ARTRITIS REUMATOID

YULYANI WERDININGSIH,dr, SpPD-FINASIM

DIVISI REUMATOLOGI
KSM ILMU PENYAKIT DALAM FK-UNS/RSUD DR MOEWARDI
SURAKARTA
 Definisi ArtritisReumatoid
“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

Rheumatoid arthritis (RA) is a chronic inflammatory disease

characterized by joint swelling, joint tenderness, and destruction of
synovial joints, leading to severe disability and premature mortality
(EULAR 2010)

(The Arthritis Society, 2012; Gulanick & Myers, 2011; Firth, 2011)
 EPIDEMIOLOGY
 Prevalence ranges from 0.5% to 1% 
2.5 million Americans and 165 million people
worldwide
 Prevalence may be as high as 7% and as low as 0%
in different ethnic groups
 Up to 7% in certain American Indian tribes
 Virtually 0% in Asia and southern Africa
 Age of onset is typically between 35 and 50 years
 Female-to-male ratio is approximately 3:1
 Annual incidence ranges from 14.3 cases per
100,000 in men to 35.9 cases per 100,000 in women
Silman AJ, Pearson JE. Arthritis Res. 2002;4(suppl 3):S265–S272; CDC National Center for
Chronic Disease Prevention and Health Promotion. Available at:
http://cdc.gov/nccdphp/aag/aag_arthritis.htm;
Gabriel SE. Rheum Dis Clin North Am. 2001;27:269–281; Lawrence R, et al. Arthritis Rheum.
1998;41:778–799.
I.7
 MORBIDITY
 Increased morbidity for patients with RA
 Twice as likely to develop a myocardial infarction
(MI)
 70% more likely to suffer a stroke
 70% more likely to develop an infection
 Increased risk of lymphoma
 Up to 26-fold higher risk, depending on severity of
disease and exposure to immunosuppressive
drugs, including methotrexate
 Increased morbidity for women with RA
 2- to 3-fold increase in the risk of developing an MI
 48% higher risk of suffering a stroke

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 MORTALITY

 RA results in higher mortality rates

27% higher than in the general population
(41% higher for women)
Life expectancy in patients with RA is reduced
by as much as 18 years compared to age- and
sex-matched controls without RA

Brown SL, et al. Arthritis Rheum. 2002;46:3151–3158; Bjornadal L, et al. J Rheumatol.

2002;29:906–912;
Wolfe F, et al. J Rheumatol. 2003;30:36–40; Gabriel SE, et al. Arthritis Rheum. 2003;48:54–58;
Doran MF, et al. Arthritis Rheum. 2002;46:2287–2293; Asten P, et al. J Rheumatol. 1999;26:1705–
1714; Jones M, et al. Br J Rheumatol. 1996;35:738–745; Baecklund E, et al. BMJ. 1998;317:180–
181; Isomaki HA, et al. J Chronic Dis. 1978;31:691–696; Gridley G, et al. J Natl Cancer Inst.
1993;85:307–311; Thomas E, et al. Int J Cancer. 2000;88:497–502; Wolfe F, et al. Arthritis Rheum.
1994;37:481–494.
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 RA: Impact on Quality of Life
 RA has a negative impact on quality of life
 Pain associated with functional disability
 81% of patients suffer fatigue, 42% with severe
fatigue
 Up to 40% of patients suffer depression that impacts
personal and family life

 Loss of productivity in patients with RA is well known

 Average of 30 lost days of work per year
 Average earnings loss is 50%

Allaire SH, et al. PharmacoEconomics. 1994;6:513–522; Wolfe F, et al. J Rheumatol.

1996;23:1407–1417; Verhoeven AC, et al. Br J Rheumatol. 1998;37:612–619; Lard LR, et al. Am J
Med. 2001;111:446–451; Goldbach-Mansky R, Lipsky PE. Annu Rev Med. 2003;54:197–216.
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Sendi Normal
 SINOVIAL
Jaringan avaskular melapisi permukaan dalam kapsul
sendi, tidak melapisi permukaan rawan sendi.
Licin, lunak, berlipat-lipat  menyesuaikan diri setiap
gerakan sendi.
1-3 lapis sel sinovial tanpa dibatasi membrana bsalis.
Terdiri :
- tipe A : mirip Makrofag  fagosit debris
- tipe B : mirip fibroblas  produksi kolagen untuk
remodelling, sekresi hialuronat untuk lubrikasi sendi.
 PREDISPOSISI
 Genetik
 Gender
 Nullipara
 3 bulan setelah kehamilan
 Infeksi
 Proteus, Mycoplasma
 EBV, Parvo, HTLV-1
 Merokok
 Usia
 PATOGENESIS
 Hiperplasi sinovial
 Hiperselularitas
 Sel-sel inflamasi
 Efusi sendi
 Pannus: eksudat inflamatorik di luar lapisan sel
sinovial pada bagian dalam sendi
 Sifatnya menginvasi sel sinovial
 Mengerosi kartilago dan tulang
PATOGENESIS RA

Cytokine Signaling Pathways Involved in Inflammatory

Arthritis
Spectrum of AR
Onset
Mild Intermediate Severe

Pain Polysynovitis Systemic

Symptoms
Stiffness Functional manifestations
limitation
Fatigue Nodules
Extra-articular Secondary FM
manifestation Malaise Interstitial lung disease
Depression
s Fever Sjögren’s
Soft tissue Joint space
Disease Ankylosis
swelling narrowing
progression Deformity
Osteopenia Erosions
Impaired Disability Surgery
Morbidity & function Comorbidities Hospitalization
mortality
Pain RA Death
complications I.15
DISTRIBUTION OF AR
AR Tangan
Manifestasi Ekstraartikular
Konstitusional : letargi, anoreksia, BB turun, panas
ringan
Kulit : vaskulitis, lesi-lesi Ekimotik, nodula subkutan
Jantung : perikarditis, tamponade perikardium,lesi
peradangan pada miokardium dan katup
jantung.
Saluran nafas : Pleuritis dengan atau tanpa efusi
disfonia, fibrosis paru
Mata : Keratokonjungtivitis sikka ( Sjorgens ) skleritis
Sistem Syaraf: Neuropati perifer, Sindrom kompresi
perifer instabilitas vertebra, mono/multi neuritis
Sistemik: Anemia , Osteoporosis,
Sindrom felty, Sindrom sjorgen,
Amiloidosis
 Nodul Rheumatoid (15%)
 Nekrosis Sentral yang dikelilingi palisade
fibroblas dan limfosit
 Pada Bursa, Subcutan, dan menyelubungi
tendo
 Pada permukaan Extensor / titik tekanan
 Lengan bawah
 Tendo Achilles
 Area Ischial
 MTP
Vasculitis
 Mata
Tanda Sicca
Episcleritis
Scleritis
Scleromalacia
perforans
 Nodul
Pulmonal

Fibrosis Pulmonal
PEMERIKSAAN LABORATORIUM
RF + ---85%---buruk Cairan Sinovial
Anemia normositik viskositas turun
Trombositosis WBC naik
Eosinofilia protein naik
LED meningkat
CRP meningkat
Hipergamaglobulinemia
Hipokomplemenemia
 Lab. tanda Inflamasi
 Cairan Synovial – WBC > 2000/mm3
 Serum – Respon fase akut
 Fase protein akut
 CRP, ceruloplasmin, complement,
serum amyloid A, fibrinogen, alpha-1-
antitrypsin, haptoglobin, and ferritin
 APP negative = albumin, transferrin
 Lab– RF
 Rheumatoid Factor
 Antibody terhadap fragmen Fc dari Ig
 Tidak sensitive
 85% dari pasien RA
 Pasien dengan RF+ lebih sering karena :
 Penyakit keganasan yang lain
 Manifestasi Extraarticular
 RF tidak specifik untuk RA
 Terdapat pada penyakit autoimun yang
lain
 Sjogren’s syndrome , Systemic Lupus
 Infeksi kronis
 Hep B/C, SBE, Viral, Parasit, TB
 Peradangan paru-paru
 Sarcoid, Silicosis, Asbestosis
 Keganasan
 Terdapat pada usia muda 4 %; di atas 60
tahun 5-25%
 Antibodi lain pada RA :
 ANA ( anti nuclear antibodies )
 ANCA ( anti nuclear cytoplasmic
antibodies)
 Otoantibodi terhadap epitopsitrolin
 Otoantibodi terhadap HSP 73
 Otoantibodi terhadap E. Coli dna3
 Otoantibodi terhadap kartilago
 Anti-CCP
 Anti-cyclic citrullinated peptide
 Spesifitas = 90%
 Sensitivitas = 50-80%
 GAMBARAN RADIOLOGIK
 Osteoporosis periartikuler
 Radang periartikular
 Penyempitan ruang sendi
 OA sekunder, osteofit
 Erosi sendi
 Permukaan sendi rusak
 Dislokasi sendi
 Fusi sendi --- stadium lanjut
RA - imaging
Kriteria ACR 1987
1. Kaku sendi pagi hari
2. Artritis pada tiga atau lebih sendi
3. Artritis pada tangan
4. Artritis simetris
5. Nodul rematoid
6. Serum rematoid factor positif
7. Perubahan gambaran radiografik
Kriteria no 1-4 berlangsung selama 6 bulan
RA ditegakkan bila ditemukan minimal 4
Kriteria ACR-EULAR 2010
PENATALAKSANAAN
Edukasi
Terapi nonfarmakologis--- latihan/ program
rehabilitasi
Terapi farmakologis
Aspirin, NSAID, analgetik
DMARD : Metotreksat, Antimalaria, larutan
garam emas, Penisilamin.
steroid
Pembedahan : sinovectomy:
Lain-lain : terapi stem cell, terapi gen
 DMARDs ( Disease Modifying Anti
Rheumatic Drugs )

 Mengurangi/ mencegah kerusakan sendi

 Metotreksat ( MTX ), Sulfasalazin,
leflunomide, hidroksiklorokuin, siklosporin,
azatioprin, D Penicillamin, garam emas.
 Anti TNF-a ( etanercept, infliximab)
 Sifat slow acting --- setelah 1-6 bulan
Safety Considerations With Biologic DMARDs
 Serious infections

 Opportunistic infections (TB)

 Malignancies

 Demyelination

 Hematologic abnormalities

 Administration reactions

 Congestive heart failure

 Autoantibodies and lupus

PENILAIAN AKTIVITAS PENYAKIT (DAS-28)
Remission Criteria
 Prognose Buruk AR :
1. FR (+) dengan titer tinggi
2. Erosi sendi dini < 12 bulan
3. Gejala ekstra (+)
4. CRP/ LED terus menerus tinggi setelah
terapi DMARDs
5. HLA D4 (+)
6. Banyak sendi terlibat
7. Tingkat diksosek rendah
TERIMA KASIH