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 :