内科学课件33-新版英文RA教学幻灯(应用)AA

,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,Click to edit Master title style,RHEUMATOID ARTHRITIS (RA),RHEUMATOID ARTHRITIS (RA),What is Rheumatoid Arthritis (RA) ?,What is Rheumatoid Arthritis (,Clinical Picture,Clinical Picture,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,What happened on these joints?,What happened on these joints,Pathology,Pathology,Pathology,Synovitis: Infiltrates of inflammatory cells,Angiogenesis,Synovial cell proliferations,Formation of,Pannus,Destruction of cartilage and Subchondral bone,Narrowing of joint space and bone erosion,PathologySynovitis: Infiltrat,早中期,X,光表现,早中期X光表现,进展期,X,光表现,进展期X光表现,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,erosion,erosion,Joints frequently involved,Important clue for differential diagnosis,for,Ankylosing Spondylitis ( AS ) and Osteoarthritis,Joints frequently involvedImpo,内科学课件33-新版英文RA教学幻灯(应用)AA,Nature of RA,Systemic autoimmune,connective tissue disease,Nature of RASystemic autoimmun,Extra-articular Manifestations,Extra-articular Manifestations,Subcutaneous nodules with muscle atrophy,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,ischemic necrosis due to vasculitis,ischemic necrosis due to vascu,内科学课件33-新版英文RA教学幻灯(应用)AA,内科学课件33-新版英文RA教学幻灯(应用)AA,Neurovascular Disease,Neurovascular Disease,内科学课件33-新版英文RA教学幻灯(应用)AA,Diffuse interstitial lung fibrosis,Diffuse interstitial lung,内科学课件33-新版英文RA教学幻灯(应用)AA,Felty Syndrome:,Splenomegaly, lymphadenopathy,anemia, Bpc,WBC, RF positive,Felty Syndrome:,Rheumatoid Factor,RF are now defined as antibodies specific to,antigenic determinants on the Fc fragments of,human or animal immunoglobulin.,Seropositivity of patients with RA or with other,disease is usually defined by the latex fixation test,or red cell agglutination tests. These assays,reflect the presence of IgM Rheumatoid factors,(IgM-RFs). The presence of RF is not unique to RA,and a positive RF should not be used as the sole,criterion for the diagnosis of RA.,Rheumatoid Factor RF are,Occurrence of RF in various Disease,IgM-RF positive IgM-RF negative,Rheumatoid Arthritis Osteoarthritis,Other rheumatic Diseases Ankylosing Spondylitis,Sjogren*s Syndrome Gout,SLE, PSS, PM Psoriatic arthritis,Infections Diseases,SBE,TB,Non-infections Disease,Normal individuals (Aged),Chronic active hepatitis,Diffuse Interstitial pulmonary fibrosis,Occurrence of RF in various Di,Diagnosis,Diagnosis,Proposed 1987 Revised ARA criteria for RA,1. Morning stiffness for at least one hour and,Present for at least six weeks,2. Swelling of three or more joint6 weeks,3. Swelling of wrist, MCP or PIP joints6 weeks,4. Symmetric Joint swelling,5. Hand X-ray changes typical,of RA that must include erosions or,unequivocal bony decalcification,6. Rheumatoid nodules,7. Serum RF positive,Four or more criteria must be present to diagnose RA,Proposed 1987 Revised ARA cri,Key points,Small joints especially hands and wrists are more often involved,Symmetrical or bilateral distribution,Chronic in duration,Erosive in X ray film,deformity,Morning stiffness in chief complain,Key points Small joints especi,Lab Findings in RA,Hb : Moderate normochromic, normocytic anemia,WBC: Normal or slightly elevated,Leukopenia rare ( Felty Syn. ),Acute-phase Reactants:,ESR and C-Reactive Protein (CRP) are increased,Immune Factors,ANA Present in 15%,RF Present in 70%,Complement Normal or slightly elevated,Lab Findings in RAHb : Mod,Differential Diagnosis,Osteoarthritis,Ankylosing Spondylitis ( AS ),SLE,Differential DiagnosisOsteoart,Managements,Managements,Objective of treatment,1. relief of pain,2. reduction or suppression of inflammation,3. minimizing undesirable effects,4. preservation of muscle and joint function,5. return to a desirable and productive life,Objective of treatment 1. rel,Medical Therapy,1.,Non-steroid Anti-inflammatory Drugs ( NSAIDs ),Medical Therapy1. Non-steroi,Mechanism of action for NSAIDs,Inhibition of Prostaglandin Production,Mechanism of action for NSAIDs,Adverse effects of NSAIDs,a.,Gastrointestinal effects,b. Hepatic effects,c. Renal effects,d. others: skin rash,Adverse effects of NSAIDs a. G,COX-1/COX-2 Theory,COX-1,Constitutive,Homeostatic functions,GI tract,Renal function,Platelet function,COX-2,Regulated,Inflammation,COX-1/COX-2 TheoryCOX-1COX-2,The advantage of selective COX-2 inhibition,NSAIDs with a good GI side effect profile have been,shown to have lower ratios of COX-2/COX-1 inhibition,Newly designed selective COX-2 inhibitors have,significantly fewer GI side effects compared with traditional,NSAIDs,The advantage of selective,2. Disease - Modifying Anti-rheumatic,Drugs ( DMARDs),Features of DMARDs:,a. Modifying the progression of RA,b. Slow acting,c. More adverse effects,2. Disease - Modifying Anti-rh,Disease-Modified Anti-rheumatic Drugs ( DMARDs),Drug Major adverse reaction,Methotrexate,(MTX),Hepatic fibrosis, Nausea,Cytopenia,Anti-malanial (CQ & HCQ) Visual disturbance,Leflunomide,(LEF),Hepatic damage,Sulfasalazine (SASP) GI irritation, rashes,雷公藤多甙,Leukocytopenia and hepatic toxicity,Disease-Modified Anti-rheuma,Principles for DMARDs therapy,1. early use,2. combination therapy,Principles for DMARDs therapy,Common combination therapy,MTX+CQ(HCQ),MTX+SASP,MTX+LEF,Common combination therapyMTX+,Corticosteroids,usually low dose (below 10mg/day),combined with DMARDs,Indications for Large doses:,Rheumatoid vasculitis,Felty Syndrome,High fever (Systemic Onset),Corticosteroidsusually low do,Biological agents,Anti-TNF preparations,Infleximab and Etanercept,Biological agentsAnti-TNF pre,Surgical intervention,Synovectomy,Joint replacement,Surgical intervention Synovect,内科学课件33-新版英文RA教学幻灯(应用)AA,PRINCIPLE OF THERAPY,Individualized protocol,Risk/benefit evaluation,Patient eduacation,PRINCIPLE OF THERAPYIndividual,Comprehension questions,female, 30 years old , joint pain with low fever for two months, RF (+),diagnosis : RA ?,Choice: yes ,no, uncertain,Comprehension questionsfemale,Thank you,Thank you,