1. מקרה בראומטולוגיה דר ענת שיימן

2. בת 39 סובלת מכאבים בכפות ידיים וכפות רגליים 6 חודשים טרם קבלתה.

3. שאלות נוספות ?

4. בבדיקה

5. אבחנה מבדלת ?

6. Parvovirus B19 Rubella Hepatitis B,C PMR Adult Stills disease SLE Palindromic rheumatism Remitting seromegative symetrical synovitis with PE (RS3PE)

8. בדיקות נוספות ?

10. Anti CCP positive RF positive ESR 70 CRP 1.5 (0-0.5)

11. אבחנה וגורמים פרוגנוסטיים ?

12. פרוגנוזה תפקוד נזק רנטגני APR סרולוגיה Shared epitope on the HLA-DR

13. טיפול ? MTX HCQ SSZ Combination MTX+HCQ MTX+SSZ+HCQ MTX+SSZ+HCQ+Prednisone Prednisone Anti TNF

14. אחרי 3 חודשים : נפיחות ב 5 מפרקים, ESR 50, VAS 50 DAS 28-4.06

15. What is DAS? DAS28 Calculator Enter clinical data: tender joint count (0-28) swollen joint count (0-28) ESR (mm/hr) VAS general health patient (mm) Remission: DAS28 ≤ 2.6 Low Disease activity: 2.6 < DAS28 ≤ 3.2 Moderate Disease Activity: 3.2 < DAS28 ≤ 5.1 High Disease Activity: DAS28 >5.1 DAS28 = Disease Activity Score assessing 28 joints (range, 0 to 9.3)

16. טיפול ? MTX HCQ SSZ Combination MTX+HCQ MTX+SSZ+HCQ MTX+SSZ+HCQ+Prednisone Prednisone Anti TNF +MTX

18. SWEFOT In patients with early rheumatoid arthritis in whom methotrexate treatment failed, addition of a tumor necrosis factor antagonist to methotrexate monotherapy is clinically superior to addition of conventional disease- modifying antirheumatic drugs.

19. IE = immediate methotrexate (MTX) plus etanercept; IT = immediate triple therapy (MTX plus sulfasalazine [SSZ] plus hydroxychloroquine [HCQ]); SE = step-up from MTX to MTX plus etanercept; ST = step-up from MTX to triple disease-modifying antirheumatic drug (DMARD) therapy (MTX plus SSZ plus HCQ)

20. A randomized comparative effectiveness study of oral triple therapy versus etanercept plus methotrexate in early aggressive rheumatoid arthritis: The Treatment of Early Aggressive Rheumatoid Arthritis trial Arthritis & Rheumatism Volume 64, Issue 9, pages 2824-2835, 27 AUG 2012 DOI: 10.1002/art.34498 http://onlinelibrary.wiley.com/doi/10.1002/art.34498/full#fig2 Volume 64, Issue 9, http://onlinelibrary.wiley.com/doi/10.1002/art.34498/full#fig2

22. TEAR

24. Initial use of MTX monotherapy with the addition of sulfasalazine plus hydroxychloroquine (or etanercept, if necessary, after 6 months) is a reasonable therapeutic strategy for patients with early RA. Treatment with the combination of MTX plus etanercept resulted in a statistically significant radiographic benefit compared with oral triple therapy.

25. לתת סטרואידים ?

28. Date of download: 1/13/2014 Copyright © American College of Physicians. All rights reserved. From: Low-Dose Prednisone Inclusion in a Methotrexate-Based, Tight Control Strategy for Early Rheumatoid Arthritis: A Randomized Trial Ann Intern Med. 2012;156(5):329-339. doi:10.7326/0003-4819-156-5-201203060-00004 Individual patients' erosion scores. Totals of 112 and 110 patients were analyzed for the MTX and prednisone group and the MTX and placebo group, respectively. Arrows with percentages show the proportion of patients within each treatment strategy with no erosions at 2 y. MTX = methotrexate.

29. Date of download: 1/13/2014 Copyright © American College of Physicians. All rights reserved. From: Low-Dose Prednisone Inclusion in a Methotrexate-Based, Tight Control Strategy for Early Rheumatoid Arthritis: A Randomized Trial Ann Intern Med. 2012;156(5):329-339. doi:10.7326/0003-4819-156-5-201203060-00004 Course of disease activity variables during 2 years of treatment, based on pooled results of imputed analyses. * Significant differences between both treatment strategies at 3 mo, 6 mo, 1 y, 18 mo, or 2 y of treatment.

30. conclusion

31. החולה טופלה ב MTX+HCQ+SSZ ובהמשך ב MTX+ ETN הגיבה בתחילה אך כעת פנתה בשל כאבים בשוק ימין מאתמול. בבדיקה...

35. לחולה עדיין כאבי בכפות ידיים ורגליים, DAS 28-3

38. RTX- chimeric monoclonal AB against CD 20. TCZ- humanized monoclonal Ab against IL-6R. ABT-opposes co- stimulatory molecules which assist with binding of immune cells to T-cells

42. What is ACR 20, 50, 70? acute phase reactant patient assessment physician assessment pain scale disability/functional questionnaire

45. בשל חוסר שיפור על ETN+MTX, הוחלף הטיפול ל ADA + MTX

46. חל שיפור בכאבים, DAS 28 -1.6 מזה כחודש שיעול. אבחנה מבדלת ?

48. הטיפול בנוגדי TNF הופסק. השלימה טיפול בשחפת. אילו אפשרויות יש כעת לטיפול ב RA ?

49. תחת RTX, התיצבה. טופלה כחמש שנים.

50. סובלת כחודש מכאבים בצואר. אבחנה מבדלת ? בדיקות נוספות ?

52. Lateral view of the cervical spine done as a cross-table lateral shows a marked increase in the distance between the anterior surface of the dens and the posterior surface of the C1 tubercle (blue arrow) that measured 14 mm (black line), well in excess of the 3 mm maximum in adults. The imaginary line connecting the spinolaminar white lines (white line) shows that the body of C1 (red arrow) is displaced anteriorly relative to the remainder of the spine.

53. conclusions MTX does work as do combination DMARDs and steroids. Should you try another TNFi? Now what? The non-TNFi biologics Are there differences in efficacy?

56. Where not to use anti TNF?