30 mg of methylprednisolone IV on the day of the procedure; prompt withdrawal within 1–2 days prior to the usual dose;
- critical condition - 50 mg of hydrocortisone IV every 6 hours.
5. Methotrexate - cancel if the following factors are present:
- elderly age;
- renal failure;
- uncontrolled diabetes mellitus;
- severe damage to the liver and lungs;
- intake of HA> 10 mg / day.
Continue taking the same dose 2 weeks after surgery.
6. Sulfasalazine and azathioprine - cancel 1 day before the operation, resume taking 3 days after the operation.
7. Hydroxychloroquine can not be canceled.
8. Infliximab you can not cancel or cancel a week before the operation and resume taking it 1-2 weeks after the operation.

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; in all patients, before starting treatment with infliximab and already receiving treatment, an X-ray examination of the lungs and a consultation with a phthisiatrician should be performed; with a positive skin test (reaction> 0.5 cm), an x-ray 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; with a positive skin test and the presence of typical signs of tuberculosis or calcified lymph nodes of the mediastinum, before infliximab is prescribed, at least 3 months of therapy with isoniazid and vitamin Bb should be carried out. When isoniazid is prescribed in patients over 50 years of age, a dynamic study of hepatic enzymes is necessary.

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

Management of patients with RA during pregnancy and lactation:
- Avoid taking NSAIDs, especially in the II and III trimesters of pregnancy.
- Exclude the intake of BPVP.
- You can continue treatment with HA in the minimum effective doses.

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

Table 9. European League of Rheumatology Treatment Response 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 correction of therapy in the form of changing the dose of DMARDs or adding a second drug.
When treating DMARDs, there are options for the results of treatment:
1. Decrease in activity to low or achievement of remission;
2. Decrease in activity without reaching a low level;
3. Little or no improvement.
With the 1st option, the treatment continues unchanged; at the 2nd - it is necessary to change the DMARDs if the degree of improvement in the activity parameters does not exceed 40-50% or attachment to the DMARDs with a 50% improvement in another DMARD or GIBP; at the 3rd - drug withdrawal, selection of another DMARD.

Hospitalization

Indications for hospitalization:
1. Clarification of the diagnosis and assessment of the prognosis
2. Selection of DMARDs at the beginning and throughout the course of the disease.
3. RA articular-visceral form of a high degree of 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 Healthcare Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Rheumatology, Ed. ON THE. Shostak, 2012 2. Endoprosthetics of the hip joint, Zagorodny NV, 2011 3. Clinical guidelines. Rheumatology. 2nd edition revised and enlarged / ed. E.L. Nasonov. - 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. Diagnostics and treatment in rheumatology. Problematic approach, Pyle K., Kennedy L. Translated 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 withsynthetic and biological disease-modifying antirheumatic drugs. AnnRheumDis 2010; 69: 964-75. 7. Nasonov E.L. New approaches to the 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 guidelines. Rheumatology. 2nd ed., S. L. Nasonova, 2010 9. Nasonov E. L. The use of tocilizumab (Actemra) for rheumatoid arthritis. Scientific-Practical Chrevmatol 2009; 3 (Suppl.): 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. and others. The use of non-steroidal anti-inflammatory drugs. Clinical guidelines. M .: IMA-PRESS, 2009. 12. Rheumatology: national guidelines / 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: Сompendium / Nasonova VA, Nasonov EL, Alekperov RT, Alekseeva LI. and etc.; Under total. ed. V.A. Nasonova, E.L. Nasonov. - M .: Literra, 2007 .-- 448s. 17. Nam J.L., Wintrop 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. The use of tocilizumab (Actemra) for rheumatoid arthritis. Scientific and practical rheumatology, 2009; 3 (App. ): 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. A guide for practicing physicians. 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 as subcutaneous injection every four weeks for patients with active rheumatoid arthritis who have not previously received methotrexate treatment, ARTHRITIS & RHEUMATISM, Volume 60, No. 8, August 2009, pp. 2272-2283, DOI 10.1002 / art.24638 23. Mark C. Genovese et al. “Effect of golimumab therapy on patient-reported outcomes of 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): Multicenter, Randomized, Double-Blind, Placebo-Controlled Phase III Trial, Lancet 2009; 374: 210-21

Information

III. ORGANIZATIONAL ASPECTS OF THE PROTOCOL IMPLEMENTATION

Developer list
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, AGIUV
3. Aubakirova B.A. - chief freelance rheumatologist of Astana
4. Sarsenbayuly M.S. - Chief freelance rheumatologist of the East Kazakhstan region
5. Omarbekova Zh.E. - Chief freelance rheumatologist, 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

No Conflict of Interest Statement: missing.

Terms of revision of the protocol: availability of new methods of diagnosis and treatment, deterioration of treatment results associated with the use of this protocol

Attached files

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Gouty arthritis microbial code 10

According to the International Classification of Diseases 10 revision, rheumatoid arthritis is seropositive and seronegative. These two types also have their own classification and each subspecies 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 - М-06.8;
• seronegative RA, unspecified - M-06.9.

Seropositive RA, ICD-10 code - M-05:

• Felty's syndrome - M-05.0;
• rheumatoid lung disease - M-05.1;
• vasculitis - M-05.2;
• rheumatoid arthritis involving other organs and systems - M-05.3;
• other seropositive RA - M-05.8;
• unspecified RA - M-05.9.

A disease that develops in connection with the deposition of uric acid salts in the joints and organs. This happens when the metabolism of the human body is disturbed and crystals of uric acid (or urates) are deposited in the kidneys and joints.

This leads to inflammation, difficulty in movement, and deformation of the joint. The kidneys also suffer, in which crystals are deposited, which disrupts the normal functioning of the excretory system.

There is a classification of diseases, which lists all the names and are categorized by development, treatment, and clinical presentation. This classification is called ICD (International Classification of Diseases).

Gouty arthritis ranks under the name ICD 10.

Gout and gouty arthritis and their place in ICD 10

When a patient comes to a medical facility and he is diagnosed with gouty arthritis, the ICD code is 10, and they write this on the card. This is done so that doctors and the rest of the staff understand what the patient's diagnosis is.

All diseases according to the ICD classification are clearly divided into their groups and subgroups, where they are designated by alphabet letters and numbers, respectively. Each group of diseases has its own designation.

Also, there are generally accepted norms of therapy, as a single main criterion, tactics or method of treatment that is prescribed to all patients with a particular disease. Further, judging by the patient's condition, the development of the disease or other concomitant pathologies, symptomatic therapy is prescribed to him.

The entire classification of diseases of the musculoskeletal system in the ICD is located under the letter M and each type of such pathology is assigned a number from M00 to M99. Gouty arthritis in the ICD stands in place of M10, in which there are subgroups with the designation of various types of gouty arthritis. This includes:

• Unspecified gout
• Gout associated with impaired renal function
• Medicinal
• Secondary
• Lead
• Idiopathic

When a patient applies to a medical institution, a detailed history collection, laboratory (analyzes) and instrumental methods (X-ray, ultrasound, and so on) studies of the disease are carried out. After an accurate diagnosis, the doctor sets the ICD 10 code and prescribes the appropriate treatment and symptomatic therapy.

Cause of gouty arthritis according to ICD 10

It has been proven that gouty arthritis most often affects men and only at age, and women, if they get sick, only after menopause. Young people are not exposed to the disease due to the fact that hormones, which are secreted in sufficient quantities in young people, are able to remove uric acid salts from the body, which does not allow crystals to linger and settle in organs.

With age, the amount of hormones decreases due to the suppression of certain body processes and the process of excretion of uric acid no longer proceeds as intensively as before.

Deforming osteoarthritis, abbreviated as DOA, refers to chronic diseases joints. It leads to the gradual destruction of the articular (hyaline) cartilage and further degenerative-dystrophic transformation of the joint itself.

ICD-10 code: M15-M19 Arthrosis. These include lesions caused by non-rheumatic diseases and mainly involving peripheral joints (limbs).

• Disease spread
• Joint structure
• DOA development
• Symptoms
• Diagnostics

Knee arthrosis international classification disease is called gonarthrosis and has the code M17.

In practice, there are other names for this disease, which are synonyms according to the ICD10 code: deforming arthrosis, osteoarthritis, osteoarthritis.

Disease spread

Osteoarthritis is considered the most common disease of the human musculoskeletal system. More than 1/5 of the world's population is affected by this disease. It is noted that women suffer from this ailment much more often than men, but with age, this difference is smoothed out. After 70 years of age, more than 70% of the population suffers from this disease.

The most "vulnerable" joint for DOA is the hip joint. According to statistics, it accounts for 42% of cases of the disease. The second and third places were shared by the knee (34% of cases) and shoulder joints (11%). For reference: there are more than 360 joints in the human body. However, the remaining 357 account for only 13% of all diseases.

Joint structure

A joint is the junction of at least two bones. Such a joint is called simple.

In a complex knee joint with 2 axes of motion, three bones are articulated. The joint itself is covered with an articular capsule and forms an articular cavity.

It has two shells: outer and inner. Functionally, the outer shell protects the articular cavity and serves as an attachment point for the ligaments.

Icd code 10 rheumatoid arthritis

The code for Seropositive rheumatoid arthritis in ICD-10 is M05.

International Classification of Diseases, 10th revision (ICD-10) Class 13 M05 Seropositive rheumatoid arthritis. M05.0 Felty's Syndrome Causes of Pain in the Right Side - Woman - Jun 21 If you suffer from pain and tingling in your right side, your kidneys pain appear in the lumbar region. Seropositive rheumatoid arthritis code in the international classification of diseases ICD-10. M00-M99 Diseases of the musculoskeletal system and

ICD-10: Diseases of the musculoskeletal system and connective International Classification of Diseases (ICD-10). M00-M99 Arthritis - Pain, inflammation and loss of mobility in one or more joints. can a leg hurt only the next day after a bone fracture? most likely a bruise. When I fell off the lead and broke a finger on my hand, at first I didn’t really feel anything either. I went on to ride. But by the morning I was grabbed specifically - the finger turned blue, swollen, it was impossible to touch it. with a fracture you wouldn't run yesterday. bruise It's just a muscle problem. Let her lie down for at least a day so that the inflammation does not go up.

Arthritis and arthrosis (joint diseases) - the difference and how to treat But why do so many people complain of joint pain? The first blow is taken by the knee joints, joints of the elbows, hands. Colds (for example, arthrosis in workers in hot workshops) are of known importance. Additionally. The code. Nosology.

ICD 10 - INFLAMMATORY POLYARTHROPATHIES (M05-M14) Other arthritis (M13) [localization code see above] Excludes: arthrosis (M15-M19). M13.0 Polyarthritis, unspecified M13.1 Monoarthritis, not

• About the Medical Center - Mediart If necessary, you will be given a sick leave. If you have headaches, back pain, neuralgia, sciatica, osteochondrosis - neurologist ICD 10 code: M05-M14 INFLAMMATORY POLYARTHROPATHIES. rheumatic fever (I00) rheumatoid arthritis. youthful (M08.
• Rheumatoid Arthritis: Causes, Symptoms and Treatment ICD 10 code: M06 Other rheumatoid arthritis.
• Arthritis - During the period of exacerbation, the joints hurt, so at this time it is very important.My mother-in-law has been treating arthritis for a long time, her joints are very inflamed, Definition of rheumatoid arthritis, causes of occurrence, pathogenesis, classification of the disease, Seronegative RA, ICD-10 code - M06. 0 :.

International classification of diseases ICD-10 - codes and

Academy of Success and Healthy way life. Joints ache Nov 5 Joints ache, help yourself. Do not miss the opportunity to do a good deed: click on the button from Facebook, Vkontakte or the International Classification of Diseases ICD-10 - codes and codes of diagnoses and M03.0 Arthritis after a meningococcal infection (a39.8)

The non-fictional story of the hermit Agafya Lykova, who revealed the family secret of the treatment of joint diseases!

Moscow. Talk Show Let them talk. In this studio, we discuss non-fictional stories about which it is impossible to remain silent.

Today in our studio the Hermit Agafya Lykova... everyone knows her firsthand! On all the central channels, she began to flicker because of her unusual fate. Agafya Lykova is the only living representative of the family of hermits-Old Believers. For many centuries this family has managed to maintain longevity and ideal health, living in the taiga, far from civilization, medicines, and doctors. Using the power of nature and its gifts, they possessed truly good health and incredibly stable immunity. After that... As the whole of Russia learned about Agafya, thousands of letters from TV viewers began to come to us for transmission with the request: "Ask Agafya Lykova to tell some secret recipe of her family." All letters were in the same way - everyone wanted to get at least a small recipe that would help improve or maintain health. Well, if viewers ask, then you need to find out her recipes and secrets of longevity. After all, thousands of Russians cannot be wrong - if they ask, it means they will help!

Hello Andrey and dear audience. Probably, I would hardly agree to issue a recipe for my ancestors if I didn’t know how many people in Russia, and all over the world, suffer from osteochondrosis and terrible joint pains. Perhaps my ancient recipe will help get rid of such diseases once and for all.

Our editorial staff together with operators came to you in the taiga. On the street it was "-29", it was a terrible cold, but you didn’t need everything! You stood in light clothes, with a scarf on your head and on one shoulder holding a rocker with two 10-liter buckets filled with water. And you, after all, are already 64 years old. We were amazed: in front of us stood elderly woman, which simply shone with longevity and health.
Having entered the house, we saw that you were preparing some kind of mixture that looked like a cream. Can you tell us more?

My father and my mother knew the family recipes that they received from their parents, and they received from theirs. Many of my recipes are already hundreds of years old, they have been treated by my entire generation. All of these recipes are written in this book.

Agafya, tell us what the last thing you managed to win? You are the same person as all Russians. In any case, could something bother you?

Yes, of course I was sick with many diseases, but I got rid of them very quickly, since I have mine "Family recipe book"... The last thing I got sick with was pain in my joints and back. The pains were terrible, and the dampness in the room only aggravated my illness. Legs and arms did not bend and ached badly. But I got rid of this ailment in 4 days. I have a great-grandmother's recipe for this ailment. So be it, I'll tell you it, let the people get rid of their ailments.

After these words, Agafya opened her old book with recipes and began to dictate the composition to us. Below we will tell you how to cure arthrosis in 4 days! In the meantime, let's talk about the remaining dialogue with Agafya:

What is this tool and how to use it correctly?

At the heart of this cream antlers of the Altai maral - the most valuable substance... which is extracted only once a year from the antlers. They are mined in only one place, in the northwest of Siberia. In the spring, the Altai maral sheds its horns, and local residents go in search of them in the taiga. On the basis of maral pant, I am preparing a cream for joint pain, bruises and sprains. Due to the healing properties of the substance, local residents in the 19th century destroyed almost the entire population of Altai marals. Therefore, commercial production of pantas is impossible.

-Thank you, Agafya. Many Russians will now get rid of joint pain for good.

Release Notes (934)

Liana | 18.09. - 23:58

Thank you very much for the recipe and the opportunity to buy Artropant! I have been using it for 3 days already, the joints really stopped bothering me!

Minnie | 20.09. - 13:12

How good that ancient recipes have survived! I've had enough of these pills! My mom uses cream. She is 68, and she has more than enough health. Although recently she complained of severe pain in the lower back and elbows! And now you just don’t recognize her! Thanks to your channel for reporting!

Angelina | 20.09. - 04:57

Evgeniya | 22.09. - 23:21

How long does Artropant take? Pay right away?

Ann | 25.09. - 20:30

It is easy to pay, there are instructions and options. The cream went to me in Tyumen for 4 days! The wait was worth it, since I have been smearing for 5 days already. The bones hurt badly, now they don't bother at all! Thanks to the TV channel!

Baby mouse | 25.09. - 04:57

Is it suitable for general health improvement?

Elena | 27.09. - 23:29

I treat them muscle pains. The improvement started already on the 2nd day. I highly recommend this cream to everyone!

Mary | 27.09. - 05:31

This is what folk medicine can do! Damn the medicine! Fortunately, the cream is worth a penny, regarding the treatment itself!

MKB 10 code reactive arthritis

Elizabeth 10.09. 01:16:08

ICD code 10: m06 Other rheumatoid m06.9 Rheumatoid arthritis Does your groin hurt? -. Traditional medicine Pain may not appear immediately, but gradually. You may be concerned about groin pain, abdominal pain, and uncomfortable walking and physical exertion. ICD-10: Diseases Code. Nosology Seropositive rheumatoid arthritis: m05.0: Syndrome

ICD-10: Diseases of the musculoskeletal system and Arthritis mkb 10 arthritis code by mkb 10, rheumatoid arthritis mkb how to quickly get rid of a clogged nose. \ Make inhalation: put one tablet of validol and half a pipette of iodine on a liter mug of boiling water. Stir everything and breathe out only with your nose until the water cools down. In this way, I even cured sinusitis. Buy NAZOL and there is no problem if there is a lot of blown nose current, splash a lot of water there or pour, and blow your nose. or a lot of sprays, there are drops. Chop off. Joke. Naphtizin. Any vasoconstrictor sprays or drops. Nazol, Nazivin, fornos and many others. They work for several hours. They take effect in a few minutes. Get rid of a clogged nose? HM. was somewhere. But, you take an ax, attach it from below and, with a sharp movement, pull it up. Peel the onion or spread with an asterisk, rinse the nose with a solution of water and salt. for 1 glass (150-200 ml) - 1-1.5 teaspoons of salt, close one of the nostrils and draw in water. do this procedure 2-3 times a day! + nasal drops Get well soon! bake a head of onion in the oven or in a microwave oven, cut it in half, wrap it in a towel, apply it on the bridge of the nose until it cools down, squeeze juice from the cooled bulb, drip it into the nose. In 10 sessions, you can cure not only a clogged nose, even sinusitis. it is better to turn to a specialist, otherwise it can be brought to a chronic stage, then nothing will help Nusudex tablet - and there are no problems for half a day or more. Well, then - at home, steam your feet, mustard in socks, or smear caviar with butter (alcohol) and hot tea with raspberries or hot milk. And in order to sleep with a stuffy nose and not suffer, smear the wings of the nose (externally.) With a drop of camphor oil or just put a cotton swab moistened with camphor near the bed.

Jaw pain Dec 3 Headache, eye pain, ear pain, face pain, jaw pain When the mouth is open, the head of the lower jaw is turned into the cavity

Classification and ICD-10 codes of knee arthritis the ICD 10 code must be entered in the person's medical history. rheumatoid arthritis;

PHARMATEKA »Problems of discogenic dorsalgia: pathogenesis Gate's symptom: pain in the lower back during forced hip flexion in Minor's symptom 1: when standing up from a prone position, the patient Mkb 10 code reactive arthritis, Mkb 10 code reactive arthritis. [rheumatoid arthritis]

1. Arthritis ICD code 10 - knee joint, treatment If the site was useful to you, then please mark it by adding it to your bookmarks:

2. Psychosomatic disorders in diseases - Bookap Moreover, with the exception of angina pectoris and myocardial infarction, pain in the area with the smallest, minimal physical exertion. the tips of the fingers are directed towards the chin, the elbows are directed to the sides. Rheumatoid arthritis The international RA code is rheumatoid arthritis. ICD-10

3. ICD 10 - Seropositive rheumatoid arthritis (M05) Rheumatoid arthritis ICD 10: ICD 10 code Rheumatoid arthritis ICD 10 refers to xiii

4. Pavlyuchenkova starred with Roland Garros - Tennis. Sports / 1 day before the end of the second round match against the Dutch Kiki Bertens due to back pain. All tennis players have shoulder problems. ICD 10 code: m05 Seropositive rheumatoid arthritis m05.0 Felty's syndrome. Rheumatoid

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

Short description

Rheumatoid arthritis(RA) is an inflammatory rheumatic disease of unknown etiology, characterized by symmetric chronic erosive arthritis of the peripheral joints and systemic inflammatory lesions of internal organs.

Working Classification of Rheumatoid Arthritis (1980) By Form: Rheumatoid arthritis: polyarthritis, oligoarthritis, monoarthritis Rheumatoid arthritis with systemic manifestations Special syndromes: Felty's syndrome, Still's syndrome in adults By sero-belonging(according to the presence of RF): seropositive, seronegative With the flow: rapidly progressing, slowly progressing (assessment of the rate of development of destructive changes in the joint during long-term observation) By activity: I - low, II - moderate, III - high activity X-ray stage: I - periarticular osteoporosis, II - the same + narrowing of the interarticular gaps + single erosions, III - the same + multiple erosions, IV - the same + ankylosis H The presence of functional ability: 0 - retained, I - professional ability retained, II - lost professional ability, III - lost self-service ability.

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

Causes

Etiology unknown. Various exogenous (viral proteins, bacterial superantigens, etc.), endogenous (type II collagen, stress proteins, etc.) and nonspecific (trauma, infection, allergy) factors can act as “arthritogenic” ones.

Genetic features. 70% of RA patients have HLA-DR4 Ag, the pathogenetic significance of which is associated with the presence of a rheumatoid epitope (region of the b-chain of the HLA-DR4 molecule with a characteristic sequence of amino acids from 67th to 74th positions). The effect of the "gene dose", that is, the quantitative - qualitative relationship of the genotype and clinical manifestations, is discussed. The combination of HLA - Dw4 (DR b 10401) and HLA - Dw14 (DR b 1 * 0404) significantly increases the risk of developing RA. On the contrary, the presence of Ar - defenders, for example, HLA - DR5 (DR b 1 * 1101), HLA - DR2 (DR b 1 * 1501), HLA DR3 (DR b 1 * 0301) significantly reduces the likelihood of RA disease.

Pathogenesis. The pathological process in RA is based on generalized immunologically determined inflammation.In the early stages of the disease, Ag - specific activation of CD4 + - T - lymphocytes in combination with hyperproduction proinflammatory cytokines(tumor necrosis factor [TNF-a], IL-1, IL-6, IL-8, etc.) against the background of a deficiency of anti-inflammatory mediators (IL-4, a soluble antagonist of IL-1). IL - 1 plays an important role in the development of erosion. IL - 6 stimulates B - lymphocytes to synthesize RF, and hepatocytes to synthesize proteins of the acute phase of inflammation (C - reactive protein [CRP], etc.). TNF-a causes the development of fever, pain, cachexia, is important in the development of synovitis (it promotes the migration of leukocytes into the joint cavity by increasing the expression of adhesion molecules, stimulates the production of other cytokines, induces the procoagulant properties of the endothelium), and also stimulates the growth of pannus (granulation tissue penetrating into the cartilage from the synovial tissue and destroying it). An important prerequisite is the weakening of endogenous synthesis of HA - hormones. At the late stages of RA under conditions of chronic inflammation, tumor-like processes are activated due to somatic mutation of fibroblast-like synovial cells and defects in apoptosis.

Symptoms (signs)

CLINICAL PICTURE

1. Common symptoms: fatigue, low-grade fever, lymphadenopathy, weight loss.
2. Articular syndrome Symmetry is an important feature of RA Morning stiffness lasting more than 1 hour Symmetrical lesion of the proximal interphalangeal, metacarpophalangeal, wrist, metatarsophalangeal joints, as well as other "(Hyperextension in the proximal interphalangeal joints)," hands with lorgnette "(with mutating arthritis) Rheumatoid foot: fibular deviation, hallux valgus, soreness of the metatarsophalangeal joints Rheumatoid knee joint, flexural deformities of the Baker vein Atlantoaxial joint Cricoid joint: coarsening of the voice, dysphagia.
3. Damage to the periarticular tissues Tenosynovitis in the area of ​​the wrist joint and hand Bursitis, especially in the area of ​​the elbow joint Damage to the ligamentous apparatus with the development of hypermobility and deformities Muscle damage: muscle atrophy, myopathy, more often drugs (steroid, and also against the background of taking penicillamine or aminoquinoline derivatives).
4. Systemic manifestations Rheumatoid nodules are dense subcutaneous formations, typically localized in areas that are often traumatized (for example, in the olecranon, on the extensor surface of the forearm). Very rarely found in internal organs(for example, in the lungs). Observed in 20-50% of patients Ulcers on the skin of the legs Damage to the eyes: scleritis, episcleritis; with Sjogren's syndrome - dry keratoconjunctivitis Heart damage: dry, less often effusion, pericarditis, vasculitis, valvulitis, amyloidosis. Patients with RA are prone to early development of atherosclerosis Lung damage: interstitial pulmonary fibrosis, pleurisy, Kaplan's syndrome (rheumatoid nodules in the lungs of miners), pulmonary vasculitis, obliterating bronchiolitis Kidney damage: clinically mild mesangial or (less often) membranous membranous: compression (carpal tunnel syndrome), sensory-motor neuropathy, multiple mononeuritis (within the framework of rheumatoid vasculitis), cervical myelopathy (rarely) against the background of subluxation of the atlanto-occipital joint Vasculitis: digital arteritis with the development of gangrene of the fingers, microinfarction of the bed in the area of ​​the iron in the body caused by dysfunction of the reticuloendothelial system; thrombocytopenia Sjogren's syndrome - autoimmune exocrinopathy, clinical manifestations: keratoconjunctivitis dry, xerostomia Osteoporosis (more pronounced against the background of HA therapy) Amyloidosis Felty's syndrome: a complex of symptoms, including neutropenia, splenomegaly, systemic manifestations, often leads to the development of Stilechroma fever ° С or more for one or more weeks; arthralgia 2 weeks or more; a salmon-colored macular or maculopapular rash that appears during a fever; blood leukocytosis> 10109 / L, granulocyte count> 80% Small criteria: sore throat, lymphadenopathy or splenomegaly; an increase in the level of serum transaminases, not associated with drug toxicity or allergies; absence of RF, absence of antinuclear antibodies (ANAT).

Diagnostics

Laboratory data Anemia, increased ESR, increased CRP levels correlate with RA activity. Synovial fluid is turbid, with low viscosity, leukocytosis above 6000 / μL, neutrophilia (25–90%) RF (antibodies to IgG class IgM) is positive in 70–90% of cases With syndrome Sjogren detect ANAT, AT to Ro / La OAM (proteinuria in the framework of nephrotic syndrome caused by renal amyloidosis or drug glomerulonephritis) Increase in creatinine, serum urea (assessment of renal function, a necessary stage in the selection and control of treatment).

Instrumental data X-ray examination of the joints Early signs: osteoporosis, cystic enlightenment of the periarticular parts of the bone. Erosion of the articular surfaces earlier formed in the region of the heads of the metacarpophalangeal and metatarsophalangeal joints Late signs: narrowing of the joint spaces, ankylosis Regional features: subluxation of the atlantoaxial joint, protrusion of the femoral head into the acetabulum.

American Rheumatological Association Diagnostic Criteria for Rheumatoid Arthritis (1987) At least 4 of the following Morning stiffness> 1 h Arthritis of 3 joints or more Arthritis of the joints of the hands Symmetrical arthritis Rheumatoid nodules RF X-ray changes The first four criteria must be present for at least 6 weeks. Sensitivity - 91.2%, specificity - 89.3%.

Treatment

TREATMENT

General tactics. Since the highest rate of increase in X-ray changes in the joints is observed in the early stages of RA, active therapy (NSAIDs in an adequate dose + basic drugs) should be started within the first 3 months after the diagnosis of reliable RA is made. This is especially important in patients with risk factors for an unfavorable prognosis, which include high RF titers, a pronounced increase in ESR, damage to more than 20 joints, the presence of extra-articular manifestations (rheumatoid nodules, Sjogren's syndrome, episcleritis and scleritis, interstitial lung disease, pericarditis, systemic vasculitis , Felty's syndrome). The use of GC is indicated in patients who do not "respond" to NSAIDs or have contraindications to their appointment in an adequate dose, as well as as a temporary measure before the onset of the effect of the basic drugs. Intra-articular administration of HA is intended for the treatment of synovitis in one or more joints, which complements, but does not replace, complex treatment.

Mode. Patients should form a stereotype of movements that counteracts the development of deformities (for example, to prevent ulnar deviation, open the tap, dial a phone number and other manipulations not with the right, but with the left hand).

DRUG TREATMENT

Non-steroidal anti-inflammatory drugs Non-selective inhibitors of cyclooxygenase (COX) Diclofenac 50 mg 2–3 r / day Long-acting diclofenac preparations 100 mg / day The arylpropionic acid derivatives remain relevant as they have the lowest percentage of gastrointestinal complications: Ibuprofen 0.8 g 3-4 r / day Naproxen 500-750 mg 2 r / day Ketoprofen 50 mg 2-3 r / day (has a high analgesic activity) Indoleacetic acid derivatives Indomethacin 25-50 mg 3 r / day Prolonged preparations of indomethacin 75 mg 1-2 r / day Derivatives of enolic acids Piroxicam 10–20 mg 2 r / day Selective COX inhibitors - 2 Meloxicam 7.5–15 mg / day Nimesulide 0.1–0.2 g 2 r / day Celecoxib 0.1 g 2 r / day.

Application tactics NSAIDs Patients at risk of developing gastropathy and gastrointestinal bleeding (age over 75 years, history of gastrointestinal ulcers, concomitant use of low doses of acetylsalicylic acid and GC, smoking) can be prescribed selective or specific inhibitors of COX-2 or (subject to high individual efficacy ) non-selective COX inhibitors in combination with misoprostol 200 mcg 2–3 r / day or proton pump inhibitors (omeprazole 20–40 mg / day). COX-2 inhibitors, should simultaneously continue taking small doses of acetylsalicylic acid.

ICD 10 classification of rheumatoid arthritis

It happens that doctors confuse arthritis with arthrosis

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

The origin of the systemic disease

Rheumatoid arthritis is a terrible disease that affects not only the elderly, but also babies. This disease spreads to all age categories. It is like an epidemic, it does not spare anyone.

In the ICD 10, rheumatoid arthritis is listed under the code M06. The basis for the occurrence of the disease is the abnormal work of the immune system of the patient's body. The body is made up of cells whose functions are based on protecting the immune system. Protective cells begin to be produced after an infection is obtained, but instead of destroying the microorganisms that launched the infectious disease, they begin to attack healthy cells, destroying them. Damage to the cartilaginous tissues of the joints begins, which leads to irreversible damage in the patient's body.

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

Patients with rheumatoid arthritis with ICB code 10

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

Why it is necessary to write the encoding on the patient's card:

• So that there is no misunderstanding between the patient and the medical staff.
• Taking the card, the doctor knows the patient's complaints, what worries him the most.
• The hospital workers know what they are facing.
• There is no need to once again explain to the doctor what ailment you have, it is written in the card.

The health care system has foreseen all the nuances, albeit insignificant, but it is very convenient, especially for the hospital staff. After all, the patient is not always able to explain what he is sick with.

Varieties of ailments of the musculoskeletal system

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

There are several types of rheumatoid arthritis:

• traumatic;
• reactive;
• psoriatic;
• juvenile.

There are cases when people with identical symptoms are assigned to different ranks of the disease. The nature of the course is different, the degree of the disease can also be different, and the signs are the same.

If the ailment is not treated, complications may arise:

• disability;
• the development of osteoporosis;
• fractures and other injuries;
• immobilization.

Symptomatic manifestations of the disease

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

• inflammation of the joint capsule - swelling;
• affects simultaneously at least 3 articular joints;
• joints cease to function properly, morning stiffness is observed, which significantly worsens the patient's well-being;
• the temperature in the affected area rises, the swelling is hot to the touch and the state of health worsens;
• inflammation spreads to internal organs;
• increased risk of getting a heart attack;
• sharp pain;
• swelling and redness of the articular surfaces.

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

ICD 10. Rheumatoid arthritis: symptoms and treatment

According to ICD 10, rheumatoid arthritis belongs to class M: inflammatory polyarthropathies. In addition to him, this includes JRA (juvenile, or juvenile rheumatoid arthritis), gout and others. The causes of this disease are still not fully understood. There are several theories about its development, but no consensus has yet been formed. It is believed that the infection causes dysregulation of the immune system in people who are predisposed to it. As a result, molecules are formed that destroy the tissues of the joints. Against this theory is the fact that rheumatoid arthritis (ICD code - 10 M05) is poorly treated with antibacterial drugs.

History of the disease

Rheumatoid arthritis is an ancient disease. The first cases of it were discovered when examining the skeletons of Indians, whose age was about four and a half thousand years. In the literature, the description of RA has been found since 123 AD. People with characteristic symptoms diseases were captured on Rubens' canvases.

As a nosological unit, rheumatoid arthritis was first described by the physician Landre-Bove in the early nineteenth century and called it "asthenic gout." The disease received its present name half a century later, in 1859, when it was mentioned in a treatise on the nature and treatment of rheumatic gout. For every one hundred thousand people, fifty cases are identified, most of them women. By 2010, more than forty-nine thousand people died from the RA in the world.

Etiology and pathogenesis

RA is such a widespread disease that it has a separate chapter in ICD 10. Rheumatoid arthritis, like other joint pathologies, is caused by the following factors:

A tendency to autoimmune diseases in the family;

The presence of a certain class of histocompatibility antibodies.

Measles, mumps (mumps), respiratory syncytial infection;

The whole family of herpes viruses, CMV (cytomegalovirus), Epstein-Barr;

3. Trigger factor:

Stress, medication, hormonal disruptions.

The pathogenesis of the disease is the abnormal response of the cells of the immune system to the presence of antigens. Lymphocytes produce immunoglobulins against body tissues instead of destroying bacteria or viruses.

Clinic

According to ICD 10, rheumatoid arthritis develops in three stages. In the first stage, swelling of the joint capsules is observed, which causes pain, the temperature rises and the shape of the joints changes. In the second stage, the cells of the tissue that covers the inside of the joint begin to divide rapidly. Therefore, the synovium becomes dense and rigid. In the third stage, the inflammatory cells release enzymes that destroy the tissues of the joint. This causes difficulties with voluntary movements and leads to physical defects.

Rheumatoid arthritis (ICD 10 - M05) has a gradual onset. Symptoms appear gradually and may take months. In extremely rare cases, the process can begin acutely or subacutely. The fact that the articular syndrome (pain, defiguration and local temperature increase) is not a pathognomonic symptom significantly complicates the diagnosis of the disease. As a rule, morning stiffness (inability to make movements in the joints) lasts about half an hour, and it intensifies when trying to active movements. A harbinger of the disease is pain in the joints when the weather changes and general meteosensitivity.

Clinical course options

There are several options for the course of the disease, which should be guided by the doctor in the clinic.

1. Classical when the damage to the joints occurs symmetrically, the disease progresses slowly and there are all its precursors.

2. Oligoarthritis with the defeat of exceptionally large joints, usually the knee. It begins acutely, and all manifestations are reversible within a month and a half from the onset of the disease. At the same time, joint pains are volatile, there are no pathological changes on the x-ray, and treatment with NSAIDs (non-steroidal anti-inflammatory drugs) has a positive effect.

3. Felty's syndrome it is diagnosed if an enlargement of the spleen with a characteristic picture of blood changes is added to the joint disease.

4. Juvenile rheumatoid arthritis(code according to ICD 10 - M08). A characteristic feature is that it affects children under 16 years of age. There are two forms of this disease:

With allergoseptic syndrome;

Articular-visceral form, which includes vasculitis (inflammation of the joints), damage to the valves of the heart, kidneys and digestive tract, as well as damage to the nervous system.

Classification

As in the case of other nosological units reflected in the ICD 10, rheumatoid arthritis has several classifications.

1. By clinical manifestations:

Very early, when symptoms last up to six months;

Early, if the disease lasts up to a year;

Expanded - up to 24 months;

Late - with a disease duration of more than two years.

2. X-ray stages:

- First. There are thickening and compaction of the soft tissues of the joint, single foci of osteoporosis.

- Second. The process of osteoporosis captures the entire epiphysis of the bone, the joint space narrows, erosions appear on the cartilage;

- Third. Deformation of the epiphyses of bones, habitual dislocations and subluxations;

- Fourth. Ankylosis (complete absence of joint space).

3. Immunological characteristics:

For rheumatoid factor:

Seropositive rheumatoid arthritis (ICD 10 - M05.0). This means that rheumatoid factor is detected in the patient's blood.

Seronegative rheumatoid arthritis.

For antibodies to cyclic citrulline peptide (Anti-CCP):

Seropositive rheumatoid arthritis;

4. Functional class:

• First- all types of activities are preserved.
• Second- professional activity is disrupted.
• Third- the ability to self-service remains.
• Fourth- all types of activity are disrupted.

Rheumatoid arthritis in children

ICD 10 distinguishes juvenile rheumatoid arthritis in a separate category - as an autoimmune disease of young children. Most often, children get sick after a severe infectious disease, vaccination, or joint injuries. Aseptic inflammation develops in the synovium, which leads to excessive accumulation of fluid in the joint cavity, pain, and ultimately to a thickening of the wall of the joint capsule and its adhesion to the cartilage. After some time, the cartilage is destroyed and the child becomes disabled.

The clinic distinguishes between mono -, oligo - and polyarthritis. When only one joint is affected, then this, respectively, is monoarthritis. If up to four joints are simultaneously affected by pathological changes, then this is oligoarthritis. Polyarthritis is diagnosed when almost all joints are affected. Systemic rheumatoid arthritis is also distinguished, when other organs are affected in addition to the skeleton.

Diagnostics

In order to make a diagnosis, it is necessary to correctly and fully collect an anamnesis, conduct biochemical blood tests, make an X-ray of the joints, as well as serodiagnostics.

In a blood test, the doctor pays attention to the erythrocyte sedimentation rate, rheumatoid factor, the number of blood cells. The most progressive at the moment is the detection of anti-CCP, which was isolated in 2005. This is a highly specific indicator that is almost always present in the blood of patients, in contrast to rheumatoid factor.

Treatment

If the patient has had an infection or it is in full swing, then he is shown specific antibiotic therapy. When choosing drugs, attention is paid to the severity of the articular syndrome. As a rule, they start with non-steroidal anti-inflammatory drugs and at the same time inject corticosteroids into the joint. In addition, since RA is an autoimmune disease, the patient needs plasmaphoresis in order to eliminate all immune complexes from the body.

Treatment is usually long-term and can take years. This is due to the fact that drugs must accumulate in the tissues. One of the key points of therapy is the treatment of osteoporosis. For this, the patient is asked to follow a special diet with a high calcium content (dairy products, almonds, walnuts, hazelnuts), as well as take calcium and vitamin D supplements.

The most complete answers to questions on the topic: "MKB 10 rheumatism of the joints."

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

What is rheumatism according to ICD 10

This pathology can occur after a sore throat. In modern times, rheumatism is much less common, the massive use of antibiotics does not make it possible to develop autoimmune processes.

The incidence of the disease in developed countries among the adult population is up to 0.9%, and in childhood- not less than 0.6%. With the development of rheumatism from young years to adulthood (30-40), about 80-90% do not survive.

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

For a complete list of this pathology, the international classification of diseases of the 10th revision is used. According to Mkb - 10, each disease has its own coding. The rheumatism code starts with Latin letter I which means all diseases of the circulatory system. The code for rheumatism and rheumatic fever is 00 - 09.

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

I 00 Rheumatic fever without affecting heart disease.

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

I01.0 pericarditis;

I01.1 endocarditis;

I01.2 myocarditis;

I01.8 other acute rheumatic heart diseases.

I 02 Chorea.

Chronic rheumatic heart disease (codes I05-I09):

I 05 Rheumatic diseases of the mitral valve.

I05.0 mitral stenosis;

I05.1 mitral regurgitation;

I05.2 mitral stenosis with mitral regurgitation.

I 06 Rheumatic diseases of the aortic valves.

I 07 Rheumatic diseases of the tricuspid valve.

I 08 Multiple lesions of the valves.

I 09 Other rheumatic heart affections.

I09.0 Rheumatic myocarditis;

I09.1 chronic endocarditis, valvulitis;

I09.2 chronic pericarditis.

Classification of rheumatism

Clinicians and theorists distinguish two forms of rheumatism - active and inactive. Some people share progressive, fading and recurrent phases. This pathology can be in a chronic stage with the involvement of the valve apparatus and the myocardium. Palindromic (recurring) rheumatism was described as early as 1891.

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

Clinical manifestations of acute rheumatic fever:

Classification of rheumatism by the degree of activity:

First degree. The minimum degree that has mild symptoms. Differs in little or no symptoms.

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

Third degree (maximum). Differs in the appearance of fever with fluid effusion in the cavity (polyarthritis, serositis). V biochemical analysis the content of proteins - inflammation (CRP, a-globulins, seromucoid) and enzymes is sharply increased.

When diagnosed, damage to the central nervous system, heart, joints and other organs occurs. Often professors characterize the disease with the expression "rheumatism kisses the brain, licks the joints and bites the heart."

Such a disease is quite difficult to treat, however, with proper and timely examination and treatment, complete recovery occurs.

The World Health Organization (WHO) has developed a special medical coding for diagnosing and determining medical diseases... The ICD 10 code is the coding for the International Classification of Diseases of the 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 of diseases and conditions. Rheumatoid arthritis ICD 10 belongs to the XIII class “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 non-suppurative 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 organs of the reproductive system.

The development of arthritis occurs a month after infection, but the provocative infection that caused this disease is in the human body does not manifest itself. Men over 45 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 ailment.

If the carrier of the infection is ingested with food, reactive arthritis can become equally develop in both men and women.

Reactive arthritis symptoms

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

Reactive arthritis has acute form... In the first week, the patient has a fever, disorders of the gastrointestinal tract (GIT), acute intestinal malaise, general weakness. In the future, the symptomatology of arthritis progresses and is of a classical nature. At this stage of development, the disease can be divided into 3 types.

1. There is an inflammation of the mucous membrane of the eyes (conjunctivitis may develop).
2. The painful sensations in the joints become more and more stronger, while the motor activity decreases. Infected areas develop noticeable redness and swelling.
3. The organs of the genitourinary system become inflamed.

At first, the disease can affect only one knee joint, but later it may spread to other joints. The pronounced clinic can be minor or very strong, depending on the person's immune system. In the future, it is possible to develop rheumatoid arthritis, 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, give complications to the organs of the cardiovascular system.

Diagnosis and treatment of the disease

Today, a whole range of laboratory tests are needed to confirm whether a patient really has reactive arthritis. Various specialists are involved in the examination of the patient. It is imperative to be examined 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, anamnesis data, identifying clinical manifestations, the use of certain drugs is prescribed.

It is necessary to begin treatment of reactive arthritis by destroying the infectious focus, that is, the causative agents of the initial disease. To do this, you need to undergo a comprehensive examination of the whole body. After determining the pathogen, the sensitivity to drugs is established. 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 drugs of a non-steroidal group are used, for example, ibuprofen.

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

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

From genitourinary infections protects the use of a condom during intercourse. Having a regular sex 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 cure it. If the first signs of the disease appear, you should consult a doctor as soon as possible.

Tags:

Application tactics

Classification of arthritis according to ICD 10

(According to the presence of RF): seropositive, seronegative

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

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

Physiotherapy procedures;

Reactive arthritis symptoms

Puffiness

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

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

NSAIDs Patients at risk of developing gastropathy and gastrointestinal bleeding (age over 75 years, history of gastrointestinal ulcers, concomitant use of low doses of acetylsalicylic acid and GC, smoking) may be prescribed selective or specific inhibitors of COX-2 or (subject to high individual efficacy) non-selective COX inhibitors in combination with misoprostol 200 μg 2–3 r / day or proton pump inhibitors (omeprazole 20–40 mg / day) selective inhibitors of COX - 2, should simultaneously continue taking small doses of acetylsalicylic acid.

Diagnosis and treatment of the disease

Downstream:

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

Severe edema from the very onset of the disease

In the third degree - the impossibility of self-care, a significant loss of mobility in the joint (s).

What causes juvenile rheumatoid arthritis?

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Learning to live with ICD 10 diagnosis - rheumatoid arthritis

Acute onset;

Causes and symptoms of rheumatoid arthritis

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

The World Health Organization (WHO) has developed a special medical code for the diagnosis and definition of medical diseases. The ICD 10 code is the coding for the International Classification of Diseases of the 10th revision as of January 2007.

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

Staphylococcal arthritis and polyarthritis

How is rheumatoid arthritis treated?

RA with systemic manifestations (vasculitis, nephropathy).

Massage;

Edema appears when inflammation joins

By the nature of occurrence in medicine, several forms of arthritis are distinguished:

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

Moderate fever;

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

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

Rheumatoid arthritis: we treat with folk methods

Arthritis

By activity:

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

artrozmed.ru

Etiology and treatment of juvenile rheumatoid arthritis

Redness of the joint

Features of the disease

Reactive - a complication that occurs with untreated (untreated) infections; The pathogenesis of juvenile chronic arthritis

Polyarthritis involving small joints in the process;

Etiological factors

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

Reactive arthritis of the knee is the most common rheumatic disease. The disease is characterized by non-suppurative 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 organs of the reproductive system.

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

The main clinical manifestation of the disease is arthritis. Pathological changes in the joint are characterized by pain, swelling, deformities and limitation of movement, an increase in skin temperature over the joints. In children, large and medium joints are most often affected, in particular, knee, ankle, wrist, elbow, hip, less often small hand joints. Typical for juvenile rheumatoid arthritis is damage to the cervical spine and maxillary-temporal joints, which leads to the underdevelopment of the lower, and in some cases of the upper jaw and the formation of the so-called "bird's jaw".

Forms of the disease

Enlargement and soreness of the lymph nodes;

Possible etiological factors are the following:

• The development of arthritis occurs a month after infection, but the provocative infection that caused this disease is in the human body does not manifest itself. Men over 45 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 ailment.
• Arthritis
• X-ray stage:

Clinical symptoms

Chlorbutin (leukeran) - 2 and 5 mg tablets

• Drug
• Yes, but may not be red in the later stages
• Acute - develops after bruises, fractures, severe physical exertion;
• Juvenile Chronic Arthritis Symptoms
• Hepatosplenomegaly;

The presence of a viral or bacterial infection;

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

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

Intoxication symptoms

Other manifestations

Infectious - caused by viruses or a fungal infection that enters the joint with the blood stream, or through a non-sterile surgical instrument, often leads to the development of purulent inflammation of the knee joint;

• In the systemic variant of juvenile rheumatoid arthritis, leukocytosis (up to 30-50 thousand leukocytes) with a neutrophilic shift to the left (up to 25-30% of stab leukocytes, sometimes up to myelocytes), increased ESR up to 50-80 mm / h, hypochromic anemia are often detected, thrombocytosis, increased concentration of C-reactive protein, IgM and IgG in serum.
• Anemia;
• Traumatic joint injury;
• A characteristic feature of the course of the disease is the symmetry of the joint lesions
• Basic therapy
• The presence of functional ability:

• High RA activity with systemic manifestations, generalized lymphadenopathy, splenomegaly.
• How it works
• Observed in the case of an autoimmune nature of the disease
• Reiter's syndrome - a type of reactive arthritis;
• Diagnostics of the juvenile chronic arthritis
• Myocardial damage;
• Increased insolation;
• Reactive arthritis is acute. In the first week, the patient has a fever, disorders of the gastrointestinal tract (GIT), acute intestinal malaise, general weakness. In the future, the symptomatology of arthritis progresses and is of a classical nature. At this stage of development, the disease can be divided into 3 types.
• Basic therapy should be prescribed to all patients with proven RA.

0 - retained, I - professional ability retained, II - lost professional ability, III - lost self-service ability.

Diagnostic measures

Arthritis and polyarthritis caused by other specified bacterial pathogens If necessary to identify a bacterial agent, use an additional code (

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

• Destination schemes
• No
• Arthritis with ankylosing spondylitis, gout (uncommon);
• Suppression of the inflammatory and immunological activity of the process.

Polyserositis;

Hypothermia;

There is an inflammation of the mucous membrane of the eyes (conjunctivitis may develop).

Treatment tactics

Methotrexate, which has the best efficacy / toxicity ratio, remains the "gold standard" of basic therapy for RA. Assign to patients with active RA or with risk factors for an unfavorable prognosis (see above) at a dose of 7.5–15 mg per week. The onset of the effect is 1–2 months. Among the side effects of methotrexate are hepatotoxicity, myelosuppression, therefore control of the CBC and transaminases should be performed monthly. An increase in the level of liver enzymes is a signal to reduce the dose of the drug or to completely cancel it. A persistent increase in the level of liver enzymes after discontinuation of the drug is an indication for a liver biopsy. Taking into account the antifolate mechanism of action, the intake of folic acid 1 mg / day is indicated, with the exception of the days of using methotrexate.

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

Myelosuppression.

Possible side effects

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Juvenile rheumatoid arthritis

Joint seized symptoms

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

ICD-10 code

• Relief of systemic manifestations and articular syndrome.
• An increase in ESR in the UAC.
• Ingestion of protein components;
• The painful sensations in the joints become more and more stronger, while the motor activity decreases. Infected areas develop noticeable redness and swelling.
• Hydroxychloroquine (200 mg 2 r / day or 6 mg / kg / day) is a frequent component of combination therapy for active, especially early RA. Hydroxychloroquine monotherapy does not slow down radiographic progression. The onset of the effect is 2–6 months. With long-term treatment, an annual ophthalmological examination, examination of the visual fields is required.
• Unknown. Various exogenous (viral proteins, bacterial superantigens, etc.), endogenous (type II collagen, stress proteins, etc.) and nonspecific (trauma, infection, allergy) factors can act as “arthritogenic” ones.
• Due to the fact that the treatment regimens for RA indicated in the table are not always effective, in practice, several combinations of basic agents are used, among which the most widespread are combinations of methotrexate with sulfasalazine, methotrexate and delagil. Currently, the most promising treatment regimen is considered, in which methotrexate is combined with anticytokines.

Epidemiology of juvenile chronic arthritis

Quinoline series preparations (delagil - 0.25 g tablets)

Juvenile chronic arthritis classification

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

Preservation of the functional capacity of the joints.

Juvenile Chronic Arthritis Causes

In the subacute course of the disease, the symptoms are less pronounced. One joint is affected first. Most often it is the ankle or knee joint. One or more joints can be affected. With the oligoarticular form of the disease, 2-4 joints are affected. There may be no pain syndrome. During a physical examination, swelling and dysfunction of the joint is determined. The movement of a sick child is difficult. The liver and spleen are of normal size. The subacute course proceeds more favorably and responds better to therapy.

Hereditary predisposition;

The organs of the genitourinary system become inflamed.

The pathogenesis of juvenile chronic arthritis

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

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

Juvenile Chronic Arthritis Symptoms

In medical practice, there are often cases of lack of effect from treatment (for example, with reactive arthritis, inflammation is not relieved even when antibiotics are taken in combination with NSAIDs), when patients remain active in the disease and the rapid progression of joint deformities.

Diagnostics of the juvenile chronic arthritis

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

Goals of Juvenile Chronic Arthritis Treatment

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

Forecast

Doctors make a conclusion about the need to change the therapy program if the patient was treated for six months using at least three basic drugs.

The initial stage of RA.

Laboratory research methods

Knee arthritis should be differentiated from other pathological processes, the most common of which are arthrosis and bursitis. Bursitis, which is inflammation in the bursa, can be easily distinguished from arthritis by an experienced technician at the first appointment.

Achieving remission.

Prevention of juvenile chronic arthritis

The main diagnostic methods are:

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Causes, symptoms, diagnosis and treatment of knee arthritis

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

Etiology

In rare cases, the disease can affect the central nervous system, give complications to the organs of the cardiovascular system.

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

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

2 tab. per day for the first 2-4 weeks, then 1 table. per day for a long time.

Arthritis in children

Identify changes

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

Improving the quality of life of patients.

Collection of anamnesis;

Symptoms of the disease

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

Today, a whole range of laboratory tests are needed to confirm whether a patient really has reactive arthritis. Various specialists are involved in the examination of the patient. It is imperative to be examined 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, anamnesis data, identifying clinical manifestations, the use of certain drugs is prescribed.

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

Common symptoms:

Pyogenic arthritis, unspecified. Infectious arthritis NOS

Functional impairment

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

Dyspeptic symptoms, pruritus, dizziness, leukopenia, retinal damage.

Do not reveal specific abnormalities

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

Types of arthritis

Minimizing the side effects of therapy.

• External examination of the child;
• In this case, the following forms of juvenile arthritis are distinguished:
• It is necessary to begin treatment of reactive arthritis by destroying the infectious focus, that is, the causative agents of the initial disease. To do this, you need to undergo a comprehensive examination of the whole body. After determining the pathogen, the sensitivity to drugs is established. The bacterial infection is treated with antibiotics.
• Azathioprine is used at a dose of 50–150 mg / day. The effect develops in 2–3 months. Laboratory monitoring is required (KLA every 2 weeks, then every 1–3 months).
• Fatigue, low-grade fever, lymphadenopathy, weight loss. 2.
• Excludes: arthropathy in sarcoidosis (
• It has been reliably established that in 60% of patients with active rheumatoid articular syndrome, even with the third degree of the disease, there is a decrease (or absence) in the progression of joint changes against the background of maintenance therapy with remicade. However, the use of this form of treatment is justified if the basic therapy did not give the expected effect.

Sulfanilamide drugs (sulfasalazine, salazopyridazine) - 500 mg tablets

Instrumental research methods

Differential diagnosis

Arthritis is always an inflammation that over time, with the progression of the disease (with an autoimmune nature), spreads to the entire body. That is why there are many accompanying signs in autoimmune arthritis - this is fever, low-grade fever, and headache, and general malaise. With rheumatoid arthritis, the cardiovascular system is seriously affected.

Juvenile Chronic Arthritis Treatment

Laboratory research;

Articular;

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

Knee arthritis diagnostics

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

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

Involvement of joints in the process;

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

Long-term outpatient follow-up.

Tenosynovitis in the area of ​​the wrist joint and hand Bursitis, especially in the area of ​​the elbow joint Damage to the ligamentous apparatus with the development of hypermobility and deformities Muscle damage: muscle atrophy, myopathy, more often drugs (steroid, and also against the background of taking penicillamine or aminoquinoline derivatives). 4.

* Meningococcal arthritis (

Balneological therapy is a very effective procedure in a comprehensive program for the treatment of knee arthritis. However, this direction of rehabilitation is indicated for those patients who do not have serious illnesses cardiovascular system, malignant neoplasms, and there have been no heart attacks or strokes before. All procedures using therapeutic biological components are prescribed with great care.

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

Drug treatment

Arthritis

Treatment

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

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

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

Since there are many types of arthritis and joint pathologies, it is necessary to see a doctor at the first signs of the disease. The sooner the causes of the inflammatory process are identified, the more chances there are to cure the disease completely.

Age group

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

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

Often, the process involves joints in the cervical spine. Articular syndrome is characterized by:

New techniques

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

Evaluate and deduce the degree of improvement (20%, 50%, 70%) using indicators of swollen joints scores of painful joints at least 3 out of 5 indicators overall assessment of activity according to the patient's overall assessment of activity according to the doctor's assessment of pain by the patient acute phase blood parameters (ESR, CRP) disability (quantified using standardized questionnaires).

Arthritis

Arthritis

Arthritis and physical activity. Gordon N.F.

Rehabilitation programs

Suppression of collagen synthesis, inhibition of the activity of type I T-helpers and B-lymphocytes, destruction of the CIC

Knee arthritis can be diagnosed at home if the symptoms of the disease are carefully examined. Regardless of the etiology, symptoms such as edema, redness in the joint area, general malaise, external signs of deformation of the articular tissue appear.

No restrictions (any age)

It is worth dwelling in more detail on rheumatoid arthritis (RA), which is an autoimmune disease with unclear etiology... The disease belongs to common pathologies - about 1% of the population suffers. Cases of self-healing are very rare, in 75% of patients there is a persistent remission; in 2% of patients, the disease leads to disability.

M08. Juvenile arthritis.

Stiffness in the morning lasting up to 1 hour or more;

1. The goal of therapy for rheumatoid arthritis is to reduce rheumatic pains, reduce inflammation, improve joint mobility and prevent the patient from completely immobility. The basic principles that govern any clinic treating rheumatoid arthritis are complexity and consistency. The spa treatment with curative mud has proven itself well.
2. Rehabilitation.
3. American Rheumatological Association (1987)

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

Peripheral joints and systemic inflammatory lesions of internal organs.

2 Shoulder Shoulder Elbow bone

High clinical and laboratory activity of RA

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

Generally over 50-60 years old

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

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

Swelling in the joint area;

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

INFECTIOUS ARTHROPATHIES (M00-M03)

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

M00 Pyogenic arthritis

Doctors must determine the nature of the disease in order to prescribe adequate treatment. Traumatologists-orthopedists, surgeons, rheumatologists give directions to laboratory and instrumental studies. The treatment regimen is developed by a specialized specialist (this can be a phthisiatrician, dermatologist-venereologist, cardiologist and other doctors). Some types of arthritis only affect children and adolescents, so they should be distinguished in a separate row. M08.1. Juvenile (juvenile) ankydosing spondylitis. Soreness; The basic treatment is the suppression of the autoimmune process by means of such drugs: methotrexate, sulfasalazine and leflunomide. In terms of minimizing side effects, the latter is different, this should be taken into account from the position that they all require long-term (at least six months) use. Features in pregnant women Arthritis M06 - 4 Hand Wrist, Joints between these fingers, bones, metacarpus Skin rash, dyspepsia, cholestatic hepatitis, myelosuppression The first stage to determine the disease (according to ICD 10) is a visual examination, anamnesis collection. Acute or chronic Juvenile rheumatoid arthritis (ICD-10 code M08) affects children after bacterial and viral infections. As a rule, one knee or other large joint becomes inflamed. The child has pain with any movement, swelling in the joint area. Children limp, hardly get up in the morning. In the absence of treatment, deformity of the joints gradually develops, which is no longer possible to fix.

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

Other rheumatoid arthritis 5 Pelvic Gluteal Hip, area and thigh area, sacroiliac, femur, bone, pelvis Methotrexate (2.5 mg tablets, 5 mg ampoules) The second stage is laboratory blood tests (with inflammation, there is an increase in ESR, leukocytosis, a marker of CRP inflammation, and other specific reactions).

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