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Tata Laksana Komprehensif AR : Rekomendasi yang Terbaru Yuliasih Divisi Rematologi – Dep. SMF Ilmu Penyakit Dalam FK Unair – RSU Dr. Soetomo Surabaya

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  • Tata LaksanaKomprehensif AR : Rekomendasi yang

    Terbaru

    YuliasihDivisi Rematologi – Dep. SMF Ilmu Penyakit Dalam

    FK Unair – RSU Dr. Soetomo Surabaya

  • INTRODUCTION

    1. Women 2. Autoimmune 3. Genetic 4. Environment5. Systemic symptoms6. High grade

    inflammation7. Polyarthritis

    (PIP,MCP)8. Specific deformities

  • RA MechanismsA

    C

    B

  • Development Diseases RA

  • Clinical Manifestation

  • OUTCOME of RA

    • Need early diagnosis• Need early therapy

    Early referral

  • OUTCOME of RA

  • Screening RA

  • Pattern Joint Arthritis

    Rheumatoid Arthritis Psoriatic arthritis Ankylosing spondylitis Osteoarthritis

  • Clue of Diagnosis RA

    Small joint arthritis

    Fever & fatigue

    Poly artritis simetric

  • Poor prognostic factors

    • Moderate (after csDMARD therapy) to high disease activity according to composite measures

    • High acute phase reactant levels

    • High swollen joint counts

    • Presence of RF and/or ACPA, especially at high levels

    • Combinations of the above

    • Presence of early erosions

    • Failure of two or more csDMARDs

  • Treat-to-target strategy

    • Treat active RA in adults with the aim of achieving a target of remission or low disease activity if remission cannot be achieved (treat-to-target).

    • Consider making the target remission rather than low disease activity for people with an :• increased risk of radiological progression (presence of

    anti-CCP antibodies

    • erosions on X-ray at baseline assessment).

    • high C-reactive protein (CRP)

  • The task force endorsed 4 overarching principles for the recommendations:

    • Treatment must be based on a shared decision between the patient and the rheumatologist.

    • Treatment decisions are based on disease activity and other patient factors, such as progression of structural damage, comorbidities, and safety issues.

    • RA incurs high individual, medical, and societal costs, all of which should be considered in its management by the treating rheumatologist.

    • Rheumatologists are the specialists who should primarily care for patients with RA.

  • The EULAR steering committee and task force made the following recommendations for RA management:

    • DMARDs should be started as soon as possible

    • Treatment should be aimed at reaching a target of sustained remission

    • Monitoring every 1 to 3 months; if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months, therapy should be adjusted.

    • Methotrexate should be part of the first treatment.

    • patients intolerance to methotrexate should be considered leflunomide or sulfasalazine.

    • Short-term glucocorticoids should be considered when initiating or changing conventional synthetic DMARDs (csDMARDS) in different dose regimens and routes of administration but should be tapered as rapidly as clinically feasible.

  • DMARD nomenclature

  • EULAR GUIDELINES THERAPY of RA

  • EULAR GUIDELINES THERAPY of RA

  • EULAR GUIDELINES THERAPY of RA

  • Biologic Therapy

  • Bridging Therapy

    • Glucocorticoids used for a short period of time, intended to improve symptoms while waiting for the new DMARD to take effect (which can take 2 to 3 months).

    • Dose: ≤7.5 mg/day (prednisone equivalent)

  • When treating symptoms of RA with oral NSAIDs:

    • offer the lowest effective dose for the shortest possible time

    • offer a proton pump inhibitor (PPI), and

    • review risk factors for adverse events regularly. [2018]

  • Kasus

    • Wanita 27 tahun mengeluh nyeri dan bengkak padakedua pergelangan tangan dan sendi kecil selama 5 bulan. Selama 5 bulan minum NSAID tidak kunjungbaik. Pada pemeriksaan fisik didapatkan artritispada pergelangan tangan MCP, PIP, tangan kanandan kiri, disertai gejala sub febris, nafsu makanturun, berat badan turun dan sulit tidur.

    • KU lemah, tekanan darah 170/100 mmhg, nadi100x, suhu 37.5, RR 16x/mnt. Lain-lain dalam batasnormal.

  • Hasil Pemeriksaan GALS

    • Tenderness of:• Bilateral wrist joint

    (swelling)

    • Bilateral MCP joints

    • Bilateral PIP joints

    • Bilateral ankle joints

    • ROM is limited due to pain

  • Pemeriksaan Laboratorium

    • Hb 11.2 g/dl• WBC: 5.300• PLT : 279.000• Kreatinin : 0.8 mg/dl• SGPT : 49 U/L• SGOT : 31 U/L• CRP : 100 mg/l• RF : positif 400 unit/l• ANA (EF): positif 1/320 unit/ml• ACPA (anti CCP): positif 50 unit/ml

  • Therapy ?

    • DMARD :

    • Bridging therapy :

    • NSAID :

    • Biologic Therapy :