–едакци€ портала
04 окт€бр€ 2013, 23:19 441 +4

–евматоидный артирит 

√руппа заболеваний: аутоммунные и суставные болезни
—межные болезни: артрит, коллагенозы, псориатический артрит, септический артрит
¬рач в каталоге: ревматолог
ѕораженные органы: суставы пальцев рук, ног,
 

‘акторы риска

  • ќ–«, грипп, ангина;
  • ќбострение хронических инфекционных заболеваний;
  • —ильный эмоциональный стресс;
  • ѕереохлаждение.

ќписание

–евматоидный артрит (от др. греч.ῥεῦμα, что значит «течение»)  это хроническое воспалительное системное заболевание соединительной ткани, характеризующеес€ полиартритом, в основе которого лежит хроническое воспаление синовиальной оболочки сустава, привод€щее к нарушению его функции.

–евматоидный артрит, как и большинство всех артритов в целом, относитс€ в аутоиммунным болезн€м. ¬ данном случае лимфоциты (клетки иммунной системы ), вместо того, чтобы распознавать чужеродные вирусы, бактерии и их уничтожить, набрасываютс€ на клетки организма человека. 

«аболевание характеризуетс€ высокой инвалидностью (70%), котора€ наступает довольно рано. ќсновными причинами смерти от заболевани€ €вл€ютс€ инфекционные осложнени€ и почечна€ недостаточность. –евматоидный артрит (–ј) поражает людей самого разного возраста, но чаще всего тех, кому за 30. —реди больных ревматоидным артритом женщин примерно в 5 раз больше, чем мужчин. ѕо мировой статистике, им страдает около 1% населени€ земного шара. ¬ –оссии эпидемиологические исследовани€ не проводились уже много лет, но данные 70-х годов прошлого века, говор€т о том, что в нашей стране распространенность –ј составл€ет пор€дка 0,6%, а по официальной статистке ћинздрава –оссии, им больны 280 тыс. человек. Ёто в основном т€желые формы ревматоидного артрита, которые требуют агрессивных методов лечени€. –азвитие болезни обычно начинаетс€ в среднем возрасте, многие больные станов€тс€ инвалидами, не доработав до пенсии.

Ћечение сосредотачиваетс€ в основном на облегчении боли, замедлении развити€ заболевани€ и восстановлении повреждений с помощью хирургического вмешательства. –аннее обнаружение заболевани€ с помощью современных средств может значительно сократить вред, который может быть нанесЄн суставам и другим ткан€м.

 лассификаци€

I —тадии клинических про€влений

  • очень ранн€€: длительность до 6 мес€цев;
  • ранн€€: 6-12 мес€цев;
  • развернута€: более года;
  • поздн€€: более двух лет.

II јктивность болезни (DAS28)

  • 0 (ремисси€): DAS28 меньше 2,6;
  • 1 (низка€): DAS28 2,6-3,2;
  • 2 (средн€€): DAS28 3,2-5,1;
  • 3 (высока€): DAS28 больше 5,1.

III »нструментальна€ характеристика

  • Ќаличие эрозии;
  • –ентгенологическа€ стади€ (1-4).

IV »ммунологическа€ характеристика

  • –евматоидный фактор: серо-позитивный/серо-негативный;
  • јнти-÷÷ѕ: серо-позитивный/серо-негативный.

V ‘ункциональный класс

  • I сохранение самообслуживани€, непрофессиональной и профессиональной де€тельности;
  • II сохранение самообслуживани€, не профессиональной, нарушение профессиональной де€тельности;
  • III сохранение самообслуживани€, нарушение профессиональной и непрофессиональной де€тельности;
  • IV нарушение всех видов де€тельности.

ѕричины

ѕричины заболевани€ на сей день неизвестны. ¬ основе причин вли€ющих на развитие ревматоидного артрита лежат аутоиммунные нарушени€, преимущественно нарушени€ регул€ции синтеза ревматоидного фактора (представл€ющего собой антитела к иммуноглобулинам) и иммунокомплексными процессами, привод€щими к развитию синовиита, а в некоторых случа€х и генерализованного васкулита.

 освенные данные: увеличение количества лейкоцитов в крови и скорости оседани€ эритроцитов (—ќЁ)  указывают на инфекционную природу процесса. ѕолагают, что заболевание развиваетс€ в результате инфекции, вызывающей нарушени€ иммунной системы у наследственно предрасположенных лиц, при этом образуютс€ так называемые иммунные комплексы (из антител, вирусов и проч.), которые откладываютс€ в ткан€х и привод€т к повреждению суставов.

 ак и дл€ большинства аутоиммунных заболеваний, здесь можно выделить 3 основных фактора (ревматологическа€ триада):

1. √енетическа€ предрасположенность:

  • наследственна€ склонность к аутоиммунным реакци€м;
  • чаще встречаетс€ у носителей определенного антигена класса MHC II: HLA  DR1, DR4.

2. »нфекционный фактор, гипотетические триггеры ревматических заболеваний:

3. ¬первые может про€витьс€ после т€жЄлой физической нагрузки, эмоционального шока, утомлени€, в период гормональной перестройки, воздействи€ неблагопри€тных факторов или инфекции. “аким образом, имеет место быть пусковой фактор:

  • переохлаждение;
  • гиперинсол€ци€;
  • интоксикации;
  • мутагенные медикаменты;
  • эндокринопатии;
  • стрессы и т. д.). 

Ћ. Ўапиро, ј. ƒжонсон, ‘. јлександер доказали роль эмоций в развитии болезни. »х исследовани€ позвол€ют сказать, что к ревматоидному артриту в большей степени подвержены излишне эмоционально сдержанные люди, посто€нно скрывающие свои чувства. Ёта теори€ действительно подтверждаетс€ наукой: при стрессе гормональна€ система отвечает выбросом в кровь гормонов стресса, повыша€ веро€тность запуска аутоиммунной реакции организма против собственных суставов.

ƒл€ женщин длительность кормлени€ грудью снижает веро€тность развити€ ревматоидного артрита.  ормление грудью в течение 24 мес€цев и дольше понижает риск развити€ заболевани€ вдвое.

 ак развиваетс€ болезнь

¬не зависимости от провокаций, приведшим к началу заболевани€, всегда ревматоидный артрит сопровождаетс€ сбоем в работе иммунной системы. »ммунные клетки атакуют суставы, "дума€" что это чужеродные агенты и разрушают их.  роме того, лимфоциты выдел€ют медиаторы воспалени€  вещества, способные проникать в сустав и также уничтожать некоторые его ткани.

»з всех видов артритов, наиболее сильно синовиальна€ оболочка поражаетс€ именно при ревматоидном артрите, особенно в примыкающих к хр€щам част€х. ќна отекает и гипертрофируетс€ (разрастаетс€). ѕо мере прогрессировани€ болезни, она может врастать в хр€щ, св€зки, кость, ослабл€€ весь сустав. —ам же сустав становитс€, деформируетс€, увеличиваетс€ в размерах и разрушаетс€, если не получит должного лечени€.

—имптомы

ѕри «классическом» ревматоидном артрите (его еще ошибочно называют ревматическим артритом) основные симптомы достаточно характерные:

1. ”тренн€€ скованность также характерна дл€ больных ревматоидным артритом

Ёто «ощущение затекшего тела», «тугого корсета на теле» или «тесных перчаток на руках», по словам самих пациентов. ”тренн€€ скованность в суставах или околосуставных област€х длительностью не менее 1 ч до максимального улучшени€ (в течение 6 нед и более). 

2. јртрит трЄх и более суставных областей

ѕрипухлость м€гких тканей или выпот (но не костные разрастани€), определ€емые врачом, в трЄх или более област€х из 14 следующих: проксимальных межфаланговых, п€стно-фаланговых, лучезап€стных, локтевых, коленных, голеностопных, плюснефаланговых суставов (в течение 6 нед и более).

3. јртрит суставов кистей

ѕрипухлость в области проксимальных межфаланговых, п€стно-фаланговых или лучезап€стных суставов (в течение 6 нед и более).

4. —имметричное поражение

ќдновременное (с обеих сторон) поражение одинаковых суставных областей из 14 названных (проксимальных межфаланговых, п€стно-фаланговых, лучезап€стных, локтевых, коленных, голеностопных, плюснефаланговых суставов) (в течение 6 нед и более).

5. ѕоражение суставов стоп

„асто параллельно с поражением суставов рук поражаютс€ мелкие суставы стоп, наход€щиес€ у основани€ пальцев и про€вл€ютс€ болью при нажатии на область «подушечек» пальцев ног. Ёти суставы также поражаютс€ симметрично.

6. –евматоидные узелки

ƒиагностика вы€вл€ет наличие подкожных узелков  это плотные образовани€ под кожей в области изгиба локтей, кистей, стоп размером в горошину. ќни расположенны над костными выступами, разгибательными поверхност€ми конечностей или околосуставными област€ми. Ёти узелки могут уменьшатьс€ в объеме, исчезать, по€вл€тьс€ снова или не мен€тьс€ годами. ќбычно они не причин€ют беспокойства и создают только косметический дефект.

7. –евматоидный фактор

ѕовышенный уровень –‘ в сыворотке крови (определение провод€т любым методом, дающим положительный результат не более чем у 5% здоровых людей).

8. ¬овлечение крупных суставов

ѕозже (через несколько недель или мес€цев), по мере прогрессировани€ ревматоидного артрита, воспал€ютс€ крупные суставы  коленные, плечевые, голеностопные, локтевые. ѕри некоторых разновидност€х ревматоидного артрита сначала воспал€ютс€ именно крупные суставы или п€точные сухожили€, после чего присоедин€етс€ поражение суставов стоп и кистей. ƒанна€ форма болезни характерна люд€м после 65-70 лет.

9. »нтоксикаци€ организма

ѕериодически возникающие симптомы интоксикации организма также нередко сопровождают болезнь. Ёто слабость, разбитость, ухудшение аппетита, озноб, повышение температуры тела до 38 °—, снижение массы тела.

10. —тойка€ деформаци€ всех суставов

–азвернута€ стади€ заболевани€ сопровождаетс€ возникновением стойкой деформации кистей и пальцев рук. „асто встречаетс€ ульнарна€ девиаци€: это €вление, при котором кисти рук и пальцы, отклон€ютс€ кнаружи, фиксируютс€ в неправильном положении, ухудшаетс€ подвижность в лучезап€стных суставах. »з-за этой патологии нарушаетс€ иннерваци€ и кровообращение кистей, они станов€тс€ бледными, мышцы атрофируютс€.

11.  иста Ѕейкера  так называетс€ симптом, при котором в капсуле коленного сустава скапливаетс€ излишн€€ жидкость, раст€гивающа€ ее.  огда этого экссудата слишком много, это может привести к разрыву кисты  жидкость пропитывает ткани задней поверхности голени, провоциру€ отек и болезненность этой области.

ѕризнаки ревматоидного артрита:

  • усталость, астеновегетативный синдром;
  • утренн€€ скованностьрук и ног, обычно, чем дольше длитс€ скованность, тем активней заболевание;
  • слабость;
  • похожие на грипп симптомы, включа€ невысокий жар;
  • боли при длительном сидении;
  • вспышки активности заболевани€, сопровождающиес€ ремиссией;
  • мышечные боли;
  • потер€ аппетита, депресси€, потер€ веса, анеми€, холодные и/или потные ладони и ступни;
  • нарушение работы слюнных и слезных желез, вызывающее недостаточную выработку слЄз и слюны.

ƒиагностика

ƒл€ диагностики ревматоидного артрита, вы€влени€ его причины, а, следовательно, правильного выбора назначаемого лечени€, необходимо комплексное обследование пациента. ¬се данные, полученные при обследовании, затем должны быть св€заны с клинической картиной заболевани€.

ƒолгое врем€ не существовало определЄнного теста который мог бы однозначно подтвердить наличие заболевани€. ¬ насто€щее врем€ диагностика заболевани€ основываетс€ на биохимическом анализе крови, изменени€х в суcтавах, видимых на рентгене, и на использовании основных клинических маркеров, к которым относ€тс€: суставной синдром как таковой, а также в сочетании с общеклиническими про€влени€ми  лихорадкой, слабостью, потерей веса и другими.

–азвитие субклинически протекающего иммунопатологического процесса происходит за много мес€цев (или лет) до по€влении очевидных признаков заболевани€. ѕо данным биопсии синовиальной оболочки, признаки хронического синовита вы€вл€ют уже в самом начале болезни не только и воспалЄнных, но и «нормальных» суставах. ” «условно» здоровых людей, в последующем заболевших ревматоидным артритом, обнаруживают различные иммунологические нарушени€, характерные дл€ –ј (увеличение уровн€ –‘, анти-÷÷ѕ антител, —–Ѕ), задолго до по€влени€ первых клинических симптомов заболевани€.

” 2/3 пациентов структурные изменени€ (эрозии) возникают очень быстро, уже в течение первых двух лет с момента начала болезни. ”становлено, что предотвращение структурных повреждений в дебюте –ј способствует сохранению функциональной активности пациентов в долговременной перспективе. ќднако промежуток времени, когда активна€ терапи€ Ѕѕ¬ѕ может эффективно затормозить прогрессирование поражени€ (так называемое «окно возможности»), весьма короткий и иногда составл€ет всего несколько мес€цев от начала болезни.

јнамнез

ѕри сборе анамнеза необходимо уточнить следующую информацию:

  • ѕродолжительность симптомов.
  • ƒлительность утренней скованности (дл€ –ј характерна длительность 1 ч и более, на ранней стадии болезни 30 мин и более).
  • Ќаличие суточного ритма боли в суставах с характерным усилением в ранние утренние часы.
  • —тойкость признаков поражени€ (6 нед и более).
  •  роме того, должны быть получены сведени€ о сопутствующей патологии, ѕредшествующем лечении, а также вредных привычках (курение, злоупотребление алкоголем и т.д.). Ёти данные могут повли€ть на выбор методов лечени€ ревматоидного артрита и отдаленного прогнозов.

‘изикальное обследование

ѕри физикальном обследовании суставов необходимо оценить следующие параметры:

  • ѕризнаки воспалени€ (припухлость, дефигураци€ за счет выпота, локальна€ гипертерми€ кожи).
  • Ѕолезненность при пальпации и движении.
  • ќбъЄм движений.
  • ¬озникновение стойкой деформации за счЄт пролиферации тканей, подвывихов, контрактур.

Ћабораторна€ диагностика ревматоидного артрита

÷ели проведени€ лабораторных исследований:

  • ѕодтверждение диагноза.
  • »сключение других заболеваний.
  • ќценка активности заболевани€.
  • ќценка прогноза.
  • ќценка эффективности лечени€.
  • ¬ы€вление осложнений заболевани€.

»зменении лабораторных показателей, вы€вл€емые при ревматоидном артрите:

  • јнеми€ (уровень гемоглобина менее 130 г/л у мужчин и 120 г/л у женщин). ѕоказатель активности заболевани€. јнемию вы€вл€ют в 30-50% случаев. ¬озникают любые формы анемий, но чаще всего анеми€ хронического воспалени€ и, реже, железодефицитна€ анеми€. ѕри обнаружении данного состо€нии необходимо исключить желудочно-кишечное кровотечение.
  • ”величение —ќЁ и уровн€ —–¬.  ритерий дл€ дифференциальной диагностики ревматоидного артрита и невоспалительных заболеваний суставов. ѕозвол€ет оценить активность воспалени€, эффективность лечени€, т€жесть заболевани€, риск прогрессировани€ деструкции.
  • √ипоальбуминеми€. „асто обусловлена нефротоксичностью препаратов, примен€емых дл€ лечени€ –ј.
  • ”величение уровн€ креатинина. ќбусловлено нефротоксичностью препаратов, примен€емых дл€ лечени€ –ј.
  • Ћейкоцитоз (тромбоцитоз, эозинофили€). ѕоказатель т€жЄлого течени€ –ј, часто с внесуставными (системными) про€влени€ми. ќтмечают сочетание с высоким уровнем –‘. —читают показанием дл€ назначени€ √ . ѕри вы€влении данного состо€ни€ необходимо исключить развитие инфекционного процесса.
  • Ќейтропени€. ѕризнак развити€ синдрома ‘елти.
  • ”величение уровн€ печЄночных ферментов. ѕоказатель активности заболевани€. »зменение также может быть обусловлено гепатотоксичностью препаратов, примен€емых дл€ лечени€, или св€зано с заражением вирусами гепатита ¬ или —.
  • ”величение уровн€ глюкозы. —в€зано с применением √ .
  • ƒислипидеми€. —в€зана с применением √ , но может быть обусловлена активностью воспалени€.
  • ”величение уровн€ –‘. ¬ы€вл€ют у 70-90% пациентов. ¬ысокие титры в дебюте заболевани€ коррелируют с т€жестью, быстротой прогрессировани€ патологического процесса и развитием системных про€влений. ќднако динамика титров не всегда отражает эффективность лечени€. “ем не менее уровень –‘ недостаточно чувствительный и специфичный маркЄр ранней стадии –ј (в дебюте вы€вл€ют примерно у 50% пациентов). —пецифичность низка€ также у лиц пожилого возраста.
  • ”величение уровн€ анти-÷÷ѕ антител. Ѕолее специфичный маркЄр –ј, чем уровень –‘. ”величение титров и –‘, и анти-÷÷ѕ антител позвол€ет диагностировать –ј с более высокой чувствительностью и специфичностью, чем увеличение уровн€ только одного из этих показателей. ќбнаружение анти-÷÷ѕ антител считают критерием дл€ дифференциальной диагностики –ј на ранней стадии с другими заболевани€ми, протекающими с полиартритом (первичный синдром Ўегрена, — ¬, вирусный гепатит ¬ и — и др.).  роме того, по увеличению уровн€ анти-÷÷ѕ антител прогнозируют риск развити€ деструкции у пациентов с ранним –ј.
  • ”величение уровн€ јЌ‘. ¬ы€вл€ют в 30-40% случаев, обычно при т€жЄлом течении –ј.
  • ”величение уровн€ иммуноглобулинов (^—. ^ћ, 1&ј), концентрации компонентов комплемента. ÷» . »зменени€ неспецифичны, в св€зи с этим не рекомендуют использовать определение этих показателей в качестве рутинных исследований.
  • ќпределение Ќbј CD4. ћаркЄр т€жЄлого течени€ –ј и неблагопри€тного прогноза.
  • ¬ы€вление маркЄров вируса гепатита ¬, — и ¬»„. ¬ этом случае необходимо избегать назначени€ гепатотоксичных препаратов.
  • »зменени€ в ликворе (снижение в€зкости, рыхлые муциновые сгустки, лейкоцитоз (более 6-109л), нейтрофилез (25-90%). »сследование имеет вспомогательное значение. »спользуют дл€ дифференциальной диагностики –ј Ї другими заболевани€ми суставов. ¬ первую очередь микрокристаллическим и септическим воспалительными процессами.
  • »зменении и плевральной жидкости |белок более 3 г/л (экссудат), глюкоза более S ммоль/л, лактатдегидрогеназа более 1000 ед/мл, pH =7,0, титр –‘ более 1:320, уровень комплемента (—Ќ50) снижен, лимфоциты (нейтрофилы, эозинофилы)]. »сследование необходимо дл€ дифференциальной диагностики с другими «аболевани€ми лЄгких и плевры.

Ќеобходимо помнить, что лабораторные исследовани€, специфичные дл€ диагностики ревматоидного артрита, не разработаны.

»нструментальна€ диагностика ревматоидного артрита

»нструментальна€ диагностика имеет важное значение дл€ подтверждени€ диагноза и дифференциального диагноза ревматоидного артрита.

  • –ентгенологическа€ диагностика.

–ентгенографи€ кистей и стоп необходима дл€ подтверждени€ диагноза –ј, установлени€ стадии и оценки прогрессировани€ деструкции. ’арактерных дл€ –ј изменений в других суставах (по крайней мере, на ранних стади€х болезни) не наблюдают. ƒл€ оценки прогрессировани€ суставной деструкции по рентгенологическим признакам используют модифицированный метод Ўарпа и метод Ћарсена.

Ёксперты ≈вропейской антиревматической лиги рекомендуют метод ѕарсена, когда изменени€ оценивают несколько исследователей. ≈сли оценку деструкции проводит один специалист, лучше примен€ть модифицированный метод Ўарпа (более чувствительный).

  • ƒл€ вы€влени€ подвывиха в атланто-аксиальном сочленении или шейного спондилолистеза целесообразно выполнить рентгенографию шейного отдела позвоночника.
  • ƒопплеровска€ ультрасонографи€. Ѕолее чувствительный метод дл€ вы€влени€ синовита колена, чем рентгенографи€, но не дл€ диагностики синовита мелких суставов кистей и стоп.
  • ћ–“ диагностика. Ѕолее чувствительный метод вы€влени€ синовита в дебюте –ј, чем рентгенографи€. »зменени€, вы€вл€емые с помощью ћ–“ (синовит, отЄк и эрозии костной ткани) позвол€ют прогнозировать прогрессирование деструкции суставов (по данным рентгенологического исследовани€). ќднако сходные изменени€ иногда вы€вл€ют в клинически «нормальныхх« суставах, поэтому значение ћ–“ дл€ ранней диагностики и прогнозировани€ исходов –ј требует дальнейшего изучени€.  роме того, ћ–“ можно использовать дл€ ранней диагностики остеонекроза.
  •  “ диагностика. ƒл€ вы€влени€ поражений лЄгких целесообразно использовать  “ с высоким разрешением.
  • јртроскопи€. Ќеобходима дл€ дифференциальной диагностики ревматоидного артрита с виллезно-нодул€рным синовитом, артрозом, травматическими повреждени€ми сустава н др.
  • –ентгенографии органом грудной клетки. ѕримен€ют дл€ вы€влени€ и дифференциальной диагностики ревматоидного поражени€ органов грудной клетки с саркоидозом, опухол€ми пой локализации, туберкулЄзом и другими инфекционными процессами.
  • Ёзофагогастродуоденоскопи€. ¬ыполн€ют пациентам, получающим Ќѕ¬ѕ, и при вы€влении анемии.
  • Ёхо √. ѕримен€ют дл€ диагностики ревматоидного артрита, осложненным перикардитом и миокардитом, поражений сердца, св€занных с атеросклеротическим процессом.
  • Ѕиопси€. Ќа исследование берут образцы тканей (слизистой оболочки ∆ “, подкожного жирового слои, десны, почки и других органов) при подозрении на амилоидоз.
  • –ентгеновска€ абсорбциометри€. ћетод используют дл€ диагностики остеопороза. — его помощью определ€ют ћ√“ .

»сследование ћѕ  целесообразно при вы€влении следующих факторов риска развити€ остеопороза:

  • ¬озраст (женщины старше 50 лет, мужчины  60 лет).
  • ¬ысока€ активность заболевани€ (стойкое увеличение уровн€ —–¬ более 20 мг/л или —ќЁ более 20 мм/ч).
  • —оответствующий функциональный статус  стади€ по Ўтейнброкеру III-IV или значение индекса HAQ (Health Assessment Questionnaire) более 1.25.
  • ћасса тела менее 60 кг.
  • ѕриЄм √ .

„увствительность (при вы€влении трЄх из п€ти критериев) дл€ диагностики остеопороза при ревматоидном артрите составл€ет у женщин 76%, у мужчин  83%, а специфичность, соответственно 54 и 50%.

ѕоказани€ к консультации других специалистов

ѕациентам пожилого возраста, а также при вы€влении факторов риска развити€ кардиоваскул€рной патологии у пациентов любого возраста показана консультации кардиолога.

ѕри возникновении интеркуррентных заболеваний и осложнений болезни или лечени€ (инфекции, сахарный диабет, патологии почек с необходимостью (биопсии и прочее) необходима консультаци€ инфекциониста, гнойного хирурга, эндокринолога, нефролога, оториноларинголога и других специалистов. ѕри подозрении на развитие системных про€влений –ј, требующих верификации (склерит, неврологические про€влени€, поражение лЄгких), показана консультаци€ офтальмолога, невролога, пульмонолога. ƒл€ планировани€ протезировани€ или другого вида хирургического лечени€ приглашают хирурга-ортопеда.

ƒифференциальна€ диагностика

 руг заболеваний, с которыми необходимо дифференцировать ревматоидный артрит, весьма широк.

„аще всего необходимость в дифференциальной диагностике возникает в дебюте заболевани€ при поражении суставов в виде моно- и олигоартрита. ѕри этом необходимо, в первую очередь, обращать внимание на такие типичные признаки –ј, как симметричность артрита, преимущественное поражение суставов кистей с нарушением их функций, развитие эрозивного процесса в суставах кистей, обнаружение –‘ и, особенно, анти-÷÷ѕ антител.

Ћечение

Ћечение ревматоидного артрита назначает ревматолог, поскольку функциональное состо€ние больных, наход€щихс€ под наблюдением врача, лучше, а применение современных методов фармакотерапии ревматоидного артрита требует специальных знаний. Ќеобходимо информировать пациентов о характере заболевани€, побочных эффектах примен€емых лекарственных средств. ѕри по€влении соответствующих симптомов пациент должен немедленно прекратить приЄм препарата и обратитьс€ к врачу.

ѕри выборе лечени€ необходимо учитывать факторы риска неблагопри€тного прогноза и продолжительность периода между по€влением симптомов и началом приЄма препаратов.

  факторам неблагопри€тного прогноза, обусловливающим необходимость проведени€ более активного лечени€, относ€т следующие:

  • —еропозигивность по –‘ и анти-÷÷Ћ антителам в дебюте болезни.
  • ¬ысокую воспалительную активность.
  • ¬овлечение в патологический процесс многих суставов.
  • –азвитие внесуставных про€влений.
  • ”величение —ќЁ и уровн€ —–Ѕ.
  • ќбнаружение определЄнных аллелей HLA DR (0101, 0401, 0404/0408, 1402).
  • ќбнаружение эрозий в суставах в дебюте болезни.
  • ћолодой или пожилой возраст начала болезни.
  • ѕлохие социально-экономические услови€ жизни.

ѕри продолжительности заболевани€ более 6 мес€цев лечение должно быть более активным. 

 акие цели преследует лечение ревматоидного артрита?

  • ѕодавление симптомов артрита и внесуставных про€влений.
  • ѕредотвращение деструкции, нарушений функций и деформации суставов.
  • —охранение (улучшение) качества жизни пациентов.
  • ƒостижение ремиссии заболевани€.
  • —нижение риска развити€ коморбидных заболевании.
  • ”величение продолжительности жизни (до попул€ционного уровн€).

ѕоказани€ к госпитализации

ѕациентов госпитализируют в ревматологическое отделение в следующих случа€х.

  • ƒл€ уточнени€ диагноза и оценки прогноза.
  • ƒл€ подбора Ѕѕ¬ѕ в начале и на всЄм прот€жении болезни.
  • ѕри обострении –ј.
  • ѕри развитии т€жЄлых системных про€влений –ј.
  • ѕри возникновении интеркуррентного заболевани€, септического артрита или других т€жЄлых осложнений болезни или лекарственной терапии.

Ќемедикаментозное лечение ревматоидного артрита

¬ основе лечени€ ревматоидного артрита лежит мультидисциплинарный подход, основанный на использовании нефармакологических и фармакологических методов, привлечении специалистов других медицинских специальностей (ортопедов, физиотерапевтов, кардиологов, неврологов, психологов и др.).

ѕри отсутствии серьЄзных деформаций суставов пациенты продолжают работать, однако значительные физические нагрузки им противопоказаны. ѕациентам следует избегать факторов, которые потенциально могут провоцировать обострение болезни (интеркуррентные инфекции, стресс и прочее). –екомендуют прекратить курение и ограничить приЄм алкогол€.

ѕоддержание идеальной массы тела способствует уменьшению нагрузки на суставы и снижению риска летального исхода и развити€ остеопороза. ƒл€ этого необходимо соблюдать сбалансированную диету, включающую пищу с высоким содержанием полиненасышенных жирных кислот (рыбий жир, оливковое масло), фрукты, овощи. ”потребление этих продуктов потенциально уменьшает интенсивность воспалени€.

¬ажное значение имеют программы обучени€ пациентов (изменение стереотипа двигательной активности). Ћ‘ , специальные упражнени€ (1-2 раза в неделю), направленные на укрепление мышечной силы, физиотерапевтические методы (при умеренной активности –ј). ќртопедические методы направлены на профилактику и коррекцию типичных деформаций суставов и нестабильности шейного отдела позвоночника.

—анаторно-курортное лечение ревматоидного артрита рекомендуют только пациентам с минимальной активностью –ј или в стадии ремиссии.

Ќа прот€жении всего периода болезни необходима активна€ профилактика и лечение сопутствующих заболеваний, в первую очередь кардиоваскул€рной патологии.

—ледует особо подчеркнуть, что немедикаментозное лечение ревматоидного артрита оказывает умеренное и кратковременное действие. ¬ли€ние на прогрессирование заболевани€ не доказано. ќписанные меропри€ти€ повышают эффективность симптоматической терапии и помогают в коррекции стойких деформаций суставов.

ћедикаментозное лечение ревматоидного артрита

ѕоследние дес€тилети€ ознаменовались существенным прогрессом в расшифровке патогенетических механизмов развити€ –ј. Ќе случайно это заболевание рассматривают как своеобразную модель хронических воспалительных заболевании человека. »зучение –ј приобретает общемедицинское значение, поскольку создает предпосылки дл€ совершенствовани€ фармакотерапии многих других заболеваний человека (атеросклероз, сахарный диабет типа 2, остеопороз), развитие которых также св€зано с хроническим воспалением.

ѕринципиально новым направлением медикаментозного лечени€ ревматоидного артрита стало формирование концепции «окна возможности» (window of opportunity). ќкно возможности  это период времени в дебюте болезни, когда лечение Ѕѕ¬ѕ (базисные противовоспалительные препараты) оказывает максимальный противовоспалительный и антидеструктивный эффект и улучшает прогноз. ”становлено, что у пациентов, рано начавших получать Ѕѕ¬ѕ, не наблюдают увеличени€ риска преждевременного летального исхода в отличие от больных –ј, не получавших Ѕ√¬ѕ. ѕрогноз у пациентов с т€жЄлым –ј, пролеченных Ѕѕ¬ѕ в начале болезни, такой же, как у пациентов с более благопри€тным вариантом течени€ заболевани€. ѕримечательно, что лечение Ѕѕ¬ѕ и, особенно, ингибиторами ‘Ќќ-а позвол€ет существенно снизить смертность от кардиоваскул€рных причин. а также затормозить развитие остеопороза, привод€щего к возникновению переломов костей скелета.

ƒл€ лечени€ ревматоидного артрита используют следующие группы лекарственных средств.

  • ЌЌѕ¬ (нестероидные противовоспалительные препараты):
    • неселективные;
    • селективные.
  • √люкокортикостероиды.
  • Ѕѕ¬ѕ (базисные противовоспалительные препараты).
  • —интетические препараты.
  • Ѕиологические препараты.

ќсновой лечени€ считают медикаментозную терапию Ѕѕ¬ѕ. Ћечение ревматоидного артрита следует начинать как можно раньше, желательно в течение первых 3 мес от начала болезни. “ерапи€ должна быть максимально активной и гибкой с изменением (при необходимости) схемы лечени€ в зависимости от динамики клинических симптомов и лабораторных признаков воспалени€. ѕри выборе Ѕѕ¬ѕ необходимо учитывать факторы риска.

Ћечение инфекционных осложнений

ƒл€ –ј характерно увеличение риска развити€ инфекционных осложнений с локализацией в кост€х, суставах, дыхательной системе и м€гких ткан€х.  роме того, многие препараты, примен€емые дл€ лечени€ заболевани€ (Ќѕ¬ѕ, Ѕѕ¬ѕ и особенно √ ), могут увеличивать риск развити€ инфекционных осложнений. Ёто диктует необходимость тщательного мониторинга и активного раннего лечени€ инфекционных осложнений.

‘акторами риска развити€ инфекций при –ј считают:

  • пожилой возраст;
  • внесуставные про€влени€;
  • лейкопению;
  • коморбидиые заболевани€, включа€ хронические заболевани€ лЄгких и сахарный диабет;
  • лечение √ .

ѕациенты — –ј очень подвержены развитию септического артрита.   особенност€м септического артрита при –ј можно отнести поражение нескольких суставов и типичное течение у больных , получающих глюкокортикостероиды.

Ћечение кардиоваскул€рных осложнений у пациентов с –ј (включа€ недифференцированный артрит) выше риск развити€ кардиоваскул€рных заболеваний (острого »ћ, инсульта), поэтому они должны пройти обследование дл€ оценки риска возникновени€ данной патологии.

’ирургическое лечение ревматоидного артрита

’ирургическое лечение ревматоидного артрита считают основным методом коррекции функциональных нарушений на поздней стадии болезни. ѕрименение на ранней стадии –ј в подавл€ющем большинстве случаев нецелесообразно ввиду широких возможностей лекарственной терапии. ¬ развернутой стадии болезни необходимость применени€ хирургического лечени€ определ€ют индивидуально при установлении показаний.

ѕоказани€ к операции:

  • —давление нерва вследствие синовита или теносиновита.
  • ”грожающий или совершившийс€ разрыв сухожили€.
  • јтланто-аксиальный подвывих, сопровождающийс€ по€влением неврологи ческой симптоматики.
  • ƒеформации, затрудн€ющие выполнение простейших повседневных действий.
  • “€жЄлые анкилозы или дислокации нижней челюсти.
  • ¬озникновение бурситов, нарушающих работоспособность пациента, а также ревматических узелков, имеющих тенденцию к изъ€звлению.

ќтносительные показани€ к операции:

  • –езистентные к лекарственной терапии синовиты, теносиновиты или бурситы.
  • ¬ыраженные боли в суставах.
  • «начительное ограничение движении в суставе.
  • “€жЄла€ деформаци€ суставов.

Ёндопротезирование  основной метод лечени€ при деформаци€х тазобедренного и коленного суставов, а также суставов пальцев кисти. ѕримен€ют также синовэктомию (в последнее врем€ провод€т преимущественно в мелких суставах) и теносиновэктомию. јртроскопическа€ синовэктоми€ получает всЄ большее распространение, однако и отдаленные результаты ещЄ не изучены. ¬ыполн€ют резекции костей, артропластику (примен€ют в основном на суставах стол) јртродез может быть методом выбора при т€желой деформации голеностопного первого плюснефалангового и лучезап€стного суставов.

ѕримерные сроки нетрудоспособности

¬ременна€ нетрудоспособность может наступать при –ј с умеренной и высокой активностью и сохран€тьс€ на период развити€ клинического эффекта от медикаментозного лечени€. ѕациенты тер€ют трудоспособность и выход€т на инвалидность из-на нарушени€ функций суставов в течение первых 5 лет болезни в 50% случаен. ѕри длительности болезни более 15 лет инвалидами групп I и II признают 80% пациентов.

–аннее активное лечение ревматоидного артрита, включающее применение биологических агентов, позвол€ет существенно сократить сроки временной нетрудоспособности и количество инвалидизированных пациентов.

ѕрогноз

ќчевидно, что ревматоидный артрит  €ркий пример заболевани€, при котором отдалЄнный прогноз во многом зависит от того, насколько рано была проведена правильна€ диагностика и начата активна€ фармакотерапи€. ¬ этом отношении –ј в определЄнной степени напоминает такие заболевани€, как сахарный диабет и артериальную гипертензию.

“аким образом, одна из причин неблагопри€тного прогноза при –ј дли тельный период времени между началом болезни и поступлением пациента под наблюдение ревматолога. ќчевидно, что важный фактор, способствующий улучшению прогноза у пациентов на ревматоидный артрит, активна€ диагностика этого заболевани€ на поликлиническом этапе врачами общей практики.

¬ конце XX в. в среднем около половины пациентов тер€ли трудоспособность в течение первых 10 лет, к 15-му году болезни примерно 80% пациентов становились инвалидами групп I и II. ” больных –ј наблюдали уменьшение продолжительности жизни по сравнению с общей попул€цией на 5-10 лет. —амыми распространЄнными причинами смерти были кардиоваскул€рные заболевани€ (инсульт, острый инфаркт миокарда), возникновение которых св€зывают с интенсивным развитием атеросклероза и склонностью к тромбозам вследствие хронического иммунного воспалени€. Ќередко наблюдали летальные исходы по причине вторичного амилоидоза. сопутствующих инфекций (пневмонии, нагноени€ м€гких тканей и др.).

—овременное активное лечение, особенно н ранней стадии ревматоидного артрита, позвол€ет существенно улучшить результаты по сохранению трудоспособности, достичь клинической ремиссии у 40-50% пациентов, довести ожидаемую продолжительность жизни до попул€ционного уровн€.

„то должен знать пациент о лечении ревматоидного артрита?

–евматоидный артрит  аутоиммунное заболевание. ƒли него характерно развитие эрозивного артрита и системное поражение внутренних органов. —имптомы обычно бывают стойкими и в отсутствие лечении неуклонно прогрессируют.

ћедикаментозную терапию считают основным методом лечени€ –ј. Ёто единственный способ, позвол€ющий затормозить развитие воспалительного процесса и сохранить подвижность в суставах. ƒругие методы лечени€: физиотерапи€, диета, Ћ‘  имеют вспомогательное значение и не способны оказать существенное вли€ние на течение болезни.

¬ основе лечени€ –ј лежит применение Ѕѕ¬ѕ.   ним относ€т большое число разнообразных по химической структуре и фармакологическим свойствам лекарственных средств, таких как метотрексат, лефлуномид, сульфасалазин и т.д. »х объедин€ет способность в большей или меньшей степени и за счЄт различных механизмов подавл€ть воспаление и (или) патологическую активацию иммунной системы. Ќовым методом лечени€ –ј считают применение так называемых биологических агентов. Ѕиологические агенты (не путать с биологически активными добавками)  это белковые молекулы, избирательно воздействующие на отдельные вещества или группы клеток, участвующие в процессе хронического воспалени€.   биологическим препаратам относ€т инфликсимаб, ритуксимаб, адалимумаб.

–евматоидный артрит лечение обычно начинают с назначени€ метотрексата или лефлуномида. Ѕиологические агенты (инфликсимаб, адалимумаб и ритуксимаб), как правило, добавл€ют к этим препаратам при недостаточной эффективности ионотерапии. Ѕыстрый противовоспалительный эффект могут давать √ . Ќѕ¬ѕ представл€ют собой важный компонент лечени€ –ј, поскольку могут уменьшить боль и скованность в суставах. Ќаиболее часто примен€ют диклофенак, нимесулид, мелоксикам, кетопрофен, целекоксиб.

–евматоидный артрит лечение лекарствами может давать очень хорошие результаты, но требует тщательного контрол€.  онтроль должен проводить квалифицированный специалист-ревматолог и сам пациент. ѕациенту необходимо посещать врача не реже чем 1 раз в 3 мес в начале лечени€. ѕомимо осмотра, назначают анализы крови, ежегодно провод€т рентгенологическое исследование суставов дл€ оценки течени€ заболевани€. 

 
–едакци€ портала
04 окт€бр€ 2013, 23:19
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