Медико-экономический анализ влияния инвалидизации, ассоциированной с ревматическими заболеваниями, на экономику страны с учетом реализации пенсионной реформы

The paper presents the data of an original study evaluating the impact of disability associated with a number of rheumatic diseases (RDs) (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) on the country's economy, as well as their related losses of the state under the conditions of implementation of the upcoming pension reform (PR). The authors consider the socioeconomic importance of disability associated with RDs in the current period and after PR implementation in 2019–2028, determine the degree of its influence on the country's gross domestic product, and also calculate the economic efficiency of return of the potentially able-bodied proportion of disabled people (able-bodied population) to socioeconomic activity.The opinions of experts and leading experts in this area from different subjects of the Russian Federation were taken into account when preparing the study.В статье представлены данные оригинального исследования, посвященного оценке влияния инвалидизации, ассоциированной с рядом ревматических заболеваний – РЗ (ревматоидный артрит, анкилозирующий спондилит и псориатический артрит), на экономику страны, а также связанных с ними потерь государства в условиях реализации предстоящей пенсионной реформы (ПР). Рассмотрено социально-экономическое значение инвалидизации, ассоциированной с РЗ, в текущем периоде и после проведения ПР 2019–2028 гг., определена степень ее влияния на валовой внутренний продукт страны, а также рассчитана экономическая эффективность возврата потенциально трудоспособной части инвалидов (лиц, находящихся в трудоспособном возрасте) к социально-экономической активности. При подготовке исследования были учтены мнения экспертов и ведущих специалистов в данной области из различных субъектов Российской Федерации

Сравнительная оценка влияния синтетических базисных противовоспалительных и генно-инженерных биологических препаратов на клиническое течение, скорость развития деструктивных изменений и качество жизни больных ревматоидным артритом

There are few studies of the efficiency of therapy with disease-modifying antirheumatic drugs (DMARDs) and biological agents (BAs) in patients with early rheumatoid arthritis (eRA) as part of a treat-to-target strategy.Objective: to investigate the effects of DMARDs and BAs used in combination with methotrexate (MTX) on clinical course, quality of life (QoL), and the evolution of articular erosions and synovitis in patients with RA.Patients and methods. The investigation enrolled 151 patients with eRA. At the first stage, the patients received DMARDs. At the second stage, 101 patients with persistent moderate and high disease activity were prescribed MTX at a dose of 25 mg/week or 20 mg/week in combination with infliximab (INF), or 20 mg/week in combination with rituximab (RTX). At the third stage, 20patients with persistent high disease activity were switched to tocilizumab (TCZ) therapy.Results and discussion. At 12 months of DMARD therapy, a clinical remission was more often achieved in the MTX group. The use of INF or RTX significantly improved QoL in the patients. That of TCZ as a second- and third-line drug led to a significant decrease in DAS28-CRP. Conclusion. There were no statistically significant differences between the INF and RTMgroups with respect to the time course of changes in CRP, ESR, circulating immune complexes, and the indicators of X-ray progression, which confirms the possibility of switching from a first-line BA to its subsequent lines with an increasing clinical disease activity. TCZ can be a second- and third-line drug when the effect of therapy with other BAs escapes.Исследования эффективности терапии базисными противовоспалительными препаратами (БПВП), а также генно-инженерными биологическими препаратами (ГИБП) у пациентов с ранним ревматоидным артритом (рРА) в рамках стратегии «Лечение до достижения цели» немногочисленны.Цель настоящей работы — изучить влияние БПВП и ГИБП в комбинации с метотрексатом (МТ) на клиническое течение, качество жизни (КЖ) и эволюцию суставных эрозий и синовита у больных РА.Пациенты и методы. В исследование включен 151 больной рРА. На первом этапе пациенты получали БПВП. На втором этапе 101 пациенту с сохраняющейся умеренной и высокой степенью активности был назначен МТ 25 мг/нед, либо 20 мг/нед в комбинации с инфликсимабом (ИНФ), либо 20 мг/нед в комбинации с ритуксимабом (РТМ). На третьем этапе 20 пациентов с сохраняющейся высокой активностью заболевания были переведены на терапию тоцилизумабом (ТЦЗ).Результаты и обсуждение. К12 мес лечения БПВП клиническая ремиссия чаще достигалась в группе МТ. Назначение ИНФ или РТМ приводило к значимому улучшению КЖ пациентов. Применение ТЦЗ как препарата второй и третьей линии способствовало достоверному снижению DAS28 СРБ.Выводы. Между группами больных, получавших терапию ИНФ и РТМ, не выявлено статистически значимых различий в динамике СРБ, СОЭ, циркулирующих иммунных комплексов и показателей рентгенологического прогрессирования, что подтверждает возможность «переключения» с первого ГИБП на препараты последующих линий при нарастании активности. ТЦЗ может быть препаратом второй и третьей линии при ускользании эффекта от терапии другими ГИБП

Инвазивный аспергиллез у взрослых пациентов с ревматическими заболеваниями

Objective: to study risk factors for invasive aspergillosis (IA), its etiology, clinical manifestations, and treatment efficiency in patients with rheumatic diseases (RD).Patients and methods. The first study of proven and probable IA (EORT/MSGERC, 2019) was conducted in 18 patients with RD, who accounted for 3% of all adult IA patients (n=699) included in the 1998–2020 registry of the Department of Clinical Mycology, Allergology, and Immunology, I.I. Mechnikov North-Western State Medical University (Group 1). This group comprised 56% women; the median age was 59 [21; 75] years. Group 2 (a comparison group) included 610 adult hematology patients with IA (median age, 45 [18; 79] years; 42% women). A prospective case-control study was conducted to identify risk factors for IA in patients with RD: 36 rheumatic patients without IA (median age, 58 (18–79) years; 61% women) (a control group).Results and discussion. Patients with RD were found to often develop IA in the presence of anti-neutrophilic cytoplasmic antibody-associated vasculitis (granulomatosis with polyangiitis and microscopic polyangiitis) and systemic lupus erythematosus (50 and 16%, respectively). It was shown for the first time that the likelihood of IA in patients with RD increases with prolonged (median 14 days) lymphocytopenia during RD treatment (odds ratio 13.0; 95% confidence interval, 3.3–50.3). The main causative agents of IA were A. fumigatus (50%) and A. niger (29%). IA was more severe in Group 1 than in Group 2: in the resuscitation and intensive care units, there were 44 and 18%, respectively (p=0.01). Group 1 versus Group 2 more frequently had respiratory failure (61 and 37%, respectively; p=0.03), hemoptysis (28 and 7%; p=0.0001), chest pain (17 and 7%; p=0.04), and cardiac involvement (11 and 1%; p=0.0001), and less frequently had fever (67 and 85%; p=0.01). The common site of IA was the lung (83%); the characteristic feature detected by computed tomography (CT) is pulmonary cavitation (44%). Antifungal therapy was used in 89% of Group 1 patients; the overall 12-week survival was 69%.Conclusion. In patients with RD, it is difficult to differentiate between the progression of the underlying disease, adverse drug reactions, infectious complications, or a combination of these disorders due to the similarity of their clinical manifestations. When RD patients with infectious syndrome and respiratory failure develop prolonged lymphocytopenia during combination therapy, AI should be suspected and lung CT, bronchoscopy, and mycological examination of the material obtained by bronchoalveolar lavage be done.Цель исследования – изучение факторов риска развития, этиологии, особенностей клинических проявлений и эффективности лечения инвазивного аспергиллеза (ИА) у пациентов с ревматическими заболеваниями (РЗ).Пациенты и методы. Проведено первое исследование «доказанного» и «вероятного» (EORTС/MSGERC, 2019) ИА у 18 пациентов с РЗ, которые составили 3% всех взрослых больных ИА (n=699), включенных в регистр, созданный на базе кафедры клинической микологии, аллергологии и иммунологии ФГБОУ ВО «Северо-Западный государственный медицинский университет им. И.И. Мечникова» (1998–2020 гг.) – 1-я группа. В этой группе было 56% женщин, медиана возраста – 59 [21; 75] лет. Во 2-ю группу (группа сравнения) вошли 610 взрослых пациентов с гематологическими заболеваниями, страдающих ИА (медиана возраста – 45 [18; 79] лет, женщины – 42%). Для изучения факторов риска ИА у пациентов с РЗ было проведено проспективное исследование случай-контроль, в которое включили 36 взрослых пациентов с РЗ без ИА (медиана возраста – 58 [18; 79] лет, женщины – 61%) – контрольная группа.Результаты и обсуждение. Установлено, что у пациентов с РЗ ИА чаще развивается на фоне васкулитов, ассоциированных c антинейтрофильными цитоплазматическими антителами (гранулематоз с полиангиитом и микроскопический полиангиит), и системной красной волчанки (соответственно в 50 и 16% случаев). Впервые было показано, что вероятность возникновения ИА у пациентов с РЗ повышается при длительной (медиана – 14 дней) лимфоцитопении на фоне лечения РЗ (отношение шансов 13,0; 95% доверительный интервал 3,3–50,3). Основными возбудителями ИА были A. fumigatus (50% случаев) и A. niger (29%). В 1-й группе ИА протекал более тяжело, чем во 2-й: в отделениях реанимации и интенсивной терапии находились 44 и 18% больных соответственно (p=0,01). В 1-й группе чаще, чем во 2-й, отмечались дыхательная недостаточность (61 и 37% соответственно; p=0,03), кровохарканье (28 и 7%; p=0,0001), боль в грудной клетке (17 и 7%; p=0,04), поражение сердца (11 и 1%; p=0,0001), реже – лихорадка (67 и 85%; p=0,01). Основной локализацией ИА были легкие (у 83% больных), характерный признак, определяемый при компьютерной томографии (КТ), – наличие полостей деструкции (44% случаев). Антифунгальную терапию получали 89% больных 1-й группы, общая выживаемость в течение 12 нед составила 69%.Заключение. У пациентов с РЗ сложно провести дифференциальную диагностику между прогрессированием основного заболевания, неблагоприятными реакциями лекарственной терапии, инфекционным осложнением или комбинацией этих нарушений из-за сходства их клинических проявлений. При развитии длительной лимфоцитопении на фоне комплексной терапии у пациентов с РЗ, имеющих инфекционный синдром и дыхательную недостаточность, следует заподозрить ИА и провести обследование: КТ легких, бронхоскопию и микологическое исследование материала, полученного при бронхоальвеолярном лаваже.

Endothelium damage and vasoregulating activity of vascular wall in patients with rheumatoid arthritis

Objective. To study vasoregulating function circulating endothelial cells (CEC) number in blood of patients with rheumatoid arthritis (RA) with different activity and clinical features. Material and methods. 102 pts with RA aged 17 to 55 years were examined. RA was diagnosed according to ACR criteria. Mean disease duration was 7,2+0,6 years. 29 pts had I, 59 - II and 17 - 111 activity degree. 17 pts had Raynaud’s syndrome. Control group consisted of 26 healthy volunteers. Endothelium damage was assessed by CEC content in peripheral blood according J. Hladovec method. Vasoregulating function of vascular wall was assessed by flow-dependent and nitroglycerine-induced dilatation. Results. Flow-dependent vasodilatation was decreased (p<0,02) and CEC number was increased (p<0,01) in RA pts comparing with control group. Endothelium damage degree and vascular tone regulation disturbances depended on activity, presence of systemic features and duration of RA. Conclusion. Blood CEC number measurement can be used for assessment of endothelium damage in RA. Pts with RA have disturbance of vasoregulating function of endothelium and its degree depends on activity and duration of the disease

FEBUXOSTAT FOR TREATMENT OF CHRONIC HYPERURICEMIA IN GOUT PATIENTS

Febuxostat, a selective  inhibitor of isoforms xantinoxydoreductase, it is an alternative to a limited number of medications to reduce urates levels  applied in recent decades. Inhibition of xantinoxydoreductase by febuxostat more is more powder and effective  than by allopurinol, as evidenced  by more frequent achievement  of target urate level  in the blood serum, especially  in patients  with high urates concentration. Unlike allopurinol pharmacokinetic properties febuxostat  do not depend  to a large extent  on renal clearance, which is important for patients  with chronic renal disease.  A few studies conducted further evaluation of the febuxostat  safety for the cardiovascular system and its potential positive impact on renal function. It is also important that elderly patients didn’t require correction doses of the drug

Medical and economic analysis of the impact of rheumatoid disease-associated disability on the country's economy in terms of implementation of pension reforms

The paper presents the data of an original study evaluating the impact of disability associated with a number of rheumatic diseases (RDs) (rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis) on the country's economy, as well as their related losses of the state under the conditions of implementation of the upcoming pension reform (PR). The authors consider the socioeconomic importance of disability associated with RDs in the current period and after PR implementation in 2019–2028, determine the degree of its influence on the country's gross domestic product, and also calculate the economic efficiency of return of the potentially able-bodied proportion of disabled people (able-bodied population) to socioeconomic activity.The opinions of experts and leading experts in this area from different subjects of the Russian Federation were taken into account when preparing the study

GOUTY ARTHRITIS – MODERN VIEW OF THE PROBLEM

Gout is a fairly common rheumatic disease, the significance of which becomes an increasingly important interdisciplinary problem. It is known that about 2.5% of men over the age of 30 and women over the age of 50 suffer from gout. By the age of 80 y.o. the disease is registered already in 9% of men and 6% women. The increased incidence, high comorbidity, and low compliance of patients with gout put new questions when the adequate complex therapy is sought.Despite the fact that the treatment of this disease is well known and widely discussed in the literature, it’s possible to achieve remission of gout only in very rare cases. In the literature, there is evidence that less than ½ of patients with gout get ordinary therapy, while often drugs are prescribed in doses not sufficient to obtain the effect [1]

WEBER-CHRISTCHEN’S DISEASE (CLINICAL EXPERIENCE)

The case of severe form of Weber-Christchen’s disease in 31 year old man is described. The difficulty of diagnosis for the fist half a year is stressed - until characteristic nodes in subcutaneous layer appears. The diagnosis is confirmed by the data of biopsy of the node which revealed typical multinuclear macrophages with foamy cytoplasm (lypophages). The peculiarity of this case if the resistance of the disease to the combined treatment by high doses of GCS, cyloloxics and Sandimmune

Osteomalation under the mask of spondyloarthritis

Objective. To demonstrate the possibility of having a spondyloarthritic mask of osteomalacia in patients of both sexes.Materials and methods. Two clinical cases of osteomalacia occurring under the mask of spondyloarthritis in patients treated at the Clinical Rheumatology Hospital of Saint-Petersburg, Russia, as well as similar cases described in the literature, were analyzed.Results. In the cases described, patients were diagnosed with a disease from the group of spondyloarthritis based on a number of individual symptoms, such as pain in the lower back and stiffness, as well as instrumental examination data. At the same time, with in-depth evaluation, the pain in the lower back did not did not met to the inflammatory pain ASAS criteria, and there were also no signs of general laboratory activity of the disease. The conventional therapy for spondyloarthritis was ineffective. With the re-evaluation of clinical, laboratory and instrumental data, the diagnosis was changed to osteomalacia. Appointment of adequate therapy with vitamin D after a review of the diagnosis resulted in both a regression of clinical symptoms and an improvement in laboratory parameters.Conclusions. If the patient has pain in the lower back, especially without clear signs of inflammatory, no signs of general laboratory activity, further examination is necessary to clarify possible osteomalacia. Spondyloarthritis should be only diagnosed in cases with the secondary nature of symptoms excluded