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"Diagnosis follows the feeling, and the medication thinks about the satellite", which will lead to the doctor's choice of drug is not optimal
for the patient.
What is the best option, through 4 real small cases, reviewed 4 rheumatism and 2 complications, it will be found that the drug treatment provided with the guidelines is significantly better than the doctor's personal preference for drug
selection.
Recently, the 9th International Forum on Pediatric Rheumatology Immunization was successfully held online, and Professor Li Xiaoxia from Xuanwu Hospital of Capital Medical University raised the following question: In the process of diagnosis and treatment of rheumatology and immunology, doctors choose to use drugs according to international and domestic rheumatology guidelines, or according to doctors' own preferences?
In the clinical work of rheumatic immunology, although the clinical manifestations of the same disease are different in different patients, there are criteria
for the diagnosis of the same disease.
For example, the diagnosis of rheumatoid arthritis requires the necessary diagnostic conditions, so the treatment of rheumatoid arthritis also needs to refer to international and domestic guidelines and standards
.
Grasp macro unity and micro adjustment
in treatment.
Macroscopic unification refers to following or referring to international and domestic guidelines for the treatment of rheumatism to select drugs (both international and domestic guidelines are the crystallization of the hard work of senior rheumatologists with rich clinical experience); Microscopic adjustment refers to the selection of medication
according to the specific situation of the patient (including the patient's age, economic status and education level, disease severity and complications, medical distance and awareness of the disease, etc.
).
Instead of "diagnosis follows feeling, medication thinks about satellite will"
.
Below, let's follow the four cases shared by Professor Li Xiaoxia at the conference to explore whether the treatment of rheumatism needs a guidebook "treatment
".
Female college student with systemic lupus erythematosus (SLE), female, 21 years old, college student
。 Fatigue, rash and leukopenia appeared 8 months ago without obvious cause, so he went to the hospital
.
Physical findings: facial rash
.
Auxiliary examination: white blood cells 2.
3 x109/L, lymphopenia, urine test is normal
.
ESR and CRP are normal
.
C3, C4 decreased, antinuclear antibody (ANA) 1:1000, anti-ds-DNA negative, anti-Sm antibody negative
.
Diagnosis: SLE
.
Treatment: Initial treatment (prednisone 10mg, hydroxychloroquine 0.
2g twice a day, abatacept treatment for 5 months)
efficacy: in the first 4 months, white blood cells have changes and can achieve normal
.
However, after 5 months, the white blood cells returned to the "origin"
after repeated examination.
2.
Diagnosis and treatment ideas: the patient's SLE manifestations include rash, peripheral blood leukocyte decline and autoantibody positive
.
Let's take a look at the differences
between some drugs used to treat SLE on the clinical manifestations of SLE.
Figure 1: SLE diagnosis and treatment pathway Figure
3, clinical drug
selection of SLE According to the above list, considering that the patient has a rash, peripheral blood leukocytes and autoantibodies positive, first of all, abatacept, let's not talk about the price of drugs, but from a clinical point of view, is it appropriate? If the drug is taken according to the guidelines (international and domestic), that is, the "guideline" treatment regimen: the first choice of biologic agents is belimumab, followed by drugs for rash and leukopenia, such as immunosuppressants
such as azathioprine, mycophenolate mofeol, cyclosporine and rituximab.
After choosing methyl ponylone and azathioprine treatment for this patient, his rash and peripheral blood leukocytes were also normal, and they remained stable for more than half a year, and they are still under
follow-up.
Young women with rheumatoid arthritis (RA).
The patient, a 27-year-old female from a staff member, developed pain in the joints of her left hand and right hand with swelling and stiffness for 4 hours before 10 months ago, so she went to a local hospital
.
Physical examination findings: swelling
of the third finger PIP and wrist joint of the left hand, and MCP of the first finger of the right hand.
Auxiliary examination: white blood cells 4.
3x 10 9/L, ESR 36 mm/h, CRP 12 mg/L, C3, C4 normal, ANA 1:320, RF650IU, anti-CCP antibody 300 U/ml
.
Diagnosis: RA.
Treatment: initial treatment (prednisone 10mg, leflunomide 20mg, symptom relief is not obvious after 3 months of treatment, stop prednisone and leflunomide, only treat with adalimumab for 5 months)
Efficacy: After 5 months of treatment with adalimumab, The pain and swelling in the joints of both hands are still not completely relieved
.
1.
The diagnosis and treatment idea
of RA Figure 2: The diagnosis and treatment process
of RA At the first diagnosis of this case, we can see that the patient has no contraindications to methotrexate, but has not applied this drug, and when adalimumab is used for the second time, methotrexate is still not used, Symptom control is not ideal
.
The final result was according to the "guidebook textbook" treatment regimen: methotrexate, hydroxychloroquine and leflunomide to control the condition, and the treatment effect was satisfactory
.
Middle-aged female patient with systemic sclerosis, female, 36 years old, cleaner, One year ago, he developed Raynaud phenomenon in both hands, accompanied by joint pain in both hands, difficulty opening his mouth, and went to a local hospital
.
Physical examination: no forehead lines, 3 fingers can not enter their mouth, and the skin of both hands is low
.
Auxiliary examination: white blood cells 4.
3x109/L, ESR12mm/h, CRP6mg/L, C3, C4 normal, ANA 1:320, anti-NECP, anti-Scl-70 positive
.
Chest CT: no obvious abnormalities (small nodules, less than 0.
4 mm)
Diagnosis: systemic sclerosis
.
Treatment: initial treatment (prednisone 40 mg, cyclosporine 20 mg, nifedipine after 1 month, Raynaud phenomenon improved, prednisone decreased, after the patient developed posterior cervical hirsutism and increased blood pressure, discontinuation of cyclosporine).
Clinical features
- It is a systemic immune disease with varying degrees of skin fibrosis/vascular damage and a variety of internal organ dysfunction;
- Divided into fibrotic disorders (skin tightening and interstitial lung disease) and vascular diseases (such as Raynaud's phenomenon and pulmonary hypertension)
- More than 95% of patients with Raynaud phenomenon and ANA positivity have systemic sclerosis
.
When one or the other is missing, alternative diagnoses should be considered;
Referring to international and national guidelines, combination therapy is the most effective way to
address the disease.
For rapidly progressive patients with diffuse systemic sclerosis and rapidly progressive patients, the order of selection of immunosuppressants is:
- Mycophenolate mofetil is usually preferred with few side reactions;
- cyclophosphamide;
- Methotrexate with inflammatory joint inflammation;
- Rituximab;
- High-dose corticosteroids are generally not recommended for systemic skin inflammation
.
This case was treated according to the "Guidebook" treatment plan: mycophenolate mofetil and prednisone was reduced
.
Guidelines for interstitial lung disease and pulmonary hypertension in systemic sclerosis recommend medication1
- First-line medication: both mycophenolate mofetil and cyclophosphamide have been shown to have certain benefits in preventing and alleviating the progression of systemic sclerosis-related interstitial lung disease, but cyclophosphamide is mostly used in patients who have failed first-line therapy or cannot tolerate mycophenolate mofetil;
- nintedanib (tyrosine kinase inhibitor);
- Rituximab;
- azathioprine;
2Pulmonary hypertension
- Endothelin receptor antagonists: bosentan, abesentan, macitentan;
- phosphodiesterase 5 inhibitors: sildefina, tadalafil, vardenafil;
- Prostaglandin analogues: eprostol, iloprost, treprostinil;
- Selective prostacyclin receptor (IP receptor) agonists: celoxipag;
- Soluble guanylate cyclase inhibitor: lyosigat
.
Young female patient Adult Still Disease (AOSD) patient, female, 28 years old, farming
.
Fever appeared two months ago, with a temperature of up to 40 accompanied by a rash, which is related to body temperature, high body temperature rash appears, and normal body temperature rash disappears
.
and swelling of the joints of both hands, go to the local hospital
.
Physical examination: body temperature 39.
2, pharyngeal redness, obvious
congestion.
A "salmon"-like rash
is seen on the trunk and on both upper and lower extremities.
The PIP of the 2 fingers of the right hand and 5 fingers of the left hand are swollen
.
Auxiliary examination: white blood cells 14.
9x109/L, ESR56 mm/h, CRP106 mg/L, normal C3, C4, negative autoantibody profile ANA negative, ferritin 2600, chest CT: no obvious abnormalities (with small nodules, less than 0.
4 mm).
。
Diagnosis: AOSD
.
Treatment: methylprednisolone 48 mg, cyclosporine 20 mg (self-paid drug).
After 2 weeks of treatment, the patient's liver enzymes increased to 400IU, and then cyclosporine was stopped and changed to methotrexate treatment, and the symptoms were controlled and the condition was relieved
.
See guidelines for treatment of still disease in adults:
- First-line therapy: NSAIDs and corticosteroids (remission in 20% to 25% of patients);
- Prednisone 0.
5 to 1 mg/kg·d, relieved in 6 months to 12 months to maintain remission and avoid relapse, 70% of patients respond to glucocorticoids - Second-line therapy: immunosuppressive methotrexate 10mg-20mg/week;
- Third-line therapy: biologics IL-1, IL-6, TNF-α;
- Reactive hemophilic lymphohistiocytosis (RHL): cyclosporine, tacrolimus
.
total
knot
Professor Li Xiaoxia introduced the "guidebook" treatment of several common rheumatic immune diseases, and at the same time, through the use of the guideline-guided sequencing method of these 4 cases, the patient's symptoms were alleviated and improved, and the economic burden
of the patient was also reduced.
Professor Li Xiaoxia finally emphasized that the treatment of diseases first needs to be diagnosed correctly, and the second is to choose the right treatment drugs
.
Rheumatologists should select drugs in accordance with international or domestic rheumatology guidelines as much as possible, and also consider the patient's economic situation and ease of medication
.
Therefore, for doctors who are new to rheumatology, it is still necessary to: diagnosis according to classification criteria, treatment according to guideline medication
.
Li Xiaoxia Professor Xuanwu Hospital of Capital Medical University
Director of the Department of Rheumatology and Immunology, Xuanwu Hospital, Capital Medical University, Chief Physician, Master Tutor
Member of the 8th, 9th and 10th Rheumatology Professional Committee of the Chinese Medical Association
Member of the first, second and third sessions of the Rheumatology and Immunology Branch of Chinese Medical Doctor Association
Vice Chairman of the 4th and 5th Rheumatology Professional Committee of Beijing Medical Association
Member of the Standing Committee of Rheumatologist Branch of Beijing Medical Doctor Association
Member of the Internal Medicine Branch of Beijing Medical Association
Member of the Standing Committee of the Second Rheumatology Professional Committee of the Cross-Strait Medical and Health Exchange Association
Vice Chairman of China Soft Tissue Pain Committee
Director of the First Rare Disease Branch of the Chinese Research Hospital Association
Former Director of the Joint Department of Clinical Immunology, Capital Medical University
Former Deputy Director of the Department of Rheumatology and Immunology, Capital Medical University
Review expert of the standardized training base for residents of the Chinese Medical Doctor Association
The person in charge of the second stage of standardized residency training of Beijing Medical Doctor Association rheumatology professional examination
Lecturer of Beijing Resident Standardized Training "Doctor-Patient Communication"
He has published more than 80 articles and participated in the compilation of more than 20 books
References:
[1]2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus[J].
Chinese Journal of Internal Medicine,2020(03):172-173.
)
[2]2018 Chinese guidelines for diagnosis and treatment of rheumatoid arthritis[J].
Chinese Journal of Internal Medicine,2018,57(04):242-251.
)
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at the source of this articleMedical Rheumatology and Immunology Channel Author Mu Yi This article reviewLi Xiaoxia Professor responsible editorTangerine
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