Impaired B-cell immunological tolerance plays a central role in the pathogenesis of autoimmune rheumatic diseases and autoimmune diseases of another nature. B-cells link innate and acquired immunity: they express Toll-like receptors that respond to danger signals; act as antigen-presenting cells; induce an antigen-specific immune response; determine the development of immunological memory; and synthesize a wide range of cytokines that regulate (stimulate or suppress) an immune response and inflammation. In autoimmune diseases, there are metabolic and B-cellular signaling disturbances that lead to defects in B-regulatory, T-regulatory, follicular T-helper, and dendritic cells. B-cells synthesize organ-nonspecific and organ-specific autoantibodies that are biomarkers for autoimmune diseases and play in important role in their immunopathogenesis. Anti-B-cell therapy that causes B-cell depletion in blood and target organs is effective in a wide range of autoimmune diseases. Its efficiency is determined by various mechanisms, such as suppression of pathogenic autoantibody synthesis; modulation of the function of B-cells (antigen presentation, cytokine synthesis, and costimulation), T-lymphocytes and dendritic cells. Further study of a strategy for targeted anti-B-cell therapy, mechanisms of action, and new targets is important for the progress of modern rheumatology to improve the treatment strategy of autoimmune rheumatic diseases.

The article presents the guidelines developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons for the perioperative management of patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis, or systemic lupus erythematosus who are undergoing elective total hip or knee arthroplasty. It considers the perioperative use of antirheumatic drug therapy, including disease-modifying anti-inflammatory drugs, biological agents, tofacitinib, and glucocorticoids. All recommendations are conditional and based on the results of retrospective clinical trials, which should be considered when making decisions about perioperative antirheumatic therapy.

Objective: to study changes of acute-phase reactants (erythrocyte sedimentation rate – ESR, C-reactive protein – CRP), autoantibodies (IgM/IgA rheumatoid factors – RF, anti-citrullinated protein antibodies), immunoglobulin classes G, M, and A, and CD19+ B-lymphocytes in patients with rheumatoid arthritis (RA) 12 and 24 weeks after initiation of therapy with a rituximab (RTM) biosimilar at a total dose of 1200 mg.
Subjects and methods. Examinations were made in 20 patients with a reliable diagnosis of RA (including 18 women; median age, 61.5 [54; 66.5] years; disease duration, 39.5 [20; 84] years; DAS28, 5.6 [4.9; 6.8]). All the patients received two intravenous infusions of RTM (Acellbia®) 600 mg at a 2-week interval during therapy with methotrexate, nonsteroidal anti-inflammatory drugs, and glucocorticoids. Clinical and laboratory parameters were analyzed immediately before therapy and then 12 and 24 weeks after the first infusion of the drug.
Results and discussion. DAS28, ESR, and CRP level in respondents significantly decreased 12 and 24 weeks after RTM administration. The serum IgM RF concentration in the respondents was found to be significantly reduced at weeks 12 and 24 and amounted to 79.7 and 87.1% of baseline, respectively. The IgA RF level significantly decreased by 72 and 85% of baseline at weeks 12 and 24 of RTM therapy, respectively, in patients with a good response, and by 59.7 and 67.5% at weeks 12 and 24 in patients with a satisfactory response. The serum concentration of anti-cyclic citrullinated peptide antibodies in the respondents remained high throughout the follow-up. All the patients achieved CD19+ B-cell depletion at week 12 of therapy (absolute levels, 0); there was an increase in the level of CD19+ B-lymphocytes at week 24 (0.0030 [0.0003; 0.0270] 109/l). In both in the good and satisfactory response groups, the mean immunoglobulin levels remained within normal limits.
Conclusion. The analysis of the efficiency of two infusions of the RTM biosimilar at a total dose of 1200 mg following 24 weeks of therapy initiation suggests that the drug is able to cause reductions in disease activity, laboratory signs of inflammatory activity, autoantibody concentrations, and complete B-lymphocyte depletion.

Colon lesion induced by the intake of nonsteroidal anti-inflammatory drugs (NSAIDs) (NSAID-induced colopathy) is a serious but poorly understood condition.
Objective: to investigate the incidence, clinical and endoscopic characteristics of NSAID-induced colopathy, as well as the efficacy of sulfasalazine in this pathology.
Subjects and methods. A study group consisted of 260 patients with rheumatic diseases who regularly took NSAIDs. Clinical, laboratory, and endoscopic (video colonoscopy (VCS)) examinations were carried out. Patients (n = 16) with identified NSAID-induced colopathy (erosions and ulcers of the colon) were prescribed sulfasalazine (4 g/day). A control group included 16 patients with this disease who did not receive treatment. All the patients in the study and control groups discontinued NSAIDs. The result of treatment was assessed according to VCS readings following 4 weeks.
Results and discussion. NSAID-induced colopathy was detected in 12.3% of the examined patients. It was characterized by the presence of erosions and ulcers mainly of the right colon, abdominal pain, flatulence, and diarrhea, as well as a positive fecal occult blood test. After a sulfasalazine treatment cycle, erosion and ulcer healing was noted in more than 50% of patients. The subjective manifestations of NSAID-induced colopathy were abolished in most patients. The time course of changes in endoscopic and clinical manifestations significantly differed in the study and control groups. 

Conclusion. NSAID-induced colopathy is a common disease occurring in NSAD users. Sulfasalazine may be considered as a possible treatment for NSAID-induced colopathy.

Objective: to investigate the levels and clinical associations of vascular endothelial growth factor (VEGF) and its type 2 receptor (VEGFR-2) in patients with systemic sclerosis (SSc).
Subjects and methods. The investigation enrolled 46 patients aged 19–77 years with SSc lasting 0.5–24 years. This group included 23 patients with limited cutaneous SSc (lSSc) and 23 with diffuse cutaneous SSc (dSSc). Forced vital capacity (FVC), lung diffusing capacity (LDC), and pulmonary arterial systolic pressure (PASP) were investigated in all the patients. An enzyme immunoassay was used to estimate serum VEGF and VEGFR-2 levels in the patients and 20 healthy individuals who constituted a control group.
Results and discussion. The levels of VEGF in the healthy individuals and SSc patients ranged from 0.20 to 264.00 and from 0.02 to 1034.20 pg/ml, respectively. The mean VEGF level in the study group was more than twice that in the control group: 212.35±253.93 and 97.74±71.46 pg/ml, respectively (p=0.032). In dSSc and lSSc, the levels of VEGF were in the range of 0.02–599.80 and 0.02–1034.20 pg/ml, respectively. The VEGF level in lSSc was significantly higher than that in dSSc and averaged 267.11±268.74 and 120.40±141.09 pg/ml, respectively (p=0.012). Nineteen (41%) patients were found to have digital ulcers during examination or in the medical history. The VEGF level in the presence of the ulcers was higher than that in their absence, but this difference was statistically insignificant. PASP was greater than the upper normal limit (30 mm Hg) in 19 (43%) patients. The level of VEGF in PASP <30 and ≥31 mm Hg was in the range of 0.02–363.60 and 0.20–1034.20 pg/ml, respectively. That in elevated PASP was significantly higher than that in normal PASP (p=0.0042). The mean VEGF level in patients with LDC <50% was substantially higher than in those with LDC ≥50% (364.20±381.95 and 128.55±142.70 pg/ml, respectively; p=0.034). FVC <80% of the due value was observed in 11 (26%) of 43 patients. The level of VEGF in these patients was higher than in those with normal FVC, but this difference is statistically insignificant. In SSc patients, the level VEGFR-2 was in the range of 915.7–23 290.0 pg/ml (mean value, 5784.6±4773.8 pg/ml) and much higher than that in the control group (1552.6±272.8 pg/ml) (p<0.0001). There were no differences in the level of VEGFR-2 in the presence and absence of digital ulcers, with normal and elevated PASP, with LDC <50 or ≥50%, and with normal and reduced FVC.Correlation analysis revealed a close direct association between the level of VEGF and PASP (r=0.40; p=0.007). There was also a tendency towards an inverse correlation of LDC with VEGF levels, which was not, however, statistically significant (r=-0.28; p=0.070).

Conclusion. The patients with SSc have been found to have higher VEGF and VEGFR-2 levels. Their close association with the clinical manifestations of SSc indicates that the VEGF/VEGFR-2 axis plays a role in the pathogenesis of the disease.

Objective: to provide a rationale for selecting a health-related quality of life (HRQOL) questionnaire in patients with systemic lupus erythematosus (SLE).
Subjects and methods. The investigation enrolled 328 patients (298 women and 30 men) with documented SLE who met the 2012 Systemic Lupus International Collaborating Clinic (SLICC) criteria. The patients’ mean age was 34.4±11.5 years; the disease duration was 106.3±97.9 months. All the patients underwent an assessment of the current activity of the disease by the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and organ damages by the SLICC damage index (DI). HRQOL was assessed using the 36-item Short-Form Health Survey (SF-36) and Lupus Quality of Life (LupusQol) questionnaires, which had been filled out by the patients.
Results and discussion. The assessment using both questionnaires revealed a considerable decline in HRQOL for all domains. There was a highly significant correlation among the comparable SF-36 and LupusQoL domains: «Physical Health» and «Physical Functioning» (r=0.8), «Emotional Health» and «Psychological Health» (r=0.4), «Pain» (r=-0.3), «Fatigue», and «Vitality» (r=-0.7). Disease activity has a statistically significant effect on «Planning» (p<0.0004), «Intimate Relationships» (p<0.003), «Dependence on Other People» (p<0.03), and «Body Image» (p<0.007), which cannot be assessed using the 36-item Short-Form Health Survey (SF-36) questionnaire, but which are contained only in the LupusQol questionnaire. Both SF-36 and LupusQol equally reflect HRQOL changes in the presence of irreversible organ damages. Since lesions of the joints, skin and nervous system significantly affect domains, such as «Planning», «Intimate Relationships», «Dependence on Other People», and «Body Image» in SLE patients, LupusQol is the choice of questionnaire when these changes are present. When conducting scientific and clinical research, it is advisable to use both questionnaires for greater objectification of data. When conducting researches and clinical trials, it is advisable to use both questionnaires for greater data objectification.

Objective: to evaluate the effectiveness of an educational program for teaching self-control skills for patients with rheumatoid arthritis (RA).
Subjects and methods. Examinations were made in 85 patients: 38 of them underwent a training program for mastering self-control skills; 47 patients constituted a control group. The serum levels of rheumatoid factor (RF), C-reactive protein (CRP), anti-cyclic citrullinated peptide (anti-CCP) antibodies and DAS28 were determined at baseline and after 2 months.
Results and discussion. After training in self-control skills, the study group showed a significant reduction of DAS28 on an average from 5.2±4.9 to 3.2±3.0 and in the number of tender and swollen joints, erythrocyte sedimentation rate (ESR), and the levels of CRP, RF, and anti-CCP antibodies. At the same time, the level of hemoglobin, the number of red and white blood cells did not change substantially. There was a decrease in ESR and CRP levels in the control group.
Conclusion. Teaching the patients in self-control methods can reduce the activity of the inflammatory process.

Pulmonary hypertension (PH) in patients with systemic sclerosis (SSc) is associated with an unfavorable prognosis. The scope of investigations necessary to detect PH, the complexity of its diagnostic algorithms for routine use, as well as the impossibility to apply the existing algorithms for all PH variants increase the relevance of searching for novel PH predictors in patients with SSc.
Objective: to reveal the relationship of capillary structural changes to the clinical and immunological subtype of SSc, disease activity, and risk for PH.
Subjects and methods. The trial enrolled 57 patients with SSc. The investigators evaluated the activity of the disease, the extent of skin lesion, the fluorescent pattern and titer of antinuclear factor, and the level of N-terminal brain natriuretic propeptide. All the patients underwent nailfold videocapillaroscopy, a comprehensive assessment of external respiratory functions, and echocardiography. When there were indirect signs of PH, right heart catheterization was performed for its verification.
Results and discussion. PH was detected in 10 of the 57 patients enrolled in the trial. The patients with PH were significantly older than those without PH (61±7 and 53±10 years, respectively; p=0.036); there were also differences between these groups in the semiquantitative assessment of nailfold capillary alterations (p<0.05) and in the signs of right cardiac remodeling (p <0.05). The Rodnan skin score was found to be related to right atrial area (r=0.506; p=0.019) and pulmonary artery diameter (r=0.482; p=0.027). It has been shown that age older than 60 years (p=0.001), reduced capillary bed density (p=0.033), and lower lung diffusing capacity (p=0.024) may be an additional criterion increasing the probability of PH. In localized cutaneous SSc, the Rodman skin score correlated with right atrial area (r=0.582; p=0.009), right ventricular dimensions in parasternal (r=0.517; p=0.023) and basal  (r=0.697; p=0.001) sections, and with pulmonary artery diameter (r=0.816; p<0.001).
Conclusion. In localized cutaneous SSc, nailfold capillaroscopy can be used along with the Rodnan skin score to assess PH probability.

Multi-slice spiral computed tomography (MSCT) of the chest is the gold standard for confirming interstitial changes in the lung; but the role of this technique in evaluating the efficiency of therapy for systemic sclerosis (SSc) has not been fully defined.
Objective: to assess the time course of changes in the lung according to chest MSCT findings and pulmonary function test (PFT) results in SSc patients and interstitial lung disease (ILD) during of active treatment.
Subjects and methods. The investigation enrolled 42 patients with a reliable diagnosis of SSc who had signs of ILD, confirmed by chest MSCT. The patients’ mean age was 48±2 years; the male-to-female ratio was 1:6; that of diffuse-to-localized SSc patients was 1.5:1 (25 and 17); the mean duration of SSc was 6.6±5.9 years. Over time during therapy, forced lung capacity (FVC) and lung diffusing capacity (LDC) were studied and chest MSCT was performed in all the patients at the time of inclusion in the study and after an average of 29±15.3 months (9 to 70 months). A 10% or more change in PFT results was considered to be of clinical significance. During the follow-up period, the patients were treated with rituximab (RTM) at a mean total dose of 2.5±1.3 g (500 mg to 5 g) in combination with glucocorticoids at a mean dose of 11.7±3.9 mg calculated with reference to prednisolone; 10 (24%) patients also received immunosuppressants.
Chest MSCT data were analyzed at 5 levels. The magnitude of changes following the pattern seen in frosted glass, honeycomb, and reticular alterations was estimated using a 4-point (0–3 points) scale at each level. The time course of changes in these parameters and PFT results was separately assessed in patients with less and more than 20% of lung tissue injury in Group A (n=13 (31%) and in Group B (n=29 (69%).
Results and discussion. Semiquantitative assessment of changes as evidenced by chest MSCT in SSc patients with ILD did not reveal any changes in their total scores. According to a radiologist’s subjective assessment, there were positive and negative MSCT changes in 8 (19%) and 11 (26%) patients, respectively; the changes were present in 23 (55%) patients. A 10% and more increase in FVC was observed in 16 (38%) patients; its decrease was seen in 3 (7%). Positive and negative LDC changes were found in 5 (12%) and 1 (2.4%) patients, respectively. On average, the group showed a significant FVC increase from 73.2±18.8 to 82±21.8% (p=0.000031) and LDC stabilization. None of the patients with positive MSCT changes exhibited FVC deterioration. During therapy, Groups A and B had positive MSCT changes in 5 (38%) and 3 (10%) cases, respectively (p=0.08); no negative changes were noted in Group A while Group B had negative changes in 11 (38%) cases. FVC increased clinically significantly in 6 (46%) patients in Group A and in 10 (34%) in Group B; this decreased in 1 (8%) and 2 (7%) patients, respectively. FVC was significantly higher in Group A than that in Group B both at the time of study inclusion (88.8±18.6 and 65.4±14.5%, respectively; p=0.0002) and in the long-term period (103.3±15.9 and 74.1±18.5%; p=0.0009), while during therapy this increased statistically significantly in both groups (p=0.016 and p=0.0014, respectively). In Groups A and B, the median FVC increments were 10.2 (4.7; 21.9)% and 5.9 (2.75; 14.7)% , respectively (p>0.05). The mean frosted glass score was significantly lower in Group A than that in Group B both at the time of study inclusion (2.9±2.3 and 6.6±2.7; p=0.01) and in the long-term period (1.6±1.4 and 6.4±3.0, respectively; p=0.000006) and this tended to decrease during therapy. A similar pattern was observed with reticular alterations
(4.3±2.7 and 8.7±3.2 (p=0.001) and 3.1±2.5 and 8.8±2.0 (p<0.00001), respectively). In Group B, honeycomb scores significantly increased (p=0.047).
Conclusion. Semiquantitative assessment of structural changes by chest MSCT in SSc patients and ILD did not reveal any changes in their total scores for a sufficiently long follow-up period. At the same time, the frosted glass scores significantly decreased in patients with an ILD area of <20%, and the honeycomb scores significantly increased in those with >20% of lung tissue injury. During active therapy, the entire group displayed an increase in FVC, as well as LDC stabilization, and their median increments were higher in the patients with an ILD area of <20%. These findings allow the baseline pulmonary injury area to be considered as a potential predictor for a response to therapy in SSc patients with ILD.

Rheumatoid arthritis (RA) is an autoimmune rheumatic disease characterized by damage not only to the joints, but also to the viscera, including the heart. The cardiovascular risk in patients with RA is 1.5 times higher than that in the general population. In this connection, the treatment should be aimed not only at joint diseases, but should also prevent fatal heart failure. Rituximab (RTM) is a biological drug that has proven to be highly effective in treating different diseases, including RA.
Objective: to investigate the effect of RTM on cardiac electrophysiological parameters in patients with RA.
Subjects and methods. Examinations were made in 83 patients with seropositive RA, of whom 21 patients received RTM at a dose of 1000 mg according to the scheme for 6–12 months and oral methotrexate at a dose of up to 25 mg weekly (Group 1) and 62 took oral methotrexate at a dose of up to 25 mg weekly for at least 12 months (Group 2). In addition to standard diagnostic methods, the investigators performed electrocardiography to calculate Q–T dispersion and vectorcardiography to determine the loop areas of P, QRS and T, as well as MV vector, MV azimuth, MV elevation.
Results and discussion. In Group 1, Q–T dispersion was lower than that in Group 2 (p<0.05). There was also a correlation between ESR and T loop area (r=0.633; p<0.05).
Conclusion. When RTM is used, ventricular myocardial repolarization disorders that are a marker of cardiac electrophysiological remodeling and are related to the activity of the disease are less pronounced.

In recent decades, there has been a steady increase in the prevalence of diabetes mellitus (DM) worldwide, including Russia. Much attention has been customarily focused on micro- and macrovascular complications in DM; however, in its long and/or severe course, the complications may involve other organs, including the musculoskeletal system and skin. The involvement of these tissues in DM is largely explained by excessive production of advanced glycation end products. The paper considers the main rheumatic manifestations of DM: limited joint mobility syndrome, cheiroarthopathy, Dupuytren's contracture, trigger finger, adhesive capsulitis of the shoulder joint, rotator cuff injury, carpal tunnel syndrome, Charcot neuro-osteoarthropathy, osteoporosis, muscle infarction, and diabetic scleredema. The pathogenesis and diagnosis of DM and its possible therapy options are discussed.

Increasing attention in rheumatology is currently paid to the detection of diseases in the earliest (preclinical) stages, which can contribute to a more favorable response to therapy. To this end, various clinical, laboratory (and primarily immunological) and instrumental parameters are studied as a possible harbinger of rheumatic diseases (RDs). Periodontal diseases (PD) may be possible predictors for the development of RDs, and particularly rheumatoid arthritis (RA). This review considers the relationship between the development of periodontitis and RA and discusses the participation of individual microorganisms in the pathogenesis of PD and RA. The cell-mediated mechanisms that cause the chronic inflammatory process and lead to bone resorption are discussed. The role of PD and P. gingivalis in the processes of impaired autoantigen citrullination is described. Whether biological agents may be used to treat RDs accompanied by severe PD is considered.

Shoulder pain associated with periarticular soft tissue lesion is a common pathology and one of the most common reasons to visit rheumatologists and traumatologists. The main cause of chronic shoulder pain is subacromial impingement syndrome (shoulder rotator compression syndrome (SRCS)). This pathology is accompanied by injury and inflammation of the tendons of muscles (supraspinatus, infraspinatus, subscapularis, and teres minor ones), which determine main movements in the shoulder. This review deals with the pathophysiology of SRCS, the clinical presentations of this disease, differential diagnosis with other diseases and pathological conditions accompanied by shoulder pain. A wide range of medications, such as nonsteroidal anti-inflammatory drugs, local glucocorticoid and hyaluronic acid injections, is used to treat SRCS. The review gives the data of clinical trials evaluating the comparative efficiency of these drugs. Special attention is paid to a new method for treating SRCS – the use of platelet-rich plasma (PRP). There are the latest data on the mechanism of action of PRP, the classification of its agents, a procedure for their preparation, and the data of clinical trials that have evaluated the efficiency and safety of this agent.

The success of total elbow arthroplasty (TEA) over the past decades could improve the functional results of this surgery. However, the frequency of complications and reinterventions remains high. In the Russian literature, there is a small number of publications that describe investigations of the results of TEA in patients with rheumatoid arthritis (RA).
Objective: to assess the medium-term results of primary total replacement of the elbow joint (EJ) in patients with its rheumatoid injury and to identify potential risk factors for endoprosthetic loosening.
Subjects and methods. A group of 78 patients who had undergone replacement of EJ (a total of 81 joints) in 2000 to 2017 was retrospectively studied. The mean postoperative follow-up period was 3.3 (1.1 to 4.9) years. The data of clinical examination, radiography, and functional scales were taken into account. The survival rate of various endoprostheses was calculated using the Kaplan-Meier method. The potential risk factors for implant loosening were investigated.
Results and discussion. Aseptic loosening was recorded in 8.4% of cases; there was deep infection (2.4%) and dissociation (2.4%) of EJ components. The five-year survival rates for all EJs were 75.0%. The significant risk factors for loosening were surgical technique errors; use of an Arete endoprosthesis; a preoperative C-reactive protein level of higher than 36.1 mg/l; age of older than 59 years at surgery; and a body mass index of higher than 32 kg/m2.
Conclusion. Despite advances in TEA, the medium-term incidence of complications is quite high. Preservation of the integrity of bone tissue and capsule-ligament apparatus at the moment of surgery, correct surgical technique, and use of high-quality prostheses will be able to provide long-term EJ endoprosthesis survival.

Opening wedge high tibial osteotomy (OWHTO) is a surgical treatment option for osteoarthritis (OA) of the knee with a predominant lesion of its medial segment, which can restore the mechanical axis of the lower limb, transfer load from affected medial to intact lateral part of knee joint, and thus slow OA progression, reduce or even abolish pain, prolong the function of the patient’s own knee joint, and delay total knee arthroplasty. Like any surgical intervention, OWHTO can be responsible for common, local, and specific surgical complications
Objective: to investigate complications from OWHTO and to determine the impact of the design of short spacer plates, bone graft materials and/or bone substitutes, as well as age, body weight and wedge angle correction on the development of complications in patients undergoing this surgery.
Subjects and methods. Twenty-eight OWHTOs were performed in 26 patients in 2003 to 2016. The male and female ratio was approximately 2:1. The patients’ mean age was 58.1±11.24 years; body mass index, 28.56±3.61 kg/m2; correction angle, 11.8±2.4°. Fixation was carried out using short spacer plates of three different designs: Puddu plate I, II, and Osteomed. Bone grafting was performed applying an iliac wing autograft or a biodegradable bone substitute (β-tricalcium phosphate) as rectangular blocks, or Inject. Bone grafting was not done when the wedge size was <10 mm.
Results and discussion. Twelve complications were diagnosed in 11 of the 28 (39.25%) cases. Of these, there were 8 cases of pain at the site of the implanted plate, three intra-articular fractures of the lateral tibial plateau, and one case of impaired polymerization of liquid β-tricalcium phosphate. There were no statistically significant relationships between the parameters investigated and the development of complications.

Conclusion. Clamp-associated complications develop with the same frequency regardless of the design of short spacer plates. The use of liquid β-tricalcium phosphate should be avoided in closing wedge osteotomy. Age, body weight, and the magnitude of a correction angle are unassociated with the development of complications in OWHTO. 

Psoriasis (PS) is a chronic inflammatory disease of the skin; its prevalence in the world is 1 to 3%. Psoriatic arthritis (PsA) is a chronic inflammatory disease from a group of spondylarthritides (SpA) associated with PS, which is characterized by various manifestations: peripheral arthritis, enthesitis, dactylitis, spondylitis, and nail involvement. Therapy for enthesitis and dactylitis in PsA is a difficult task in clinical practice. The efficacy and safety of apremilast (APR), a tableted phosphodiesterase 4 inhibitor, have been demonstrated in the treatment of patients with active PsA in four phase III PALACE (Psoriatic Arthritis Long-term Assessment of Clinical Efficacy) placebo-controlled studies evaluating its long-term clinical efficacy and safety in PsA. The investigators analyzed the efficacy and safety of long-term APR treatment, in which 1493 patients received therapy with this drug for 260 weeks during the randomized clinical trials (RCTs) of PALACE 1–3: a placebo (PL) group consisted of 495 patients; a twice-daily APR 30 mg group included 497 patients, and twice-daily APR 20 mg group comprised 500 patients.
At week 260, the percentage of patients who met the American College of Rheumatology (ACR) response criteria for 20%, 50%, and 70% improvement (ACR20, ACR50, and 70% ACR) with APR 30 mg twice daily were 67.2, 44.4, and 27.4%, respectively. The data of 208-week PALACE 4 showed that among 250 PsA patients, the percentage of those who met the ACR20, ACR50, and ACR70 were 68.2, 43.4, and 23.1%, respectively. The ACTIVE RCTs demonstrated that the effect of APR therapy in patients with PsA, which earlier had not received biological agents, was observed just at week 2, and then the efficiency of therapy increased at 52 weeks of treatment. After 52 weeks of taking APR 30 mg twice a day, the ACR20, ACR50 and ACR70 response rates were 67.1; 36.7% and 21.3%, respectively. The data of PALACE 1, 2, and 3 during a 156-week follow-up that reflected the effect of APR on enthesitis and dactylitis at 24 weeks of treatment with APR 30 mg twice daily indicated that there was a more pronounced reduction in the MASES index (-1.3 vs -0.9; p<0.05) and dactylitis scores (-1.8 vs -1.3; p<0.01) compared to PL. Among the patients treated with APR 30 mg twice daily for 24 weeks, the proportion of patients, in whom the enthesitis index reached zero, was significantly higher than in the PL group. At week 24 in the twice-daily APR 30 mg group, the mean dactylitis scores decreased significantly compared to baseline and to that in the PL group (p ≤ 0.01). Thus, APR, a new targeted synthetic disease-modifying antirheumatic drug (DMARD), a phosphodiesterase 4 inhibitor, is an effective agent that alleviates the manifestations of PsA and PS. This drug has a favorable safety profile and can be used alone and in combination with DMARD.  

The paper analyzes the foreign and Russian literature devoted to teaching patients how to control rheumatoid arthritis (RA) disease activity. It shows the historical development of this matter. The paper also describes currently known methods for the self-assessment of RA disease activity. The factors that affect the correctness of both a patient's selfassessment and a rheumatologist's evaluation are indicated. The results of studies, which prove the practical importance of self-control of RA activity, are presented. The paper demonstrates the ambiguity of rheumatologists' opinions on whether self-control can be applied.

The paper describes a clinical case of adverse reaction (AR) to leflunomide (LEF) in a female patient with rheumatoid arthritis (RA). In 2007 to 2017, the female patient with a reliable diagnosis of RA took LEF (Arava) at a dose of 20 mg/day, which showed a good clinical effect. However, the patient developed atypical bone cysts in the hands, feet, right elbow, and left heel 10 years after start of therapy. The differential diagnosis with deep mycosis, tuberculosis, cancer pathology, endocrine system disease, and AR to the long-term use of LEF was made to clarify the nature of bone cysts.

Enthesitis is inflammation at the site of attachment of tendon, ligament, or joint capsule to bone, a typical symptom of psoriatic arthritis (PsA). Heel enthesitis is of the greatest clinical significance. The activation of the interleukin 23/interleukin 17 (IL-23/IL-17) axis plays a pivotal role in the development of enthesitis. The latter can seriously limit the function of the musculoskeletal system and is incurable. If nonsteroidal anti-inflammatory drugs are ineffective, a biological agent should be immediately prescribed. The use of synthetic disease-modifying antirheumatic drugs for the treatment for enthesitis is not recommended due to their inefficacy. Despite the progress in the treatment of enteritis in PsA with tumor necrosis factor-α inhibitors, there is a need for the use of new drugs.
The paper describes the clinical case of a patient with PsA who has been successfully treated for isolated destructive enthesitis of the heel with the IL-17А inhibitor secukinumab (Cosentyx).

The paper discusses data on the high frequency of non-indicated use of proton pump inhibitors and on the manifestations of potential harms of their use.