蒋小敏教授痹证学术思想总结及治疗类风湿性关节炎的临床研究

发布时间：2018-07-26 13:57

【摘要】：目的：总结导师临床治疗痹证的学术思想和经验：探讨清热解毒、除湿通络法治疗活动期类风湿性关节炎的疗效及安全性,并分析其辨治本病用药规律。方法：1、理论研究：跟随导师临床诊疗、记录笔记、收集整理导师相关临证医案、查阅检索导师相关论文、著作及与导师探讨等方式,梳理、总结导师治疗痹证的经验,探讨其治疗痹证的学术思想。2、临床研究：按照随机、对照的临床试验原则,入选60例符合西医类风湿性关节炎活动期诊断标准及中医辨证符合湿热痹阻证候的病人。将病人分为治疗组和对照组各30例,治疗组每日以清热治旭汤剂内服治疗,对照组以甲氨蝶呤片1Omg/周+双氯芬酸钠片75mg/日进行治疗,两组疗程均为4周。结果：理论研究：从理论上阐述导师治疗痹证的学术思想及经验。导师提对本病的治疗当从肝、脾、肾三脏辨治。影响痹证发生、发展、转归、预后最重要的在于此三脏。脾肾亏虚,正气不足,肝失疏泄,情志过激极易致病。其临床表现以正虚为本,感邪为标,邪毒内伏,是导致本病反复发作、经久不愈的根本原因,日久必当气血亏虚、痰瘀阻络,最终废痿不用、致畸致残。本病的治疗分为急性期和缓解期进行,急则治标,缓则治本。导师临证时常灵活使用有毒药物,以毒攻毒,从六经辨治痹证,把握痹证发生、发展过程中的病机关键。对痹证的临床用药方面,擅用有毒药物,祛除湿毒浊瘀,有效控制和缓解类风湿性关节炎活动期的疼痛症状,搭配药对提高疗效。临床研究：经对参与试验的60例患者临床研究结果进行统计学分析后显示：1、两组患者总疗效比较,治疗组总有效率为76.7%,对照组总有效率为83.3%,统计学分析,两组患者疾病总疗效无显著性差异(P0.05)。2、中医证候疗效比较,治疗组总有效率为86.7%,对照组总有效率为80.0%；统计学分析,两组中医证候疗效比较,无显著性差异(P0.05)。3、治疗后两组患者主要临床症状比较,其关节疼痛个数、肿胀个数明显减少,与治疗前相比有非常显著性差异(P0.01),治疗后两组平均握力均较治疗前明显增强,有显著性差异(P0.05)。两组治疗后主要临床症状改善情况比较无统计学差异(P0.05)。4、治疗组治疗后中医各项症状积分均减少,与治疗前比较有统计学差异,其中在关节疼痛、关节压痛方面有非常显著性差异(P0.01)；在关节压痛、屈伸不利、晨僵方面呈显著性差异(P0.05)；对照组治疗后中医各项症状积分也均减少,均呈显著性差异(P0.05)。5、实验室检测指标：两组治疗后RF有所下降,但均无统计学差异(P0.05)：两组治疗后ESR、CRP值均有下降,有非常显著性差异(P0.01)；两组治疗后各实验室指标变化均无统计学差异P0.05。结论：导师经验方清热治旭汤治疗活动期类风湿性关节炎湿热痹阻证总体治疗效果及中医证候疗效确切。在改善关节疼痛、肿胀方面优于甲氨蝶呤片联合双氯芬酸钠缓释片组。其安全性良好。
[Abstract]:Objective: to summarize the academic thoughts and experiences of tutor in the treatment of arthralgia syndrome: to explore the efficacy and safety of clearing heat and detoxifying toxin and removing dampness and dredging collaterals in the treatment of active rheumatoid arthritis, and to analyze the law of treating rheumatoid arthritis by differentiation and treatment. Methods: 1, theoretical research: follow the tutor's clinical diagnosis and treatment, record notes, collect and sort out the tutor's related clinical medical records, consult and search the tutor's related papers, books and discuss with the tutor, and summarize the tutor's experience in the treatment of arthralgia syndrome, so as to sum up the experience of the tutor's treatment of arthralgia syndrome. To discuss the academic thought of treating arthralgia syndrome. 2. Clinical study: according to the principle of randomized, controlled clinical trial, 60 patients who met the diagnostic criteria of active stage of rheumatoid arthritis in western medicine and syndrome differentiation of traditional Chinese medicine accorded with the syndrome of damp-heat arthralgia obstruction were selected. Patients were divided into treatment group (n = 30) and control group (n = 30). The treatment group was treated with Qingre Zhixu decoction daily, while the control group was treated with methotrexate tablet 1Omg/ weekly diclofenac sodium 75mg/ day. The course of treatment in both groups was 4 weeks. Results: theoretical study: the academic thought and experience of tutor treating arthralgia syndrome were expounded theoretically. The tutor raised the treatment of this disease from liver, spleen, kidney three viscera differentiation treatment. Arthralgia syndrome occurrence, development, outcome, prognosis is the most important three viscera. Deficiency of spleen and kidney, deficiency of qi, loss of liver, extreme emotion easily cause disease. Its clinical manifestations are based on positive deficiency, pathogenic as standard, pathogenic toxin is the underlying cause of repeated attacks of the disease, long unhealed, the long must be deficiency of qi and blood, phlegm stasis obstruction collaterals, the final waste of impotence need not, deformity. The treatment of this disease is divided into acute stage and remission stage, emergency treatment, slow cure. Mentor often flexibly use toxic drugs to attack poison, from the six meridians to treat arthralgia syndrome, grasp the arthralgia syndrome occurrence, development process of pathogenesis key. In the aspect of clinical medication of arthralgia syndrome, it is good to use toxic drugs, remove dampness and toxin turbid stasis, effectively control and relieve the pain symptoms of rheumatoid arthritis in active period, and improve the curative effect with medicine. Clinical study: after statistical analysis of the clinical study results of 60 patients who participated in the trial, we found that the total effective rate of the two groups was 76.77.The total effective rate of the control group was 83.3%, statistical analysis showed that the total effective rate of the two groups was 76.775, the total effective rate of the control group was 83.3%. There was no significant difference in the total curative effect between the two groups (P0.05). 2. The total effective rate of the treatment group was 86.7, and the total effective rate of the control group was 80.0. There was no significant difference (P0.05) .3After treatment, the number of joint pain and the number of swelling were significantly decreased in the two groups after treatment (P0.01). After treatment, the average grip strength of the two groups was significantly stronger than that before treatment. There was significant difference (P0.05). There was no significant difference in the improvement of major clinical symptoms between the two groups after treatment (P0.05). There was significant difference in joint tenderness (P0.01); in joint tenderness, flexion and extension unfavorable, morning stiffness showed significant difference (P0.05); the control group after treatment of TCM symptoms were also reduced, The results showed significant difference (P0.05). The laboratory test index: the RF of the two groups decreased after treatment, but there was no statistical difference (P0.05): after treatment, the CRP value of ESRN in the two groups were all decreased, there was a very significant difference (P0.01); There was no statistical difference between the two groups in the changes of laboratory indexes after treatment (P 0.05). Conclusion: the total therapeutic effect and TCM syndromes of active rheumatoid arthritis with Qingre Zhixu decoction are definite. It was superior to methotrexate combined with diclofenac sodium sustained-release tablets in improving joint pain and swelling. Its safety is good.
【学位授予单位】：南京中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R259;R249

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