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TRANSCRIPT
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Tata LaksanaKomprehensif AR : Rekomendasi yang
Terbaru
YuliasihDivisi Rematologi – Dep. SMF Ilmu Penyakit Dalam
FK Unair – RSU Dr. Soetomo Surabaya
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INTRODUCTION
1. Women 2. Autoimmune 3. Genetic 4. Environment5. Systemic symptoms6. High grade
inflammation7. Polyarthritis
(PIP,MCP)8. Specific deformities
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RA MechanismsA
C
B
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Development Diseases RA
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Clinical Manifestation
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OUTCOME of RA
• Need early diagnosis• Need early therapy
Early referral
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OUTCOME of RA
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Screening RA
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Pattern Joint Arthritis
Rheumatoid Arthritis Psoriatic arthritis Ankylosing spondylitis Osteoarthritis
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Clue of Diagnosis RA
Small joint arthritis
Fever & fatigue
Poly artritis simetric
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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
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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)
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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.
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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.
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DMARD nomenclature
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EULAR GUIDELINES THERAPY of RA
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EULAR GUIDELINES THERAPY of RA
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EULAR GUIDELINES THERAPY of RA
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Biologic Therapy
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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)
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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]
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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.
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Hasil Pemeriksaan GALS
• Tenderness of:• Bilateral wrist joint
(swelling)
• Bilateral MCP joints
• Bilateral PIP joints
• Bilateral ankle joints
• ROM is limited due to pain
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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
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Therapy ?
• DMARD :
• Bridging therapy :
• NSAID :
• Biologic Therapy :