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Literatura


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 Immunology

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 program.
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 occured.
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

Signs Number of serum positive patients Number of serum negative patients Total number of patients
Sex M
F
8
30
1
6
9
36
Age 0-40
40-60
more than 60
14
17
7
1
4
2
15
21
9
Degree of activity I
II
III
5
19
14
-
5
2
5
24
16
Functional I
insufficiency II
of joints III
IV
14
17
7
-
-
4
3
-
14
21
10
-
X-ray stadium I
II
III
IV
4
23
5
6
-
2
4
1
4
25
9
7
Form joint
with inner
organ damage
16
22
1
6
17
28

Table II Basic clinical signs of joint syndrom

Signs 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
(mm.rt.st.) L
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

Groups Signs of immunological statute
Sedimentation
mm/hour
CIC Titer of antibody
against n-DNA, lg
aCL
%
Serum positive
(IgM - RF (+))
28.8 + 0.14* 119.2 + 0.29* 1.68 63.16
Serum negative
(IgM - RF (-))
33.0 + 0.82* 81.0 + 1.29* 1.34 85.7

* - statistically significant differences p< 0.05

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).

Figure 1: Frequency of an aCL occurance in patients with rheumatic arthritis with different courses.

Sizia1.gif (4226 bytes)

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 treatment therapy.
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.

Sizia3.gif (7476 bytes)

Figure 3: Effect of Wobenzym in the rheumatic arthritis treatment.

Sizia4.gif (4129 bytes)

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.

 

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