The problem of systemic scleroderma (SSD) activity enters into the view of standardized patient examination and it is important for choosing a therapeutic complex, for determining the dose of drugs, and for monitoring therapy. Great difficulties in the determination of activity in SSD are caused by the pathogenetic and morphogenetic features of the disease. It should be emphasized that there are no clearly defined exacerbation and remission periods. It is difficult to differentiate the potentially reversible inflammatory changes determining the activity of SSD from the irreversible fibrous changes characterizing the severity of the disease. The laboratory parameters of inflammatory activity are also of little informative value. The complicated problem of activity in SSD is to be further investigated both to improve and modify existing indices and to search for a common specific marker and/or key pathogenetically and clinically relevant markers of disease activity.

The paper presents data on different approaches to analgesia in relation to the mechanism of pain. Pregabalin (lyrica) has demonstrated a rapid development of an analgesic effect in different types of non-inflammatory pain: neuropathic pain, pain in fibromyalgia syndrome. The dose-dependent effect of pregabalin and its satisfactory tolerance are noted.

The paper describes the major clinical manifestations of osteonecrosis (ON), considers methods for its radiodiagnosis, and characterizes changes depending on the stage of ON. Different classifications of this process are presented.

Pathological changes that develop in the hip joints (HJ) have different origins and mechanisms of development, but their main manifestation is pain. The nature of this pain cannot be well established on frequent occasions. The English-language medical literature currently classifies such disorders as greater trochanter pain syndrome (GTPS). Its major signs are chronic pain and local palpatory tenderness in the outer part of HJ. The development of GTPS may be associated with inflammation of the synovial bursae situated in the greater tronchanter, as well as with tendinitis, myorrhexis, iliotibial band syndrome, and other local changes in the adjacent tissues or with systemic diseases. So GTPS may be characterized as regional pain syndrome that frequently mimics pain induced by different diseases, including myofascial pain syndrome, osteoarthrosis, spinal diseases, etc.

A reduction in immunological parameters during therapy for rheumatoid arthritis (RA) can yield new data on the mechanisms of anti-inflammatory action and be of great practical importance since this allows judgment of the depth of impact on the immunological process and therefore may be regarded as one of the components of improvement and remission. Objective: to study the effect of the tumor necrosis factor-a (TNF-а) inhibitor adalimumab (ADA) on a number of key immunological parameters in RA. Subjects and methods. The study included 100 patients (11 men and 89 women) diagnosed with RA from 5 research centers. The patients were observed to have high RA activity: at baseline, DAS28 6.22+0.84 scores; C-reactive protein (CRP) 37.1+34.7 mg/l. The mean number of disease-modifying antirheumatic drugs (DMARDs) used by a patient in the history was 2.1. During 24-week treatment, the patients took ADA in a subcutaneous dose of 40 mg every 2 weeks both alone and in combination with DMARDs. The time course of changes in the serum levels of CRP, IGM rheumatoid factor (RF) and in the concentration of anti-cyclic citrullinated peptide 2 (anti-CCP2) antibodies was determined by enzyme immunoassay (EIA) using the Axis-Shield Diagnostics commercial kits (United Kingdom). The levels of TNF-a, interleukin (IL) 6, 12, matrix metalloproteinase 3 (MMP3) were measured in pg/ml by EIA using the Bender MedSystems commercial kits (USA) according to the manufacturer's directions. Results. During ADA therapy, there was a rapid reduction in the level of CRP from 34.3 to 11.317.2 mg/l following 2 weeks (p<0.001), which thereafter remained low (11.9 mg/l), with some fluctuations, until week 24 of the study. There was a significant reduction in blood RF levels from 169.24 to 111.97 at 24 weeks (p<0.001). After 12 weeks of ADA treatment, there was virtually a two-fold decrease in IL-6 content from 8.87 to 4.87 pg/ml and later on to 4.03 pg/ml at week 24 (p>0,05). The mean levels of anti-CCP2 antibodies, IL-12, VEGF, and MMP3 remained unchanged. Conclusion. The time course of changes in immunological parameters during ADA treatment demonstrates the rapid and deep effect of TNF-a inhibitors on the different components of the pathogenesis of RA.

Objective: To analyze the results of using methotrexate (MT) in the treatment of psoriasis and psoriatic arthritis (PsA). Results. The mechanism of action of MT, the historical aspects of its use in the treatment of psoriasis and PsA, and the data of clinical trials of the efficacy and safety of the drug are considered. MT therapy is shown to cause a high rate of adverse reactions, which requires measures to prevent and treat adverse events. MT has been found to be frequently used in different combinations, including with other disease-modifying antirheumatic drugs (sulfasalazine), prednisolone, and biological agents, such as tumor necrosis factor inhibitors. In accordance with the European S3-guidelines S3 on the systemic treatment of psoriasis, MT (15-22.5 mg weekly) should be recommended from the results of randomized clinical trials and the extensive clinical experience with this drug. In terms of the present-day views, the indications for immunosuppressive therapy for PsA may be expanded it should be initiated in the early stage of the disease, particularly in its severe forms, until there are destructive changes in the osteoarticular apparatus. Conclusion. MT is an effective drug to treat psoriasis and PsA. It is recommended for use in moderate and severe peripheral arthritis (Grade B) and skin lesions (Grade A).

Objective: to evaluate the efficacy and safety of etoricoxib (Arcoxia ®) in gouty patients with an acute arthritis attack in real clinical practice. Subjects and methods. Thirty patients (25 men and 5 women; mean age 52.4±13.5 years) with crystal-verified gout participated in the pilot open-label study of the patients with arthritis, including those who had taken other nonsteroidal anti-inflammatory drugs (NSAIDs) without any effect. All the patients received etoricoxib (Arcoxia ®) in a dose of 120 mg/day for 7 days and, if arthritis persisted, in a dose of 90 mg/day for 7 more days. The authors estimated an articular index, swelling and hyperemia indices, resting and movement pain by a visual analogue scale (VAS), therapy tolerance in the patient's opinion before and 7 days after therapy and, in the patients taking etoricoxib for 14 days, after 14 days of therapy. Biochemical and clinical blood tests were carried out at the first and subsequent visits. Results. Seven days after therapy, an arthritis attack was abolished in 24 of the 28 patients, following 14 days, arthritis persisted only in 1 patient, but the number of affected joints reduced from 8 to 2. Following 7 days, there was a reduction in the mean erythrocyte sedimentation rate from 37.2+10.2 (before etoricoxib intake) to 15.3±8.3 mm/h (p<0.001), VAS resting pain from 48.6±21.4 to 5.2±3.5 mm (p<0.001), swelling (p<0.001) and hyperemia (p< 0.001) indices, and articular index (p<0.001). In 2 patients with baseline uncontrolled arterial hypertension, the drug was discontinued because of elevated blood pressure; periorbital edema was noted in one case by the end of a therapy course. There were no increases in the serum levels of liver enzymes, in the concentrations of creatinine and urea, and in glomerular filtration rate. Conclusion. Etoricoxib (Arcoxia ®) is highly effective and safe when used in patients with acute gouty arthritis, including those who had not benefited from previous NSAID therapy and those with oligoand polyarthritis.

Objective: to evaluate the effect of rituximab (RTM) on quality of life (QL) in patients with rheumatoid arthritis (RA) from the results of EQ-5D questionnaire total scores. Subjects and methods. Ninety-eighty patients with a valid diagnosis of RA were followed up. All the patients were randomized to two groups according to the basic therapy option: 1) 56 patients on combination therapy with methotrexate (MT; mean dose 13.72±0.06 mg weekly) and rituximab (RTM) by the standard regimen; 2) 42 patients receiving only MT (mean dose 12.6±0.08 mg weekly). The follow-up was 24 months. The international EQ-5D questionnaire was employed to assess QL. Results. While filling out the EQ-5D questionnaire, all the patients with RA mentioned baseline health problems to one extent or another. One year after therapy, there was a statistically significant increase in health index in both Groups 1 and 2: 0.61±0.04 and 0.63±0.07 (р<0.05 and р<0.05, respectively). Group 1 showed a statistically significant rise in VAS scores at 12 (46.7±6.3 mm; р<0.05) and 24 (49.3±11.4 mm; р<0.05) months versus at baseline. Conclusion. There was a satisfactory therapeutic effect only in the MT + RTM combination group whereas there was a minimal one in the MT monotherapy group.

In the past years considerable progress has been made in the treatment of systemic lupus erythe-matosus; however, not all questions have been answered. The range of medications has substan-tially increased. The paper describes a case of the long-term use of the new genetically engineered agent belimumab in a patient with systemic lupus erythematosus.

The paper provides data on the treatment of patients with end-stage rheumatoid arthritis (RA) and a rationale for the long-term treatment with disease-modifying antirheumatic drugs, including leflunomide as a first-line agent. It describes a clinical case of a patient with end-stage RA during arava treatment.

Systemic connective tissue diseases, systemic scleroderma in particular, constitute a group of diseases in which vascular disorders underlying diverse clinical manifestations are one of the pathogenetic components. Raynaud 's syndrome and ulceration are the most common symptoms of these diseases, which influence quality of life in patients and require constant drug therapy. The paper discusses the authors' clinical experience with intravenous iloprost used in the combination therapy of the vascular manifestations of systemic scleroderma and systemic lupus erythematosus.

The paper gives data on the progression of X-ray and magnetic resonance imaging changes in the hand and foot joints of patients with rheumatoid arthritis and psoriatic arthropathy and in the axial skeleton of those with ankylosing spondylitis when golimumab is used. Golimumab therapy is shown to retard the progression of structural changes in the peripheral joints and vertebral column. There is a significant correlation between magnetic resonance imaging evidence and blood C-reactive protein concentrations.

Osteoarthrosis (OA) is one of the most common diseases in the elderly; nonetheless, its treatment calls for further investigation. Present views are changing on the pathophysiology of OA, the role of the subchondral bone (SB), and an interaction between SB and articular cartilage in the natural history of the disease. Recent data point to novel therapeutic strategies, one of which is to use strontium ranelate in order to delay the progression of chondrolysis in knee and hip OA.

Effective pain relief is an essential component of combination therapy for rheumatic diseases (RD). Amongst analgesics, there are nonsteroidal anti-inflammatory drugs (NSAIDs) that hold a central position. Nineteen different representatives of this group are currently used in Russia, which allows the most appropriate medication to be chosen for each clinical situation and a specific patient. The primary difference between NSAIDs is their safety. There are two polar groups of NSAIDs: 1) nonselective COX-2 inhibitors (nNSAIDS) that rather frequently cause complications in the gastrointestinal tract (GIT), but are safer for the cardiovascular system; and 2) highly selective COX-2 inhibitors (coxibs) that are, on the contrary, characterized by a lower risk for GIT disease, but a higher risk for cardiovascular events. Aceclofenac, a drug that has moderate COX-2 selectivity, holds a good position between nNSAIDs and coxibs, which makes its use advisable for most patients with RD. Clinical trials and epidemiological studies show that both the GIT and cardiovascular system well tolerate the drug. This review gives the basic data pertaining to the evaluation of the safety of aceclofenac, including the results of the last (2012) meta-analysis of population-based studies of the risk of GIT bleeding due to the use of various NSAIDs and those of the AEROPLAN Russian study (of aceclofenac versus nimesulide).

A large role in the pathogenesis of osteoarthrosis (OA) is assigned to proinflammatory cytokines, such as interleukin 1 (IL1) and tumor necrosis factor-α, which activate catabolic processes in the cartilaginous tissue and subchondral bone. Diacerein is a medication that is able to block IL1 receptors, to lower the activity of metalloproteinases and nitric oxide, and thus to prevent joint inflammation and destruction in OA.