类风湿关节炎RheumatoidArthritis(RA)

郑州大学第一附属医院类风湿关节炎RheumatoidArthritis(RA)ByRaoulDufy(1877-1953)Outline•Definitionandhistory•Prevalance•Etiology,pathogenesisandpathology•Clinicalfeatures•Laboratoryfindings•Imaging•Diagnosisanddifferentialdiagnosis•ManagementRA定义•Anautoimmunedisorderofunknownetiologycharacterizedbysymmetric,erosivesynovitisand,insomecases,extraarticularinvolvement.•Mostpatientsexperienceachronicfluctuatingcourseofdiseasethat,despitetherapy,mayresultinprogressivejointdestruction,deformity,disability,andevenprematuredeath-----2003,AmericancollegeofRheumatologyMedicineasanartTheholyfamilywithSt.Anne(C1633—C1635)byPeterPaulRubens历史History:Pierre-AugusteRenoir(1841-1919)OntheTerrace(1878)ByPierre-AugusteRenoir历史：ErikWaalerErikWaalerTheoccurrenceofafactorinhumanserumactivatingthespecificagglutinationofsheepcorpuscles.ActaPatholMicroboilScand1940;1:172-88.患病率病因•遗传因素•感染因素•内分泌因素发病机理病理•Synovitis(滑膜炎）•Vasculitis–Rheumatoidnodules临床表现•关节表现–晨僵Morningstiffness–关节痛Arthralgia和关节压痛tenderness–关节肿Jointswelling–关节变形Jointdeformity•关节外表现APictureisWorthaThousandWords关节外表现•类风湿结节Rheumatoidnodule•类风湿血管炎Rheumatoidvasculitis•类风湿肺病变Lungdiseases•干燥综合征Sjogren’ssyndrome•心包炎Pericarditis•肾病变KidneydiseasesAPictureisWorthaThousandWords实验室检查•血液学异常–血小板数增多•炎症指标:–血沉增快–C反应蛋白水平升高•类风湿因子Rheumatoidfactor（RF）•抗CCP抗体RF=RA?CategoryDiseasesRheumaticdiseasesRA,SLE,scleroderma,sjogren’ssyndromeViralinfectionsAIDS,Hepatitis,influenza,aftervaccinationChronicbacterialinfectionsTuberculosis,leprosy,syphilis,subacutebacterialendocarditis,NeoplasmsAfterirradiationorchemotherapyOthersChronicliverorlungdisease放射学检查•确立诊断•监测疾病发展•监测药物治疗效果鉴别诊断•血清阴性脊柱关节病•骨关节炎•系统性红斑狼疮SLE•风湿热Rheumaticfever•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ESR24mm/h,RF（＋）。血常规正常。处理•Theultimategoalsareto:–Preventorcontroljointdamage–Preventlossoffunction–Decreasepain.治疗方法•非药物治疗•药物治疗•外科治疗治疗药物种类•改变病情抗风湿药DiseaseModifyingAnti-rheumaticDrugs(DMARDs)•糖皮质激素Glucocorticoids•非甾体抗炎药NonsteroidalAnti-InflammatoryDrugs(NSAIDs)•生物制剂Biologicagents•抗生素Antibiotics？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•金制剂Gold,oralorintramuscular•硫唑嘌呤Azathioprine•青霉胺D-penicillamine•环孢素Cyclosporine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•症状缓解不等于治愈BiologicsinthetreatmentofRA小剂量糖皮质激素•每天不超过10mg的泼尼松:–有效缓解症状–可能减慢关节侵蚀进展•应权衡得弊，综合考虑：–骨质疏松osteoporosis–感染Infection非甾体抗炎药NSAIDs•不应做为RA的单一治疗–具抗炎、镇痛作用–不改变RA病程、减慢关节破坏发展•选择应基于疗效、安全、方便性及费用–布洛芬–萘普生–双氯芬酸总结•定义•病理•临床表现•诊断•治疗RaoulDufy,LeBouquetd'Arums,1939