Artritis Reumatoid

dr. Eka Kurniawan, SpPD

Subbagian Reumatologi
Bagian Ilmu Penyakit Dalam
FK Unand/RSUP dr. M. Djamil Padang
 Definisi

Penyakit Autoimun

Etiologi belum jelas

Sinovitis erosif simetris

Jaringan ekstraartikular dapat terlibat

 Manifestasi klasik :
sinovial sendi sendi kecil tangan dan kaki

Mengenai organ lain:

kulit, jantung, paru, mata

Destruksi sendi, deformitas, disabilitas

 What are joints?
Joint pain is an early symptom of Arthritis
The joint is the area where bones meet!
Synovial joints are responsible for movement

The joint is the area most commonly targeted by inflammation

(American Academy of Orthopaedic Surgeons, 2012; Day et al., 2010)

 Anatomy of the Joint

Articular/hyaline cartilage
-acts as a shock absorber
- allows for friction-free movement
- not innervated!
Synovial membrane/synovium
-secretes synovial fluid
-nourishes cartilage
-cushions the bones (Day et al., 2010; Cartilage Health, 2008)
Synovitis causes the
Erosions and Juxta
articular osteopenia

Pamela E. Prete MD
 What is the evidence for genetic
factors in Rheumatoid arthritis?
1970s association with
HLA DR4

But only certain alleles of

HLA DR4

All RA associated alleles

share an amino acid
sequence, located HLA
DRB1 gene

In all populations, RA
susceptibility is in the
shared epitope
Pamela E. Prete MD
 Rheumatoid arthritis Systemic
autoimmune / auto inflammatory
disease--
How does RA affect all
these organ systems ?

By causing
1. Synovitis
2. Serositis
3. Nodules
4. Vasculitis
5. Autoantibodies
Pamela E. Prete MD
A chronic autoimmune disease characterized by the inflammation of the synovial joints

Has a symmetrical bilateral effect on joints

Results in joint deformity and immobilization

Multiple factors increase ones risk

(The Arthritis Society, 2012; Gulanick & Myers, 2011; Firth, 2011)
Symptoms
Morning stiffness lasting
more than half an hour
Simultaneous symmetrical
joint swelling
Not relieved by rest
Fever
Weight loss
Fatigue
Anemia
Lymph node enlargement
Nodules
Raynauds phenomenon
(The Arthritis Society, 2012; Firth, 2011; Oliver, 2010; Day et al., 2010)
Diagnosis
 Skor > 6
Sendi yang terkena : bukti sinovitis secara
pencitraan
Tidak masuk kategori : DIP, CMC I, MTP I

Sendi besar : bahu, siku, lutut, pangkal paha,

pergelangan kaki
Sendi kecil : MCP, PIP, MTP II-IV, IP ibu jari,
pergelangan tangan
 Diagnosis banding
Spondiloartropati seronegatif

Artritis gout poliartikuler

LES

Artritis reaktif
 Diagnosis
No single test is specific to Rheumatoid Arthritis

CBC
Radiographs of involved joints
CT/MRI scans
Direct arthroscopy
Synovial/Fluid aspirate
Synovial membrane biopsy
Arthrocentesis

(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2012)

 Inflammatory Markers: ESR and
CRPTest

The level of CRP in the blood is normally low

Increasing amount
suggests inflammation

ESR rates for men: 0-15mm/hr

ESR rates for women: 0-20mm/hr

(Day et al., 2010)

 Antibody Tests:
Rheumatoid Factor Test and CCP
Other blood tests check for the presence of
antibodies that are not normally present in
the human body

(National Rheumatoid Arthritis Society, 2012; Day et al., 2010)

Direct arthroscopy

Benefits
Minimally invasive
Less tissue damage
Fewer complications
Reduced pain
Quicker recovery time
Outpatient basis
(American Academy of Orthopaedic Surgeons, 2012; Day et al., 2010)
 Synovial/Fluid aspirate
Synovial membrane biopsy
Arthrocentesis
Athrocentesis: synovial fluid is aspirated and analysed for inflammatory components

Abnormal synovial fluid: cloudy, milky, or dark yellow containing leukocytes

(Day et al., 2010)

 X-Ray

X-rays are an important diagnostic test for monitoring the disease progression

Patients may reveal NO changes on an X-ray in the early stages

(Gulanick & Myers, 2011; Day et al., 2010)

 Arthography
A radiopaque substance or air is injected
into the joint, which outlines soft tissue
structures surrounding the joint

http://www.youtube.com/watch?v=2 (Day et al, 2010)

YJsuDxxNJE&feature=related
 CT/MRI scans
Used for better visualization of soft tissue

MRI is particularly sensitive for the early and subtle features of RA

Can detect changes of Rheumatoid Arthritis prior to an X-Ray

(Radiopaedia, 2010; Dat et al., 2010)

 Pilar Pengobatan

Edukasi
Latihan/Program rehabilitasi
Pengobatan : DMARD, agen biologik, Steroid,
OAINS
Pembedahan
Edukasi :
1. Penjelasan penyakit
AR, perjalanannya, prognosis, pengobatan

2. Penjelasan diet / terapi komplementer

bukti nyata (-), saran : sayur, buah, ikan,
kurangi lemak/daging merah
 Exercise
Being overweight strains joints and leads to further inflammation

Walking
4 times a week for
Light jogging
30 minutes Water aerobics
Cycling
Yoga
Tai chi
stretching

(Arthritis Foundation, 2012)

Terapi fisik
Laser dan TENS : mengurangi nyeri jangka
pendek

Parafin/termoterapi dan latihan aktif

Terapi Psikologis

Relaksasi, mengatasi stres dan memperbaiki

pandangan hidup

(Walker, 2012; Gulanick & Myers, 2011; The Arthritis Society, 2011; Firth, 2011)
 Medications

There are four types of medications used to treat

RA:
Non-steroidal anti-inflammatory drugs
(NSAIDs)
Disease-modifying anti-rheumatic
drugs(DMARDS).
Corticosteroids
Biologic Response Modifiers (Bioligics)

(Arthritis Foundation, 2012; Gulanick & Myers 2011)

 Non-steroidal anti-inflammatory drugs (NSAIDs)
Examples General Use Side Effects Nursing
Considerations
Aspirin, ibuprofen, anti- Nausea Use cautiously in
naproxen, COX-2 inflammatory: Vomiting patients with hx of
inhibitors, propionic Used in the Diarrhea bleeding disorders
acid, phenylacetic acid management Constipation Encourage pt to
inflammatory Dizziness avoid concurrent
conditions Drowsiness use of alcohol
Antipyretic: Edema NSAIDs may
used to control Kidney failure decrease response
fever Liver failure to diuretics or
Analgesic: Prolonged antihypertensive
Control mild to bleeding therapy
moderate pain Ulcers

(The Arthritis Society, 2011; Day et al., 2010)

 Corticosteroids
Examples General Use Side Effects Nursing
Considerations
Cortisone, Used in the Increased Take medications
hydrocortisone, management appetite as directed
prednisone, inflammatory Weight gain (adrenal
betamethasone,dexa- conditions Water/salt suppression)
methasone When NSAIDS retention Used with caution
may be Increased blood in diabetic patients
contraindicate pressure Encourage diet
d Thinning of skin high in protein,
Promptly Depression calcium, potassium
improve Mood swings and low in sodium
symptoms of Muscle weakness and carbohydrates
RA Osteoporosis Discuss body
Delayed wound image
healing Discuss risk for
Onset/worsening infection
of diabetes

(The Arthritis Society, 2011; Day et al., 2010)

 Disease-modifying anti-rheumatic drugs(DMARDS)
Examples General Use Side Effects Nursing
Considerations
Methotrexate immunosuppressive Dizziness, May take several
(the gold activity drowsiness, weeks to months
standard) Reduce headache before they
, gold salts, inflammation of Pulmonary fibrosis become effective
cyclosporine, rheumatoid arthritis Pneumonitis Discuss
sulfasalazine, Slows down joint Anorexia teratogenicity,
azathioprine destruction Nausea should be taken off
Preserves joint Hepatotoxicity drug several
function Stomatitis months prior to
Infertility conception
Alopecia Discuss body
Skin ulceration image
Aplastic anemia
Thrombocytopenia
Leukopenia
Nephropathy
fever
photosensitivity

(The Arthritis Society, 2011; Day et al., 2010)

 Biologic Response Modifiers (Bioligics)
Examples General Use Side Effects Nursing
Considerations
Etanercept, anakinra, Used in the Increased appetite Take medications
abatacipt, management Weight gain as directed (adrenal
adalimumab, inflammatory Water/salt suppression)
Infliximab (Remicade) conditions retention Encourage diet
When NSAIDS Increased blood high in protein,
may be pressure calcium, potassium
contraindicated Thinning of skin and low in sodium
Promptly Depression and carbohydrates
improve Mood swings Discuss body
symptoms of RA Muscle weakness image
Osteoporosis Discuss risk for
Delayed wound infection
healing
Onset/worsening
of diabetes

(The Arthritis Society, 2011; Day et al., 2010)

 Pembedahan

Sinovitis refrakter terapi

Keterbatasan gerak
Nyeri terus menerus tidak terkendali obat
Kerusakan : ruptur tendon, kompresi saraf
 Synovectomy
Increases function of the joint
Decreases pain and inflammation
Beneficial as an early treatment option
Not a cure!

(Day et al., 2010; Sung-Jae, 2007)

 Braces/casts/splints
Support injured joints and weak muscles
Improve joint mobility and stability
Help to alleviate pain, swelling and muscle spasm
May prevent further damage and deformity

(Johns Hopkins Arthritis Center, 2012)

 Pemantauan Pengobatan
Evaluasi klinis dan biologis
DAS 28 atau Kriteria remisi ACR 1987

DAS 28
Nilai nyeri dan pembengkakan 28 sendi
LED , CRP , VAS
Kriteria remisi ACR 1987
 Peran Dokter Umum

Mengenali , mendiagnosis AR di awal penyakit

Kondisi tertentu : pengelolaan dapat dilakukan

dengan konsultasi konsultan reumatologi
First and foremost - inflammatory
arthritis symmetric

Pamela E. Prete MD
PIP Swelling
Ulnar Deviation, MCP Swelling,
Left Wrist Swelling
 Rheumatoid nodules?
Occur over extensor
tendons
Elbow most common
Firm nodule -0.3-1cm
Occur with disease
activity
Can occur anywhere
Have a characteristic
pathology

Pamela E. Prete MD
 Pamela E. Prete MD
Nodules
TERIMA KASIH