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M.Olejárová Subkatedra revmatologie IPVZ Revmatologický ústav Praha. Osteoartróza. Současné možnosti farmakoterapie. Klasifikace léků pro OA. Strukturu modifikující léky OA. Symptomatické léky OA. s dlouhodobým efektem chondroitinsulfát glukosaminsulfát kyselina hyaluronová

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M.Olejrov

Subkatedra revmatologie IPVZ

Revmatologick stav Praha

Osteoartrza.Souasn monosti farmakoterapie


Klasifikace lk pro OA

Strukturu modifikujc

lky OA

Symptomatick lky

OA

s dlouhodobm efektem

  • chondroitinsulft

  • glukosaminsulft

  • kyselina hyaluronov

  • hylany

  • diacerhein aj.

s krtkodobm efektem

  • analgetika

  • NSA


Doporuen pro lbu osteoartrzy

ACR - OA kyle a kolene - 2000 ACR subcom., Arthritis Rheum 2000;43:1905

EULAR - OA kolene

Pendleton et al., Ann RheumDis2000;59: 936-44

EULAR - OA kyle

Zhang et al. Ann Rheum Dis 2005;64:669-81

EULAR - OA rukou

Ann Rheum Dis 2006


Paracetamol

Paracetamol je perorln analgetikum 1. volby a v ppad spchu i preferovan lk pro lbu dlouhodobou.

Pincus T et al. Arthritis Rheum 1999; 42: 404

Wolfe O et al. Arthritis Rheum 2000; 43: 378-89

Rodriguez G et al. Epidemiology 2001; 12: 570-6

Chandrascaran. PNAP 2002; 99: 1326


Nesteroidn antirevmatika

Lokln lba NSA je klinicky inn a bezpen (koleno, ruce).

Altman RD, Sem Arthritis Rheum 1994;23:25-32

Moore RA, BMJ 1998; 316: 333-342

Vail J, Drugs 1998; 56: 783-799

Systmov NSA jen u nedostaten reakce na paracetamol.

U zvenho GI rizika - neselektivn NSA s gastroprotektivy nebo COX-2 specifick inhibitory.

Laine L, Gastroenterology 1999; 117: 776

Hawkey C et al. Arthritis Rheum 2000; 43: 370

Hochberg M, Arthritis Res 2003; 5: 28-31


Opioidy

Opioidn analgetika (v monoterapii nebo kombinaci s paracetamolem) jsou alternativou v ppad, kdy jsou NSA, vetn koxib, kontraindikovna, neinn nebo patn tolerovna.

Roth SH. J Rheumatol 1998; 25: 1358-63

Pavelka K et al. Clin drug Invest 1998; 16: 1-9


Symptomatick pomalu psobc lky OA (SYSADOA)

SYSADOA - symptomaticky pomalu psobc lky OA - jsou symptomaticky inn a mohou modifikovat i strukturu.

Glukosamin sulft, chondroitin sulft, kyselina hyaluronov, hylan GF-20, diacerhein, ASU

Reginster J et al. Lancet 2001; 357: 251-56

Pavelka K et al. Arch Inter Med 2002; 162: 2113-23

Dougados et al. Arthritis Rheum 2001; 44: 2539


Dlouhodob symptomatick efekt glukosamin sulftu

Lequesnv index


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Vvoj ky kloubn trbiny na RTG kolen u terapie GS a placebem

Pavelka K et al, Arch Intern Med 2002;162:2113-23


Zmna ky kloubn trbiny kolennho kloubu bhem 2 let u pacient lench CHS a placebem

Michel B. et al. Arthritis Rheum 2005;52:779-786


Chondroitin sulft u OA rukou

  • Systems to assess the progression of finger joint OA and the effects of disease modifying OA drugs

  • Dv dvojit slep, placebem kontrolovan, tlet studie, n=165

  • Terapie

    • Chondroitin polysulft, n = 46

    • Chondroitin sulft, n = 34

    • Placebo, n = 85, po dobu 3 let

  • Zvry

    • CHS nezabrnil vvoji OA na dosud nepostiench kloubech

    • U CHS a CHPS men RTG progrese

    • Ni rozvoj EOA u CHS a CHPS

Verbruggen G et al., Clin Rheumatol 2002;21:231-43


Kyselina hyaluronovVvoj bolesti pi chzi (gonartrza)

VAS (mm)

Carraba at al. 1996


Strukturln efekt diacereinu u koxartrzy (dvojit slep, tlet studie)

Dougados et al. Arthritis Rheum 2001;44:2539-47


Intraartikulrn injekce depotnho kortikosteroidu je indikovna pi vzplanut bolesti, zvlt pi ptomnosti vpotku.

Jones A, Doherty M, Ann Rheum Dis, 1996


Zvry

Adekvtn analgetick terapie

Paracetamol analgetikum volby

NSA

Opioidy (slab, stedn siln)

Mon kombinace

SYSADOA

U symptomatick OA II.-III.st. podle Kellgrena-Lawrence

i.a. injekce kortikosteroid

Pi sekundrn zntliv reakci (koleno, ruce)


Otzky ? Odpovdi !


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