Rheumatoid arthritis doc MUDr elmra Macejov Ph D

Rheumatoid arthritis doc. MUDr. Želmíra Macejová, Ph. D III. Internal clinic LF UPJŠ

Rheumatoid arthritis n n n n Chronic systemic disease Prevalence 1% More common in women, women: men 3: 1 autoimuniy disease- production of rheumatoid factor – antibody agains human Ig. G synovitis, deformity, destraction, instability, subluxatio symetrical involvement of periferial joints possibility of involvement of all joints in the body

Chronical disease Clinical features: general: n Fatigue, general malaise, subfebrility, weight loss, depression local: n arthralgia, myalgia, morning stiffness, joint pain, n Pain is the worst in the morning: PIP, MCP, wrist, MTP - symmetrical

Pathogenesis of RA unknown n Multifactorial: genetic: associátion with specific type of n HLA (HLA DR-4) pro-inflammatory cytokines: TNF alfa, IL-17, IL-1, IL-6 hormonal factors: prolactine, lack of testosterone

Clinical features pain and stiffness in the small joints of the hand feet, chronic bilateral symmetrical peripherial polyarthritis involvement of all joints in the body: knees, wrists, elbows, etc. Symptoms: Joint pain Morning stiffness: several hours (more than one hour) General symptoms: fatigue, general malaise Disability Non-articular symptoms n

Sings Swelling Warmth Tenderness Deformities Nodules Involvement of joints is symmetrical

Diagnostic criteria of RA 1. Morning stiffness (more than 1 hour) 2. Arthritis of three and more joints 3. Arthritis of hand joints (PIP, MCP, wrist) 4. Symetrical arthritis 5. Rheumatoid nodules 6. Rheumatoid facktor 7. X-ray changes

Laboratory findings RF ( Latex, ELISA) – seropositivity n : anaemia trombocytosis n CRP, ESR n gamaglobulins, alfa 2 globulins n Synovial fluid: aseptic n

Steinbrocker – X-ray classification I. st: periartikular osteoporosis II. st: destruction, loss of joint space, erosions, cysts III. st. : + subluxation IV. st. : ankylosis

Treatment NSA n DMARDs n Biologic treatment n

NSA Fosfolipidy cell membranes fosfolipase inhibition by corticosteroids Arachidonic acid cyklooxygenase inhibition by NSA Endoperoxids tromboxane B 2 PGE 2 PG 2 F 2 prostacykline

NSA n Cyklooxigenase: NSA clasification I. COX-1 : fyziological effect (stomach, colon, kidney, Trc) COX-2: inflammation Inhibition of both isoforms: COX-1 a COX-2 II. Most inhibition of COX-2 III. Selective inhibition of COX-2

DMARDs: disease modifying antirheumatic drugs n n n Antimalarics Methotrexate Sulfasalazine Gold Leflunomide Imunosupressive drugs: cyklosporine cyklofosfamide

DMARDs: combination Most common combination: n metotrexate +sulfasalazine rics rine n metotrexate+antimala metotrexate+cyklospo Possible combination: NSA, DMARDs, corticosteroids synergic effect lower doses less AE remission of disease

Corticosteroid drugs n p. o. n Rapid effect n i. a. n n i. m. Strong antiinflammatory effect n Analgetic effekt n AE, SAE !! n n i. v. lokálne

Biological treatment n n n Anticytokine treatment Anti - TNF alfa: infliximab, adalimumab, etane rcept Anti - IL-1: anakinra Anti - CD 20 B-lymfocyt: rituximab Many others on clinical trials n n Rapid effect Strong effect AE: n Activation of TBC n