FARMAKOTERAPI OSTEOARTHRITISDEWI RAHMAWATI

PEMERIKSAAN MUSKULOSKELETAL3 MENITGaits (Cara Berjalan)

Arms (Tangan)

Legs (Kaki)

Spine (Tulang Belakang)

PERTANYAAN KUNCIAPAKAH ANDA MERASA NYERI ATAU KEKAKUAN DI SENDI-SENDI ATAU TULANG BELAKANG?

APAKAH ANDA MENGALAMI KESULITAN BERJALAN, MENAIKI TANGGA ATAU BANGUN DARI TEMPAT TIDUR?

APAKAH ANDA MENGALAMI KESULITAN BERPAKAIAN?

PENYAKIT REUMATIK YANG LAZIM DITEMUI DALAM PRAKTEK UMUMREUMATISME JARINGAN LUNAKOSTEOARTRITISARTRITIS REUMATOIDGOUTSYSTEMIC LUPUS ERYTHEMATOSUSARTRITIS SEPTIKREUMATOID ARTRITIS JUVENILSPONDILITIS ANKILOSAARTRITIS PSORIATIKSKLERODERMAPURPURA HENOCH-SCHONLEIN

PENYAKIT REUMATIK RAWAT JALAN

REUMATISME JARINGAN LUNAKOSTEOARTRITISGOUT

BONE REMODELLING

PEMBENTUKAN TULANGDAN KARTILAGOBONE REMODELLING SEPANJANG HIDUP TERGANTUNG KEBUTUHAN PERTUMBUHAN DAN PERUBAHAN BEBAN TUBUH (WEIGHT-BEARING)

PEMBENTUKAN TULANG BARU & MATRIX MINERALIZATION (OLEH OSTEOBLAST) RESORPSI TULANG & RELEASE MINERAL (OLEH OSTEOCLAST)

RESERVOIR UNTUK MINERAL (CA, PO4, DLL)

PEMBENTUKAN TULANG & KARTILAGOSEL PROGENITOR

SEL IMMATURE SEL IMMATURE (OSTEOBLAST) (CHONDROBLAST) PEMBELAHAN SEL & SEKRESI MATRIXOSTEOCYTE CHONDROCYTE (UTK TULANG)(UTK KARTILAGO)

Sejumlah osteoblast & fibroblast disimpan di periosteum dan chondrocyte disimpan di perichondrium, untuk pembentukan kembali tulang & kartilago

MINERAL HOMEOSTASISPENYIMPANAN & PELEPASAN MINERAL DI TULANG KADAR MINERAL (CA, PO4) DI DLM DARAH

SEX HORMON (ESTROGEN & TESTOSTERON) DAN GROWTH FACTOR TERUTAMA MEM- PENGARUHI SAAT USIA MUDA

DIPENGARUHI OLEH PARATHYROID HORMON (PTH), HORMON THYROID CALCITONIN, DAN 1,25 DIHYDROXYCHOLECALCIFEROL (CALCITRIOL) + SUMBER MINERAL DARI MAKANAN

DIPENGARUHI JUGA OLEH SITOKIN DAN GROWTH FACTOR

MINERAL HOMEOSTASIS (LANJUTAN)OSTEOCYTE BERPERAN MELEPASKAN MINERAL DARI TULANG

OSTEOCLAST TERUTAMA BERPERAN DALAM RESORPSI TULANG

PTH MENINGKATKAN JUMLAH DAN AKTIVITAS OSTEOCLAST, TETAPI DIDUGA HAL INI KARENA PENGARUH PTH-ACTIVATED OSTEOBLAST YANG PADA KONDISI NORMAL SELALU BERADA DI DALAM KESEIMBANGAN

MINERAL HOMEOSTASIS

SENDI NORMAL VS. OApenebalan kapsulLutut OsteoartritikLutut NormalPembentukan kistasklerosis tulangsubkondralfibrillated cartilagehipertrofi sinovialpembentukan osteofitkapsulkartilagosinoviumtulang

OSTEOARTHRITISDIAWALI DENGAN JARINGAN KARTILAGO AUS / TERCABIK

LALU TERJADI KERUSAKAN JARINGAN DI SEKITARNYA (RUANG ANTAR SENDI MENYEMPIT), TERBENTUK SUBCHONDRAL CYST

TIMBUL NYERI

USAHA UNTUK MEMPERBAIKI / REGENERASI (SCLEROSIS, OSTEOPHYTE LIHAT GAMBAR SENDI NORMAL VS OA)

OSTEOARTHRITIS-DEGENERATIVE JOINT DISEASE. -PREVALENSI MENINGKAT SEIRING DG USIA, MENINGKAT 2-10X DR USIA 30-65 TH

RISK FACTORS FOR OSTEOARTHRITIS

AGE OLDER THAN 50 CRYSTALS IN JOINT FLUID OR CARTILAGE HIGH BONE MINERAL DENSITY HISTORY OF IMMOBILIZATION INJURY TO THE JOINT JOINT HYPERMOBILITY OR INSTABILITY OBESITY (WEIGHT-BEARING JOINTS) PERIPHERAL NEUROPATHY PROLONGED OCCUPATIONAL OR SPORTS STRESS

ETIOLOGY CALCIUM DEPOSITION CONGENITAL OR DEVELOPMENTAL ENDOCRINE GENETIC DEFECTS :INTERLEUKIN-1 FAMILY,INTERLEUKIN-4 RECEPTORINFECTIOUS METABOLIC

NEUROPATHIC POST-TRAUMATIC RHEUMATOLOGIC DISEASES (OTHER THAN PRIMARY OSTEOARTHRITIS) OBESITYOCCUPATION :CARPENTERS, AGRICULTURAL WORKERSSPORT : BOXING, BASEBALL PITCHING, CYCLING, FOOTBALL

TINJAUAN UMUM OSTEOARTHRITISDEGRADASI KARTILAGO: HILANGNYA INTEGRITAS MATRIKSPERAN BERBAGAI SITOKIN, ENZIM DAN OKSIDA NITRATUMUR ADALAH FAKTOR RISIKO PALING KUATFAKTOR RISIKO LAIN: OBESITAS, CEDERA, KELEMAHAN OTOTLUTUT DAN PANGGUL MERUPAKAN TEMPAT YANG PALING SERING TERKENANODUS HEBERDEN DAN BOUCHARDNYERI MEKANIK, TIDAK ADA GEJALA SISTEMIK

DEGRADASI TULANG KARTILAGO

HERBEDENS NODES

OSTEOARTHRITIS PADA LUTUT

PERUBAHAN STRUKTUR TULANG

GENERAL MILD SYMPTOMS FOR MONTHS TO YEARS TYPICAL AGE :USUALLY >50 YEARS.

SYMPTOMS PAIN IN THE AFFECTED JOINTS (HANDS, KNEES,HIPS ) PAIN IS MOST COMMONLY ASSOCIATED WITH MOTION,PAIN IN LATE DISEASE CAN OCCUR WITH REST JOINT STIFFNESS IN THE MORNING < 20-30 THAT RESOLVES WITH MOTION; RECURS WITH REST

SIGNS JOINT STIFFNESS WITH OR WITHOUT JOINT ENLARGEMENT. CREPITUS A CRACKLING OR GRATING SOUND HEARD WITH JOINT MOVEMENT THAT IS CAUSED BY IRREGULARITY OF JOINT SURFACES

CLINICAL PRESENTATION

LIMITED RANGE OF MOTION THAT MAY BE ACCOMPANIED BY JOINT INSTABILITY. LATE-STAGE DISEASE IS ASSOCIATED WITH JOINT DEFORMITY (FIGURE 95-3 )

LABORATORY TESTS NO SPECIFIC LABORATORY TESTS USEFUL IN THE DIAGNOSIS.

OTHER RADIOLOGIC TESTSPLAIN RADIOGRAPHIC FILMS JOINT SPACE NARROWING, APPEARANCE OF OSTEOPHYTES IN MODERATE DISEASE (GAMBAR 95-4) ABNORMAL ALIGNMENT OF JOINTS AND JOINT EFFUSION IN LATE DISEASE.

DIAGNOSISHIP OAPAIN IN THE HIP, ESR 50 YEARS,MORNING STIFFNESS 30 , CREPITUS ON MOTION,BONY ENLARGEMENT, BONY TENDERNESS, OR PALPABLE WARMTH

Characteristics of osteoarthritis in the diarthrodial joint.

PENATALAKSANAAN OANON-FARMAKOLOGITERAPI PEMANASAN ATAU DINGINPROTEKSI SENDI MISALNYA PENURUNAN BERAT BADAN ORTOTIK, ALAT-ALAT BANTULATIHAN, MISALNYA ISOMETRIK, SEPEDA STATIS

FARMAKOLOGIANALGESIK - SISTEMIK AND TOPIKALOBAT ANTIINFLAMASI NON-STEROID (TERUTAMA COX-2 SPECIFIK INHIBITORS)STEROID INTRA-ARTIKULERHYALURONAT INTRA-ARTIKULAR?DISEASE-MODIFYING DRUGS

OPERASI

PERTIMBANGAN LATIHAN PADAOSTEOARTHRITIS PANGGUL DAN LUTUTPERTAHANKAN BERAT YANG SESUAI

PERTAHANKAN RANGE OF MOTION DAN FLEKSIBILITAS

LATIHAN DALAM AIR, DENGAN SEPEDA ATAU MESIN DAYUNG

LAKUKAN AKTIVITAS WEIGHT-BEARING DAN NON-WEIGHT- BEARING SECARA BERGANTIAN

GUNAKAN TARUK PADA SISI KONTRALATERAL

PERTIMBANGAN LATIHAN PADAOSTEOARTHRITIS PANGGUL DAN LUTUTJANGAN MEMBAWA BEBAN LEBIH DARI 10% BERAT TUBUH

SESEDIKIT MUNGKIN MENAIKI TANGGA, BERDIRI SATU KAKI ATAU DUDUK DI KURSI RENDAH

KECEPATAN BERJALAN JANGAN MEMBUAT GEJALA-GEJALA SENDI KAMBUH

PILIH SEPATU DAN SOL YANG MENAHAN GONCANGAN

PEMANASAN SEBELUM MELAKUKAN LATIHAN JALAN

SENDI NORMAL VS OA VS RA

TERAPI

DESIRED OUTCOMETO EDUCATE THE PATIENT, CAREGIVERS, AND RELATIVESTO RELIEVE PAIN AND STIFFNESS(C) TO MAINTAIN OR IMPROVE JOINT MOBILITY(D) TO LIMIT FUNCTIONAL IMPAIRMENT(E) TO MAINTAIN OR IMPROVE QUALITY OF LIFE

GENERAL APPROACH TO TREATMENTTHE PRIMARY OBJECTIVE TO ALLEVIATE PAINACETAMINOPHEN UP TO 4 G/DAY (INITIALLY)IF THIS IS INEFFECTIVE NSAIDS OR COX-2 SELECTIVE INHIBITOR (CELECOXIB)APPLICATION OF CAPSAICIN OR METHYLSALICYLATE TOPICAL CREAMS ADJUNCTS FOR PAIN CONTROLGLUCOSAMINE AND CHONDROITIN IN COMBINATION MODERATE TO SEVERE ARTHRITIS

JOINT ASPIRATION FOLLOWED BY GLUCOCORTICOID OR HYALURONATE CONCOMITANTLY WITH ORAL ANALGESICS OR AFTER THEIR LACK OF EFFICACYOPIOID ANALGESICS FINAL MEDICATION IF OTHER THERAPIES ARE UNSUCCESSFULSYMPTOMS ARE INTRACTABLE OR THERE IS SIGNIFICANT LOSS OF FUNCTION JOINT REPLACEMENT

TERAPIA. NON FARMAKOLOGI EXERCISE UTK HINDARKAN STRESS PD SENDI SAMBIL PERKUAT OTOT PERIARTIKULER HINDARI MUATAN BERLEB PD SENDI LUTUT DAN PINGGUL DG GUNAKAN ALAT BANTU (TONGKAT, SEPATU ORTO-PAEDI), TURUNKAN BB, EDUKASI PERLINDUNGAN SENDI

PHYSICAL AND OCCUPATIONAL THERAPYPHYSICAL THERAPYWITH HEAT OR COLD TREATMENTS AND AN EXERCISE PROGRAM TO MAINTAIN AND RESTORE JOINT RANGE OF MOTION AND TO REDUCE PAIN AND MUSCLE SPASMS. WARM BATHS OR WARM WATER SOAKS (RENDAM AIR HANGAT) DECREASE PAIN AND STIFFNESS

SURGERYOA WITH FUNCTIONAL DISABILITY AND/OR SEVERE PAIN UNRESPONSIVE TO CONSERVATIVE THERAPYTOTAL JOINT REPLACEMENT (ARTHROPLASTY) OF THE KNEE ,TOTAL HIP REPLACEMENT

B. FARMAKOLOGIPARASETAMOL UTK NYERI RINGAN (PILIHAN PERTAMA) , SEDANGKAN NSAID LBH EFEKTIF UTK NYERI SEDANG AD BERAT. * ESO : HEPATOTOXICITY, RENAL TOXICITY (LONG-TERM USE) TOPIKAL NSAID, CAPSAICIN KRIM SEKUAT NSAID LOKAL.- INJEKSI KORTIKO INTRA-ARTIKULER SGT EFEKTIF TX NYERI & INFLAMASI ISOLATED JOINT

NSAID DAN COX-2 INHIBITOR

- DIGUNAKAN BILA TX DOSIS MAKS PARACETAMOL(4G/HARI) TDK BERRESPON DAN DG EFFUSI SENDI.- KOMBINASI PAMOL + NSAID EFEKTIF- PX DG INFLAMASI SENDI : PILIHANNYA NSAID- EFEK SERIUS : GI BLEEDING, DISFUNGSI RENAL, PETD , RETENSI CAIRAN, EKSASERBASI HF. - COX-2 INHIBITOR SEEFEKTIF NSAID NON SELEKTIF, DG ESO RETENSI NA DAN PENURUNAN GFR.TRAMADOL PD PX YG KI DG COX INHIBITORNYERI SEDANG AD BERAT. ESO : MUAL, KONSTIPASI, DROWSINNES

ROFECOXIB WITHDRAWN IN 2004 BECAUSE OF INCREASED CARDIOVASCULAR EVENTS (ARITMIA) ANALYSIS OF THE ADENOMATOUS POLYP PREVENTION ON VIOXX (APPROVE) TRIALCELECOXIB IS LESS OFTEN USED NOW AND CARRIES A BLACK BOX WARNING FOR CARDIOVASCULAR AND GI RISKSTHE NEWER COX-2 INH: ETORICOXIB 30 MG, LUMIRACOXIB 100 MG/DAY ~ CELECOXIB

Other Toxicities with NSAIDs

Kidney diseases ~Acute renal insufficiency, tubulointerstitial nephropathy, hyperkalemia, renal papillary necrosis Clinical features :Cr and BUN , hyper-kalemia,TD , peripheral edema, weight gainMonitoring : Cr (3 to 7 days of drug initiation)

RISK FACTORS FOR ULCER COMPLICATIONS INDUCED BY NSAIDS

DEFINITE RISK FACTORS -PATIENT > 65 YEARS OF AGE -PREVIOUS ULCER DISEASE OR UPPER GASTROINTESTINAL TRACT BLEEDING -USE OF MULTIPLE NSAIDS OR USE OF A HIGH DOSAGE OF ONE OF THESE DRUGS -CONCOMITANT ORAL CORTICOSTEROID THERAPY -CONCOMITANT ANTICOAGULANT THERAPY -DURATION OF THERAPY (RISK IS HIGHER IN FIRST THREE MONTHS OF TREATMENT)

POSSIBLE RISK FACTORS -FEMALE GENDER -SMOKING -ALCOHOL CONSUMPTION -HELICOBACTER PYLORI INFECTION

KORTIKOSTEROIDKORTIKO SISTEMIK TDK DIREKOMENDASIKAN OK INFLAMASI BKN KOMPONEN PRIMER PATOFIS OA. INJEKSI INTRAARTIKULER (TRIAMCINOLONE HEXACETONIDE 40 MG) EFEKTIF UTK ASPIRASI EFUSI SENDI YG NYERI DAN BENGKAK, - FREKUENSI :3-5X / YEAR : * POTENTIAL SYSTEMIC EFFECTS OF STEROIDS * THE NEED FOR MORE FREQUENT INJECTIONS INDICATES LITTLE RESPONSE TO THE THERAPY).

VISCOSUPPLEMENT- MEDICAL DEVICES SBG PENGGANTI AS HYALURONAT DI SENDI YG RUSAK PD OA- NA HYALURONAT, HYLAN ( ALAMI DI CAIRAN SENDI) BUAT LINGK VISCOUS, BANTALAN SENDI, JAGA FGS NORMAL SENDI- SBG LUBRIKAN & SHOCK ABSORBER PD SENDI, SHG LINDUNGI TLG RAWAN DR KERUSAKAN- DIPAKAI BILA ANALGESIK GAGAL UTK OA LUTUT ( DI-BERIKAN ONCE WEEKLY DG 3-5 X INJEKSI SERI) RELIEF NYERI BERTAHAN AD 6 BLN

HYALURONATE INJECTIONSCONTAINING HYALURONIC ACID (HA; SODIUM HYALU-RONATE)AVAILABLE FOR INTRAARTICULAR INJECTION FOR TREATMENT OF KNEE OA DECREASE PAINHA IS AN IMPORTANT CONSTITUENT OF SYNOVIAL FLUID AND ENDOGENOUS HA HAVE ANTIINFLAMMATORY EFFECTS.HA PRODUCTS ARE INJECTED ONCE WEEKLY FOR EITHER 3 OR 5 WEEKS

GLUKOSAMIN DAN CHONDROITIN- GLUKOSAMIN ENDOGEN (MONOSAKARIDA AMIN) *DISINTESIS DR GLUCOSA, BAGIAN INTEGRAL PD BIO-SINTESIS PROTEOGLIKANS & GLIKOSAMINOGLIKAN (SUBSTRAT HYALURONIC ACID), YG BENTUK BLOK TLG RAWAN- CHONDROITIN SULFAT, SUBTRAT UTK PEMBENTUKAN MATRIK SENDI & MEMBLOK ENZYM YG BERTANGUNG JWB KERUSAKAN TLG RAWAN KOMBINASI GLUKO DAN CHONDRO : MODERATE TO SEVERE OA

PROBLEM MEDIKPERSISTENT PAIN AND INFLAMMATIONHEMATOLOGIC DISORDER (ANEMIA, TROMBOSITOPENIA DLL)GI DISORDER HEMATEMESIS MELENA, GI BLEEDINGUNDERLYING DISEASE AND COMORBID * CKD * CIRRHOSIS HEPATIC * CARDIOVASCULAR DISEASE (HYPERTENSION, HF DLL) * GASTRITIS * HEPATITIS

DRUG RELATED PROBLEMINAPPROPRIATE DRUG LESS OPTIMAL DOSAGEDRUG INDUCE ADVERSE DRUG REACTIONFAILURE TO RECEIVE A DRUGMONITORKONDISI NYERI DAN INFLAMASIDATA HEMATOLOGI, RFT,LFTSIDE EFFECT : GASTRIC BLEEDING ( MELENA )TEK DARAH, ELEKTROLIT

Algoritme OA

STUDI KASUS1. PASIEN A.N NY. SH USIA 67 TH, MRS TGL 11 SEPTEMBER 2010 DGN KELUHAN MUAL, MUNTAH DAN BAB WARNA HITAM,PANAS SELAMA TIGA HARI . PASIEN GEMUK,SERING ALAMI KEKAKUAN DAN NYERI SENDI TERUTAMA PAGI HARI. RIWAYAT OBAT JAMU PEGAL LINU DAN PUYER 16. DATA VITAL SIGN ( NADI : 90 X/MNT ; RR 22X/MNT;SUHU 38C). DATA LAB, LEUKOSIT 12.000 / MM3,HB.12,0 G/DL, K 2,5 MEQ/L. PASIEN DIDIAGNOSIS OBS. FEBRIS + GASTRITIS + MELENA. DARI FOTO GENUE PASIEN MENGALAMI OATEOARTHRITIS. DOKTER YANG MERAWAT MEMBERI ANTASIDA SIR 3X CII, OMEPRAZOLE 20 MG 2X1, PARASETAMOL 4X1, CEFTRIAXONE INJ 2X1, PIROKSIKAM 10 MG 2X1

2. TN. STR UMUR 60 THN, DATANG KE POLI REUMATOLOGI DGN KELUHAN NYERI BERAT DAN INFLAMASI PADA LUTUT KIRI HINGGA BETIS.PASIEN SUDAH MENDAPAT NA DIKLOFENAK 3X50 MG, RANITIDIN 150 MG 2X1, NEUROBION TAB 3X1 SAAT KONTROL 1 BULAN YANG LALU. DATA LAB MENUNJUKKAN LEUKOSIT 5000 / MM3 ( 4000-10.000/MM3), LED 30 MM/JAM ( 0 20 MM/JAM), TROMBOSIT 60.000 (150.000-400.000/MM3). PASIEN TERDIAGNOSIS OA

3. PASIEN A.N. TN SPD UMUR 50 TH, MRS DGN KELUHAN PERUT MEMBESAR 1 BLN,OEDEMA PADA KAKI, BICARA NGLANTUR, SOMNOLENCE, NYERI PADA TANGAN YANG DIGERAKKAN TERASA SAKIT.DATA KLINIK ,TD 130/100, SUHU 36C, NADI 88X / MNT, DATA LAB,LEUKOSIT 7500 / MM3, TROMBOSIT 90.000 / MM3, ALBUMIN 2,5 ( 4-6 G/DL), GLOBULIN 4,5 G/DL ( 4-6 G/DL). PASIEN TERDIAGNOSIS SIROSIS HEPATIKA DENGAN PENYAKIT PENYERTA OSTEOARTHRITIS. PASIEN PUNYA RIWAYAT HEMATEMESIS MELENA.DI BANGSAL, PASIEN MENDAPAT TERAPI FUROSEMIDA INJ 1-1-0, SPIRONOLAKTON 100 MG 1-1-0, KANAMYCIN KAPS 4 X 2, LAKTULOSE SIR 3 X CII, MELOXICAM 7,5 MG 2X1

PERTANYAAN :- BAGAIMANA PHARM CARE PADA PASIEN TSB DI ATAS ?

OA primarily starts as a cartilage problem, later involving other structures. Once these are affected, the patient starts to develop the pain characteristic of this condition.