When rheumatoid encounters Sjogren’s syndrome, how can clinical treatment achieve the "double kill" achievement? |

*It is only for medical professionals to read for reference.
Iramod is not only suitable for the treatment of RA, but also has a good effect on SS.

The complex and refractory nature of rheumatic immune diseases is often reflected in multiple pathogenic factors, multiple symptoms, multiple system involvement, and repeated illnesses.

Rheumatoid arthritis (RA) is a rheumatic immune disease with erosive arthritis as the main manifestation; Sjogren’s syndrome (SS) mainly affects the exocrine glands (especially the lacrimal and salivary glands), and can also involve multiple organs and organs throughout the body.
system.

Both are relatively common autoimmune diseases.

RA combined with SS is not uncommon in clinical practice.
Compared with pure RA and SS, RA combined with SS has different clinical and laboratory characteristics, such as seropositivity, high disease activity, long course of disease, high incidence of comorbidities and erosion lesions , Its clinical diagnosis and treatment is more difficult [1].

In this issue, Director Zhang Yingze of the Rheumatology Department of the China-Japan Friendship Hospital will share with us a clinical diagnosis and treatment process of patients with RA combined with SS for your reference.

The classic case first look at the basic situation: female, 72 years old.

Main complaint: Pain in multiple joints of the extremities has been recurrent for more than 10 years, and worsened with dry mouth and nose for 1 year.

History of present illness: In November 2002, there was no obvious cause of multi-articular pain in the extremities, symmetrical, morning stiffness, and RA was diagnosed in the local hospital; in June 2011, joint pain worsened with increased rheumatoid factor (RF).
Abnormal liver function.
A liver biopsy at Beijing Ditan Hospital revealed drug-induced liver damage.
After 2 months of hepatoprotective treatment, liver function returned to normal; symptoms such as dry mouth and nose gradually appeared.
For further diagnosis and treatment in November 2012 Moved to our department on the 27th.

Past history: The patient has a history of hypertension for more than 10 years, and oral antihypertensive drugs control blood pressure smoothly.

No history of drug allergy.

Physical examination: body temperature was normal, blood pressure 130/85 mmHg, cardiac auscultation showed no obvious abnormalities, a small amount of crackling sounds could be heard at the bottom of both lungs, liver and spleen were not palpable in the abdomen, no percussive pain in the kidney area, and no edema in both lower limbs.

The tongue is dark red and slightly cracked, the coating is thin and slightly greasy, and the pulse is heavy and stringy.

Auxiliary examination: 1.
Blood routine: erythrocyte sedimentation rate (ESR) 32 mm/h; RF68 IU/ml, C-reactive protein (CRP) 1.
3 mg/dl, immunoglobulin A (IgA) 395 mg/dl; antinuclear Antibody (ANA) 1:80, anti-keratin antibody (AKA), anti-perinuclear factor (APF) positive, anti-cyclic citrullinated polypeptide (CCP) antibody>3200 U/ml.

2.
Imaging examination: X-ray examination revealed osteoporosis in both hands and wrists, and degenerative changes in the joints between the fingers and the knee joints.

Chest CT showed interstitial lung lesions.

3.
Others: Ophthalmology consultation revealed dry eye, labial gland biopsy showed focal gland atrophy, and a large number of lymphocytes and plasma cells infiltration.

Liver and kidney functions are normal, and lung function tests indicate small airway ventilation disorders.

Treatment history and curative effect Admission diagnosis: RA, SS, interstitial lung disease (ILD), knee osteoarthritis, hypertension.

Treatment plan: November 2012: Leflunomide (LEF) tablets 10mg QD; total glucosides of paeony capsules 0.
6g BID; acetylcysteine ​​capsules 0.
4g TID; amlodipine besylate tablets 5mg QD; tartaric acid beauty Torol tablet 25mg QD; also take Chinese herbal medicine for conditioning.

He stopped taking Chinese herbal medicine in February after he was discharged from the hospital.

In July 2013, due to elevated blood pressure, chest tightness, palpitation, fatigue and other discomforts, LEF was discontinued, and the rest of the drugs were the same as before.

December 2014: Due to poor control of joint inflammation, Iramod (IGU) tablets 25mg BID were used, combined with total glucosides of paeony capsules, and Chinese herbal medicines were taken orally intermittently according to the card.

The condition was relieved in about half a year.

In February 2017, he was admitted to the hospital for reexamination due to increased pain in both knee joints.

Maintain IGU 25 mg BID + total paeony glycosides capsule 0.
6g BID treatment.

Supplemented with acetylcysteine ​​capsule 0.
2g TID; Valsartan and Amlodipine tablets 1 QD; Rosuvastatin calcium tablets 5mg QD; Clopidogrel bisulfate tablets 50mg QD.

With Chinese herbal medicine conditioning.

In February 2018, he was admitted to the hospital for reexamination of his left knee joint swelling and pain.

On the basis of the original treatment plan, sodium hyaluronate injection (25 mg, once a week) was injected into the left knee joint cavity for a total of 3 times.

After the treatment, the symptoms disappeared and the disease was relieved again.

From November 2020 until now, IGU 25 mg QD + total glucosides of white peony capsule 0.
6g BID maintenance treatment.

Figure 1: The patient’s past medical history and treatment outcome: No obvious joint pain, no obvious bone destruction; dry mouth, dry eyes and other symptoms are not obvious, and basically disappeared; chest CT showed obvious absorption of lung interstitial lesions, no new progress.

Expert profile Professor Zhang Yingze, Doctor of Medicine, Chief Physician of the Department of Traditional Chinese Medicine Rheumatology, China-Japan Friendship Hospital, Member of the Rheumatology Professional Committee of the Chinese Society of Chinese Medicine, Standing Director of the World Federation of Chinese Medicine Rheumatology Professional Committee, Standing Director of the World Federation of Chinese Medicine Osteoporosis Professional Committee Standing director of the Rheumatology Professional Committee of the Chinese Society of Chinese Medicine, Member of the Rheumatology Professional Committee of the Beijing Society of Chinese Medicine, Member of the Professional Committee of Chinese Medicine Service Trade of the Beijing Society of Chinese Medicine, Beijing Chaoyang District Traditional Chinese Medicine Experts and Academic Experience Inheritance Project 3 and 6 Approved instructors to participate in the completion of more than ten scientific research projects, including the National Natural Science Foundation of China, the National Science and Technology Research Project, the Capital Medical Development Research Fund Funding Project, the State Administration of Traditional Chinese Medicine Research Project, the China-Japan Friendship Hospital Research Project, etc.
, in national, provincial and ministerial publications Published more than 20 academic papers and participated in the compilation of five monographs on rheumatology.
The completed projects have won awards from the Chinese Society of Chinese Medicine, the Chinese Society of Integrative Medicine, Beijing Science and Technology, etc.
Professor Zhang Yingze RA and SS are common in clinical practice Of autoimmune diseases. Patients with RA combined with SS can show the disease characteristics of RA and SS at the same time, such as both obvious joint pain/deformity and dry mouth and eyes, and even cause other organ damage, involving other parts of the body, such as liver, kidney, and lungs.
Wait.

However, some patients have no typical symptoms, which can easily lead to misdiagnosis and delayed diagnosis.
Therefore, in the actual diagnosis and treatment process, it is necessary to rely on the comprehensive consideration of serology, objective examination and labial gland biopsy to make an accurate diagnosis.

This patient has recurrent polyarticular swelling and pain, morning stiffness, high titers of anti-CCP antibodies, AKA and APF are all positive, and is definitely diagnosed as RA; in addition, the patient also has symptoms of dry mouth and eyes, and is diagnosed as dry by ophthalmology.
Ocular symptoms and labial gland biopsy are also in line with the pathological manifestations of SS, so the diagnosis of SS is also established.

It is also reported in the literature that the incidence of ILD in patients with RA and SS is high [2].
In this case, the lung CT showed ILD, and the condition was consistent with the literature.

The patient's medical history is as long as 18 years, and the treatment follow-up has also been 8 years.

During the treatment process, because of side effects or fear of side effects, the basic slow-acting drug methotrexate was not used.
IGU combined with total glucosides of paeony and intermittent oral Chinese herbal medicine treatment not only relieved the patient’s joint pain and prevented bone destruction, but also The symptoms of SS are reduced, and systemic symptoms related to SS such as ILD are also alleviated.
This shows that the combination therapy with IGU as the core has a good effect in controlling the progression of RA and SS.

After the condition was relieved, IGU combined with total glucosides of paeony was still used for maintenance treatment.
The patient's condition remained stable for many years and his mental state was good.

IGU is a small-molecule anti-rheumatic drug (DMARD) that is suitable for the treatment of active RA.
It has the effects of anti-inflammatory, suppressing immunoglobulin, suppressing cytokine production, anti-bone absorption and promoting bone formation, etc.
Effectively inhibit synovial inflammation and reduce bone destruction.

In addition, a large number of research results also show that IGU also has a significant effect on the treatment of SS, which can reduce the disease activity of patients, improve various laboratory indicators, and thereby improve the condition [3-11].

In our experience of diagnosis and treatment, it is indeed found that IGU may play a decisive role in controlling the progression of SS, helping to relieve the local and system symptoms of patients.

In the latest version of the domestic SS diagnosis and treatment specifications, IGU as an immunomodulator is recommended for the treatment of SS patients with systemic involvement [12], and its related new drug clinical trial applications have also been approved.

In the future, there will be more and more research and practical evidence to support the clinical application of IGU and provide us with more diversified diagnosis and treatment ideas.

References: [1] Qin Si, Lu Yahua.
Clinical and laboratory characteristics of patients with rheumatoid arthritis combined with Sjogren’s syndrome[J].
CLINICS, 2015, 30(5): 548-551.
[2] Lin Maohuang, Zhang Qichuan .
The clinical manifestations, physiological index changes and intervention effect analysis of pulmonary interstitial lesions caused by connective tissue diseases[J].
Modern Diagnosis and Treatment, 2015, 26(10):2161-2163.
[3] Wang Yanling, Zhao Futao, Ai Xiangyan, Et al.
Observation on the efficacy and safety of Ailamod in the treatment of primary Sjogren’s syndrome in the elderly[J].
Geriatrics and Health Care, 2019, 25(2):209-213.
[4] Wang Xue, Yuan Xiang, Wang Qikai , Et al.
The therapeutic effect of Iramod on primary Sjogren’s syndrome and its mechanism[J].
Chinese Journal of Disease Control, 2018, 22(1):75-78.
[5] Jiang Wei.
Iramod Evaluation of the curative effect of Sjogren’s syndrome and its mechanism of action on B cells[D].
Sichuan: Luzhou Medical College, 2014.
[6] Jiang Dexun, Bai Yunjing, Zhao Liping, et al.
Combination of Ilamod in the treatment of primary Sjogren’s syndrome Observation of clinical effects[J].
Clinical misdiagnosis and mistreatment, 2016, 29(8): 90-93.
[7] Xu Dong, Lv Xiaowei, Cui Peng, et al.
Efficacy and safety of islammod and hydroxychloroquine in the treatment of patients with Sjogren’s syndrome Sexual comparison[J].
Journal of Difficult and Difficult Diseases, 2017,16(9):915-918.
[8] Luo Qiwen, Guo Dongmei, Yu Yangtao, et al.
Efficacy and safety of islammod and hydroxychloroquine in the treatment of patients with Sjogren’s syndrome [J].
Chinese Journal of Clinical Research, 2018, 10(24):94-95.
[9] Li Chuanjing, Li Rui, Liu Hanzhong, et al.
Efficacy and immunity of methylprednisolone combined with ilamod in the treatment of primary Sjogren’s syndrome The effect of globulin levels[J].
China Pharmaceutical, 2018, 27(14): 35-27.
[10] Chen H, Qi X, Li Y, et al.
Iguratimod treatment reduces disease activity in early primary Sjögren's syndrome: An open-label pilot study[J].
Mod Rheumatol, 2020:1-5.
[11] Jiang W, Zhang L, Zhao Y, et al.
The efficacy and mechanism for action of iguratimod in primary Sjögren's syndrome patients[J].
Int Ophthalmol, 2020, 40(11):3059-3065.
[12] China Sjogren's Syndrome Group of the Rheumatology and Immunology Physician Branch of the Association of Physicians.
Standards for diagnosis and treatment of primary Sjogren’s syndrome[J].
Chinese Journal of Internal Medicine, 2020, 59(4): 269-276.