How did this patient get a new lease of life after being "entangled" with rheumatoid arthritis for many years?

*For medical professionals to read for reference only Thin body
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During the long course of the disease, many of his joints have been deformed, his limbs have been restricted, and he has lost his ability to take care of himself
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At the same time, a variety of basic diseases have made Uncle Fu's body weaker and weaker
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Treatment after treatment has made hope continue to ignite and shatter.
Today's Uncle Fu has lost confidence in treatment - but the family is not willing to give up hope.
They encourage and support Uncle
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The hard work pays off.
This time, Uncle Fu finally saw the "dawn" of life.
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In this issue, Professor Ma Wukai and Professor Huang Ying of the Rheumatology and Immunology Department of the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine will tell us about Uncle Fu in detail tortuous diagnosis and treatment experience
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Case details ▎Basic situation: Mr.
Fu, male, 53 years old ▎Main complaint: Recurrent polyarticular pain for more than 21 years, recurrence for 2 days Hip, ankles, first toe joints of both feet, metacarpophalangeal joints, proximal interphalangeal joints, with morning stiffness and limited joint movement
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Long-term external treatment with "powder medicine, painkiller injection" (specifically unknown), no standardized follow-up; Joint pain relief is not good under the treatment plan of "fluid"
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On June 11, 2020, the patient visited the outpatient department of our department and was admitted to the hospital with "rheumatoid arthritis"
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▎Physical examination: Vital signs are still stable, weight 35kg, chronic pain, poor nutrition, weight loss, pushed into the ward on a flat cart, mild kyphosis of the spine, subluxation of multiple metacarpophalangeal joints, both hands pointing to the ulnar side, and bones of the whole body , muscle and joint tenderness, limited movement of multiple joints, double-knee grinding test (+), double-knee floating test (-), bilateral straight leg raising test (+), double "4" test (+ ), and there was no edema in both lower extremities
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Nervous system examination: the muscle strength and muscle tone of the limbs were normal, the physiological reflex sign was present, and the pathological reflex sign was not elicited
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▎Auxiliary examinations: Laboratory tests: white blood cells 3.
8×109/L, red blood cells 3.
64×1012/L, hemoglobin 8g/dl (anemia), platelets 583x109/L ↑; aspartate aminotransferase (AST) 12U/L, alanine aminotransferase (ALT) ) 3U/L, creatinine 51 μmoI/L, total cholesterol 2.
67 mmol/L, triglyceride 1.
25 mmol/L; rheumatoid factor (RF) IgM 72.
22 RU/mL, anti-cyclic citrullinated peptide antibody (anti-CCP antibody) >400 ↑; erythrocyte sedimentation rate (ESR) 127 mm/h, C-reactive protein (CRP) 38 mg/L; tuberculosis infection interferon release test (T-SPOT) positive; chest CT (Figure 1): 1.
Right Middle lobe nodule, 2.
Chronic infection in right upper lobe and right lower lobe, 3.
Bilateral pleural thickening, 4.
Old calcification in right lower lobe, 5.
Changes after PICC tube placement, 6.
Aortic sclerosis, 7.
Mediastinal and right pulmonary lymph node calcification, 8.
Thoracic vertebral degeneration, 9.
Liver cyst, small nodule in left lobe of liver
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Figure 1: The patient's chest CT and bilateral knee musculoskeletal ultrasound: moderate synovial hyperplasia, moderate synovitis, bone hyperplasia, bone erosion, and moderate effusion in the suprapatellar bursa
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▎Admission diagnosis: rheumatoid arthritis (DAS28 score 7.
23, high disease activity), chronic gastritis with bile reflux, multiple cysts in the liver, right kidney atrophy, chronic renal failure CKD stage 2
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 ▎Treatment plan: Anti-rheumatic therapy: leflunomide (LEF) + IL-6 receptor inhibitor tocilizumab (160 mg-240 mg/month), during the treatment, the patient experienced repeated joint swelling and pain, and the curative effect was ineffective.
Long-term maintenance; in October 2021, the re-examination of T-SPOT was negative, and the biological preparation was adjusted to abatacept 125 mg (once a week, subcutaneous injection); after December 2021, abatacept alone was used for treatment
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Pain relief: compound betamethasone (intra-articular injection); infection prevention: ceftazidime (10 days) + isoniazid (4 months) + low-dose intravenous gamma globulin (5 days); stomach protection: esomela azole + colloidal bismuth pectin; ▎Treatment results: 1.
Blood routine: the hemoglobin level gradually increased to the normal range, the platelet level decreased (Fig.
2), the patient's anemia and nutritional status were significantly improved, and the weight increased to 45 kg; Fig.
2 : During the treatment, the patient's blood routine changes 2.
The level of inflammatory indexes improved
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During tocilizumab treatment, inflammatory markers were poorly controlled, and ESR and CRP levels decreased significantly after switching to abatacept (Figure 3)
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Figure 3: During the treatment period, the patient's inflammatory markers (ESR and CRP) changed 3.
The level of autoantibody RF IgM decreased
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During the later period of tocilizumab treatment, patients' RF IgM levels increased, and after switching to abatacept, their levels decreased significantly (Fig.
4)
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Figure 4: Changes in RF IgM Levels in Patients During Treatment 4.
Steady decrease in disease activity
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Throughout the treatment period, the patient's overall disease activity score showed a downward trend, and by November 2021 (having received abatacept for 1 month), the DAS28-ESR score was 2.
16, and the DAS28-ESR score was 2.
36 in March 2022.
, achieving sustained clinical remission (≤2.
6 points)
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Figure 5: Changes in the patient's disease activity (DAS28-ESR score) during
treatment
Case Discussion This middle-aged male patient had a long, severe and progressive disease
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RA with high disease activity resulted in multiple joint pain, deformity, and even limited mobility and loss of self-care ability in this patient, and a very poor quality of life
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From the clinical examination, the patient has high levels of inflammatory indicators, RF and anti-CCP antibodies, high risk of disability, and is accompanied by a variety of underlying diseases.
Irregular early treatment leads to drug dependence (hormone, tramadol), which is difficult to treat and has a poor prognosis.

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 Based on the complex underlying diseases of the patient, in this treatment, we give the patient a combination of antirheumatic drugs, analgesics, infection prevention and stomach care drugs
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In the selection of anti-rheumatic drugs, considering that the patient's RA disease has reached a high disease activity, we initially adopted the traditional synthetic disease-modifying anti-rheumatic drug (csDMARD) combined with the biological agent tocilizumab, but the treatment lasted for more than one year.
The patient still felt joint pain from time to time, and the inflammatory indicators, RF, etc.
rebounded and increased in the later stage
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In October 2021, after switching tocilizumab in the treatment plan to abatacept, a T cell costimulatory regulator, the patient's indicators and physical functions were significantly improved, and the patient himself was satisfied with the treatment effect
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 Different from various biological agents targeting inflammatory factors, abatacept acts on T cell co-stimulatory signals and inhibits the activation of T cells, thereby attenuating immune and inflammatory responses and effectively treating RA
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According to the results of relevant clinical studies, the treatment response rate of abatacept is related to the titer of anti-CCP antibody.
RA patients with positive anti-CPP antibody and high titer are the dominant group who benefit from abatacept treatment, which is helpful for relieving the patient's symptoms.
disease symptoms and control imaging progression [1-5]
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For RA patients with multiple poor prognostic factors, such as multi-joint involvement and high risk of infection, abatacept is a biologic with both efficacy and safety, and the risk of tuberculosis infection is low [6-7]
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Therefore, under comprehensive consideration, abatacept is the best choice for this biologics conversion treatment
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 In general, the diagnosis and treatment process of the patient in this case can be described as twists and turns, ups and downs, and finally the twists and turns, the willows and darks are bright, and it is inseparable from the persistence and cooperation of the patient and his family, as well as the scientific judgment and courage of the clinician in the adjustment of the treatment plan.
choice
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At present, medical development is progressing rapidly, and advanced and effective treatment plans are emerging constantly
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 Expert Profile Ma Wukai Professor, Chief Physician, Doctor of Medicine, Doctoral Supervisor of the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine Director of Guizhou Province Traditional Chinese Medicine Rheumatism Clinical Research Center Director of the Editorial Department of the Journal of Guizhou University of Traditional Chinese Medicine Second Affiliated to Guizhou University of Traditional Chinese Medicine Director of the Rheumatology and Immunology Department of the Hospital Member of the Standing Committee of the Rheumatology Branch of the Chinese Association of Traditional Chinese Medicine, the Standing Committee of the Rheumatology Branch of the Chinese Association of Integrative Medicine, has undertaken 4 projects of the National Natural Science Foundation of China, and published more than 80 papers in SCI and core journals.
Deputy Chief Physician of the Hospital, Master Supervisor, Member of the Standing Committee of Guizhou Provincial Association of Integrated Traditional Chinese and Western Medicine Rheumatology Association Director of Rheumatology Branch of Chinese National Medical Association Director of the Osteoporosis Group of the Rheumatology and Immunology Department of Guizhou University of Traditional Chinese Medicine, presided over 1 National Natural Science Foundation of China, and social research in Guizhou Province 1 project, 2 projects of Guizhou Provincial Science and Technology Fund and a number of department and bureau-level projects, published more than 20 academic papers and won 1 second prize for scientific and technological progress of China Association for the Promotion of Traditional Chinese Medicine, and 1 third prize for scientific and technological progress of China National Medical Association , 2 references for the third prize of Natural Science of Guizhou Province: [1] Jansen DTSL, Emery P, Smolen JS, et al.
Conversion to seronegative status after abatacept treatment in patients with early and poor prognostic rheumatoid arthritis is associated with better radiographic outcomes and sustained remission: post hoc analysis of the AGREE study[J].
RMD Open, 2018, 4(1): e000564.
[2] Gottenberg JE, Courvoisier DS, Hernandez MV, et al.
Brief Report:Association of Rheumatoid Factor and Anti-Citrullinated Protein Antibody Positivity With Better Effectiveness of Abatacept: Results From the Pan-European Registry Analysis[J].
Arthritis Rheumatol, 2016, 68(6): 1346-52.
[3]Schiff M, Weinblatt ME, Valente R, et al.
Head-to-head comparison of subcutaneous abatacept versus adalimumab for rheumatoid arthritis: two-year efficacy and safety findings from AMPLE trial[J].
Ann Rheum Dis, 2014, 73(1):86- 94.
[4] Fleischmann R, Weinblatt M, Ahmad H, et al.
Efficacy of Abatacept and Adalimumab in Patients with Early Rheumatoid Arthritis With Multiple Poor Prognostic Factors: Post Hoc Analysis of a Randomized Controlled Clinical Trial (AMPLE) [J].
Rheumatol Ther, 2019, 6(4): 559-571.
[5]Harrold LR, Litman HJ, Connolly SE, et al.
Effect of Anticitrullinated Protein Antibody Status on Response to Abatacept or Antitumor Necrosis Factor-α Therapy in Patients with Rheumatoid Arthritis: A US National Observational Study[J].
J Rheumatol, 2018, 45(1): 32-39.
[6]Kremer JM, Dougados M, Emery P, et al.
Treatment of rheumatoid arthritis with the selective costimulation modulator abatacept:twelve-month results of a phase iib, double-blind, randomized, placebo-controlled trial[J].
Arthritis Rheum, 2005, 52(8):2263-2271.
[7]Westhovens R, Kremer JM, Emery P, et al.
Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study [J].
Clin Exp Rheumatol, 2014, 32(4): 553-562.
This article is only for providing scientific information to healthcare professionals and does not represent the platform’s positionJ Rheumatol, 2018, 45(1): 32-39.
[6]Kremer JM, Dougados M, Emery P, et al.
Treatment of rheumatoid arthritis with the selective costimulation modulator abatacept:twelve-month results of a phase iib, double -blind, randomized, placebo-controlled trial[J].
Arthritis Rheum, 2005, 52(8):2263-2271.
[7]Westhovens R, Kremer JM, Emery P, et al.
Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study[J].
Clin Exp Rheumatol, 2014, 32(4): 553-562.
This article is for scientific information only for healthcare professionals , does not represent the platform's positionJ Rheumatol, 2018, 45(1): 32-39.
[6]Kremer JM, Dougados M, Emery P, et al.
Treatment of rheumatoid arthritis with the selective costimulation modulator abatacept:twelve-month results of a phase iib, double -blind, randomized, placebo-controlled trial[J].
Arthritis Rheum, 2005, 52(8):2263-2271.
[7]Westhovens R, Kremer JM, Emery P, et al.
Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study[J].
Clin Exp Rheumatol, 2014, 32(4): 553-562.
This article is for scientific information only for healthcare professionals , does not represent the platform's position[7] Westhovens R, Kremer JM, Emery P, et al.
Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study[J].
Clin Exp Rheumatol, 2014 , 32(4): 553-562.
This article is for the purpose of providing scientific information to healthcare professionals only and does not represent the platform's position[7] Westhovens R, Kremer JM, Emery P, et al.
Long-term safety and efficacy of abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: a 7-year extended study[J].
Clin Exp Rheumatol, 2014 , 32(4): 553-562.
This article is for the purpose of providing scientific information to healthcare professionals only and does not represent the platform's position
.