【作者】 刘健；

【导师】 韩明向；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2003， 博士

【摘要】 1 目的 以中医理论为指导，总结中医学对类风湿性关节炎（RA）的认识和治疗经验，提出RA的中医学病机、治疗原则和治法，观察健脾益气、化湿通络法治疗RA的临床疗效，探讨RA从脾论治的作用机制。 2 方法 2．1 理论研究：以文献研究法，总结历代对RA相关病证的认识；提出RA的中医学病机，总结导师治疗RA的经验，拟定RA从脾论治的方药新风胶囊（XFC）。 2．2 临床研究：40例RA患者随机分为2组，治疗组20例应用新风胶囊，对照组20例应用雷公藤多甙片，2组均以3个月为一疗程，治疗一个疗程，观察临床疗效（晨僵、关节疼痛、肿胀及关节功能）、治疗前后CRP、RF、Ig、OKT₄、OKT₈、OKT₄／OKT₈、细胞因子（IL-1、TNF-α、IL-4、IL-10）及血管内皮生长因子等指标的变化及不良反应。 2．3 实验研究 （1）实验一：将60只大鼠随机分为正常对照组、模型对照组、新风胶囊（XFC）组和雷公藤多甙片（TPT）组，每组15只，制备完全佐剂并分别向除正常对照组以外的其余动物右后足跖皮内注射0.1ml制成佐剂性关节炎（AA）模型。观察各组大鼠的足跖肿胀度，电镜观察滑膜细胞、脾脏、胸腺、胃粘膜细胞超微结构的变化（包括线粒体肿胀、空泡变、嵴突病变等），计算各组线粒体病变率。 （2）实验二：将50只大鼠随机分为正常对照组、模型对照组、新风胶囊（XFC）组、雷公藤多甙片（TPT）组和甲氨喋呤（MTX）组，每组10只，制备完全佐剂并分别向除正常对照组以外的其余动物右后足跖皮内注射0.5ml致炎，观察动物体重、关节炎指数及血清细胞因子（IL-1、TNF-α、IL-4、IL-10）及血管内皮生长因子（VEGF）含量的变化。 （3）实验三：采用弗氏完全佐剂造模，设立正常组、模型组、甲氨喋呤（MTX）组、雷公藤（TPT）组和新风胶囊（XFC）组各10只，以电子显微镜观察各组大鼠滑膜、胸腺细胞凋亡情况；以免疫组化法检测各组大鼠滑膜、胸腺fas、fasL、bcl-2的表达；应用流式细胞仪（FCM）分别以线粒体膜电位（MMP）标记法、TUNEL法、Annexin V／PI法检测各组大鼠滑膜、胸腺、胃粘膜细胞凋亡率。 3 结果 3．1 理论研究结果：RA的中医学病机为脾胃虚弱，湿浊内生；气血不足，营卫失调；痰瘀互结，脉络阻滞。脾虚在RA的发病中起关键性作用；RA中医治疗原则是顾护脾胃，调补后天；扶助正气，益气养血；祛痰化湿，佐以通经活络，透达关窍。RA从脾论治的治法为健脾益气，化湿通络，治疗方药为新风胶囊（XFC）。 3．2 临床研究结果：XFC治疗RA在总有效率、改善RA关节症状（晨僵、疼痛、肿胀、关节功能）及部分实验室指标方面（ESR、CRP、RF、ESR、IgG、IgA、IgM）与TPT作用相似，但在改善全身整体症状（倦怠乏力、少气懒言）、脾虚湿盛（关节重着、大便稀溏）、瘀血症状（皮下硬节、局部发热），调节OKT₄／OKT₈，调整细胞因子平衡（下调IL-1、TNF-α，上调IL-4、IL-10）及降低VEGF方面显著优于TPT；而且XFC组药物不良反应（如食欲减退、食后腹胀、大便稀溏）的积分值显著低于TPT。 中文摘要53．3实验研究结果： ＊)实验一：与模型组相比，XF C组和h T组治疗后足路肿胀度显著降低(＜0．05＊关节滑膜细胞线粒体的病变率显著降低广＜0．05卜肝C组脾脏、胸腺淋巴细胞及胃粘膜细胞线粒体病变率显著降低（＜0刀5入而h T组上述指标差异无显著性仁＞0．05L与＊＊T组比较，地C组滑膜细胞、脾脏、胸腺淋巴细胞、胃粘膜细胞线粒体病变率显著降低o＜0刀5人 胆）实验二：与模型组相比，汀C组、h T组及＊TX组治疗后AA大鼠的关节炎指数（AI）显著降低尸＜0．05或P＜0．of人XFC组治疗后体重增加值与正常组比较差异无显著性(＞0．05人 TIT组及 MTX组给药前后体重增加值显著低于正常组和 XFC组仁＜0．01人与模型组比较，XF C组I卜1、’’l’－－。显著降低，1＊＊、1卜10显著升高o＜0刀1L并与＊＊T、MTX组无显著差异厂＞0刀5hXF C组VE GF显著低于模型组、＊PT组及MTX组。 （3）实验三： 电镜观察结果显示：正常组滑膜、胸腺细胞皱缩、核染色质分布不均，呈早期凋亡趋势；模型组则无凋亡改变；新风胶囊组滑膜细胞和胸腺淋巴细胞核染色质呈凝块状、边聚呈月芽状、胞浆内及胞膜外可见凋亡小体或核膜皱缩，呈凋亡早期改变；TIT组及Mh组虽也有核膜的皱缩、染色质分布不均，但凋亡表现没有XFC组明显。 免疫组织化学检测结果显示：与模型组比较，XFC组滑膜fsL表达显著增加(P＜刀习、bcl－2表达减少，且与 11，7’组、NTIX组比较差异无显著性（Pt．05h与模型组比较，XFC组胸腺 fsL表达显著增加，bclZ的表达显著减少，NlX组及TIT组上述指标的表达无显著性差异po．05人与L厂口【组和h T组比较，XF C组胸腺bd2表达显著减少、fsL表达显著增加叶卜0刀5人 流式细胞仪检测结果显示：以MMP法、TUNEL法和Anni Vrpl法分别检测结果表明，模型组与正常组比较，滑膜细胞、胸腺淋巴细胞凋亡率显著降低，而胃粘膜细胞凋亡率显著升高o＜0．05h 肝C组与模型组相比，滑膜细胞、胸腺淋巴细胞凋亡率显著升高，胃粘膜细胞凋亡率显著降低广＜O．OS）；且地C组滑膜细胞、胸腺淋更多还原

【Abstract】 1 Objective According to the theory of Tranditional Chinese Medicine (TCM), summing up TCM’s recognize on Rheumatoid Arthritis (RA), advancing TCM’s pathologic mechanism, therapeutic principle and method. Observing the effect of Strengthening the spleen-Resolving dampness-Promoting collaterals method on RA and inquiring into the mechanisms on the treatment of RA based on "Spleen".2 Methods2.1 Theory research: To sum up TCM’s recognize on the symptoms correlated with RA and advance TCM’s pathologic mechanism of RA; To sum up the tutor’s experience on the treatement of RA and draft the therapeutic method and prescription梄infeng Capsule (XFC,ff JxlJKH) on RA based on "Spleen".2.2 Clinical research: 40 cases of RA were randomly divided into two groups. The treatment group (n=20) was treated with XFC for three months as a therapeutic course. The control group (n=20) was treated with tripterygium wilfordii polycoside tablet (TPT, If ^H^^M") for three months as a therapeutic couse. Two groups were treated for one course all. The targets included clinical curative effects, CRP, RF, OKT4, OKT8, OKTVOKTg, cytokin (CK), vascular endothelial growth factor (VEGF) were observed.2.3 Experimental researchTest 1: Sixty rats were randomly divided into normal control group, model group, XFC group and TPT group, 15 in each. Complete adjuvant 0.1 ml was injected into right posterior metatarsus of rats subcutaneously to induce inflammation, except that in the normal control. The ultrastructural change including mitochondria swelling, vacuolation and ridge pathologic change of synoviocyte, thymus-lymphocyte, splenic lymphocyte and gastric mucosa cell was observed by transmission electron microscopy (TEM). The mitochondria lesion rate (MLR) of each group was then calculated.Test 2: 50 rats were averagely divided into normal control group, model control group, XFC treated group, TPT treated group, methotrexate (MTX, f Hi ^^) treated group. Except for the rats of normal control group, the others were intracutaneously injected with 0.05 ml of Freung’s complete adjuvant in the right hindlimb. The body weight (BW), arthritis index (AT), serum cytokine and VEGF levels of each rat were assayed.Test 3:60 rats were randomly divided into the normal group, the model group, the MTX group, the TPT group and the XFC group. Except for the rats in the normal group, animals were modeled to adjuvant arthritis (AA) with Freund’s complete adjuvant, and the latter three groups were treated with MTX, TPT and XFC respectively. The expressions of fas, fasL and bcl-2 in rats’ synovia! membrane and thymus-lymphocyte were determined using immunohisto chemistry (IHC) technique.The apoptosis of every group’s synovial membrane and thymus-lymphocyte were observed usingTEM. The apoptotic percentage of the synoviocyte, thyms-lymphocyte and gastric-mucosa cell ofAA were measured by flow cytometry (FCM) using mitochondrial membrane potential (MMP),terminal deoxynucleotidyl transferase mediated DUTP nick end labeling (TUNEL) and AnnexinV/PI.3 Results3.1 The results of theory research: TCM’s pathotogic mechonism of RA was qi-blood deficiency, dis harmony between nutritive-qi and defensive-qi; deficiency of the spleen and stomach, stagnancy of pathogenic damp; accumulation of phlegm and stasis, block of meridians and collaterals. Spleen deficiency played an important role in the invasion of RA. The therapeutic principle in TCM of RA was supporting vital-qi, tonifying qi-blood; protecting spleen and stomach, reinforcing acquired constitution; dispelling phlegm and resolving dampness, relieving the secondary in an urgent case; restoring menstrual flow and activating energy flow, expelling joint. The therapeutic method of treating RA based on "Spleen" was strengthening spleen and tonifying qi, resolving dampness and activating collaterals. The prescription of treating RA was XFC.3.2 The results of clinical research: The effects of XFC was similar to TPT in the total effective rate, improving the joint symptoms et al.更多还原