Rheumatic diseases Zdeněk Fojtík Revmatologická ambulance, Interní hematoonkologická klinika, FN Brno Classification of arthritis and rheumatism I * Inflammatory arthritis - rheumatoid arthritis - spondyloarthropathy - psoriatic arthritis * Diffuse connectice tissue diseases - SLE - systemic sclerosis - Sjogren syndrom - dermatomyositis/polymyositis •Vasculitis, ANCA associated vasculitis - GPA – granulomatosis with polyangiitis - EGPA – eosinophilic granulomathosis with polyangiitis s Classification of arthritis and rheumatism II * Degenerative joint diseases – osteoarthritis * Rheumatic syndromes associated with infectious agens - reactive arthritis – postdysenteric, post- gonoccocal, after other infections - direct infection arthritis G+, G-, spirochete, Lyme disease? Classification of arthritis and rheumatism III * Metabolic and endocrine diseases – crystal associated conditions - gout - CPPD chondrocalcinosis * Bone and cartilage disorders - osteoporosis - osteomalacia - Paget disease Classification of arthritis and rheumatism IV * Extraarticular disorders - polymyalgia rheumatica - fibromyalgia - chronic fatigue syndrom - sarcoidosis Inflammatory arthritis - rheumatoid arthritis - spondyloarthropathy - psoriatic arthritis Rheumatoid arthritis is chronic, frequently progressive and destructive, systemic, inflammatory disorders. The main character of pathofysiology is inflammation of synovial tissue, membrane of joints, tendons and bursis Rheumatoid arthritis is chronic, systemic, inflammatory disorders Atacs of exacerbation and remision, we can treat, it is treatable but incurable Corse of RA: schematic model, RA is frequently progresivve and destructive autoimmune disease 0 Time in years of RA 5 10 15 20 25 30 inflammation disability X-changes Kirwan JR. J Rheumatol. 1999;26:720-725. Rheumatoid arthritis is chronic, systemic, inflammatory disorders - Not only joints, but also others organs - Systemic changes ( lung, cor, kidney) - RA is associated with comorbidities - RA is associated with reduction of life -expectancy appr. 5 -10 years - Rheumatoid vasculitis 5-C-14 Episcleritis 5-C-17 Scleromalatia 1-11.png Rheumatoid arthritis is chronic, systemic, inflammatory disorders The main character of pathofysiology is inflammation in synovial tissue, infiltration of pro inflammatory cytokines (Interleukines - 1,6, TNF) Incidence RA is higher in women Uhlig T, et al. J Rheumatol. 1998;25:1078-1084. 0 20 40 60 80 20-29 30-39 40-49 50-59 60-69 70-79 Age ženy muži RA Etiology Several studies have noted a disproportionate incidence of RA in females compared to males [eg, Buckwalter JA and Lappin DR. Clin Orthop Relat Res. 2000;372:159-168], although the reasons for the differential incidence are not entirely clear. For example, one study examined the incidence of RA in Oslo utilizing a community registry. [Uhlig T, et al. J Rheumatol. 1998;25:1078-1084] The Oslo registry assessed 550 patients (409 women; 141 men) aged 20-79 years who had an established diagnosis of new-onset RA during the years 1988-1993. Incidence data were compiled by yearly inception cohort, gender, and by age. Health-related quality of life measures (MHAQ; AIMS2) were also assessed using a postal survey. The overall incidence of RA over a 6 year period was 25.7/100,000 (females 36.7; males 13.8). The incidence of RA increased with age, from 7.8 in patients aged 20-29 to 61.0 in patients aged 70-79 years. The incidence of RA was higher in women than in men in all age groups. The incidence ratio of women to men was highest at ages 30-49 (ratio ~4.5-5.0) and decreased after menopause (ratio ~1.6 at ages 70-79). Smoke and risc of RA Pedersen M, et al. Arthritis Res Ther. 2006;8:R133. RA Etiology The risk for developing RA increased with the number of pack-years of smoking; risk was similarly increased for both men and women. [Pedersen M, et al. Arthritis Res Ther. 2006;8:R133] Hypothesis of pathophysiology of RA 25 American College of Rheumatology / European League Against Rheumatism (ACR/EULAR) 2010 Classification Criteria for RA Factor Points Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0 2-10 large joints 1 1-3 small joints (metacarpophalangeal, proximal interphalangeal, 2nd through 5th metatarsophalangeal joints, and wrist) 2 4-10 small joints 3 > 10 joints (at least 1 small joint required) 5 Serology* Negative RF and negative ACPA 0 Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3 Acute-phase reactants* Normal CRP and normal ESR 0 Elevated CRP or elevated ESR 1 Duration of symptoms <6 weeks 0 ≥6 weeks 1 Criteria to be classified as RA = At least 1 swollen joint (unexplained by another disease) and a total of ≥6 points * at least 1 laboratory test result is needed for classification Legend: CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, RF= rheumatoid factor, ACPA = anti-citrullinated protein antibody Aletaha D, et al. Arthritis Rheum. 2010;62:2569-2581. Revmatoidní artritida- otok PIP kloubů Pokročilé změny u RA 5-C-9 RA 5-C-6 Revmatoidní artritida teleskopické prsty 5-C-8 Arthritis mutilans 5-R-11 Pokročilé deformity. MCP: zúžení kloubních štěrbin, subluxace, ulnární deviace, eroze v hlavičkách. PIP - zúžení kloubních štěrbin 5-R-16 Revmatoidní artritida subperiostální novotvorba kosti zúžení štěrbiny eroze 5-R-14 Revmatoidní artritida protruze acetabula Rheumatoid nodulus Indexis for measure aktivity RA https://img.medscapestatic.com/article/932/416/Slide5.png DMARDs – disease modifiyng antirheumatic drugs •csDMARDs - conventional syntetic DMARDs •boDMARDs – biologic originator DMARDs •bbDMARDs – biosimilar DMARDs •smDMARDs – small molecul DMARDs Conventional syntetic DMARDs Střeva Zánětlivá choroba střevní Enterogenní reaktivní arthritida Spondylartropatie .... hlavní charakteristiky Axiální postižení Sacroiliitida, spondylitida Močový trakt Urogenitální reaktivní arthritida Periferní postižení Arthritida, enthesitida, daktylitida Oko Uveitida Kůže Psoriáza There is a genetic susceptibility (HLA-B27). Much to the contrary of rheumatoid arthritis, the therapeutic optons in these patients are limited to the use of NSAIDs, Sulphasalazine (in case of peripheral arthritis) and physiotherapy. https://img.medscapestatic.com/article/943/191/Slide2.png Text.jpg Text_logo.jpg Medicines_Text.jpg Material intended for Medic-to-Medic communication ONLY. Not to use for promotion. ASAS progression of nr-axSpA slides/p1/slide1 Diagnosis of axSpA: Diagnostic algorythm Rudwaleit M et al, Ann Rheum Dis 2004; 63: 535-43 57 ASAS-Diagnosis-10 ASAS-Diagnosis-8 Percentages indicate disease probability bambusová páteř sakroiliitida IV Psoriatic Arthritis Související obrázek C:\Users\25180\Desktop\inflammatory-arthritis-an-overview-33-638.jpg ASYMMETRICAL OLIGOARTICULAR ARTHRITIS Ò Ò Ò Ò Ò Ò Ò MC type (70%) Asymmetrical similar to low grade gout. Sausage lik... Dactylitis in PsA Enthesitis in PsA SYMMETRICAL POLYARTHRITIS Ò Ò Ò Ò - - - Rheumatoid like pattern. 15% Hands, wrists, ankles, and feet may be involved. D... DISTAL INTERPHALANGEAL ARTHROPATHY Ò Ò Ò Ò Classical form Less common 16% Involvement of the nail with significant infla... Key Cell Types and Activated Pathways in Psoriatic Arthritis GRAPPA Treatment Scheme PsA C:\Users\25180\Desktop\F1_large.jpg PsA C:\Users\25180\Desktop\imagesOYPAJ0JH.jpg Postižení nehtů u PsA Postižení DIP kloubů s onycholýzou „Olejové skvrny“ RTG nálezy u psoriatické artritídy Kloubní postižení u PsA Párkovitý prst Postižení DIP kloubů Mutilující artritida