【作者】 方勇飞；

【导师】 戴裕光；

【作者基本信息】 中国人民解放军军医进修学院 ， 中西医结合， 2009， 博士

【摘要】 导师戴裕光教授从医40余年,中医经典理论功底深厚,临证经验丰富,擅长内科杂病、妇科、风湿病等的中医及中西医结合治疗,在治疗活动期类风湿关节炎患者证属风湿热郁型时善用当归拈痛汤加减以治之,临床效果较显著。本课题总结戴裕光教授学术思想及治疗类风湿关节炎的经验,并分别从临床与基础两方面,对加减当归拈痛汤治疗类风湿关节炎活动期的临床疗效进行了观察,并对该方的抗炎免疫作用及治疗类风湿关节炎的作用机制进行了研究。本文以中医专家经验分析软件,对导师的经验和临证处方进行了研究;通过文献检索、归纳分析,总结历代文献对类风湿关节炎的认识;临床研究导师经验方加减当归拈痛汤治疗选取湿热痹阻型类风湿关节炎的疗效。湿热痹阻型类风湿关节炎患者76例,分组对照研究,在治疗前及治疗后评价压痛关节数、肿胀关节数、ESR、患者对疾病活动性总体VAS评价、疾病活动性评分DAS28、美国风湿病学会改善标准ACR20、ACR50、ACR70的达标比例及不良反应;实验研究以佐剂性关节炎大鼠为研究模型,通过药理、病理、细胞增殖、ELISA等方法,从整体、细胞及分子水平,观察加减当归拈痛汤的抗炎作用及其作用机制。导师经验方分析显示,从性味归类来研究,导师用药喜寒温并用,注重阴阳之间的平衡,且偏好辛开、苦降、甘缓之味,以调畅脏腑气机。药物的归经分析显示多数药物直入病变所在之脏腑经脉。文献分析显示历代文献对关节肿胀已有较深入的论述,其病因多斥之于湿邪为患,与君火有余、脾土失运相关,其病机多为水湿流注关节、阳气郁结、湿痰凝滞、瘀血阻络。湿邪常与风、寒、热等邪气相合,临证之时,抓住“湿”这一导致关节肿胀的要素是施治的关键。关节肿胀的治疗原则不外祛湿利水、行气通阳、化痰活血,对与水湿相合之风、寒、热等邪气则针对性地采取疏风、散寒、泻热等治则。临床研究提示两组患者晨僵时间、压痛关节数、肿胀关节数、ESR、疾病总体状况VAS评分、DAS28各项指标在治疗后均有明显改善(P＜0.05),两组间对照发现实验组的各项指标改善程度明显优于对照组(P＜0.05)。实验组中达到ACR20、ACR50、ACR70的比例明显高于对照组。两组患者的不良反应发生率均小,组间比较比较无显著性差异;实验研究提示加减当归拈痛汤具有明显的抗炎作用,可显著降低佐剂性关节炎大鼠足爪肿胀程度和关节炎指数评分,减轻滑膜炎性细胞浸润、滑膜增生、血管翳形成,防止软骨损伤及骨的破坏;可抑制佛波醇乙酯(PhorbolMyristate Acetate,PMA)诱导的大鼠脾淋巴细胞增殖;可降低佐剂性关节炎大鼠血清TNF-α、IL-1等炎症细胞因子水平。本文总结了戴裕光教授的学术思想、分析了其临证处方。导师经验方加减当归拈痛汤能显著改善类风湿关节炎的各项活动性指标,控制类风湿关节炎患者的急性期病情活动,无明显不良反应发生。加减当归拈痛汤可抑制淋巴细胞增殖,下调TNF-α、IL-1等炎症细胞因子的表达,具有明显的抗炎作用,这可能是加减当归拈痛汤治疗RA机制之一。更多还原

【Abstract】 My doctoral supervisor,professor Dai Yuguang has been engaging in doctor for more than forty years.He has a solid foundation in Chinese Traditional Medicine,and a great deal of experience in clinical.Rheumatoid arthritis(RA) is a chronic systemic autoimmunity disease which threatened human’s health. Jiajiandangguiniantong Tang had a good effect to treat RA.Professor Dai Yu-guang is experienced in treating RA with Jiajiandangguiniantong Tang in its acute stage of combination of wind,dampness and pyretic stagnation pattern.This research carries on a study on anti-inflmmation,immunity and treatment mechanism to RA of Jiajiandangguiniantong Tang.To study the experience and prescription of professor Dai by analyzing the frequency of drugs,the class of efficacy,the property and flavor,the meridian distribution,and the dosage of drugs.We summarize the cognition of rheumatoid arthritis in TCM through literature retrieval and induction.76 RA patients were divided into 2 groups,including 12 males and 64 females,who were diagnosed as moist heat arthralgia spasm syndrome during march 2006 to march 2008.The average age was 46.6±5.3,and average course was 5.3±6.7 years.The control group was taken methotrexate(MTX) plus leflunomide,while experimental group was treated with therapeutic alliance of MTX,leflunomide and Jiajiandangguiniantong Tang.The course of treatment was 12 weeks.The effect was evaluated by number of tenderness joints,number of swelling joints,ESR,Visual analogue scale of global disease activity estimated by the patient(VAS),Disease Activity Score in 28 joints(DAS28),recover rate whether reaches standard of American College of Rheumatology 20%,50%,70% improvement criteria(ACR20,ACR50,ACR70),and adverse effect after treatment finished.Took adjuvant-induced arthritis rat as experimental model,treat with Jiajiandangguiniantong Tang,observed the anti-inflmmation,and treatment mechanism of Jiajiandangguiniantong Tang from the view of pharmacology, pathology,cell multiplication,ELISA.The study showed that the two groups all produce a remarkable effective in early morning stiffness,number of tenderness joints,number of swelling joints, ESR,VAS score(by patient),DAS28(P＜0.05).The recover rate was much higher in experimental group than in control group.(P＜0.05).The incidence of adverse effect was quite low in each group,and had no significant difference.2). Jiajiandangguiniantong Tang has obviously effect of anti-inflammation,inhibition swelling of joints,reduce the arthritis index score,perimeter of ankle and thickness of calw.It can also lighten the synovial inflammation and the lesion of joints distinctly,and prevent the joint cartilage and bone from destruction. PMA-induced spleen lymphocytes proliferation in rat and the serum level of IL-1 and TNF-αin adjuvant-indued arthritis rat could also be inhibitied by Jiajiandangguiniantong Tang.We summarized the learning thought and clinical experience of professor Dai Yuguang.Jiajiandangguiniantong Tang could significantly improve reactiveness indexes of RA,lessen pathogenetic condition,with no adverse effect.This decoction can inhibit spleen lymphocytes proliferation,decrease the serum level of IL-1 and TNF-αin adjuvant-indued arthritis rat,which may be one of the therapeutic mechanisms of Jiajiandangguiniantong Tang on RA.更多还原