poliartrita reumatoida petras final

7/26/2019 Poliartrita Reumatoida Petras Final

1/166

Universitatea de Medicin i Farmacie Victor Babe Timi oara

Facultatea de Medicin General

Specializarea Medicin General

LUCRARE DE LICEN


2/166

Coordonator tiin ific:

Prof Univ !r Mi"ai !r#oi

Candidat:

Petra $lin % &u#en

T'M' ($)$


3/166

*+,-

1


4/166

Universitatea de Medicin i Farmacie Victor Babe Timi oara

Facultatea de Medicin General

Specializarea Medicin General

TERAPII MODERNE


5/166

N REUMATISMUL INFLAMATOR

Coordonator tiin ific:

Prof Univ !r Mi"ai !r#oi

Candidat:

Petra $lin.&u#en

T'M' ($)$

*+,-


6/166

2


7/166

/uprins

Cuprins3

List a!r"#i"ri 4

PARTEA $ENERAL 6

I% Dat" d" anato&i" i !io&"canic 6

i% D"'"t"(" i po(ic"(" 7

ii% Articu(a ia radiocu!itocarpian )RCC* 7

iii% Articu(a ii(" carpo&"tacarpi"n" )CMC* 7

i#% Articu(a ii(" &"tacarpofa(an'i"n" )MCF* 8

#% Articu(a ii(" int"rfa(an'i"n" pro+i&a(" )IFP* i int"rfa(an'i"n" dista(" )IFD* 8

#i% ,ascu(ari-a i" i in"r#a i" 8

II% D"fini i" i "tiopato'"ni" 9

III% Ta!(ou c(inic 11

I,% Anato&i" pato(o'ic 14


8/166

,% Manif"stri "+traarticu(ar" 14

,I% Dia'nostic 19

,II% Dia'nostic dif"r"n ia( 20

,III% Trata&"ntu( po(iartrit"i r"u&atoid" 21

I. E#o(u i" i co&p(ica ii 24

PARTEA SPECIAL 25

Introduc"r" 25

Stadia(i-ar"a ACR a !o(ii 27

Moti#a i" i scop 28

Mat"ria( i &"tod 29

R"-u(tat" 41

Discu ii 53

Conc(u-ii 55

/i!(io'rafi" 57


9/166

3


10/166

0ist abrevieri

ACR 0 A&"rican Co(("'" of R1"u&ato(o'2 ADL 0Acti#it"s of Dai(2 Li#in'

AINS 0 Antiinf(a&ator n"st"roidian CRP 0 Prot"ina CR"acti#

CCR 0 C"ntru( d" C"rc"tar" 3n R"u&ato(o'i" CT 0Co&put"r To&o'raf

CO. 4 Cic(oo+i'"na-a

CDAI 0 Cro1ns Dis"as" Acti#it2 Ind"+ DAS 0 Dis"as"Acti#it2 Scor"

DMARD 0 Dis"as" Modif2in' Antir"u&atic Dru' E54

6D 0 7"a(t1 R"a(t"d 5ua(it2 of Lif"

EULAR 0 T1" Europ"an L"a'u" A'ainst R1"u&atis&FR 0 Factor R"u&atoid

7ACA 0 7u&an Anti4C1i&"ric Anti!odi"s 7A5 0 7"a(t1Ass"s&"nt 5u"stionnar" IFP 0 Int"rfa(an'i"n" pro+i&a("


11/166

IFD 0 Int"rfa(an'i"n" dista(" IL 4 Int"r("u8in

LDA 0 Lo9 Dis"as" Acti#it2

LES 0 Lupus Erit"&atos Sist"&ic

MAP 0 8ina-" 0 Mito'"n Acti#at"d Prot"in8ina-" MT.4 M"t1otr"+at

4


12/166

MCF 4 M"tacarpofa(an'i"n"

PE, 0 P"rfu-i" Intra#"noas

PR 0 Po(iartrit R"u&atoid

RAA 0 R"u&atis& Articu(ar Acut

RCC 4 Radiocu!itocarpian

RMN 0 R"-onan Ma'n"tic Nuc("ar

TACE 0 TNF 0 a(p1a Con#"rtin' En-2&" TNF 0Tu&or N"crosis Factor

SMARD 0 Si&pto& Mod2fin' R"u&atic Anti Dru's,AS 0 ,isua( Ana(o' Sca("

,E$F 0 ,ascu(ar Endot"(ia( $ro9t1 Factor


13/166


14/166

5


15/166

P$)T&$ G&1&)$02

' !ate de anatomie i biomecanic

!ate anatomice 3oase4 mu c"i4 tendoane5

Mna; principa(u( or'an a( &anipu(rii; r"pr"-int o structur co&p("+; &o!i(; adaptatfunc iona( p"ntru a r"a(i-a &i cri d" prind"r" i apucar"; und" part"a radia( a &inii r"a(i-"a- prind"r"a s(a! 3ntr" d"'"tu( &ar" i arttor ;iar part"a u(nar a &inii;r"a(i-"a-prind"r"a put"rnic 3ntr" d"'"t" i pa(& %

Sc"eletul d" !a- a( &inii;"st" a(ctuit dintr4un nu&r d" ?@ d" oas" ;dispus" in tr"i 'rup":

/arpul: for&at din oas"(" carpi"n"; dispus" p" ? rnduri

Pri&u( rnd; d" (a po(ic" spr" d"'"tu( &ic s" 'as"sc oas": scafoidu(; s"&i(unaru(;pira&ida(u( si pisifor&u(% A( ?4("a rnd cuprind": trap"-u(; trap"-oidu(; capita(u( i osu( cucr(i'%

Metacarpul:a(ctui" t" sc1"("tu( pa(&"i i a( dosu(ui &inii; for&at din cincioas"&"tacarpi"n"; nu&"rotar"a (or fcndu4s" 3n s"ns radio4u(nar d" (a I (a ,%

(asele de#etelor6 sunt 3n nu&r d" cinci: po(ic" )Po(("+*; indic" )Ind"+*;&"diu )Di'itus&"dius*; in"(ar )Di'itus anu(aris* i &ic )Di'itus &ini&us*)

Fi'ura% =* %


16/166

Fi'%=% ,"d"r" ant"rioarpost"rioar a articu(a ii(or &inii

6


17/166

Musculatura i tendoanele

Muscu(atura &inii "st" 3&pr it 3n dou 'rup": intrins"c i "+trins"c% Mu c1ii intrins"ci sau f("+ori; sunt (oca(i-a i 3n int"rioru( &inii; iar c"i "+trins"ci sau "+t"nsori sunt (oca(i-a i pro+i&a( (a ni#"(u( ant"!ra u(ui i s" ins"r (a ni#"(u( sc1"("tu(ui &inii prin t"ndoan" (un'i%

Tendoanele

Sunt structuri no!i(" c" fac ("'tura dintr" &u c1i i oas"; cu autoru( crora contrac ia &uscu(ar s" transfor& 3n &i car"a s"'&"nt"(or anato&ic"% Mna "st" s"'&"ntu( anato&iccu c"(" &ai &u(t" t"ndoan"; "(" fiind dir"ct i&p(icat" 3n &i car"a d"'"t"(or %Fi"car" t"ndon

ar" an"+at o t"ac; ac"asta a#nd ro(u( d" a u ura a(un"car"a%

!e#etele i policele

Po(ic"(" sau d"'"tu( &ar"; "st" situat p" part"a "+t"rn a &inii; ac"sta s" poat" roti (a GH p"p(an p"rp"ndicu(ar cu pa(&a; fa d" c"("(a(t" d"'"t" ; car" s" pot roti doar 6H%E( "st" ac ionat d" nou &u c1i; datorit crora r"u " t" s s" opun c"(or(a(t" d"'"t"; c""a c" p"r&it" o

&i car" d" p"nsar"; "s"n ia(a p"ntru pr"1"nsiun" )apucar"* %

$rticula ia radiocubitocarpian 3)//5

Articu(a ia radiocu!itocarpian sau articu(a ia pu&nu(ui; "st" o articu(a i" "(ipsoid car" ("a' radiusu( d" u(n i rndu( pro+i&a( d" oas" carpi"n"%

Mi car"a pu&nu(ui p"r&it" o f("+i" p(antar d" apro+i&ati# GH 4GH ; o "+t"nsi" sau f("+i"dorsa( d" @GH4GH;3nc(inar" u(nar d" GH46GH ;3nc(inar" radia( d" =6H4?GH i circu&duc i" %

$rticula iile carpometacarpiene 3/M/5


18/166

Datorit po-iJi"i anato&ic" dif"rit" a articu(aJi"i carpo&"tacarpi"n" a po(ic"(ui; 3n co&paraJi"cu c"(" a(" d"'"t"(or II ;III;I,;,; #o& trata s"parat :

Articulaia carpometacarpian a policelui0car" "st" o articu(aJi" sino#ia(s"(ar; fiinda(ctuit din suprafaJa articu(ar a trap"-u(ui Ki pri&u( &"tacarpian%

Articulaiile carpometacarpiene ale celorlalte degete0 car" sunt articu(aJiisino#ia(" p(an";a#nd ca i supraf"J" articu(ar" ur&toar"(" co&pon"nt" :

M"tacarpianu( II cu trap"-u(;trap"-oidu( Ki osu( capitat

7


19/166

%

M"tacarpianu( III cu osu( capitat

M"tacarpianu( I, cu osu( capitat Ki osu( cu cr(i'

M"tacarpianu( , cu osu( cu cr(i'

$rticula iile metacarpofalan#iene 3M/F5

Articu(aJii(" &"tacarpofa(an'i"n" sunt r"a(i-at" d" "+tr"&itaJi(" dista(" a(" &"tacarpi"n"(or si"+tr"&itaJi(" pro+i&a(" a(" fa(an'"(or%

Ac"st"a p"r&it 'rad" &ari d" f("+i" i "+t"nsi"; dar 'rad" #aria!i(" d" a!ducJi" Ki adducJi";d"#iaJi" radia( Ki d"#iaJi" u(nar% Astf"(; "(" r"a(i-"a- GH4=GGH d" f("+i" Ki BGH d" "+t"nsi"

%

$rticula iile interfalan#iene pro7imale 3'FP5 i interfalan#iene distale 3'F!5

Sunt articu(aJii(" proprii a(" d"'"t"(or% D"'"t"(" pr"-int ct" dou articu(aJii: una pro+i&a()3ntr" capu( pri&"i fa(an'" i !a-a c"("i d"4a doua* i una dista( )3ntr" capu( c"("i d"4a doua fa(an'" i !a-a fa(an'"i tr"i*% D" (a ac"ast r"'u( fac" "+c"p i" po(ic"("; car" pr"-int doar o

sin'ur articu(a i"

Articu(a ii(" IFP p"r&it GH d" f("+i" si GH d" "+t"nsi"; iar articu(a ii(" IFD p"r&it nu&ai BGH d" f("+i" i GH d" "+t"nsi"%

Vasculariza ie i inerva ie


20/166

,ascu(ari-a ia &inii s" r"a(i-"a- prin int"r&"diu( art"r"(or radia(" si u(nar"; ra&uri dinart"ra !ra1ia(%

,"n"(" s" 'rup"a- 3n:

,"n" sup"rficia(": s" af( su!cutanat; nu 3nso "sc art"r"(" i s" anasto&o-"a- cu #"n"(" profund"; a#nd ori'in"a (a ni#"(u( d"'"t"(or 3n #"n"(" di'ita(" pa(&ar"

,"n"(" profund": profund" sunt du!("; 3nso "sc art"r"("; a#nd trai"ct" i raporturi id"ntic" cu #"n"(" p" car" (" 3nso "sc

1ervii ac"st"i r"'iuni sunt 3n nu&r d" tr"i;nervul median;nervul ulnar i nervul

radial;fi"car" dintr" ac" tia pr"-"ntnd co&pon"nt"s"nsiti#" i &otorii )Figura 2*


21/166

Fi#ura * In"r#a ia cutanat a &inii i carpu(ui

'' !efini ie i etiopato#enie


22/166

Po(iartrit r"u&atoid "st" o !oa( inf(a&atori" sist"&ic cronic; d" "tio(o'i" n""(ucidat ipato(o'i" autoi&un; cu caract"r pro'r"si#; distructi# i d"for&ant; caract"ri-at c(inic prinartrit (a &ai &u(t" articu(a ii dar i &anif"stri c(inic" sist"&ic"


23/166

distru'"r"a carti(au(ui d" ctr" sino#ita pro(if"rati# s d"t"r&in" apari ia ac"stor anticorpi

defect in func ionalitatea aparatului imun

Proc"su( 3nc"p" cu o sino#it inf(a&ator4"+udati# c" pro'r"s"a- spr" o for& pro(if"rati#si infi(trati#% La pro'r"sia !o(ii concur"a- o s"ri" d" c"(u(" i d" sist"&" !io(o'ic" u&ora("

:

C"(u("("; (oca(i-at" &ai a("s 3n sino#ia(; contri!ui" 3n &od principa( (a "#"ni&"nt"("inf(a&atoar" articu(ar" acut" i cronic" i anu&": c"(u(" sino#ia(" &acrofa'ic" C"(u("(" sino#ia(" fi!ro!(astic" Li&focit" L"ucocit" po(i&orfonuc("ar" purttoar" d" "n-i&"prot"o(itic" c" pot aun'" in ca#itat"a articu(ar C"(u(" "ndot"(ia(" #ascu(ar" car" 3n ti&pu(inf(a&a i"i s" 3n&u( "sc i &i'r"a- for&nd o r" "a d" n"o#ascu(ari-a i"%

Sist"&"(" !io(o'ic" u&ora(" an'aat" in di#"rs" &o&"nt" a(" "#o(u i"i !o(ii 3 i au ori'in"a in c"(u("(" pr"-"nt" in articu(a i" in star" d" acti#itat" sau pro#in din sn'" prin "+udar":

Sist"&u( co&p("&"ntu(ui car" poat" fi acti#at intraarticu(ar p" ca(" c(asic sau d" prot"ina Cr"acti# car" s" 's" t" (a titruri ridicat" 3n (ic1idu( sino#ia(

Produ ii acidu(ui ara1idonic )("ucotri"n" si prosta'(andin"* E("&"nt"(" sist"&u(ui coa'u(riii fi!rino(i-"i Su!stan " intrac"(u(ar" "(i!"rat" 3n &"diu d" di#"rs" c"(u(" prot"ina-";

i&uno'(o!u(in"; di#"r i factori d" sti&u(ar" a pro(if"rrii si cr" t"rii

c"(u(ar"%

n pato'"nia PR "st" 'r"u d" d"finit o succ"siun" ri'uroas a "#"ni&"nt"(or% E#"ni&"nt"(" s"d"sfasoar 3n dou p(anuri: 3n structura sino#ia("i si 3n ca#itat"a articu(ar; 3ntr" c"(" douco&parti&"nt" "+istnd &u(tip(" inf(u"n " r"ciproc"%


24/166

Sc1"&atic 3n suf"rin a articu(ar din po(iartrita r"u&atoida s" d"os"!"sc tr"i &o&"nt""#o(uti#": sino#ita inf(a&atori"; distruc ia carti(au(ui i fi!ro-a%

n pri&"(" &o&"nt" d" sino#it inf(a&atori" s" produc" o ("-ar" &ini&a( a c"(u("(or"ndot"(ia(" cu "d"& cons"cuti# i cu infi(trar" d" c"(u(" apoi au (oc fi" a'(o&"rri fo(icu(ar";fi" difu-ri c"(u(ar" p"ri#ascu(ar" &ai a("s in uru( #"nu("(or postcapi(ar" %

S" d"c(an "a-a un proc"s d" an'io'"n"-% Sino#iocit"(" 3nc"p s s" 3n&u( "asca n"contro(at%

n &od nor&a( ac"st" c"(u(" sunt dispus" in =4? straturi% n PR apar 3n c"( pu in B46 straturi

10


25/166

car" prin; pro(if"rri u(t"rioar"; dau na t"r" (a &icro i &acro4#i(o-it i% F"no&"nu( s" p"tr"c" att (a suprafa a ct i 3n 'rosi&"a sino#ia("i% Ac"ast 3n&u( ir" n"contro(at poat" fi fa#ori-at i d" faptu( c sino#ia(a "st" (ipsit d" &"&!rana !a-a(; structura 1isto(o'ic

dotat cu propri"tat"a d" a contro(a pro(if"rri(" c"(u("(or supraiac"nt"% n p(us (ipsa&"&!ran"i !a-a(" u ur"a- difu-iun"a produs"(or !io(o'ic acti#" dar i a &"dica&"nt"(or 3n spa iu( articu(ar% "sutu( sino#ia( 1ip"rtrofiat; a&p(u #ascu(ari-at; poart nu&"(" d" panus articu(ar; putnd cntri d" =GG ori 'r"utat"a &as"i ori'inar" %E( in#ad"a- articu(a ia d"(a p"rif"ri"; pri&"(" ("-iuni aprnd (a onc iun"a osu(ui cu carti(au(% Panusu( articu(ar; princr" t"r"a (ui; af"ct"a- carti(au( i osu( su!condra(; capsu(a i (i'a&"nt"(" i &ai rar t"ci(" t"ndinoas" i !urs"("%

La distruc ii(" carti(a'inoas" &ai contri!ui" i "n-i&"(" d" d"'radar; "(i!"rat" d" condrocit" "(i!"rat" 3n ca#itat"a articu(ar pr"cu& i s"cr" ii(" tuturor c"(u("(or i&p(icat" 3n PR%

n "#o(u ia tr-i" a suf"rin "i; s" for&"a- un "sut fi!ros; ur&ar" a acti#it ii "+c"si#" a fi!ro!(a ti(or su! sti&u(ar" &acrofa'ic% Mi cri(" articu(ar" sunt (i&itat" din c" 3n c" &ai &u(t; ducnd (a s"&ianc1i(o-a sau (a anc1i(o-a tota(; &ai a("s atunci cand s4au for&atad"-iuni fi!roas" c" au suf"rit ca(cificri %

''' Tablou clinic

D"!utu( po(iartrit"i r"u&atoid" s" produc" (a #rst" tin"r" )d"cad"(" B46*; dar nu "st" "+c(usd"!utu( (a oric" #rst% n ca-u( 3n car" PR 3nc"p" dup 6 for&"(" s"ron"'ati#" sunt &aifr"c#"nt" i &anif"stri(" "+tra4articu(ar" sunt rar" %

P)poat" d"!uta 3n &ai &u(t" f"(uri

!ebut insidios (a G46 dinca-uri; fa#ori-at d" str"s"&o iona(; "+pund"r" (a fri';trau&atis&"; inf"c ii


26/166

!ebut acut sau subacut (a =64?G din ca-uri;caract"ri-at

prin dur"ri i tu&"fac ii articu(ar"; d" o!ic"i asi&"tric"

11


27/166

Af"ctar"a articu(ar )tip inf(a&ator* :

Durerea i redoarea matinal : "st" produs d" acu&u(ar" d" (ic1id sino#ia( din ti&pu(so&nu(ui i "d"&

Tumefac ia i cldura local : datorat &odifiri(or anato&o4pato(o'ic": "d"&; infi(tratinf(a&ator; cr" t"r"a cantit ii d" (ic1id sino#ia(; pro(if"rar" sino#ia(

Lezarea func ional apar" tr"ptat

Caract"ristici i&portant" a(" af"ctrii articu(ar":

Simetria

Aditivitatea0 pr"-int o &ani"r c"ntrip"d )&ini Q coat" Q u&"ri*

Evolutivitatea0 "#o(u"a- cronic spr" "ro-iuni; d"for&ri; anc1i(o-"

Principa("(" articu(a ii af"ctat" d" PR sunt c"(" car" au c"( &ai &ar" raport 3ntr" suprafa a sino#ia("i i c"a a carti(au(ui articu(ar 4 articu(a ii(" &"tacarpofa(an'i"n" MCF; int"rfa(an'i"n" pro+i&a(" IFP )=*; radiocu!itocarpi"n" RCC i carpi"n" )@*%Articu(a ii(" &ari sunt af"ctat" &ai tr-iu fa d" c"(" &ici; iar c"(" fr sino#ia( )&anu!rio4 st"rna(; si&fi-a pu!ian; disco4#"rt"!ra("* nu sunt int"r"sat" %

Mini(" sunt c"(" &ai af"ctat" 3n cadru( ac"st"i !o(i; ducnd (a &anif"stri pr"cu& tu&"fac ii

i dur"ri (a ni#"(u( articu(a ii(or RCC; MCF; IFP; dur"ri (a co&pr"sia sti(oid"i u(nar; s(!iciun" &uscu(ar; af"ctar"a func i"i d" pr"1"nsiun"%


28/166

Modificri (a ni#"(u( &inii:

Tu&"fac ia articu(a i"i IFP i (ipsa af"ctrii c"("i dista(" Q d"'"t" fu-ifor&"

Tu&"fac ia carpu(ui c1ist" (a ni#"(u( t"ndoan"(or &u c1i(or "+t"nsori

Tu&"fac ia articu(a i"i RCC i MCF atrofia &u c1i(or int"roso i Q &n 3n spat" d" c&i(

Modificri (a ni#"(u( d"'"t"(or :)figura 3*

3n 't d" ("!d 0 f("+ia IFD i 1ip"r"+t"nsia IFP "st" dat d" scurtar"a &u c1i(or int"roso i; "+"rcitnd o trac iun" asupra t"ndoan"(or "+t"nsori(or

12


29/166

3n !utoni"r 0 t"ndonu( "+t"nsoru(ui co&un a( d"'"t"(or s" rup" (on'itudina( ducnd (a1"rni"r"a articu(a i"i IFP; 3n ti&p c" articu( ia IFD s" af( 3n 1ip"r"+t"nsi"

Af"ctar"a po(ic"(ui 0 dat adduc ia "+a'"rat a pri&u(ui &"tacarpian; f("+ia MCF;1ip"r"+t"nsia IF

Af"ctar"a carpu(ui "st" constant% S(!iciun"a &u c1u(ui "+t"nsor u(nar a( carpu(ui duc" (arotar"a oas"(or carpi"n"; pri&u( rnd 3n s"ns u(nar; iar a( ?4("a 3n s"ns radia(%

Ac"ast &odificar" produc" o d"#i"r" u(nar a d"'"t"(or


30/166

Fi#ura 8% Modificri (a ni#"(u(

d"'"t"(or

A(t" -on" af"ctat" d" PR :

Cotu( 0 (i&itar"a "+t"nsi"i; !ursit" o("crani"n"

La ni#"(u( u&"ri(or 0 articu(a ia '("no41u&"ra(; acro&ioc(a#icu(ar )rar*; !urs"("; ca(otarotatori(or

Co(oana c"r#ica( 0 sin'uru( s"'&"nt a( co(oan"i #"rt"!ra(" af"ctat 3n PR

Articu(a ia t"&poro4&andi!u(ar 0 apar dur"ri (a &astica i"; dificu(tat" (a 3nc1id"r"a 'urii; cr"pita ii; apari ia d" "ro-iuni i '"od" "#id"n iat" cu autoru( CT sau RMN

$("-n"(" 0 doar 3n for&"(" s"#"r" d" !oa(

Picioar"(" 0 af"ctat" (a p"st" =B din paci"n i c"(" &ai af"ctat" sunt articu(a ii(" &"tatarsofa(an'i"n" MTF

$"nunc1ii 0 fr"c#"nt af"cta i

13


31/166

o(du( 0 rar; 3n ca- d" af"ctar" poat" apr"a co+ita r"u&atoid sau !ursita tro1ant"rian

'V $natomie patolo#ic

Modificri(" 1istopato(o'ic" a(" sino#ia("i r"u&atoid" sunt r"pr"-"ntat" d" proc"s" int"ns" d"n"oan'io'"n"- )dat" d" d"-"c1i(i!r" 3ntr" factorii an'io'"n"tici i in1i!itorii an'io'"n"-"i*;

r"sp"cti# &i'rar"infi(trar" c"(u(ar% Ac"st proc"s d" an'io'"n"- "st" inf(u"n at d" ur&toriifactori: ,E$F )#ascu(ar "ndot"(ia( 'ro9t1 factor*; TNF4; IL4=; IL4% Dup ct"#a (uni d""#o(u i"; apar" pro(if"rar"a sino#ia("i )fa- 'ranu(o&atoas*; ca ur&ar" a p"rtur!rii r"ac i"i inf(a&atorii; a pro(if"rrii sino#iocit"(or; r"sp"cti# (i&fop(as&ocitar"% R"-u(tatu( ac"st"ir"ac ii "st" for&ar"a unui "sut d" 'ranu(a i" 1"p"rtrofiat i 1ip"r#ascu(ari-at nu&it panussinovial )fi'ura *%Apari ia d" fi!ro!(ast" duc" (a an8i(o- i fi!ro- %


32/166

Fi'ura % Panus articu(ar% Ero-iun"% 7ip"rp(a-i"%

Infi(trar" c"(u(ar

V Manifestri e7traarticulare

Manif"stri(" "+tra4articu(ar" sunt foart" dif"rit" ca i &anif"star"; r"sp"cti# s"#"ritat"% Ac"st"&anif"stri d"pind d" durata i s"#"ritat"a !o(ii% E(" sunt d"t"r&inat" d" infi(trat"("

(i&fop(as&ocitar" sau proc"s" #ascu(itic" i apar (a !o(na#ii cu titru &ar" d" FR )factor

14


33/166

r"u&atoid*; co&p("&"nt s"ric V; co&p("&"nt" i&un" circu(ant" W; crio'(o!u(in" i factoriantunuc("ari pr"-"n i%

Af"ctri "+tra4articu(ar" :

Noduli reumatoizi0 c"a &ai fr"c#"nt &anif"star" din cadru( ac"st"i !o(i% Nodu(iir"u&atoi-i;din punct d" #"d"r" 1isto(o'ic; sunt c"ntra i d" o art"rio( i cuprind o -on c"ntra( d" n"cro-; cu r"sturi c"(u(ar"; fi!r" d" co(a'"n i r"ticu(in; inconurat d" o coroan d"fi!ro!(ast" distri!uit" 3n pa(isad" i (a p"rfif"ri" o -on !o'at 3n (i&focit"% Ac" ti nodu(i apar

3n proc"nt d" ?G4B6 din paci"n ii cu PR i au o (oca(i-ar" pr"f"r"n ia( p" supraf" "(" d" "+t"nsi" )o("cran; u(na pro+i&a(*; !urs"; t"ndoan" i 3n #"cintat"a articu(a ii(or af"ctat"% Sunt (oca(i-a i su!cutan; cu o consist"n d" (a &oa(" (a "(astic; &o!i(i sau ad"r"n i (a p"riost sau t"ndoan"% n c""a c" pri#" t" di&"nsiun"a; #aria- d" (a c i#a && (a c i#a c&% Pot a#"a i a(t" (oca(i-ri: (a ni#"(u( (arin'"(ui; sc("r"(or; cordu(ui; p(&ni(or; p("ur"i; rinic1i(or%

Vasculita0s" poat" "+pri&a prin &ai &u(t" &oduri:

Art"rit dista( cu "ro-iuni; u(c"ra ii punctifor&" sau 'an'r"n"

U(c"ra ii cutanat"

Purpur pa(pa!i(

N"uropati" p"rif"ric )vasa nervorum*

Art"rit" #isc"ra(" )cardiac"; pu(&onar"; di'"sti#"; r"na("; 1"patic" "tc%*

Af"ctar" pu(&onar 0 &anif"stat prin: p("ur"-i"; fi!ro- int"rsti ia(; sindro& Cap(an; nodu(ipu(&onari; pn"u&otora+; !ron io(it; art"rit d" #as" pu(&onar"; o!struc i" pu(&onar


34/166

Af"ctar" cardiac 0 p"ricardit )6G din ca-uri*; &iocardit; "ndocardit; #ascu(it

Af"ctar" r"na( 0 sindro& n"frotic

Af"ctar" n"uro(o'ic 0 dat d" #ascu(it d" #asa n"r#oru& )po(in"#rit" s"n-iti#" i &otorii"+pri&at" prin par"st"-ii; pra(i-ii; ar"f("+i"; a&iotrofi"*

Af"ctar" di'"sti#

Sindro& F"(t2 0 PR asociat cu sp("no&"'a(i"; n"utrop"ni" ) an"&i"; tro&!op"ni";

1"pato&"'a(i"; ad"nopati"*

15


35/166

Af"ctar" osoas i &uscu(ar

&7amenul radiolo#ic "st" una dintr" c"(" &ai acc"si!i(" i d"s uti(i-at &"tod i&a'istic d" dia'nostic 3n PR%Modificri(" radio(o'ic" "+pri& ("-iuni(" anato&o4pato(o'ic" c"caract"ri-"a- po(iartrita r"u&atoid; fiind dif"rit" 3n func i" d" stadiu( !o(ii%n pri&"(" stadiia(" !o(ii; "+a&"nu( radio(o'ic a( articu(a ii(or af"ctat" poat" fi unu( nor&a(%S" pot uti(i-a i a(t" &i(oac" i&a'istic" ost"o4articu(ar"; pr"cu& scinti'rafia cu Tc i r"-onan a &a'n"tic nuc("ar )RMN*%Ac"st"a pot "#id"n ia &odificri(" inf(a&atorii c"(" &ai pr"coc" car" nu potfi "#id"n iat" prin radio'rafia standard %

n ca-u( dia'nosticrii prin radi'rafia standard;s" #or ur&ri ct"#a "("&"nt" :

Tu&"fi"r"a pr i(or &oi p"riarticu(ar" a(" articu(a ii(or p"rif"ric"; car" "st" pr"coc" i pr"c"d" &odificri(" carti(a'inoas" i osoas"%

n'ustar"a spa iu(ui articu(ar 3n ur&a distru'"rii carti(au(ui articu(ar car" s" produc" 3nprincipa( su! inf(u"n a "n-i&"(or din (ic1idu( sino#ia( i &ai pu in ca ur&ar" a "ro-iunii dir"ct" prin panus%

Ero-iuni(" &ar'ina(" s" produc (a (ocu( d" ins"r i" a( sino#ia("i p" carti(a; fiind ur&ar"ar"sor! i"i osoas" produs d" inf(u"n a d" #"cintat" a panusu(ui%

n stadii(" a#ansat" a(" !o(ii; s" poat" o!s"r#a d"t"riorar"a 3n profun-i&" a conturu(ui osu(ui%

Apari ia d"for&ri(or articu(ar"; sunt ur&ri(" su!(u+a ii(or i (u+a ii(or d"t"r&inat" d" distruc ia carti(au(ui; capsu("(or; t"ndoan"(or; (i'a&"nt"(or i nu 3n u(ti&u( rnd a

oas"(or%

Anc1i(o-a "st" s"&nu( u(ti&"i fa-" a !o(ii; fiind cons"cin a distru'"rii tota(" ost"o4articu(ar"%


36/166

C"(" &ai su'"sti#" s"&n" apar 3ns (a articu(a ii(" &ici a(" &inii i picioru(ui dar i (a '"nunc1i% Articu(a ii(" MCF a(" d"'"t"(or II i III sunt d" as"&"n"a af"ctat" 3n stadii(" incipi"nt" a(" !o(ii% La picioar" c"(" &ai "#id"nt" &odificri apar (a articu(a ii(" MTF a("

d"'"t"(or I, i ,% La articu(a ii(" &ari pr"cu& '"nunc1ii i articu(a ii(" co+o4f"&ura("; &odificri(" radio(o'ic" apar &ai tr-iu i const 3n 3n'ustar"a spa iu(ui articu(ar i &ai rar 3n "ro-iuni &ar'ina("% La ni#"(u( co(oan"i c"r#ica("; c"a &ai 3nta(nit &odificar" "st" su!(u+a iaant"rioar (a ni#"(u( articu(a i"i at(anto4a+ia(" %

16


37/166

Ecografia articularpoat" pun" pr"coc" 3n "#id"n a (ic1idu( sino#ia( dar i inf(a&a ia d" (ani#"(u( sino#ia("(or i a t"ci(or t"ndinoas" dar i pr"-"n a c1ist"(or sino#ia("%

Fi#ura - Eco'rafi" (a ni#"(u( &"tacarpu(ui )stn'a; dr"apta*


38/166

Fi#ura 9 Eco'rafi" articu(ar 0fa(an'a pro+i&a( fa(an'a dista(


39/166

17


40/166

Rezonan magnetic nuclear (RMN) "st" o &"tod d" i&a'istic p"rfor&ant c" poat""#id"n ia pr"coc" "ro-iuni(" osoas"; c1ist"(" osoas" su!condra("; a(t"rar"a carti(au(uiarticu(ar; star"a structuri(or p"riarticu(ar" i &odificri (a ni#"(u( unor (oca(i-ri &ai 'r"u d"

o!s"r#at radio(o'ic %

Fi#ura : Articu(a ia M"tacarpofa(an'ian


41/166

Fi#ura ; Po(iartrit R"u&atoid


42/166

18


43/166

V' !ia#nostic

Dia'nosticu( po(iartrit"i r"u&atoid" s" !a-"a- p" dat" c(inic" i parac(inic"% Co("'iu(

A&"rican d" R"u&ato(o'i" a "(i!"rat un s"t d" crit"rii c(inic"; !io(o'ic"; r"sp"cti# radio(o'ic"p"ntru dia'nosticar"a PR:

R"doar" &atina( cu durat d" &ini& = or; c"( pu in spt&ni

Artrit si&u(tan (a &ini& B arii articu(ar"

Artrita articu(a ii(or &inii; MCF sau IFP

Artrit si&"tric; c"( pu in spt&ni

Pr"-"n a nodu(i(or r"u&atoi-i

Pr"-"n a d" FR )factor r"u&atoid*; 3n condi ii(" un"i r"ac ii po-iti#" (a X 6 dintr" nor&a(i*

Modificri radio(o'ic" tipic": "ro-iuni sau ost"oporo- articu(ar a &ini(or i picioar"(or 3narticu(tii(" c(inic af"ctat"

La "+a&"nu( c(inic a( articu(a ii(or put"& d"c"(a ur&toar"(" "("&"nt" c(inic" :

Tu&"fi"r" )#i-ua( sau pa(patoriu*

C(dur (oca( (a ni#"(u( articu(a ii(or af"ctat"


44/166

Dur"r" (a pr"siun" a intr"'ii articu(a ii sau nu&ai a unor -on" articu(ar"

D"for&ar" ost"oarticu(ar produsa prin distruc ii (i'a&"ntar"; &riri osoas"; su!(u+a ii; contracturi &uscu(ar" "tc

Li&itar"a &i cri(or prin cau-" intraarticu(ar" i "+traarticu(ar"

Cr"pita ii(" d" o!ic"i indic o pato(o'i" articu(ar sau t"nosino#ia(

Scd"r"a for "i &uscu(ar" cu ur&ri p" fi-io(o'ia nor&a(a a fi"car"i articu(a ii; d" "+"&p(u scd"r"a for "i d" prind"r"; cu scpar"a o!i"ct"(or din &n

n cadru( t"st"(or d" (a!orator apar ur&toar"(" &odificri: ("ucocito- tro&!ocito- "o-inofi(i" 3n ca- d" n"utrop"ni" "st" n"c"sar d" "+c(us sindro&u( F"(t2 sindro& an"&ic

,S7 i prot"ina C r"acti# pr"-int #a(ori cr"scut" ("ucocituri"; prot"inuri"; ci(indruri" (apaci"n ii cu af"ctar" r"na(% R"duc"r"a conc"tra i"i d" a(!u&in; cr" t"r"a ni#"(u(ui "n-i&"(or

19


45/166

1"patic"; cr" t"r"a cr"atini"i sunt s"cundar" trata&"ntu(ui cu corticost"roi-i sau acti#it ii

inf(a&torii a &a(adi"i d" !a-


46/166

R"u&atis&u( articu(ar acut )RAA*: "#id"n i"ra inf"c i"i str"ptococic" )cr" t"r"a titru(ui ASLO*; &anif"stri(" cardiac" i n"uro(o'ic"; (ipsa FR i "#o(u ia si&pto&ato(o'i"i duc spr" RAA

Spondi(artropatii(" s"ron"'ati#": dif"r"n a 3ntr" PR i spondi(artropatii(" "st" "f"ctar"a articu(a ii(or sacro4i(iac" i a co(oan"i #"rt"!ra("

Artro-a: r"doar" scurt d" BG &inut"; acc"ntuar" dup "fort; af"ctar" asi&"tric aarticu(a ii(or; (ipsa sindro&u(ui !io(o'ic inf(a&ator i a FR; pr"-"n a ost"ofit"(or; sc("ro- su!condra(

$uta: ni#"(u( acidu(ui uric 3n s"r i urin; "#id"n i"r"a crista("(or d" acid uric 3n (ic1idu( sino#ia(; dif"r"n i"r"a !ioptic a tofi(or 'uto i d" nodu(ii r"u&atoi-i contri!ui" (a sta!i(ir"a unui dia'nostic cor"ct

Artrita psoria-ic: &anif"stri(" cutanat" i un'1ia("; af"ctar"a articu(a ii(or IFD; pr"-"n a d" FR (a doar ?6 din paci"n i; (ipsa int"r"sri(or sist"&ic" i a nodu(i(or r"u&atoi-i

20


47/166

/0$S'F'/$)&$ P(0'$)T)'T&' )&UM$T('!&

/lasificarea clinico.func ional

C(asa I 4 capacitat" n"a(t"rat d" "f"ctuar" a tuturor acti#it i(or -i(nic"%

C(asa II 4 acti#it i(" -i(nic" pot fi "f"ctuat" dar cu dur"r" i cu r"duc"r"a &o!i(it ii articu(ar"%

C(asa III 4 capacitat"a d" a s" 3n'rii sin'ur%

C(asa I, 4 i&o!i(i-ar" (a pat sau 3n scaun cu roti(" i incapacitat" d" auto3n'riir"


48/166

Modificatorii rspunsu(ui !io(o'ic 3n t"rapia ac"stor !o(i sunt r"pr"-"nta i d" prot"in"("r"co&!inat"; car" au dr"pt tint &o("cu("(" sp"cific" i&p(icat" 3n proc"su( inf(a&ator%

Prot"in"(" r"co&!inat" sunt c(asificat" 3n :

A'"n i 3ndr"pta i 3&potri#a (i&focit"(or T )anticorpi &onoc(ona(i anti CD*

A'"n i 3ndr"pta i 3&potri#a &ar8"ri(or d" acti#ar" ai (i&focit"(or T

A'"n i 3ndr"pta i 3&potri#a (i&focit"(or / )anticorpi &onoc(ona(i anti CD?G*

Anta'oni ti ai &o("cu("(or costi&u(atoar" )CTLA4I'; anti CDG; anti CDG (i'and*

Anta'oni ti ai cito8in"(or i cito8in"

In1i!itorii TNF4 )infli!ma"; etanercept in#i"itorii TA$E*

In1i!itorii IL4= )ana%inara prainacasan*

In1i!itorii IL4

In1i!itorii IL4=?

In1i!itorii IL4=6

In1i!itorii IL4=

IL4=G

IL4==


49/166

Int"rf"roni

A'"n ii car" int"rf"r cascada d" s"&na(i-ar" intrac"(u(ar )pB MAP\; I8/*

21


50/166

%

In1i!itorii co&p("&"ntu(ui )eculizuma"*

Anta'oni tii &o("cu("(or d" ad"-iun" )p"ptid" ICAM antis"ns; anti a,]B; efalizuma";alefacept*

A'"n ii antic1"&o8in"r"c"ptori )anti4CCLB; anti4CCL?; anta'onistii r"c"ptori(or MCP4= siPF4; anticorpi &onoc(ona(i anti CCR=*

A'"n ii antin"o#ascu(ari-a i" )tro&!ospondin; "ndostatin; an'iostatin "tc%*

Datorit faptu(ui c TNF4 "st" cito8ina c1"i" 3n po(iartrita r"u&atoid "st" pr"f"rat 3ntrata&"ntu( standard a( PR i a( spondi(artrit"(or% P" (n' TNF4; s" uti(i-"a- i anta'onistu( r"c"ptoru(ui IL4= )IL4=Ra*; anticopri anti4int"'rin"; anticorpi &onoc(ona(i 3ndr"ptati3&potri#a (i&focit"(or T si /% T"rapia !io(o'ic poat" uti(i-a un sin'ur a'"nt sau co&!ina iia(" ac"stora %

A% In1i!itorii TNF4

IN&LI'I(A)*(

Est" un anticorp &onoc(ona( 1i&"ric car" ("a' &o("cu("(" d" TNF4 (i!"r" i fi+at" d"c"(u("; a#nd i "f"ct citoto+ic% S" uti(i-"a- d" r"'u(a asociat cu M"t1otr"+atu& 3n do-" d" B&'

\'c; 3n PE,; ad&inistrat 3n -iua G i apoi (a ? r"sp"cti# spt u(t"rior (a fi"car" spt&ni% n ca- d" rspuns inco&p("t s" poat" cr" t" do-a pn (a =G &'8'c sau s" r"duc"

tr"ptat int"r#a(u( d" ad&inistrri pn (a 4 spt&ni


51/166

R"ac ii ad#"rs" a(" IM/ sunt:

R"ac ii ad#"rs" a(" p"rfu-i"i: f"!r; frison; c"fa(""; prurit; urticari"; 1ipot"nsiun"; dispn""

Fr"c#"n a &ai &ar" a inf"c ii(or

7ip"rs"nsi!i(itat" d" tip 3ntr-iat

Apari ia anticorpi(or anti &o("cu( 1i&"ric 7ACA

F"no&"n" autoi&un": pr"-"n a d" anticorpi antinuc("ari; f"no&"n" (upus4(i8" r"#"rsi!i("

F"no&"n" cardio#ascu(ar": arit&ii; tro&!of("!it"

F"no&"n" di'"sti#": 'r"a a; diar""; dur"ri a!do&ina("

Sindroa&" d"&i"(ini-ant"; f"no&"n" 1"&ato(o'ic"; n"op(a-ii

ETANE+$E,T

Est" o &o("cu( 1i&"ric for&at din doua r"'iuni "+trac"(u(ar" d" ("'ar" a r"c"ptoru(ui p@6a( TNF4 d" por iun"a I' $= u&an"% S" ad&instr"a- in do-" d" ?6 &' d" ? ori p" spt&n

sau 6G &' o data p" spt&n; su!cutanat s" asocia- cu M"t1otr"+at p"ntru "ficacitat"&a+i&%

22


52/166

ADALI(*(A)

Est" un anticorp &onoc(ona( anti TNF4 co&p("t u&ani-at; cu un ti&p d" 3nu&t ir"as"&anator cu c"( a( I'$= nati#" )=G4=B; -i("*% S" ad&inistr"a-a o data (a doua sapta&ani G&'; su!cutanat 3n ca- d" raspuns insufici"nt s" poat" ad&instra do-a d" G &' o dat p"spt&n% P"ntru o "ficacitat" &a+i& s" asocia- cu M"t1otr"+at%

/% In1i!itorii IL4=

ANA-IN+A

Est" un anta'onist n"'(ico-i(at a( r"c"ptoru(ui p"ntru IL4= )IL4= Ra* o! inut prin r"co&!inar"'"n"tic% S" ad&instr"a- 3n do-a d" =GG &'-i sc%; a#nd un ti&p d" 3nu&t ir" d" 4 or"%Co&!ina ia cu DMARD )MT. isau a(t"("* i cu corti-onic" pr"-int "f"ct" !"n"fic"%

R"ac ii ad#"rs":

Inf"c ii

N"utrop"ni"

R"ac ii (a (ocu( in"c i"i

+E$,T.+*L S.L*)IL TI, / AL IL0/ 1sIL0/+/2 3 r"-u(tat" !un" doar (a do-" &ari d"ad&instrar"%

IL0/ T+A, 0 "st" o &o("cu( d" fu-iun" car" ("a'do&"niu( "+trac"(u(ar a( r"c"ptoru(ui tip =a( IL4= i prot"ina acc"sori" a IL4= d" r"'iun"a Fc a I'$= %

C% A(t" p"rsp"cti#" t"rap"utic" 3n PR


53/166

In1i!ar"a s"("cti# a acti#rii (i&focit"(or T prin prot"ina d" fu-iun" CTLAI' 0

A)ATA$E,T

Trata&"ntu( anti int"'rin ,]B 0 VITA'IN

Uti(i-ar"a prot"in"i d" fi+ar" a IL4= )IL4= /P*

Ac &onoc(ona(i anti r"c"ptor d" IL

Anticorpi &onoc(ona(i anti Tac

Anticorpi &onoc(ona(i anti CD?G 0+IT*'I(A)

Antic1"&o8in"

Anticorpi &onoc(ona(i anti &o("cu( d" ad"-iun" )ca ,E$F*

/(ocar"a ac iunii NF48/

In1i!itorii MAP48ina-"(or

In1i!itorii TACE


54/166

23


55/166

'< &volu ie i complica ii

Pus""(" inf(a&atorii d"t"r&in apari ia si d"-#o(tar"a unui picior static d" "#o(u i" rapid Ac"sttip d" picior s" as"a&n frapant cu c"( din 1a((u+ #a('us a#ansat i co&p(icat%

D"for&ri(" s" a'ra#"a- datorit unor cau-" d" tip &"canic: "f"ctu( 'r"uta ii corpora(" asupra("-iuni(or inf(a&atorii insta!i("; 3nc( &int" n"ad"c#at; d"-"c1i(i!ru 3ntr" 'rup"(" &uscu(ar"%

E#o(u ia poat" fi &ono4cic(ica )pus"" inf(a&atorii a(t"rnnd cu p"rioad" d" r"&isiun"*;

pro'r"si# sau c"( &ai ad"s"a po(i4cic(ica)pus"" fr#"rita!i(" p"rioad" d" r"&isiun"*%

Nu "st" posi!i( pr"dic ia "#o(u i"i un"i po(iartrit" r"u&atoid" af(at" 3n stadiu d" d"!ut%

E+ist totu i factori pr"dicti#i n"'ati#i: nu&ru( &ar" d" articu(a ii i&p(icat" (a d"!ut; pr"-"nta &anif"stri(or "+tra4articu(ar"; pr"-"n a nodu(i(or r"u&atoi-i; ("-iuni(" radio(o'ic" pr"coc";pr"-"n a unui sindro& inf(a&ator i&portant !io(o'ic ini ia( )CRP cr"scut*; factor r"u&atoid pr"-"nt ini ia( i 3n conc"ntra i" ridicat 3n sn'" %


56/166

24


57/166

P$)T&$ SP&/'$02

'ntroducere

Po(iartrita r"u&atoid r"pr"-int o !oa( inf(a&atori" articu(ar car" prin toat" &anif"stri(""i; dur"r" i r"duc"r"a &o!i(it ii articu(ar"; apari ia d"#ia ii(or i a &anif"stri(or sist"&ic"; ar" dr"pt ur&ar" a(t"rar"a s"&nificati# a ca(it ii #i" ii !o(na#u(ui% Totodata ac"ast !oa( pr"-int i r"p"rcursiuni psi1o(o'ic" prin pi"rd"r"a 3ntr4o anu&it &sur a ro(u(ui din #ia a socia( ct i prin dificu(t ii(" 3nt&pinat" 3n #ia a d" -i d" -i; 3n cadru( &"diu(ui fa&i(ia(%

Trata&"ntu( &"dica&"ntos a( po(iartrit"i r"u&atoid" a pr"-"ntat o "#o(u i" sp"ctacu(oas 3nu(ti&u( d"c"niu; 3n ur&a c"rc"tri(or i studii(or a&p(" "f"ctuat" 3n ac"st do&"niu; i ar" ca scop r"duc"r"a inf(a&a i"i i a dur"ri(or articu(ar"; 3nc"tinir"a "#o(u i"i ("-iuni(or distructi#" (a ni#"( osos i &"ntin"r"a func iona(it ii i a &o!i(ittii articu(ar"% n trata&"ntu( '"n"ra(; c"( &ai fr"c#"nt s" uti(i-"a- &"dica&"nt" din c(as"(": antia('ic"; antiinf(a&atoar" )n"st"roidi"n"i corti-onic"*; i&unosupr"si#" )a-atioprina; cic(ofosfa&ida; &"totr"+at*; r"&isi#" )sruri d"

aur; d4p"nici(a&ina; antipa(udic" d" sint"-*%

M"dica ia si&pto&atic 0 fac" part" din Si&pto& Modif2in' R"u&atic Anti Dru's)SMARD*; AINS ac ion"a- prin supri&ar"a sint"-"i d" prosta'(andin"(or prin in1i!ar"acic(oo+i'"na-"i = i ?% AINS n"s"("cti#"; asociat" cu prot"c i" 'astric; su!stan "("

antiinf(a&atoar" n"st"roidi"n"; prin !(ocar"a cic(oo+i'"na-"i; d"pri& sint"-a d"prosta'(andin"; prostacic(in" i tro&!o+ani; fiind astf"( ana('"tic"; antipir"tic" i antiinf(a&atoar"% Din trata&"ntu( si&pto&atic fac" part" corticot"rapia car" ad&inistrata p"ca(" '"n"ra(; d" i "st" foart" "ficac" 3n a&"(iorar"a si&pto&ato(o'i"i c(inic" i !io(o'ic"; tr"!ui" "#itat p"ntru c nu inf(u"n "a- "#o(u ia !o(ii )distruc ii(" carti(au(ui i osu(ui*; iar f"no&"n"(" s"cundar" (a cur" pr"(un'it" sunt r"ducta!i("; &ai a("s c"( d" acc"("rar" aost"oporo-"i %


58/166

T"rapii(" d" fond sau r"&isi#")DMARD*; d"Ki rar"ori d"t"r&in o r"&isiun" r"a( a !o(ii i aufi"car" o to+icitat" sp"cific car" n"c"sit o at"nt &onitori-ar"; au ad"s"a un "f"ct !"n"ficcar" s" insta("a- (a p"st" ?B dintr" !o(na#i; 3n circa =4 (uni; 3&pi"dicnd pro'r"sia

25


59/166

("-iuni(or ost"oarticu(ar" Ki pi"rd"r"a funcJii(or articu(ar"; c" pot apr"a d"stu( d" rapid (apaci"n ii cu for&" acti#"a'r"si#" d" PR %

Pr"parat"(" r"&isi#" c(asic" d" pri& int"n i" uti(i-at" 3n trata&"ntu( d" fond a( PR suntr"pr"-"ntat" d" &"t1otr"+at; ("f(uno&id; su(fasa(a-in; iar 3n ca- d" (ipsa d" rspuns s" potintroduc" 1idro+ic(oroc1ina; cic(osporina A; sruri(" d" aur; D4p"nici(a&ina; a-at1ioprina;cic(ofosfa&ida% Ac"st" &"dica&"nt" s" pot ad&inistra fi" s"c#"n ia( )s9itc1* ;fi" ca ico&!ina i" din car" s" r"tra' pro'r"si# un"(" produs"; p" &sur c" s" o! in" contro(u( !o(ii)st"p4do9n* sau 3n car" s" adau' pro'r"si# a(t a'"nt t"rap"utic d" ac"s tip (a pr"paratu(ad&inistrat ini ia( sin'ur)st"p4up* 3n ca- d" rspuns inco&p("t sau !oa(a r"fractara (atrata&"nt i; foart" i&portant; nu s" intr"rup att ti&p ct s" o! in" contro(u( satisfctor sau r"&isiun"a !o(ii; p"ntru a nu "+pun" paci"ntu( (a riscu( un"i r"cd"ri car"; foart" pro!a!i(; nu#a &ai put"a fi contro(ata prin r"(uar"a trata&"ntu(ui initia(%

T"rapia !io(o'ic cu !(ocanJi d" TNF )Inf(i+i&a!; Ada(i&u&a!; Etan"rc"pt; $o(i&u&a!;

C"rto(i-u&a! p"'o(*; !(ocanJi IL4 )Toci(i-u&a!*; anti CD4?G )Ritu+i&a!*; sau &odu(atori aicosti&u(rii c"(u("i T )A!atac"pt*; s" poat" ad&inistra doar cnd "+ist dia'nosticu( c"rt d"PR )dup crit"rii(" ACR*; 3n for&a s"#"r acti# )Scor d" acti#itat" a !o(ii DAS ^ 6;=* 3n

ciuda trata&"ntu(ui ad&inistrat; pr"-"ntnd c"( puJin 6 sau &ai &u(t" articu(aJii cu sino#itacti# )dur"roas" Ki tu&"fiat"* ? din ur&toar"(" B crit"rii ) r"doar" &atina( p"st" G d"&inut"; ,S7 ^ ? && (a o or; prot"ina C r"acti# ^ ?G &'( sau d" B ori #a(oar"a nor&a( 4d"t"r&inat cantitati#*% D" as"&"n"a; ac"ast t"rapi" s" poat" ini ia nu&ai (a ca-uri(" d"po(iartrit r"u&atoid car" nu au rspuns (a t"rapia r"&isi# standard a !o(ii; cor"ctad&inistrat )ca do-" Ki durat a t"rapi"i*; r"sp"cti# dup uti(i-ar"a a c"( puJin ? so(uJiit"rap"utic" r"&isi#" standard; cu durata d" &ini& =? spt&ni fi"car"; dintr" car" una "st"d" o!ic"i M"t1otr"+atu(% Un paci"nt "st" d"c(arat ca fiind nonr"spond"r (a t"rapia standardcnd pr"-int p"rsist"nJa crit"rii(or d" acti#itat"; dup =? spt&ni d" trata&"nt in &odcontinuu; cu do-a &a+i& u-ua( r"co&andat Ki to("rat din pr"paratu( r"&isi# r"sp"cti#%naint" d" 3nc"p"r"a t"rapi"i cu oricar" dintr" ac"st" produs"; tr"!ui" "#a(uat riscu( paci"ntu(uip"ntru acti#ar"a un"i inf"c ii cu !aci( \oc1 sau cu #irusuri(" 1"patitic" / sau C %

Mana'"&"ntu( t"rap"utic 3n po(iartrita r"u&atoid 3nc"p" cu "#a(uar"a factori(or pro'nostici;a acti#it ii !o(ii; a ("-iuni(or pr"-"nt"; a statusu(ui func iona( i a co&or!idit i(or asociat"


60/166

26


61/166

iar trata&"ntu( co&p("+ cuprind" &ai &u(t" "tap"; d" (a &suri '"n"ra(";trata&"nt cu AINS itrata&"nt si&pto&atic; t"rapi" d" fond )MT.; ("f(ono&ida; SS_*; corticot"rapi"; t"rapi"!io(o'ic cu !(ocanJi d" TNF ; !(ocanti IL4; anti CD4?G; (a trata&"nt d" r"cup"rar";

r""ducar" i r"int"'rar" socio4prof"siona( %

$0G()'TM !& T)$T$M&1T $0 P(0'$)T)'T&' )&UM$T('!&


62/166

E#a(uar"a acti#it ii !o(ii n"c"sit o &onitori-ar" p"riodic car" s sta!i("asc "fici"n i to("ran (a trata&"nt i totodat stadiu( d" r"&isiun" a( !o(ii%

Stadializarea $/) a bolii

A&"rican Co(("'" of R"u&at1o(o'2 )ACR* a r"a(i-at 3n anu( =@ o c(asificar" !a-at p"crit"rii c(inic" i func iona("; i o a(ta !a-at p" crit"rii anato&ic" i radio(o'ic" %

Stadia(i-ar" 3n func i" d" star"a anato&ic:

Stadiu I; pr"coc": asp"ct radio(o'ic nor&a( ost"oporo-

27


63/166

Stadiu II; &od"rat: ost"oporo- #i-i!i( radio(o'ic distruc ii osoas"; posi!i(a d"t"riorar" acarti(au(ui articu(ar atrofi" &uscu(ar (i&itar"a &i crii articu(ar" a!s"n a d"for&ri(or articu(ar" ("-iuni d" pr i &oi; nodu(i r"u&atoi-i; t"nosino#it"

Stadiu( III; s"#"r: ost"oporo-; distruc ii osoas" i a(" carti(au(ui "#id"n ia!i(" radio(o'ic d"for&ar" articu(ar cu su!(u+a ii; d"#i"r" u(nar sau 1ip"r"+t"nsi"; dar fr fi!ro- sauan8i(o- osoas atrofi" &uscu(ar &arcat i "+tins pr"-"n a d" nodu(i r"u&atoi-i i t"nosino#it"

Stadiu I,; t"r&ina(: crit"rii stadiu III fi!ro- articu(ar i an8i(o-

Trata&"ntu( opti& a( !o(ii; n"c"sit un dia'nostic pr"coc" pr"cu& i uti(i-ar"a (a ti&p a a'"n i(or car" r"duc pro!a!i(itat"a apari i"i ("-iuni(or articu(ar" ir"#"rsi!i("% C"rc"tari(" 3n do&"niu r"("#c paci"n ii cu PR acti#" po(iarticu(ar; au o pro!a!i(itat" d" @G d" a d"-#o(ta "ro-iuni sau("-iuni articu(ar" 3n pri&"(" ? d" (uni d" (a d"!utu( !o(ii; astf"( c ap(icar"a ct &ai pr"coc" aunui trata&"nt a'r"si#; poat" a&"(iora "#o(u ia 3n ti&p a !o(ii%

E#o(u ia cronica a po(iartrit"i r"u&atoid"; datorit pot"n ia(u(ui "i in#a(idant; i&p(ic o

"#a(uar" p"r&an"nt; att p"ntru apr"ci"r"a "#o(u i"i !o(ii ct i 3n #"d"r"a &"n in"rii r"&isiunii !o(ii i totodat a &"n in"rii func iona(it ii i &o!i(it ii articu(ar"% Sta!i(ir"a for&"(or c(inico4"#o(uti#" i a stadii(or d" !oa(; a p"rioad"(or acti#" i d" r"&isiun"; a 'radu(ui d" acti#itat" articu(ar i sist"⁣ a factori(or d" risc; pro'nosticu(ui i co&p(ica ii(or; n"c"sit &u(tip(" in#"sti'a ii i instru&"nt" d" (ucru i o at"nt &onitori-ar" p"riodic%

Motiva ie i scop

Moti#a ia a("'"rii ac"st"i t"&" r"-id 3n pri&u( rnd din faptu( c po(iartrita r"u&atoidr"pr"-int o !oa( inf(a&atori" cronic; car" 3n "#o(u ia "i pr"-int un &ar" pot"n ia( in#a(idant cu un &ar" i&pact psi1o4socia( i cu a(t"rar"a s"&nificati# a ca(ita ii #i" ii


64/166

paci"ntu(ui; dar car" printr4o conduit t"rap"utic ad"c#at; opti&; co&p("+ i pr"coc";ur&r"st" att stopar"a distruc ii(or ost"o4carti(a'inoas"; pr"#"nir"a 1andicapu(ui fi-ic ct i a&"(iorar"a s"&nificati# a ca(it ii #i" ii paci"n i(or%

28


65/166

Din ac"st" &oti#"; dia'nosticar"a i instituir"a pr"coc" a trata&"ntu(ui ac"st"i af"c iuni "st" foart" i&portant i i&pun" introduc"r"a ct &ai rapid a unui trata&"nt r"&isi#%

Lucrar"a d" fat 3 i propun" s "#id"n i"-" "fici"n a cr"scut a t"rapi"i !io(o'ic" d" (inia a II4 a asociat cu trata&"ntu( d" r"cup"rar" (a paci"n ii cu po(iartrit r"u&atoid stadiu( I sau IIco&parati# cu t"rapia cu &"dica i" DMARD asociat cu trata&"ntu( d" r"cup"rar"; pr"cu& i "#a(uar"a "f"ct"(or ad#"rs" asociat" ac"stor t"rapii%

Material i metod

Studiu( "f"ctuat a inc(us un nu&r tota( d" ?G d" paci"n i 3&par i i 3n dou (oturi%P"ntru apr"ci"r"a "fici"n "i i to("ran "i t"rap"utic" a trata&"ntu(ui &"dica&"ntos cu t"rapi" DMARD asociat cu t"rapi" !io(o'ic d" (inia a II4a i cu trata&"ntu( d" r"cup"rar" 3n PR afost ur&rit pri&u( (ot d" =G paci"nti int"rna i i dia'nostica i cu po(iartrita r"u&atoid stadiu(

II sau III i a( doi("a (ot d" =G paci"n i car" au ur&at trata&"nt DMARD asociat cu trata&"nt d" r"cup"rar"% Paci"n ii au fost int"rna i 3n C(inica d" R"cup"rar" M"dica(; M"dicina Fi-ica; /a(n"o(o'i" i R"u&ato(o'i" a Spita(u(ui C(inica d" Ur'"nt Ti&isoara 3n p"rioada ianuari"?G= 4 ianuari" ?G=6 i car" au fost dia'nostica i confor& crit"rii(or ARA r"#i-uit" 3n =@; apar innd a&!"(or s"+" i r"sp"ctnd crit"rii(" d" inc(ud"r" i d" "+c(ud"r" din (ot% Studiu( s4 a d"sfsurat p" o p"rioada d" = an% Paci"n ii au fost "#a(ua i (a ini i"r"a t"rapi"i !io(o'ic" sau t"rapi"i DMARD )"#a(uar"a =* i dupa (uni d" trata&"nt )"#a(uar"a ?*%

/riterii de includere =n lot6

#rsta cuprins intr" =4@6 ani;


66/166

dia'nostic confir&at d" PR;

PR af(at in stadiu( I "#o(uti# )dup St"in!roc8"r* sau stadiu( II; cu o #"c1i&" a !o(ii 3ntr" (uni 0 B ani;

PR acti# (a d"!utu( trata&"ntu(ui d"finit prin pr"-"n a a &ini& ? crit"rii din B: 4 nu&ar d"articu(a ii tu&"fiat" ^ d" ;

29


67/166

r"doar" &atina( ^ G &inut";

,S7 ^ BG &&1;

paci"n i fr trata&"nt d" fond i d" r"cup"rar" sau (a car" ac"sta a fost 3ntr"rupt d" &ini& (uni;

paci"n i fr corticot"rapi";

co&p(ian a ad"c#at a paci"ntu(ui fa a d" trata&"nt;

consi& &ntu( infor&at a( paci"ntu(ui%

/riterii de e7cludere din lot6

a(coo(is&;

!o(i 1"patic" i r"na("; !o(i psi1ic"

sarcina sau n"uti(i-ar"a un"i &"tod" contrac"pti#" "ficac" (a f"&"i 3n p"rioada f"rti(

n"op(a-i"


68/166

/riteriile clinice de evaluare a pacientului cu P) au inclus6

"#a(uar"a s"&n"(or su!i"cti#" i o!i"cti#" d" !oa( acti#:

dur"r" articu(ar

r"doar" &atina( )"+pri&at 3n &inut"*

d"ficit func iona(

ast"ni"

nu&r d" articu(atii dur"roas" i tu&"fiat" ) figura 9, figura 10*

30


69/166

Fi#ura >

Fi#ura ,+


70/166

"#a(uar"a dur"rii ),AS*

"#a(uar"a statusu(ui func iona(: 7A5; DAS ?; E56D


71/166

"#a(uar"a '(o!a( "f"ctuat d" ctr" &"dic i d" ctr" paci"nt p" o scarcon#"n iona( G4;cu ur&toar"a s"&nifica i":

G ` nici o a&"(iorar"

31


72/166

= ` r"-u(tat" s(a!"

? ` r"-u(tat" &"diocr"

B ` r"-u(tat" !un"

` r"-u(tat" foart" !un"%

P"ntru "#a(uar" a& fo(osit:

Scala VAS

Fi#ura ,,0Sca(a ,AS

Scorul DAS

P"ntru a "#a(ua acti#itat"a !o(ii 3n ca-u( paci"n i(or cu po(iartrita r"u&atoid a& fo(ositScoru( DAS?4CRP )=B;=*% Ac"sta s" ca(cu("a- dup ur&toar"(" for&u("; toat" fiind#a(idat":

DAS?4 CRP )* ` G%6sbrt )TC?* G%?sbrt )SC?* G%B(n )CRP=* G%G=$7 G%


73/166

DAS?4 CRP )B* ` =%=G =%=6; 3n car":

TC r"pr"-int nu&ru( d" articu(aJii dur"roas";

SC "st" nu&ru( d" articu(aJii tu&"fiat" din c"(" ? d" articu(aJii (uat" 3n ca(cu(;

CRP` #a(ori(" prot"in"i C r"acti#"

$7` ass"ss&"nt of dis"as" acti#it2 p" sca(a ,AS

R"-u(tatu( s" int"rpr"t"a- astf"(:

P"rioada cronic acti# (a un scor ^6%=; acti#itat" sc-ut a !o(ii X B%? Ki r"&isiun"

cnd scoru( "st" X ?% )figura 12*%

32


74/166

Fi#ura ,*


75/166


76/166

33


77/166


78/166


79/166

Fi#ura ,8 4 C1"stionaru( 7A5

34


80/166


81/166


82/166

Fi#ura ,? 4 C1"stionaru( 7A5

35


83/166


84/166


85/166

Fi#ura ,- 4 C1"stionaru( E56D

36


86/166


87/166


88/166

Fi#ura ,9 4 C1"stionaru( E56D

37


89/166

Ana(i-a statistic a dat"(or s4a "f"ctuat uti(i-nd : EPI B%?%?; Op"nEpi Ki SPSS =G% Ac"astana(i- a constat 3n:

ca(cu(ar"a fr"c#"nJ"(or Ki a proc"nt"(or p"ntru #aria!i("(" ca(itati#"

ca(cu(ar"a &"dii(or arit&"tic" Ki a d"#iaJii(or standard p"ntru #aria!i("(" cantitati#"

co&parar"a statistic a &"dii(or d" "Kantioan" cu t"st"(":

t4 Stud"nt n"p"r"c1" )unpair"d t4t"st* Ki t4Stud"nt p"r"c1" )pair"d t4t"st* 4dou "Kantioan"

ANO,A )ana(i-a #ariaJi"i*4 &ai &u(t" "Kantioan"

co&parar"a statistic a proc"nt"(or cu t"stu( c1i ptrat )t"stu( ?*

o!Jin"r"a dr"pt"i d" r"'r"si"

"sti&ar"a statistic a r"-u(tat"(or s4a "f"ctuat fo(osind crit"riu( d" d"ci-i" a t"st"(or

statistic":

p^G%G64 dif"r"nJ n"s"&nificati# )NS*

pXG%G64 dif"r"nJ s"&nificati# )S*

pXG%G=4 dif"r"nJ foart" s"&nificati# )FS*


90/166

pXG%GG=4 dif"r"nJ "+tr"& d" s"&nificati# )ES*%


91/166

38


92/166

Lotu( = a fost for&at din =G paci"n i d" s"+ &ascu(in i d" s"+ f"&inin; B pro#"nind din &"diu( rura( i @ din &"diu( ur!an; dia'nostica i cu PR stadiu( II sau III; car" au ur&at trata&"nt si&pto&atic i DMARD asociat cu trata&"nt co&p("+ d" r"cup"rar"%

Grafic , Lot =4 Structura (otu(ui 3n functi" d" s"+


93/166

Grafic * Lot =4 Structura (otu(ui in functi" d" &"diu( d" pro#"ni"nta


94/166

39


95/166

Lotu( ? a fost for&at din =G paci"n i ? d" s"+ &ascu(in i d" s"+ f"&inin; din &"diu( rura(

i din &"diu( ur!an; 3n stadiu( II sau III cu PR; car" au ur&at t"rapi" !io(o'ic d" (inia a II4aasociat cu trata&"nt co&p("+ d" r"cup"rar"%

Grafic 8 4Distri!u ia (otu(ui ? p" s"+"


96/166

Grafic ? 4Distri!u ia (otu(ui ? in functi" d" &"diu( d" pro#"ni"n


97/166

40


98/166

)ezultate

Dup (uni d" trata&"nt ur&at a& o!s"r#at c paci"n ii inc(u i 3n (otu( ? au pr"-"ntat o "#o(u i" &ai !un co&parati# cu c"i din (otu( =% I&!unt iri(" (a paci"n ii din (otu( ? s4au produs (a to i para&"trii "#a(ua i:

r"duc"r"a dur"rii 0 scd"r"a ,AS

r"duc"r"a acti#it ii !o(ii 0 scd"r"a scoru(ui DAS?

i&!unt ir"a ca(it ii #i" ii 0 cr" t"r"a scoru(ui 7A5 i E56D

Rezultate privin !"#

n ca-u( paci"n i(or din (otu( = &"dia scoru(ui ,AS (a "#a(uar"a ini ia( a fost i dup (uni d" trata&"nt (a "#a(uar"a fina( a sc-ut (a % n fi'ura i ta!"(u( ur&toar" sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul , 4E#o(u ia ,AS (a (otu( =


99/166

0ot ,

V$S,

;

V$S*

?


100/166

41


101/166

Grafic - 4E#o(u ia ,AS (a (otu( =

8

6

4

2

0

VAS 1 VAS 2

6 luni


102/166

n ca-u( paci"n i(or din (otu( ? &"dia scoru(ui ,AS (a "#a(uar"a ini ia( a fost i dupa (uni d" trata&"nt (a "#a(uar"a fina( a sc-ut (a B% n fi'ura i ta!"(u( sunt pr"-"ntat" r"-u(tat"("o! inut"%

Tabelul * 4E#o(u ia ,AS (a (otu( ?

0ot *

V$S,

;


103/166

V$S*

8

42


104/166

Grafic 9 4E#o(u ia ,AS (a (otu( ?

8

6

4

2

0

VAS 1 VAS 2

6 luni

Din dat"(" o! inut" s" o!s"r# o "#o(u i" &ai !un 3n ca-u( paci"n i(or din (otu( ?% n fi'ura "st" pr"-"ntat co&para ia 3ntr" "#o(u ia ,AS (a c"(" dou (oturi d" (a "#a(uar"a ini ia(a pn (a "#a(uar"a fina( dup c"(" (uni d" trata&"nt%


105/166

Grafic : 4 Co&para ia ,AS 3ntr" c"(" ? (oturi

9

9

8

8

7

7

6

6

5

5

Lot 1

4


106/166

4

Lot 2

3

3

2

2

1

1

0

0

VAS 1

VAS 2


107/166

43


108/166

Rezultate privin $"#

n ca-u( paci"n i(or din (otu( = &"dia scoru(ui DAS (a "#a(uar"a ini ia( a fost 6%= i dup (uni d" trata&"nt (a "#a(uar"a fina( a sc-ut (a B%=% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul 8 4E#o(u ia DAS (a (otu( =

0ot ,

!$S,

-,


109/166

!$S*

8,

Grafic ; 4E#o(u ia DAS (a (otu( =

6


110/166

5

4

3

2

1

0

DAS 1 DAS 2

6 luni

44


111/166

n ca-u( paci"n i(or din (otu( ? &"dia scoru(ui DAS (a "#a(uar"a ini ia( a fost 6%? i dup (uni d" trata&"nt (a "#a(uar"a fina( a sc-ut (a ?%@% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Grafic > 4E#o(u ia DAS (a (otu( ?

6

5

4

3

2

1

0

DAS 1 DAS 2


112/166

6 luni

Tabelul ? 4E#o(u ia ,AS (a (otu( =

0ot *

!$S,

-*


113/166

!$S*

*:

Din dat"(" o! inut" s" o!s"r# o "#o(u i" &ai !un 3n ca-u( paci"n i(or din (otu( ?% n fi'ura "st" pr"-"ntat co&para ia 3ntr" "#o(u ia DAS (a c"(" dou (oturi d" (a "#a(uar"a ini ia(a pn

(a "#a(uar"a fina( dupa c"(" (uni d" trata&"nt%

45


114/166

Grafic ,+ 4Co&para ia DAS 3ntr" c"(" ? (oturi


115/166

Rezultate privin %"&

n ca-u( paci"n i(or din (otu( = &"dia scoru(ui 7A5 (a "#a(uar"a ini ia( a fost ?%=? si dup

(uni d" trata&"nt (a "#a(uar"a fina( a cr"scut (a ?%=% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul - 4E#o(u ia 7A5 (a (otu( =

0ot ,


116/166

@$A,

*,*

@$A*

*9,

46


117/166

Grafic ,, 4E#o(u ia 7A5 (a (otu( =

3

2.5

2

1.5

1

0.5

0

HAQ 1 HAQ 2

6 luni

n ca-u( paci"n i(or din (otu( ? &"dia scoru(ui 7A5 (a "#a(uar"a ini ia( a fost ?%= i dup


118/166

(uni d" trata&"nt (a "#a(uar"a fina( a cr"scut (a ?%% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul 9 4E#o(u ia 7A5 (otu( =

0ot *

@$A,

*,?

@$A*

*;?


119/166

47


120/166

Grafic ,* 4E#o(u ia 7A5 (otu( ?

3

2.5

2

1.5

1

0.5

0

HAQ 1 HAQ 2

6 luni


121/166

Din dat"(" o! inut" s" o!s"r# o "#o(u i" &ai !un 3n ca-u( paci"n i(or din (otu( ?% n fi'ura "st" pr"-"ntat co&para ia 3ntr" "#o(u ia 7A5 (a c"(" dou (oturi d" (a "#a(uar"a ini ia(a pn (a "#a(uar"a fina( dup c"(" (uni d" trata&"nt%


122/166

48


123/166

Grafic ,8 4Co&para ia 7A5

3ntr" c"(" ? (oturi

3


124/166

3


125/166

2.5

2.5


126/166


127/166

2

2


128/166

Lot 2


129/166


130/166

1.5

1.5


131/166


132/166

1

1

Lot 1


133/166


134/166

0.5


135/166

0.5


136/166

0

0


137/166

HAQ 1

HAQ 2


138/166

Rezultate privin E&'$

n ca-u( paci"n i(or din (otu( = &"dia scoru(ui E56D (a "#a(uar"a ini ia(a a fost ?%=? i dup (uni d" trata&"nt (a "#a(uar"a fina( a cr"scut (a ?%=% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul : 4E#o(u ia E56D (otu( =

0ot ,


139/166

&A-! ,

8*

&A-! *

:8


140/166

49


141/166

Grafic ,8 4E#o(u ia E56D (otu( =

8

7

6

5

4

3

2

1

0

EQ5D 1 EQ5D2


142/166

6 luni

n ca-u( paci"n i(or din (otu( ? &"dia scoru(ui E56D (a "#a(uar"a ini ia( a fost ?%= i dup (uni d" trata&"nt (a "#a(uar"a fina( a cr"scut (a ?%% n fi'ura i ta!"(u( sunt pr"-"ntat"r"-u(tat"(" o! inut"%

Tabelul ; 4E#o(u ia E56D (otu( =

0ot *

&A-! ,

8,-


143/166

&A-! *

;,

50


144/166

Grafic ,? 4E#o(u ia E56D (a (otu( ?

10

8

6

4

2

0

EQ5D 1 EQ5D2

6 luni


145/166

Din dat"(" o! inut" s" o!s"r# o "#o(u i" &ai !un 3n ca-u( paci"n i(or din (otu( ?% n fi'ura "st" pr"-"ntat co&para ia 3ntr" "#o(u ia 7A5 (a c"(" dou (oturi d" (a "#a(uar"a ini ia(a pn (a "#a(uar"a fina( dup c"(" (uni d" trata&"nt%


146/166

51


147/166

Grafic ,- 4 Co&para ia E56D 3ntr" c"(" ? (oturi


148/166

La sfr itu( c"(or (uni d" trata&"nt paci"n ii (otu(ui ? au o! inut 3&!unt iri s"&nificati#" statistic co&parati# cu c"i din (otu( = 3n ca-u( tuturor para&"tri(or "#a(ua i p" ti&pu( studiu(ui),AS; DAS; 7A5; E56D*%

Introduc"r"a t"rapi"i !io(o'ic" ct &ai pr"coc" 3n sc1"&a t"rap"utic a paci"ntu(ui cupo(iartrit r"u&atoid of"r ac"stuia ansa un"i ca(it i &ai !un" a #i" ii%


149/166

52


150/166

!iscu ii

Dat"(" din (it"ratur arat c trata&"ntu( opti& a( !o(ii n"c"sit un dia'nostic pr"coc"; pr"cu&

Ki uti(i-ar"a (a ti&p a a'"nJi(or car" r"duc pro!a!i(itat"a ("-iuni(or articu(ar" ir"#"rsi!i("%

Est" d"&onstrat c paci"nJii cu PR acti#; po(iarticu(ar; au o pro!a!i(itat" d" p"st" @G d" ad"-#o(ta "ro-iuni sau ("-iuni articu(ar" 3n pri&ii doi ani d" (a d"!utu( !o(ii%

Totodata studii(" sustin ca ap(icar"a ti&puri" a unui trata&"nt a'r"si# poat" s a&"(ior"-""#o(uJia 3n ti&p a !o(ii; &oti# p"ntru car" 3n pr"-"nt s" r"co&and a!ordar"a un"i sc1"&"t"rap"utic" pr"coc" Ki a'r"si#%

Atunci cnd "st" co&parat cu c(asa anti TNF; t"rapia !io(o'ic d" (inia aII4a s4a do#"dit a fi&ai "fici"nt i i&p(ic costuri &ai sc-ut"% Studii(" arat c s9itc14u( p" t"rapia !io(o'ic d"(inia a II4a "st" !"n"fic paci"n i(or car" nu sunt 3n r"&isiun" sau LDA su! t"rapia anti TNF;indif"r"nt d" &oti# sau car" au r"ac i" ad#"rs (a t"rapia anti TNF

n tota(; =66 d" paci"n i trata i cu DMARD; au o! inut o r"&isi" sus inut% Strat"'ii sp"cific" d" trata&"nt au fost s"&nificati# asociat" cu r"a(i-ar"a r"&isi"i )p XG;GG=*% R"'r"si" Co+austat p"ntru anticorpi anticitru((inat"d prot"in" factor r"u&atoid; nu&ru( d" co&unu&f(at"; rata d" s"di&"ntar" a 1"&atii(or; prot"ina C r"acti#a r"("#at 7R p"ntru4DMARD'ratuit r"&isi" sus inut d" =;=B )6 CI G%4?%* (a paci"n ii dia'nostica i 3n anii =4 =; ?;B )=%G@46%B?* (a paci"n ii trata i cu &"totr"+at pr"coc" )inc(ud"r"a =4?GG* i

B;@? )=%G4%?*; 3n c"i tratati pr"coc" cu &"totr"+at i t"rapia DAS dir"ctoar" )inc(ud"r"a

?GG64?G==*% La &o&"ntu( d" r"&isi"; C1"stionaru( d" E#a(uar" a Sanatatii a fost (a ni#"(u(popu(a i"i '"n"ra(" )&"di" G;=B; I5R G4G%B*% D" as"&"n"a; acti#itat"a d" sca(a #i-ua(ana(o'a paci"nt4"#a(uat ),AS* ri'iditat" di&in"a a; o!os"a(a; dur"r" i !oa(a au fost sc-ut"


151/166


152/166

=;GB; =;BG*>% A( i factori cu& ar fi tipu( d" !DMARD i anu( ca("ndaristic d" pr"scrip i" au fost asociat" cu un "f"ct &ai put"rnic asupra r"t"n i"i d" dro'uri% Rspunsu( (a trata&"nt 3nc""a c" pri#" t" "#o(u ia DAS? fost; d" as"&"n"a u or; dar s"&nificati# &ai pu in fa#ora!i(

3n &onot"rapi" )p ` G;G* %

Paci"n ii )n ` ?6* au fost ur&ri i o p"rioada d" =? (uni; cu o sc1i&!ar" &"di" a CDAI d" 4 %= )6 CI 4%44%*% Dintr" c"i ?= d" paci"n i cu !oa(a &od"rat acti#itat" &ar" (a&o&"ntu( ini ia(; paci"n ii cu = 3naint" anti4TNF )#a(oar"a ini ia(a CDAI ?6;G* a d"&onstrat o &odificar" &"di" in CDAI d" 4=G%= )6 CI 4=B%?44@%G* paci"n ii cu e ? ant"rior anti4TNF

)#a(oar"a initia(a CDAI BG;G* a d"&onstrat o sc1i&!ar" &"di" d" 4=G%6 )6 CI 4=?%44 %G*%N"austat OR p"ntru r"a(i-ar"a LDA r"&isiunii (a paci"n ii cu acti#itat"a !o(ii &od"rat &ar" (a &o&"ntu( ini ia( "+pus" (a e ? #"rsus = 3naint" anti4TNF a fost G;G )6 CI G%??4G%@B*; car" a fost ro!ust p"ntru &od"(" austat" dif"rit" )sau 'a&a G%B 4 G%* %

Dup o sin'ur t"rapi" cu RT. )co1orta =* fr"c#"n a d" pr"4co&utator )M_4cu& ar fi*; c"(u("/ au fost r"dus" s"&nificati# 3n fo((o94up d" @ ani i cifr" a!so(ut" r"popu(at 3nc"t (a aproap"6G din #a(oar"a ini ia(; fr nor&a(i-ar" nu&"ric% Ac1i-i ia d" &uta ii 3n r"c"ptorii I' d" pr"4co&utator )M_4cu& ar fi* c"(u(" / d" &"&ori" a fost; d" as"&"n"a; r"dus 3n &od

s"&nificati# (a =G ani dup un curs% n sc1i&!; cifr" a!so(ut" d" c"(u(" )c(asic* post4co&utator

/ au a#ut t"ndin a d" a nor&a(i-a (a #a(ori(" ini ia(" dup @ ani% Ana(i-nd capacit i(" d" r"popu(ar" cu c"(u(" / dup &ai &u(t" cic(uri r"#"(at" )co1ort ?* un &od"( d" r"popu(ar"co&para!i( dup fi"car" cic(u cu nici un i&pact sup(i&"ntar su!stan ia( asupra c"(u("(or / d"&"&ori" %


153/166

54


154/166

/oncluzii

=% Po(iartrita r"u&atoid prin caract"ru( "i cronic; r"pr"-int o pro!("& i&portant din punctd" #"d"r" socio4"cono⁣ n"c"sitnd p"riodic spita(i-ar" 3n c(inici d" sp"cia(itat"; o a!ordar"&u(tidiscip(inar; "#a(uri p"riodic" c(inico4parac(inic" i &"dica i" ad"s"a costisitoar"%

?% Ur&rind "#o(u ia !o(ii (a paci"n ii inc(u i 3n studiu; s" poat" spun" c 3n fa- acut ad&inistrar"a trata&"ntu(ui &"dica&"ntos ) si&pto&atic; DMARD i !io(o'ic* ar" un ro(foart" i&portant a(turi d" fi-iot"rapia cu ro( anta('ic% n fa-a cronic; paci"n ii !"n"ficia- 3nfunc i" d" r"-u(tat"(" "+a&"nu(ui c(inic i parac(inic ; p" (n' trata&"ntu( &"dica&"ntos i d" r"cup"rar" fi-iot"rap"utic p" car" o "f"ctu"a- r"p"tat 3n c"ntr" sp"cia(i-at"%

n studiu( d" fa tr"!ui" &"n ionat faptu( c a&"(iorar"a si&pto&ato(o'i"i c(inic" d"scris d" &aoritat"a paci"n i(or 3n p"rioada studiu(ui i cons"&nat 3n ac"ast (ucrar" "st" o "+pr"si" a

"ficacit ii trata&"ntu(ui &"dica&"ntos ur&at d" ac" tia%

Uti(i-ar"a scoru(ui DAS ?; "st" foart" uti( p"ntru o "#a(uar" ct &ai pr"cis a strii d"sntat" a paci"n i(or 3naint" i dup "f"ctuar"a trata&"ntu(ui co&p("+ ) &"dica&"ntos i d"

r"cup"rar"* i r"pr"-int 3ntr4un proc"nt ridicat "ficacitat"a ac"stuia%

6% R"-u(tat"(" fa#ora!i(" o! inut" n" 3ndr"pt "sc s afir&& prin a&"(iorar"a s"&nificati# a dur"rii; &"n in"r"a sau cr" t"r"a a&p(itudinii d" &i car" a articu(a ii(or; r""ducar"a i &"n in"r"a func i"i d" pr"1"nsiun" a &inii i cr" t"r"a statusu(ui func iona( a( paci"n i(or; protoco(u( t"rap"utic adaptat 3n func i" d" stadiu( !o(ii i d" af"c iuni(" asociat" a a#ut r"-u(tat" sup"rioar" pri#ind &aoritat"a para&"tri(or c(inici i func iona(i%


155/166

% R"-u(tat" car" ("4a& o!Jinut (a 'rupu( d" paci"nJi inc(u i 3n studiu au do#"dit o co&p(ianJcr"scut (a trata&"nt; car" (" p"r&it" "f"ctuar"a unui pro'ra& d" t"rapi" co&p("+; p" durat3nd"(un'at; cu asoci"r"a &"dicaJi"i si&pto&atic"; DMARD i a t"rapi"i !io(o'ic" cupro'ra&" d" fi-io8in"tot"rapi"%

@% n ur&a trata&"nt"(or ap(icat" a&!"(or (oturi d" paci"n i s4a o!s"r#at o "#o(u i" fa#ora!i( att din punct d" #"d"r" a( strii d" sntat" ct i a( psi1icu(ui% Astf"(; un trata&"nt co&p("+;

55


156/166

&"dica&"ntos i d" r"cup"rar"; !in" docu&"ntat i indi#idua(i-at "st" dir"ct propor iona( cu 3&!unt ir"a ca(it ii #i" ii%

% D"ficitu( func iona( i dur"r"a su!i"cti# )"#a(uat prin sca(a ,AS* s" af( 3n strns ("'tur cu ca(itat"a #i" ii !o(na#u(ui; inf(u"n ndu4s" r"ciproc% A&"(iorar"a func iona(it ii articu(ar" "st" 3n r"(a i" dir"ct proportiona( cu ca(itat"a #i" ii paci"ntu(ui% Un d"ficit func iona( &"diu &aor car" 3&pi"dica p"rfor&ar"a ADL4uri(or; d"sf urar"a &uncii prof"siona(" '"n"r"a- &ari d"-"c1i(i!r" 3n #iata "cono&ic i socia( a !o(na#u(ui d"po(iartrita r"u&atoid%

% Ini i"r"a t"rapi"i con#"n iona(" cu &"dica&"nt" d" tip DMARD tr"!ui" s s" r"a(i-"-" ct &ai pr"coc" d" (a d"!utu( !o(ii; 3n pri&"(" B (uni% A('orit&u( actua( d" trata&"nt; pr"#-ut d"&aoritat"a '1iduri(or d" t"rapi"; "st" ur&toru(: ini i"r"a cu M"totr"+at )&"dica&"nt d" tipu(

DMARD*; ur&at fi" d" cr" t"r"a do-"(or; fi" d" adu'ar"a unui a(t &"dica&"nt din 'rupac"(or DMARD con#"n iona(" (a insta(ar"a rspunsu(ui insufici"nt% Dac !oa(a paci"ntu(ui nu"st" 3n r"&isiun" dup ac"st" dou cur" d" ct" =? spt&ni fi"car"; s" tr"c" 3n "tapaur&toar"; a introduc"rii &"dica&"nt"(or !io(o'ic" d" pri& (ini" ur&nd c dac "#o(u ia nu"st" fa#ora!i( s s" introduc t"rapia !io(o'ic d" (inia a II4a; confor& protoco(u(ui%

=G% Monitori-ar"a strict a acti#it ii !o(ii s" r"a(i-"a- (a un int"r#a( d" B; &a+i& (unip"ntru surprind"r"a "#"ntua("(or acuti-ri i ac ionrii 3n cons"cin ; cu austar"a sau sc1i&!ar"a t"rapi"i pn (a atin'"r"a o!i"cti#u(ui 4 r"&isiun" sau acti#itat" sc-ut d" !oa(%

==% E#a(uar"a r"-u(tat"(or t"rapi"i s" fac" prin ana(i-a factori(orinf(a&atori: prot"ina Cr"acti#; #it"-a d" s"di&"ntar" a sn'"(ui ),S7* prin ca(cu(ar"a DAS? i s" c(asific 3n

rspuns !un; &od"rat i (ipsa rspunsu(ui confor& '1idu(ui EULAR%

Mana'"&"ntu( paci"ntu(ui cu po(iartrita r"u&atoid "st" un proc"s co&p("+ i car" "st"condi ionat d" o s"ri" d" factori c" in d" paci"nt dar i d" func iona(itat"a sist"&u(ui d" sntat" )&o&"ntu( dia'nosticrii; acc"su( (a s"r#icii d" sntat"; co&p(ian a (a trata&"nt;af"c iuni asociat"*%


157/166

Dat"(" o! inut" 3n studiu( d" fa a ar tr"!ui co&p("tat" 3n #iitor cu a(t" infor&a ii strns" 3n d"cursu( "#o(u i"i 3nd"(un'at" a !o(ii p"ntru a put"a o!s"r#a "f"ct"(" trata&"ntu(ui co&p("+

&"dica&"ntos i d" r"cup"rar" asupra po(iartrit"i r"u&atoid"%

56


158/166

Biblio#rafie

/a(an"scu A%; Po(iartita r"u&atoida%Esentialul in reumatologieRu+andra Ion"scu; Ed% A&a(t"a?GG ?=4?6=

/o(osiu 7%; Po(iartrita r"u&atoida% Tratat de (edicina Internacoordonator prof% Dr% St% Sut"anu;su! r"dactia prof% dr%Radu Paun% Ed% M"dica(a =; #o(%=: 4@@B

$1id d" trata&"nt a( po(iartrit"i r"u&atoid"; Minist"ru( Sanatatii 4445ms5ro

Suta M%; P"st" A%M%; Mat"i L%; Dra'1ici C%; Dificu(tati in dia'nosticu( pr"coc" si "#a(uar"apaci"ntu(ui cu po(iartrita r"u&atoida;+ev +omana de +eumatol5?GG?; ,o(% . )=4?*: B46?

Codr"anu C%; Istoria natura(a a po(iartrit"i r"u&atoid": factori pro'nostici ai !o(ii+ev5+omana de+eumatol5?GG6; ,o(% .I, )B*: =4=@=

7(s"&ann %L%; Mitt"ndorf T%; M"r8"sda( S% "t a(%: Dir"ct costs r"(at"d to r1"u&atoid art1ritis: t1"pati"nt p"rsp"cti#";Ann5 +#euma5 Dis5?GG6:=64==

Pau( E&"r2; $"rd4Rudi'"r /ur&"st"r; F"rdinand /r""d#"(d; Rona(d #an ,o(("n1o#"n% IsR"&ission t1" Mission in RAg N"9 Infor&ation fro& t1" ?GG6 EULAR Conf"r"nc" )M"dscap"4Cop2ri'1t h ?GG6 Post'raduat" Institut" for M"dicin" )PIM*%*

Andra /(n"scu 0 Po(iartrita r"u&atoid% Din: Ru+andra Ion"scu )coord%*% Es"nJia(u( 3nR"u&ato(o'i"% EdiJia a II4a r"#i-uit% /ucur"Kti: Ed% A&a(t"a ?GG@% ,)=*:?=4?

Sut"anu S%; I#an D%; Carina Mi1ai% 0 Trata&"ntu( r"&isi# )d" fond* a( po(iartrit"i r"u&atoid"

0 stadiu( actua(% R"#% M"dicina Mod"rn ,o(% .I, 0 Nr% % Au'ust ?GG@


159/166

S&o("n% %S% 0 Tr"atin' r1"u&atoid art1ritis to tar'"t: r"co&&"ndation of an int"rnationa( tas8forc"% Ann R1"u& Dis ?G=G :B=4B@%Doi: =G%==B ard% ?GG% =?B=

Co1"n S%/%; E&"r2 P%; Maria j% $r""n9a(d% 0 Ritu+i&a! for R1"u&atoid Art1ritis R"fractor2 to

Anti4Tu&or N"crosis Factor T1"rap2 R"su(ts of a Mu(tic"nt"r; Rando&i-"d; Dou!("4/(ind;P(ac"!o4Contro(("d; P1as" III Tria( E#a(uatin' Pri&ar2 Effi cac2 and Saf"t2 at T9"nt24Fourj""8s% Ann R1"u& Dis ?GG S"p 6)*: ?@B4?G

Maria %7% /ou&ans; T1ur(in's R%M%; k"o L% 0 Ritu+i&a! a!ro'at"s oint d"struction inr1"u&atoid art1ritis !2 in1i!itin' ost"oc(asto'"n"sis% AnnR1"u& Dis ?G=? @=: =G 0 ==B doi:=G%==B annr1"u&dis4?G==4 ?GG=

Arn"tt F%C%; Ed9ort12 S%M%; /(oc1 D%A% 0 T1" A&"rican R1"u&atis& Association =@ r"#is"dcrit"ria for t1" c(assifi cation of r1"u&atoid art1ritis% Art1ritis R1"u& = B=: B=64B?

Minist"ru( SntJii% 0 $1id d" trata&"nt a( po(iartrit"i r"u&atoid"% Ordin nr% =B?? din ==G?G=G%Monitoru( Ofi cia( nr% @ din ?== ?G=G

Ma2a 7% /uc1; S&o("n %S%; /"tt"rid'" N% 0 Updat"d cons"nsus stat"&"nt on t1" us" of ritu+i&a!

in pati"nts 9it1 r1"u&atoid art1ritis% Ann R1"u& Dis doi:=G%==Bard%?G=G%=

E&"r2 P%; D"od1ar A%; Ri'!2 j%F% 0 Effi cac2 and saf"t2 of diff"r"nt dos"s and r"tr"at&"nt ofritu+i&a!: a rando&is"d; p(ac"!o4contro(("d tria( in pati"nts 91o ar" !io(o'ica( nal#" 9it1 acti#"r1"u&atoid art1ritis and an inad"buat" r"spons" to &"t1otr"+at" )Stud2 E#a(uatin'

Ritu+i&a!s Effi cac2 in MT. inad"buat" r"spond"rs )SERENE**% Ann R1"u& Dis doi:

=G%==B ard% ?GG% ==BB

onat1an C%j% Ed9ards; M%D%; L"s-"8 S-c-"pams8i L% 0 Effi cac2 of /4C"((0Tar'"t"d T1"rap29it1 Ritu+i&a! in Pati"nts 9it1 R1"u&atoid Art1ritis% N En'( M"d ?GG B6G:?6@?4?6=

57


160/166

Finc81 A%; Ciur"a A%; /ru(1art L% 0 / c"(( d"p("tion &a2 !" &or" "ff"cti#" t1an s9itc1in' to ana(t"rnati#" anti4tu&or n"crosis factor a'"nt in r1"u&atoid art1ritis pati"nts 9it1 inad"buat"r"spons" to anti4tu&or n"crosis factor a'"nts% Art1ritis R1"u& ?GG@ 6:==@4=?B

,"n8atac1a(a& S%; Ros8"(( S%; Suc1itra R% 0 Ritu+i&a! &a2 !" &or" "ff"cti#" t1an s9itc1in' to ana(t"rnati#" TNF in1i!itor in r1"u&atoid art1ritis pati"nts 91o 1a#" fai("d ot1"r TNF in1i!itors%R1"u&ato(o'2O+ford En'(and ?GG @ )supp(*: ii ?

/(o& M%; \i"#it j%; d"n /ro"d"r A% 0 Co&parison of t1" "ff"cti#"n"ss of ritu+i&a! and a t1irdTNF !(oc8in' a'"nt aft"r fai(ur" of t9o TNF !(oc8in' a'"nts in dai(2 c(inica( practic"% Art1ritisR1"u& ?GG 6: SBG

#an ,o(("n1o#"n R%; Car(i C%C% 0 T1" "ffi cac2 of ritu+i&a! in pati"nts 9it1 r1"u&atoid art1ritis)RA* 91o pr"#ious(2 fai("d on" or t9o anti4TNFs as co&par"d to t1" "ffi cac2 of s9itc1in'!"t9""n anti4TNFs: a r"'istr2 stud2% Art1ritis R1"u& ?GG 6:S

Finc81 A%; Ciur"a A%; /ru(1art L% 0 j1ic1 su!'roup of pati"nts 9it1 r1"u&atoid art1ritis !"n"fi tsfro& s9itc1in' to ritu+i&a! #"rsus a(t"rnati#" anti4tu&our n"crosis factor )TNF* a'"nts aft"rpr"#ious fai(ur" of an anti4TNF a'"ntg% Ann R1"u& Dis ?G=G :B@4BB doi:=G%==B

ard%?GG%=G6G

\"2ston" E "t a(% Saf"t2 and "fficac2 of additiona( cours"s of ritu+i&a! in pati"nts 9it1 acti#"r1"u&atoid art1ritis: An op"n4(a!"( "+t"nsion ana(2sis% Art1ritis and R1"u&atis&?GG@6)=?*:B4 G

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% Ada(i&u&a!; "tan"rc"pt; inf(i+i&a!;ritu+i&a! and a!atac"pt for t1" tr"at&"nt of r1"u&atoid art1ritis aft"r t1" fai(ur" of a aTNF% NICE

t"c1no(o'2 appraisa( 'uidanc" =6 )Au'ust ?G=G*% A#ai(a!(" fro&999%nic"%or'%u8'uidanc"TA=6 %

/uc1 M7; S&o("n S; /"tt"rid'" N "t a(% Updat"d cons"nsus stat"&"nt on t1" us" of ritu+i&a! inpati"nts 9it1 r1"u&atoid art1ritis% Ann R1"u& Dis ?G== @G:G4?G%

Scott DL; jo(f" F; 7ui-in'a Tj% R1"u&atoid art1ritis% Lanc"t ?G=G B@:=G4=G%


161/166

Lutt R; D"od1ar A% R1"u&atoid art1ritis: strat"'i"s in t1" &ana'"&"nt of pati"nts s1o9in' aninad"buat" r"spons" to TNFa(p1a anta'onists% Dru's ?GG :6=4G%

Frans"n ; #an Ri"( PL% Outco&" &"asur"s in inf(a&&ator2 r1"u&atic dis"as"s% Art1ritis R"s T1"r?GG ==:?%

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% R1"u&atoid art1ritis: T1" &ana'"&"nt ofr1"u&atoid art1ritis in adu(ts% NICE c(inica( 'uid"(in" @ )F"!ruar2 ?GG*% A#ai(a!(" fro&999%nic"%or'%u8'uidanc"C$@

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% Ada(i&u&a!; "tan"rc"pt and inf(i+i&a! fort1" tr"at&"nt of r1"u&atoid art1ritis% NICE t"c1no(o'2 appraisa( 'uidanc" =BG )Octo!"r ?GG@*%A#ai(a!(" fro& 999%nic"%or'%u8'uidanc"TA=BG

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% C"rto(i-u&a! p"'o( for t1" tr"at&"nt ofr1"u&atoid art1ritis% NICE t"c1no(o'2 appraisa( 'uidanc" = )F"!ruar2 ?G=G*% A#ai(a!(" fro&999%nic"%or'%u8'uidanc"TA=

58


162/166

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% $o(i&u&a! for t1" tr"at&"nt of r1"u&atoidart1ritis aft"r t1" fai(ur" of pr"#ious dis"as"4&odif2in' anti4r1"u&atic dru's% Nic" t"c1no(o'2appraisa( 'uidanc" ??6 )un" ?G==*% A#ai(a!(" fro& 1ttp:'uidanc"%nic"%or'%u8TA??6

Roc1" Products Ltd% Ma!t1"ra =GG&' and 6GG&' conc"ntrat" for so(ution for infusion% Su&&ar2of Product C1aract"ristics% 999%&"dicin"s%or'%u8 (ast updat"d G==?G=G

Nationa( Institut" for 7"a(t1 and C(inica( E+c"(("nc"% Toci(i-u&a! for t1" tr"at&"nt of r1"u&atoidart1ritis% NICE t"c1no(o'2 appraisa( 'uidanc" = )Au'ust ?G=G*% A#ai(a!(" fro&999%nic"%or'%u8'uidanc"TA=

T1" Sc1oo( of 7"a(t1 and R"(at"d R"s"arc1 )Sc7ARR*% Us" of ritu+i&a! in pati"nts 9it1r1"u&atoid art1ritis 9it1 conco&itant DMARDs; or as &onot1"rap2; for pati"nts 91o ar"into("rant to &"t1otr"+at"% S"pt"&!"r ?GG%

Ed9ards C; S-c-"pans8i L; S-"c1ins8i "t a(% Efficac2 of /4c"((4tar'"t"d t1"rap2 9it1 ritu+i&a!in pati"nts 9it1 r1"u&atoid art1ritis% N En'( M"d ?GGB6G:?6@?4=%

Strand ,; /a(!ir4$ur&an A; Pa#"(8a \ "t a(% Sustain"d !"n"fit in r1"u&atoid art1ritis fo((o9in'on" cours" of ritu+i&a!: i&pro#"&"nts in p12sica( function o#"r ? 2"ars% R1"u&ato(o'2 )O+ford*?GG6:=6G64=B%

Finc81 A; Ciur"a A; /ru(1art L "t a(% / c"(( d"p("tion &a2 !" &or" "ff"cti#" t1an s9itc1in' to ana(t"rnati#" anti4tu&or n"crosis factor a'"nt in r1"u&atoid art1ritis pati"nts 9it1 inad"buat"r"spons" to anti4tu&or n"crosis factor a'"nts% Art1ritis R1"u& ?GG@6:==@4?B%

ois RN; Masdin' A; So&"r#i((" M "t a(% Ritu+i&a! t1"rap2 in pati"nts 9it1 r"sistant r1"u&atoidart1ritis: r"a(4(if" "+p"ri"nc"% R1"u&ato(o'2 )O+ford* ?GG@:G4?%

Mc$ona'(" D; Tan AL; Madd"n "t a(% Ritu+i&a! us" in "#"r2da2 c(inica( practic" as a first4(in"!io(o'ic t1"rap2 for t1" tr"at&"nt of DMARD4r"sistant r1"u&atoid art1ritis% R1"u&ato(o'2)O+ford* ?GG@:64@%


163/166

,ita( "t a(%; Co&!ination ritu+i&a! and ("f(uno&id" produc"s (astin' r"spons"s in r1"u&atoidart1ritis% Ann R1"u& Dis ?GG@)Supp(% II*: G=% Ritu+i&a! in RA )non4NICE* NETA$ Nort1East Tr"at&"nt Ad#isor2 $roup; u(2 ?G== =

E&"r2 P; F("isc1&ann R; Fi(ipo9ic-4Sosno9s8a A "t a(% T1" "fficac2 and saf"t2 of ritu+i&a! inpati"nts 9it1 acti#" r1"u&atoid art1ritis d"spit" &"t1otr"+at" tr"at&"nt: r"su(ts of a p1as" II/rando&i-"d; dou!("4!(ind; p(ac"!o4contro(("d; dos"4ran'in' tria(% Art1ritis R1"u& ?GG6:=BG4GG%

E&"r2 P; D"od1ar A; Ri'!2 jF "t a(% Efficac2 and saf"t2 of diff"r"nt dos"s and r"tr"at&"nt ofritu+i&a!: a rando&is"d; p(ac"!o4contro(("d tria( in pati"nts 91o ar" !io(o'ica( nai#" 9it1 acti#"r1"u&atoid art1ritis and an inad"buat" r"spons" to &"t1otr"+at" )Stud2 E#a(uatin' Ritu+i&a!sEfficac2 in &"t1otr"+at" iNad"buat" rEspond"rs )SERENE**% Ann R1"u& Dis ?G=G:=?4B6%

Ru!!"rt4Rot1 A; Ta8 PP; _"r!ini C "t a(% Efficac2 and saf"t2 of #arious r"p"at tr"at&"nt dosin'r"'i&"ns of ritu+i&a! in pati"nts 9it1 acti#" r1"u&atoid art1ritis: r"su(ts of a P1as" IIIrando&i-"d stud2 )MIRROR*% R1"u&ato(o'2 )O+ford* ?G=G:=B4B%

59


164/166

Assous N; $oss"c L; Di"ud" P "t a(% Ritu+i&a! t1"rap2 in r1"u&atoid art1ritis in dai(2 practic"% R1"u&ato( ?GGB6:B=4%

R"nato $M% / c"(( d"p("tion in "ar(2 r1"u&atoid art1ritis: a n"9 conc"pt in t1"rap"utics% Ann N kAcad Sci ?GG==@B:@?4B6%

$a!a2 "t a(%; Eff"cti#"n"ss of Diff"r"nt DMARD Co4T1"rapi"s in Ritu+i&a!4Tr"at"d R1"u&atoidArt1ritis )RA* Pati"ntsR"su(ts of a On"4k"ar Fo((o9 Up Stud2 fro& t1" CERRERA Co((a!oration%% Art1ritis R1"u& ?G=G? Supp( =G :=G?%

7"n"s C; Sc1"d"( ; \an- L "t a(% Ritu+i&a! and conco&itant ("f(uno&id" for t1" tr"at&"nt ofr1"u&atoid art1ritis% R1"u&ato( Int ?G=GBG:@G4=?%

Nar#a"- "t a(%; Co&parati#" "ff"cti#"n"ss of ritu+i&a! in co&!ination 9it1 "it1"r &"t1otr"+at" or("f(uno&id" in t1" tr"at&"nt of r1"u&atoid art1ritis % ACR &""tin' ?G=G%

/u81ari M; A!"rn"t12 R; D"i'1ton C "t a(% /SR and /7PR 'uid"(in"s on t1" us" of ritu+i&a! inr1"u&atoid art1ritis% R1"u&ato(o'2 )O+ford* ?G==%


165/166


166/166

60

poliartrita reumatoida petras final

Documents