View
227
Download
2
Category
Preview:
DESCRIPTION
note
Citation preview
OSTEOARTHRITISOSTEOARTHRITIS
Blondina Marpaung
Rheumatology DivisionInternal MedicineDepartment
Medical Faculty Sumatera Utara University
The most common degenerative joint had been seen in :
•human
•Rats
• whales
•Dinosaur fossil
It had been recognice since 5000 years ago
* Over 40 years old
* Woman : man = 4 : 1
• The most common joint disease
in Indonesia
* Weight bearing joints
Chronic disease due to articular Chronic disease due to articular cartilage damage with a new bone cartilage damage with a new bone
formation.formation.
OsteoarthritisOsteoarthritis
• degenerative joint disease
• cartilage and sub chondral damage
• imbalance between synthesa and
degradation
• cartilage erosives, cyst formation, osteophytes formation
• synovial inflammation
FUNCTONAL IMPAIRMENT:
Restricted movement
Intermitten
Mild at early phase
Joint stiffness : - localized / temporary
- in the morning before activity - weather alteration
Crepitation :-The sensation of bone rubbing against bone
- palpable at knee joint
Helpful for diagnosis
GAIT DISORDER
* ANTALGIC GAIT (PAIN AT WEIGHT BEARING JOINT)
* TRENDELENBURG GAIT ( HIP )
* STIFF KNEE GAIT
* LUMBAR CLAUDICATION (VERTEBRA LUMBAL)
RISK FACTOR
Knee joint: * Body weight- linier association- obese woman 7 x fold risk
* Activity- menekuk sendi lutut- weight bearing
Panggul : * obesitas kurang berperan* hubungan erat dgn aktivitas (petani)
* Race Kaukasia >> Asia (orang Asia sering jongkok)
Joint Predilection Joint Predilection Most common : weight bearing joint - knee - lumbal - cervical
Generalized OA DIP ( Heberden node )
thickening capsule
OA KNEENORMAL KNEE
Cyst formationSubchondral
bone sclerosisCartilge articular
fibrillation
Synovium hypertrophyOsteofphyte formation
capsule
cartilageArticular
Synovium
bone
ACRFP
NORMAL versus OA JOINT
Clinical featuresClinical features
OA of HandsOA of HandsHeberden’s and Bouchard’s NodesHeberden’s and Bouchard’s Nodes
Chondrocyte : Play role in collagen and proteoglycan
synthesis
Articular Cartilage
MATRIX EXTRACELLULER : Water (65-85 %) Collagen type I (15-25 %) Proteoglycan (10 %) Collagen type VI, IX, XI and XIV Connective Protein etc
Mature chondrocyte cell
Produces Collagen & proteoglycan
CHONDROCYTE
Function : produces syntheses and degradates articular cartilage enzymes
Stabil and balance articular cartilage
COLLAGEN
a protein with strenght and elastic fibre Play role as tissue skeleton
Function : perekat yang membangun matriks rawan
sendi
PROTEOGLYCANMacromolecule yang dibangun oleh protein & gula
Terdiri dari : Inti protein Glycosaminoglycan Chondroitin sulphate Keratan sulphate
menyokong stabilitas dan kekuatan rawan sendiProteoglikan membentuk kesatuan dgn asam hialuronat
Fungsi :
menghisap dan mengeluarkan air sesuai dgn gerakan sendi
Evaluation Konventional Radiology
cant assess early OA
because : cartilage thickening can assessbut surface alteration cant
- Cartilage thinning / narrowing joint cleave
OA process had been 10 year
Clinical Presentation of OA
Symptoms*Pain–initially with useStiffnessLimitation of motion
SignsCrepitusBony hypertrophyBony tendernessLimitation of range
of motion
MalalignmentAltered gait*Insidious onset
Risk factor for osteoarthritisRisk factor for osteoarthritisNon-modifiable
Age Race Genetics (Col 2A1 gene) Female sex Metabolic and endocrine
disease Congenital defect Neurological defect
Modifiable Major trauma Repetitive stress Inflammatory joint
disease Obesity Smoking Hormone Quadriceps muscle
weakness
Hochberg MC. J Rheumatol 1991; 18: 1438-40.
Therapy principle
• Pain Reduction / elimination
•Functional impairment prevention/
reduction
•Disability prevention
Management of OsteoarthritisManagement of Osteoarthritis
Non-pharmacological therapyNon-pharmacological therapy Pharmacological therapyPharmacological therapy
SurgerySurgery
Non-pharmacological therapyNon-pharmacological therapy
Patients education, self-management program Weight control Physical therapy, occupational therapy Exercise program Assistive devices Joint protection Appropriate foot ware
Modified from ACR subcommittee. A&R 2000; 43:1905-15.
Pharmacologic Management of OAPharmacologic Management of OA
Systemic therapySystemic therapy Nonopioid analgesicsNonopioid analgesics NSAIDs / Cox 2 inhibitorNSAIDs / Cox 2 inhibitor Opioid analgesics Opioid analgesics DMOAD’s / SYSADOA’s: DMOAD’s / SYSADOA’s:
Chondroitin & Glucosamine Chondroitin & Glucosamine DoxicyclineDoxicyclineChloroquine Chloroquine visco suplementvisco suplement
Diacerine Diacerine
Local therapyLocal therapyTopical agents Topical agents Intra-articular Intra-articular
agentsagents
CAUSAL DRUGS / DMOADS
• Visco supplementation
Hyaluronan / Hyalgan Intra articular
- Main molecule of proteoglycan - Activates repairing cartilage process.
- Normalyzed synovial fluid quality.
* Intra articular inj. 20 mg (1 amp) weekly, 5-7 weeks
• Chloroquin
- inhibits IL-1 expression
- inhibits supression of prostaglandin synthese-Slowing progression of OA stage-Repairs OA pathology
• Chondroitin Sulphate
- matrix proteoglycan formation-Dose : per-oral 400 mg , 3 x / day
OA: Intra-articular TherapyOA: Intra-articular Therapy
• Intra-articular steroid• Good pain relief • Most often used in knees,
up to q 3 mo• With frequent injections,
risk infection, worsening diabetes, or CHF
• Joint lavage• Significant symptomatic
benefit demonstrated
• Hyaluronate injection• Symptomatic relief • Improved function• Expensive• Require series of injections• No evidence of long- term
benefit• Limited to knees
* Altman, et al. J Rheumatol. 1998;25:2203.
Surgical Therapy for OASurgical Therapy for OA• ArthroscopyArthroscopy
• May reveal unsuspected focal abnormalitiesMay reveal unsuspected focal abnormalities• Results in tidal lavageResults in tidal lavage
• Osteotomy: May delay need for TKR for 2 to 10 yearsOsteotomy: May delay need for TKR for 2 to 10 years
• Total joint replacement: When pain severe and Total joint replacement: When pain severe and function significantly limitedfunction significantly limited
PHARMACOLOGICAL THERAPY OF PHARMACOLOGICAL THERAPY OF OSTEOARTHRITISOSTEOARTHRITIS
EULAR Recommendation(Ann Rheum Dis 2003;62:1145-55)
Analgesics Acetaminophen NSAIDs and COX-2 inhibitors Tramadol and opioids
Topical Capsaicin and topical NSAIDs
Intra-articular Corticosteroids Hyaluronan
Symptomatic slow acting drugs Glucosamine sulfate Chondroitin sulfate Diacerein
Treatment of osteoarthritis Treatment of osteoarthritis (of the knee)(of the knee)
Education, PT, OT, weight reduction, topic analgesics
Simple analgesicsIA co
rtico
stero
ids, IA hya
luronan
SurgeryExercise, assistive devices
NSAIDs or specific COX-2 inhibitors, or tramadol, or
opioids analgesics
SYSADOAs
Glucosamin:o Stimulates chonrocytes to produces more
and faster collagen and proteoglycan o Normalyzed metabolism of cartilage articularo Eliminates of pain o Supports joint movement
GLUCOSAMIN & KONDROITIN GLUCOSAMIN & KONDROITIN FUNCTIONFUNCTION
Chondroitin:
o Role as liquid magnet membantu menarik cairan ke dalam molekul-molekul proteoglikan sehingga membantu jalannya nutrisi kartilago dan juga berperan sebagai Spongy Shock Absorber
o Mempercepat penyembuhan luka dan tukak
IL1
DNA
mRNA
iNOS
NO
apoptosis
Cartilago Degradation
Inhibitor sitokin( diacerhein, kloroquin ? )
Terapi gen
Inhibitor NOS
Inhibitor protease
CollagenProteoglican
Autolytic Enzyme
ChondroitinGlucosamine
Hyaluronate
Teori kerja beberapa obat pada Osteoartritis
Tetracyklin, ASA, SA
Cyclosporin,Metothrexat
ASA
COX2 NSAID ?
Inflammation
Thank You . . . .
Dr. Blondina Marpaung, SpPD - KR
Recommended