類風濕性關節炎之治療

Treatment of rheumatoid arthritis

類風濕性關節炎在一般的印象中，是較為人所熟悉的風濕性關節炎，而風濕性關節炎，實際上包括了以小關節對稱性發作為主的類風濕性關節炎、以及下肢大關節部對稱發作的血清陰性脊椎關節病變，如僵直性脊椎炎、乾癬性關節炎、反應性關節炎等多種的關節炎，這些關節炎基本上都是導因於體內免疫調控異常，所形成的結晶性關節炎，如痛風、假性痛風或是退化性關節炎等，也都屬於廣泛的風濕性疾病。類風濕性關節炎是個古老而非新興的疾病。但是，對於這個疾病相關的致病機轉，及診斷治療的進步，卻是這幾十年的事。最大的進展，是在 1950年代腎上腺皮質類固醇的使用，大大改善了患者的臨床症狀，及生活品質。但是隨著類固醇的大量使用，其相關的副作用，卻使得臨床上顯著的療效大大地打了折扣。不過隨著免疫學的進展，免疫調節藥物的出現，如金製劑與 D-penicillamine，又開啟類風濕性關節炎治療的另一個里程，不過金劑及D-penicillamine 的藥物，雖有效的緩解了部分患者的症狀或病程，並減少了類固醇的使用。但由於腎臟蛋白尿及骨髓抑制劑等副作用，隨著其他免疫調節藥物的進展，如 hydroxychloroquine、sulfasalazine、methotrexate、cyclosporine、azathioprine 等不僅具備了相當療效，同時又相對安全性較高的情況下，金劑與 D-penicillmaine 已很少使用，除非是相當頑固性患者，尤其是抗腫瘤壞死因子（anti-TNF-α） 的生物製劑，打破了類風濕性關節炎的治療思維，可以迅速有效的改善患者的臨床症狀疾病程，同時也可以相對地減少，其他種類藥物的使用，但中醫藥的臨床搭配使用，或單獨使用，在臨床上已獲得突破性的進展，未來考慮中西醫共同治療也是一種願景。

Rheumatoid arthritis is the most known rheumatic arthritis to the general population, and rheumatic arthritis is actually composed of rheumatoid arthritis which characterized by affecting symmetric small joints, and the seronegative spondyloarthritis which characterized by affecting lower limbs, such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis etc. These kinds of arthritis are basically arising from abnormal regulation of immunity. Crystal deposition arthritis, such as gout, pseudo-gout or degenerative arthritis, are also generally belong to rheumatic diseases. Rheumatoid arthritis is an ancient rather than new disease. However, the pathogenesis, diagnosis and treatment advancements are established in recent decades. The greatest progress is the usage of adrenal corticosteroids since the 1950s. It significantly improved the clinical symptoms and quality of life of the patients. But with the extensive use of steroids, the associated side effects make a significant clinical compromised. But with the progress of Immunology, for example, the emergence of immunomodulatory drugs such as gold preparations and D-penicillamine, another milestone in the treatment of rheumatoid arthritis was achieved. The D-penicillamine effectively alleviates some of the symptoms or disease progression of the patients and reduced the use of steroids. But it is notorious of its proteinuria, renal toxicity, and bone marrow suppression. Other immunomodulatory drugs such as hydroxychloroquine, sulfasalazine, methotrexate, cyclosporine, azathioprine, etc. were raised later. They not only have a considerable effect, but also have the higher safety. So, the gold preparations and the D-penicillmaine were seldom use later except quite refractory disease. The biological agent--anti-tumor necrosis factor (anti-TNF-α) was invented later and broke the original thinking of treatment of rheumatoid arthritis. It can not only quickly and effectively improve the clinical symptoms and disease procession but also reduces other types of drug usage. But both combine with the Traditional Chinese Medicine, and treat only by the Traditional Chinese Medicine were also getting some breakthrough progress. In the future, combine the Traditional Chinese and as well as the Western medicine treatment is also a vision.