From the medical journey of the "pioneer" of rheumatology, explore the essence of integrated Chinese and Western medicine in the treatment of RA

*For medical professionals only

In 1999, the World Health Organization listed rheumatism as the third major killer of human health after cardiovascular disease and cancer ^[1].

In China, rheumatology and immunology is the latest specialty established in internal medicine ^[2], and the first generation of "rheumatologists" shoulders the dual responsibility of disease diagnosis and treatment and discipline development and construction, faces various opportunities and challenges, and has achieved great development
in the past decades.
To this end, the medical community specially invited Professor Qiu Mingshan, a "pioneer" of the Department of Rheumatology of Xiamen Hospital of Traditional Chinese Medicine, to review the medical journey of the department construction and share the expert experience
of rheumatology diagnosis and treatment.

Western medicine should be strong, Chinese medicine should be refined, and the rheumatology department that came out of "two legs" pioneered the road

Rheumatism is an autoimmune disease that affects about 355 million people worldwide, which seriously affects the physical and mental health of patients, brings a heavy economic burden to patients, and hinders the development of society^[1].

In China, due to the late start of the recognition and knowledge popularization of rheumatic diseases, it was not until 1985 that the Rheumatology Branch of the Chinese Medical Association was established
.
In order to improve patients' awareness of diseases, improve treatment compliance, and thus improve the prognosis and quality of life of patients, various regions in China have successively carried out the construction of rheumatic disease specialties and trained professional diagnosis and treatment personnel
.

Professor Qiu Mingshan, as one of the first pioneers in the construction of the Department of Rheumatology of Xiamen Hospital of Traditional Chinese Medicine, said: "The Department of Rheumatology of Xiamen Hospital of Traditional Chinese Medicine is a relatively young discipline, and it has only been 17 years since the establishment of the department ward in 2005
.
”

At the beginning of the establishment of the team, only three doctors in the department carried the beam of the construction of the rheumatology department of Xiamen Hospital of Traditional Chinese Medicine
.
Professor Qiu Mingshan recalled: "In the past, due to the lack of scientific materials for rheumatic diseases, the general public lacked access to disease knowledge, so many patients delayed diagnosis and treatment, and even caused irreversible physical harm
.
Therefore, in order to strengthen patients' understanding of the disease, Professor Qiu Mingshan took the initiative to use his spare time to popularize rheumatism knowledge, and in the long run, he also established a preliminary understanding
of rheumatism in the hearts of the public.

"Adhering to the motto of Dean Chen Yinglong's 'I wish to treat people's illnesses as their own diseases, and save his life is my life', inheriting the academic thought
of Zhu Liangchun, a master of traditional Chinese medicine.
Taking the theory of 'phlegm and stasis causing disease' of President Chen Jinchun as the starting point, we have established a diagnosis and treatment model of integrated Chinese and Western medicine, and formed a unique system
of combining Chinese and Western differentiation of rheumatism.
Professor Qiu Mingshan
, shared.

As a practitioner of the combination of Chinese and Western medicine diagnosis and treatment, Professor Qiu Mingshan said, "Our department has always adhered to the discipline development concept of 'walking on two legs', and strives to be strong in Western medicine and refined in Chinese medicine
。 On the one hand, we require department staff to master immunology technology, have a clear understanding of the diagnosis and treatment guidelines of various rheumatological diseases, keep up with the forefront of medical development, and practice standardized rheumatology diagnosis and treatment practices; On the other hand, based on the fact that most of the doctors in the department come from traditional Chinese medicine, we have accumulated rich experience in the diagnosis and treatment of traditional Chinese medicine, so it is more conducive to integrating the essence of traditional Chinese medicine with western medical technology, combining the external treatment decoction of traditional Chinese medicine, acupuncture moxibustion, and ultrasound shock wave treatment with the treatment of ultrasound shock wave, providing more treatment options for rheumatology patients through the comprehensive treatment strategy of internal and external treatment
.
”

Today, the Department of Rheumatology of Xiamen Hospital of Traditional Chinese Medicine has become a key specialty established by the State Administration of Traditional Chinese Medicine, the fourth batch of key medical specialties in Xiamen, and has formed a technical team
integrating medical treatment, teaching and scientific research.

Glucocorticoids still need to be weighed in RA for lack of speed

Rheumatoid arthritis (RA) is the most common systemic rheumatism in China [2], as an expert in the field of rheumatology diagnosis and treatment, Professor Qiu Mingshan mentioned: "RA is an autoimmune disease with joint synovial inflammation as the main pathological basis ^[3], due to repeated and gradual aggravation of the disease.
Eventually, it can lead to destruction
of the patient's joint structure.
If timely and effective treatment is not received, it is easy to cause disability and bring a heavy burden to patients and their families ^[2,3].

”

Patients with RA typically present with arthritis, varying degrees of pain and swelling, which may be accompanied by limited mobility, and morning stiffness for more than
1 hour.
"Suffering great physical pain, rapid relief of symptoms is one of the treatment needs that patients need to be urgently solved ^[3]", said Professor Qiu Mingshan, who has been deeply involved in the diagnosis and treatment of rheumatic diseases for more than 20 years: "Clinicians must first develop a strong anti-rheumatic treatment plan to improve the physical symptoms
of patients.
"

"Glucocorticoids are a powerful anti-inflammatory drug that can quickly anti-inflammatory and relieve pain and improve the symptoms of joint swelling and pain in patients ^[4]", Professor Qiu Mingshan continued, "Based on the 2018 Chinese Rheumatoid Arthritis Diagnosis and Treatment Guidelines, for patients with RA with moderate/high disease activity, The use of traditional synthetic DMARDs in combination with low-dose glucocorticoids (prednisone≤ 10 mg/day or equivalent other drugs) can rapidly control symptoms and assist traditional synthetic DMARDs to play a role ^[4].

”

However, it is worth noting that the adverse effects of glucocorticoids are also a focus
of clinicians.
In this regard, Professor Qiu Mingshan particularly emphasized: "There is no doubt that the application of glucocorticoids in clinical practice is still a 'double-edged sword' ^[5].

Whether it is a rheumatologist or a patient, they love and fear it, on the one hand, because glucocorticoids act quickly, they can quickly relieve patients' symptoms; On the other hand, long-term use may bring many adverse reactions ^[5].

”

Talking about the adverse reactions of glucocorticoids, Professor Qiu Mingshan shared based on clinical experience: "A large number of hormone applications in the acute phase can lead to patient hypernervousness, insomnia, and may also induce and aggravate infection and peptic ulcer; At the same time, acute application may also cause patients to have hypokalemia, edema, and blood pressure and blood glucose fluctuations; Long-term use of glucocorticoids can lead to fat redistribution, full moon face, buffalo back, thin limbs (skin), and cause adverse reactions such as hyperglycemia, hypertension, osteoporosis, femoral head necrosis, and spontaneous fractures ^[5-9].

”

For glucocorticoids, which are widely used and controversial drugs in clinical ^{practice [5]}, Professor Qiu Mingshan said: "In the past, glucocorticoids dominated the treatment of autoimmune diseases because of their rapid onset, and with the gradual deepening of clinicians and researchers of glucocorticoids, people realized that glucocorticoids mainly play an anti-inflammatory role in the treatment of autoimmune diseases.
Immunosuppressants can help with disease remission
.
It is with this change in treatment views that the domestic and foreign RA diagnosis and treatment guidelines emphasize that the standardized use of glucocorticoids should follow the treatment principle of 'small dose, short course of disease' ^[3,10].

”

Professor Qiu Mingshan continued: "Due to the slow onset of traditional synthetic disease-modifying antirheumatic drugs (DMARDs), which take about 1~3 months, glucocorticoids can be combined with corticosteroids as bridging therapy for patients with moderate/high disease activity to quickly control symptoms ^[3].

。 According to the European Union Against Rheumatology (EULAR) guidelines, glucocorticoids can be given short-term, low-dose use (no more than 7.
5 mg/day in the case of prednisone) at the initiation or conversion of csDMARDs, and gradually tapered and discontinued over three months ^[10].

”

The development of innovative drugs promotes the innovation of RA treatment, and the selection of new drugs should be based on the needs of patients

With the gradual deepening of the understanding of RA, the clinical diagnosis and treatment of RA has increasingly emphasized early and standardized treatment
.
Although RA cannot be cured at present, standard treatment can effectively alleviate the patient's symptoms and achieve the control of the patient's condition ^[4].

Professor Qiu Mingshan said: "According to the Rheumatoid Arthritis Diagnosis and Treatment Standard, the treatment of RA is mainly aimed
at improving the symptoms of joint swelling and pain, controlling disease progression, reducing disability rate, and improving the quality of life of patients.
As an effective drug to control or delay the progression of the disease, DMARDs are currently one of the most critical drugs for the treatment of RA, therefore, patients with RA should start DMARDs as soon as possible once diagnosed ^[3].

”

In the past 20 years, the rapid development of drugs has once again changed the treatment landscape of RA, and the advent of a series of biologics and small molecule targeted drugs has provided patients with more drug options ^[3].

For this reason, the 2018 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis also pointed out that when the treatment of single traditional synthetic DMARDs does not meet the standard, a traditional synthetic DMARDs combined with a biological agent DMARDs/targeted synthetic DMARDs can be treated [^4].

Recalling the development of new drugs in recent years, Professor Qiu Mingshan couldn't help but sigh: "The advent of the era of biologics has significantly improved the efficacy of RA treatment, and also brought hope for more patients to achieve standard treatment, thus greatly improving the prognosis of patients ^[3].

Biologics currently used in clinical practice include tumor necrosis factor-α (TNF-α) inhibitors, interleukin (IL) 6 receptor antagonists, and T cell co-stimulation signal modulators ^[4].

The approval of oral JAK inhibitors baricitinib and tofacitinib further fills the gap of oral targeted therapy in RA patients and brings new options for RA patients with poor efficacy of traditional synthetic DMARDs or biologics ^[3].

”

Finally, Professor Qiu Mingshan concluded on how to weigh the choice of treatment options for RA patients: "In general, in the new era of targeted therapy with new drugs, RA patients have ushered in more treatment options
.
As clinicians practice management strategies for early treatment and standard treatment, patients' quality of life gradually improves
.
However, considering the individual differences of patients, clinicians should still reasonably formulate treatment plans and weigh medication options according to the actual condition and treatment needs of patients, so as to bring more significant efficacy to patients, ensure the safety of patients' medication, and reduce adverse reactions
in patients' treatment.
”