世界中医药

目的：探讨桂枝芍药知母汤加减治疗类风湿性关节炎的疗效及其对程序性死亡分子配体-1(PD-L1)表达的影响。方法：选取2016年5月至2018年1月湖北医药学院附属襄阳市第一人民医院收治的符合纳入条件的类风湿性关节炎患者116例，按照数字随机表法将患者分为对照组和观察组，每组58例。对照组来氟米特初始50 mg，3 d后改维持量20 mg口服；泼尼松片10 mg，1次/d，口服；双氯芬酸钠缓释片20 mg，1次/d，口服。观察组双氯芬酸钠缓释片20 mg，1次/d,口服，加用桂枝芍药知母汤加减治疗，均连续治疗8周。比较2组治疗前、治疗末在关节压痛数、关节肿胀数、晨僵时间、疼痛视觉模拟评分（VAS评分）、红细胞沉降率（ESR）、C反应蛋白（CRP）、类风湿因子（RF）指标变化情况，比较治疗前、治疗4周、治疗8周后PD-L1水平，对治疗期间不良反应进行归纳，治疗结束后进行疗效观察。结果：2组患者治疗前关节压痛数、关节肿胀数、晨僵时间、VAS评分、ESR、CRP、RF比较，差异无统计学意义（P>0.05），完成治疗方案后，2组患者以上指标较治疗前均显著下降，差异有统计学意义（P<0.05）。治疗后观察组患者以上指标显著低于对照组，差异有统计学意义（P<0.05）。2组患者治疗前PD-L1比较，差异无统计学意义（P>0.05），治疗4周、8周后较治疗前2组PD-L1均显著下降，且观察组低于对照组，差异有统计学意义（P<0.05）。观察组在胃肠道症状、色素沉着、皮下出血、皮疹发生率上均显著低于对照组，差异有统计学意义（P<0.05）。观察组患者临床控制率、治疗有效率为43.1%、87.93%，显著高于对照组的31.03%、75.86%，差异有统计学意义(P<0.05)。结论：桂枝芍药知母汤加减能提高类风湿性关节炎疗效，减少不良反应，可能和该药物能抑制炎性反应，抑制PD-L1表达有关。

English Summary:

To explore the effects of Guizhi Shaoyao Zhimu Decoction on rheumatoid arthritis and its influence on the expression of PD-L1 protein.Methods：A total of 116 patients with rheumatoid arthritis who were admitted to Xiangyang First People's Hospital Affiliated to Hubei University of Medicine from May 2016 to January 2018 were divided into a control group(58 cases)and an observation group(58 cases)according to the order of treatment.In the control group，leflunomide was given orally at a dose of 50 mg at the beginning and 20 mg at the end of 3 days，prednisone tablets at a dose of 10 mg once a day，and diclofenac sodium sustained-release tablets at a dose of 20 mg once a day.The observation group was given diclofenac sodium sustained-release tablets 20 mg，once a day oral，plus Guizhi Shaoyao Zhimu Decoction modified treatment，continuously treated for 8 weeks.The changes of joint tenderness，joint swelling，morning stiffness，VAS score，ESR，CRP and RF were compared between the 2 groups before and after treatment，and the programmed death receptor(PD-L1)protein was compared before treatment，4 weeks after treatment and 8 weeks after treatment.The levels of adverse reactions were summarized during the treatment period and the curative effect was observed after the treatment.Results：There was no significant difference in the number of tenderness，swelling，morning stiffness，VAS score，ESR，CRP and RF between the 2 groups before treatment(P>0.05).After the treatment，the above indexes of the 2 groups were significantly decreased than those before treatment(P<0.05).At the end of treatment，the above indexes of the observation group were significantly lower than those of the control group(P<0.05).There was no significant difference in PD-L1 between the 2 groups before treatment(P>0.05).After 4 and 8 weeks of treatment，the level of PD-L1 in the observation group was significantly lower than that in the control group(P<0.05).The incidence of gastrointestinal symptoms，pigmentation，subcutaneous hemorrhage and rash in the observation group was significantly lower than that in the control group(P<0.05).The clinical control rate and total effective rate of the observation group were 43.1% and 87.93%，which were significantly higher than those of the control group(31.03% and 75.86%，P<0.05).Conclusion：Guizhi Shaoyao Zhimu Decoction can improve the efficacy of rheumatoid arthritis and reduce adverse reactions，which may be related to the drug can inhibit inflammation and the expression of PD-L1 protein.

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