2 The origins of Rheumatology Rheumatology - a branch of medicine devoted to the study of rheumatic diseases and disorders of the function and / or structure of the musculoskeletal system.In the I century AD was the first appeared in the literature, the concept of rheuma (revma). The word "rheuma" of Greek origin. Rheuma refers to "a substance that flows", probably formed from phlegm. This is the "primary juice," by definition of the ancients, which was formed in the brain and flowed in different parts of the body, causing illness.
3 The origins of Rheumatology In 1642, the term "rheumatism" was introduced in the literature by french physician Dr. G. Baillou, who supposed that arthritis can be a manifestation of systemic disease.
4 The origins of Rheumatology In 1928, in the USA Dr. R. Pemberton organized the American Committee for the treatment of rheumatism, which was renamed the American Association for the Study and Treatment of rheumatic diseases (1934), followed by the American Association of rheumaticism (1937) and, finally, the American Rheumatology Association (1988).
5 The origins of Rheumatology In 1940, Bernard Comroe suggested the term "rheumatologist.“In 1949, Hollander uses the term "rheumatology" in his textbook on arthritis and painful condition (Arthritis and Allied Conditions).
6 History of the discovery of some rheumatic diseases
8 Acute rheumatic feverThe doctrine of rheumatism has a long history. For the first time information about rheumatic arthritis appeared in the writings of Hippocrates. There was humoralism (Latin humor - fluid) - current through the joint process.In the early XX century, all were regarded as diseases of the joints and rheumatism.Classic works consecrated to the ARF, have been written by Jean-Bapite Bomllard and Walter B Cheadle and published in 1836, which detailed the "rheumatic arthritis" and carditis.At one time Lasegue said: "Rheumatism licks the joints but bites the heart.“S. Botkin has been shown that ARF affects many organs: kidneys, skin, nervous system, liver and lungs.
9 Acute rheumatic feverIn 1904 morphologist Ludwig Aschoff first discovered and described the morphological substrate of rheumatic fever - a kind of cell granuloma. In 1929 Talalayev showed that rheumatic granuloma Aschoff - only one stage, but it has 3 phases: exudative, proliferative phase, cell proliferation and sclerosis. So now the rheumatic granuloma-called Aschoff Talalayev.In 1933, Rebecca Lancefield was divided into groups hemolytic streptococci, helping researchers clarify the epidemiology of the disease. For the first time the criteria for leadership in the diagnosis of ARF were developed by Dr. T Duckett Jones and published in Later they were adopted and revised by the American Heart Association.
13 Rheumatoid arthritisThe earliest signs of rheumatoid arthritis were found in 4500 BC. They were found on the remains of skeletons of Indians in Tennessee, USA.The first paper describing the symptoms are very reminiscent of the symptoms of rheumatoid arthritis dates back to 123 a year.
14 The first clinical description of this pathology in 1800, is credited with Augustin-Jacob Landre-Beauvais. The author called the disease variant of gout - a "simple asthenic gout" (goutte asthenique primitif).Benjamin Brodie described the slow progression of synovitis by involving joint capsule and tendon sheath.
15 Joint swelling in early rheumatoid arthritis Deformities of long-standing rheumatoid arthritis
17 Rheumatoid arthritisA. Garrod suggested the term "rheumatoid arthritis" in 1858 and differentiate it from gout in 1892, the disease got its present name.
18 Systemic lupus erythematosus The name lupus, the Latin version as Lupus erythematosus, comes from the Latin "lupus", which means wolf and "eritematozus" - red, because of its similarity to the bite injuries hungry wolf.
19 This disease is known to doctors since 1828, after describing the French dermatologist Biett skin symptoms
20 45 years later Kaposhi (dermatologist) observed that some patients with skin symptoms are also symptoms of internal organs.
22 In 1845, Ferdinand von Hebra described a rash on the type of "butterflies" on her nose and cheeks.
23 Systemic lupus erythematosus In 1948,William Hargraves described the LE-cells. This discovery allowed doctors to identify many patients with systemic lupus erythematosus.In 1956, Miescher, described the absorption of LE- cell factor kernels.In 1958, George Friou described a method for identification of antinuclear antibodies.
24 Spondyloarthropathies (ankylosing spondylitis) The archaeological study of Egyptian mummies found the disease, which is now called ankylosing spondylitis is known to mankind since ancient times.The first historical description of the disease in the literature refers to 1559, when Realdo Colombo described the two skeletons with typical changes of ankylosing spondylitis in his book "Anatomy.“100 years later, in 1693, an Irish physician Bernard Connor described the skeleton of a man with signs of scoliosis, in which the sacrum, hip bone, lumbar vertebrae and 10 thoracic vertebrae with ribs are fused into one bone.
25 Spondyloarthropathies (ankylosing spondylitis) In the late 1890s, Russian doctor, Vladimir Bekhterev and French doctors Adolf Strumpell and Pierre Marie described ankylosing spondylitis.Linking disease to a gene class I HLA-B27 belongs to the Americans Lee Schlosstein, Rodney Bluestone and Paul Terasaki, as well as the British Derrick Brewerton, Caffrey and Nichols.
27 Classification of rheumatic / musculoskeletal syndromes in different years
28 Rheumatology as a specialty Rheumatology as an independent scientific and practical discipline was formed 45 years ago.Rheumatic diseases are one of the most common pathologies of the human body.The term "rheumatic disease" include a variety of origins of the disease predominantly systemic, less local character, proceeding with persistent or transient articular syndrome.
29 The origins of the classification Theoretical basis for combining these various diseases in the same group was the fact that their basis is a preferential loss of connective tissue, as dense, which include the dermis, tendons, ligaments, cartilage, bone and others, and its special types (synovial and serous membranes, basal membranes of blood vessels and epithelium, etc.).
30 Working classification and nomenclature of rheumatic diseases (1999) I. Rheumatism (rheumatic fever)II. Diffuse diseases of connective tissue1.0. Lupus Erythematosus2.0. Systemic Scleroderma3.0. Diffuse Fasciitis4.0. Dermatomyositis (polimiozit)5.0. Disease Šhoegren6.0. Mixed connective tissue disease7.0. Rheumatic polimialgia8.0. Recurrent polihondritis, including Tietze disease9.0. Recurrent pannikulitis (Weber-Christian disease)
32 Working classification and nomenclature of rheumatic diseases (1999) IV. Rheumatoid arthritis V. Juvenile arthritis VI. Ankylosing spondylitis (Bechterew) VII. Arthritis, combined with spondylarthritis psoriatic arthritis Reiter's disease Arthritis in chronic nonspecific bowel disease (ulcerative colitis, ileitis regionar-ny Crohn's disease) Arthritis, and (or) sacroiliitis unspecified etiology
33 VIII. Arthritis associated with infection 1. infectious arthritis 1. 1 VIII. Arthritis associated with infection infectious arthritis Bacterial (staphylococcal, brucellosis, syphilis, spirochetal, mycobacterial, tuberculosis, etc.) Lyme disease Whipple's disease viral fungal parasitic
34 2.0. Reactive arthritis Postenterocolitic (shigellosis, yersiniosis, salmonellosis, klebsiellosis, etc.) Urogenital (excluding Reiter's disease and gonorrhea) After nasopharyngeal infection After vaccination
35 2.0. Реактивные артриты2.1. Постэнтероколитические (шигеллез, иерсиниоз, сальмонеллез, клебсиеллез и др.)2.2. Урогенитальные (исключая болезнь Рейтера и гонорею)2.3. После носоглоточной инфекции2.4. Поствакцинальные
36 IX. microcrystalline arthritis 1. primary gout 2 IX. microcrystalline arthritis primary gout Gout secondary (drug, renal insufficiency, lead intoxication, etc.) Chondrocalcinosis (pseudogout) hydroxyapatite arthropathy
37 Рабочая классификация и номенклатура ревматических болезней (1999) IX. Микрокристаллические артриты1.0. Подагра первичная2.0. Подагра вторичная (лекарственная, при почечной недостаточности, свинцовой интоксикации и др.)3.0. Хондрокальциноз (псевдоподагра)4.0. Гидроксиапатитовая артропатия
38 X. osteoarthritis XI. Other joint diseases 1. palindromic rheumatism 2 X. osteoarthritis XI. Other joint diseases palindromic rheumatism intermittent hydrarthrosis multiple retikulohystiocytosis Sinovioma chondromatosis of the joint Villonodulary synovitis
39 XI. Другие болезни суставов 1.0. Палиндромный ревматизм2.0. Интермиттирующий гидрартроз3.0. Множественный ретикулогистиоцитоз4.0. Синовиома5.0. Хондроматоз сустава6.0. Виллонодулярный синовит
40 XII. Non-rheumatic diseases with arthropathy 1.0. allergic diseases Metabolic disorders2.1. Amyloidosis2.2. Ochronosis2.3. Hyperlipidemia2.4. hemochromatosis Congenital defects of the connective tissue metabolism3.1. Marfan's syndrome3.2. Desmogenez imperfecta (Ehlers - Danlos syndrome)3.3. Hypermobility syndrome3.4. MPS
42 4. endocrine diseases 5. nervous 6. Diseases of the blood 7 4.0. endocrine diseases nervous Diseases of the blood Paraneoplastic syndrome (malignant tumors of various sites) occupational diseases Other diseases 9.1. Sarcoidosis is 9.2. Periodic disease 9.3. Chronic active hepatitis hypovitaminosis C
43 4.0. Эндокринные заболевания 5.0. Поражения нервной6.0. Болезни системы крови7.0. Паранеопластический синдром (при злокачественных опухолях различной локализации)8.0. Профессиональные болезни9.0. Другие заболевания 9.1. Саркоидоз Периодическая болезнь 9.3. Хронический активный гепатит 9.4. Гиповитаминоз С
44 XIII. Diseases of the extra-articular soft tissues 1 XIII. Diseases of the extra-articular soft tissues Diseases of the muscles of1.1. Myositis1.2. Ossifitsiruyuschy myositis2.0. Diseases of the tissues around3.0. Diseases of the fascia and aponeuroses 4.0, subcutaneous disease. Fat5.0. Poliosteoartromialgiya (psychogenic rheumatism)
45 Рабочая классификация и номенклатура ревматических болезней (1999) XIII. Болезни внесуставных мягких тканей Болезни мышц 1.1. Миозиты Оссифицирующий миозит 2.0. Болезни околосуставных тканей 3.0. Болезни фасций и апоневрозов 4.0, Болезнь подкожной .жировой клетчатки 5.0. Полиостеоартромиалгия (психогенный ревматизм)
46 XIV. Bone disease and osteochondropathy 1. bone disease 1. 1 XIV. Bone disease and osteochondropathy bone disease Osteoporosis (osteopenia), generalized osteomalacia Osteopathy hypertrophic pulmonary (Marie- Bamberger syndrome) Osteitis deformans (Paget's disease) Osteolysis (unspecified etiology)
47 XIV. Болезни костей и Остеохондропатии 1.0. Болезни костей 1.1. Остеопороз (остеопения) генерализованный1.2. Остеомаляция1.3. Остеопатия гипертрофическая легочная (Мари- Бамбергера синдром)1.4. Деформирующий остеит (болезнь Педжета)1.5. Остеолиз (неуточненной этиологии)
48 2.0. osteochondropathy Aseptic necrosis of the femoral head (Perthes disease) and other sites (Köhler's disease I and II, disease Kenbeka, etc.) osteochondritis dissecans Osteochondropathy vertebral disease (Sheyermana - May, Calve's disease) Osteochondropathy tuberosity of the tibia (Osgood disease - Schlatter
49 2.0. Остеохондропатии2.1. Асептические некрозы головки бедренной кости (болезнь Пертеса) и других локализаций (болезнь Келера I и II, болезнь Кенбека и др.)2.2. Рассекающий остеохондрит2.3. Остеохондропатии тел позвонков (болезнь Шейермана — May, болезнь Кальве)2.4. Остеохондропатии бугристости большеберцовой кости (болезнь Осгуда — Шлаттера
51 The values of laboratory data Laboratory tests may help in diagnosis and to confirm data obtained by history taking and examination, but are not independently diagnostic criteria.In addition, laboratory tests can help monitoring disease activity, but they are meaningful only when correlated with clinical outcome.
52 Laboratory studies in rheumatic diseases AnemiaNormochromic - Correlation with disease activityIron - NSAID-associated gastrointestinal pathologyHemolytic - SLE, APSAplastic - Citostatic, phenylbutazone, D-penicillamine, etc.LeukocytesLeukocytosis - A high activity of inflammation, with Still, the infectionLeukopenia - SCR (lymphopenia), with m-Felty (neutropenia)PlateletsThrombocytosis - The high activity of inflammationThrombocytopenia - SLE, APSKLF - Increase - Inflammatory myopathies
53 Laboratory studies in rheumatic diseases Transaminases, bilirubin - Increase - Pathology of the liver with "rheumatologic" manifestations of the toxicity of drugs (methotrexate, NSAIDs)Uric acid - Hyperuricemia – GoutMarkers of inflammationIncreased ESR - Active inflammation , a diagnostic criterion for polymyalgia rheumatica and giant cell arteritis, intercurrent infectionIncreased CRP - PA - activity of inflammation, joint destruction, SLE - intercurrent infectionUroscopyMicrohematuria – nephritidis (SLE, systemic vasculitis), toxic drugsProteinuria – nephritidis (SLE, systemic vasculitis, amyloidosis), the toxicity of drugs
54 The value of immunological tests in rheumatic diseases Diagnosis in tipical clinic manifestDif-DiagnosisScriningMonitoringAnti-nuclearSLE+++++-?Anti-DNA+Anti-body -Sm, RNPSLE, Mixt pathС3, С4Nephropaties in SLEСН50Rheumatoid factorRA
55 The value of immunological tests in rheumatic diseases Diagnosis in tipical clinic manifestDif-DiagnosisScriningMonitoringCRPAR+-+++CryoglobulinsAR, SLE?АSL-0ARF++ANCAVasculitidisАnti-phosfolipidesAPhSHLA B-27ASAnti-body at LymeLyme d.
56 The disease, in which can increase the RF in the serum Subacute bacterial endocarditisLeprosyChronic inflammatory disease of unknown etiologyTuberculosisSyphilisSarcoidosisLyme DiseasePeriodontal diseaseInterstitial lung diseaseViral diseasesLiver diseaseRubellaCytomegalovirusMixed cryoglobulinemia
57 Autoantibodies in rheumatic diseases TypeDescriptionClinical interfaceАnti –ds DNAAntibodies to double strand of DNA, have greater specificity than antibodies to ssDNAHighly specific for SLE, rarely detected in other diseases and in healthy peopleAnti – HistonMost diagnostic tools are not shared by antibodies to the five main types of histonesSLE, lupus medication, other autoimmune diseasesAnti – ENATypical diagnosticum to 2 extractable nuclear antibodies (Sm and RNP - ribonucleoprotein)Highly specific for SLEAnti – SSA/RoribonucleoproteinSLE (especially subacute cutaneous lupus), lupus neonatal syndrome ShogrenAnti – SSB/LaShogren's syndrome, lupus erythematosus, SLE newborn
58 Autoantibodies in rheumatic diseases TypeDescriptionClinical interfaceAnti – centromerAntibodies to the centromere / kinetochore region of chromosomeLimited scleroderma (CREST)Anti – Scl 70Antibodies to topoisomerase 1 DNAsclerodermaAnti – Jo-1Antibodies to the transfer-RNA synthetasePoly / dermatomyositis, particularly in patients with insterstitsialnym lung disease, Raynaud's phenomenon, cracked skin of hands (mechanical arm), arthritis, and resistance to therapyAnti – PM-SclAntibodies to nuclear components of granularPolymyositis / scleroderma Overlap syndromeAnti – Mi-2Antibodies to nuclear antigens of unknown functiondermatomyositis
59 The main indications for diagnostic arthrocentesis MonoartritisTrauma with effusion into the joint cavitySuspected purulent arthritisSuspicion of microcrystalline (urate, hydroxyapatite), arthritisunclear diagnosis
60 The value of radiology in rheumatic diseases ThoraxHand and footSacroiliacKnee jointsotherRheumatoid arthritis++++The thoracic spineOsteoarthritis-++ASLumbar spineReactive arthritisHeel boneSLESclerodermaThe EsophagusGoutOsteoporosisDensitometry, spine
61 Minimum set of laboratory tests to diagnose the causes of joint pain The total blood count,plateletsESRBilirubinTransaminaseCKCreatinineuric acidUrinalysis, daily urine for proteinMicroscopic analysis of synovial fluid, including crystalsCRPrheumatoid factorantinuclear factorAnti-DNAA/b to extractable nuclear antigen (RNP)ANCAASL-ODetermination of chlamydial antigen A/b to B.burgdorferiHLA B-27
62 Minimum set of radiographic studies to diagnose the causes of joint pain ChestHands and distal foot in front projectionPelvis in frontal projectionKnee in frontal and lateral projectionsCervical spine in a straight line and lateral projectionsThe lumbar spine and lateral projectionsHeel boneEsophagusDensitometry
63 Application of the morphological study (biopsy) in diagnosis of rheumatic diseases and their complicationsPolymyositisSjogren's diseaseDiffuse eosinophilic fasciitisSystemic vasculitisSecondary amyloidosisDifferential Diagnosis in subcutaneous sites (rheumatoid nodule / tophi)Differential diagnosis of suspected tumor of the synovial
65 Non-steroidal anti-inflammatory drugs for treatment of rheumatic diseases MedicationDosePossible side effectsDiclofenac potassiummg/24 h, divided into 2-4 receptionFor all NSAIDS: abdominal pain, or stomach, cramps, discomfort, edema (oedema), diarrhea, nausea, vomiting, heartburn, dizziness, headache, allergic reactionsDiclofenac sodiummg/24 h, divided into 2-4, or 100 mg in the form of retardEtodolakmg/24 h, divided into 2-4 reception. In the form of retard 1 dose mg/24 hIbuprofenmg/24 h, divided into 3-4 receptionIndomethacinmg/24 h, divided into 2-4, either in the form of retard 75 mg 1 times a day, 75 mg 2 times dailyKetoprofenmg/24 h divided into 3-4 reception or retard mg/24 h 1 timesMeloxicammg/24 h 1 times per dayNaproxenmg/24 h divided 2 receptionNimesulidemg/24 to 1-2 receptionPiroxicam20 mg/24 h in 1-2 reception
66 Prevention and treatment of GASTROINTESTINAL pathologies resulting from receiving NSAIDS Antacidshave no data about their effectivenessH2-blockersCure duodenal injury duodenal injury in Warn high doses were effective at the level of the stomach and eliminate symptoms caused by NSAIDSImprove semiologyInhibitors proton pumpis effective for the prevention and treatment of gastroduodenal of defeatsImproves semiology
67 Risk factors for the development of renal failure in the application of NSAIDs High risk Reducing the volume of circulating blood, as significant bleeding or hemodynamic disturbances on the type of shock Severe heart failure Cirrhosis of the liver with / without ascites Clinically significant dehydration Low - medium risk True kidney disease diabetic nephropathy nephrotic syndrome hypertensive nephropathy beginning of anesthesia The controversial risk advanced age
68 CorticosteroidsCorticosteroids are widely used in the treatment of inflammatory forms of arthritis and related systemic autoimmune diseases.In addition to their strong anti-inflammatory effect, they regulate a wide range of metabolic, immunological and central nervous system function.For systemic therapy have been issued numerous synthetic derivatives, but the prednisone, prednisolone, and methylprednisolone are used most widely.
70 Side effects of long-term Cortico-Therapy FrequentHypertensionNegative calcium balance and secondary hyperparathyroidismNegative nitrogen balanceObesity, moon face, supraclavicular fat accumulation in the area, fat accumulation in the form of a mountain on his back,Slowing of wound healing, erythema face, thin, fragile skin, blue striae, petechiae and ecchymosisAcne
71 Side effects of long-term Cortico-Therapy Growth retardation in childrenAdrenal insufficiency, resulting in suppression of the hypothalamic-pituitary-adrenal systemHyperglycemia, diabetes mellitus, dyslipidemia, atherosclerosisSodium retention, hypokalemiaIncreased risk of infection, neutrophilia, lymphopeniaOsteoporosis, compression fractures of vertebrae, OsteonecrosisMood changes such as euphoria, emotional lability, insomnia, depression, increased appetitesubcapsular cataract
72 Side effects of long-term Cortico-Therapy medium frequencymetabolic alkalosisDiabetic ketoacidosis, hyperosmolar diabetic comaPeptic ulcer (usually the stomach), gastric bleeding"Silent" intestinal perforationIncreased intraocular pressure and glaucomaMild intracranial hypertension or pseudotumor of the brainspontaneous fracturespsychosis
73 Side effects of long-term Cortico-Therapy RareSudden death in the rapid introduction of high-dose, pulse therapyValvular damage in SLEIn susceptible patients may develop heart failureCellulitis (after cancellation)Hirsutism or virilism, impotence, secondary amenorrheaHepatomegaly as a result of fatty liver exophthalmosAllergies to synthetic corticosteroids (urticaria, angioedema)
74 Pathogenic (Basic) therapy of inflammatory rheumatic diseases Disease modifying antirheumatic drugs (DMARDs) - the basic drugs from diverse group of funds that reduce the symptoms of rheumatoid arthritis (RA) and other inflammatory autoimmune diseases.In addition, there is increasing evidence that treatment with DMARD, especially if appointed early in the course of the disease, can delay the progression of cartilage and bone.When the RA is not responding to treatment DMARD, can be applied biological therapy. Biologicals alter the action of cytokines
75 Basic therapyWhen to start - an understanding that changes in the joints can occur within the first 12 months of the debut of RA, led to the earlier introduction of DMARD and more aggressive combination DMARD.Monotherapy - Methotrexate is considered standard therapy for DMARD.Combination therapy - Join one or two DMARD therapy with methotrexate for the background is often used in an attempt to improve clinical response in those patients who did not give an answer to monotherapy with methotrexate. The most commonly used combinations of DMARD - "triple therapy" (methotrexate + hydroxychloroquine sulfosalazin +) or methotrexate plus a biological agent.
76 Pathogenetic (Basic) drugs MedicationDosagePossible side effectsAzathioprinemg/day in 1-3 receptionLeukopenia, increased transaminaseWobenzym15-9 drops in 3 receptionFlatulence, change the color and smell of urine, rarely allergic reactions in the form of urticariaCyclophosphamidemg per day in single doseHematuria, hair loss, leukopenia, amenorrhea, nausea, vomitingCyclosporinemg daily in 2 receptionHypertension, increased hair growth, reduced kidney function, hypertrophy of gum, tremorHydroxychloroquinemg daily in 2-1 receptionViolation of, diarrhea, rash
77 Pathogenetic (Basic) drugs MedicationDosagePossible side effectsLeflunomid10-20 mg/day in 1. Treatment begins with a dose of 100 mg support screens from 3 consecutive daysDiarrhea, dizziness, hair loss, hypertension, increased transaminase, leukopenia, rash on the skinMethotrexatemg/weekDiscomfort in the stomach, skin rash, headache, photosensitivity, increased transaminase, leukopenia, ulcers in the mouth, weakness, fatigueMycophenolate Mikofenolat1.5-dayDiarrhea, moderate leukopeniaSulfasalazinemg daily in 2-4 receptionAbdominal pain, diarrhea, increased sensitivity, reduced appetite, nausea, vomiting, rash on the skinWobenzym9-15 drops in 3 receptionThe feeling of crowding in the stomach, nausea, allergies (skin rashes).
78 Treatment strategies with drugs Sequential monotherapyStep-up (ascending) combination therapy3. Step-down (descending) combination therapy4. Combination with a biological agent
79 Biological therapyOne of the most important achievements of the pharmacotherapy of inflammatory rheumatic diseases associated with the development of entirely new group of drugs, which are called "biological" agents.Their mechanism of action is associated with suppression of synthesis of "inflammatory" cytokines, play a fundamental role in the immunopathogenesis of these diseases, especially RA.
80 Immunomodulating and proinflammatory effects of cytokines in the pathogenesis of inflammatory rheumatic diseases (1)Vascular endothelial cells - enhance the expression of adhesion molecules (ISAM-1, VSAM-1, E-selectin) through the activation of NF-kV stimulate angiogenesis, leading to disruption of anticoagulant activity (stimulation of the synthesis of tissue factor, suppression of synthesis of thrombomodulin).Lymphocytes - contribute to the development of lymphoid tissue, modification of SV44 and the ability to bind to the ligand.Dendritic cells - cells induce the maturation and migration from nonlymphoid organs to secondary lymphocyte organs.Neutrophils and platelets - contribute to activation.
81 Immunomodulating and proinflammatory effects of cytokines in the pathogenesis of inflammatory rheumatic diseases (2)Fibroblasts and synoviocytes - lead to proliferation.Pro-inflammatory cytokines - in addition induce the synthesis of IL-1, IL-6, granulocyte-macrophage colony-stimulating factor.Other pro-inflammatory mediators - induce the synthesis of PGE2 through activation of COX-2, leukotrienes, platelet activating factor, nitric oxide and reactive oxygen species.Metalloproteinases - induce the synthesis of collagenase, gelatinase, stromelysin.Other effects - increase pain, induce cachexia, induce fever, mobilize calcium from the bones; modulate apoptosis.
82 Biological therapyThe particular interest is the use of monoclonal antibodies.These drugs have very high specificity, which provides a selective effect on certain links in the immunopathogenesis of disease, minimally affecting normal functioning mechanisms of the immune system.This can significantly reduce the risk of "generalized" imunosupresed, which is typical of many drugs, especially glucocorticoids and cytotoxic drugs.
83 Monoclonal antibody to TNF-α HummanHummanisedKimerikMouse100% human protein5% -10% protein of the mouseAdalimumab GolimumabAdalimumab (Adalimumab)25% protein of the mouse100% mouse proteinInfliximab
84 Biological therapyThe main target for anticytokine monoclonal antibody therapy is:TNF-alpha (infliximab, adalimumab, etc.)IL-6 (tocilizumab)CD20 B cells (rituximab)IL-1, IL-2, etc.
85 Contraindications of biological therapy Congestive heart failure,Severe infectionLatent tuberculosisMalignant neoplasmsPregnancy and lactation.
86 The need for biological specimens The number of patientsThe gravity of the condition of the patientBiologicalsCorticosteroidsBasic drugs(methotrexate, sulfasalazine, leflunomid)
90 What is Rheumatology?Rheumatology is the non-surgical subspecialty of internal medicine that focuses on common and complex problems that may affect the entire body, and frequently involves the musculoskeletal system. Such diseases include: rheumatoid arthritis; gout; lupus; scleroderma; osteoporosis; fibromyalgia and spondylitis. Common problems such as tendonitis, back pain, bursitis and carpel tunnel syndrome can be a result of rheumatologic disorders as well.There are more than 100 types of rheumatological disorders, some of which are very serious and difficult to diagnose and treat.