Clinical and immunological criteria of activity of different rheumatic
arthritis courses and their treatment by Wobenzym.
Siziakina L.P., Artemenko N.A.
State Medical University in Rostow on Don, Center of Clinical
III. Internat. Congress on Immunorehabilitation and Rehabilitation
in Medicine, Eilat, Israel, 1997.
Rheumatic arthritis (RA) is a chronical disease, its pathogenesity
includes deep immune system disorders with a disbalance of qualitative
and quantitative composition of immunocompetent cells including functional
and cell cooperation disorders (8). Joint damage is the most obvious
syndrom of rheumatic arthritis. But other symptoms than joint damage
mostly determine an aggressivity of the disease and its prognosis. Role
and place of different components of inflammation immune complex in
a rheumatic arthritis process development is beeing currently discussed.
A progresive character of the disease with a formation of irreversible
joint and inner organ damage, an early invalidity of patients, and a
decrease of working ability define a medical and social importance of
this problem as well as a necessity of continuing study of clinical-pathogenetic
peculiarities of rheumatic arthritis and a search for optimal treatment
An important role in a rheumatic arthritis diagnosis plays a determination
of IgG-RF (rheumatic factor) which seems to be an autoantibody against
IgG fragment (6). Both an existence of serum negative variant of rheumatic
factor and its detection in other rheumatic and nonrheumatic diseases
determine a necessity to investigate RA serological markers, for example
antibodies against cardiolipins (aCL), associated with thromboses during
rheumatic diseases, and antibody against native DNA (n-DNA) determining
a formation of immunopathological component.
In many cases a rheumatic arthritis course is complicated by systemic
symptoms which cause a development of pathological process (3, 13).
Various changes in rheological properties of blood during rheumatic
arthritis cause damages of microcirculation and seem to be one of the
factors which make the disease become chronic (2, 20).
Despite of different clinical symptoms of thrombohemorragical syndrom
and expression of damages of rheological, coagulational, and fibrinolytical
properties of blood (2, 3, 7), the most important way to diagnose changes
in microcirculation is the use of immunological methods.
Such methods include determination of antigen factor van Billebrand
(FB) in blood plasma. FB is a macromolecular protein synthesized by
the vascular endothelium cells which define a function of thrombocytes
(TC) and an activity of VIII. coagulating factor structural part of
which FB makes (7).
Except this, investigation of new pathogenetic mechanisms of a rheumatic
arthritis formation, insufficient efficacy of existing preparations
for treatment, and serious side effects (treatment by corticosteroids,
nonsteroidal antirheumatic substances, cytostatics) show a need for
new treatment methods of different types of rheumatic arthritis.
45 patients (9 men, 36 women) with reliable rheumatic arthritis (criteria
of American Rheumatological Association, 1987) were observed. An average
age was 46.9 (from 23 to 76) years. 38 patients were serum positive
on IgM-RF and 7 were serum negative. 5 patients showed activity of rheumatic
arthritis corresponding to degree I, 24 patients to degree II and 16
patients to degree III. Confirmation of diagnosis by X-ray for all patients
is available (Table 1).
In 28 patients syndroms such as fever, rheumatic nodes, amiotrophic
syndrom, damage of cardiovascular system, digestive system and others
In some cases concomitant diseases appeared: tuberculosis - 1, malignant
tumors - 1, diabetes - 1, periodical illness - 1.
During clinical observations of patients joint index, oedema index,
joint sum (by Richi), functional test by Li and an intensity of hand
clasp (mm.rt.st) were followed.
All patients were subjected to a general clinical observation and also
basic signs of immunological statute (9) were observed. Using IFA a
titer of antibody against n-DNA was determined. IgM-RF and a presence
of antibody against cardiolipins and antigen factor von Billebrand (FB)
were determined in patients’ serum (test of the “AGAB” system, Moscow).
Wobenzym (Mucos Pharma) was administred together with methotrexate 15mg
on Sunday; 10 dragees three times a day, 40 minutes before meals - 15
days, then 7 dragees three times a day - 15 days, followed by 5 dragees
three times a day - 30 days. To observe an efficacy of the preparation,
a group of 8 people (serum positive, joint form) was established. Control
group included 9 people treated with nonsteroidal antirheumatic substances
and methotrexate (15 mg). Results were evaluated statistically using
nonparametrical criterium by Mann-Whitney.
Observed group included 38 patients (84.4%), positive on IgM-RF, and
7 (15.6%) serum negative patients.
Comparison of clinical signs in both groups showed an absence of significant
differences (Table II). In serum negative group dominated patients with
inner organ damage 85.7%, in serum positive group inner organ damage
occured in 57.9% patients.
Presence of antibodies against cardiolipins was tested in serum positive
group. A positive result was obtained in 24 patients (63.2%). In 17
patients (70.8%) inner organ damage developed and only in 7 patients
(29.2%) joint form of rheumatic arthritis was diagnosed.
Table I General clinical characterization of patients
||Number of serum positive patients
||Number of serum negative patients
||Total number of patients
more than 60
|Degree of activity I
of joints III
|X-ray stadium I
Table II Basic clinical signs of joint syndrom
||Serum positive patients
||Serum negative patients
|Joint index by Richi
||25.9 + 0.12*
||24 + 0.69*
|Joint sum by Richi
||25.9 + 0.13*
||24.1 + 0.7*
|Oedema index by Richi
||26.2 + 0.13
||26.6 + 0.74
|Functional index by Li
||13.4 + 0.10*
||16.4 + 0.58*
|Intensity of a hand clasp R
|97.5 + 0.26*
85.7 + 0.24*
|85.0 + 1.32*
66.4 + 1.16*
* - statistically significant differences
p< 0.05 as compared to control
A degree of autoimmune process activity can be derived from a titer
of antibody against n-DNA. Among serum positive patients antibody against
n-DNA was detected in 22 patients (57.9%) - 8 (36.4%) with the joint
form and 14 (63.6%) with the inner organ damage.
In the serum negative group aCL were detected in 85.7% of patients (83.3%
with the inner organ damage and only 16.7% of patients with the joint
form of rheumatic arthritis).
Among observed patients antibody against n-DNA was detected in 4 patients
(57.1%). Interestingly, all of them had a rheumatic arthritis with inner
organ damage (Table III).
Table III Changes in signs of immunological statute dependent
on a type of rheumatic arthritis course
||Signs of immunological
||Titer of antibody
against n-DNA, lg
(IgM - RF (+))
|28.8 + 0.14*
||119.2 + 0.29*
(IgM - RF (-))
|33.0 + 0.82*
||81.0 + 1.29*
* - statistically significant differences
From obtained results it can be concluded that aCL occur in rheumatic
arthritis patients sufficiantly frequently - in 66.7% of cases. In patients
with inner organ damage aCL were detected more often - in 73.3%. In
the groups of serum negative and serum positive patients on IgM -RF,
aCL occured with the same frequency - in 83.3% and 70.8%, respectively
Figure 1: Frequency of an aCL occurance in patients with
rheumatic arthritis with different courses.
Analysis of antibody against n-DNA showed that higher titer of the
antibody appeared in rheumatic arthritis patients with inner organ damage
- 64.3%. When compared serum positive and serum negative groups, antibody
against n-DNA was detected in approximately same number of patients
- 57.1% and 57.9%, resp.
Based on the results of our investigation it could be concluded that
inner organ damage (accompanied with an increase of polyclonal hyperglobulinemy,
CIC level and of the titer of antibodies against n-DNA and aCL) is considered
to be an undesirable symptom caused by a high activity of autoimmune
process. Therefore, there is a need for an improvement of the current
Serum negativity on IgM-RF does not presume a favourable course of rheumatic
arthritis with a high titer of antibody against n-DNA, high value of
CIC and a presence of aCL. Additionally, in such cases a positivity
on IgG or IgA-RF is possible.
Clinical sign analysis of rheumatic arthritis patients, administred
with methotrexate and Wobenzym, gave following results. In patients
treated with Wobenzym a faster reduction of joint swelling, reduction
of a degree of morning tightness and a lessening of Li index was observed
compared to a control group (Figure 2). Analysis of immunological statute
signs showed that in patients treated with Wobenzym a more significant
lessening of IgM level occured as well as a faster normalization of
sedimentation. CIC degree remained higher ( Figure 2).
A faster clinical and immunological remission in patients treated with
Wobenzym and methotrexate enabled to lessen a dosage of methotrexate
to 7.5 mg. Two patients voluntarily gave up on methotrexate. During
next three months an activation of pathological process did not occur.
In the case of one patient an effect of Wobenzym treatment was negligible,
glucocorticoids were therefore administred. Comparison of a treatment
efficacy in Wobenzym group and a control group is shown in Figure 3.
Figure 2: Signs of immunological statute in RA patients treated
with and without Wobenzym.
Figure 3: Effect of Wobenzym in the rheumatic arthritis treatment.
With regard to a higher CIC values after Wobenzym administration it
is necessary to include a plasmapheresis during first month of treatment.
Based on all above mentioned facts it can be concluded that a presence
of antibodies against cardiolipins and n-DNA is associated with inner
organ damage at IgM-RF serum positive and serum negative rheumatic arthritis.
Rheumatic arthritis with inner organ damage, accompanied with an increased
titer of antibody against n-DNA, CIC level and a presence of an antibody
against cardiolipins, is considered a unfavourable course which needs
a therapy improvement.
An increase of n-DNA antibody titer, CIC level and a presence of antibodies
against cardiolipins appear to be a more informative signs of an autoimmune
process activity in comparison to general clinical observations. Therefore,
it is suggested to use these immunological tests for prognosis of a
disease course and for control of the therapy efficacy.