Tata Laksana

Komprehensif AR :
Rekomendasi yang
Terbaru
Yuliasih
Divisi Rematologi – Dep. SMF Ilmu Penyakit Dalam
FK Unair – RSU Dr. Soetomo Surabaya
 INTRODUCTION
1. Women
2. Autoimmune
3. Genetic
4. Environment
5. Systemic symptoms
6. High grade
inflammation
7. Polyarthritis
(PIP,MCP)
8. Specific deformities
A RA Mechanisms

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

Poly artritis simetric

Small joint arthritis

Fever & fatigue

 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 pada

kedua pergelangan tangan dan sendi kecil selama 5
bulan. Selama 5 bulan minum NSAID tidak kunjung
baik. Pada pemeriksaan fisik didapatkan artritis
pada pergelangan tangan MCP, PIP, tangan kanan
dan kiri, disertai gejala sub febris, nafsu makan
turun, berat badan turun dan sulit tidur.
• KU lemah, tekanan darah 170/100 mmhg, nadi
100x, suhu 37.5, RR 16x/mnt. Lain-lain dalam batas
normal.
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 :