19t04t2016

ARTRITIS REUMATOID
Artritis reumatoid (RA) :

penyakit autoimun yang ditandai

adanya kelainan sastem imun yang
menyerang membran sinovial.

Awalia

Divisi Rematologi Dept. llmu Penyakit Dalam

FK UNAIR - RSUD Dr. Soetomo Surabaya

TIU

TUJUAN INSTRUKSIONAL UMUM

. Siswa dapat menjelaskan, membuat diagnosis dan
tata laksana awal kasus artritis reumatoid (RA)
. Siswa dapat merujuk kasus RA yang berat setelah
memberikan terapi awal yang tepat

TIK
*'"m *
APC, macrophage in
synovium engulfs
th€ antigen.
. Siswa dapat mengenali dan menjelaskan gambaran (peroxides) inside ffi''n'"
the APC break down
klinis penyakit RA
.
the antigen into
small€r particles.
\ Mdcro'hose
Siswa dapat mendiagnosis RA
**-&
. Siswa dapat melakukan penatalaksanaan awal RA
. Siswa dapat menentukan rujukan untuk terapi
\.
t'll3il,',.1,,,,",,u,,,,,
selanjutnya kasus RA dan mampu menindaklanjuti
setelah kembali dari rujukan
ro' *!t qTft:
&
if::ii:..,.,
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19104t2016
I

V
Gejala Klinik RA

Sel limfositT akan berikatan e '1as 'r' Articular Extra-artikuler

dg AglMHC-comptex ) o Poliartikuler simetris r Nodul reumatoid
k *,* ;i.
.1f o Sendi bengkak dan
. Gerak terbatas
nveri o Vaskulitis
=l't"'"tn"nsitokin' . Malalignmentsend,i
o Fibrosis paru
e Mata (sicca, scleritis)
) IFN-o W '4," t. ',..u
c Kaku dan nveri sendi pagi r Carditis, pericarditis
) tFN-y \ffi
) TNF- a, dll. W:' Sistemik
. Demam, BB J, fatigue, anemia, CRp t

Keterlibatan sendi pada RA

Efek sitokin:
Aktivasldan migrasl
leukosit ke jaringan . MCP, PIP tangan & MTp kaki 90%
inflamasi ) . Lutut, pergelangan tangan dan kaki g0%
pembentukan
pannus, kerusakan . Bahu 60%
cadilage dan sinovial
. Siku

50%
. TMJ, Acromio-clavicular & atlanto axial - 30%

Artritis Reumatoid Ulnar Deviation, MCP Swelling,

Th.synsiuh cdduebbrood!.ss.tdi,btions.nd Plus tBnulations forn over the sFovial
Left Wrist Swelli
thi.k.n.d du! ro infl,mdan.n.nd +ilular infl h.!on. memb€ne now called as Dannus,

Rheumotoid

.: Ponrus
t+r fornotion
j ,:j
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Geja la Ekstraa rtiku ler RA - Vaskulitis

. Gejala konstitusional : demam, fatigue dll
. Nodulreumatoid (30%)
. Hematologi
anemia, leukositosis/leucopenia,trombositosis
. Respirasi - efusi pleura, pneumonitis, nodul
paru/pleura, ILD (interstitial lung disease)
" CV - perikarditis, efusi perikard, kardiomiopati

. Rheumatoid vasculitis- mononeuritis multiplex, ulkus

kulit, gangren digiti, infark viseral
Laboratorium
. neuropati perifer, kompresi spinal cord l<crcn;
CNS-
kompresi atlantoaxial/midcervical spine subluxation,
. Rheumatoid Factor, atiii-CCi
entra pme nt neu ro path i es . Peningkatan LED, CRP
. Mata - kerato conjunctivitis sicca, episcleritis, scieritis . Anemia, trombositosis
. Antinuclear antibodies (ANA)
. Cairan sendi: WBC >2000/mm3
 19t04t2016

ACR 1987 CI-A.SSIFICATION CRITERIA FOR

ARTHRITIS RHEUMATOID

. Rheumatoid Factor
- Antibodi lgM terhadap fragmen Fc lgG
- Tidak sensitif 2. Arthritis of three
. 80% of RA patients 3. Arthritis of hand
- RF+ cs6dslunt
. Penyakit lebih berat
. Manifestasi extraarticular

*Must have been present for at least six weeks

ACR/EULAR 2010 Rheumatoid Arthritis criteria

A Joint involvement 1 large ioint 0

. Anti-cyclic citrullinated peptide (anti-CCP)

. lgG terhadap protein membran sinovial
. Spesifisitas 90%, sensitivitas 50-80%
1-3 small ioints

10 ioints ( min. I small join.

-E z

) 5
. Anti CCP + cenderung penyakit berat, progresif
RF or ACPA high positiw ] l

D Duation of illness < 6 weks

Radiologi
Diagnosis Banding RA
. Pen-articularosteopenia
. Penyempitan celah sendi
- Rheumaticfaner: migratory orthritis, ASO titer t
. Erosi subkondral marginal
. - SLE ; manifestasi klinis lebih luas
Subluksasi sendi
. - Osteoarthritis: gejala konstitusi (-l , tanpa inflamasi sendi
Destruksi sendi yanS nyata
. USG deteksi lebih dini - Artritis gouti terutama yang lanjut
 CARE - Ctiteria for Eatly Referal

Clinical suspicion of RA
Presence of any of the following should support
rapid
referral to rheumatologist:
- >3swollenjoints
- MTP/MCP involvement
Squeeze test positive
- Morning stiffrress > 30 minutes

Terapi RA Drugs used in RA management

. Mengatasi nyeri dan mencegah kecacatan . NSAID, Coxib

. Edukasi penderita . Corticosteroids :topical/systemic, low / high dose
. Terapi frsik(stretching & range of motion exercises)
. 'DMARDs
Occupational Therapy (splints & adaptive devices)
. Biologic agents: anti TNF,anti CD20,anti IL1
. Terapi dini dan asresi-i bersifat individual

Tujuan Terapi Kortikosteroid pada RA

. Steroid (sistemik/intraartikuler) penting pada terapi RA
lndikasi steroid :

1. Terapi flare
2. Vaskulitis dan ILD
3. Bridging theropy (6-8 minggu sebelum DMARDS
bekerja)
4. Terapi pemeliharaan pada RA aktil dosis < 10mg
prednison
5. Pada kehamilan bila ada kontraindikasi DMARDs
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]blogic Agent Usual dose/EUte Side etf€c Contnlndi€tlons

DMARDS nfliximob 3 mg/kg i.v infusion at lnfusion readions,
Anti-lllF) wks 0,2 and 6 followed
Commonly used Less commonly used by mainbinence
increased risk of infedions,uncontaolled

Methotrexate dosing every 8 wks ol TB ,etc wks po* op)

Chloroquine Hasto b€ combined
with MTX.

Hydroxychloroquine Gold(parenteral &oral)

,anercept 25 mg s/c 6iice e wk
'anti-tNFl I{ay be gvfl trith \'{TX reacrion,URTI, infedions,uncontrolled
iulphasalazine CyclosporineA or as moflothcrip\'. DM,surgerylwith hold for 2
TBder€lopmhr of

Leflunomide of demFlenatn[l
D-penicillamine/bucillamine

Minocycline/Doxycycline
Levamisole Gollmuwb Once month, subcubn Same as that ot Adive infedions
(Anti-fvFl May be given with infliximab
Azathioprine,cyclophospha mide, Mfl or as
chlorambucil

DMARD therapy Monitor RA

DMARD Apprcximate time to Usual malntenance do*
benetit (months) Menilai aktivitas penyakit :

Hydroxychlorcquine 24 200 mg twie daity

. Klinis (lama kaku dan nyeri pagi hari, jumlah
Sulfasalazine 1-2 1,000 mg 2 or 3 times daily sendi terkena, skor nyeri, DAS-28)
Methotrexate 1-2
lnjectable gold 3-6
7.5-15 mg per wFk
25-50 mg lM every 2-4 weks
. Laboratoris (LED, CRP)
Oral gold 4-€ 3 mg on@ or twi@ daily
Azathioprine 2-3 1.25-2.5 mg.tkg daity
Cyclosporine 1-2 3.6 mg/kg daity (mdian dos)
D-Penicillamine 3--5 25G-750 mg daily

ACR d h@ Mnnee m cknd 9uk[n6. Adtu tuD g71T7n. ,w

Limitations of existing therapies Indicators of Poor Prognosis in RA

Agent - Reduced functional status
NSAID Often inefiective in severe cases - Early radiographic changes
Does not prevent damage
Dos not alter disease couFe - Multiple involved joints
Corticosteroid SewE toxicity with chronic use - Older age at onset
Repeat injections ill-advi$d in sam joint within 3 months
- High titers of rheumatoid factor
Prcbably does not alter di$a* cour
DMARD May not prevent damage d€spite appacnt clinical control - Prolonged elevation ofESR
May not have lasting efiicacy - Lower educational level
May not be tolerated due to toxicity
Delayed onset of action
- Genetics (shared epitope)

ACRd @ mmfle on ctinhl Sdetin6, Adft fireuh 39f 1172,1W

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Pembedahan
. Synovectomy.
. Totaljoint arthroplasties (lutu! hip, dll.)
. Operasi lain seperti releose of nerve entrapments (e.g,,
corpal tunnel syndrome), artroskopi, removol of a
sym ptomati c rheu ma toi d nod u le.

2At2 ACR Update