从抗炎护骨角度探讨复方雷公藤外敷治疗类风湿关节炎的机制

The treatment of rheumatoid arthritis (RA) is aimed at controlling synovitis and inhibiting bone destruction. This needs to be achieved by inhibiting synovial inflammation, progressive articular cartilage and bone destruction. Tripterygium wilfordii is an effective Chinese medicine for the treatment of RA, but oral administration can cause severe toxic and side effects. In the past, it lacked its external treatment mechanism. We change it from oral to topical, so drug components act directly on the lesion and Tripterygium can exert unique therapeutic advantages by reducing its toxicity. Our preclinical studies confirmed that topical compound Tripterygium wilfordii could quickly reduce joint pain symptoms in patients with active RA, and the safety is improved. Experimental studies suggested that compound Tripterygium wilfordii external application could inhibit the proliferation of synovial tissue and reduce the angiogenesis and pannus formation in synovium by decreasing the level of inflammatory cytokines and reducing the activation of ERK pathway in synovial tissue of arthritis. On the basis of previous research, we want to observe the effect of compound Tripterygium wilfordii on the destruction of cartilage and bone,and the importance of ERK mediated RANK/RANKL/OPG pathway in the pathological process of RA, to further explore its external mechanism. Through the study ,we aim to explain the mechanism of RA interpretation of external therapy of Traditional Chinese Medicine, rich connotation in the theory of medicine foundation, offer theoretical basis for its clinical application and provide new ideas and methods for the research of Traditional Chinese Medicine.

类风湿关节炎(RA)以控制滑膜炎、抑制骨破坏为治疗目标。这需通过抑制滑膜炎症、关节软骨和骨进行性破坏而实现。雷公藤是治疗RA有效中药，但口服可致严重毒副作用，以往缺少其外治作用机制研究。课题组改变雷公藤给药途径，内服改为外用，直接作用于病变局部，发挥雷公藤方药独特疗效优势，减低其毒性，前期多项临床研究证实复方雷公藤外敷可以迅速减轻活动性RA患者关节肿痛症状，并且安全性有所提高。实验研究证实复方雷公藤外敷剂可通过降低关节炎滑膜组织炎症细胞因子水平、减弱ERK 通路活化，从而抑制滑膜组织增殖、减少滑膜中血管新生和血管翳形成。本研究拟在前期研究的基础上，观察复方雷公藤外敷对RA病理过程中软骨及骨质破坏及相关ERK介导RANK/RANKL/OPG通路的影响，进一步探讨其外治作用机制，以诠释RA中医外治法疗效机制特点，丰富中医基础理论的内涵，为其临床应用提供理论依据，为中医药研究提供新的思路和方法。

类风湿关节炎（RA）是临床常见的高致残性疾病，本课题围绕其核心病理改变“滑膜炎和骨破坏”，以临床优效中医外用药“复方雷公藤外敷剂”为干预措施，开展体内、体外实验，多维度探索复方雷公藤外敷剂抑制炎症、延缓骨破坏的作用机制。动物实验主要围绕复方雷公藤外敷剂对RA组织形态学的改善与作用机制探索。采用CIA大鼠模型，治疗组设置为扶他林乳胶外敷组、雷公藤多苷片口服组和复方雷公藤外敷剂组。观察各组大鼠一般状态、双下肢肿胀程度，膝、踝关节病理形态，借助micro-CT观察骨质改变，采用ELISA、Western Blot观察外周血及组织MMP、RANKL、ERK等因子与蛋白表达。细胞实验建立滑膜成纤维细胞-单核细胞共培养体系，模拟活动性RA滑膜炎和骨破坏的病理转变，采用ELISA、Western Blot、PCR、TRAP染色等方法，进一步探究复方雷公藤外敷剂对滑膜细胞的影响。结合实验发现与文献研究，在课题基础上，开展实验动物血清非靶向代谢组学检测，分析复发雷公藤外敷剂对CIA大鼠免疫代谢的影响。结果表明复方雷公藤外敷剂能够有效抑制大鼠血清、滑膜组织、滑膜细胞的ERK、MMP1、MMP13和RANKL/OPG表达，减弱ERK通路活化，抑制滑膜组织增殖，降低炎症反应，减轻骨破坏，促进新骨形成，且无肝、肾及生殖毒性。代谢组学显示活动性RA发生明显代谢紊乱，复发雷公藤外敷剂通过抑制活动性RA代谢重塑，下调RANKL水平，减轻滑膜炎。本研究结果证实了复方雷公藤外敷剂能够有效改善CIA大鼠关节炎症反应与骨破坏，其作用机制可能与抑制ERK、降低MMP、RANKL水平，调节RANKL/OPG通路、调控骨平衡、改善局部免疫代谢有关。本研究丰富了复方雷公藤外敷剂治疗RA的中医基础理论的内涵，验证了湿热瘀阻是导致RA骨破坏的病理机制，为其临床应用提供理论依据，为中医药外治法研究提供新的思路和方法。