内科学PPT课件 类风湿关节炎RA 风湿性疾病
类风湿关节炎Rheumatoid Arthritis (RA),Outline,Definition and history Etiology,pathogenesis and pathology Clinical features Laboratory findings and Imaging Diagnosis and differential diagnosis Management,定义,Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by joint swelling, joint tenderness, and destruction of synovial joints, leading to severe disability and premature mortality. 2010 Rheumatoid Arthritis Classification Criteria (An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative),Medicine as an art,历史,The Three Graces 1639 by Peter Paul Rubens,History :Pierre-Auguste Renoir (1841-1919),历史： Erik Waaler,Erik Waaler,The occurrence of a factor in human serum activating the specific agglutination of sheep corpuscles. Acta Pathol Microboil Scand 1940; 1: 172-88.,Rheumatoid Pannus（血管翳）,Pannus （血管翳）,Rheumatoid Arthritis: Hand, Fusiform Swelling,（梭形）,Windows sign,Ulnar Deviation and Muscle Atrophy,Swan Neck Deformity and Boutonnire Deformity,钮扣花,Telescoping Sign,Arthritis Mutilans,残毁,Arthritis Mutilans,Hypermobility,Arthritis Mutilans,Subcutaneous Nodule, Olecranon,鹰嘴,Rheumatoid Nodules,Rheumatoid Nodules in the Lung,Rheumatoid Nodule: Pathology,RA and the lung,Vasculitis and Gangrene,（坏疽）,Scleromalacia Perforans（穿孔性巩膜软化）,Extensor Tendon Rupture,RS3PE,Popliteal Cyst（腘窝囊肿）,病因和发病机制,病理,Synovitis(滑膜炎） Vasculitis Rheumatoid nodules,临床表现,关节表现 晨僵Morning stiffness 关节痛Arthralgia 和关节压痛 tenderness 关节肿 Joint swelling 关节变形 Joint deformity 关节外表现,A Picture is Worth a Thousand Words,关节外表现,类风湿结节 Rheumatoid nodule 类风湿血管炎 Rheumatoid vasculitis 肺病变：肺间质病变最常见 心脏病变 心包炎 胃肠道 肾 神经系统 血液系统 干燥综合征 Sjogrens syndrome,A Picture is Worth a Thousand Words,实验室和其他辅助检查,血象 贫血，血小板数增多 炎性标志物: 血沉增快 C反应蛋白水平升高 自身抗体 类风湿因子 Rheumatoid factor（RF） 抗角蛋白抗体谱：抗CCP抗体等,实验室和其他辅助检查,免疫复合物和补体 关节滑液 关节影像学检查 X线平片 其他：MRI, 超声 类风湿结节活检,Progressive Right PIP3 Erosions in a 60-year Old Lady Suffering From RA,3/1989,Right Wrist in the Same Patient,3/1989,11/1990,3/1992,11/1993,1/1995,6/1996,3/1989,11/1990,3/1992,11/1993,1/1995,6/1996,Protrusio Acetabuli,髋臼突出,Target Population of the Criteria,Two requirements: (1) Patient with at least one joint with definite clinical synovitis (swelling) (2) Synovitis is not better explained by “another disease” Differential diagnoses differ in patients with different presentations. If unclear about the relevant differentials, an expert rheumatologist should be consulted.,2010 ACR/EULARClassification Criteria for RA,6 = definite RA,What if the score is <6? Patient might fulfill the criteria Prospectively over time (cumulatively) Retrospectively if data on all four domains have been adequately recorded in the past,鉴别诊断,骨关节炎 脊柱关节炎 银屑病关节炎 系统性红斑狼疮 风湿热,Psoriatic arthritis,72岁女性，双膝关节痛10余年，双手指关节肿痛8个月。膝痛以上楼时为重，劳累可以诱发。近8个月来双手近端指间关节、远端指间关节疼痛明显，天气变化时加重。晨僵半小时。查血ESR 24mm/h, RF（）。血常规正常。,处理,The ultimate goals are to: Prevent or control joint damage Prevent loss of function Decrease pain.,RA 是否为一“良性”疾病?,J Rheumatol 1986;13:841-5,Survival(%),Survival(%),Survival(%),Survival(%),治疗方法,一般性治疗 教育 休息 关节制动（急性期）及功能锻炼（恢复期） 物理疗法 药物治疗 外科治疗,治疗药物种类,改变病情抗风湿药 生物制剂靶向治疗 糖皮质激素 非甾体抗炎药 植物药制剂,改变病情抗风湿药(DMARDs),甲氨蝶呤 Methotrexate （ MTX） 来氟米特 Leflunomide 柳氮磺吡啶 Sulfasalazine 羟氯喹 其他DMARDs,生物制剂靶向治疗,TNF-拮抗剂 依那西普 英夫利西单抗 阿达木单抗 IL-6拮抗剂 妥珠单抗 CD20单克隆抗体 细胞毒T细胞活化抗原-4,目前观点,所有RA患者均应采用DMARD治疗 首选MTX. 严重RA患者可采用DMARD联合治疗，但方案中应包含MTX 目标治疗 (treat-to-target) 完全缓解 低疾病活动度,糖皮质激素,配合DMARD使用 小剂量、短疗程 缓解症状，减慢关节侵蚀进展 重症患者可使用中、大剂量短期使用 关节腔内注射 注意不良反应的防治 骨质疏松 GIOP 感染、高血压、高血糖,非甾体抗炎药 NSAIDs,具抗炎、镇痛作用 不改变RA病程、减慢关节破坏发展 不应做为RA的单一治疗 药物选择及不良反应 避免2种及以上的NSAID同时服用 选择性COX-2抑制剂可以减少胃肠道风险 心血管风险,预 后,预后不良指标 受累关节数多 RF/抗CCP高滴度 早期即出现骨侵蚀 全身症状重 存在关节外表现 死亡原因 感染 血管炎 肺间质纤维化,
