Treatment art rose of joints
- Training of patients (an adequate assessment of activity of a disease, rational use of symptomatic therapy, the physical exercises supporting function of joints)
- Pain reduction
- Inflammation reduction
- Improvement of a functional condition of joints
- Prevention of further destruction of an articulate cartilage
Indications to hospitalization
According to recommendations of Association of Rheumatologists of Russia (ARR), treatment of patients with OA should be carried out in out-patient conditions, except for need of surgical intervention, at an obvious inefficiency of carried-out standard therapy.
Osteoarthritis, part I: risk factors, classification, clinic>>> Osteoartrit, part II: laboratory, morphology, X-ray>>> Osteoartrit, part III: Differential diagnostics>>>
Paracetamol is a choice preparation for treatment an art rose of a knee joint and other localizations, at patients with a moderate pain syndrome (dokazatelnost level – And, see tab. 1). According to the European recommendations (ESCISIT) based on the metaanalysis of RKI, a dose of paracetamol 2-4 recommended for continuous reception (and above) g/days. However in the Russian recommendations, more approximate to the real clinical conditions, the dose of a preparation recommended for continuous reception should not exceed 2 g/days. In the specified dose safety of application of paracetamol is proved at OA within 2 years (And). Higher doses of a preparation, especially at elderly patients, conduct to essential increase of frequency of undesirable reactions (In).
At purpose of paracetamol it is necessary to consider:
- Potential gepato/nefrotoksichnost of a preparation with development possibility агранулоцитоза.
- Sinergizm with gepatotoksichny preparations
- Complications from ZhKT
- Undesirable combination to alcohol
Nonsteroid anti-inflammatory preparations (NPVP)
The general characteristic of NPVP most often used in Russia, is presented in the table.
General characteristic of NPVP most often used in Russia
Duration of action, h
The highest daily dose, mg
* Are selective TsOG-2 inhibitors
Unlike inflammatory arthritises, to treatment of osteoarthritis of NPVP apply only in strengthening of pains in minimum effective doses. Now the researches proving advantage of any NPVP over others are absent (And). In this regard the choice of a preparation is defined first of all by its safety in specific clinical conditions. Even short-term reception of NPVP at a certain part of patients can lead to development of serious side effects. The most frequent undesirable effects of NPVP – ZhKT defeat (10-50 %), aggregation violation тромбоцитов, a nefrotoksichnost (1-5 % at elderly patients of 5-15 %), negative influence on blood circulation system (1-5 %) – are a class – specific and are connected with suppression of activity of the TsOG "physiological" isomer (TsOG-1). Other side effects meet less often and, possibly, are not connected TsOG-1. Most often undesirable reactions arise at the persons of advanced age having accompanying diseases: coronary heart disease, diabetes, nephritic insufficiency, etc.
Reception of NPVP increases risk of development of ZhKK and ulcer punching more than in 4 times (C). Bleeding and punching of mucous ZhKT arise approximately at 1 of 100 the patients who are regularly accepting NPVP, and are an immediate cause of death approximately in 2 times more often than in the general population. Development NPVP-indutsirovannykh of ulcers in some cases can proceed bessimptomno («mute ulcers»). According to RKI, ulcers come to light at 15-40 % and more the patients who are regularly accepting NPVP of not selective row within not less than 6 months. The risk of development of serious complications among NPVP accrues as follows: ibuprofen < диклофенак < напроксен < индометацин. Для большинства НПВП риск ЖКК становится максимальным в среднем к 84 дню лечения, для индометацина - в течение первых 7 дней. Наличие клинических признаков развития серьезных ЖКТ-осложнений требует незамедлительной консультации хирурга, при необходимости - врача-реаниматолога. Эндоскопическими особенностями НПВП-гастропатии, позволяющими дифференцировать ее от язв, ассоциированных с H. Pylory, являются: преимущественная локализация в антральном отделе желудка, а также умеренно или минимально выраженные признаки воспаления слизистой оболочки. В случае выявления признаков кишечного кровотечения или железодефицитной анемии и гипоальбуминемии, при отсутствии иной причины (НПВП-гастропатии, поражения толстого кишечника и др.), показано обследование, направленное на выявление патологии тонкого кишечника. Важнейшие факторы риска развития НПВП-гастропатии суммированы в таблице.
Risk factors of development of NPVP-gastropatiya
Relative risk of development serious ZhKT-oslozhneny
- Existence of the ulcer anamnesis
- Simultaneous reception of NPVP of various groups (including low doses of aspirin)
- Reception of high doses of NPVP
- Reception of anticoagulants
- Advanced age (70 years are more senior)
- Reception of high doses of GKS
As gastroprotektor efficiency of appointment synthetic простагландинов and inhibitors of a proton pomp is proved (And). Blockers H2-gistaminovykh of receptors are effective for treatment NPVP-indutsirovannykh of ulcers and erosion of 12 perst
ny guts, but not a stomach (And). Inhibitors of a proton pomp are more effective than blockers of histamine receptors and мизопростол (And). Duration of reception of a course dose should be not less than 4 weeks, and at the big sizes and localization of ulcers in a stomach – 8-12 weeks. Duration of reception of "gastroprotektor" should correspond to duration of a course of reception of NPVP. Application of retardny forms, candles and enterosoluble tablets does not reduce risk of development of serious complications from ZhKT (In).
Increase of risk of development of kardiovaskulyarny pathology is a class – specific. According to Scott P. and сотр. (2006), these 12 observant researches which have presented the metaanalysis on the case control type, the relative risk of development of a sharp myocardial infarction against reception of all NPVP makes 1,14 (0,88-1,49), напроксена – 1,13 (0,98-1,29), tselekoksib – 1,17 (0,97-1,42), an ibuprofen – 1,19 (1,05-1,35), диклофенака – 1,42 (1,23-1,64) and rofekoksib – 1,61 (1,34-1,94). Indometacin, пироксикам and напроксен in sredneterapevtichesky doses and an ibuprofen (in a high dose) reduce efficiency of beta-blockers, диуретиков (фуросемид, a hydrochlorothiazide), APF inhibitors, to a lesser extent – calcium blockers.
Use of not selective NPVP (indometacin, an ibuprofen, пироксикам, пиразолоны, aspirin) and not narcotic analgetics (analginum, фенацетин, paracetamol) is the second (after antibiotics) on frequency the reason causing development of sharp nefropatiya. The heaviest and zhizneugrozhayushchy is development NPVP-indutsirovannoy of sharp nephritic insufficiency (OPN) and/or sharp interstitsialny nephrite. At 30 % of patients with HPN its development can be connected with NPVP reception. Risk factors haemo dynamic NPVP-indutsirovannoy OPN are: Gipovolemiya (warm insufficiency, диуретики, sepsis, nephrotic syndrome, etc.), advanced age, arterial hypertension, diabetes and giponatriyemiya.
In spite of the fact that nominally диклофенак treats the NPVP group of not selective row described above, this preparation is allocated by us separately owing to the greatest number of the mistakes allowed by doctors. The indication to application is generalizovanny polyosteoarthritis with the expressed pain syndrome, secondary sinovity. Duration of reception of a preparation in a dose of 75-150 mg/days should not exceed 10 days. Considering high risk of development of the gastropatiya, expediently accompanying purpose of gastroprotektor, especially at elderly patients. According to ARR recommendations, the daily dose диклофенака makes 50-100 mg. At patients with HPN it is obligatory dynamic (not more rare than once in 3-4 – month) control of level of nitrogenous slags, potassium, speed of a glomerular filtration (SKF), control of arterial pressure (HELL).
Selective TsOG-2 inhibitors
On expressiveness of analgetichesky effect it is proved surpass paracetamol (And). Possess the smallest risk concerning development of complications from ZhKT, cause ZhKK (approximately for 50 %), stomach ulcer and 12 perstny guts, defeat of thick intestines less often (And). Despite it, precautionary measures when using selective TsOG-2 inhibitors do not differ from those when using traditional NPVP. Purpose of these preparations is shown in all cases when the patient needs carrying out anti-inflammatory and analgetichesky therapy, but thus has at least one risk factor of development of NPVP-gastropatiya (And). At long use of preparations of this group it is necessary to consider physiological role TsOG-2 in synthesis простагландинов (healing of ulcers), простациклина endoteliy vessels, «an adaptive cytopatronage» ZhKT cages to toxic substances and a stress, regulation of an ovulation, function of kidneys, a reparation of fractures of bones of a skeleton. It is also necessary to consider that reception of preparations in the doses exceeding therapeutic, conducts to loss of selectivity and increase of frequency of side effects.
Sredneterapevtichesky doses of selective TsOG-2 inhibitors at OA
Nimesulid – 100 mg 2 times per day
Meloksikam – 7,5-15,0 mg 2 times per day
Tselekoksib – 100 mg 1-2 times per day.
NPVP local forms
The NPVP local forms (gels, ointments, creams) possess satisfactory analgetichesky activity and are safer in comparison with tabletirovanny forms concerning the pains connected with defeat of soft fabrics and OA of a knee joint. (А).
Tramadol – a synthetic opioidny analgetic. Does not influence haemo dynamics, does not oppress function of breath and does not cause accustoming. It is shown to application at OA for knocking over of the expressed pain syndrome at a paracetamol and NPVP inefficiency, and also impossibility of purpose of adequate doses of these HP (And). In the first days a daily dose – 50 mg, with the subsequent its increase to 200-300 mg/days. It is necessary to consider sedative effect of a preparation, potentiation of effect of ethanol.
Symptomatic medicines of slow action
It can be applied both as monotherapy, and in a combination to selective/not selective NPVP. In the latter case the risk of development of a miyelodepressiya (лейко / thrombocytopenia) considerably raises. Indications to application – generalizovanny polyarthritis with expressed inflammatory and painful components, torpedo to standard therapy. Efficiency of its application is based on detection in sinovialny liquid of crystals пирофосфата calcium, and also on ability колхицина to brake a degranulyatsiya of neutrophils. The preparation is appointed in a dose of 0,5-1 mg/days under dynamic control of function of a liver, kidneys, ZhKT. Lozhnopolozhitelny reactions of urine to hemoglobin and erythrocytes are possible.
Intra articulate introduction of corticosteroids
Accumulation and the analysis of results of the researches devoted to studying of pharmacological and farmakokinetichesky properties, efficiency and safety intra articulate (in / c) introductions of corticosteroids (GKS), led to essential revision of a role of these preparations in treatment an art rose of a knee joint. If in 1995 in WHO recommendations this type of therapy took a leading position, in the last recommendations (ESCISIT: 2003 – knee joints, 2005 – coxofemoral joints, 2007 – brushes) expediency from introduction of GKS admits only for knocking over expressed secondary синовита.
So-called locality from introduction of GKS is very conditional. A significant amount of a preparation gets into a system blood-groove that in fact, approaches local therapy to system purpose of GKS. Oppression of a bark of adrenal glands, emergence of a syndrome of Kushinga, an arterial hypertension, especially at elderly patients, can be shown even after one injection. The local katabolichesky effect is well-known – GKS promote loss протеогликана a cartilage, and at frequent introduction promote destruktsiya progressing up to osteonecrosis development (this fact is not strictly proved). Repeated GKS from introduction is possible not earlier than in 4-6 weeks from the moment of the first injection. Duration of the effect expressing in reduction of pain and symptoms of an inflammation, varies within 1 week – 1 month. (And). According to methodical recommendations of Ministry of Health of the Russian Federation (2001/25), lack of signs secondary синовита (so-called« the dry joint») is contra-indication to in/with GKS introduction.
Sredneterapevtichesky doses of preparations: триамцинолон – 20-40 mg, метилпреднизолон – 20-40 mg, beta metazones – 2-4 mg.
cosamine sulfate (GS), хондроитин sulfate (XC)
Despite low-study of the mechanism of the action, both preparations are widely used for symptomatic treatment of OA. The carried-out metaanalyses of numerous RKI according to efficiency of a glycosamine / хондроитин sulfate testify to existence of the authentic moderate delayed analgetichesky effect (an ibuprofen often conceding to therapeutic doses) at patients with a srednetyazhely current of OA of knee, coxofemoral joints and brushes (And). There is an impression about smaller efficiency of these preparations at patients with OA of coxofemoral joints. Actually hondroprotektivny effect is not proved and continues to be studied.
хондроитин sulfate - is applied on 750 mg by 2 times per day – the first 3 weeks, then on 500 mg in 2 times per day. Duration of a course – not less than 6 months.
glycosamine sulfate – inside on 1500 mg/days (once) or in/m 2-3 times a week. The general course – 4-12 weeks, repeated courses – 2-3 times a year.
Hyaluronic acid (group of companies)
According to results of carried-out RKI similar to a glycosamine / хондроитин to sulfate, group of companies possesses the proved moderate analgetichesky action (And). For treatment of OA use two versions of group of companies: with low molecular weight (500-730 кДа) and high-molecular group of companies (~600 кДа). It is shown that the last possesses more expressed anesthetizing effect. Duration of effect remains 3-12 months. Efficiency of treatment of OA of brushes, also as the hondroprotektivny effect of group of companies is not proved.
The means replacing sinovialny liquid (синвиск, ферматрон, etc.), homeopathic medicines (артрофоон, etc.), numerous biological active additives, поливинилпирролидон, and also the substances, urged to improve to a traffic хондроцитов (румалон, etc.) have now no sufficient demonstrative base in this connection cannot be recommended for application.
Training of patients
It is included in the Russian and European recommendations about maintaining patients with OA. Now the given method of treatment has low level of a dokazatelnost: it is shown that application of educational programs promotes reduction of a pain syndrome (And, C). Influence on function of a joint is discussed. Regular communication of the doctor with the patient by phone allows to reduce number of hospitalization and a total cost of treatment of OA (C).
Mode and physical activity
Now exists a large number of the various programs directed on decrease in pain and preservation of functional activity of joints at OA, prevention of cardiovascular diseases. Run and liftings on a ladder are undesirable. The individual program of physical exercises is made taking into account functionality of the specific patient. It is expedient to begin with isometric exercises, with gradual transition to exercises with counteractions in the conditions of moderate aerobic loading.
Absolute contra-indications for occupations by physiotherapy exercises:
- Uncontrollable arrhythmia
- Atrioventricular blockade of the 3rd degree
- Unstable stenocardia
- Infectious diseases in the sharp period
Application of various physiotherapeutic procedures still is the integral component of treatment of OA and other diseases of bone and muscular system that conducts to its unreasonably wide use, often in absence of necessary knowledge at doctors and пациен
The carried-out RKI devoted to local application of cold and heat, showed moderate analgetichesky effect at patients with OA of large joints that is reflected in the Russian and European recommendations (ESCISIT 2007). The last point to possibility of an ekstrapolirovaniye of the received results on patients from OA of brushes. Application of ultrasonic techniques is investigated at patients with OA of large joints – the effect does not exceed плацебо, unlike OA of peripheral joints at which the authentic anesthetizing effect is revealed. Chreskozhny stimulation of nerves, акупунктура also give authentic moderate analgetichesky effect. (А) The system review and the metaanalysis of RKI of efficiency of a magnetotherapy showed authentic analgetichesky effect at patients with OA of peripheral joints (And).
Thus, now according to results of the carried-out researches, application of physiotherapy is proved only at patients with OA of peripheral joints, for lack of expressed secondary синовита, infectious process, a tumor. Also it is necessary to mean possible increase of arterial pressure at a part of the predisposed patients.
Use of special adaptations
Use of an additional support (cane, crutch, etc.)
The purpose – unloading of joints. Support use in the hand opposite to the struck joint, is brought in the international recommendations (the special researches devoted to the assessment of efficiency of this method, are absent). At a bilateral severe damage of knee or coxofemoral joints use of crutches of the Canadian type / is recommended
Unloading of a knee joint
It is carried out by means of application of bandages or the nadkolennik of a various design fixing a knee in valgusny situation, and also use of orthopedic insoles with raised on 5?-10? lateral edge. An indirect sign of efficiency – reduction of intensity of a pain syndrome.
Application ортезов and a shinirovaniye of the 1st carpal пястного a joint (In). Promotes elimination of an incomplete dislocation and improvement of function of a brush.
Endoprotezirovaniye of knee, coxofemoral joints leads to pain reduction, improvement of impellent function and improvement of quality of life of sick OA (And). Duration of effect makes about 10 years (And). Frequency of infectious complications and repeated operations – 0,2-2,0 % annually (And). The best results of an endoprotezirovaniye are noted at patients at the age of 45-75 years, mass of a body – менее70 by kg., high social standard of living (And).
Indications to an endoprotezirovaniye of a knee and/or coxofemoral joint
- The expressed pain syndrome, resistant to carried-out therapy
- Mobility loss in a joint
- Impossibility to rise more than on one floor because of pains
- Impossibility to be at a stop more than 20-30 minutes because of pains
- Continuous violation of a dream because of pains
Unleavened wheat cake of knee joints
Indications to application – treatment an art rose of knee joints, resistant to conservative therapy and intra articulate introduction of GKS.
It is carried out arthroscopic by the qualified expert during which are removed детрит and blood clots, «articulate mice». The purpose – the anesthetizing effect lasting on the average 3 months. The best results are reached at detection in sinovialny liquid of crystals пирофосфата calcium
New type of surgical treatment of OA. The purpose – anesthesia and restoration of function of a joint. Less травматична at comparison with endoproteziruyushchy operations. Now results of carried-out researches are inconsistent, in this connection the place of this type of treatment continues to be specified.
Osteoarthritis, part V: Assessment of outcomes>>>