Y HQC Vl|T NAM THANG 7/2011 - SO OAC BIET
THANG OIEM DlT BAO BENH NHAN VIEM KHOP
KHONG OAC HIEU TIEN TRIEN THANH VIEM KHCJP DANG THAP
Hoang Van Dung*
TOM TAT:
Chin doan benh viem khdp dang thap hien nay vSn dira theo tieu chuan cOa Hoi thap khdp hpc IVly 1987. Tuy nhien, nhufng benh nhan dap umg dO tieu chuan chan doan nay thi benh cung da d giai doan tien trien.
Tren thi/c te, cd rat nhieu benh nhan viem khdp l<hdng dac hieu giai doan sdm da bj bo qua chan doan benh viem khdp dang thap va l<hdng diTdc dieu trj tich circ vi chi/a dap flng di/gc cac tieu chuan chan doan. Tren cd sd dd mot tieu chuan mdi de chan doan viem I<h6p dang thap s6m dang dirdc quan tam nghien cflu va thanh lap.
Tiir khoa: Viem khdp khong dSc hidu, Viem khdp dang thap
SUMMARY:
The criteria diagnosis of rheumatoid arthritis is still based on ACR 1987 criteria.
But, most of patients who are fulfilled ACR 1987 criteria are in advanced stages. In practically, many patients with very early undifferentiated arthritis are skipped iii diagnosis and treatment. So a new criteria diagnosis for the early rheumatoid arthritis is very useful and necessary.
Key word: UA: undifferentiated arthritis, RA- rheumatoid arthritis
I. 0^1 Cl/ONG
Vidm khdp dang thip (Rheumatoid Arthritis - RA) li mdt bdnh die mmg bdi tinh trang vidm man tmh cua mang boat dich khdp.
La mdt trong cic benh tu midn hay gap nhit, ndu khdng dugc chin doin sdm, dieu tri dung va kip thdi bdnh se tidn tri^n ngay cang nang din, din ddn phi buy khdp, giy tan phe cho ngudi benh anh hudng nhi^u ddn kha nang lao ddng sinh hoat va chit lupng sdng cua ngudi benh. Su phi huy khdp nhu: bao mdn xuong, loang xuong quanh khdp va mit sun khdp di dupe xie dinh la didn ra ngay trong 2 nam diu khdi phit benh neu nhu khdng dupe di6u tri hieu qua. [5,7].
Hien nay, chin doin viem khdp dang thip vin dua vao tieu chuin chin doin cua Hdi Thip ididp hpc My (ACR 1987- The American College of Rheumatology). Tuy nhien, tidu chuin nay cdn cd nhieu ban chd' trong viec chin doin sdm viem khdp dang thip nhu: tidu chuin nay dupe phit triln trdn CO sd sd lidu tfl nhflng benh nhin vidm khdp dang thip da tidn triln. Khing the khing citruUinated peptides vdng (anti-CCP antibodies) chua dugc bidt ddn vao thdi dilm thidt lip tidu chuin niy. Trong khi nhflng xet nghidm tu khing thi nay dugc chflng minh cd vai trd rit quan trpng trong chin doin va tidn lugng bdnh vidm khdp dang thip. Mdi lidn quan gifla ndng dd cao cua yeu td dang thip (Rheumatoid Factor RF) vdi bdnh vidm khdp dang thip chua dugc dinh gii mdt cich thich ding trong tieu chuin ma chi la dinh tinh RF [8]. Vl viy, nhilu benh nhin vidm khdp d giai doan sdm chua dip flng du cac tidu chuin dl chin doin theo ACR 1987 se bi bd qua chin doin sdm. Khi benh nhin dip
HOI THAP KHdP HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
flng du tieu chuin thi bdnh da d giai doan tidn triln, khi dd su phi buy va bieh dang khdp da diln ra. Hon the' nfla, mflc dp khdng hdi phuc cua tori thuong va bidn dang khdp se phu thudc chu ydu vao thdi gian tfl khi khdi phit bdnh den khi bit diu thiet lip phic dd dilu tri thich hgp [2, 8]. Vi vay, mdt chie'n lupc dugc thid't k l cd hieu qua dl phi vd co che bdnh sinh benh vidm khdp dang thap va cd hidu qua lau dai ngin chan su tien triln cua bdnh se phu thudc rit Idn vao vide quylt dinh dieu tri sdm theo dflng phac dd [2, 4].
Trdn thuc td d giai doan sdm cua bdnh, mdt lugng Idn benh nhin vdi bilu hidn vidm khdp dai dang thi mdt khdp (monoarthritis), vai khdp (oligoarthritis), hay nhieu khdp (polyarthritis) khdng rd chin doin vi khdng du tieu chuin chin doin vidm khdp dang thip hay mdt bdnh ly viem khdp dac hidu nao khic. Nhiing bdnh nhin cd bilu hien vidm khdp kilu nhu viy dugc gpi la viem khdp khdng die hieu (Undifferentiated arthritis UA). Vidm khdp khdng dac hieu dugc dinh nghia la bit kl loai viem khdp nao cd tiem ning trd thanh vidm khdp dai dang ma khdng
sau 1 nim, cdn lai la viem khdp die hidu khic va viem khdp khdng die hidu dai dang vin tdn tai [1,9].
Do dd, viec xac dinh xem bdnh nhin nao se tien triln thanh viem khdp dang thip la hit sflc quan trpng dl tien hanh dieu tri cang sdm cang td't. Tuy nhien, cung cin phai trinh tinh trang dilu tri tfch cue khdng cin thilt, thim chi cd hai cho nhung benh nhin it cd nguy co trd thanh vidm khdp dang thip.
Hien tai, viec dilu tri nhihig bdnh nhin viem khdp khdng die hieu vin chi dua vao cic thud'c chdng viem khdng steroid. Viec dilu tri bing cic thud'c chd'ng thi'p khdp lam thay ddi benh (DMARDs - Disease Modifying Anti Rheumatic Drugs) vin chi dugc bit diu ap dung cho nhflng bdnh nhin da du tieu chin doan vidm khdp dang thip theo tieu chuin ACR 1987. Trong viem khdp dang thip, hidu qua cua cic thudc DMARDs trong dilu tri da dugc nhilu nghi6n cflu chflng minh la Iam giam thim chi lam ngflng su tiln triln bdnh, lam giam su phi buy ciu trflc khdp tren xquang, duy tri chflc nang vin ddng cua khdp so vdi nhiing bdnh nhin dip ung du tidu chuin di chin doin vao mdt khdng dupe dilu tri [4]. Tren co sd dd cd gia loai vidm khdp die hidu [6]. thuylt cho rang vide dieu tri cac thudc nhdm Tien lugng cua nhflng bdnh nhin viem DMARDs se lam thay ddi thim chi Iam khdp khdng die hidu ri't khic nhau tfl tu ban
chd' cho de'n su phi buy ci'u trflc khdp nghiem trpng nhu trong viem khdp dang thip. Sau mdt thdi gian tien triln vai thing hoac thim chi vai nam cd nhung bdnh nhin lui benh hoan toan, cd nhung benh, nhin tie'n triln
ngflng su tiln tridn tinh trang viem khdp khdng die hidu khdng chuyin thanh benh vidm khdp dang thip neu nhflng bdnh nhin nay dupe dilu tri sdm. Theo nghifin cflu Henrike van Dongen, Jill van Aken nim 2007 cho thiy: trong 1 nim diu theo ddi 22/55 thanh viem khdp dang thip hay nhihig benh (40%) benh nhin tiln triln tfl vidm khdp ly vidm khdp khac nhu: viem cdt sd'ng dinh khdng die hieu thanh vidm khdp dang thi'p khdp, vidm khdp viy nen, lupus... Dua tren thudc nhdm cd dilu tri methotrexate. Trong ket qua cua nhilu nghien cflu cho thiy cd den khi nhdm chung la 29/55 (53%) bdnh nhin.
30 40% bdnh nhin viem khdp khdng die Tuy nhien, d nhdm cd dilu tri methotrexate hieu cd tien trien la tu lui benh hoan toan, 6 bdnh nhin dip ung du tidu chuin de chin 55 % tid'n triln thanh vidm khdp dang thip doin viem khdp dang thi'p or thdi dilm mudn
Y HOC VIET NAM THANG 7/2011 - SO OAC BIET
hon so vdi nhdm chung, ddng thdi it bdnh nhin cd bilu hidn tien triln trdn xquang hon so vdi nhdm chung sau 18 thing [4, 9].
tl. CAC THANG DIEM DU BAO Sii TIEN TRIEN COA VIEM KHdR KHONG OAC HIEU THANH VIEM KHdP DANG THAP.
Trdn co sd dd mdt tieu chuin mdi dl chin doin vidm khdp dang thap sdm dang dupe quan tim nghidn cuu va thanh lip. Ly tudng nhit dinh gii dugc cac yeu td tidn lupng dl nhin ra nhung bdnh nhin viem khdp khdng die hieu nao se cd nguy co tien triln thanh viem khdp dang thip thi ap dung dieu tri sdm, ddng thdi se trinh dilu tri thud'c dilu tri CO ban cho nhiing benh nhan it cd nguy co trd thanh vidm khdp dang thip. Da cd mdt sd thang dilm da va dang ap dung trong nghidn cflu va thuc hanh lim sang bao gdm:
.2.1. Thang diem du bao Leiden
Diy la mdt thang dilm dua tren kit qua nghien cflu Leiden tai Ha Lan cua Annette va cdng su tfl nam 1993 din 2005 tren 17.000 bfnh nhin vidm khdp giai doan sdm, trong dd cd 570 b6nh nhin la vidm khdp khdng dac hifu, nhdm tic gia da tie'n hanh theo ddi
Thang diem du bao ciia Leiden
nhung benh nhan nay it nhit 1 nam. Kit qua nghien cflu da dua ra thang dilm du bao viem khdp dang thap. Thang dilm du bao bao gdm 9 biln sd nhu: tudi, gidi, vi tri khdp cd tridu chung, cflng khdp budi sang, sd lupng khdp sung, sd lupng khdp dau, ndng dp protein C phan flng (CRP), su duong tinh cua yeu td dang thip, su duong tinh cua khang thi khang CCP. Tdng dilm cua thang dilm du bao cd gii tri tfl 0 den 14 dilm, vdi mdi mflc dilm tuong flng vdi phin tram kha nang tien triln thanh viem khdp dang thip. Cd nhilu gia tri tdi ban (cutoff), vdi mdi gia tri tdi han diu cd gii tri du bao duong tinh va gia tri du bio am tinh dupe xac dinh. Trong dd, d mflc
< 6 dilm 94% benh nhan se khdng tiln triln thanh viem khdp dang thip va 100% bdnh nhan > 8 dilm cd tien triln thanh viem khdp dang thip. Nhu vay, neu quyet dinh dieu tri thudc chd'ng thip khdp thay ddi benh (DMARDs) cho nhihig benh nhan cd mflc dilm > 8 va se khdng dilu tri cho nhung benh nhan cd dilm < 6 thi ti le ip dung dilu tri sai cho benh nhan la 0% va ti le khdng dilu trj cho nhung benh nhan cin dilu tri la 6% [1].
STT 1 2
3
Bien so Tudi benh nhan
Gidi nijf
Sir phan bd cOa khdp viem
Khdp nho d ban tay/ ban chan C6 tinh chat dd'i xifng
Chi d chi tren
Ca chi tren va chi dirdi
Cach cho diem x0.02
1.0 0.5 0.5 1.0 1.5
Diem benh nhan
HOI THAP K H 6 P HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THlT IX Cirdng do cifng khdp budi sang (VAS 0
100 mm)
Tir 26 - 90 mm
> 9 0 m m
1.0 2.0 Sd lUdng khdp dau (TJC)
TCr 4 den 10 khdp
> 10 khdp
0.5 1.0 Sd lirdng khdp song (SJC)
TLr4den10kh6p
> 10 khdp
0.5 1.0 Nong do protein C phan ufng (CRP)
T i ^ 5 - 5 0 m g / L
> 50 mg/L
0.5 1.5
Yeu td dang thap diTdng tinh 1.0
Anti - CCP difdng tfnh 2.0
Tong 0 - 1 4 diem
2.2. Thang diem cua Hdi Th^p khdp hoc Chau Au (EULAR 2009)
Tfl nhiing nhu ciu cip thilt tren lim sang, tai Hdi nghi Thip khdp hpc Chiu Au nim 2009 diln ra tai Copenhagen- Dan Mach cac nha khoa hpc cua Hdi Thip khdp hpc Chiu Au (EULAR The European League Against Rheumatism) va Hdi Thip khdp hpc My (ACR - The American College of Rheumatology), da cung vdi nhau xiy dung ndn mdt tieu chuin mod cho chin doin vidm khdp dang thip sdm. Tidu chuin nay ip dung cho chin doin vidm khdp dang thi'p giai doan
sdm, khi chua thiy tdn thuong trdn xquang.
Can cfl vao cic bang chflng y hpc va kinh nghidm cua cic chuydn gia diu nghanh Khdp hpc tren Thd gidi, tieu chuin mdi dua trfen 4 ylu to la: sd lugng va vi tri khdp tdn thuong, xet nghiem huye't thanh, thdi gian mic bdnh, va xet nghidm vl ylii td vidm trong mau.
Tidu chuin nay se giup ich rit nhilu trong thuc hanh lim sang va nghidn cflu khoa hpc va dl hd trg cho tidu chuin cu ACR 1987 trong nhflng trudng hpp vidm khdp giai doan sdm [3]
Ton thifdng khdp (0-5 diem) 1 khdp nha hoac ldn
2-10 khdp nha hoacldn 1-3 khdp nho
4-10 khdp nho
> 10 khdp (tdi thieu 1 khdp nho)
-
0 1 2 3 5
Y HOC VIET NAM THANG 7/2011 - SO OiB^C BIET
Huyet thanh (0-3 diem) RF (-) va anti -CCP (-)
Tdi thieu 1 test dUdng tinh yeu Tdi thieu 1 test diTdng tinh manh Thdi glan mac benh (0-1 diem)
< 6 tuan
> 6 tuan
Xet nghiem ve yeu to viem (0-1 diem) CRP tang va tdc do lang mau binh thudng
CRP t&ng ho§c tdc dp lang mau tang 1
ChSn doan viem khdp dang thap khi tong diem > 6/10 diem
Ghi chu:
Khdp nhd: khdp ban ngdn tay (5 khdp), khdp khdp gin ngdn tay (5 khdp), khdp ban ngdn chin (tfl 2 den 5: 4 khdp), va c6 tay hai ben.
Khdp ldn: khdp vai, khdp khuyu tay, khdp hang, khdp gd'i, khdp c6 chin hai ben
Khdng tinh cic khdp: ddt ngdn xa, khdp gifla xuong ban ngdn 1 ban tay vdi cd tay, khdp ban ngdn chin cii
Xet nghiem RF va Anti -CCP duong tinh ylu khi dat ngudng tijt mflc 1-3 lin tri sd binh thudng (vi du RF < 50 Ul/ml)
Xet nghidm RF va Anti -CCP duong tinh manh khi dat ngudng tfl mflc > 3 lin tri sd bmh thudng (vi du RF > 50 Ul/ml)
III. KET LUAN:
Viec ip dung cic thang dilm du bao dl chin doan sdm bdnh vidm khdp dang thip se gdp phin vao phin loai chin doin va dilu tri tinh trang vidm khdp khdng die hidu. Dilu niy khdng nhflng giup cac thiy thud'c lim skng cd thdm cdng cu hidu qua trong chin doin vi dilu tri sdm bdnh vidm khdp dang thip mi cdn trinh cho ngudi bdnh nhQng hiu
qua cua tdn thuong d co quan van ddng khi khdng dupe chin doan va dilu tri kip thdi.
TAI LIEU THAM K H A O :
1. Annette H.M, van der Helm, Saskia le Cessie, Henrike van Dongen (2007), A Prediction Rule for Disease Outcome in Patients with Recent - Onset Undifferentiated Arthritis, Arthritis &
Rheumatism, Vol 56, N"2, Feb 2007, P 433 - 440.
2. Daniel Aletaha, Julia Funovits, Eward C, Josef S, (2007), Disease Activity Early in the Course of Treatment, Predicts Response to therapy After One Year in Rheumatoid Arthritis Patients, Arthritis
& Rheumatism, Vol 56, NTO, Oct 2007, P 3226 - 3235.
3. Daniel Aletaha,l Tuhina Neogi, 2010 Rheumatoid Arthritis Classification Criteria, Arthritis & Rheumatism, Vol.
62, N"9, September 2010, pp 2569-2581 4. Henrike van Dongen, Jill van Aken,
(2007), Efficacy of methotrexate in patients with probable rheumatoid arthrtitis. A double blind randomized placebo controlled trial. Arthritis &
HOI THAP KHdP HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
Rheumatism, Vol 56, ISP'S, May 2007, P 1424-n 1432
Leroy R. Lard, MD, Henk Visser, MD, Irene Speyer, MD, Irene E, (2001), Early versus Delayed Treatment in Patients with Recent-onset Rheumatoid Arthritis: Comparison of Two Cohorts Who Received Different Treatment Strategies, The American Joumal of Medicme, Volume 111, P 446- 451, October 15, 2001.
Maria Dahl Mjaavatten, Anne Julsrud Haugen, Lnut Helgetvett (2009), Pattern of Joint Involvement and Other Disease, Characteristics in 634 Patients with Arthritis of Less Than 16 weeks Duration, The Joumal of Rheumatology 2009; 36:7
Nell V. P. K.; Machold K. P.; Eberl G.;
Stamm T. A.; UfTmann M.; Smolen J.
S., (2004), Benefit of very early referral and very early therapy with disease- modifying anti- rheumatic dmgs in patients with early rheumatoid arthritis.
Rheumatology; Jul 2004; 43, 7, P 906- 914
Josef S Smolen MD, Daniel Aletaha MD (2009), Assessing the probability of developing rheumatoid arthritis in patients with undifferentiated inflammatory arthritis. Last literature review version 17.2: May 2009
Van Aken J, H van Dongen, S le Cessie (2006), Comparison of long term outcome of patients with rheumatoid arthritis preseting with undifferentiated arthritis, Ann Rheum Dis 2006; 65:20-25.