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Ayu Paramaiswari
Rheumatology sub division, Department of Internal
Medicine Sardjito General Hospital
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Inflammatory
Characterized by
inflammation affecting
Synovium
Synovial Cavity
Entheses
JOINT PAIN
Noninflammatory/
degenerative
Alteration in the structure or
mechanic of the joint
May occur as a result of:Cartilage or meniscal
damage
Alteration in joint anatomy
(congenital,
developmental,metabolic,
post inflammatory
Athralgia:
Joint tenderness withno abnormality Altered pain
sensation
Early rheumatic
syndrome(SLE).
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OSTEOARTHRITIS
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Age > 50 ys
Stiffness < 30 mts
Crepitus
Bony pain
Bony swelling
Palp: No warm
ESR < 40 mm/hrs
Sinovial Fluid
OA: 5 of the 9 above
Age > 50 yrs
Stiffness < 30 mts
Crepitus
Bony pain
Bony swelling
Palp: no warm
OA: 3 of the 6 above
Clinical & lab clinical
American College of Rheumatology (ACR 1986)
Adopt: IRA 2004, panduan Diagnosis &
Pengelolaan OA
Diagnosis knee OA
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Grade 0 = normal
Grade I = doubtful narrowing of joint space and possible
osteophyte lipping
Grade II = definite osteophyte and possible narrowing of
the joint space
Grade III = moderate multiple osteophytosis, definite
narrowing of joint space, some sclerosis and possible
deformity of bone contour.
Grade IV = large osteophytes, markednarrowing of joint
space, severe sclerosis and definite deformity of joint
contour
Radiological grading of Kellgren
Laurence
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Drugs in OA
Symptom modifying drugs
Analgesics, NSAIDs
Corticosteroids
Accupuncture?
Structure modifying drugs
Diacerein
Glucosaminechondroitin Hyaluronate
Doxycyclin, minocyclin
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RheumatoidArthritis
TheSpondiloarthropathies
Systemic LupusErithematosus (SLE)
Psoriatic arthritis Ankilosing Spondilitis
Reiter s disease
Entherophatic arthritis
+ RA : Rhupus Sydr + Scleroderma:MCTD
Type of inflammatory disorder
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9
Spondyloarthropathies
A group of Inflammatory diseases
Inheritance of human leukocyte antigen
(HLA)-B27 increases the relative risk of
developing spondyloarthropathy
These diseases are not associated withrheumatoid factor and thus are often
referred to as the "seronegative"
spondyloarthropathies
Insidious Disease
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Alternate buttock pain
Sacroiliitis
Positive family history
Psoriasis
Inflammatory bowel disease
Urethritis or cervicitis or acute diarrhea occurring within 1
month before the onset of arthritis
Clinical Symptoms and Sign ofSpondyloarthopathies
InflammatorySpinal Pain
Synovitis
(Asymmetrical or
Predominantly lower limbs)
OR
PLUS (One or more of the following:)
* European Spondyloarthropathy Study Group Criteria for Spondyloarthropathy, 1991
Dougados M, et al. Arthr i t is Rheum. 1991 Oct;34(10):1218-1227.Sensitivity 78-88%; Specificity 92-95%
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Spondyloarhtropathies (SpA)
Spondyloarthropathies
(SpA)
Arthritis of
IBD
Psoriatic
Arthritis
Arthritis
associated
with acute
anterior
uveitis
Ankylosing
Spondylitis
(AS)
Juvenile
Chronic
Arthritis
Reactive
Arthritis
(Reiters)
uSpA
Granfors, K. et al. Arthritis & Rheum 2002, 46:606-13.
DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227
Munoz-Fernandez and Martin-Mola. Best Pract Res Clin Rheumatol. 2006 Jun;20:487-505
SpA are a group of
rheumatic disorders that
share several common
factors:
1. Synovitis and enthesitis
2. Similar association with
HLA-B27
3.AS is the prototype
Ankylosing
Spondylitis
(AS)
Psoriatic
Arthritis
Granfors, K. et al. Arthritis & Rheum 2002, 46:606-13.
DougadosM. et al. Arthritis & Rheum 1991;34:1218-1227
Munoz-Fernandez and Martin-Mola. Best Pract Res Clin Rheumatol. 2006 Jun;20:487-505
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Distribution of pain
with sacroiliitis.
INFLAMMATORY BACK PAIN
http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14http://bmj.bmjjournals.com/cgi/content/full/310/6990/1321/F14 -
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Arthritis ( Oligoarthritis)
Arthritis 4Polyarthritis ( joint)
Peripheral Arthritis
Rheumatoid ArthritisSpondyloarthropathy
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Manifestations in Ankylosing Spondylitis
(AS)
Gut
Inflammatory bowel disease (IBD)
Axial disease
Sacroiliitis, spondylitis
Peripheral diseaseArthritis, enthesitis, dactylitis
EyeUveitis
Skin
Psoriasis
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15
EntesitisTrigger finger
Achiles Tendinitis Plantar fasciitis
Carpal Tunnel
Syndrome
De Quervain
Tendinitis
Tendinitis dorsum
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Special maneuvers: Test of lumbar stifness
M difi d N Y k it i f
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Modified New York riteria forAS
Clinical criteria Low back pain and stiffness for >3 mo, which improves
with exercise, but is not relieved by rest
Limited lumbar spine motion: in sagittal and frontal planes
Limitations of chest expansion (age/sex standardized) Radiographic criteria: Requires EITHER Bilateral
sacroiliitis Grade 2 or Unilateral sacroiliitis Gr 3
Definite AS = 1 clinical plus 1 radiographic criteria
Probable AS = 3 clinical criteria and no radiologic
criteria or 1 radiologic criterion and no
clinical criteria
van der Linden S, et al. Arthr i t is Rheum .1984;27:361-368.
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Contrasted to RA
SpA
Mostly MALE
Negative RF
Primary involvementof AXIAL JOINT
Less prominent
involvement of
peripheral joint
RA
Mostly FEMALE
Typically RF positive
Primary involvementof PERIPHERAL
JOINT
Rare involvement of
axial joint.
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Treatment
Medication
NSAID
DMARDS ( mtx,
suflasalazine,
leflunomide,
azathioprine)
Anti Tnf alfa
Glucocorticoid
Non pharmacologic
Physical therapy
Exercise
Surgical intervention
Corrective surgery
Decompression
surgery
Peripheral joint
arthroplasty
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Rheumatoid Arthritis
Description Morning stiffness
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes
A person shall be said tohave rheumatoid arthritis if
he or she has satisfied 4of 7 criteria, with criteria 1-4 present for at least 6weeks
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Rheumatoid Arthritis: PIP Swelling
Swelling is confinedto the area of the
joint capsule
Synovial thickeningfeels like a firm
sponge
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Rheumatoid Arthritis:
Ulnar Deviation and MCP SwellingAn across-the-room
diagnosis
Prominent ulnar
deviation in the righthand
MCP and PIP
swelling in both
hands
Synovitis of left wrist
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Rheumatoid Arthritis
Classification 1987 Criteria
Arnett, A&R, Vol 31, pp. 315-324
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Rheumatoid Arthritis
Classification 2010 Criteria
Aletaha, A&R, Vol 62, pp. 2569-2581
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Rheumatoid ArthritisDeformities
Rheumatoid vasculitis
Swan neck deformities
Boutenaire deformities
Rheumatoid Nodules
Bayonete
deformities
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Rheumatoid ArthritisExtraarticular Involvement
Pulmonary
Pleurasy
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Cyclic Citrullinated Peptide
Antibodies (anti CCP)
Schellekens, A&R, Vol 43, pp. 155-163
DMARD (Di M dif i A ti
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DMARDs (Disease-Modifying Anti-
Rheumatic Drugs)
Hydroxychloroquine(Plaquenil)
Sulfasalazine
Methotrexate Leflunomide (Arava)
Less commonly used: Minocycline
Azathioprine Gold, PO or IM
Cyclosporine
Etanercept (Enbrel) Infliximab (Remicade) Adalimumab (Humira) Golimumab (Simponi) Certolizumab Pegol
(Cimzia) Anakinra (Kineret) Rituximab (Rituxan) Abatacept (Orencia)
Tocilizumab (Actemra)
Traditional Biologics
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THANK YOU