FARMAKOTERAPI

OSTEOARTHRITIS

DEWI RAHMAWATI

PEMERIKSAAN MUSKULOSKELETAL
3 MENIT
Gaits (Cara Berjalan)
Arms (Tangan)
Legs (Kaki)
Spine (Tulang
Belakang)

PERTANYAAN KUNCI
APAKAH ANDA MERASA NYERI ATAU KEKAKUAN DI SENDISENDI ATAU TULANG BELAKANG?
APAKAH ANDA MENGALAMI KESULITAN BERJALAN, MENAIKI
TANGGA ATAU BANGUN DARI TEMPAT TIDUR?
APAKAH ANDA MENGALAMI KESULITAN BERPAKAIAN?

PENYAKIT REUMATIK YANG LAZIM

DITEMUI DALAM PRAKTEK UMUM

REUMATISME JARINGAN LUNAK

OSTEOARTRITIS
ARTRITIS REUMATOID
GOUT
SYSTEMIC LUPUS ERYTHEMATOSUS
ARTRITIS SEPTIK
REUMATOID ARTRITIS JUVENIL
SPONDILITIS ANKILOSA
ARTRITIS PSORIATIK
SKLERODERMA
PURPURA HENOCH-SCHONLEIN

PENYAKIT REUMATIK RAWAT JALAN

REUMATISME JARINGAN LUNAK

OSTEOARTRITIS
GOUT

BONE REMODELLING

PEMBENTUKAN TULANG
DAN KARTILAGO
BONE REMODELLING SEPANJANG HIDUP
TERGANTUNG KEBUTUHAN PERTUMBUHAN DAN
PERUBAHAN BEBAN TUBUH (WEIGHT-BEARING)
PEMBENTUKAN TULANG BARU & MATRIX
MINERALIZATION (OLEH OSTEOBLAST)
RESORPSI TULANG & RELEASE MINERAL (OLEH
OSTEOCLAST)

RESERVOIR UNTUK MINERAL (CA, PO4, DLL)

PEMBENTUKAN TULANG &

KARTILAGO
SEL PROGENITOR

SEL IMMATURE SEL IMMATURE (OSTEOBLAST)

(CHONDROBLAST)
PEMBELAHAN SEL &
SEKRESI MATRIX
OSTEOCYTE
(UTK TULANG)

CHONDROCYTE
(UTK KARTILAGO)

Sejumlah osteoblast & fibroblast disimpan di periosteum dan chondrocyte

disimpan di perichondrium, untuk pembentukan kembali tulang & kartilago

MINERAL HOMEOSTASIS

PENYIMPANAN & PELEPASAN

MINERAL DI TULANG
KADAR MINERAL (CA, PO4) DI
DLM DARAH

SEX HORMON (ESTROGEN

& TESTOSTERON) DAN

GROWTH FACTOR
TERUTAMA MEMPENGARUHI SAAT USIA
MUDA

DIPENGARUHI OLEH
PARATHYROID HORMON
(PTH), HORMON THYROID
CALCITONIN, DAN 1,25
DIHYDROXYCHOLECALCIFER
OL (CALCITRIOL) + SUMBER
MINERAL DARI MAKANAN

DIPENGARUHI JUGA
OLEH SITOKIN DAN
GROWTH FACTOR

MINERAL HOMEOSTASIS
(LANJUTAN)
OSTEOCYTE BERPERAN MELEPASKAN MINERAL DARI
TULANG
OSTEOCLAST TERUTAMA BERPERAN DALAM RESORPSI
TULANG
PTH MENINGKATKAN JUMLAH DAN AKTIVITAS OSTEOCLAST,
TETAPI DIDUGA HAL INI KARENA PENGARUH PTH-ACTIVATED
OSTEOBLAST YANG PADA KONDISI NORMAL SELALU BERADA
DI DALAM KESEIMBANGAN

MINERAL HOMEOSTASIS

SENDI NORMAL VS. OA

Lutut Normal
kapsul

Lutut Osteoartritik
penebalan kapsul
Pembentukan kista

kartilago
sinovium
tulang

sklerosis tulang
subkondral
fibrillated cartilage
hipertrofi sinovial
pembentukan osteofit
ACRFP

OSTEOARTHRITIS
DIAWALI DENGAN JARINGAN KARTILAGO AUS / TERCABIK
LALU TERJADI KERUSAKAN JARINGAN DI SEKITARNYA (RUANG
ANTAR SENDI MENYEMPIT), TERBENTUK SUBCHONDRAL
CYST
TIMBUL NYERI
USAHA UNTUK MEMPERBAIKI / REGENERASI (SCLEROSIS,
OSTEOPHYTE LIHAT GAMBAR SENDI NORMAL VS OA)

OSTEOARTHRITIS
-DEGENERATIVE JOINT DISEASE.
-PREVALENSI MENINGKAT SEIRING DG USIA,
MENINGKAT 2-10X DR USIA 30-65 TH

RISK FACTORS FOR OSTEOARTHRITIS

AGE OLDER THAN 50

CRYSTALS IN JOINT FLUID OR CARTILAGE
HIGH BONE MINERAL DENSITY
HISTORY OF IMMOBILIZATION
INJURY TO THE JOINT
JOINT HYPERMOBILITY OR INSTABILITY
OBESITY (WEIGHT-BEARING JOINTS)
PERIPHERAL NEUROPATHY
PROLONGED OCCUPATIONAL OR SPORTS STRESS

ETIOLOGY

CALCIUM DEPOSITION
CONGENITAL OR DEVELOPMENTAL
ENDOCRINE
GENETIC DEFECTS :INTERLEUKIN-1
FAMILY,INTERLEUKIN-4 RECEPTOR
INFECTIOUS
METABOLIC

 NEUROPATHIC
POST-TRAUMATIC
RHEUMATOLOGIC DISEASES (OTHER THAN
PRIMARY OSTEOARTHRITIS)
OBESITY
OCCUPATION :CARPENTERS, AGRICULTURAL
WORKERS
SPORT : BOXING, BASEBALL PITCHING,
CYCLING, FOOTBALL

TINJAUAN UMUM OSTEOARTHRITIS

DEGRADASI KARTILAGO: HILANGNYA INTEGRITAS MATRIKS
PERAN BERBAGAI SITOKIN, ENZIM DAN OKSIDA NITRAT
UMUR ADALAH FAKTOR RISIKO PALING KUAT
FAKTOR RISIKO LAIN: OBESITAS, CEDERA, KELEMAHAN OTOT
LUTUT DAN PANGGUL MERUPAKAN TEMPAT YANG PALING
SERING TERKENA
NODUS HEBERDEN DAN BOUCHARD
NYERI MEKANIK, TIDAK ADA GEJALA SISTEMIK

DEGRADASI TULANG KARTILAGO

HERBEDENS NODES

OSTEOARTHRITIS PADA LUTUT

PERUBAHAN STRUKTUR TULANG

CLINICAL PRESENTATION
GENERAL

MILD SYMPTOMS FOR MONTHS TO YEARS

TYPICAL AGE :USUALLY >50 YEARS.
SYMPTOMS

PAIN IN THE AFFECTED JOINTS (HANDS, KNEES,HIPS )

PAIN IS MOST COMMONLY ASSOCIATED WITH MOTION,PAIN IN LATE DISEASE
CAN OCCUR WITH REST
JOINT STIFFNESS IN THE MORNING < 20-30 THAT RESOLVES WITH MOTION;
RECURS WITH REST
SIGNS

JOINT STIFFNESS WITH OR WITHOUT JOINT ENLARGEMENT.

CREPITUS A CRACKLING OR GRATING SOUND HEARD WITH JOINT
MOVEMENT THAT IS CAUSED BY IRREGULARITY OF JOINT SURFACES

 LIMITED RANGE OF MOTION THAT MAY BE ACCOMPANIED BY

JOINT INSTABILITY.
LATE-STAGE DISEASE IS ASSOCIATED WITH JOINT
DEFORMITY (FIGURE 95-3 )

LABORATORY TESTS
NO SPECIFIC LABORATORY TESTS USEFUL IN THE
DIAGNOSIS.

OTHER RADIOLOGIC TESTSPLAIN RADIOGRAPHIC FILMS

JOINT SPACE NARROWING, APPEARANCE OF OSTEOPHYTES
IN MODERATE DISEASE (GAMBAR 95-4)
ABNORMAL ALIGNMENT OF JOINTS AND JOINT EFFUSION IN
LATE DISEASE.

DIAGNOSIS
HIP OA
PAIN IN THE HIP, ESR <20 MM/H, FEMORAL OR
ACETABULAR (TWO OF THE THREE)
OSTEOPHYTES ON RADIOGRAPHY, OR JOINT
SPACE NARROWING ON RADIOGRAPHY.
KNEE OA
PAIN AT THE KNEE,OSTEOPHYTES ON
RADIOGRAPHY
AGE > 50 YEARS,
MORNING STIFFNESS 30 , CREPITUS ON
MOTION,BONY ENLARGEMENT, BONY
TENDERNESS, OR PALPABLE WARMTH

Characteristics of osteoarthritis in the diarthrodial joint.

PENATALAKSANAAN OA
NON-FARMAKOLOGI
TERAPI PEMANASAN ATAU DINGIN
PROTEKSI SENDI MISALNYA PENURUNAN BERAT
BADAN ORTOTIK, ALAT-ALAT BANTU
LATIHAN, MISALNYA ISOMETRIK, SEPEDA STATIS
FARMAKOLOGI
ANALGESIK - SISTEMIK AND TOPIKAL
OBAT ANTIINFLAMASI NON-STEROID
(TERUTAMA COX-2
SPECIFIK INHIBITORS)
STEROID INTRA-ARTIKULER
HYALURONAT INTRA-ARTIKULAR
?DISEASE-MODIFYING DRUGS
OPERASI

PERTIMBANGAN LATIHAN PADA

OSTEOARTHRITIS PANGGUL DAN
LUTUT

PERTAHANKAN BERAT YANG SESUAI

PERTAHANKAN RANGE OF MOTION DAN FLEKSIBILITAS

LATIHAN DALAM AIR, DENGAN SEPEDA ATAU
DAYUNG
LAKUKAN AKTIVITAS WEIGHT-BEARING DAN
WEIGHT- BEARING SECARA BERGANTIAN

GUNAKAN TARUK PADA SISI KONTRALATERAL

MESIN

NON-

PERTIMBANGAN LATIHAN PADA

OSTEOARTHRITIS PANGGUL DAN
LUTUT

JANGAN MEMBAWA BEBAN LEBIH DARI 10% BERAT

TUBUH
SESEDIKIT MUNGKIN MENAIKI TANGGA, BERDIRI SATU
KAKI ATAU DUDUK DI KURSI RENDAH
KECEPATAN BERJALAN JANGAN MEMBUAT GEJALAGEJALA SENDI KAMBUH
PILIH SEPATU DAN SOL YANG MENAHAN GONCANGAN
PEMANASAN SEBELUM MELAKUKAN LATIHAN JALAN

SENDI NORMAL VS OA VS RA

TERAPI
DESIRED OUTCOME
(a) TO EDUCATE THE PATIENT, CAREGIVERS, AND
RELATIVES
(b) TO RELIEVE PAIN AND STIFFNESS
(C) TO MAINTAIN OR IMPROVE JOINT MOBILITY
(D) TO LIMIT FUNCTIONAL IMPAIRMENT
(E) TO MAINTAIN OR IMPROVE QUALITY OF LIFE

GENERAL APPROACH TO TREATMENT

THE PRIMARY OBJECTIVE TO ALLEVIATE PAIN
ACETAMINOPHEN UP TO 4 G/DAY (INITIALLY)
IF THIS IS INEFFECTIVE NSAIDS OR COX-2
SELECTIVE INHIBITOR (CELECOXIB)
APPLICATION OF CAPSAICIN OR
METHYLSALICYLATE TOPICAL CREAMS
ADJUNCTS FOR PAIN CONTROL
GLUCOSAMINE AND CHONDROITIN IN
COMBINATION MODERATE TO SEVERE
ARTHRITIS

 JOINT ASPIRATION FOLLOWED BY

GLUCOCORTICOID OR HYALURONATE
CONCOMITANTLY WITH ORAL ANALGESICS
OR AFTER THEIR LACK OF EFFICACY
OPIOID ANALGESICS FINAL MEDICATION
IF OTHER THERAPIES ARE UNSUCCESSFUL
SYMPTOMS ARE INTRACTABLE OR THERE IS
SIGNIFICANT LOSS OF FUNCTION JOINT
REPLACEMENT

TERAPI

A. NON FARMAKOLOGI
- EXERCISE UTK HINDARKAN STRESS PD
SENDI SAMBIL PERKUAT OTOT
PERIARTIKULER
- HINDARI MUATAN BERLEB PD SENDI LUTUT
DAN PINGGUL DG GUNAKAN ALAT BANTU
(TONGKAT, SEPATU ORTO-PAEDI), TURUNKAN
BB, EDUKASI PERLINDUNGAN SENDI

PHYSICAL AND OCCUPATIONAL THERAPY

PHYSICAL THERAPYWITH HEAT OR COLD

TREATMENTS AND AN EXERCISE PROGRAM
TO MAINTAIN AND RESTORE JOINT RANGE
OF MOTION AND TO REDUCE PAIN AND
MUSCLE SPASMS.
WARM BATHS OR WARM WATER SOAKS
(RENDAM AIR HANGAT) DECREASE PAIN
AND STIFFNESS

SURGERY

OA WITH FUNCTIONAL DISABILITY AND/OR

SEVERE PAIN UNRESPONSIVE TO
CONSERVATIVE THERAPYTOTAL JOINT
REPLACEMENT (ARTHROPLASTY) OF THE
KNEE ,TOTAL HIP REPLACEMENT

B. FARMAKOLOGI
- PARASETAMOL UTK NYERI RINGAN (PILIHAN
PERTAMA) , SEDANGKAN NSAID LBH
EFEKTIF UTK NYERI SEDANG AD BERAT.
* ESO : HEPATOTOXICITY, RENAL TOXICITY
(LONG-TERM USE)
- TOPIKAL NSAID, CAPSAICIN KRIM SEKUAT
NSAID LOKAL.
- INJEKSI KORTIKO INTRA-ARTIKULER SGT
EFEKTIF TX NYERI & INFLAMASI ISOLATED
JOINT

NSAID DAN COX-2 INHIBITOR

- DIGUNAKAN BILA TX DOSIS MAKS
PARACETAMOL(4G/HARI) TDK BERRESPON DAN
DG EFFUSI SENDI.
- KOMBINASI PAMOL + NSAID EFEKTIF
- PX DG INFLAMASI SENDI : PILIHANNYA NSAID
- EFEK SERIUS : GI BLEEDING, DISFUNGSI RENAL,
PETD , RETENSI CAIRAN, EKSASERBASI HF.
- COX-2 INHIBITOR SEEFEKTIF NSAID NON
SELEKTIF, DG ESO RETENSI NA DAN PENURUNAN
GFR.
- TRAMADOL PD PX YG KI DG COX
INHIBITORNYERI SEDANG AD BERAT.
ESO : MUAL, KONSTIPASI, DROWSINNES

 ROFECOXIB WITHDRAWN IN 2004

BECAUSE OF INCREASED CARDIOVASCULAR
EVENTS (ARITMIA) ANALYSIS OF THE
ADENOMATOUS POLYP PREVENTION ON
VIOXX (APPROVE) TRIAL
CELECOXIB IS LESS OFTEN USED NOW AND
CARRIES A BLACK BOX WARNING FOR
CARDIOVASCULAR AND GI RISKS
THE NEWER COX-2 INH: ETORICOXIB 30 MG,
LUMIRACOXIB 100 MG/DAY ~ CELECOXIB

 Other

Toxicities with NSAIDs

- Kidney diseases
~Acute renal insufficiency, tubulointerstitial
nephropathy, hyperkalemia, renal papillary
necrosis
Clinical features :Cr and BUN , hyperkalemia,TD , peripheral edema, weight gain
- Monitoring : Cr (3 to 7 days of drug initiation)

RISK FACTORS FOR ULCER COMPLICATIONS

INDUCED BY NSAIDS

DEFINITE RISK FACTORS

-PATIENT > 65 YEARS OF AGE
-PREVIOUS ULCER DISEASE OR UPPER
GASTROINTESTINAL TRACT BLEEDING
-USE OF MULTIPLE NSAIDS OR USE OF A HIGH
DOSAGE OF ONE OF THESE DRUGS
-CONCOMITANT ORAL CORTICOSTEROID THERAPY
-CONCOMITANT ANTICOAGULANT THERAPY
-DURATION OF THERAPY (RISK IS HIGHER IN FIRST
THREE MONTHS OF TREATMENT)

POSSIBLE RISK FACTORS

-FEMALE GENDER
-SMOKING
-ALCOHOL CONSUMPTION
-HELICOBACTER PYLORI INFECTION

KORTIKOSTEROID

- KORTIKO SISTEMIK TDK

DIREKOMENDASIKAN OK INFLAMASI BKN
KOMPONEN PRIMER PATOFIS OA.
- INJEKSI INTRAARTIKULER (TRIAMCINOLONE
HEXACETONIDE 40 MG) EFEKTIF UTK
ASPIRASI EFUSI SENDI YG NYERI DAN
BENGKAK,
- FREKUENSI :3-5X / YEAR :
* POTENTIAL SYSTEMIC EFFECTS OF STEROIDS
* THE NEED FOR MORE FREQUENT INJECTIONS
INDICATES LITTLE RESPONSE TO THE THERAPY).

VISCOSUPPLEMENT
- MEDICAL DEVICES SBG PENGGANTI AS
HYALURONAT DI SENDI YG RUSAK PD OA
- NA HYALURONAT, HYLAN ( ALAMI DI CAIRAN
SENDI)
BUAT LINGK VISCOUS, BANTALAN
SENDI, JAGA FGS NORMAL SENDI
- SBG LUBRIKAN & SHOCK ABSORBER PD SENDI,
SHG LINDUNGI TLG RAWAN DR KERUSAKAN
- DIPAKAI BILA ANALGESIK GAGAL UTK OA LUTUT
( DI-BERIKAN ONCE WEEKLY DG 3-5 X INJEKSI
SERI) RELIEF NYERI BERTAHAN AD 6 BLN

HYALURONATE INJECTIONS
CONTAINING HYALURONIC ACID (HA;
SODIUM HYALU-RONATE)
AVAILABLE FOR INTRAARTICULAR
INJECTION FOR TREATMENT OF KNEE OA
DECREASE PAIN
HA IS AN IMPORTANT CONSTITUENT OF
SYNOVIAL FLUID AND ENDOGENOUS HA
HAVE ANTIINFLAMMATORY EFFECTS.
HA PRODUCTS ARE INJECTED ONCE
WEEKLY FOR EITHER 3 OR 5 WEEKS

GLUKOSAMIN DAN CHONDROITIN

- GLUKOSAMIN ENDOGEN (MONOSAKARIDA AMIN)
*DISINTESIS DR GLUCOSA, BAGIAN INTEGRAL PD
BIO-SINTESIS PROTEOGLIKANS &
GLIKOSAMINOGLIKAN (SUBSTRAT HYALURONIC
ACID), YG BENTUK BLOK TLG RAWAN
- CHONDROITIN SULFAT, SUBTRAT UTK
PEMBENTUKAN MATRIK SENDI & MEMBLOK
ENZYM YG BERTANGUNG JWB KERUSAKAN TLG
RAWAN
- KOMBINASI GLUKO DAN CHONDRO : MODERATE
TO SEVERE OA

PROBLEM MEDIK
- PERSISTENT PAIN AND INFLAMMATION
- HEMATOLOGIC DISORDER (ANEMIA, TROMBOSITOPENIA DLL)
- GI DISORDER HEMATEMESIS MELENA, GI BLEEDING
- UNDERLYING DISEASE AND COMORBID
* CKD
* CIRRHOSIS HEPATIC
* CARDIOVASCULAR DISEASE (HYPERTENSION, HF DLL)
* GASTRITIS
* HEPATITIS

DRUG RELATED PROBLEM

- INAPPROPRIATE DRUG LESS OPTIMAL
DOSAGE
- DRUG INDUCE
- ADVERSE DRUG REACTION
- FAILURE TO RECEIVE A DRUG
MONITOR
- KONDISI NYERI DAN INFLAMASI
- DATA HEMATOLOGI, RFT,LFT
- SIDE EFFECT : GASTRIC BLEEDING ( MELENA )
- TEK DARAH, ELEKTROLIT

Algoritme OA

STUDI KASUS
1. PASIEN A.N NY. SH USIA 67 TH, MRS TGL 11 SEPTEMBER
2010 DGN KELUHAN MUAL, MUNTAH DAN BAB WARNA
HITAM,PANAS SELAMA TIGA HARI . PASIEN
GEMUK,SERING ALAMI KEKAKUAN DAN NYERI SENDI
TERUTAMA PAGI HARI. RIWAYAT OBAT JAMU PEGAL LINU
DAN PUYER 16. DATA VITAL SIGN ( NADI : 90 X/MNT ; RR
22X/MNT;SUHU 38C). DATA LAB, LEUKOSIT 12.000 /
MM3,HB.12,0 G/DL, K 2,5 MEQ/L. PASIEN DIDIAGNOSIS
OBS. FEBRIS + GASTRITIS + MELENA. DARI FOTO GENUE
PASIEN MENGALAMI OATEOARTHRITIS. DOKTER YANG
MERAWAT MEMBERI ANTASIDA SIR 3X CII, OMEPRAZOLE
20 MG 2X1, PARASETAMOL 4X1, CEFTRIAXONE INJ 2X1,
PIROKSIKAM 10 MG 2X1

2. TN. STR UMUR 60 THN, DATANG KE POLI

REUMATOLOGI DGN KELUHAN NYERI BERAT DAN
INFLAMASI PADA LUTUT KIRI HINGGA BETIS.PASIEN
SUDAH MENDAPAT NA DIKLOFENAK 3X50 MG,
RANITIDIN 150 MG 2X1, NEUROBION TAB 3X1 SAAT
KONTROL 1 BULAN YANG LALU. DATA LAB
MENUNJUKKAN LEUKOSIT 5000 / MM3 ( 400010.000/MM3), LED 30 MM/JAM ( 0 20 MM/JAM),
TROMBOSIT 60.000 (150.000-400.000/MM3). PASIEN
TERDIAGNOSIS OA

3. PASIEN A.N. TN SPD UMUR 50 TH, MRS DGN

KELUHAN PERUT MEMBESAR 1 BLN,OEDEMA
PADA KAKI, BICARA NGLANTUR, SOMNOLENCE,
NYERI PADA TANGAN YANG DIGERAKKAN TERASA
SAKIT.DATA KLINIK ,TD 130/100, SUHU 36C, NADI 88X
/ MNT, DATA LAB,LEUKOSIT 7500 / MM3, TROMBOSIT
90.000 / MM3, ALBUMIN 2,5 ( 4-6 G/DL), GLOBULIN 4,5
G/DL ( 4-6 G/DL). PASIEN TERDIAGNOSIS SIROSIS
HEPATIKA DENGAN PENYAKIT PENYERTA
OSTEOARTHRITIS. PASIEN PUNYA RIWAYAT
HEMATEMESIS MELENA.DI BANGSAL, PASIEN
MENDAPAT TERAPI FUROSEMIDA INJ 1-1-0,
SPIRONOLAKTON 100 MG 1-1-0, KANAMYCIN KAPS 4
X 2, LAKTULOSE SIR 3 X CII, MELOXICAM 7,5 MG 2X1

 PERTANYAAN :
- BAGAIMANA PHARM CARE PADA PASIEN TSB DI ATAS
?