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doc.MUDr. Želmíra Macejová, PhD III. Internal clinic LF UPJŠ

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1 doc.MUDr. Želmíra Macejová, PhD III. Internal clinic LF UPJŠ
Rheumatoid arthritis doc.MUDr. Želmíra Macejová, PhD III. Internal clinic LF UPJŠ

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

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

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


6 Clinical features pain and stiffness in the small joints of the hand and 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

7 Sings Swelling Warmth Tenderness Deformities Nodules Involvement of joints is symmetrical


9 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

10 Laboratory findings RF ( Latex, ELISA) – seropositivity : anaemia
trombocytosis CRP, ESR gamaglobulins, alfa2globulins Synovial fluid: aseptic


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

13 Treatment NSA DMARDs Biologic treatment

14 NSA Fosfolipidy cell membranes fosfolipase inhibition by
corticosteroids Arachidonic acid cyklooxygenase inhibition by NSA Endoperoxids tromboxane B PGE PG2F prostacykline

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

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

17 Most common combination: metotrexate +sulfasalazine
DMARDs: combination Most common combination: metotrexate +sulfasalazine metotrexate+antimalarics metotrexate+cyklosporine Possible combination: NSA, DMARDs, corticosteroids synergic effect lower doses less AE remission of disease

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

19 Biological treatment Rapid effect Strong effect AE: Activation of TBC
Anticytokine treatment Anti - TNF alfa: infliximab,adalimumab,etanercept Anti - IL-1: anakinra Anti - CD20 B-lymfocyt: rituximab Many others on clinical trials Rapid effect Strong effect AE: Activation of TBC







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