11 rheumatoid athritis

8/13/2019 11 Rheumatoid Athritis

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Age Mostly in 30-40 yrs Increasing in older patients

US Health Examination (1960-62)0.3% age< 35 th

10.0% age> 60 th Sex

Women : Man (2,5 :1) Another factors

Social status, education, & Psycho-stress

EPIDEMIOLOGY


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Unclear Suggested

Genetic factor, HLA DR-4

Environment

Arthritogenic agents (bacteria, virus)

ETIOLOGIC FACTOR


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Genetic Arthritogenicfactors (Bacteri,virus) (HLA DR4)

AutoimmuneHumoral immunity (RF)

Cellular immunityInflamatory mediators, cytokines

SYNOVITIS


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AntigenB lymphocyteSynovium

Ig G Production(abnormal)

FR Production

Immune complex

Complemen activation

Synovium inflammation

Ag 1 Ab 1 / Ag 2

Ab 2

(Ag2 + Ab2)

Arthriti s

Humoral Immunity (RF) in RA


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An auto antibody to antibody An Ab that bind to Fc portion of IgG

molecule 75-80 % in RA High titer in severe case of RA

May be present in other disesas 3% in normal population

Rheumatoid Factor (RF)


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Phatologic Inflammation of RA


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Synovium inflammation (synovitis)with hypertropic, and villi proliferation

tumor-like proliferation (pannus)

to damage cartilage, bone and tendon

PATHOLOGIC


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History : pain, swelling and morningstiffness of small peripheral joint

Often with general symptom ,(generalfatigue,

Symmetrical arthritis in small peripheral joint

Extra articuler manifestation : rare

CLINICAL MANIFESTATION OF RA


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Early sign : tenderness andswelling mono articular andasymmetric

Within a week or few monthsymmetrical arthritis (warm, pain,tender, without local heat)Joints : wrist, MCP, PIP,small joint s of the feet, etc

Late stage : joint deformitySwan neck deformity

Arthritis in small peripheral joints


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Early onset of RA Late stage of RA

Rheumatoid Arthritis of hand


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Skin Rheumathoid nodul in pressure areas (rare in

Indonesia) Vasculitis (purpura, echimosis, necrosis of nail,

ulcer or gangren) Eye

Kerato- conjungtivitis sicca (Sjogrens Syndrome) Scleritis, episcleritis

EXTRA ARTICULAR MANIFESTATION OF RA


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Lung

Instertitial Pnemonitis

Pleural effusions, fibrosis

Cardiovascular

Pericarditis , myocarditis

Nodul reumathoid in myocard atau palve

Hematology

Mild Anaemia (on chronic disease)Feltys Syndrome (granulocytopenia,splenomegaly &

recurrent infection)

EXTRA ARTICULAR MANIFESTATION OF RA(cont)


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Rheumatoid nodule


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Laboratory Test Anemia (nn) ESR or CR (Good indication of inflamation)

Lymphocyteosis Rheumatoid Factor positip (85%) Electrophoresis (increasing of Ig) )

DIAGNOSTIC INVESTIGATIONS


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Imaging / X Ray Normal (in early onset) Soft tissue swelling Periarticular osteopenia Marginal or central erossion and cysts

DIAGNOSTIC INVESTIGATIONS


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CRITERIA of RHEUMATOID ARTHRITIS(The American Rheumatism Associations, 1987 revised criteria)

1. Morning stiffness ( 1 jam)2. Arthritis of 3 joints or more

3. Arthritis of hand joints

4. Symetrical Arthritis

5. Rhematoid nodule

6. Serum Rheumatoid Factor

7. Typical radiologic changes of RA

Rheumatoid Arthritis : 4 criterias or more,Note : Criteria 1 through 4 must have been present for at least 6 weeks


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Early Diagnosis and early treatment The goal : to achive the remission

Patient Education and motivation To suppress the inflamations To perform maximal joint function To protect joint damage

The tool : Education Physical rehabilitation Medications Surgical therapy Other : alternatif treatmant

By the teams (Ruematologist/Internist, Orthopedist,Physioterapist, Psychiater, Social worker and Family)

MANAGEMENT OF RA


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Simptomatis NSAID

Glucocorticoid Antiinflammatory dan immunosupressive effect Without disease modifying effect

DMARDs (Disease Modifying Anti Rheumatic Drugs)

Biologic response modifiers TNF alfa=antagonist, IL1-Ra

MEDICINAL THERAPY


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Traditional methode (Pyramida sytem)

Combination of Multiple drugs :

Step-do w n B r idge

Start with multiple drugs (oral Steroid, methotrexate,Sulfasalazine, Chloroqiun, etc)

Start with multiple drugs (step by step, stop the mostdangerous drug and the last, chloroquin)

Continuous until several month-years.

The choice of DMARDs


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DMARD FOR RHEUMATOID ARTHRITIS THERAPYDrugs Onset Dose Side effects

Hydroxychloroquine 2-4mont

200 mg;2x/day

Rash, diarrhea, retina toxicity

Sulfazalacine 1-2mont

1000 mg;2-3x/day

Rash, myelosuppression, GIintolerance

Methotrexate 1-2mont

7,5-17,5mg/wk

GI symptoms, stomatitis, rash ,alopesia, myelosuppression, liverand lung impairment

Azatioprine 2-3mont

50-150mg/day

Mielosuppression, liver impairment,flu-like illness, GI symptoms

D-penisillamine 3-6mont

250-750mg/hr

Myelosuppression. stomatitis,dyspepsia, proteinuria,autoimmune disorder, rash


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11 rheumatoid athritis

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