Reumatoid ArthritisFDH2013
Reumatoid ArthritisFDH2013
Reumatoid ArthritisFDH2013
Artritis Reumatoid :
Tersebar luas, semua kelompok, ras, etnik di dunia
Penyakit inflamasi sistemik autoimun
Inflamasi yg kronik pd sendi
Suatu poli artritis progresif
Sendi dan organ tubuh lain
Gejala penyakit kronis yang hilang timbul
kerusakan sendi deformitas
disabilitas
Etiologi pasti ????
Autoimmune Diseases
Endocrine system
Type 1 diabetes
Multiple organs
Systemic lupus
Erythematosus
Penyakit autoimun :
Messenger molecules
Antibodi (RF)
Anti cyclyc citrullinated C-peptic antibody (anti-CCP-ab)
Berbagai sitokin
- Interleukin-1 (IL-1)
- Tumor necrosis factor (TNF- )
- Kemokin dan Reseptornya
Signalling and co stimulatory molecules
Sel mast
Sinoviosit
Ectopic lymphoid neogenesis
Angiogenesis
HLA-class II
Non-MHC risk genes
Arthritogenic antigen
Macrofag
Sel dendrit
Blys (B-lymphocytes stimulator)
APRIL (a proliferating inducing legand)
Merokok
Gender
Epidemiology
Common
Predominantly
Onset
affects women
Aetiology/pathogenesis
Rheumatoid
Mainly
a polyarticular disease
Chronic
The
PATOGENESIS ETIOLOGIK
Perubahan berupa :
Kerusakan mikrovaskuler, oedem jaringan sinovial, proliferasi
lining sel pada sinovial.
Terdapat sel leukosit polimorfonuklear pada permukaan
sinovial.
Terjadi obliterasi pada pembuluh darah kecil akibat adanya
inflamasi dan trombi yang terorganisir.
Cairan sinovial mengandung banyak sel mononuklear leukosit
PATOLOGI SELULER
Tampak adanya :
Oedema sinovial
Hiperplasia dan hipertropi sel lining sinovial yang dapat
menebal oleh karena peningkatan sel A (reticuloendothelial
like) dan sel tipe B
Lisosom merusak
Obstruksi kapiler
infiltrasi sel neutrofil pada dinding arteri
Daerah trombosis
Perdarahan perivaskuler
Etiopathogenese RA
Sitokin Proinflamasi :
TNF- , IL-1 , GM-CSF, M-CSF dan IL-8
Sitokin anti inflamasi :
IL-10, IL-11, TGF-
Antagonis reseptor IL-1, reseptor TNF terlarut
PATOGENESA
CD4+
Fagositosis
Radikal
Radikal
Masuknya
PROSES PENGRUSAKAN
- Kerusakan rawan
- Kerusakan tendon
- Kerusakan ligament
- Kerusakan tulang
Pathogenesis
Maini. Rheumatology
Secretion of proinflammatory
cytokines
Antigen presentation
T-cell activation
B cell
B cell
B cell
Dendritic
cell
IL-6
TNF-
Autoantibody production
and self-perpetuation
IL-10
Plasma
cell
T cell
RF
TNF-
Macrophage
RF
RF
RF
RF
Fix complement
IL-1
IL-6
TNF-
IL-10
Inflammatory
damage
(Drner & Burmester, 2003; Edwards et al, 1999; Gause & Berek,
2001; Shaw et al, 2003; Takemura et al, 2001; Zhang & Bridges,
1986)
Cartilage loss
Inflamed
synovia
Compromised integrity of
the joint structure leading to disability
Clinical pattern
Progressive
onset (from
weeks to months)
Pain and stiffness
(synovitis)
Swollen joints
Symmetric articular pattern
Flu-like symptoms
Morning stiffness
Fatigue
Lipsky (1998); Wolfe
(1996)
TANGAN
Bentuk jari spindle- shape fusiform ok pembengkakan PIP
Swan neck deformitis ( hiperextensi PIP flexi DIP )
Boutonniere deformitas ( Flexi PIP extensi DIP)
Ibu jari :
- hiperextensi sendi interphalang dan flexsi MCP
daya jepit jempol menghilang
Slide 9
- Simetris
Penting untuk RA
Bedakan dengan arthritis yang lain
DIP tak kena
morning stiffness dapat dipakai sebagai ukuran beratnya
penyakit
PERGELANGAN TANGAN
(Sangat sering terkena A.R.)
* Boggy synovium
* Pembengkakan ulnar
* Dorsoflexi pergelangan tangan terganggu
* Sindrome Carpal-tunnel ( N.Medianus tertekan)
SIKU
BAHU
* fleksi kontraktur
* Sendi glenohumeralis
* Pembengkakan
* Acromioclavicularis
* Destruksi para-olekranon
* Thoracoscapularis
* Dislokasi sendi
PANGGUL
LUTUT
* Langkah abnormal
* Efusi sendi
paha
CERVICAL
* Nyeri dan kaku leher
* Erosi progressif
* Sub luxatio Atlanto axial.
= compressi Med. Spinalis gejala neurologis
= perputaran dan penekanan arteri vertebralis
(dpt menimbulkan sinkope sewaktu menundukan kepala)
* Nyeri lokal
* Spasme otot gerak memutar terbatas
* Sakit kepala daerah occiput
Extra-articular pattern
In
Usually
More
common in men
Vaskulitis
Kelainan Paru (Pleuritis, Pneumonitis)
Perikarditis
Nodul Reumatik : - bursa olekranon
- eksternal lengan atas
- tendo Achilles
- telinga
Neuropati
Lesi kornea dan konjunctiva
Skleritis
LABORATORIUM
* BSR meninggi
* Anemia ringan
* Rheuma factor :
Rose waaler lebih spesific / latex lebih sensitif.
* Faktor APF amat spesifik
* Darah rutin, urine rutin, faal ginjal, faal hepar
* Cairan sinovial berupa exudat
Diagnosis
Clinical
pattern
Biology
Imagery
Biology
Cartilage
damage (joint
space narrowing)
Bone
erosion
clinically
In
MRI
Diagnostic criteria
The
As
DIAGNOSA BANDING
Rheumatic Fever :
SLE :
- Butterfly rash
- Renal disease
- L.E positif
Osteoarthrosis ::
Gouty Arthritis:
- acute onsetc
- rystal urate
- tophi
Therapeutic goals
Primary
Prevention
joints
Prevention or reversal of disability
Pain relief
To improve quality of life
The
Evaluate
Disease activity/extent of synovitis
Structural damage
Functional/psychosocial status
Initiate Treatment
Patient education
Physical and occupational therapy, etc.
NSAIDs
Possible local or oral steroids ( 10 mg. Prednisone)
Reactivation of Disease
Remission or Satisfactory Control
Surgical Intervention
Mechanical Joint Symptoms
Persistent
Active
Disease
>1.2
Good response
0.6
Moderate response
>3.7
(DAS attained
during follow-up)
(van Gestel 1996)
No response
Nama Generik
Parasetamol
Mefenamic acid
Tramadol
Metamizole
Methampyron
Morphin sulfate
Meloxicam
Nimesulide
Etodolac
Fenbufen
Golongan
Preparat
Panadol 500 mg
Ponstant 250, 500 mg
Novalges 50 mg
Novalgin 500 mg
Neoralgin 500 mg
MST continus 10,15,30,60,100 mg
Meloxin tabs 7,5 mg, 15 mg
Nicox tabs 100 mg
lonene 100, 300 mg
Cybufeb 300 mg
Nama Generik
Golongan
Preparat
Piroxicam
Oxicam
Tenoxicam
Oxicam
Na.Diclofenac
Indomethasin
Diflunisal
Tiaprofenic acid
Ibuprofen
Ketoprofen
Naproxen
Pirprofen
Carprofen
Acetic Acid
Acetic Acid
Tilcotil tabs 20 mg
Voltaren tabs 25,50,SR75 mg
Indocid caps 25 mg
Carbonic Acid
Propionic Acid
Propionic Acid
Propionic Acid
Propionic Acid
Propionic Acid
Propionic Acid
Celecoxib
Cox 2 inhibitor
OBAT-OBAT REMITIF
DMADRS
Bekerja lambat menunggu kadar di darah cukup
Khasiat baru mulai 3-12 bulan
Side effect dan toksisitas tinggi
Diharapkan dapat menghentikan progresifitas/
menjadi remisi.
DMARD