The diagnosis of сhronic cerebral ischemia is widely used in domestic neurological practice. A significant part of the patients observed with a diagnosis of сhronic cerebral ischemia suffer from primary or secondary headache, dizziness of various origins, emotional disorders and other diseases that are not diagnosed and therefore do not have effective treatment. Improving the management of patients with a diagnosis of сhronic cerebral ischemia requires the diagnosis and treatment of other diseases that are erroneously defined as сhronic cerebral ischemia. The observation data of 90 patients are analyzed, in which the identification of primary headaches (chronic migraine, chronic tension headache) and drug-induced headache allowed an adequate and effective combination treatment, including rational pharmacotherapy, educational conversations, cognitive-behavioral therapy sessions, relaxation classes and therapeutic exercises, with a pronounced positive effect. The results of a survey of 700 patients are discussed, in which the identification of the causes of dizziness (benign paroxysmal positional vertigo, Meniere’s disease, vestibular neuronitis, emotional disorders with instability) made it possible to carry out effective treatment, while most patients were observed for a long time with a diagnosis of chronic cerebral ischemia or vertebrobasilar insufficiency. In the management of patients with vascular cognitive impairment, which is the main clinical manifestation of chronic cerebrovascular disease, the leading role is given to both non-drug methods (regular physical activity, smoking cessation) and drug therapy aimed at normalizing blood pressure and blood lipid spectrum, preventing blood clots and improving cognitive function. The possibilities of naftidrofuril and nimodipine as drugs for improving cognitive function are discussed.

The new COVID-19 coronavirus infection caused by SARS-CoV-2 is a global health threat. Neurological disorders detected in patients with coronavirus infection have a wide range of clinical signs: headache, dizziness, altered level of consciousness, acute ischemic stroke, intracerebral hemorrhage, cerebral venous sinus thrombosis. Evidence suggests that patients with more severe systemic symptoms were more likely to experience neurological symptoms. The main risk factors for the development of ischemic stroke in patients with coronavirus infection are considered. It was shown that COVID-19 more often occurred in people with vascular risk factors, among which the mortality rate was higher. Various possible and not mutually exclusive mechanisms which may play a role in the development of ischemic stroke in patients with COVID-19 are described in detail, including hyper-inflammatory state («cytokine storm»), «COVID-19-associated coagulopathy», and disseminated intravascular coagulation syndrome. Stroke risk factors associated with the critical condition in these patients are presented. Stroke, the leading cause of death and disability worldwide, requires immediate treatment and decision-making as well as 24/7 availability for specialized vascular centers. The results of observation of patients with acute cerebral circulation disorder in specialized vascular centers 2 months before and 15 days after quarantine due to COVID-19 are presented. The tactics of managing patients with ischemic stroke under conditions of coronavirus infection is considered.

Cerebrovascular disease is one of the most important problems of clinical neurology, which is a significant cause of cognitive impairment and depression. Chronic forms of cerebrovascular insufficiency are most often associated with cerebral microangiopathy or a disease of small vessels, which is characterized by the presence of lacunae, microinfarction and microbleeding, leukoaraiosis and dilated perivascular spaces. One of the main and most common clinical symptoms is vascular cognitive impairment. They are characterized by extremely variable cognitive deficits, highly dependent on the location and severity of vascular damage. However, clinical manifestations associated with impaired frontal circulation are usually observed. Recent international criteria for vascular cognitive impairment presented by the VASCOG (International Society for Vascular Behavioral and Cognitive Disorders) working group emphasize the particular importance of impaired information processing speed, attention, and/or frontal regulatory functions, often in combination with personality or emotional disorders. The frequency of vascular depression in chronic cerebrovascular insufficiency reaches 70%. The addition of affective disorders significantly aggravates the existing cognitive deficit, increases the risk of dementia. This is due to the fact that depression itself leads to the development of cognitive impairment, causes multiple functional disorders of cerebral microcirculation and a number of other mechanisms. The presence of cerebral microangiopathy underlying this pathology makes the use of drugs with vascular effects in the treatment of these patients. The use of preparations with multimodal action, in particular the combined drug and, is most preferable.

5560 patients with the diagnosis “Other cerebral vascular diseases” per 100 000 of elderly population were registered in RF in 2017. Usually this is a code for chronic brain ischemia (CBI) – the most popular diagnosis in Russian neurological practice. However, diagnostic criteria of CBI are not well defined and need to be ascertained. Recent studies show that the most reliable clinical feature of CBI could be cognitive impairment. It is developed before other clinical signs and correlate with severity of vascular brain lesions. Typically, cognitive impairment is subcortical with prominent bradyphrenia, attentional, dysexecutive and visuospatial deficit and relative sparing of memory. However clinical diagnosis of CBI could be only hypothetical. Diagnosis should be verified by MRI or other visualization technic. Diagnosis is verified if neuroimaging revealed silent strokes, microbleeds and vascular leukoencephalopathy. The most important objective of chronic brain ischemia management is the control of basic vascular disease. Besides this, pathogenetic therapy should be performed to improve cerebral microcirculation, neuronal metabolism and to provide neuroprotection. There is positive data on dipyridamole usage in chronic brain ischemia. It has desagregative, vasotropic, antioxidative and antiinflammation properties. Dypiridamole treatment in CBI patients lead to decrease of neuropsychiatric symptoms and improvement of well-being.

Low back pain or lumbalgia is one of the most common reasons for going to the doctor. Non-specific (musculoskeletal) pain is the most common (90%) cause of chronic lumbalgia. The chronic course of lumbalgia is determined not only by the anatomical sources of pain, but also by psychological and social factors that should be considered when managing patients. In the treatment of chronic nonspecific lumbalgia, a comprehensive multidisciplinary approach is effective, including optimization of drug therapy and motor activity, psychological methods (cognitive-behavioral therapy), an educational program, and manual therapy. When identifying common emotional disorders and insomnia, their therapy is required. Kinesitherapy (therapeutic gymnastics) is the most effective direction in the treatment of chronic nonspecific lumbalgia; оf primary importance are the regularity of physical exercises under the supervision of a specialist, the exclusion of sudden and excessive movements. In combination with activities, regular walking is highly effective. Cognitive-behavioral therapy is the most effective psychological direction in the management of patients with chronic nonspecific lumbalgia. It should be aimed not only at pain, but also at those often found in chronic non-specific lumbalgia insomnia, depression, and anxiety disorders. In some patients with damage to the facet joints, the sacroiliac joint, radiofrequency denervation or therapeutic blockades with anesthetics and corticosteroids can be used. Nonsteroidal anti-inflammatory drugs are used as medicines for chronic nonspecific lumbalgia, when prescribing them, it is necessary to take into account the presence and nature of risk factors for adverse events, concomitant diseases, interaction with other drugs The use of etoricoxib in chronic non-specific lumbalgia is discussed.

Introduction: The combined use of non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and group B vitamins is a promising direction for combined pharmacotherapy of peripheral pain syndromes.

Purpose: to analyze the molecular mechanisms of the synergism of the muscle relaxant tolperisone, a non-steroidal anti-inflammatory drug meloxicam and vitamins B₁, B₆ and B₁₂ as part of complex pharmacotherapy of pain.

Materials and methods: differential chemoreactome analysis of NSAID molecules and muscle relaxants, proteomic analysis of the effects of B vitamins.

Results: Synergistic interactions are maintained by (1) inhibiting cyclooxygenase-2 and leukotriene A4 hydrolases; (2) inhibition of the effects of IL-1β, TNFα, NF-kB, TLR4, RANKL, matrix metalloproteinases; (3) antioxidant effect (increased expression of superoxide dismutase-1 and glutathione peroxidase). Group B vitamins enhance the effects of tolperisone and meloxicam due to the manifestation of independent anti-inflammatory (neutralization of homocysteine, decreased expression of pro-inflammatory cytokines TNFα, IL-1b and factor NF-kB activity), analgesic (modulation of opioidergic pathways) and neuroprotective effects (support of amino acid expression, metabolism and neuro lipids, ATP synthesis and remyelination).

Conclusions: The triple scheme “tolperisone + meloxicam + vitamins B₁ / B₆ / B₁₂” is characterized by a number of undeniable advantages: (1) lack of dependence, (2) anti-inflammatory effect, (3) neuroprotective and remyelinating effects, (4) elimination of muscle hypertonicity. Such combination therapy can be used in patients of various age groups with comorbid conditions (diabetes mellitus, arterial hypertension, cerebrovascular diseases, gastrointestinal diseases) and does not require an increase in NSAIDs and significantly reduces the risk of side effects.

Low back pain is an important public health problem and one of the major causes of disability worldwide, as well as a symptomatic and benign condition. The article describes the main mechanical, systemic and non-specific causes of pain development. The “red flag” symptoms, which call for special attention from the practitioner, are considered in detail and if they are detected, a thorough diagnostic search for the causes of the pain syndrome is required. It is noted that a specific cause of pain can only be detected in a small percentage of patients. Emphasis is placed on the diagnosis and differential diagnosis carried out in individuals with low back pain, indicating the features of anamnestic data and the results of an objective examination. Non-contrast magnetic resonance imaging is considered the best imaging method for examining low back pain, when conservative treatment fails or when red flag symptoms indicating the underlying cause of the pain are present. Imaging is not recommended for most patients with nonspecific mechanical low back pain. The author presents the main therapy approaches in the treatment of acute and chronic low back pain. Several treatment methods can be used to treat acute or chronic low back pain, which are aimed at reducing the intensity of pain syndrome and improving the patient’s quality of life. The main groups of drugs used in these patients are described. Non-steroidal anti-inflammatory drugs and nimesulide in particular are discussed in more depth.

Arterial hypertension is one of the main modifiable risk factor for cognitive impairement (CI). Most frequently executive dysfunction is seen independent of age. Pathophysiological mechanisms linking hypertension and CI include the impact of increased blood pressure on large and small cerebral arteries. Large arteries dysfunction leads to occlusion, remodeling and arterial stiffness. Hypertension also causes small arteries dysfunction: lipohyalinosis and fibrinoid necrosis and due to insufficient amount of anastomosis and collaterals can lead to white matter damage. Treatment approach for patients with hypertension and CI should be multimodal and include treatment of the main cause of CI (antihypertensive therapy, statins and antithrombotics if necessary), symptomatic therapy (e.g. anti-dementia medications) and pathogenic treatment drugs that influence microcirculation, neuromethabolic therapy. Antihypertensive therapy is known to decrease dementia incidence, but the interclass differences remain unclear. Nicergoline (the ergot alkaloid derivative) is used in 30 countries to treat CI. Nicergoline improves CI due to its multidoi modal action, which includes increasing glucose metabolism in the brain, stimulation of cholinergic neurotransmission, increasing cerebral blood flow, influencing microcirculation due to decreasing arterial stiffness, blocking α1-adrenergic receptors. Nicergoline is effective in treating hypertensive patients with CI according to the data of a number of studies and meta-analysis. Evidencebased data also shows good tolerance profile of nicergoline.

Parkinson’s disease is a multifactorial disorder of the nervous system, the main features of which are progressive degeneration of dopaminergic neurons in the nigra pars compacta nigrostriatal tract and subsequent deficiency of the neurotransmitter dopamine in the areas of the brain, leading to the loss of motor function, the emergence of non-motor symptoms, rigidity, akinesia or bradykinesia, motor block, and decline in cognitive functions. Parkinson’s disease has high prevalence throughout the world, and has no curative treatment in modern medicine. The available drugs such as anticholinergics, levodopa and a DOPA-decarboxylase inhibitor provide symptomatic relief only. Although dopaminergic therapy is the standard treatment of motor disabilities associated with Parkinson’s disease, it does not managed all the aspects of the disease. For this reason, the increasing numbers of patients are looking for more holistic approach to the treatment of this disease. Mucuna pruriens L. – an annual self-pollinating legume plant, can be considered as a potential complementary therapy for patients with Parkinson’s disease, as it is an extremely rich source of levodopa. Numerous studies have shown that Mucuna pruriens extracts restore biochemical and behavioral abnormalities in animals with the experimental model of Parkinson’s disease. The plant also demonstrates some antioxidant activity. The clinical effects of high-dose Mucuna pruriens are similar to levodopa, but have a more favorable tolerance profile. If long-term use of Mucuna pruriens proves safe and effective in controlled clinical trials, it could become a sustainable complementary therapy for the treatment of Parkinson’s disease, especially in low-income countries.

Multiple sclerosis (MS) is a chronic autoimmune inflammatory demyelinating and neurodegenerative disease with a multifactorial etiology of development. MS in most cases has a wave-like course (periods of exacerbations and remissions), over time, the disease becomes progressive, which worsens the quality of life of patients. The drugs disease-modifying therapies (DMT) has been actively used in clinical practice for more than 30 years to prevent exacerbations and progression of MS. In patients with MS, in which the disease occurs with frequent exacerbations and signs of radiological activity of the demyelinating process, according to magnetic resonance imaging (MRI) of the brain and spinal cord, it is recommended to use monoclonal antibody preparations. The only drug registered for the treatment of primary progressive MS is ocrelizumab. In addition, ocrelizumab is indicated for patients with remitting and secondary progressive MS. Ocrelizumab is a humanized monoclonal antibody that selectively depletes a population of CD20+ B cells. The article presents data from clinical studies of OPERA I and OPERA II and describes a clinical case from the practice of a neurologist. Depletion of the B cell population is achieved by several mechanisms, including antibody-dependent cell-mediated phagocytosis, antibody-dependent T cell-mediated cytotoxicity, complement-dependent cytotoxicity, and apoptosis induction. The issues of efficacy and safety of ocrelizumab therapy in patients with MS are considered.

Introduction. According to the data of various authors Cervicogenic headache (CH) is met in 2.5 to 70% of population. Diagnostic criteria are described at The International classification of headache (3d revision). CH represents a heterogeneous group of headaches based on functional and organic changes of various anatomical structures of the cervical spine. There are no clinical recommendations for the treatment of patients with CH to date.

The purpose of this clinical study is the assessment of the effectiveness of use of Traumeel® S in cervicogenic headache treatment.

Materials and methods. 60 patients at the age from 18 to 45, divided into 3 groups were examined. Therapy in various combinations was applied to these patients of all the groups. The 2nd and the 3d groups were treated with the Traumeel® S local injection therapy. The patients of the 4th group were additionally given Traumeel® S in sublingual pill form. The visually analogue scale (VAS), the grading scale of the vertebral neurological symptoms, relapse rate of the CH during a year were applied.

Results. The most effective treatment was observed in the 2nd group patients. This was manifested in Better dynamics of pain syndrome and the final result. The CH relapse rate during the year of patients treated with Traumeel® S was significantly lower.

Conclusions. Traumeel® S inclusion into combined therapy of CH increases the effectiveness of treatment, helps reduce severity of pain, accelerate the appearance of positive therapeutic effect, operates to reduce severity of vertebral neurological symptoms, reduces frequency of recurrence.

The article discusses the participation of interleukin-6 (IL6) in the formation of pathogenetic mechanisms of immuno-inflammatory diseases (IID). IL6 is one of the central cytokine in progressive IID. The biological activity of IL6 is determined by its ability to activate target genes that regulate differentiation, apoptosis and proliferation of immunocompetent cells. The immune-inflammatory effects of IL6 include regulation of the acute phase reaction, differentiation of immune cells, switching from innate to adaptive type of immune response (activation of T-helper 17 (Th17) cells and T-follicular Th-cells, suppression of the formation of T-regulatory cells, synthesis antibodies by B cells), stimulation of hematopoiesis (maturation of myeloid progenitors and megakaryocytes, leading to neutrophilia and thrombocytosis), neoangiogenesis, osteoclast-mediated bone remodeling. Currently, the use of a humanized monoclonal antibody to the IL-6α receptor (tocilizumab) is one of the most promising directions in the treatment of rheumatoid arthritis, systemic lupus erythematosus, systemic scleroderma, large arterial vasculitis – aortoarteritis, temporal arteritis. The use of tocilizumab is included in the draft recommendations for the treatment of IID in conditions of coronavirus disease 2019 (COVID-19) developed by the All-Russian public organization “Association of Rheumatologists of Russia”. The presented data from international and domestic studies, as well as our own clinical experience, suggest that Tocilizumab (Actemra) is a highly effective and safe genetic engineering biological drug (GEBD) in the treatment of IID, and its use leads to a decrease in clinical and immunological activity and helps to improve life prognosis both when appointing as a first-line GEBD therapy and in case of ineffectiveness of other biological drugs and basic anti-inflammatory drugs in this category of patients.

The article presents the main approaches to choosing the treatment of osteoarthritis and the main links in the pathogenesis of this disease. The effects of glucosamine and chondroitin on the main pathogenetic mechanisms of osteoarthritis that prevent its progression are described. There are discussed an effectiveness and safety of treatment of the disease with a focus on the use of a combination of glucosamine hydrochloride and chondroitin sulfate (Arthra), as well as their combination with methylsulfonylmethane and sodium hyaluronic acid (Arthra MSM). Methylsulfonylmethane reduces pain, it is involved in the processes of maintaining and regeneration of connective tissue, in the synthesis of sulfated glycosaminoglycans and collagen. It is suggested that this compound may have analgesic and anti-inflammatory properties due to the inhibition of the nuclear factor kB signaling pathway, which allows to reduce the local and systemic inflammatory response, as well as suppressing the expression of proinflammatory cytokines and much more. This article also presents experimental and clinical evidence of the effectiveness and safety of these compounds. It has been convincingly demonstrated the possibility with these drugs to reduce joint pain and the need for analgesics and non-steroidal anti-inflammatory drugs, to improve the quality of life. Currently, symptomatic slow-acting drugs, which include the discussed ones, are recommended to be prescribed as first-line drugs for the treatment of osteoarthritis. Timely administration of symptomatic slow-acting drugs, their long-term use contributes not only to reducing the progression of the disease, but also makes it possible to avoid or delay endoprosthetics. In this article there is indicated the contribution of Russian scientists to obtaining evidence of the effectiveness and safety of Arthra and Arthra MSM in the application of various treatment modes in osteoarthritis of the knee joints and lower back pain.

Introduction: Decrease in bone mineral density (BMD) and risk of fractures in rheumatic diseases (RD) is caused by the pathogenetic mechanisms underlying RD and the effects of drugs used to treat them on bone.

Aim of the study: to assess the condition of BMD, frequency and risk of fractures in postmenopausal women with different RD.

Material and methods: The study enrolled 260 women in postmenopause (median age 61 years) (54; 68 year) with systemic scleroderma (SS), rheumatoid arthritis (RA) and osteoarthritis (OA). Patients were sanitized and examined using dual energy X-ray absorptiometry; a 10-year risk of fractures was calculated using the FRAX® algorithm.

Results: A reduced BMD was observed in 210 (81%) women with RD, while osteoporosis (OP) was found in 43% of women with SS, 31% of women with RA and 17% of women with OA. In all RD, osteoporosis was more common in the lumbar spine than in the proximal femur. The frequency of low-energy fractures in the anamnesis was 35, 29 and 20 percent for those with SS, RA and OA, respectively. The most frequent fractures among women with SS and RA were vertebral fractures, and in patients with OA - forearm fractures. The 10-year risk of new fractures according to FRAX® and the need for antiosteoporotic treatment in women with OA was less than in patients with SS and RA (p < 0.0001). Of all patients examined, 44% needed pathogenetic antiosteoporotic therapy, and in actual practice 25% of women received it. Patients with RA were most often treated with zoledronic acid, alendronate and parenteral form of ibandronate.

Conclusions: The frequency of OPs and the 10-year risk of fractures in autoimmune RD was significantly higher than in OA. The structure of low-energy fractures in RD is different: in autoimmune processes and glucocorticoids (GC) intake, spinal compression fractures were significantly more common. Pathogenetic treatment for OP in women in post-menopause with RD is not performed frequently enough, which may cause repeated low-energy fractures.

The article discusses the social significance of osteoarthritis as a widespread disease that develops mainly in older people, which makes it difficult to carry out anti-inflammatory and analgesic therapy due to the frequent combination of osteoarthritis with other diseases at this age, the need to treat comorbid conditions, which is often poorly combined with systemic therapy with non-steroidal anti-inflammatory drugs. It is noted that osteoarthritis not only worsens the quality of life of patients, but also leads to a decrease in the length of their life, which emphasizes the medical and social importance of conducting the safest possible therapy for this disease. Data on the negative impact of the presence of chronic pain on the progression of osteoarthritis are presented. The negative aspects of the use of oral forms of non-steroidal anti-inflammatory drugs are discussed: the development of adverse events primarily from the gastrointestinal tract and cardiovascular system, the negative effect on the synthesis of glycoaminoglycans («chondronegative effect»). Discusses the place of topical forms of NSAIDs in the treatment of patients with osteoarthritis in accordance with the recommendations of the International society for the use of topical forms of NSAIDs in the management of patients with osteoarthritis of large and small joints. Data on transdermal transport of the topical form of diclofenac, a small molecule with lipophilic properties, are presented. Data on the effectiveness of topical forms of diclofenac in comparison with oral forms are presented according to numerous randomized controlled trials, and the comparable effectiveness of both forms of diclofenac is demonstrated, with maximum safety of the topical form. A special structure of Voltaren® Emulgel (Voltaren® Emulgel), combining the properties of a gel and cream, which provides rapid transdermal penetration and longer retention of the active substance in the area of inflammation, is described, as well as a special prolonged form of Voltaren® Emulgel), which creates additional convenience for use.

The disease caused by the new coronavirus COVID-19 is considered by the world community as an emergency of internationalimportance. Along with the huge social importance, the COVID-19 pandemic has highlighted a number of principally new clinical and fundamental problems of immunopathology of human diseases. This problem is extremely urgent for patients suffering from immune-inflammatory rheumatic diseases (IIRD) due to their higher exposure to infectious complications. Achieving and maintaining control over the activity of IIRD plays an important role in reducing the incidence of comorbid infections in these patients. It has been shown that patients with IIRD undergoing active anti-rheumatic therapy are most likely not characterized by increased risk of respiratory or other life-threatening complications within COVID-19 compared to the general population. Given the need for continued monitoring of patients receiving these therapy, unjustified “prophylactic” cancellation should nevertheless be avoided, thereby increasing the risk of relapse of major IIRD. The article also discusses the issues related to the use of basic anti-rheumatic drugs in COVID-19. Currently there is no evidence to support the therapeutic and prophylactic efficacy of chloroquine or hydroxychloroquine in COVID-19. Tocilizumab can be considered as “lifesaving therapy” for patients with acute respiratory distress syndrome in COVID-19, if other treatments have failed or are unavailable. The use of baricitinib in hospitalized pneumonia patients as part of COVID-19 should be considered with extreme caution. The need for further research to assess the potential role of baricitinib for these patients is highlighted. In the absence of a COVID-19 vaccine in a continuing pandemic, vaccination against influenza and pneumococcal infection should be strongly recommended to the absolute majority of patients with IIRD. This is associated with a high risk of fatal respiratory infection in rheumatological patients, especially given the high respiratory tract involvement in COVID-19.

Gout, one of the most common forms of inflammatory arthritis, is characterized by severe joint pain, which often interferes with daily activities. In recent years, further research on its causes and on improving diagnosis, treatment and prevention has been ongoing. It is known that gout usually occurs due to the accumulation of sodium monourate crystals in joints due to high levels of serum uric acid. In 2019, the Annals of the Rheumatic Diseases journal published new data on imaging and clinical diagnostics methods based on the principles of evidence-based medicine. Formulated by experts, they were adopted as a consensus of the European League Against Rheumatism (EULAR). The American College of Rheumatology (ACR) has now developed new strategies to treat and prevent gout. On May 11, 2020, the Arthritis & Rheumatology Journal presented guidelines for the management of gout patients, including the treatment of acute gout attack, indications for urate-lowering therapy and instructions for its optimal use, as well as recommendations on lifestyle and drugs that are often prescribed to patients with comorbidity. The purpose of this review is to summarize current knowledge with a focus on recent advances in the algorithm for managing acute and chronic gout patients.