Rheumatoid arthritis on a global scale

If the enemy does not surrender...
The epidemic of rheumatoid diseases threatens to ruin the health systems of many countries

Alla Astakhova, "Results" No. 36-2012

This decade will bring a lot of trouble to specialists in the fight against autoimmune diseases. Recently at the Congress of EULAR (European League against Rheumatism) a disappointing forecast was made public: by 2015, the number of patients with rheumatoid arthritis will increase by 75 percent compared to 2005. And this is despite the fact that 21 million people in the world have already been diagnosed with the corresponding diagnosis. The problem is also acute in Russia – about 850 thousand people suffer from this disease in our country.

The map shows the losses incurred by different countries due to the spread of rheumatic arthritis, measured in units of DALY (Disability-adjusted life year - a year of life adjusted for disability). One DALY denotes one under-lived year of healthy active life per 100 thousand population. Russia was among the countries where this disease most often leads to disability

Today, rheumatoid diseases are among the most severe in terms of treatment costs. In the United States, for example, it is estimated that they spend up to $ 8.4 billion annually to fight arthritis: every fifth dollar of all direct medical expenses. And the indirect damage due to the loss of disability can reach almost 11 billion a year. If the number of cases of autoimmune diseases continues to grow at the same rate, the national health systems as a whole will be bankrupt. So breakthroughs on this front are eagerly awaited not only by those who, due to constant joint pain, can hardly move. What fortresses is the army of rheumatologists going to storm in the near future?

Identify the enemyIt is almost impossible to prevent rheumatoid arthritis.

It can first manifest itself after heavy physical exertion, emotional shock, fatigue, during hormonal adjustment. The trouble is that the causes of its development in the body are not known for certain. Numerous studies have shown that every hundredth person suffers from this disease on average. And for some reason, it occurs much more often in the weaker sex. There are other risk factors: heredity, smoking. At the same time, joint diseases are not the lot of the elderly at all. Of the 80 thousand who annually receive disability due to rheumatic diseases, half are people of active age: men – up to 49 years, women – up to 44. Children suffer from juvenile idiopathic arthritis.

And recent studies have revealed a link between the spread of rheumatoid arthritis and the epidemic of obesity, which is rapidly gaining momentum. According to WHO forecasts, the number of overweight people in the world from 2005 to 2015 will increase by the same 75 percent as in the case of arthritis. Moreover, the risk of getting arthritis among obese people increases in women. However, immunologists in this case are not in a hurry to call overweight the cause of arthritis. "I would not look for cause and effect among them," says Alexander Poletaev, scientific director of the Immunculus Research Center. – Metabolic disorders have become a real scourge of modernity. Perhaps both rheumatoid arthritis and obesity are associated with some kind of metabolic factor. The lifestyle of a modern person and numerous adverse environmental impacts may be to blame for this."

However, experts still have some assumptions about the nature of arthritis. It is believed that immune disorders are at the heart: the body does not recognize its own cells and begins to attack them as strangers. The so-called immune complexes are deposited in tissues. This gradually leads to damage to the joints.

Some experts suggest that the disease can develop as a result of infection – inflammation is its first sign. However, antibiotics do not work here, so it is still unclear whether this assumption is true or not. Doctors have learned to identify a terrible disease by the rheumatoid factor – there are antibodies in the blood serum of patients attacking their own immunoglobulins. But here's the problem: approximately 15 percent of patients do not find this factor at all. And in the elderly, its presence may have nothing to do with rheumatoid arthritis. It turns out that it is not easy to determine the disease in time. Now for this, doctors use analysis of various blood parameters, and tomography, and X-rays, and ultrasound. But what does it give?

Closer to the goalModern specialists are doing everything possible to diagnose the disease as early as possible.

After all, without adequate treatment, it can make a person deeply disabled in just five years. In addition, rheumatoid arthritis is a systemic disease. It affects not only the joints and spine. The kidneys, lungs and even the skin suffer. Atherosclerosis of blood vessels is developing at an accelerated pace, so from 30 to 50 percent of patients with arthritis die from stroke, heart attack, heart failure. However, now it is possible not only to postpone the onset of terrible consequences for a long time, but also to achieve remission – a state when the development of the disease is suspended so much that its signs practically do not appear. Previously, doctors started treatment with the least effective drugs, moving on to stronger drugs. It had no special effect – sooner or later 70 percent of patients became disabled, unable to move. But in 2010, the American College of Rheumatology (ACR) and EULAR identified a new goal of struggle.

Now the disease is treated aggressively at the earliest stages: they try to detect it as early as possible and achieve remission using modern drugs. This concept is called Treat-to-Target, loosely translated as "treat to remission". However, there are problems here too. It's a small matter: to understand what remission is. It seems that in the near future, doctors will have to work hard to improve the diagnosis. "Now all existing remission criteria are based on clinical and laboratory parameters," says Mikel Ostergaard, professor at the University of Copenhagen. "However, modern imaging techniques – MRI and ultrasonography – can give a different picture."

There is another problem: new genetically engineered biological products (they are also called biological agents), thanks to which progress has been made in treatment, are not cheap. Of course, not all patients need them: according to some data, they are suitable for only about 15 percent of patients. However, doctors would like to be able to prescribe modern treatment in each specific case, if necessary. So far, out of 46 European countries, only 36 pay for such medicines to their citizens. And where there is access to new drugs, there is a big difference in the level of funding.

For example, Turkey spends 9431 euros a year on medicines for one patient with rheumatoid arthritis, and Germany - 21,349. However, Russia seems to have surpassed everyone in terms of inequality. We have different treatment conditions for residents of different regions of the country. "In Russia, the state seems to pay for these drugs," says a rheumatologist at one of the capital's clinics. – But in fact, it all depends on which region a person lives in – rich or poor. It turns out that we are forced to select not those medicines that are suitable for the patient, but those that the region in which he lives can pay for. Of course, this is unfair. It shouldn't be that easy."

So it turns out that in our country, patients often have access to expensive "biological agents" only if they get a disability. But after all, it is necessary to treat a person precisely so that he does not become disabled... Now European countries are developing criteria for the availability of biological products. "There should be common EU standards defining access to treatment for those patients who really need it," says Polina Putnik from Maastricht University, author of a special study on this topic. Here it is not a sin for us to learn from the Europeans and make sure that access to such medicines is equal at least for residents of all regions of Russia. Otherwise, treatment in accordance with uniform standards becomes a fiction.

From which to choose?However, problems also exist where there are no interruptions with expensive "biological agents".

As it turned out, patients tend to exaggerate the effect of biotechnological drugs. Studies have shown that the condition of patients usually improves during the first year of taking such medications. Then comes a period of stabilization, which can last quite a long time. Scientists from the University of Calgary carefully monitored all the parameters of the patients' condition – they studied both laboratory data and survey results. It turned out that four years after the condition stabilized, patients begin to attribute improvement to themselves. Of course, doctors have a lot to choose from – there are about ten major biotechnological drugs for the treatment of rheumatoid arthritis in the world today. In Europe, eight are used. In Russia – seven. There are so many drugs that specialists can afford the luxury of conducting a new type of clinical research – they compare the effect of drugs not with placebo, but with other biotechnological drugs. However, no matter how you compare it, it is clear that so far none of them cures rheumatoid arthritis, but only suspends the development of the disease.

That is why doctors are so intensely following new discoveries of the fundamental mechanisms of the development of rheumatoid arthritis. Researchers from the Hospital for Special Surgery in New York recently identified another violation of the immune system, which may be the cause of the disease. We are talking about violations of intercellular signals. Scientists have shown that such disorders can affect the development of macrophages – immune cells that attack extraneous pathogens. Now they want to test this theory on laboratory animals. And if they prove their case, they will immediately start creating a new medicine.

"It is likely that success may await them on this path," Alexander Poletaev predicts. – After all, the mechanism of development of the immune response largely boils down to the transmission of signals from one cell to another. Autoimmune diseases may be associated with a violation of such signals."

However, even in this case, we are unlikely to get a magic pill, taking which the patient will wake up healthy in the morning. Therefore, rheumatologists today do not neglect anything that could improve the condition of patients. They study the role of physical exercise – it has been proven that those who exercise regularly feel better. They conduct special trainings that teach how to cope with pain. They study how certain symptoms of the disease affect the lives of patients. For example, Scandinavian scientists have found out that morning stiffness – difficulty in movement – in more than 70 percent of patients leads to the fact that they are forced to leave work. After all, you can't be late to the office on a regular basis. Meanwhile, doctors used to consider this symptom not particularly important compared to pain and inflammation. Now they will change their attitude to this and, most likely, will offer additional methods of treatment. And Norwegian researchers decided to ask how patients with rheumatoid arthritis are doing on the personal front. It turned out that 82 percent of them have a partner. So, you can live with this disease, hoping that victory over it is not far off.

Portal "Eternal youth" http://vechnayamolodost.ru04.09.2012