RHEUMATOID

ARTHRITIS :
Diagnose & Management
Update

dr.Sandra Sinthya Langow SpPD-KR

SILOAM HOSPITAL LIPPO VILLAGE
INTRODUCTION
 Rheumatoid Artritis
RA is an autoimmune disease lead to
systemic chronic inflammation. Activated T
cells in the synovium producing a variety of
cytokines (particularly IL-1 and TNFα) is
central in the pathogenesis of RA.
Chronic polyarthritis lead to joint erosions are
the most prominent clinical manifestations.
• Affects approximately 0.8 percent of adults
worldwide (0,3 – 1,2%)
• More common in women (by a ratio of 3 to 1)
• 80% in range 35-50 years-old
• The burden :
 Chronic polyarthritis  joint erosions
 Deformity, disability
 Decrease in quality of life
 premature mortality
Scott DL, et al. Lancet 1987;1:1108-1111
Gabriel SE. Rheum Dis Clin North Am 2001;27:269-281
Lipsky, PE. In: Harrison's Principles of Internal Medicine.2005,p.1968-77
 Work disability of RA

l 10% of patients with RA stop working

within 1 year of diagnosis
l 50% stop working within 10 years of
diagnosis
l 60% stop working within 15 years of
diagnosis

l 90% leave work within 30 years of diagnosis

Yalin E .t &, Arthritis Rheum 30:507–512, 1987

PATOGENESIS
Immunopathogenesis

not fully understood Genetic

Auto
immune
T
disease

DC
Imune
Regulation Environment
 CAUSES OF RA
• Heterogenous disease of variable severity, and
unpredictable response to therapy
• Genetic and environmental factors are clearly
implicated in its etiology and pathogenesis
• Environmental factors :
– Cigarrete (risk of developing anti-CCP (+))
– Silica dust
– Infection : bacterial (bacterial DNA,
peptidoglycans, LPS) and viral (EBV)

Klareskog L, et al In: Rheumatoid Arthritis. 2009,p. 28-34.

Introduction to Rheumatoid Arthritis

The Role of TNF- in RA

TNF

Pannus/Synovitis

Osteoclasts Chondrocytes
Synoviocytes

Joint Cartilage
Bone resorption inflammation degradation

Pain Joint space

Bone erosion
Joint swelling narrowing

Magnani A, et al. Pediatric Rheumatology Online 2005; Volume 3, No 4.

Slide 10
 Stage of RA
1 month 6 months 2 years
DIAGNOSIS
Deformitas pada RA
 }

Classical appearance
Rare finding
Not always positive
Late finding
 2010 ACR/EULAR Classification
Criteria for Rheumatoid Arthritis
 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)

SEROLOGY (0-3)

SYMPTOM DURATION (0-1)

ACUTE PHASE REACTANTS (0-1)

 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint 0
2-10 large joints 1
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5

SEROLOGY (0-3)

SYMPTOM DURATION (0-1)

ACUTE PHASE REACTANTS (0-1)

 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint 0
2-10 large joints 1
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5

SEROLOGY (0-3)
Negative RF AND negative ACPA 0
Low positive RF OR low positive ACPA 2
High positive RF OR high positive ACPA 3

SYMPTOM DURATION (0-1)

ACUTE PHASE REACTANTS (0-1)

 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint 0
2-10 large joints 1
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5

SEROLOGY (0-3)
Negative RF AND negative ACPA 0
Low positive RF OR low positive ACPA 2
High positive RF OR high positive ACPA 3

SYMPTOM DURATION (0-1)

<6 weeks 0
≥6 weeks 1

ACUTE PHASE REACTANTS (0-1)

 2010 ACR/EULAR
Classification Criteria for RA
JOINT DISTRIBUTION (0-5)
1 large joint 0
≥6 = definite RA
2-10 large joints 1
1-3 small joints (large joints not counted) 2
4-10 small joints (large joints not counted) 3
>10 joints (at least one small joint) 5 What if the score is <6?
SEROLOGY (0-3)
Negative RF AND negative ACPA 0
Patient might fulfill the criteria…
Low positive RF OR low positive ACPA 2
High positive RF OR high positive ACPA 3  Prospectively over time
(cumulatively)
SYMPTOM DURATION (0-1)
<6 weeks 0
 Retrospectively if data on all four
≥6 weeks 1
domains have been adequately
ACUTE PHASE REACTANTS (0-1) recorded in the past
Normal CRP AND normal ESR 0
Abnormal CRP OR abnormal ESR 1
Peran ultrasound untuk diagnosis RA
Introduction to Rheumatoid Arthritis

Improving RA Diagnosis and Referral Recommendations for

Simplified Diagnosis in Primary Care

1. ≥3 swollen joints

2. MCP and/or MTP involvement: squeeze test

3. Morning stiffness ≥30 min

Emery P et al. Ann Rheum Dis 2002;61:290–7

Slide 24
Treatment
 Most RA Patients Develop Bone
Erosions During First 2 Years of Disease

100
Cumulative Percentage of

90
Patients with Erosions

80
70
60
50
Hands
40
Feet
30
Hands or Feet
20
Hands and Feet
10
0
Baseline 1 2 3 4 5
Years of Follow-Up

Patients with RA < 1 year underwent annual radiologic assessment of hands and feet.
Hulsmans HM et al. Arthritis Rheum. 2000;43:1927-1940.
 Functional Decline Begins Early in RA

Very severe
Moderate loss Severe loss of loss of
of function* function* function*

0 2 5 10
Years from Symptom Onset
* 50% rates of loss of function based on HAQ scores

Wolfe F, Cathey MA. J Rheumatol. 1991;18:1298-1306.

 Critical window for treating RA

Radiographic progression occurs early and continues over

the lifetime of a patient

• Severe functional decline

Early

Disease • Radiographic damage

onset Established End stage
• Work disability
• Premature death
Critical
window of
opportunity

O’Dell JR. Arthritis Rheum 2002;46:283-285

Landewe RB. Et al. Arthritis Rheum.2002;46:347-356
Ann Rheum Dis 2004;63:627–633. doi: 10.1136/ard.2003.011395
Types of RA therapy currently available
Disease-modifying
Terapi simtomatik
therapies
• NSAIDs • Traditional DMARDs
• (COX-2) inhibitors • Biological agents
• Corticosteroids

Sifat Sifat

Tidak
menghentikan Mengurangi Mencegah Safety
Mengurangi Mengatasi
progresivitas progresivitas kerusakan
nyeri peradangan
dan kerusakan penyakit sendi lanjut issues
sendi

Gaffo A, et al. Am J Health Syst Pharm 2006; 63:2451–2465.

Treatment of RA: launch of the TNF inhibitors
DMARDs
1980s
Benefits
l First biologic agents for RA
l Substantial improvement of
signs/symptoms, disease
progression & quality of life
l Became the standard of care
after methotrexate
TNF inhibitors
• Etanercept (1998)
• Infliximab (2001)
• Adalimurab (2003)
2000s
Unmet needs
l Only 40% of patients achieve an
ACR50
l May be associated with serious
adverse events leading to
discontinuation
l Secondary loss of effect not
uncommon
 SUMMARY
• RA is the leading cause of chronic and
progressive disability
• Early diagnosis and treatment increases the
chances for succesful treatment
• The goal of treatment is remission, or
alternatively low disease activity.
THANK YOU

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