ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. №170

The publication of a new revision (ICD-11) is planned by WHO in 2017 2018.

With amendments and additions by WHO.

Processing and translation of changes © mkb-10.com

Rheumatoid arthritis codes in the International Classification of Diseases

The most important thing in the diagnosis and treatment of any disease is to make the correct diagnosis. Understanding the causes and knowing the symptoms helps the doctor assess the situation and make a decision on the tactics of therapy, which is especially important with a wide variety of diseases in humans. The International Classification of Diseases 10th Revision (ICD-10) is not only disease statistics, but also a real assistant to the doctor in daily work. Rheumatoid arthritis is classified under Arthropathy and is a type of disease that affects the peripheral joints. There are a lot of different types of pathological processes associated with inflammation. To easily navigate among this variety, the specialist uses a convenient and detailed classification that takes into account all the nuances of joint diseases.

Arthropathy options

Articular diseases that mainly affect the limbs include the following types of pathology:

• infectious (in ICD-10 they have the code M00-M03);
• inflammatory pathology of the joints (M05-M14);
• arthrosis (M15-M19);
• other joint lesions (M20-M24).

Rheumatoid arthritis is included in the group "Inflammatory arthropathies", which indicates the nature of the disease and helps the doctor to correctly assess the causative factor of articular pathology.

Disease coding

The defeat of the joints by rheumatism manifests itself in a variety of ways, being the cause of diseases of the internal organs and forming complex syndromes. The doctor needs to choose the correct code in the ICD-10 in order to carry out effective treatment, taking into account the possible damage not only to the joints, but also to other organs and systems of the human body. At the preliminary examination stage, a specialist can use a code that does not accurately indicate a specific disease, but as new diagnostic information is received, the diagnosis is corrected.

Table. ICD-10 code for various variants of rheumatoid joint disease

In the ICD-10, codes M07-M14 encode numerous joint diseases caused by any factors other than rheumatism. Their use involves identifying the exact causes and detecting typical symptoms of pathology.

For any type of joint disease, the doctor can find the appropriate ICD-10 code. It is important to conduct a complete diagnosis and identify the underlying causative factor of the disease in order to accurately determine the code.

Significance of the ICD-10

The classification of diseases used by doctors all over the world makes it possible to accurately account for all cases of severe articular pathology associated with rheumatic disease. Thanks to this, specialists in different countries can learn and adopt the experience of other doctors, better understand the causes of inflammatory arthropathy and use advanced therapies. Rheumatoid arthritis requires a careful approach to examination and treatment, because this problem can become the basis for severe complications and disability of a person.

ICD-10 - generally accepted international classification of diseases

Having determined the diagnosis, the doctor will prescribe treatment. Rheumatoid arthritis should be treated comprehensively, providing a therapeutic effect with drugs, the action of which is aimed at removing pain and improving joint mobility. It is necessary to accurately and consistently follow the recommendations of a specialist in order to get rid of problems in the present and prevent complications in the future. This is especially important in the complicated course of articular disease, when there is damage to internal organs. The main factor of treatment is basic therapy prescribed for a long time. Be sure to use symptomatic treatment. The effectiveness of therapy will be much higher if therapeutic measures are started as early as possible, before external changes in small joints. That is why timely examination and correct diagnosis in accordance with ICD-10 is the best way to prevent complicated forms of the disease.

Classification of rheumatoid arthritis according to ICD 10

Here you will learn:

To facilitate the coordination of doctors and medical staff, a unified international classification has been developed, which is periodically updated with the discovery of new diseases. How is rheumatoid arthritis classified by ICD 10? What codes are assigned to certain varieties of this joint pathology? And what are the principles for diagnosing certain types of rheumatoid arthritis?

Objectives of the ICD-10

The full rubricator of the international classification of diseases of the tenth revision includes all currently known types of diseases, with each pathology assigned a specific alphanumeric code. It is required in order to simplify the electronic processing of information, speed up the process of compiling and issuing statistics, and also facilitate the coordination of medical staff at the highest and middle levels.

This careful division into subspecies allows for a more accurate diagnosis for the patient, as a result of which people with similar symptoms may belong to different diagnostic groups. A refined diagnosis makes it possible to prescribe and carry out more effective treatment, which is selected according to individual examination results, the nature of the disease and its uncharacteristic signs.

The affiliation of rheumatoid arthritis with the ICD 10 code to one or another variety allows you to complete the picture of the symptoms of the disease, because the set of characteristic manifestations of severe systemic inflammation in patients may differ. The main symptoms of rheumatoid arthritis include:

• general weakness and fever;
• changes in the structure of cartilaginous and bone tissues, which are accompanied by pain;
• joint mobility disorders, expressed in a change in gait, the inability to perform grasping movements with fingers, etc .;
• swelling and redness in the problem area.

Varieties and codes of rheumatoid arthritis according to ICD 10

Rheumatoid arthritis is represented by a wide list of varieties, so there are several groups of this pathology.

Code M-05 with an additional digital index assigned to:

• Felty's syndrome - M-05-0 - a complication that includes a triad: arthritis, splenomegaly (an increase in the volume of the spleen) and agranulocytosis (a decrease in the number of ranulocytes in the blood, which leads to a decrease in immunity);
• arthritis with lung tissue damage - M-05-1;
• vasculitis (chronic skin lesions) - M-05-2;
• complications of other internal organs - M-05-3;
• other varieties of seropositive rheumatoid arthritis - M-05-8;
• unspecified seropositive arthritis - M-05-9.

Code M-06 received seronegative varieties of rheumatoid arthritis, in which the rheumatic factor is not detected:

• Still's disease in patients of mature age - M-06-1 - an inflammatory disease with lesions of the skin, the nature of which has not been fully established;
• bursitis - M-06-2 - inflammation of the synovial joint bag;
• "nodules" - M-06-3 - subcutaneous neoplasms in the area of ​​joints affected by rheumatoid arthritis;
• rheumatoid arthritis - M-06-4 - inflammatory processes occur simultaneously in several joints;
• other varieties of seronegative arthritis - M-06-8;
• unspecified seronegative arthritis - M-06-9.

Juvenile (juvenile) rheumatoid arthritis according to the ICD received the M-08 code, and its varieties:

• ankylosing spondylitis (Bekhterev's disease) - M-08-1 - damage to the spine and sacroiliac joints;
• systemic - M-08-2 - a large-scale pathology that captures the joints, skin and internal organs;
• seronegative polyarthritis - M-08-3 - damage to a group of joints.

Principles of diagnosis of rheumatoid joint damage

It is customary to distinguish several clinical stages of the course of chronic autoimmune pathology:

• preliminary - the onset of the disease was recorded less than six months ago;
• early - the disease attacks the joints and the body on average from six months to a year;
• extended - the disease has been observed for more than a year, while the typical symptoms of rheumatoid arthritis persist at all stages of observation;
• late - the disease was diagnosed two years ago or more, while the patient has joint destruction and complications appear.

According to X-ray examinations, magnetic resonance imaging and ultrasound studies, a non-erosive or erosive nature of the pathology is established.

In addition, X-rays allow you to assign a particular stage to rheumatoid arthritis:

• Stage 1 - periarticular osteoporosis is detected on x-rays;
• Stage 2 - an obvious narrowing of the joint space, a few erosions are added to osteoporosis;
• Stage 3 - there is an increase in the number of erosions plus articular subluxations occur;
• Stage 4 - all of the above manifestations are supplemented by bone ankylosis (immobility of the joint due to deformation and growth of bone tissues).

In addition, the ICD-10 code for rheumatoid arthritis is supplemented by indicators of disease activity, which, in accordance with international standards, is calculated using the DAS28 index after assessing the condition of 28 joints.

The list of required tests includes:

• general analysis of blood and urine;
• microreaction;
• analysis of feces for the content of latent blood cells;
• activity of liver enzymes;
• analysis to determine the amount of urea, protein, glucose, cholesterol, etc.;
• tests for the presence of rheumatoid factor;
• determining the amount of C-reactive protein;
• activity of antibodies to cyclic citrullinated peptide.

The chronic nature of rheumatoid arthritis will cause patients to regularly bypass screenings, including doing:

• X-ray of OGK (chest organs),
• fluorography,
• radiography of the hands and pelvic bones,
• gastroscopy,
• Ultrasound of the abdominal organs.

Careful laboratory studies allow to exclude other types of diseases, confirm the diagnosis and assign an ICD-10 code to rheumatoid arthritis, assess the activity of the disease and its prognosis, as well as identify the effectiveness of ongoing therapy and timely detect side effects from both the disease itself and the treatment.

Rheumatoid arthritis

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)

Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan

general information

Short description

Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan

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

M05 Seropositive rheumatoid arthritis;

M06 Other rheumatoid arthritis;

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 Adult Still's disease;

M06.9 Rheumatoid arthritis, unspecified

APP - Russian Association of Rheumatologists

ACCP - antibodies to cyclic citrullinated peptide

DMARDs - basic anti-inflammatory drugs

VAS - Visual Analogue Scale

GIBP - genetically engineered biological preparations

GIT - gastrointestinal tract

STDs - sexually transmitted diseases

drugs - medicines

MRI - magnetic resonance imaging

NSAIDs - non-steroidal anti-inflammatory drugs

OSS - general health

RA - rheumatoid arthritis

RF - rheumatoid factor

CRP - C-reactive protein

Ultrasound - ultrasonography

FK - functional class

NPV – number of swollen joints

ECHO KG - echocardiogram

Protocol users: rheumatologists, therapists, general practitioners.

Classification

1. Seropositive rheumatoid arthritis (M05.8).

2. Seronegative rheumatoid arthritis (M06.0).

1. Felty's syndrome (M05.0);

2. Still's disease in adults (M06.1).

3. Probable rheumatoid arthritis (M05.9, M06.4, M06.9).

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 with typical RA symptoms.

4. Late stage: the duration of the disease is 2 years or more + severe destruction of small (III-IV X-ray stage) and large joints, the presence of complications.

2. Low (DAS28=2.6-3.2).

3. II - medium (DAS28=3.3-5.1).

1. Rheumatoid nodules.

2. Cutaneous vasculitis (necrotizing ulcerative vasculitis, nail bed infarcts, digital arteritis, livedoangiitis).

3. Neuropathy (mononeuritis, polyneuropathy).

4. Pleurisy (dry, effusion), pericarditis (dry, effusion).

5. Sjögren's syndrome.

6. Eye damage (scleritis, episcleritis, retinal vasculitis).

The presence or absence of erosions [according to radiography, magnetic resonance imaging (MRI), ultrasound (ultrasound)]:

I - periarticular osteoporosis;

II - periarticular osteoporosis + narrowing of the joint space, there may be single erosions;

III - signs of the previous stage + multiple erosions + subluxations in the joints;

IV - signs of previous stages + bone ankylosis.

I class - the possibilities of self-service, non-professional and professional activities are fully preserved.

II class - the possibilities of self-service, non-professional occupation are preserved, the possibilities of professional activity are limited.

Class III - self-service opportunities are preserved, opportunities for non-professional and professional activities are limited.

Class IV - limited self-service opportunities for non-professional and professional activities.

1. Secondary systemic amyloidosis.

2. Secondary osteoarthritis

3. Osteoporosis (systemic)

5. Tunnel syndromes (carpal tunnel syndrome, compression syndromes of the ulnar, tibial nerves).

6. Subluxation in the atlanto-axial joint, incl. with myelopathy, instability of the cervical spine

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.

Modified stages of RA according to Steinbroker:

Stage I - periarticular osteoporosis, single small cystic enlightenments of bone tissue (cysts) in the subchondral section of the articular surface of the bone;

Stage 2A - periarticular osteoporosis, multiple cysts, narrowing of the joint spaces;

2B stage - symptoms of stage 2A of varying severity and single erosions of the 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.

To the rubric "Functional class". Description of characteristics. Self care - dressing, eating, personal care, etc. Non-professional activities - creativity and / or recreation and professional activities - work, study, housekeeping - are desirable for the patient, specific to gender and age.

According to the nature of the progression of joint destruction and extra-articular (systemic) manifestations, the course of RA is variable:

Prolonged spontaneous clinical remission (< 10%).

Intermittent course (15-30%): intermittent complete or partial remission (spontaneous or treatment-induced), followed by an exacerbation with involvement of previously unaffected joints in the process.

Progressive course (60-75%): increase in joint destruction, damage to new joints, development of extra-articular (systemic) manifestations.

Rapidly progressive course (10-20%): constantly high activity of the disease, severe extra-articular (systemic) manifestations.

Felty's syndrome - a symptom complex, including severe destructive damage to the joints with persistent leukopenia with neutropenia, thrombocytopenia, splenomegaly; systemic extra-articular manifestations (rheumatoid nodules, polyneuropathy, chronic trophic ulcers of the legs, pulmonary fibrosis, Sjögren's syndrome), a high risk of infectious and inflammatory complications.

Adult Still's disease is a peculiar form of RA, characterized by a severe, rapidly progressive articular syndrome in combination with generalized lymphadenopathy, maculopapular rash, high laboratory activity, significant weight loss, prolonged relapsing, intermittent or septic fever, RF and ANF seronegativity.

Arthritis mcb

Varieties of the disease of the musculoskeletal system

As a rule, arthritis worsens sharply - and this is how it differs, for example, from osteoarthritis. The disease manifests itself in sharp pains, which can intensify at rest or during movement.

Patients experience an increase in body temperature or skin over the affected joint. The joint swells, ceases to function in the usual mode.

His appearance is changing.

Why is the ICD code needed? It fits into the medical history after diagnosis. In the international classification, arthritis is assigned an index from M-00 to M-99. The number 10 next to the abbreviation means the tenth revision of this classification.

According to the flow time, they distinguish:

• acute arthritis - up to six months;
• protracted - up to a year;
• chronic - more than a year;
• recurrent - aggravated with a certain regularity.

There is a classification according to the type of affected joint:

• synarthrosis - pathology develops in a fixed connection of bones;
• amphiarthrosis - in a sedentary;
• diarthrosis - in a highly mobile.

With arthralgia, not only joints are involved in negative processes, but also muscles and ligaments, which can lead to their atrophy.

Rheumatoid arthritis

Three times more often than men, women suffer from rheumatoid arthritis, in which, along with damage to the small joints of the hands, pathologies of the eyes and lungs are observed. The formation of rheumatoid nodules is fixed (code M-06.3), as well as frequent insomnia. The code for this arthritis according to ICD 10 is M-05.

A variation of rheumatoid spondylitis is Still's syndrome, in which body temperature rises, inflammation appears on the skin, and lymph nodes increase. The code for Still's syndrome is I-00.

Features of rheumatoid spondylitis:

• women suffer more often - up to 75%;
• age of patients from 10 to 55 years;
• previous colds (tonsillitis, flu, etc.);
• the nature of the course of the disease - rapid progression;
• affects other organs - the heart, kidneys, lungs.

Reactive arthritis

Inflammatory pathology of the joints is the result of inflammation in influenza and certain types of infectious diseases (tuberculosis, intestinal infection, etc.).

). This type of arthritis rarely becomes chronic, and with proper treatment, it is usually mild.

The ICD code for reactive arthritis is M-00 and M-03.

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.

9. These are the main points into which the disease is subdivided.

In fact, each type has several sub-items. In the ICD 10 system, rheumatoid arthritis has a code from M05 to M99.

Rheumatoid arthritis is of several types:

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

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

Symptoms of reactive arthritis mkb 10

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

• inflammation of the joint capsule - swelling;
• affects at least 3 articular joints at the same time;
• the 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 the 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.

If you find an error, please select a piece of text and press Ctrl+Enter.

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

Such arthritis can be classified as gouty arthritis according to microbial 10. This will happen if the following is found in the medical history and during the tests:

• general metabolic disorders
• renal dysfunction
• failures in the system of water-salt balance
• polyarthritis

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

Gouty arthritis according to ICD 10 and its symptoms

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

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

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 symptoms of arthritis progresses and is of a classic nature. At this stage of development, the disease can be divided into 3 types.

1. There is inflammation of the mucous membrane of the eyes (may develop conjunctivitis).
2. Pain in the joints becomes stronger, while motor activity decreases. In the areas affected by the infection, noticeable redness and swelling appear.
3. The organs of the genitourinary system become inflamed.

The complexity of determining the specific type of arthritis is due to different signs of diseases. In some cases, the joints are affected symmetrically, while in others, asymmetrically. Some patients are concerned about one joint, and some - several at once.

Pain appears with all types of inflammatory pathology, but it can be of a different nature - from aching, aggravated by immobility of the joints (gouty and rheumatoid arthritis) or during movement, to acute, which can only be eliminated by strong painkillers.

The degree of swelling can also be different - from slight to severe, as with gout. During the examination, changes in the physiologically correct location of the articulation, ligament instability, muscle hypertonicity are detected.

In the process of palpation, the following is revealed:

• the place of localization of pain;
• characteristic crunch with slight movements of the joints;
• increase in skin temperature.

To assess the degree of limited movement of the joints, the patient is asked to perform a series of simple exercises. With an asymmetric lesion, disturbances in the work of the motor function will be especially obvious.

In addition, a person tries to keep the joint motionless in order to reduce pain, which leads to gait disturbances or stiffness in movements (does not bend the elbow to the end, holds the head unnaturally, etc.).

For diagnostics, the following instrumental types of examinations are used:

• x-ray;
• Magnetic resonance imaging;
• bone scintigraphy;
• NMR spectroscopy;
• ultrasound examination of the joints;
• arthroscopy.

One of the laboratory tests is the puncture of the synovial fluid, which becomes cloudy with arthralgia, its viscosity decreases. It also has a low glucose content.

In addition, a biochemical blood test is done and immunological studies are carried out.

It is worth remembering that the course of treatment is determined only by a doctor. Depending on the diagnosis, medications may be prescribed, primarily anti-inflammatory non-steroids.

With rheumatoid inflammation, blood purification is sometimes carried out.

Traditional methods of treatment during remission also include physiotherapy, phono- and electrophoresis.

An effective preventive measure is sanatorium treatment with the restoration of the body in institutions specializing in inflammatory pathologies of bone tissues of various nature.

The International Classification of Diseases simplifies the coordination of all doctors and medical staff who work with the patient. For patients, the codes are just incomprehensible numbers in the medical history, because it is much more important for them to receive qualified help and cure the disease they have discovered.

Today, to confirm whether a patient really has reactive arthritis, a whole range of laboratory tests is needed. Various specialists are involved in the examination of the patient.

It is necessary 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 with the destruction of the infectious focus, that is, the causative agents of the original disease. To do this, you need to undergo a comprehensive examination of the whole organism.

After determining the pathogen, sensitivity to drugs is established. A bacterial infection is treated with antibiotics.

The use of antibacterial drugs is recommended at the initial, most acute stage of the disease. In the future, their use becomes less effective. In some cases, symptomatic treatment is prescribed, in which non-steroidal drugs, such as ibuprofen, are used.

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

An important point in the preventive measures associated with reactive arthritis is to prevent infection of the bone tissue. To do this, you must adhere to the elementary rules of personal hygiene.

Avoid getting intestinal infections into the body, wash hands before eating and after going to the toilet, use individual cutlery. Pay attention to the need for a heat treatment process for food before consumption.

Using a condom during sexual intercourse will protect against urinary tract infections. Having a regular sexual partner will reduce the risk of the disease. All of the above methods will contribute to the prevention of the disease.

It is easier to prevent a disease than to treat it. In the event of the first signs of the disease, it is necessary to consult a doctor as soon as possible.

Diagnosis and treatment of the disease

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

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

ICD code 10 rheumatoid arthritis

The ICD-10 code for seropositive rheumatoid arthritis 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 the right side, then kidney pain may appear in the lumbar region. Code Seropositive rheumatoid arthritis 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 an injury. When I fell off the bike and broke my finger on my hand, at first I didn’t feel anything too much. Went on to ride. But in the morning it grabbed me specifically - the finger turned blue, swollen, it was impossible to touch it. with a fracture you wouldn't be running yesterday. contusion It's just a muscle problem. Give her at least a day to lie down, so that the inflammation does not go up.

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

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

• About the Medical Center - Mediaart If necessary, you will be given a sick leave. If you have headaches, back pain, neuralgia, sciatica, osteochondrosis - a neurologist ICD 10 code: M05-M14 INFLAMMATORY POLYARTROPATHIES. rheumatic fever (I00) rheumatoid arthritis. youthful (M08.
• Rheumatoid arthritis: causes, symptoms and treatment
• 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, 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 lifestyle. Joints hurt 5 Nov Joints hurt - help yourself. Do not miss the opportunity to do a good deed: click on the button from Facebook, Vkontakte or International Classification of Diseases ICD-10 - codes and codes of diagnoses and M03.0 Arthritis after meningococcal infection (a39.8)

The true 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 real-life stories that are impossible to keep silent about.

Today we have the Hermit Agafya Lykova in our studio. Everyone knows her firsthand! On all central channels, she began to flicker because of her unusual fate. Agafya Lykova is the only living representative of a family of Old Believers hermits. For many centuries this family managed to maintain longevity and perfect 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 all of Russia found out about Agafya, thousands of letters from viewers began to come to our program with a request: “Ask Agafya Lykova to tell some secret recipe of her family.” All letters were in the same way - everyone wanted to receive at least a small prescription that would help improve or maintain health. Well, if viewers ask, then you need to find out her recipes and the secrets of longevity. After all, thousands of Russians cannot be wrong - if they ask, then it will help!

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

Our editors, together with the operators, came to you in the taiga. It was "-29" outside, it was terribly cold, but you didn't care how much! You were standing in light clothes, with a scarf on your head and holding a yoke with two 10-liter buckets filled with water on one shoulder. And you, after all, are already 64 years old. We were amazed: in front of us stood an elderly woman who simply glowed with longevity and health.

When we entered the house, we saw that you were preparing some kind of cream-like mixture. 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 prescriptions are hundreds of years old and have been used by my entire generation. All of these recipes are included in this book.

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

Yes, of course, I suffered from many diseases, but I got rid of them very quickly, since I have my “family recipe book”. The last thing I was sick with was pain in my joints and back. The pains were terrible, and the dampness in the room only exacerbated my illness. Legs and arms did not bend and ached a lot. But I got rid of this disease in 4 days. I have a great-grandmother's recipe for this ailment. So be it, I will tell it to you, let the people get rid of ailments.

After these words, Agafya opened her old book with recipes and began to dictate the composition to us. Below we will talk about 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, the antlers of the Altai deer are the most valuable substance. which is extracted only once a year from deer antlers. They are mined only in one place, in the north-west of Siberia. In the spring, the Altai maral sheds its horns, and the locals go to search for them in the taiga. Based on maral antlers, I prepare 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 the Altai deer. Therefore, industrial production of antlers is impossible.

Thank you Agafia. Many Russians will now get rid of joint pain forever.

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

It's good that ancient recipes have been preserved! 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 it's just unrecognizable! Thank you for your channel!

Angelina | 20.09. - 04:57

Evgeniya | 22.09. - 23:21

How long does Artropant go? Pay immediately?

Ann | 25.09. - 20:30

Paying is easy, there are instructions and options. The cream went to Tyumen for 4 days! The wait was worth it, as I have been smearing for 5 days already. The bones hurt a lot, now they don’t bother at all! Thank you channel!

Baby mouse | 25.09. - 04:57

Is it good for overall health?

Elena | 27.09. - 23:29

I treat them for muscle pain. Improvement began already on the 2nd day. I highly recommend this cream to everyone!

Mary | 27.09. - 05:31

That's what folk medicine can do! To hell with drugs! Fortunately, the cream costs a penny, relative to the treatment itself!

Mkb 10 code reactive arthritis

Elizabeth · 10.09. 01:16:08

ICD code 10: m06 Other rheumatoid m06.9 Rheumatoid arthritis Pain in the groin? -. Traditional medicine Pain may not appear immediately, but gradually. You may be disturbed by pain in the groin, in the abdomen, a feeling of discomfort when walking and exercising. ICD-10: Diseases Code. Nosology Seropositive rheumatoid arthritis: m05.0: Syndrome

ICD-10: Diseases of the musculoskeletal system and Arthritis mkb 10 arthritis code for mkb 10, rheumatoid arthritis mkb how to quickly get rid of a clogged nose. \ Make an inhalation: put one tablet of validol and half a pipette of iodine on a liter cup of boiling water. Mix everything and breathe only through the nose until the water cools down. I even cured sinusitis in this way. Buy NAZOL and there are no problems if there is a lot of current blowing nose, splash a lot of water there or pour it and blow your nose. or a lot of sprays, there are drops. Cut off. Joke. Naphthyzin. Any vasoconstrictor sprays or drops. Nazol, nazivin, for the nose and many others. They work for several hours. They start working in a few minutes. Get rid of a stuffy nose? HM. was somewhere. And here, you take an ax, put 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 (ml) - 1-1.5 teaspoons of salt, close one of the nostrils and draw in water. do this procedure 2-3 times a day! + nose drops Get well soon! bake an onion head in the oven or in the microwave, cut it in half, wrap it in a towel, put it on the bridge of your nose until it cools down, squeeze the juice from the cooled onion, drip it into your nose. In 10 sessions, you can cure not only a clogged nose, even sinusitis. it is better to turn to a specialist, otherwise you can bring it 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 legs, mustard in your socks, or smear caviar with oil (alcohol) and hot tea with raspberries or hot milk. And in order to sleep with a stuffy nose and not suffer, lubricate the wings of the nose (externally.) with a drop of camphor oil or simply put a cotton swab moistened with camphor near the bed.

Pain in the jaw Dec 3 Headache, pain in the eyes, pain in the ears, pain in the face, pain in the jaw When the mouth is open, the head of the lower jaw is turned into the cavity

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

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

1. Arthritis code mkb 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 most insignificant, minimal physical exertion. fingertips are directed to the chin, elbows are directed to the sides. Rheumatoid arthritis The international RA code is rheumatoid arthritis. ICD-10

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

4. Pavlyuchenkova starred from Roland Garros - Tennis. Sports / 1 day before the end of the second round match against 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

Don't crunch!

treatment of joints and spine

• Diseases
  • Arothrosis
  • Arthritis
  • Bechterew's disease
  • Bursitis
  • Dysplasia
  • Sciatica
  • Myositis
  • Osteomyelitis
  • Osteoporosis
  • fracture
  • flat feet
  • Gout
  • Radiculitis
  • Rheumatism
  • Heel spur
  • Scoliosis
• joints
  • Knee
  • Brachial
  • Hip
  • Other joints
• Spine
  • Spine
  • Osteochondrosis
  • cervical
  • Thoracic
  • Lumbar
  • Hernias
• Treatment
  • Exercises
  • Operations
  • From the pain
• Other
  • muscles
  • Bundles

Rheumatoid arthritis ICD code 10

ICD 10 coding for rheumatoid arthritis

Arthritis classification according to ICD 10

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

A 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 body is established, but neither microorganisms nor antigens are detected in the joint; and "post-infectious arthropathy", in which the microbial antigen is present, but the recovery of the organism is incomplete and there is no evidence of local reproduction of the microorganism.

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

Reactive Arthritis Symptoms

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

1. The symptom complex of the disease included: symmetrical damage to the joints, the formation of deformities, contractures and ankylosis in them; development of anemia, enlarged lymph nodes, liver and spleen, sometimes the presence of febrile fever and pericarditis. In the subsequent years of the last century, numerous observations and descriptions of Still's syndrome revealed much in common between rheumatoid arthritis in adults and children, both in clinical manifestations and in the nature of the course of the disease. However, rheumatoid arthritis in children was still different from the disease of the same name in adults. In this regard, in 1946, the term "juvenile (juvenile) rheumatoid arthritis" was proposed by two American researchers Koss and Boots. Nosological separation 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 is distinguished by the following features:
3. Juvenile rheumatoid arthritis is a pathology that develops in children and adolescents under 16 years of age, in which not only the joints, but also other organs can be affected. A doctor can make a similar diagnosis if a child has arthritis that lasts more than 6 weeks. The disease does not occur very often. International statistics says that JRA is detected in 0.05-0.6% of children. Children under 2 years of age suffer from this disease extremely rarely. There are gender differences in the incidence rate among children. Arthritis is diagnosed more often in girls. The disease is steadily progressing.

Stages of development of the disease and the degree of destruction of the joint

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

Diagnosis and treatment of the disease

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

Pronounced edema from the very beginning of the disease

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

What causes juvenile rheumatoid arthritis?

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

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 coding for the diagnosis and definition of medical diseases. ICD 10 code - 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​​быстропрогрессирующий, медленнопрогрессирующий (оценка темпа развития деструктивных изменений в суставе при длительном наблюдении) ​

Staphylococcal arthritis and polyarthritis

How to treat rheumatoid arthritis?

RA with systemic manifestations (vasculitis, nephropathy).

Edema appears when inflammation is attached

According to 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.

The primary incidence rate is from 6 to 19 cases per 100,000 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 severe, with severe fever, joint syndrome, damage to the lymphatic system and sore throat. This pathology also occurs in adults.

There are currently 21 disease classes, each containing subclasses with disease and condition codes. 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 folk methods

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

Etiology and treatment of juvenile rheumatoid arthritis

Features of the disease

reactive - a complication that occurs with untreated (undertreated) infections; 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 a non-purulent inflammatory formation in the bone structure. In some cases, the disease occurs as a response to infectious diseases of the gastrointestinal tract (GIT), urinary tract and 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 medications, NSAIDs, cytostatics, hormonal agents, antibiotics, etc. are prescribed. The set of medications 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, increased 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 joints of the hand. Typical for juvenile rheumatoid arthritis is the defeat of the cervical spine and maxillotemporal joints, which leads to underdevelopment of the lower, and in some cases, the upper jaw and the formation of the so-called "bird's jaw".

Forms of the disease

Enlargement and soreness of the lymph nodes;

Possible etiological factors are:

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

Clinical symptoms

Chlorbutin (leukeran) - tablets of 2 and 5 mg

• drug
• Yes, but in the later stages of redness may not be
• Acute - develops after bruises, fractures, strong physical exertion;
• Symptoms of juvenile chronic arthritis
• hepatosplenomegaly;

the presence of a viral or bacterial infection;

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

• , any changes in the skin near the puncture site, tuberculosis of the joint, tabes of the spinal cord, aseptic bone necrosis, intra-articular fracture, subluxation of the joint. The following drugs are used (a full dose of drugs is injected into large joints, 50% into medium-sized joints, 25% into small ones): Methylprednisolone 40 mg Hydrocortisone 125 mg Betamethasone in the form of injections (celeston, flosteron, diprospan) Pulse therapy methylprednisolone leads to a rapid but short-term effect (3-12 weeks); not affecting the rate of progression of the process In order to prevent osteoporosis, people receiving GCs 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 interarticular spaces + single erosions, III - the same + multiple erosions, IV - the same + ankylosis H
• Other streptococcal arthritis and polyarthritis
• Alkylating cytostatic; forms alkyl radicals with DNA, RNA and proteins, disrupting their function; has an antiproliferative effect
• ​Operating principle​

Other manifestations

infectious - caused by viruses or a fungal infection that enters the joint with the blood stream, or through an unsterile 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 a thousand leukocytes) is often detected with a neutrophilic shift to the left (up to 25-30% of stab leukocytes, sometimes up to myelocytes), an increase in ESR domm / h, hypochromic anemia, thrombocytosis, an increase in the concentration of C-reactive protein , IgM and IgG in blood serum.
• anemia;
• traumatic joint injury;
• A characteristic feature of the course of the disease is the symmetry of joint damage
• ​Basic Therapy​
• Availability of functional ability:

• High RA activity with systemic manifestations, generalized lymphadenopathy, splenomegaly.
• ​Operating principle​
• Observed in the case of an autoimmune nature of the disease
• Reiter's syndrome is a type of reactive arthritis;
• Diagnosis of juvenile chronic arthritis
• myocardial damage;
• increased insolation;
• Reactive arthritis is severe. In the first week, the patient has a fever, disorders of the gastrointestinal tract (GIT), acute intestinal malaise, general weakness. In the future, the symptoms of arthritis progresses and is of a classic nature. At this stage of development, the disease can be divided into 3 types.
• ​Basic therapy should be given to all patients with reliable RA.​

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

Diagnostic measures

​Arthritis and polyarthritis caused by other specified bacterial pathogens Use an additional code if necessary to identify the bacterial agent (​

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

• Destination schemes
• No
• Arthritis in Bechterew's disease, gout (rare);
• Suppression of the inflammatory and immunological activity of the process.

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

Treatment tactics

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

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

Possible side effects

Juvenile rheumatoid arthritis

Symptoms of a stuck joint

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;
• Pain in the joints becomes stronger, while motor activity decreases. In the affected areas, noticeable redness and swelling appear.
• Hydroxychloroquine (200 mg 2 r / day or 6 mg / kg / day) is a frequent component of combination therapy for active, especially "early" RA. Monotherapy with hydroxychloroquine does not slow radiological progression. The term of the effect is 2-6 months. With long-term treatment, an annual ophthalmological examination, examination of the visual fields is necessary.
• 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" factors.​
• Due to the fact that the RA treatment regimens indicated in the table are not always effective, several combinations of basic drugs are used in practice, among which the combinations of methotrexate with sulfasalazine, methotrexate and delagil are the most common. Currently, the treatment regimen in which methotrexate is combined with anticytokines is considered the most promising.

Epidemiology of juvenile chronic arthritis

Quinoline drugs (delagil - tablets of 0.25 g)

Classification of juvenile chronic arthritis

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

Preservation of the functional ability of the joints.

Causes of juvenile chronic arthritis

In the subacute course of the disease, the symptoms are less pronounced. First, one joint is affected. Most often it is the ankle or knee joint. Both 1 joint and several can be affected. In the oligoarticular form of the disease, 2-4 joints are affected. Pain syndrome may not be. During a medical examination, swelling and dysfunction of the joint are determined. The movement of a sick child is difficult. The liver and spleen are of normal size. The subacute course proceeds more favorably and is better amenable to therapy.

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 dose to 2-3 g/day in 2 divided doses after meals. Taking into account the myelotoxicity of the drug with its long-term use, it is necessary to control the OAC every 2-4 weeks for the first 2 months, then every 3 months.

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

Symptoms of juvenile chronic arthritis

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

Diagnosis of juvenile chronic arthritis

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

Treatment goals for juvenile chronic arthritis

• The clinical picture differs from other types of arthritis, since the accompanying 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, swelling of the eyelids.
• ​Prevention or slowdown of joint destruction, 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, the symptoms may be mild, so the diagnosis is often difficult.
• Dysfunction of the immune system.
• Initially, the disease can affect only one knee joint, but later it can spread to other joints. A pronounced clinic can be insignificant 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 with 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. Apply at a dose of 10-20 mg / day. The effect develops after 4-12 weeks. Monitoring of toxicity involves monitoring the level of liver enzymes and TAC.​
• The pathological process in RA is based on generalized immunologically conditioned inflammation. In the early stages of the disease, Ag is detected - specific activation of CD4 + - T - lymphocytes in combination with hyperproduction of pro-inflammatory cytokines (tumor necrosis factor, IL - 1, IL - 6, IL - 8, etc. .) against the background of a deficiency of anti-inflammatory mediators (IL-4, a soluble antagonist of IL-1). IL - 1 plays an important role in the development of erosion. IL - 6 stimulates B - lymphocytes to the synthesis of RF, and hepatocytes - to the synthesis of proteins of the acute phase of inflammation (C - reactive protein, etc.). TNF-a causes the development of fever, pain, cachexia, is important in the development of synovitis (it promotes the migration of leukocytes into the joint cavity by enhancing the expression of adhesion molecules, stimulates the production of other cytokines, induces 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 the endogenous synthesis of HA - hormones. In 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 has been treated for six months using at least three basic drugs.

The initial stage of RA.

​Laboratory research methods​

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

Prevention of juvenile chronic arthritis

The main diagnostic methods are:

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 the development of the disease is associated with autoimmune disorders. When exposed to any adverse factor in the body of a child, special immunoglobulins are formed. In response to this, the synthesis of rheumatoid factor occurs. Joint damage occurs. In this case, the synovial membranes and blood vessels, cartilage tissue are affected. Not only the joints, but also the marginal parts of the bones (epiphyses) can be destroyed. The resulting circulating immune complexes are carried through the blood vessels to various organs. At the same time, 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 (eg, sodium aurothiomalate) are used to treat seropositive RA. Trial dose 10 mg IM, then 25 mg weekly, then 50 mg weekly. As the total dose of 1000 mg is reached, they gradually switch to a maintenance regimen of 50 mg 1 time in 2-4 weeks. The effect develops in 3–6 months. Among the side effects are myelosuppression, thrombocytopenia, stomatitis, proteinuria, therefore OAC and OAM are recommended to be carried out 1 time in 2 weeks.

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

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

Arthritis in children

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.

Symptoms of the disease

JRA classification 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, to confirm whether a patient really has reactive arthritis, a whole range of laboratory tests is needed. Various specialists are involved in the examination of the patient. It is necessary 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 refractory 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.

Pyogenic arthritis, unspecified. Infectious arthritis NOS

Degrees of dysfunction

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

Dyspeptic phenomena, skin itching, dizziness, leukopenia, retinal damage.

Do not reveal specific abnormalities

Arthrosis is a degenerative process in cartilage and bone tissue that occurs when there is a metabolic disorder, not associated with an inflammatory component. The main group of patients is the elderly (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 with the destruction of the infectious focus, that is, the causative agents of the original disease. To do this, you need to undergo a comprehensive examination of the whole organism. After determining the pathogen, sensitivity to drugs is established. A 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 (OAC every 2 weeks, then every 1–3 months).​
• Fatigue, subfebrile condition, 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) of the progression of articular changes during maintenance therapy with Remicade. However, the use of this form of treatment is justified if the basic therapy did not give the expected effect.

Sulfa drugs (sulfasalazine, salazopyridazine) - 500 mg tablets

Instrumental research methods

Differential Diagnosis

Arthritis is always inflammation, which 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, subfebrile temperature, headache, and general malaise. With rheumatoid arthritis, the cardiovascular system is seriously affected.

Treatment of juvenile chronic arthritis

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

Diagnosis of arthritis of the knee

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

Treatment is carried out only after diagnosis. It is required to exclude such diseases 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 in the process of joints;

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

Long-term outpatient observation.

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

Balneological therapy is a very effective procedure in a comprehensive program for the treatment of arthritis of the knee joint. However, this direction of rehabilitation is indicated for those patients who do not have serious diseases of the cardiovascular system, malignant neoplasms, and have not previously had heart attacks or strokes. 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.

Treatment

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

Treatment of juvenile rheumatoid arthritis includes restriction of motor activity, avoidance of insolation, use of NSAIDs to eliminate pain and inflammation, immunosuppressants, exercise therapy, physiotherapy.

• a slight increase in body temperature;
• Polyarthritis is understood as systemic multiple lesions of the joints, in which not only almost all types of joints become inflamed and destroyed, simultaneously or sequentially, but also other organ systems. Sometimes the result of a neglected form of polyarthritis can be disability. Rheumatoid polyarthritis can act as an independent disease as an infectious-nonspecific rheumatoid arthritis, and sometimes it is a consequence of other diseases - sepsis, gout, rheumatism. Even those who have bad teeth should be wary of the disease, but the word "dentistry" is unacceptable in the lexicon.
• Observation is carried out jointly with a specialist - a rheumatologist and a district (family) doctor. The competence of a rheumatologist includes making a diagnosis, choosing a treatment strategy, teaching the patient the correct regimen, and conducting intra-articular manipulations. General practitioners are responsible for organizing the systematic management of the patient; they also carry out clinical monitoring. During each visit, the patient is assessed: the severity of pain in the joints on a 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 varieties of arthritis and joint pathologies, it is necessary to consult a doctor at the first signs of the disease. The sooner the causes of the inflammatory process are determined, the more likely it is to cure the disease completely.

Anemia, an increase in ESR, an increase in CRP levels correlate with RA activity Synovial fluid is turbid, with low viscosity, leukocytosis is above 6000 / μl, neutrophilia (25-90%) RF (AT to IgG class IgM) is positive in 70-90% of cases ANAT, AT to Ro / La OAM (proteinuria as part of the nephrotic syndrome caused by amyloidosis of the kidneys or drug-derived glomerulonephritis) are detected in Sjögren's syndrome. An increase in creatinine, blood serum urea (assessment of renal function, a necessary stage in the selection and control of treatment).

The disease is not limited by age, but middle-aged women are diagnosed with this diagnosis somewhat more often than the representatives of the stronger half. An exception is infectious reactive arthritis, which is diagnosed mainly in older men (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 joints in the cervical spine are involved in the process. Articular syndrome is characterized by:

New methods

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

​Assess and infer rate of improvement (20%, 50%, 70%) using scores swollen joint scores tender joint scores of at least 3 out of 5 scores overall activity score according to the patient overall activity score according to the clinician patient score pain acute phase blood counts (ESR, CRP) disability (quantified using standardized questionnaires).​

Arthritis and movement. Gordon N.F.​

Rehabilitation programs

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

Arthritis of the knee joint can be diagnosed at home if you carefully examine the symptoms of the disease. Regardless of the etiology, symptoms such as swelling, redness in the joint area, general malaise, external signs of deformation of the articular tissue appear.

​Unlimited (any age)​

It is worth dwelling in more detail on rheumatoid arthritis (RA), which is an autoimmune disease with an unclear etiology. The disease is a common pathology - about 1% of the population suffers. Very rarely there are cases of self-healing, in 75% of patients there is a stable remission; in 2% of patients, the disease leads to disability.​

M08. Juvenile arthritis.

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

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

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 Humerus Elbow Bone

High clinical and laboratory activity of RA

However, one should not wonder how to treat arthritis of the knee joint on their 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.​

As a rule, older

With 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 is not the same - from several months to several years. Features of the clinical picture of one or another type of inflammation of the joints make it possible to suspect the disease and prescribe the necessary examinations to confirm the diagnosis. In accordance with ICD-10, RA is classified as seropositive (code M05), seronegative (code M06), juvenile (code MO8)

M08.0. Juvenile (juvenile) rheumatoid arthritis (seropositive or seronegative).​

swelling in the joint area;

The first stage is the suppression of the autoimmune process, which actually leads to the destruction of tissues, 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, they restore blood circulation, increase the efficiency of joints, and normalize metabolism. All these stages combine both medical and physiotherapeutic methods of treatment.​

INFECTIOUS ARTHROPATHY (M00-M03)

Physical therapy plays an important role. Sanatorium - resort treatment is recommended during the period 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 hour International Classification of Diseases Code ICD-10: 3 - bone, ulna Initial dose of 250 mg / day with a gradual increase to 500-1000 mg / day; maintenance dose - 150-250 mg / day

M00 Pyogenic arthritis

Physicians must determine the nature of the disease in order to prescribe adequate treatment. Orthopedic traumatologists, surgeons, rheumatologists give directions for laboratory and instrumental studies. The treatment regimen is developed by a specialized specialist (it can be a phthisiatrician, a dermatologist-venereologist, a cardiologist and other doctors). Nature of the process Some types of arthritis affect only children and adolescents, so they should be singled out in a separate row. M08.1. Juvenile (juvenile) ankydotic spondylitis. Painfulness; The basic treatment is the suppression of the autoimmune process through such drugs: methotrexate, sulfasalazine and leflunomide. In terms of minimizing side effects, the latter differs, 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 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, joint deformity gradually develops, which is no longer possible to correct.

M08.2. Juvenile (juvenile) arthritis with a systemic onset, a 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, nimesulide are widely used. All of them affect the gastrointestinal tract to a greater or lesser extent. Pregnancy improves the course of RA, however, after delivery, a relapse always occurs due to hyperprolactinemia. NSAIDs in the first trimester of pregnancy and 2 weeks before delivery are undesirable (in the first trimester - the risk of a teratogenic effect, before childbirth - the threat of developing 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 correlated with the possible risk. 3 joints or more

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

Arthritis rheumatoid, Diseases and treatment of folk and medicinal products. Description, application and healing properties of herbs, alternative medicine

• Always chronic

Arthritis rheumatoid: Brief description

Reactive childhood arthritis (ICD-10 code MO2) manifests itself two weeks after an intestinal infection. If the process develops in the knee joint, then external signs are clearly visible: the skin turns red, swelling without pronounced boundaries is visible under the patella. The child often has a fever, which is reduced by antipyretic drugs, but pain in the knee area remains. M08.3. Juvenile (juvenile) polyarthritis (seronegative). Dysfunction of the affected area of ​​the body. It happens that non-steroidal drugs are not able to alleviate the suffering of the patient, so the clinic decides on the use of glucocorticosteroid (GCS) drugs - hormones that can be injected directly into affected joint. GCS have a lot of side effects, but they are prescribed in short courses, which significantly reduces the risk.

​The factors for an unfavorable prognosis of RA include: seropositivity in the Russian Federation at the onset of the disease female gender young age at the onset of the disease systemic manifestations high ESR, significant concentrations of CRP carriage of HLA-DR4 early onset and rapid progression of erosions in the joints low social status of patients.

6 Calf Fibula Knee joint, bone, tibia Folic acid antagonist; inhibits the proliferation of T- and B-lymphocytes, the production of antibodies and pathogenic immune complexes. The third stage is radiography. In the presence of arthritis, a curvature of the articular surface, bone ankylosis is detected. Onset of the disease In addition to infectious, reactive, rheumatoid arthritis, children are often diagnosed with an allergic disease. The disease begins in a child suddenly - immediately after allergens enter the bloodstream. The joints quickly swell, there is shortness of breath, urticaria. Quincke's edema, bronchial spasm may develop. When the allergic reaction is eliminated, signs of arthritis disappear. M08.4. Pauciarticular juvenile (juvenile) arthritis. If juvenile arthritis affects the small joints of the fingers or toes, then deformity of the fingers is possible. In the articular form of arthritis, damage to the organs of vision is often observed. Iridocyclitis or uveitis develops. This may reduce visual acuity. The seronegative form of arthritis is more mild than the seropositive form. In the latter case, rheumatoid nodules are often detected in the area of ​​​​the joints. Modern medicine, which treats rheumatoid arthritis, uses new biological products that inhibit the activity of the protein. These drugs include etanercept (Enbrel), infliximab (Remicad), and adalimumab (Humira). They have significantly fewer side effects, and they give a positive result. Arthritis of the joints of the hands Symmetrical arthritis 7 Ankle Metatarsus, Ankle joint, tarsal joint and foot, other joints of the foot, toes RA with systemic manifestations , high activity of RA, low efficiency of other basic means. Fourth stage - MRI, ultrasound (assigned to differentiate arthritis from arthrosis, Bechterew's disease and bursitis). With erased signs that occur during a sluggish chronic process, additional hardware studies of the joint may be prescribed - tomography of the articular tissue, CT, pneumoarthrography. Acute, sudden Arthritis of the knee joint can develop as an independent disease, or be a complication after injuries and diseases .M08.8. Other juvenile arthritis. With this pathology, other important organs often suffer. With a systemic form of arthritis, there may be:

Statistical data

Arthritis rheumatoid: Causes

Etiology

genetic features

Pathogenesis

Rheumatoid Arthritis: Signs, Symptoms

Clinical picture

​8 Others Head, neck, ribs, skull, trunk, spine​​7.5-25 mg per week orally.​​At the same stage, joint puncture and synovial fluid collection for laboratory testing (biopsy if indicated) is indicated. Gradual (develops over months, years) Arthritis-affected knee joint swells, pain occurs when it moves. The skin in the joint area changes color (turns red or becomes "parchment"), but this is not a reliable sign of an inflammatory process. M08.9. Juvenile arthritis, unspecified. Exanthema; Folk methods cannot be the only treatment when it comes to polyarthritis. It is better to use them during the remission period, as they are more gentle in terms of side effects. In visible inflammation, chamomile baths have worked well. Arthritis Rheumatoid nodules RF Radiological changes Sensitivity - 91.2%, specificity - 89.3%. Rheumatoid

Arthritis rheumatoid: Diagnosis

Laboratory data

instrumental data

When determining the type and degree of reactive arthritis (ICD-10 code), biological material is examined (general blood and urine tests), urogenital and ophthalmological examinations are performed, a test for the presence of HLA-B27, ECG, thymol test, sial test, ALT determination, AST, culture of biological fluids.​​Symptoms​​The main cause of swelling and a visually noticeable increase in the patella is the accumulation of fluid inside the joint. Excessive pressure on the walls of the articular tissue causes severe pain. The volume of fluid steadily increases over time, so the pain syndrome becomes more intense. Juvenile rheumatoid arthritis is one of the most common and most disabling rheumatic diseases that occurs in children. The incidence of juvenile rheumatoid arthritis is from 2 to 16 people of the child population under the age of 16 years. The prevalence of juvenile rheumatoid arthritis in different countries is from 0.05 to 0.6%. Girls are more likely to get rheumatoid arthritis. Mortality is 0.5-1%. Kidney damage by the type of glomerulonephritis; Infusions of birch buds, tricolor violet, nettle, hernia are taken orally. They also use the collection of herbs, which includes wild rosemary, chamomile, string, cranberries, juniper (berries). This collection of half a cup three times a day before meals is very effective in exchange polyarthritis. early stages of RA, active therapy (NSAIDs at an adequate dose + basic drugs) should be started within the first 3 months after the diagnosis of definite RA. 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, and also as a temporary measure before the onset of the effect of basic drugs. Intra-articular administration of HA is intended for the treatment of synovitis in 1 or several joints, which complements, but does not replace, complex treatment. Arthritis Disorders predominantly affecting peripheral joints (limbs)

Arthritis rheumatoid: Methods of treatment

Treatment

General tactics

Mode

In addition, uric acid crystals, which look like thin needle-shaped spikes, are deposited in the joint. They injure small vessels, which is the basis for the development of associated infections. Adolescents have a very unfavorable situation for rheumatoid arthritis, its prevalence is 116.4 per (in children under 14 years old - 45.8 per), the primary incidence is 28, 3 per (in children under 14 years old - 12.6 per).​

Pericarditis; In the period of remission, pepper rubs with kerosene are also used. Such procedures not only relieve pain and inflammation, but also penetrate the blood, partially cleansing it. Both in the hospital and at home, cold treatment can be applied. In the hospital, cryosaunas are used - special cabins with chilled air, which are replaced at home with ice packs. After the procedure, which lasts about 10 minutes, the joints are massaged and kneaded. For one procedure, cooling is performed three times. Duration of treatment - 20 days.​

ICD-10 Patients should form a movement stereotype that counteracts the development of deformities (for example, to prevent ulnar deviation, open a tap, dial a phone number and other manipulations not with the right hand, but with the left hand).​​: polyarthritis, oligoarthritis, monoarthritis Rheumatoid Note Inhibition of the proliferative activity of T- and B-lymphocytes.

Despite the leading role of radiography in the diagnosis of arthritis, it must be remembered that in the early stages of the disease, pathological changes are not always visible in the pictures. Arthrography is of informative value for physicians in the study of large joints, and in case of polyarthritis this diagnostic method is not effective. Serological tests are used to identify the causative agent of arthritis of an infectious nature.

Manifested with changes in cartilage and bone tissue

Arthritis of the knee is difficult not only because of the intense pain syndrome, but also due to disruption of the functioning of functional systems. The cardiovascular and endocrine systems are particularly affected. There is shortness of breath, tachycardia, low-grade fever, sweating, circulatory disorders in the limbs, insomnia and other non-specific signs.

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

inflammation of the heart muscle;

Pay special attention to diet. Healers recommend a raw-food diet, especially the widespread use of eggplant in food. In any case, rheumatoid arthritis can be curbed without letting it spoil the patient's quality of life.

M05 Seropositive rheumatoid

RA with systemic manifestations.

Treatment of arthritis is a long process and requires not only the implementation of the doctor's recommendations regarding drug therapy, but also the passage of rehabilitation courses. Pain intensity

Surgery

Classification of juvenile chronic arthritis

Any arthritis, put in the ICD 10 under the codes M05, M06, M08, M13.0, requires constant attention, since even a long remission will not help to avoid a spontaneous exacerbation of the disease.

Non-steroidal anti-inflammatory drugs

with systemic manifestations Special syndromes: Felty's syndrome, Still's syndrome in adults This group covers arthropathies caused by microbiological agents

150 mg / day, maintenance dose - 50 mg / day. The diet for arthritis of the knee must be strictly observed. Excluded food rich in carbohydrates, smoked meats, fatty meats, legumes. With the transfer to dietary nutrition and the use of individual therapy, a positive effect is observed. In general, the treatment of arthritis of the knee joint includes the following areas:

Strongly expressed from the very beginning of the disease

The first degree is characterized by a moderate pain syndrome, there is a slight limitation of movement when rotating the knee, when lifting or while squatting.

Forecast

Synonyms

Abbreviations

By seroprescription Myelosuppression, activation of foci of chronic infection. Medications (tablets, injections, ointments, gels);

Moderate at first, gradually increasing

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

Rheumatoid arthritis, unspecified (M06.9)

Rheumatology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 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. INTRODUCTION

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 - Russian Association of Rheumatologists
ACCP - antibodies to cyclic citrullinated peptide
DMARDs - basic anti-inflammatory drugs
VAS - Visual Analog Scale
GIBP - genetically engineered biological preparations
GC - glucocorticoids
GIT - gastrointestinal tract
STDs - sexually transmitted diseases
LS - medicines
MT - methotrexate
MRI - magnetic resonance imaging
NSAIDs - non-steroidal anti-inflammatory drugs
OSZ - general health
RA - rheumatoid arthritis
RF - rheumatoid factor
CRP - C-reactive protein
Ultrasound - ultrasonography
FK - 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)

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

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

Clinical stage:
1. Very early stage: duration of illness<6 мес..
2. Early stage: disease duration 6 months - 1 year.
3. Advanced stage: disease duration >1 year with typical RA symptoms.
4. Late stage: the duration of the disease is 2 years or more + severe destruction of small (III-IV X-ray stage) 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 infarcts, digital arteritis, livedoangiitis).
3. Neuropathy (mononeuritis, polyneuropathy).
4. Pleurisy (dry, effusion), pericarditis (dry, effusion).
5. Sjögren's syndrome.
6. Eye damage (scleritis, episcleritis, retinal vasculitis).

Instrumental characteristic.
The presence or absence of erosions [according to radiography, 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 erosions + subluxations in the joints;
IV - signs of previous stages + bone ankylosis.

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

Functional class (FC):
I class - the possibilities of self-service, non-professional and professional activities are fully preserved.
II class - the possibilities of self-service, non-professional occupation are preserved, the possibilities of professional activity are limited.
Class III - self-service opportunities are preserved, opportunities for non-professional and professional activities are limited.
Class IV - limited self-service opportunities for 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, tibial nerves).
6. Subluxation in the atlanto-axial joint, incl. with myelopathy, instability of the cervical spine
7. Atherosclerosis

Comments

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

To the heading "Disease activity". Assessment of activity in accordance with modern requirements is carried out using the index - DAS28, which evaluates the pain and swelling of 28 joints: DAS 28 =0.56. √ (CHBS) + 0.28. √ (NPV) + 0.70 .Ln (ESR) + 0.014 NOSZ, where NVR is the number of painful joints out of 28; NPV - the number of swollen joints; Ln - natural logarithm; HSSE is the general health status or overall assessment of disease activity as judged by the patient on 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 characteristic".
Modified stages of RA according to Steinbroker:
I stage- periarticular osteoporosis, single small cystic enlightenments of bone tissue (cysts) in the subchondral part of the articular surface of the bone;
2A stage - periarticular osteoporosis, multiple cysts, narrowing of joint spaces;
2B stage - symptoms of stage 2A of varying severity and single erosions of the 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;
4 stage - symptoms of stage 3 and ankylosis of the joints.
To the rubric "Functional class". Description of characteristics. Self care - dressing, eating, personal care, etc. Non-professional activities - creativity and / or recreation and professional activities - work, study, housekeeping - are desirable for the patient, specific to gender and age.

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

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

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures before planned hospitalization

Laboratory research:
1. Complete blood count
2. Urinalysis
3. Microreaction
4. Fecal occult blood test
5. Activity of liver enzymes (ALT, AST)
6. Contents of creatinine, urea, total protein, glucose, bilirubin, cholesterol
7. The content of C-reactive protein (C-RP), rheumatoid factor
8. Antibodies to cyclic citrullinated peptide (ACCP)
9. At the initial 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. X-ray of OGK; FLG;ECG
2. X-ray of the hands - annually
3. Radiography 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. Hepatitis B, C and HIV markers
2. Daily proteinuria;
3. ECHO-KG
4. Biopsy for amyloidosis
5. CT scan 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. Echocardiography
5. Ultrasound of the abdominal organs and kidneys
6. R-graphic 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-graphy of OGK - according to indications
4. Urinalysis according to Nechiporenko - according to indications
5. Densitometry according to indications
6. Determination of Ca, alkaline phosphatase
7. Feces for occult blood
8. Ultrasound of 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 should use the criteria of the American League of Rheumatologists (1997).

American League of Rheumatology Criteria (1997).
Morning stiffness - stiffness in the morning in the area of ​​​​the joints or periarticular tissues, which persists for at least 1 hour, existing for 6 weeks.
Arthritis of 3 or more joints - swelling of the periarticular soft tissues or the presence of fluid in the joint cavity, determined by the doctor in at least 3 joints.
Arthritis of the joints of the hands - swelling of at least one of the following groups of joints: radiocarpal, metatarsophalangeal and proximal interphalangeal.
Symmetrical arthritis - bilateral damage to the joints (metacarpophalangeal, proximal interphalangeal, metatarsophalangeal).
Rheumatoid nodules are 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 region of other joints).
RF - detection of elevated titers in blood serum by any standardized method.
X-ray changes typical for RA: erosions or periarticular osteoporosis, bone decalcification (cysts), localized in the wrist joints, joints of the hands and most pronounced in clinically affected joints.
RA is diagnosed when at least 4 out of 7 criteria are met, with criteria 1 through 4 being met for at least 6 weeks.
For the new diagnostic criteria, four groups of parameters were selected, and each parameter, based on multivariate static analysis, received a score, with a score of 6 or more, a definite diagnosis of RA was established.
It is necessary to collect information about comorbidities, previous therapy, the presence of bad habits.

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

Symmetrical polyarthritis with gradual(within a few 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, severe morning stiffness (usually accompanied by the early appearance of RF in the blood).

Mono-, oligoarthritis of the knee or shoulder joints with subsequent rapid involvement 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 pronounced systemic phenomena (febrile fever, lymphadenopathy, hepatosplenomegaly) are more often observed in young patients (reminiscent of Still's disease in adults).

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

Recurrent bursitis and tendosynovitis 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 "pincushion" 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 at 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 brush;
- 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 "boutonniere" type (flexion in the proximal interphalangeal joints) or "swan neck" (overextension in the proximal interphalangeal joints); deformity of the hand according to the type of "lorgnette".
- Knee joints: flexion and valgus deformity, Baker's cyst.
- Feet: subluxations of the heads of the metatarsophalangeal joints, lateral deviation, deformity of the thumb.
- cervical spine: subluxations in the area of ​​the atlantoaxial joint, occasionally complicated by compression of the spinal cord or vertebral artery.
- Crico-arytenoid joint: coarsening of the voice, shortness of breath, dysphagia, recurrent bronchitis.
- Ligament apparatus and synovial bags: tendosynovitis in the area of ​​the wrist and hand; bursitis, more often in the elbow joint; 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).
- Skin:rheumatoid nodules, thickening and hypotrophy of the skin; digital arteritis (rarely with the development of gangrene of the fingers), microinfarcts in the nail bed, livedo reticularis.
- Nervous system:compression neuropathy, symmetric sensory-motor neuropathy, multiple mononeuritis (vasculitis), cervical myelitis.
- Muscles:generalized amyotrophy.
- Eyes:dry keratoconjunctivitis, episcleritis, scleritis, scleromalacia, peripheral ulcerative keratopathy.
- Kidneys:amyloidosis, vasculitis, nephritis (rare).
- Blood system: anemia, thrombocytosis, neutropenia.

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

Laboratory research
Objectives of the laboratory examination
- confirmation of the diagnosis;
- exclusion of other diseases;
- assessment of disease activity;
- evaluation 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; combined with high RF titers; may be associated with GC 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.
- increase in 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:
- decrease in albumin correlates with the severity of the disease.
- an increase in creatinine is often associated with NSAID and/or DMARD nephrotoxicity.
- 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; inflammation activity (decrease in high-density lipoprotein cholesterol concentrations, increase in low-density lipoprotein cholesterol concentrations).

Immunological study:
- an increase in RF titers (70-90% of patients), high titers correlate with 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;
- 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%).

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

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

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

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

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

High resolution computed tomography: diagnosis of lung injury.

Echocardiography: diagnosis of rheumatoid pericarditis, myocarditis and CAD-associated heart disease.

Dual energy x-ray absorptiometry

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

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

Biopsy indicated for suspected amyloidosis.

Indications for expert advice:
- Traumatologist-orthopedist - to resolve the issue of surgical intervention.
- Oculist - with 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

sign	Rheumatoid arthritis	rheumatic fever	Osteoarthritis
Pain in the joints in the acute phase morning stiffness Signs of joint inflammation Joint mobility Heart failure Course of the disease Amyotrophy Association with focal infection X-ray of the joints Hyper-Y-globulinemia Titer ASL-O, ASL-S Rheumatoid factor The effect of the use of salicylates	Intensive Expressed Constantly expressed limited slightly Myocardial dystrophy progressive Expressed, progressing Expressed Osteoporosis, narrowing of joint spaces, usura, ankylosis Noticeably increased characteristic Less than 1:250 Positive in seropositive variant of RA Weakly expressed	Intensive Missing Expressed in the acute phase Limited in the acute phase rheumatic heart disease or heart disease Arthritis resolves quickly Missing Expressed No change Increased in the acute phase Only in the acute phase Over 1:250 Negative Good	Moderate Missing not expressed Normal or limited Missing slowly progressive Weakly expressed not expressed Narrowing of joint spaces, exostoses Fine Missing Negative Missing

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, lack of severe morning stiffness, increased pain by the end of the day.

Systemic lupus erythematosus. Symmetrical lesions of the small joints of the hands, wrist and knee joints. Arthritis, non-deforming (with the exception of Jaccous 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; radiographs show no bone erosions.

Gout. Diagnosis is based on the detection of crystals in the 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 tophi; possible subcortical erosion on radiographs.

Psoriatic arthritis. Monoarthritis, asymmetric oligoarthritis, symmetrical polyarthritis, mutilating arthritis, lesions of the axial skeleton. Frequent damage to the distal interphalangeal joints, spindle-shaped swelling of the fingers, skin and nail changes characteristic of psoriasis.

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

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

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

Rheumatic fever. Migrating oligoarthritis with a predominant lesion of large joints, carditis, subcutaneous nodules, chorea, erythema annulare, fever. Specific (for streptococci) serological reactions.

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

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

Systemic scleroderma. Raynaud's phenomenon and thickening of the skin; arthritis, usually arthralgia, can rarely 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, arthralgia and myalgia, 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; characteristic of AT to ribonucleoprotein.

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

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

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

Amyloidosis. Periarticular deposition of amyloid; there may be an effusion in 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 ability; X-rays may show chondrocalcinosis. Diagnosed by liver biopsy.

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

Hypertrophic osteoarthropathy. Oligoarthritis of the knee, ankle and wrist joints; periosteal 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 in the biopsy of the affected area of ​​the skin.

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

Relapsing polychondritis. Widespread progressive inflammation and destruction of cartilage and connective tissue; migrating asymmetric and non-erosive arthritis of small and large joints; inflammation and deformity 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 enough for a diagnosis); laboratory researches and research of joints - without pathology.

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Treatment

Tactics of treatment of patients with RA

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

To achieve this goal:
1. Treatment of DMARDs should begin as early as possible;
2. Treatment should be as active as possible with a change (if necessary) in the treatment regimen within 2-6 months;
3. When choosing therapy, it is necessary to take into account:
- risk factors for poor prognosis, which include high RF titers, increased ESR and CRP, rapid development of joint destruction
- length of time between onset of symptoms and 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) increase in dose 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.

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

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

3. Maintain ideal body weight.

4. A balanced diet that includes 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 motor activity, etc.)

6. Therapeutic exercise (1-2 times a week)

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

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

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

10. Active prevention and treatment of comorbidities is necessary throughout the illness.

Medical treatment

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

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

Non-steroidal anti-inflammatory drugs (NSAIDs)
Basic provisions:
1. NSAIDs are more effective than paracetamol.
2. Treatment with NSAIDs should be combined with active DMARD therapy.
3. The frequency of remission against the background of NSAID monotherapy is very low (2.3%).

In the general population of patients with RA, NSAIDs in equivalent doses do not significantly differ in effectiveness, but differ in the frequency of side effects:
- since the effectiveness of NSAIDs in individual patients can vary significantly, it is necessary to individually select the most effective NSAID for each patient
- the 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 side effects from the gastrointestinal tract, kidneys and cardiovascular system than placebo.
Selective COX-2 inhibitors are less likely to cause gastrointestinal damage than standard NSAIDs.
If there is a history of severe damage to the gastrointestinal tract, 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;
- conduct careful monitoring of cardiovascular complications (especially arterial hypertension) throughout the entire time of taking the drugs;
- Do not exceed recommended doses.

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

Risk factors for the development of NSAID gastropathy include the following:
- age over 65;
- severe damage to the gastrointestinal tract in history (ulcers, bleeding, perforation);
- concomitant diseases (cardiovascular pathology, etc.);
- taking high doses of NSAIDs;
- combined use of several NSAIDs (including low doses of aspirin);
- taking GCs and anticoagulants;
- infection Helicobacter pylori.
Do not prescribe celecoxib to patients with a history of allergy to sulfonamides, cotrimaxosole.

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

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

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

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

Indications for prescribing low doses of HA:
- suppression of inflammation of the joints before the onset of action of DMARDs.
- suppression of inflammation of the joints during exacerbation of the disease or the development of complications of DMARD therapy.
- ineffectiveness of NSAIDs and DMARDs.
- contraindications to the appointment of NSAIDs (for example, in elderly people with an "ulcerative" history and / or impaired renal function).
- achieving remission in some variants of RA (for example, in seronegative RA in the elderly, resembling polymyalgia rheumatica).

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

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

Local (intra-articular) therapy(betamethasone):
Basic provisions:
- used to suppress arthritis at the onset of the disease or exacerbations of synovitis in one or more joints, improve joint function;
- leads only to temporary improvement;
- the effect on the progression of joint destruction has not been proven.
Recommendations:
- repeated injections in the same joint no more than 3 times a year;
- use sterile materials and instruments;
- wash the joint before the introduction of drugs;
- eliminate the load on the joint within 24 hours after the injection.

Basic anti-inflammatory drugs (DMARDs)

Key points
To achieve the goal, it is necessary to prescribe early 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) in the regimen for 2-6 months, constant monitoring of therapy tolerance , informing patients about the nature of the disease, the side effects of the drugs used and, if appropriate symptoms appear, the need to immediately stop taking them and consult a doctor. When choosing therapy, it is necessary to take into account risk factors for an unfavorable prognosis (high titers of RF and / or ACCP, an increase in ESR and CRP, the rapid development of joint destruction).

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

Recommendations for use:
1. Methotrexate is prescribed once a week (orally or parenterally); more frequent use 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 when taken orally (or with the development of toxic reactions from the gastrointestinal tract), switch to parenteral administration (i / m or s / c):
- the lack of effect with oral administration of methotrexate may be due to low absorption in the gastrointestinal tract;
- the initial dose of methotrexate is 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 administer to patients with severe lung disease.
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 in the range of 7.5 to 25 mg/week. Reception at a dose of more than 25-30 mg / week is not advisable (an 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 another NSAID;
- with insufficient efficacy and tolerability (not severe adverse reactions) 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 (folic acid intake reduces the risk of developing gastrointestinal and hepatic side effects and cytopenia);
- to exclude the intake of alcohol (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.

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

Sulfasalazine 500 mg- an important component of combination therapy in patients with RA or in the presence of a contraindication to the appointment of MT.
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 daily with food:
- 1st week - 500 mg
- 2nd week - 1000 mg
- 3rd week - 1500 mg
- 4th week - 2000 mg.
2. If there is a sore throat, mouth ulcers, fever, severe weakness, bleeding, itching, patients should immediately stop the drug on their own.

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

Leflunomide drug:
1. The effectiveness is not inferior to sulfasalazine and methotrexate.
2. Surpasses methotrexate and sulfasalazine in terms of the effect on the quality of life of patients.
3. The frequency of side effects is lower than other DMARDs.
The main indication for the appointment: insufficient efficacy or poor tolerability of methotrexate.

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

Examinations before prescribing therapy	In dynamics
General blood analysis	Every 2 weeks for 24 weeks, then every 8 weeks
Liver enzymes (ACT and ALT)	Every 8 weeks
Urea and creatinine	Every 8 weeks
HELL	Every 8 weeks

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

4-aminoquinoline derivatives:
1. Inferior in clinical efficacy to other DMARDs.
2. Do not slow down the progression of joint destruction.
3. Positively affect the lipid profile.
4. Chloroquine has more side effects than hydroxychloroquine.
5. Potential indications for use:
- early stage, low activity, no risk factors for poor prognosis
- undifferentiated polyarthritis, if it is impossible to exclude the onset of a systemic connective tissue disease.

Recommendations for use:
1. Do not exceed the daily dose: hydroxychloroquine 400 mg (6.5 mg/kg), chloroquine 200 mg (4 mg/kg).
2. 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 impairment.
6. Recommend wearing goggles in sunny weather (regardless of the season).

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

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

Main side effects: increased blood pressure, impaired renal function, headaches, tremor, 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. With a decrease in creatinine levels by 30%, continue treatment with drugs, and if the 30% increase is maintained, stop treatment.

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

Combination therapy for DMARDs.
There are 3 main options for combination therapy: start treatment with monotherapy followed by the appointment of one or more DMARDs (within 8-12 weeks) while maintaining the activity of the process ; start treatment with combination therapy with subsequent transfer to monotherapy (after 3-12 months) with suppression of the activity of the process, combination therapy is carried out throughout 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 if treatment is insufficient.
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 poor prognosis factors;
- MT and sulfasalazine - with any duration of RA, high activity, signs of a poor prognosis;
- MT + hydroxychloroquine + sulfasalazine - in the presence of poor prognosis factors and in moderate / high disease activity, regardless of the duration of the disease.

Genetically engineered biological preparations
Anti-B cell drug rituximab (RTM) and interleukin 6 receptor blocker tocilizumab (TCZ) are used to treat RA.
Indications:
- patients with RA, insufficiently responding to MT and/or other synthetic DMARDs, with moderate/high activity of RA in patients with signs of poor prognosis: high disease activity, RF + /ACCP + , early 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 of therapy with at least two standard DMARDs, one of which should be MTX for 6 months and more or less than 6 months if it is necessary to stop the DMARD 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 the titers of serological tests (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 within the previous 12 months, HIV infection, hepatitis B and C, etc.);
- heart failure III-IV functional class (NYHA);
- demyelinating diseases of the nervous system in history;
- age less than 18 years (decision on each case individually).

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

etanercept is indicated for adults in the treatment of moderate to severe active rheumatoid arthritis in combination with methotrexate, when the response to DMARDs, including methotrexate, has been inadequate.
Etanercept may be given as monotherapy if methotrexate has failed or is intolerable. Etanercept is indicated for the treatment of severe, active, and progressive rheumatoid arthritis in adults not previously treated with methotrexate.
Treatment with etanercept should be initiated and monitored by a physician experienced in the diagnosis and treatment of rheumatoid arthritis.
Etanercept in the form of a ready 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 the solution.
The recommended dose is 25 mg etanercept twice weekly, 3 to 4 days apart. An alternative dose is 50 mg once a week.
Therapy with etanercept should be continued until remission is achieved, usually no more than 24 weeks. The introduction of the drug should be discontinued if after 12 weeks of treatment there is no positive dynamics of symptoms.
If it is necessary to re-prescribe etanercept, the duration of treatment indicated above should be observed. It is recommended to prescribe a dose of 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 risk of sepsis;
- active infection, including chronic or localized infections (including tuberculosis);
- pregnancy and lactation;
- patients weighing less than 62.5 kg.
Carefully:
- Demyelinating diseases, congestive heart failure, immunodeficiency states, blood dyscrasia, diseases predisposing to the development or activation of infections (diabetes mellitus, hepatitis, etc.).

infliximab prescribed with respect to the dose and frequency of administration, in combination with GEBA treatment of adult patients with severe active RA in case of failure or intolerance of other DMARDs, you can start with inhibition of tumor necrosis factor (infliximab). Infliximab is prescribed in compliance 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. 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.
All patients should be screened for mycobacterial infection prior to infliximab in accordance with current national guidelines.

Indications:
- no effect ("unacceptably high disease activity") during treatment with methotrexate at the most effective and tolerable dose (up to 20 mg/week) for 3 months or other DMARDs
- 5 or more swollen joints
- an increase in ESR more than 30 mm / h or CRP more than 20 mg / l.
- activity corresponds to DAS>3.2
- ineffectiveness of other DMARDs (if there are contraindications for the appointment of methotrexate)
- The need to reduce the dose of HA.
- if there are contraindications to 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. Therapy with infliximab is continued only if, after 6 months after the start of therapy, an adequate effect is noted. The effect is considered adequate if there is a decrease in the disease activity score (DAS28) by 1.2 points or more. Monitor treatment with DAS28 assessment every 6 months.

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

Recommendations for use:

- intravenous infusion at a dose of 3 mg / kg, the duration of the infusion is 2 hours;
- 2 and 6 weeks after the first injection, additional infusions of 3 mg / kg each are prescribed, then the injections are repeated every 8 weeks;
- re-administration of infliximab 2-4 years after the previous injection may lead to the development of delayed-type hypersensitivity reactions;
- Patients with RA who have signs of possible latent TB (history of TB or changes on chest x-ray) should be given advice on prophylactic anti-TB therapy prior to initiation of GIBT, in accordance with current national guidelines;
- if clinically warranted, patients with RA should be screened 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 MTX, in patients with an insufficient “response” to MTX in early and late RA, and in patients who do not respond to other TNF-alpha inhibitors. It is applied subcutaneously.
Before initiating golimumab, all patients should be screened for active infections (including tuberculosis) in accordance with current national guidelines.

Indications:
Golimumab in combination with methotrexate (MT) is indicated for use in
quality:
- therapy of moderate and severe active rheumatoid arthritis in adults who have an unsatisfactory response to DMARD therapy, including MT;
- therapy of severe, active and progressive rheumatoid arthritis in adults who have not previously received MT therapy.
It has been shown that golimumab in combination with MT reduces the incidence of progression of joint pathology, which was demonstrated using radiography, and improves their functional state.
Golimumab is prescribed in compliance with the dose and frequency of administration, in combination with MT. Therapy with golimumab is continued only if an adequate effect is noted after 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. Monitor treatment with DAS28 assessment every 6 months.

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

Recommendations for use:
- treatment is carried out under the supervision of a rheumatologist with experience in the diagnosis and treatment of RA;
- Golimumab 50 mg is injected subcutaneously once a month, on the same day of the month;
- Golimumab in patients with RA should be used in combination with MTX;
In patients weighing more than 100 kg who have not achieved a satisfactory clinical response after 3-4 doses of the drug, an increase in the dose of golimumab to 100 mg 1 time per month may be considered.

Patients with RA who have evidence of possible latent TB (history of TB or changes on chest x-ray) should be advised on prophylactic anti-TB therapy prior to initiation of GIBT, in accordance with current national guidelines.
When clinically warranted, patients with RA should be evaluated for possible tumors. If a malignant tumor is detected, treatment with anti-TNF drugs should be 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 with contraindications to their administration (presence of 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 the ESR and the concentration of CRP, the rapid development of destruction in the joints) within 3-6 months from the start of therapy. Rituximab is prescribed according to the dose and frequency of administration (at least every 6 months), in combination with methotrexate. Therapy with rituximab is continued if an adequate effect is observed after the start of therapy and if this effect is maintained after repeated use of rituximab after at least 6 months. The effect is considered adequate if there is a decrease in the disease activity score (DAS28) of 1.2 points or more.

Tocilizumab. It is used for RA duration of more than 6 months, high disease activity, signs of poor prognosis (RF+, ACCP+, multiple erosions, rapid progression). Tocilizumab is prescribed in compliance with the dose and frequency of administration (1 time per month) as monotherapy or in combination with DMARDs in patients with moderate to severe rheumatoid arthritis. It leads to a stable objective clinical improvement and an increase in the quality of life of patients. Treatment in monotherapy or in combination with methotrexate should be continued if an adequate effect is noted after 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 an acute inflammatory process, such as C-reactive protein and amyloid-A, as well as the erythrocyte sedimentation rate, decreases. Hemoglobin levels increase as tocilizumab reduces the effect of IL-6 on hepcidin production, resulting in increased iron availability. The greatest effect is observed in patients with rheumatoid arthritis with concomitant anemia. Along with the inhibition of 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 moderate or high activity in monotherapy or as part of complex therapy (methotrexate, basic anti-inflammatory drugs), including to prevent the progression of radiographically proven joint destruction.
- systemic juvenile idiopathic arthritis alone or in combination with methotrexat in children older than 2 years.

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

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

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); with inefficiency within 2 weeks - azathioprine 50-150 mg / day.
Blood transfusions are recommended except for very severe anemia associated with a risk of cardiovascular events.

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

Recommendations for the treatment of extra-articular manifestations of RA:
Pericarditis or pleurisy - GC (1 mg / kg) + DMARDs.
Interstitial lung disease - GC (1 - 1.5 mg / kg) + cyclosporine A or cyclophosphamide; avoid methotrexate.
Isolated digital arteritis - symptomatic vascular therapy.
Systemic rheumatoid vasculitis - intermittent pulse therapy with cyclophosphamide (5 mg / kg / day) and methylprednisolone (1 g / day) every 2 weeks. 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 emergency surgery:
- Nerve compression due to synovitis or tendosynovitis
- Threatened or completed 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 mandible
- The presence of bursitis that disrupts the patient's performance, as well as rheumatic nodules that tend to ulcerate.

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.

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

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

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

Prevention of tuberculosis infection: pre-screening of patients reduces 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 examination of the lungs should be performed. In the absence of radiographic changes, treatment with isoniazid (300 mg) and vitamin B6 should be carried out for 9 months, after 1 month. possible appointment of infliximab; with a positive skin test and the presence of typical signs of tuberculosis or calcified mediastinal lymph nodes, at least 3 months of therapy with isoniazid and vitamin Wb should be carried out before the appointment of infliximab. When prescribing isoniazid in patients older than 50 years, a dynamic study of liver enzymes is necessary.

Further management
All patients with RA are subject to dispensary observation:
- 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 - independent factors of poor 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 in 3 months.
Every 3 months: general blood and urine tests, biochemical blood test.
Annually: lipid profile study (to prevent atherosclerosis), densitometry (diagnosis of osteoporosis), radiography of the pelvic bones (detection of aseptic necrosis of the femoral head).

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

Indicators of treatment efficacy and 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: TPS; NPV; Improvement in any 3 of the following 5 parameters: a patient's overall disease activity score; overall assessment of disease activity by the doctor; assessment of pain by the patient; health assessment questionnaire (HAQ); ESR or CRP.

Table 9 European League of Rheumatology Criteria for Response to Therapy

DAS28	DAS28 improvement over original >1.2 >0.6 and ≤1.2 ≤0.6
≤3.2	good
>3.2 and ≤5.1		moderate
>5.1			absence

The minimum degree of improvement is the 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 a correction of therapy in the form of a change in the dose of DMARDs or the addition of a second drug.
In the treatment of DMARDs, treatment options are possible:
1. Reducing activity to low or achieving remission;
2. Decrease in activity without reaching its low level;
3. Little or no improvement.
With the 1st variant, treatment continues without changes; at the 2nd - it is necessary to change the DMARD if the degree of improvement in activity parameters does not exceed 40-50% or joining the DMARD with a 50% improvement in another DMARD or GIBP; at the 3rd - the abolition of the drug, the 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 disease or drug therapy.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Rheumatology, Ed. ON THE. Shostak, 2012 2. Endoprosthetics of the hip joint, Zagorodniy N.V., 2011 3. Clinical guidelines. Rheumatology. 2nd edition corrected and supplemented / 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, C 10-15. 5. Diagnosis and treatment in rheumatology. Problem 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 recommendations. Rheumatology. 2nd ed., S.L. Nasonova, 2010 9. Nasonov E.L. The use of tocilizumab (Actemra) in rheumatoid arthritis. Scientific-practical rheumatol 2009; 3(App.):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 other 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 V.A., Nasonov E.L., Alekperov R.T., Alekseeva L.I. 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) in 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. Guide for practitioners. Ed. IN AND. Mazurova - St. Petersburg. Folio, 2001.- P.116 22. Paul Emery et al. "Golimumab, a human monoclonal antibody to tumor necrosis factor-alpha given as a subcutaneous injection every four weeks in patients with active rheumatoid arthritis not previously treated with methotrexate, ARTHRITIS & RHEUMATISM, Vol. 60, No. 8, August 2009, pp. 2272-2283 , DOI 10.1002/art.24638 23. Mark C. Genovese et al. "Effect of golimumab therapy on patient-reported rheumatoid arthritis outcomes: 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 tumor necrosis factor inhibitor therapy (GO-AFTER study): a multicenter, randomized, double-blind, placebo-controlled, phase III study, Lancet 2009; 374:210–21

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers
1. Togizbaev G.A. - Doctor of Medical Sciences, Chief Freelance Rheumatologist of the Ministry of Health of the Republic of Kazakhstan, Head of the Department of Rheumatology, AGIUV
2. Kushekbaeva A.E. - Candidate of Medical Sciences, Associate Professor of the Department of Rheumatology, AGIUV
3. Aubakirova B.A. - chief freelance rheumatologist in Astana
4. Sarsenbayuly M.S. - chief freelance rheumatologist of the East Kazakhstan region
5. Omarbekova Zh.E. - chief freelance rheumatologist in 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 Module of Rheumatology of the Kazakh National Medical University named after S.D. Asfendiyarov

Indication of no conflict of interest: missing.

Conditions for revision of the protocol: Availability of new methods of diagnostics and treatment, deterioration of treatment results associated with the use of this protocol

Attached files

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

Branches of medicine: Rheumatology

General information Brief description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 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. INTRODUCTION

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 - Russian Association of Rheumatologists

ACCP - antibodies to cyclic citrullinated peptide

DMARDs - basic anti-inflammatory drugs

VAS - Visual Analogue Scale

GIBP - genetically engineered biological preparations

GC - glucocorticoids

GIT - gastrointestinal tract

STDs - sexually transmitted diseases

drugs - medicines

MT - methotrexate

MRI - magnetic resonance imaging

NSAIDs - non-steroidal anti-inflammatory drugs

OSS - general health

RA - rheumatoid arthritis

RF - rheumatoid factor

CRP - C-reactive protein

Ultrasound - ultrasonography

FK - functional class

NPV – number of swollen joints

COX - cyclooxygenase

FGDS - fibrogastroduodenoscopy

ECG - electrocardiogram

ECHO KG - echocardiogram

Protocol development date: 2013Patient category: patients with RA

Protocol Users: rheumatologists, therapists, general practitioners.

Classification

Clinical classification

Working Classification of Rheumatoid Arthritis (APP, 2007)Main diagnosis: 1. Seropositive rheumatoid arthritis (M05.8).

2. Seronegative rheumatoid arthritis (M06.0).

Special clinical forms of rheumatoid arthritis 1. Felty's syndrome (M05.0);

2. Still's disease in adults (M06.1).

3. Probable rheumatoid arthritis (M05.9, M06.4, M06.9).

Clinical stage: 1. Very early stage: disease duration of 1 year in the presence of typical symptoms of RA.

4. Late stage: the duration of the disease is 2 years or more + severe destruction of small (III-IV X-ray stage) and large joints, the presence of complications.

The degree of disease activity: 1. 0 - remission (DAS285.1).

Extra-articular (systemic) signs: 1. Rheumatoid nodules.

2. Cutaneous vasculitis (necrotizing ulcerative vasculitis, nail bed infarcts, digital arteritis, livedoangiitis).

3. Neuropathy (mononeuritis, polyneuropathy).

4. Pleurisy (dry, effusion), pericarditis (dry, effusion).

5. Sjögren's syndrome.

6. Eye damage (scleritis, episcleritis, retinal vasculitis).

Instrumental characteristic. Presence or absence of erosion:

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 erosions + subluxations in the joints;

IV - signs of previous stages + 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, non-professional and professional activities are fully preserved.

II class - the possibilities of self-service, non-professional occupation are preserved, the possibilities of professional activity are limited.

Class III - self-service opportunities are preserved, opportunities for non-professional and professional activities are limited.

Class IV - limited self-service opportunities for 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, tibial nerves).

6. Subluxation in the atlanto-axial joint, incl. with myelopathy, instability of the cervical spine

7. Atherosclerosis

Comments

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

To the heading "Disease activity". 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 √ (NBJ) + 0.28 √ (NRT) + 0.70 Ln (ESR) + 0.014 OSHA, where NJS is the number of painful joints out of 28; NPV – number of swollen joints; Ln is the natural logarithm; BHA is the overall health status or overall assessment of disease activity as judged by the patient on the Visual Analogue Scale (VAS).

DAS28 value >5.1 corresponds to high disease activity; DAS3 g/l, glucose 1000 units/ml, pH 7.0; RF titers > 1:320, complement reduced; cytosis - cells 5000 mm3 (lymphocytes, neutrophils, eosinophils).

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

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

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

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

High resolution computed tomography: diagnosis of lung injury.

Echocardiography: diagnosis of rheumatoid pericarditis, myocarditis and CAD-associated heart disease.

Dual energy x-ray absorptiometry

Diagnosis of osteoporosis in the presence of risk factors:- age (women>50 years, men>60 years). - disease activity (persistent increase in CRP > 20 mg/l or ESR > 20 mm/h). - functional status (Steinbroker score > 3 or HAQ score > 1.25). - body weight 30 mg / day) leads only to a temporary correction of granulocytopenia, which recurs after a decrease in the dose of GC.
In patients with agranulocytosis, the use of GC pulse therapy according to the usual scheme is indicated.

Interstitial lung disease - GC (1 - 1.5 mg / kg) + cyclosporine A or cyclophosphamide; avoid methotrexate.
Isolated digital arteritis - symptomatic vascular therapy.
Systemic rheumatoid vasculitis - intermittent pulse therapy with cyclophosphamide (5 mg / kg / day) and methylprednisolone (1 g / day) every 2 weeks. 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 interventionIndications for emergency or emergency surgery:- Nerve compression due to synovitis or tendosynovitis

Threatened or completed 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 mandible
- The presence of bursitis that disrupts the patient's performance, as well as rheumatic nodules that tend to ulcerate.

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.

The main types of surgical treatment:- joint prosthetics,

synovectomy,
- arthrodesis.

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

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

Prevention of tuberculosis infection: pre-screening of patients reduces 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 examination of the lungs should be performed. In the absence of radiographic changes, treatment with isoniazid (300 mg) and vitamin B6 should be carried out for 9 months, after 1 month. possible appointment of infliximab; with a positive skin test and the presence of typical signs of tuberculosis or calcified mediastinal lymph nodes, at least 3 months of therapy with isoniazid and vitamin Wb should be carried out before the appointment of infliximab. When prescribing isoniazid in patients older than 50 years, a dynamic study of liver enzymes is necessary.

Further management All patients with RA are subject to dispensary observation:

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 - independent factors of poor 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 in 3 months.
Every 3 months: general blood and urine tests, biochemical blood test.
Annually: lipid profile study (to prevent atherosclerosis), densitometry (diagnosis of osteoporosis), radiography of the pelvic bones (detection of aseptic necrosis of the femoral head).

Management of patients with RA during pregnancy and lactation:- Avoid taking NSAIDs, especially in the II and III trimesters of pregnancy.

Avoid taking DMARDs.
- You can continue treatment with HA at the lowest effective doses.

Indicators of treatment efficacy and 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: TPS; NPV; Improvement in any 3 of the following 5 parameters: a patient's overall disease activity score; overall assessment of disease activity by the doctor; assessment of pain by the patient; health assessment questionnaire (HAQ); ESR or CRP.

Table 9 European League of Rheumatology Criteria for Response to Therapy

The minimum degree of improvement is the 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 a correction of therapy in the form of a change in the dose of DMARDs or the addition of a second drug.
In the treatment of DMARDs, treatment options are possible:
1. Reducing activity to low or achieving remission;
2. Decrease in activity without reaching its low level;
3. Little or no improvement.
With the 1st variant, treatment continues without changes; at the 2nd - it is necessary to change the DMARD if the degree of improvement in activity parameters does not exceed 40-50% or joining the DMARD with a 50% improvement in another DMARD or GIBP; at the 3rd - the abolition of the drug, the 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 disease or drug therapy.

Information Sources and Literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Rheumatology, Ed. ON THE. Shostak, 2012 2. Endoprosthetics of the hip joint, Zagorodniy N.V., 2011 3. Clinical guidelines. Rheumatology. 2nd edition corrected and supplemented / 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, C 10-15. 5. Diagnosis and treatment in rheumatology. Problem 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 recommendations. Rheumatology. 2nd ed., S.L. Nasonova, 2010 9. Nasonov E.L. The use of tocilizumab (Actemra) in rheumatoid arthritis. Scientific-practical rheumatol 2009; 3(App.):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 other 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 V.A., Nasonov E.L., Alekperov R.T., Alekseeva L.I. 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) in 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. Guide for practitioners. Ed. IN AND. Mazurova - St. Petersburg. Folio, 2001.- P.116 22. Paul Emery et al. "Golimumab, a human monoclonal antibody to tumor necrosis factor-alpha given as a subcutaneous injection every four weeks in patients with active rheumatoid arthritis not previously treated with methotrexate, ARTHRITIS & RHEUMATISM, Vol. 60, No. 8, August 2009, pp. 2272-2283 , DOI 10.1002/art.24638 23. Mark C. Genovese et al. "Effect of golimumab therapy on patient-reported rheumatoid arthritis outcomes: results from the GO-FORWARD study", J Rheumatol first issue April 15, 2012, DOI: 10.3899/jrheum.111195 24. Josef S Smolen "Golimumab therapy in patients with active rheumatoid arthritis after Treatment with tumor necrosis factor inhibitors (GO-AFTER study): a multicenter, randomized, double-blind, placebo-controlled phase III study, Lancet 2009; 374:210–21

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of developers 1. Togizbaev G.A. - Doctor of Medical Sciences, Chief Freelance Rheumatologist of the Ministry of Health of the Republic of Kazakhstan, Head of the Department of Rheumatology of the AGIUV

2. Kushekbaeva A.E. – Candidate of Medical Sciences, Associate Professor of the Department of Rheumatology, AGIUV

3. Aubakirova B.A. - chief freelance rheumatologist in Astana

4. Sarsenbayuly M.S. - chief freelance rheumatologist of the East Kazakhstan region

5. Omarbekova Zh.E. – chief freelance rheumatologist in 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 Module of Rheumatology of the Kazakh National Medical University named after S.D. Asfendiyarov

Indication of no conflict of interest: missing.

Conditions for revision of the protocol: Availability of new methods of diagnostics and treatment, deterioration of treatment results associated with the use of this protocol

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The most important thing in the diagnosis and treatment of any disease is to make the correct diagnosis. Understanding the causes and knowing the symptoms helps the doctor assess the situation and make a decision on the tactics of therapy, which is especially important with a wide variety of diseases in humans. The International Classification of Diseases 10th Revision (ICD-10) is not only disease statistics, but also a real assistant to the doctor in daily work. Rheumatoid arthritis is classified under Arthropathy and is a type of disease that affects the peripheral joints. There are a lot of different types of pathological processes associated with inflammation. To easily navigate among this variety, the specialist uses a convenient and detailed classification that takes into account all the nuances of joint diseases.

Variants of arthropathy Making the correct diagnosis is the main task in the diagnosis and treatment of rheumatoid arthritis

Articular diseases that mainly affect the limbs include the following types of pathology:

• infectious (in ICD-10 they have the code M00-M03);
• inflammatory pathology of the joints (M05-M14);
• arthrosis (M15-M19);
• other joint lesions (M20-M24).

Rheumatoid arthritis is included in the group "Inflammatory arthropathies", which indicates the nature of the disease and helps the doctor to correctly assess the causative factor of articular pathology.

Disease coding

The defeat of the joints by rheumatism manifests itself in a variety of ways, being the cause of diseases of the internal organs and forming complex syndromes. The doctor needs to choose the correct code in the ICD-10 in order to carry out effective treatment, taking into account the possible damage not only to the joints, but also to other organs and systems of the human body. At the preliminary examination stage, a specialist can use a code that does not accurately indicate a specific disease, but as new diagnostic information is received, the diagnosis is corrected.

Table. ICD-10 code for various variants of rheumatoid joint disease

The code	Disease	Short description
M05.0	Felty syndrome	A special variant of joint damage, accompanied by blood changes (anemia, a decrease in leukocytes and platelets) and pathology of the spleen
M05.1	Rheumatoid lung disease	Combined rheumatoid arthritis and diseases of the respiratory system (bronchitis, pleurisy, interstitial pneumonia)
M05.2	Vasculitis	Concomitant articular pathology disease of small and medium vessels
M05.3	Rheumatoid arthritis with damage to other organs and systems	The doctor will use this cipher when detecting concomitant diseases of organs and systems (kidneys, liver, gastrointestinal tract, and others)
M05.8	Other seropositive joint problems	The code is used for any variant of articular pathology and against the background of the detection of a specific factor in the blood
M05.9	Unspecified seropositive pathology	Rarely used code that is needed at the preliminary diagnosis stage
M06.0	seronegative rheumatoid arthritis	The classic version of the disease, when the doctor sees typical changes, but there is no specific factor in the blood
M06.1	Still's disease in adults	The code applies when a person over the age of 16 is diagnosed with juvenile rheumatoid arthritis
M06.2	Bursitis	Inflammatory lesion of the articular capsule against the background of rheumatoid lesions
M06.3	Rheumatoid nodule	Detection of specific subcutaneous formations in the area of ​​​​the joints, but in the absence of classical manifestations of the disease
M06.4	Multiple lesions of the joints of an inflammatory nature	The code indicates polyarthritis of the extremities of inflammatory origin, and is used at the stage of preliminary diagnosis
M06.8	Other arthritis	Code for any variants of articular pathology associated with the rheumatic process
M06.9	Unspecified joint pathology of rheumatic origin	The cipher is used at the stage of preliminary diagnostics

In the ICD-10, codes M07-M14 encode numerous joint diseases caused by any factors other than rheumatism. Their use involves identifying the exact causes and detecting typical symptoms of pathology.

For any type of joint disease, the doctor can find the appropriate ICD-10 code. It is important to conduct a complete diagnosis and identify the underlying causative factor of the disease in order to accurately determine the code.

Significance of the ICD-10

The classification of diseases used by doctors all over the world makes it possible to accurately account for all cases of severe articular pathology associated with rheumatic disease. Thanks to this, specialists in different countries can learn and adopt the experience of other doctors, better understand the causes of inflammatory arthropathy and use advanced therapies. Rheumatoid arthritis requires a careful approach to examination and treatment, because this problem can become the basis for severe complications and disability of a person.

ICD-10 - generally accepted international classification of diseases

Having determined the diagnosis, the doctor will prescribe treatment. Rheumatoid arthritis should be treated comprehensively, providing a therapeutic effect with drugs, the action of which is aimed at removing pain and improving joint mobility. It is necessary to accurately and consistently follow the recommendations of a specialist in order to get rid of problems in the present and prevent complications in the future. This is especially important in the complicated course of articular disease, when there is damage to internal organs. The main factor of treatment is basic therapy prescribed for a long time. Be sure to use symptomatic treatment. The effectiveness of therapy will be much higher if therapeutic measures are started as early as possible, before external changes in small joints. That is why timely examination and correct diagnosis in accordance with ICD-10 is the best way to prevent complicated forms of the disease.

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

For endoprosthetics, the presence of:

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

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

Preoperative preparation and operation.

Sometimes a patient, having learned about the need for a hip joint prosthesis, is set up exclusively for foreign surgical intervention. So to speak, there are no comrades for the taste and color. Everyone makes their choice.

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

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

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

Untimely access to a doctor, attempts to cure the disease on their own only aggravate its course. The patient loses the ability to move normally and even sit. All this is accompanied by severe pain, negatively affects the physiological state of a person and the psychological background.

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

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

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

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

1. Consultation, examination by specialists (rheumatologist, orthopedist).
2. X-ray examination, MRI of the joint.
3. Visiting highly specialized specialists (cardiologist, anesthesiologist, gynecologist/urologist).
4. Laboratory tests: detailed, complete blood count, clotting diagnostics.
5. Ultrasound examination of the heart, cardiography.
6. In 4-8 weeks, you need to start attending physiotherapy exercises to strengthen the ligamentous apparatus in order to quickly adapt to the prosthesis.

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

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

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

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

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

Highly qualified ECSTO specialists in most cases perform arthroplasty in a minimally invasive way, involving the use of small incisions (from 6 cm) to access the hip joint.

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

READ ALSO: Osteoarthritis of the hip joint 2 degree treatment

The ECSTO Clinic has no age limits for hip arthroplasty; the clinic's specialists have vast experience in the surgical treatment of elderly patients. If necessary, the patient is prepared for surgery by several specialists - a cardiologist, a neurologist, and other specialists.

In the surgical treatment of elderly patients, additional parameters are taken into account when choosing an endoprosthesis. For elderly patients, endoprostheses with a large head diameter are installed to eliminate the risk of dislocation after surgery, even with weakened muscles.

The arthroplasty procedure takes from half an hour to several hours and is performed under general or spinal anesthesia (in this case, sleeping pills are administered intravenously to the patient). In order to prevent thromboembolic complications, anticoagulants are administered to the patient on the eve of the operation.

After the surgical intervention, the patient is in the postoperative ward, where specialists monitor his condition around the clock. When the patient's condition is stable, after a while he is transferred to a regular ward. As a rule, after a week the patient can leave the clinic on his own.

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

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

1. You need a large package of certificates and documents to apply for a quota.
2. If you are lucky and the application is accepted, you may be offered to be operated on at any clinic in Russia.
3. You will not be able to choose a surgeon based on recommendations.
4. The endoprosthesis will be installed from the available clinic, more often these are domestic products.

You can get joint replacement free of charge according to an individual rehabilitation program. For this you need:

1. Select clinic and doctor.
2. Prepare documents for participation in the program.
3. Select an implant and buy it from the manufacturer.
4. Make an operation.
5. To return the money for the purchase of the prosthesis after a few weeks.

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

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

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

Prices are much lower than European, Turkish or Israeli. Here we are always happy to meet the needs of the patient.

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

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

Since 2014, quotas for most of these operations have been canceled, with the exception of some systemic diseases, for example, systemic lupus erythematosus or for iatrogenic reasons (doctors' mistake during the initial replacement).

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

It was planned that joint arthroplasty operations would be carried out at the expense of the CHI policy, but so far this period is transitional and, often, there is misunderstanding and confusion on the part of hospitals and doctors.

The presence of any of the above indications is the basis for an operation to replace the joint or part of it.

Head of the department, traumatologist-orthopedist

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

GKB address. S.P. Botkin

Moscow, 2nd Botkinsky pr-d, 5, building 22, sector "B", 7th floor Phones

Professor, doctor of medical sciences, doctor of the highest category. He has been the head of the Center since 2006, has extensive experience in the treatment of patients with orthopedic and traumatological profile. During the year, performs more than 500 operations for primary and revision arthroplasty of the hip, knee and shoulder joints using the most modern technologies

The Moscow City Center for Endoprosthetics of Bones and Joints is a unique structural unit in the healthcare system of the city of Moscow. The center was founded by Professor Movshovich I.A. in 1989

READ ALSO: yoga for hip joints benefit limitation

At that time, hip arthroplasty was considered a unique operation. 15 years ago in the GKB im. S.P. Botkin performed no more than 30 hip arthroplasty per year. Currently, the Center for Endoprosthetics performs more than 1,000 surgeries annually.

hip arthroplasty, about 700 knee arthroplasty operations. Today, the most complex high-tech surgeries for revision hip and knee arthroplasty have become routine for the Center, while in the early 2000s they were performed no more than 5-7 annually.

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

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

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

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

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

Endoprosthesis replacement of the knee joint using navigation equipment

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

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

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

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

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

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

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

Weekly in the consultative and diagnostic clinic at the GKB. About 30 patients undergo a commission of S. P. Botkin to determine indications for joint replacement. About 2,000 patients receive inpatient treatment at the Center every year.

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

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

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

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

The small cost associated with a hip replacement will only include the purchase of the prosthesis itself. The rest, that is, anesthesia, a separate ward or a bed, meals, sampling, everything will be paid for by the state budget.

Rheumatoid arthritis ICD code 10: juvenile, seropositive, seronegative.

Clinical picture of a schematic representation of a joint damaged by rheumatoid arthritis.

The disease begins with persistent arthritis, affecting mainly the joints of the feet and hands.

Subsequently, all joints of the limbs without exception can be involved in the inflammatory process.

Arthritis is symmetrical, affecting the joints of one articular group on both sides.

Before the onset of symptoms of arthritis, the patient may be disturbed by muscle pain, slight flying pains in the joints, inflammation of the ligaments and articular bags, weight loss, and general weakness.

In the initial stage of arthritis, the clinic of joint damage can be unstable, with the development of spontaneous remission and the complete disappearance of the articular syndrome.

However, after some time, the inflammatory process resumes, affecting more joints and with increased pain.

The mechanism of development of rheumatoid arthritis

Despite the fact that the etiology of rheumatoid joint damage is not clear, the pathogenesis (development mechanism) has been sufficiently studied.

The pathogenesis of the development of rheumatoid arthritis is complex and multi-stage, it is based on the launch of a pathological immune response to the impact of an etiological factor.

Inflammation begins with the synovial membrane of the joint - it is the inner layer of the joint capsule.

The cells that make up it are called synoviocytes or synovial cells. Normally, these cells are responsible for the production of joint fluid, the synthesis of proteoglycans, and the removal of metabolic products.

During inflammation, the synovial membrane is infiltrated by cells of the immune system, with the formation of an ectopic focus in the form of an overgrowth of the synovial membrane, such an overgrowth of synoviocytes is called pannus.

Constantly growing in size, the pannus begins to produce inflammatory mediators and antibodies (altered IgG) against synovial components that destroy the surrounding cartilage and bone tissue. This is the pathogenesis of the beginning of the formation of articular erosions.

At the same time, the growth of cells that produce antibodies to synovial structures is stimulated by various colony-stimulating factors, cytokines, and metabolic products of arachidonic acid.

The pathogenesis of the development of rheumatoid inflammation of the joints at this stage is included in a kind of vicious circle: the more cells that produce aggression factors, the more inflammation, and the more inflammation, the more stimulated the growth of these cells.

The altered IgG produced by the synovial membrane is recognized by the body as a foreign agent, which triggers autoimmune processes and the production of antibodies against this type of immunoglobulin begins.

This type of antibody is called rheumatoid factor, and their presence greatly simplifies the diagnosis of rheumatoid arthritis.

Rheumatoid factor, getting into the blood, interacts with altered IgG, forming immune complexes circulating in the blood. The formed immune complexes (CIC) settle on the articular tissues and vascular endothelium, causing their damage.

CEC, settled in the walls of blood vessels, are captured by macrophages, which leads to the formation of vasculitis and systemic inflammation.

Thus, the pathogenesis of systemic rheumatoid arthritis is the formation of immunocomplex vasculitis.

Cytokines, in particular tumor necrosis factor, also have a great influence on the pathogenesis of the disease.

It triggers a number of immunological reactions, leading to stimulation of the production of inflammatory mediators, joint damage and chronicity of the process.

Rheumatoid arthritis ICD 10

For the classification of rheumatoid arthritis in modern medical practice, ICD 10 and the classification of the Russian Rheumatological Association of 2001 are used.

The ICD classification of rheumatoid arthritis refers it to diseases of the musculoskeletal system and connective tissue (code M05, M06).

The classification of the Rheumatological Association is more extensive.

It not only divides rheumatoid arthritis according to clinical manifestations, but also takes into account the results of serological diagnostics, the radiological picture and the violation of the patient's functional activity.

Rheumatoid arthritis code according to ICD 10:

1. M05 - seropositive rheumatoid arthritis (rheumatoid factor is present in the blood):

• Felty's syndrome - M05.0;
• Rheumatoid vasculitis - M05.2;
• Rheumatoid arthritis spreading to other organs and systems (M05.3);
• RA seropositive unspecified M09.9.

1. M06.0 - seronegative RA (no rheumatoid factor):

• Still's disease - M06.1;
• Rheumatoid bursitis - M06.2;
• Unrefined RA M06.9.

1. M08.0 - juvenile or childhood RA (in children from 1 to 15 years old):

• ankylosing spondylitis in children - M08.1;
• RA with systemic onset - M08.2;
• Juvenile seronegative polyarthritis - M08.3.

Inflammatory activity, reflected in this classification, is assessed by a combination of the following symptoms:

• the intensity of the pain syndrome on the VAS scale (Scale from 0 to 10, where 0 is the minimum pain, and 10 is the maximum possible pain. The assessment is subjective). Up to 3 points - activity I, 3-6 points - II, more than 6 points - III;
• stiffness in the morning. Up to 60 minutes - activity I, up to 12 hours - II, all day - III;
• ESR level. 16-30 - activity I, 31-45 - II, more than 45 - III;
• C-reactive protein. Less than 2 norms - I, less than 3 norms - II, more than 3 norms - III.

If the above symptoms are absent, then stage 0 of activity is set, that is, the stage of remission.

Course and forecast

Rheumatoid arthritis is a chronic, steadily progressive disease with periods of exacerbations.

Exacerbation of rheumatoid arthritis can provoke viral infections, hypothermia, stress, trauma.

The prognosis of rheumatoid arthritis depends, first of all, on the stage at which the disease was detected, and on the literacy of the selected treatment.

The earlier basic drug therapy begins, the better the prognosis of the disease regarding the preservation of working capacity and the ability to self-service.

The most frequent complications of rheumatoid arthritis are the development of joint dislocations, their deformation and the occurrence of ankylosis, which causes such consequences as limitation of the patient's normal daily activities and inability to move.

A condition such as ankylosis is the worst thing that rheumatoid arthritis is dangerous for, it leads to complete immobility of the joint and loss of self-care.

The gait is disturbed, over time it becomes more and more difficult to move. Ultimately, progressive rheumatoid arthritis leads to disability.

The prognosis for life is favorable, the average life expectancy in patients with confirmed rheumatoid arthritis is only 5 years less than in people from the general population.

With complex treatment, regular exercise therapy, 20-30% of patients manage to maintain activity, despite the progressive disease.