关节内注射甲氨蝶呤和地塞米松改善类风湿患者膝关节功能

Amelioration of knee joint function by intra-articular injection of methotrexate and dexamethasone in patients with rheumatoid

目的:类风湿关节炎膝关节受累是影响患者行走功能的重要因素,观察关节内注射甲氨蝶呤和地塞米松改善类风湿关节炎膝关节功能障碍的疗效,并与单纯应用地塞米松做比较。方法:选择2000-06/2001-11解放军第二○二医院收治的类风湿关节炎住院患者30例为观察对象。多伴有大关节的炎症、并处于活动期(休息时伴有中度疼痛、晨僵>1h、3个以上关节肿胀、关节压痛>8个,血沉>30mm/h)。所有患者均获全面知情同意。随机分为实验组16例,对照组14例。实验组用甲氨蝶呤和地塞米松联合膝关节腔内注射,对照组只用地塞米松膝关节腔内注射治疗。疗程4周。①于治疗前及治疗后1,4周采用膝关节功能评分标准评定膝关节功能改善情况。②采用类比评分法(0分无痛、1～3分轻度疼痛、4～6分中度疼痛、7～10分重度疼痛)进行疼痛程度的评定。③疗效评估以治疗后膝关节功能评分增分值(疗后-疗前)为评估指标,>20分为显著进步,>10分为进步,<10分为无效。治疗后进步曾经>10分,后又降低至<10分者为复发,于治疗后1,2,3,4周进行。④在治疗前,治疗后1,4周进行肿胀指数、压痛指数的评定及血沉、C反应蛋白、类风湿因子滴度、血象及肝肾功能变化的检测。结果:30例患者均完成4周治疗,全部进入结果分析。①治疗4周后实验组显著进步11例,进步4例,总有效率93.8%;对照组显著进步1例,进步2例,总有效率21.4%,实验组有效率显著高于对照组(P<0.01)。实验组有效率随治疗后时间的推移由100%下降至93.8%,对照组由100%降至21.4%。②治疗后1周两组膝关节的功能评分、疼痛评分、肿胀指数及压痛指数均有显著改善(P<0.05),但治疗4周后对照组各项指标与治疗前差异不显著(P>0.05),而实验组各项指标与治疗前差异仍显著(P<0.05)。实验组治疗4周后血沉,C反应蛋白比治疗前明显提高(P<0.05),而类风湿因子滴度无明显改善。对照组治疗后血沉,C反应蛋白及类风湿因子滴度均无明显变化(P>0.05)。两组治疗前后白细胞、血红蛋白、谷丙转氨酶、血肌肝、尿素氮均无明显变化(P>0.05)。结论:关节内注射甲氨蝶呤和地塞米松治疗类风湿关节炎膝关节功能障碍不仅能缓解患者的疼痛而且能显著改善其膝关节功能,有效防止复发,远期疗效优于单纯应用塞米松治疗的效果。

AIM： The involvement of knee joint is an important factor that influences the walking function of the patients with rheumatoid arthritis The paper was to observe the effect of intra-articular injection of methotrexate and dexamethasone in ameliorating the disorder of knee joint function in patients with rheumatoid arthritis, and compare with the simple application of dexamethasone. METHODS： Thirty inpatients with rheumatoid arthritis in the 202 Hospital of Chinese PLA between June 2000 and November 2001 voluntarily took part in the study, most of them were accompanied by articular inflammation and at the active phase （accompanied by moderate pain at rest, morning stiffness 〉 1 hour, 3 and more swelling of joint, 〉 8 tenderness of joint, erythrocyte sedimentation 〉 30 mm per hour）. The patients were randomly divided into study group （n=16） and control group （n=14）, The intra-articular injection of methotrexate and dexamethasone and that of simple dexamethasone was given respectively in the study group and control group for 4 weeks. ① The amelioration of the knee joint function was assessed with the scoring standard for knee joint function before treatment and 1 and 4 weeks after treatment. ② The severity of pain was assessed with the visual analog scale （VAS） （0 point was taken as painless, 1-3points as mild pain, 4-6 as moderate pain, 7-10 as severe pain）. ③ Taking the increased value of score （posttreatment-pretreatment） of the score of knee joint function as the evaluation index, the effects were evaluated at 1, 2, 3 and 4 weeks after treatment respectively （〉 20 points as significantly improved, 〉 10 points as improved, 〈 10 points as invalid）; after treatment, if the score 〉 10 points at first, and then decreased to 〈 10 points as relapse. ④ Before treatment and 1 and 4 weeks after treatment, the swelling index and tender index were evaluated, and the changes of erythrocyte sedimentation, C reactive protein, titre of rheumatoid factor, hemogram, and functions of liver and kidney were detected. RESULTS： All the 30 patients finished the 4-week treatment, and were involved in the analysis of results. ① After the 4-week treatment, it was significantly improved in 11 cases and improved in 4 cases, and the total effective rate was 93.8% in the study group; it was significantly improved in 1 cases and improved in 2 cases, and the total effective rate was 21.4% in the control group, and the total effective rate was significantly higher in the study group than in the control group （P 〈 0.01）. With the prolongation of time after treatment, the total effective rate was decreased from 100% to 93.8% in the study group and from 100% to 21.4% in the control group respectively. ② The score of knee joint function, score of pain, swelling index and tender index at 1 week after treatment were significantly ameliorated in both groups （P 〈 0.05）, but those in the control group at 4 weeks after treatment had no significant difference as compared with those before treatment （P 〉 0.05）, and there were still significant differences in the study group （P 〈 0.05）. After the 4-week treatment, erythrocyte sedimentation and C reactive protein in the study group were obviously increased as compared with those before treatment （P 〈 0.05）, but the titre of rheumatoid factor was unobviously improved; all the 3 indexes had no obvious changes in the control group （P 〉 0.05）. The leucocyte, hemoglobin, glutamic-pyruvic transaminase, serum creatine and urea nitrogen were not markedly changed before and ＂after treatment in both groups （P 〉 0.05）. CONCLUSION： lntra-articular injection of methotrexate combined with dexamethasone in the treating the knee joint functional disorder of patients with rheumatoid arthritis cannot only relieve their pain, but also significantly improve their knee joint function, effectively prevent the recurrence. Its long-term effect is superior to that of dexamethasone only.