In the past, it was thought that there was no effective treatment for ankylosing spondylitis, but recent research shows that if the disease can be diagnosed and treated early, most of it can be well controlled or even cured in clinic. But unfortunately, because the onset of this disease is similar to general low back pain, patients often fail to seek help and seek medical treatment, suffering physically and mentally, and a few have been misdiagnosed or missed for a long time, which eventually leads to disability. Therefore, early and timely diagnosis is the key to successful treatment.
Treatment objectives:
(1) Control inflammation, relieve pain and stiffness symptoms, and prevent spinal joint deformity;
(2) Maintain a good posture and keep the range of motion and function of the spine and joints;
(3) Prevention of complications and drug side effects;
(4) It is feasible to correct joint dysfunction by surgery in the late stage of the disease.
Treatment methods include drug therapy, local therapy, physical therapy, gymnastics exercise, surgical treatment and traditional Chinese medicine treatment, among which drug therapy is the key. Drug therapy can quickly control the symptoms of patients, eliminate inflammation, alleviate the condition and make patients exercise better. At present, the commonly used drugs are non-steroidal anti-inflammatory drugs, slow-acting drugs, glucocorticoids and Chinese patent medicines. Because various drugs have their own advantages and disadvantages, the combined application of different drugs has become a new trend in the treatment of severe patients. For example, the combination of slow-acting drugs and Chinese patent medicines has become very common in clinic. It is worth pointing out that antimalarial drugs, gold preparations, penicillamine and azathioprine used to treat rheumatoid arthritis are ineffective against ankylosing spondylitis.
1, non-steroidal anti-inflammatory drugs (NSAID)
Non-steroidal anti-inflammatory drugs play an anti-inflammatory role by inhibiting cyclooxygenase (cox) and blocking arachidonic acid from forming prostaglandin. Sensitivity to NSAIDs is one of the characteristics of ankylosing spondylitis. This kind of medicine takes effect quickly, can control symptoms in a short time, can quickly improve patients' low back pain and stiffness, reduce joint swelling and pain, and increase joint range of motion, so it is the most widely used medicine. Therefore, the purpose of using such drugs is to relieve pain, enable patients to do more exercise and improve their quality of life, but it cannot change the course and activity of the disease.
Commonly used drugs are ibuprofen, oxaprozin (Nozon), loxoprofen (Le Song), naproxen, Tometin, diclofenac (Yingtaiqing, Oxfam, Dai Fen, Votalin), indomethacin (Indomethacin), sulindac (Chinoli), acemetacin (Youtuo) and etodolac (Etodol). The dosage can be adjusted according to the degree of pain of the patient, and the long-acting dosage can be given before going to bed if the symptoms are mainly morning stiffness. Anal suppository can be used for patients with obvious gastrointestinal reaction, and gastric mucosal protective agent can be used if necessary.
2. Chronic drugs
Commonly used are sulfasalazine and methotrexate. This kind of drugs take effect slowly, and it takes about 1 ~ 3 months to take effect, so it is called chronic drugs. Using these drugs to treat ankylosing spondylitis may slow down or prevent the development of the disease.
(1) sulfasalazine
Sulfasalazine (SSZ) has anti-infection, immunomodulation, anti-inflammatory and analgesic effects. It can control the disease activity of ankylosing spondylitis, improve joint pain and stiffness, and reduce serum IgA level, which is especially suitable for improving peripheral joint synovitis and is also effective for spinal symptoms. Generally, it takes effect 6 ~ 8 weeks after taking the medicine, and maintenance treatment can keep the condition relatively stable. The medicine has a good curative effect on patients with ankylosing spondylitis and acute attack with high ESR at the early stage, especially those with a history of chronic diarrhea. The initial impression is that this product is more suitable for early and mild symptoms, and it is better to use it early. Some scholars believe that the main indications for using this product include: ① 16 years old patients; ② When the disease activity is still high; ③ Patients with peripheral arthritis and extraarticular symptoms; ④ within 5 ~ 10 years after onset.
(1) Usage: SSZ is 0.25g/ time on 1 week, 3 times on 1 day, and then the dose is increased by 0.25g/time every week until the 4th week and 3 times on 1 day. Generally, the minimum effective dose is 0.5g/ time, 1, three times a day.
(2) Side effects: A few patients have adverse reactions after use, mainly gastrointestinal symptoms (nausea, gastrointestinal discomfort, loss of appetite, etc.). ), while other side effects such as rash (skin allergy), leukopenia and abnormal liver function are rare. It has been reported that this product can affect male reproductive ability, such as decreased sperm count, decreased vitality, abnormal morphology, etc., but it can be recovered after stopping taking the drug. Attention should be paid to the examination of blood picture and liver function during medication. HBV operators should use it with caution. Those who are allergic to sulfonamides are prohibited.
(2) Methotrexate (MTX)
Methotrexate (MTX) is a dihydrofolate reductase inhibitor (folic acid antagonist), and its efficacy is similar to that of sulfasalazine. Methotrexate may be effective for patients who have no response to NSAIDs and sulfasalazine. Oral administration and intravenous injection have similar curative effects.
(1) Usage: The usual dosage is 7.5 ~ 10mg(2.5mg/ tablet), once a week, and the short-term effect is acceptable.
(2) Side effects: mainly gastrointestinal reaction, other nervous system symptoms such as bone marrow suppression, stomatitis, alopecia, headache, etc. are rare, and can be recovered after drug withdrawal. Adding folic acid may be effective in relieving gastrointestinal reaction and stomatitis. Use with caution for the elderly, obesity, diabetes, active peptic ulcer, liver disease, hepatitis B virus carriers and patients with kidney disease; It is not suitable for pregnant women. It is not advisable to drink alcohol during taking medicine, and the blood picture and liver function should be checked regularly.
3. glucocorticoid
Glucocorticoid has a strong anti-inflammatory and analgesic effect on ankylosing spondylitis, but it can't control the development of the disease and has many side effects. Long-term use does more harm than good, so it should not be used as the first choice for the treatment of ankylosing spondylitis, especially in large and medium doses. For patients with the following conditions, it can be applied appropriately. The dosage of prednisone is generally10 ~ 30 mg/d.
(1) Severe peripheral arthritis resistant to NSAIDs can be treated by intra-articular corticosteroid injection or systemic medication.
(2) Patients who are allergic to NSAIDs or whose symptoms cannot be controlled by NSAIDs can be treated with low-dose corticosteroids (equivalent to less than 10mg of prednisone per day).
(3) If the symptoms are serious and NSAIDs or low-dose hormones can't be controlled, a larger dose, such as prednisone (20-30 mg per day), can be used. The symptoms are controlled, and the slow-acting drugs will gradually reduce or even stop after they play their roles.
(4) If the condition is acute, accompanied by high fever, the peripheral joints are obviously swollen and painful, or complicated with extra-articular symptoms, such as acute iritis and lung involvement, glucocorticoid should be used for treatment.
(5) The routine treatment of corticosteroids is to take it every morning. If the nociceptive pain is severe but the steroidal anti-inflammatory drugs are ineffective, taking 5mg orally before going to bed is effective in relieving nociceptive pain and morning stiffness.
(6) Some scholars reported that methylprednisolone was used as "shock therapy" for cases with rapid progress, that is, methylprednisolone 1g was injected intravenously every day for three days. Or dexamethasone 30 ~ 50 mg daily for 3 days, it seems that it can also effectively control the disease. But "shock therapy" is by no means a routine method, and the author does not recommend it.
The toxic and side effects of long-term use of corticosteroids are well known, so I won't repeat them here. However, if the short-term dose is less than 10mg per day, its side effects are generally not great. However, even a small dose of sensitive person can cause Cushing's syndrome if taken for a long time. In addition, some side effects of hormones, such as osteoporosis, are related to the total dose and course of treatment. Ankylosing spondylitis itself is prone to osteoporosis, especially in advanced patients, which often leads to severe osteoporosis. Therefore, corticosteroids should not be used for a long time in principle.
4. Stop the reaction
Domestic thalidomide is produced by Changzhou Pharmaceutical Factory, 25mg/ tablet. Some scholars have tried it in ankylosing spondylitis, and the preliminary results are satisfactory. The initial dose is 50mg/d, which is taken at night before going to bed. Then increase 1 times every 10d until it reaches 200 mg/d.
According to reports, 80% of 26 refractory cases are effective. After 3 ~ 6 months of treatment, some experimental indexes such as ESR and C-reactive protein decreased obviously. Most of them showed the greatest curative effect after 6 ~ 12 months of treatment. In 26 cases, 9 patients' pain symptoms disappeared. After the drug is effective, it is still necessary to continue taking the drug to maintain the curative effect, and the condition may be repeated after stopping taking the drug. The main side effects were mild drowsiness (8 cases) and dry mouth (6 cases), which disappeared after 4 weeks of continuous treatment. Dandruff increased significantly in 3 patients. Liver enzymes in 3 patients were slightly elevated (
The author thinks that thalidomide can be tried for refractory ankylosing spondylitis, but attention should be paid to the observation of side effects and the follow-up of long-term curative effect.
5. Tripterygium wilfordii polyglycoside
Tripterygium wilfordii polyglycoside is a Chinese patent medicine, which has strong anti-inflammatory, analgesic and immunosuppressive effects. It has effects on lymphocytes, monocytes and macrophages, and can also improve microcirculation and enhance adrenal cortex function. This product has the characteristics of no addiction and no drug resistance. This product is mainly used for rheumatoid arthritis (see 1 chapter # for details), and it has also been used to treat ankylosing spondylitis in China in recent years. It has certain effect on controlling joint pain and relieving morning stiffness. Some scholars have used this product in combination with methotrexate or azathioprine to treat ankylosing spondylitis with rapid progress or resistance to other treatment methods, but there are few cases and little experience, which needs further verification.
(1) Administration and dosage: 1 20mg above the head, 3 times a day, and 10mg after disease control, 2-3 times a day.
(2) Side effects: including gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhea), menstrual disorder, female amenorrhea (individual functional uterine bleeding), inhibition of sperm production, liver and kidney damage, leukopenia, rash or pigmentation, etc. Because of the influence of this product on germ cells, those who intend to have children should use it with caution or avoid using it, such as taking it in small doses for a short time.
6.sinomenine
The trade name of sinomenine is Zhengqingfengtongning. It is an alkaloid extracted from Sinomenium, which has analgesic, anti-inflammatory and immune effects. Zhengqingfengtongning is similar to morphine in chemical structure, but it is not addictive. It can inhibit granulation hyperplasia, promote the recovery of joint function, and has obvious cellular immune excitement and weaken humoral immune response, which is the same as corticosteroids. This product can be used to treat rheumatoid arthritis and ankylosing spondylitis, especially for ankylosing spondylitis patients with swelling and pain of peripheral joints. Has the functions of relieving symptoms and improving joint function.
(1) Usage and dosage: the dosage is 20mg/ time, three times a day, and it can be increased to 40mg/ time, three times a day after three days without adverse reactions, with the maximum dosage not exceeding 60mg/ time, three times a day.
(2) Side effects: The adverse reactions of this drug are mainly allergic reactions, such as itchy skin and rash, which may lead to leukopenia and thrombocytopenia. Routine blood tests and platelets should be checked regularly during medication. This product should be used under the guidance of a doctor; Use with caution those who have a history of drug allergy, allergic asthma or hypotension; Pregnant or lactating women should use it with caution.
7. Pavlin
Pavlin is a total glucosides of paeony capsule. The effective components are paeoniflorin, paeoniflorin, hydroxypaeoniflorin and benzoyl paeoniflorin. Paeonia lactiflora is a traditional Chinese medicine, which has the function of strengthening the body resistance and eliminating pathogenic factors. Pavlin can treat autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus and ankylosing spondylitis by anti-inflammation and regulating immune function. Each capsule contains 300 mg of total glucosides of paeony.
(1) Administration and dosage: orally, 600mg(2 capsules) once, 2-3 times a day, or as directed by the doctor.
(2) Adverse reaction: Pavlin is very safe to take orally, and has no obvious toxic effect on heart, liver, kidney, brain and other important organs. Can be taken for a long time, and has no teratogenic, mutagenic and carcinogenic effects. Occasionally, the soft stool can disappear without special treatment.
8. Slice the root of torch flower
The effective components of Huobahuagen tablets are alkaloids, terpenoids, lactones, phenolic acids, etc. Has the effects of expelling pathogenic wind, removing dampness, relaxing muscles and tendons, activating collaterals, and clearing away heat and toxic materials. It can obviously inhibit pathological immune response, and has anti-inflammatory and analgesic effects, and the effect will be enhanced with the increase of dose. The toxicity test shows that Huobahuagen tablet is a low toxic drug, which has no obvious effect on hemogram, liver and kidney function, liver, heart, spleen, kidney, thymus and other organs, and will not cause immune system damage after long-term use. Can be used for autoimmune diseases such as rheumatoid arthritis, rheumatoid arthritis, systemic lupus erythematosus, vasculitis and scleroderma. It can also be used for ankylosing spondylitis.
(1) Administration and dosage: taken orally, adults take 3-5 tablets each time (0. 18g each), three times a day. Take it after meals. 1 ~ 2 months is the course of treatment. Can be taken continuously for 2-3 courses of treatment. Still follow the doctor's advice.
(2) Adverse reactions: A few patients have epigastric discomfort and nausea after taking the medicine, which can be relieved after taking the medicine after meals. Young men and women with moderate or severe renal insufficiency or family planning and children should use it with caution.