dr. Mahriani Sylvawani Sp.PD

DEFINISIartritis Reumatoid (AR) : penyakit inflamasi sistemik kronik yang terutama mengenai sendi diartrodial.

Merupakan penyakit autoimun yang ditandai dg sinovitis erosil simetrik yang terutama mengenai jaringan persendian, & juga melibatkan organ tubuh lainnya.

EtiologiGenetikkompleks histokompatibilitas utama kelas II (MHC Class II determinants), khususnya HLA-DR4 dengan AR seropositif HLA-DR4 memiliki risiko relatif 4:1 untuk menderita AR

EtiologiHormon sexPrevalensi AR diketahui 3 : 1 antara wanita dan priaPada wanita hamil prevalensi bisa meningkat 5 : 1

EtiologiInfeksiDugaan faktor infeksi sebagai penyebab AR timbul karena:- Onset penyakit ini terjadi secara mendadak - Timbul dengan disertai oleh gambaran inflamasi yang mencolok

PATOGENESISAntigen membran sinovial diproses oleh APC melekat pada CD 4+ CD 4+ teraktivasi mitosis & proliferasi sel tjd aktivitas fagositosis (monosit,macrofag) proliferasi sel B anti body compleks anti imun difusi bebas ke ruang sendi pengendapan kompleks imun permeabilitas vaskuler degranulasi mast cell, pembebasan radikal O2 dll inflamasi & kerusakan jaringan erosi rawan sendi & tulang

Pengendapan kompleks imun sel T masuk ke membran sinovial terbentuk pannus

Pannus jaringan granulasi (macrofag yg teraktivasi, sel fibroblast yg berproliferasi) menginvasi jar.kolagen & proteoglikan rawan, sendi & tulang menghancurkan struktur persendian

RA Is Characterised by Synovitis and Joint DestructionNORMALRASynovial membraneCartilageCapsuleSynovial fluidInflamed synovial membranePannusMajor cell types:T lymphocytesmacrophagesMinor cell types:fibroblastsplasma cellsendotheliumdendritic cellsMajor cell type:neutrophilsAdapted from Feldmann M, et al. Annu Rev Immunol. 1996;14:397-440.Cartilage thinning

Gejala KlinisPada umumnya gejala penyakit ini berkembang secara perlahan dalam masa beberapa minggupalindromic rheumatism pauciarticular rheumatism

Manifestasi ARManifestasi Artikuler Jari tangan, Pergelangan Tangan, Vertebra cervicalis, gelang bahu, panggul,lutut dan pergelangan kaki

Manifestasi ekstra artikuler Mata, kulit, saluran nafas, ginjal, kardiovaskular dan saluran cerna

RA pada TANGAN

Manifestasi ekstra-articular RABerupa vasculitis

Manifestasi ekstra articular RAPada mata

Rheumatoid athritis stadium lanjut

Laboratorium1. Rematoid Faktor Titer > 1:1602. LED> 100mm/jam3. AnemiaNormositik normocrom atau defesiensi besi4. Cairan sinovialLeukosit 15000-20.000

Pembengkakan jaringan lunakPenyempitan ruang sendi dan mulai erosi tulang minimalPerluasan erosi tulang dan deformitasGambaran Radiologi

Kriteria American Reumatism Association untuk Artritis Reumatoid revisi 1987

Kaku Pagi hari pada persendian >1 jamArtritis pada 3 sendi atau lebihArtritis pada persendian tanganArtritis SimetrisNodul ReumatoidFaktor Reumatoid serum positifPerubahan Gambaran RadiologiHarus ada 4 dari 7 kriteria

PenangananPenatalaksanaanPenanganan NonfarmakologiEdukasi tentang penyakitMengistirahatkan Sendi yang terserangKompres hangat dan dinginGunakan alat bantu jalan, gunakan toilet duduk.Kurangi Berat Badan

PenangananFarmakologi Analgetik (NSAID)Prednison tablet 5-20 mg/hariMethylprednisolon tablet 20-40 mg/hariIbuprofen tablet 4 x 600 mg

DMARD (Disease Modifing Anti Rheumatoid Drugs)Metotreksat tablet 7,520 mg/minggu (3-4 bln)2. Klorokuin fosfat tablet 250mg/hari atau Hidroksiklorokuin tablet 400 mg/hari3. Sulfasalazine tablet 500 mg/hari ditingkatkan tiap 1 minggu 500 mg s/d 2000 mg/hari jika remisi tercapai diturunkan hingga 1000 mg/hari utk jangka panjang sampai remisi sempurna

4. D-Penicillamine tablet 250-300 mg/hari ditingkatkan setiap 2-4 minggu 250-300 mg s/d 1000-1200 mg/hari (1thn)

5. Garam Emas IM 10 mg minggu pertama IM 20 mg minggu kedua IM 50 mg/minggu selama 20 minggu

6. Cyclosporin A 2,5 3,5 mg/KgBB/hari 2x17. Leflunomide Dosis awal 100mg/hari selama 3 hariDosis lanjutan 10-20 mg/hr selama 8 minggu

Modulator Inflamasi BiologisEtanercept Vial 25 mg 2x perminggu (SC)InfliximabDosis awal 3mg/KgBB (drip selama 2 jam)Ulangi pada minggu ke 2 dan ke 6Selanjutnya setiap 8 minggu

KESIMPULANArtritis Reumatoid (AR) : penyakit inflamasi sistemik kronik terutama mengenai sendi. Termasuk penyakit autoimun dg etiologi yg belum diketahui

Manifestasi Reumatoid Artritis terdiri dari manifestasi artikular & ekstraartikular

Diagnosis Reumatoid Artritis dg menggunakan kriteria American Rheumatism Association

Penatalaksanaan Reumatoid Artritis dilakukan dengan non farmakologis dan farmakologis

Penatalaksanaan yg tepat prognosisnya baik

*********Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disease, characterised by synovitis and joint destruction,1 and often results in significant disability and premature mortality.2 The pathogenesis of this chronic autoimmune disease is mediated by an interdependent network of cytokines, prostanoids, and proteolytic enzymes.3 Cytokines possess proinflammatory and immunosuppressive anti-inflammatory properties that regulate immune responses.1An imbalance between proinflammatory and anti-inflammatory effects is thought to contribute to the chronic nature of RA. Hence, the current pathogenetic model for RA is one of a chronic, tissue-specific inflammatory process to which a variety of immune responses can contribute.1 This slide depicts the unique pathophysiological elements of RA that arise from interactions between the variety of leucocytes that invade the joint, andthe native cellular components of joint tissue.

1. Feldmann M, Brennan FM, Maini RN. Role of cytokines in rheumatoid arthritis. Annu Rev Immunol. 1996;14:397-440.2. Pincus T. The underestimated long term medical and economic consequences of rheumatoid arthritis. Drugs. 1995;50(suppl 1):1-14.3. Tak PP, Bresnihan B. The pathogenesis and prevention of joint damage in rheumatoid arthritis. Advances from synovial biopsy and tissue analysis. Arthritis Rheum. 2000;43:2619-2633.**********Slide 10 Notes. Rheumatoid Arthritis: Radiologic FeaturesEarly in the course of RA, soft tissue swelling may be the only radiographic sign of disease.1 During the intermediate stage of the disease, signs include mild juxtaarticular osteoporosis, narrowing of the joint space (from cartilage loss), and bone erosions.1,2 Early radiographic joint damage is predictive of aggressive further development of RA.In late-stage RA, radiographs can reveal large erosions, anatomic deformities, and ankylosis.1Initially, RA usually affects the ulnar styloid, I-III metacarpophalangeal joints, and II-III proximal interphalangeal joints.2 The most common extra-articular lesions are subcutaneous nodules, usually appearing on the extensor surfaces of the arms and elbows.Other imaging techniques (eg, ultrasound of the affected joint, computed axial tomography, magnetic resonance imaging) can be helpful in assessing the features of a patients disease and the extent of anatomic damage.2

1. Resnick D, Yu JS, Sartoris D. Imaging. In: Kelley WN, Harris ED Jr, Ruddy S, et al, eds. Textbook of Rheumatology. 5th ed. Philadelphia, PA: WB Saunders; 1997:626-685.2. Grassi W, De Angelis R, Lamanna G, Cervini C. The clinical features of rheumatoid arthritis. Eur J Radiol. 1998;27(suppl 1):S18-S24.

*Slide 13 Notes. Diagnosis of Rheumatoid Arthritis: American College of Rheumatology CriteriaThe revised clinical criteria for the diagnosis of rheumatoid arthritis published in 1987 by the American College of Rheumatology are generally accepted today. At least 4 of the following 7 criteria must be present, with the first 4 being present for 6 weeks or more.Morning stiffness in and around the joints lasting more than 1 hour before maximal improvement. Physician-observed simultaneous soft tissue swelling (arthritis) or fluid present in 3 or more of 14 joints: right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle, or metatarsophalangeal (MTP).Soft tissue swelling in at least one area of the wrist; MCP, or PIP joint.Simultaneous involvement of the same joint areas bilaterally.Physician-observed rheumatoid nodules over bony prominences, on extensor surfaces, or in juxtaarticular regions.Abnormal amounts of serum rheumatoid factor by any method for which the result has been positive in