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Penatalaksanaan
Osteoarthritis
Rawan Broto
Bagian Ilmu Penyakit
Dalam
FK UMY Jogjakarta
Men
53%
37%
Truth:
Batasan
OA adalah penyakit sendi yang ditandai
dengan berbagai sindroma, karakteristik
dengan menipisnya rawan sendi secara
progresif, disertai respon pembentukan
tulang baru/osteofit pada trabekula
subkhondral atau tepi sendi
Osteoartritis
Epidemiology
Population
Male (%)
English
>35
70
69
US Caucasians
>40
44
43
Alaskan Eskimos
>40
24
22
Jamaican (rural)
35-64
62
54
Pima Indians
>30
74
56
Blackfoot
Indians
>30
74
61
South African
Black
>35
53
60
Epidemiologi
Indonesia:
Desa
Malang*
Bandungan**
13.5%
5.4%
10.0 %
OSTEOARTRITIS NODULAR
Prevalensi (%)
60
50
40
30
20
Lutut, Laki-laki
10
0
DIP, laki-laki
Lutut, perempuan
30
40
50
Usia (tahun)
60
70
DIP, perempuan
Faktor Risiko OA
Faktor mekanik:
trauma, bentuk sendi, penggunaan sendi,
kurang gerak
Occupation
Gender
OA
Family history
Genetics
Bone injury
Joint injury
Trauma
Joint
dysplasia
Solomon L. 1997
history
of disease
history of
disease
Increasing
age
history of
disease
Increasing
Being
age
female
Overuse
joint
of the
Overuse
of the
joint
Major
injury
Overuse
of the
joint
Major
injury
Overweight
Overuse
of the
joint
Major
injury
Overweight
Muscle
weakness
Pandangan Terbaru
Patogenesis OA
Anatomy of a normal
synovial joint
Muscle
Bone
Capsule
Ligaments hold the
bones together
Synovium
Secretes the
synovial fluid
Cartilage
Protects the
end of the bone
Synovial fluid
Lubricates the
joint capsule
Tendon
Dieppe P. 1998
Light load
Unaffected
cartilage
Light
contact
Cartilage
Cartilage
distortion
Cartilage
and bone
rebound when
weight is
removed
Characteristics of OA
Normal joint
OA joint
Thickening
of capsule
Modest, patchy
chronic synovitis
Cartilage:
Pitted and frayed surface
Loss of elasticity
Cartilage may wear away
completely
Articular cartilage in OA
Erosion
Softening Stage
Fibrillation Stage
Fragmentation Stage
Joint =
Bone + Cartilage +
Synovial Fluid
PATOGENESIS OA
Bukan sekedar Wear and Tear :
Obesity,
Developmental
and anatomic
abnormalities
Bony remodeling
and micro
fracture
Aging
Stresses
Abnormal
Cartilage
abnormal
Inflammation
Administration of
toxins
Normal
cartilage
Loss of joint
stability
Genetic and
metabolic
disease
Immune
response
Trauma
Theory A Biomaterial
failure
collagen network
fracture
Proteoglycan
unravelling
Theory B
Cell injury
Increase of degradative responses
Inhibitors reduced
Proteolytic enzymes increased
Destruction of prteoglycans collagen
and other proteins
Cartilage breakdown
RAWAN SENDI OA
Remodelling in OA
Hyaluronic acid
acid
Hyaluronic
Bone
Cartilage
HA
Capsule
Chondrocytes
HA
Synovial
lining
Osteoblast
Osteoclast
Bone
Synthesis: Synoviocyte, chondrocyte
INFLAMASI PADA
OSTEOARTRITIS
Before treatment
After treatment
khondrosit
Kerusakan jaringan kolagen
Peningkatan kadar air
Penurunan proteoglikan
Penurunan kualitas kolagen,
proteoglikan
Classification of OA
Primary
OA
Secondary
OA
Solomon L. 1997
primary OA (idiopathic)
secondary OA
Symptoms
Joint grinding/grating
Bony outgrowths
(osteophytes)
Joint deformities e.g.
Heberdens nodes
Gambaran Klinis
Nyeri sendi: jalan, naik tangga, waktu
malam, gerak lutut, kadang waktu diam
(seperti sakit gigi di lutut).
Hambatan gerak
Pembesaran sendi
Tanda keradangan minimal
Krepitus
Sendi yang sering terkena: lutut, koksa,
DIP, pergelangan kaki, tulang belakang.
Finger deformities in OA
Deformities
occur at:
The base of the thumb
(Bouchards nodes)
The middle joint of a finger
(Bouchards nodes)
The finger tip
(Heberdens nodules)
Heberdens nodules
in a patient with OA
Sciencephoto.com
OA Primer
OA Sekunder
Laboratory Tests
No specific laboratory test or value is
diagnostic for OA.
The erythrocyte sedimentation rate (ESR)
and hematologic & chemistry panels are
usually unremarkable.
Aspirated synovial fluid (if obtained) often
displays leukocytosis & high viscosity.
Other Diagnostic Tests
Radiologic evidence may be misleading
because structural evidence of OA
correlates poorly with symptoms.
Radiographic changes are often absent in
early OA.
As the disease progresses, joint-space
narrowing, subchondral bone sclerosis,
& osteophytes may be detected.
In late OA, there is gross deformity and
possibly effusions.
Gambaran radiologik OA
Indeks Kellgren dan Lawrence (KL)
KL-0
KL-1 (penyempitan celah sendi)
KL-2 (osteofit)
KL-3 (pembesaran tulang)
KL-4 (deformitas)
Osteofit
Celah sendi
menyempit
Celah sendi
Adakah deformitas?
Pencegahan
Balanced Diet
Stay
healthy
Exercise is important
Strengthening
Aerobic
Stretching
Aerobic Exercises
Walking, Biking
Walking Aides
Cane
Walker
Exercices
Suppress the signal
transduction
pathways of
proinflammatory/cata
bolic mediators
Goals
of therapy include
OA Medications !
NSAIDs
Nutritional Therapies
Non Traditional therapy
Future Therapies
Doctor
Perspectives !!!
Medications
Analgesics,
pain relievers,
may provide
temporary relief
of arthritis pain.
Must know what
the side effect
Farmakoterapi
OAINS : hanya menekan nyeri dan inflamasi, tidak
dapat menghentikan perjalanan penyakit
Kortikosteroid oral: tidak lazim diberikan pada OA
Steroid injeksi IA diberikan dengan temporary
Hyaluronan diberikan dengan pertimbangan tertentu
DMARD (Disease Modified Anti-Rheumatic Drugs
atau DC-ART (Disease Controlled Anti-Rheumatic
Therapy) : dapat mengontrol dan menghentikan
perjalanan penyakit
Moderate/severe
pain/inflammation
Acetaminophen
Steroids IA
COX-2 specific
Inhibitors
OTC NSAIDs
Tramadol
Propoxyphene
Opioids
Hyaluronans
(Hyalgan)
Traditional NSAIDs
(plus gastrorptection)
Surgery
PENGOBATAN SIMPTOMATIK
Jangka Pendek
NSAIDs mana ?
Sulit dijawab dengan singkat
Perhatikan perbedaan :
- Efektifitas pada berbagai individu Individual
- Efektifitas dan dosis optimal pada penyakit yang berbeda
- Farmakokinetik
- Efek samping
- Kepatuhan penderita
- Harga obat
- Lain-lain : faktor yang mempengaruhi perjalanan suatu obat
sebelum mencapai target organ, misalnya interaksi
dengan makanan, interaksi dengan obat lain,
bioavailibilitas dsb.
Tetrasiklin
Glycosaminoglycan polysulfuric acid
(GAPS)
Glycosaminoglycan peptide complexes
Pentosan polysulfate
Growth factors and sitokin (TGF-b)
Terapi genetik
Transplantasi stem cell
Osteochondral Graft
Anti TNF Alfa (Etanercept)
a. Topical NSAIDs
b. Counterirritants
VISCOSUPLEMENT
Advantages :
Safe and effective
Better than placebo
As effective as
NSAID
Improves patient
assessed pain
Low rate of
complication
Disadvantages :
Patient with more
severe radiographic
grade have responded
less
Potential adverse
event (rare): joint
effusion, joint swelling,
arthralgia, joint warm,
injection site erythema
Wang CT et al. J.Bone Joint SurbAm 2004.86A.538-545. Kemper F et al.CurrMed ResOpn2005.21.1261-1269. LussierA et al.
J Rheumatol1996.23.1579-1583. VadVB et al.Arch Phys Rehab 2003.84.634-637. PetrellaRJ et al. Arch Intern Med
2002.162.292-298
Recent advances
Weight loss 3,9 kg improves symptom of OA
Quadriceps exercises are beneficial in
patients with OA of the knee
Cox-2 selective drugs reduce the incidence of
ulcers
The prevalence of OA necessitates a shared
care approach to management between
general practitioners and hospital specialist
Several non surgical interventions to alleviate
pain and disability : education, social support,
physiotherapy and occupational therapy
Other Interventions
Enzym engineering
Total Knee
Joint
Replacement
Total Knee
Replacement