Recommendations for treating various types of established Juvenile Idiopathic Arthritis Текст научной статьи по специальности «Биотехнологии в медицине»

of rheumatology

EAAHNIKH PEYMATQAOriA

ANAXKOnHXH REViEW

Iuoraoeiq GepcneuriKUv Gxnparwv oriq SiaQopeq popQeq rnq SiCYvwopevnq NecviKnq ISioncGouq ApGpiriScq.

OAwpevrla KavaKouSn-ToaKaAiSou, MD, PhD, noXu^evn npaToiSou-rKepTon, MD, PhD, Mapia Tpaxava, MD, PhD A' naiSiarpiKr] KAiviKn, IarpiKr] IxoAr], ApioToTeAeio navenioTrpo OeooaAovlKriQ

nEPIAHYH

Ta nporeivopeva GepaneuriKa oxnpara, ano rnv «Enirponn epneipoYvwpovwv» tou ACR 2011-2013 Yia rn NIA, aQopouv 5 «GepaneuriKeq» opaSeq aoGevuv, pe paon Kupiwq tov apidyo q/Kai to si5oq rw npo-oPsPAqysvwv apdptioswv, rqv uapouoia q yq 5uoysvtiv upoyvwonrnv uapayovrw paZi pe Tn oQaipiKq sKriyqoq rou iarpou yia rq ouvoAiKq dpaoTqpidrqra rqq vooou (MDVAS global) kcu rqv uapouoia q yq ouoTqyariKtiv sK5qAtiosw.1n dspausuriKq oya5a: EvraooovTai aoGeveiq pe enipovn oAiYoapGpiriSa. 2n dspausuriKq oya5a: EvraooovTai aoGeveiq pe enipovn noAuapGpiriSa (RF GeTiKoi n apvnTiKoi). 3n dspausuriKq oyada: EvraooovTai aoGeveiq pe KAiviKeq Kai aneiKovioriKeq evSe'^eiq evepYou iepoAaYov'mSaq, onwq oi aoGeveiq pe apGpiriSa nou oxeTiZerai pe evGeo'mSa Kai pe ^wpiaoiKn apGpiriSa, aAAa Kai aoGeveiq pe onoiaSnnore aAAn popQn rnq vooou Kai evepYO iepoAaYoviriSa. AvaQeperai oxnpariKa n oAn orparnYiKn rnq Gepaneiaq Yia riq rpeiq npureq GepaneuriKeq opaSeq. Oi «GepaneuriKeq opaSeq» rnq ouornpariKHQ NIA SiaKpivovrai oe «ouorqyariKq NIA ys svspysiq ouorqyariKsq SK5qAtiosiq Kai 5ia$opou Padyou svspyo apdpiri5a (4n oya5a) Kai oe «ouorqyariKq NIA xwpiq ouorqyaTiKsq sK5qAtiosiq aAAa ys 5ia$opou Padyou svspyo apdpiri5a (5q oya5a). EiSiKorepa, ornv 4n dspausuriKq oya5a: ApxiZoupe pe KopriKoorepoeiSq (KI) paZi pe n x^piq MIAO Kai av Sev anavrnoei o aoGevnq pera ano 2 epSopaSeq xopnYoupe ouvGeriKa n PioAoYiKa DMARDs pe paon ra npoavaQepGevra Kpirnpia (n.x. eav npoexouv oi ouornpariKeq eKSnAuoeiq xopnYouvrai anti-IL-1 n anti- IL-6 evu eav npoexei n noAuapGpiriSa xopnYouvrai ouvGeriKa DMARDs Kai orn ouvexeia anti-TNF napaYovreq). Irqv 5n dspausuriKq oya5a: ApxiZoupe pe MIAO Kai KI evSoapGpiKa Kai av Sev anavrnoei o aoGevnq pera ano eva pnva xopnYoupe ouvGeriKa Kai pioAoYiKa DMARDs pe paon rov

apiGpo ruv npooPepAnpevuv apGpuoewv. 'Eroi, oe INIA pe oAiyo-"KOVSKOYgni-'SaK^ou apGpiriSa xopnYouvrai ouvGeriKa DMARDs Kai eav Sev anavrnoei

M^MfliT^54643, 0ECCaAoviKn' o aoGevnq pera ano 3 pnveq, xopnYouvrai pioAoYiKoi napaYovreq,

evu oe INIA pe noAuapGpiriSa xopnYouvrai KareuGeiav pioAoYiKoi napaYovreq.

Tr|A. 2310839291, 6972127338 Corresponding author:

Florentia Kanakoudi-Tsakalidou M. Botsari 2, 54643 Thessaloniki, Greece, e-mail : flkan@auth.gr,

Tel: 2310839291, 6972127338 Mediterr J Rheumatol 2015; 26(1): 17-40

Ae^eiq-KAeiSia: NeaviKn ISionaGnq ApGpiriSa (NIA) , Gepaneia, orparnYiKn, ouornpariKn veaviKn iSionaGnq apGpiriSa

of rheumatology

EAAHNIKH PEYMATQAOriA

Recommendations for treating various types of established Juvenile Idiopathic Arthritis

Florentia Kanakoudi-Tsakalidou, MD, PhD, Polyxeni Pratsidou-Gertsi, MD, PhD, Maria Trachana, MD, PhD First Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, Greece

ABSTRACT

The therapeutic regimens, recommended by the ACR (2011-2013) for Juvenile idiopathic Arthritis (JIA), refer to "5 treatment groups", according to the number and type of the joints affected, the presence or absence of poor prognostic factors in combination with the physician's global assessment for the disease activity (MDVAS global) and the presence of systemic features. 1st therapeutic group: Patients with persistent oligoarthritis. 2nd therapeutic group: Patients with persistent polyarthritis. 3rd therapeutic group: Patients with clinical or imaging indications of active sacroiliitis, as patients with enthesitis related arthritis or psoriatic arthritis or any other type of arthritis with active sacroiliac arthritis. The therapeutic strategy is schematically depicted for the first 3 groups. The systemic JIA therapeutic groups are divided into the "systemic JIA with active systemic features and varying degrees of synovitis (4th group)" and the "systemic JIA without active systemic features and varying degrees of synovitis (5th group)". For the 4th therapeutic group : Initial treatment with corticosteroids (CS) with or without NSAIDs; in case of non-response within 2 weeks, synthetic or biologic DMARDs are administered, based on the criteria aforementioned; in case of predominant systemic features, initial treatment with anti-IL-1 or anti- IL-6 and in case of predominant polyarthritis, synthetic DMARDs followed by anti-TNFs is recommended. For the 5th therapeutic group: Initial treatment with NSAIDs and intra-articular steroids; in case of non-response within 1 month, synthetic or biologic DMARDs are administered based on the number of joints affected. Thus, in oligoarthritis, synthetic DMARDs first, followed by biologic ones in case of non-response within 3 months, are administered; in polyarthritis, biologic DMARDs are administered.

Mediterr J Rheumatol 2015; 26(1): 17-40

Keywords: Juvenile idiopathic arthritis, therapy, strategy, systemic juvenile idiopathic arthritis

ЕПАГПГН

O 6poQ "NeaviKn ISiona6nQ Ap9pm6a, NIA" (npwqv "veaviKn xp6via ap9pm6a" n "veaviKn peupaToeiSnQ ap9pm6a" ката touq ApepiKavouQ), ouM0wva ме та ava9ewpr|H6va Kprnipia thq ILAR (Edmonton 2001) ava0epeTai oe каве арвртба aYvwoTqq amoAoYiaq (idionadqq) пои npoofiaAAei naiSia qAiKiaq катш tmv 16 stwv Kai eniyevei TouAaxioTov Yia 6 efiSoyaSeq. H SiaYvwoq TieeTai афои anoKAeioeouv aAAeq Yvwcreq KaTaoTaoeiq nou ynopei va екб^Ашвом це аита та XapaKTqpioTiKa.

Та ava9ewpn|j6va 6ie9vn Kprnipia Yia Tqv катата^п ev6Q ao9evoйQ orqv ораба тпс NIA eíval:

1. H ap9píтlбa va exei 6rapKeia TOuAaxioTOv 6 евбо-мабед.

2. Na apxiZei npiv апо тпv nAiKia тwv 16 e^v.

3. Na mhv aпобíбeтal oe aAAq ата/vooo пои eíval бuvaт6 va npoPaAAei KAiviKa wq xp6vla ap9píтlбa.

4. Na pnopei va тa£lvoмn9eí 6 MnveQ мета апо тпv evap^n тпQ oe мla апо hq opa6eQ пои avaф¿po-vтal otov Пívaкa 1 п.х.

ZuoTqyaTiKri (п ap9píтlбa va ouvoбeйeтal апо ouo^-ма^^ eK6nAwoeiQ) n OAiYoapepmSa ^pooPoAn 1-4 ap9pwoewv) n ПoAuap9píтlбa ^pooPoAn > 5 M^XPi 6Awv тwv ap9pwoewv) k.o.k. ito бутима тои ме-ooAaPei апо тlQ 6 eP6opa6eQ M^XPi тouQ 6 MnveQ, n veaviKn lбюпa9nQ ap9píтlбa парам^! ата^омФЛ. Та кplтnpla аита, 6ПWQ YÍveтal av^Anm^, eivai KAiviKa Kai n 6raYvwon тnQ NIA eivai SiaYvwoq "e£, ano-кАеюцои" aAAwv oxernwv кaтaoтaoewv. Iймфwva Me та Kprnipia аита, oi ao9eveiQ pe NIA кaтaтaooo-vтal oe 7 oмaбeQ (niv. 1)1,2.

Zuxvornxa - HAiKia. H NIA eivai то peuMa™6 v6on-ма тои кaAйптel тo 80% пepíпou ^Q пalбopeuмaто-AoYiKnQ пpa^nQ. H ouxv6тnтa тnQ пolкíAAel апо xwpa oe x^pa, кuмalv6мevn апо 2-19,5/100.000 катон-kouq/etoq. ПpooPaAAel 6AeQ hq nAiKieQ тwv пай^ апо тп Ppeфlкn (пplv та пpwтa Yeve9Aia) м^! тnv eфnPlкn (<16 e^v), ouxv6тepa та кopíтola oтlQ то-ploo6тepeQ мopф6Q тnQ 3.

AmonaGoyeveia. Ie мla т6oo eтepoYevn oмaбa xp6-viwv ap9pm6wv Aoyik6 eivai va ^p^evei KaveiQ eтe-poYevn n пoAuпapaYovтlкn alтюпa9oY6veon. 'Eroi, тo YevenK6 uп6oтpшмa пou oxeтíZeтal мe ^v пapouoía oplOмëvшv HLA avтlY6vшv n a^o^^wv Kai 6^opoi e^шYeveÍQ/пeplPaAAovтlкoí (KupiwQ AolмoY6vol) пapa-YOvтeQ п.х. ioi n та пpoÍ6Vтa тouQ (i6q YPÍпnQ, пapPo-i6q B19, i6q epu9paQ, i6q Coxsackie), ми^Ра^т^ю (M. тnQ фuмaтíшonQ), evoxoпoln9nкav ката кalpoйQ wq бleYepтlкoí мnxavlOMOÍ тnQ xp6viaQ ap9piKnQ фAeY-MovnQ. ria то aп6фelQ aureQ кaмía мeA¿тn 6ev e6woe aтобelкгlкa oтolxeía. AAAeQ мeA¿тeQ evoxoпoínoav Yia тnv evap^n ^Q фAeYMOvnQ ev6oYeveiQ пapaYOVтeQ (DAMPs), 6ПWQ п.x. тlQ пpwтeíveQ тnQ 9epмoпAn^íaQ (heat shock proteins)4. TeAoQ, пp6Oфата, тo evбlaф¿-

pov eпlкevтpш9nкe o^ бlaтapaxn тnQ looppoпíaQ тшv uпoпAn9uoмшv тшv CD4+ Т кuттapшv Treg Kai Th17 (eAaттшon тшv Treg Kai a^non тшv Th17) мe aпoт¿Aeoмa тnv uпep¿ккplon фAeYMOvoY6vшv шт-тapoкlvшv Kai мeтaAAoпpштeÍvaoшv пou ouvтnpoйv тп фAeYMovn тou ap9plкoй им^а Kai пpoкaAoйv ap-9piKn PAaPn5. ria тп ouoтnмaтlкn мopфn e^i^epa, пloтeйeтal 6т1 aпoтeAeí ^exшploтn ovт6тnтa oe oxeon мe тlQ aAAeQ мopф¿Q, 616т1 6ev oxeтíZeтal мe ouYKe-кplмeva HLA-avтlY6va / aпA6тuпouQ, 6ev exei 9eтlкa ANA n aAAa auтoavтloшмaтa Kai мeYaAo пooooт6 ao9evwv 6ev aпavтa oтn 9epaTOia мe avтl-TNF па-paYovтeQ aAAa aпavтa oтn 9epaпeía мe avn-IL-1 Kai avтl-IL-64. EпlпA¿ov, o kAivik6q фalV6TuпoQ тnQ v6oou Kai n a™uoia lplбoкuкAíтlбaQ (auтoavoon кaтaoтaon) пapaп¿мпel oe auтoфAeYMovшбeQ oйvбpoмo. Eтol, та тeAeuтaía xp6via бlaмopфш9nкe n апэфп, отг n Mopфn auтn бlaкpíveтal oe бйo uпoпAn9uoмoйQ, апо touq oпoíouQ, o evaQ aпavтa сттп 9epaпeía мe avтl-IL-1 Kai o OAAoq 6ev aпavтa n aпavтa мeplкшQ. H пa9oYevela тои пpштou oxeтíZeтal мe тnv IL-1, 6ПШQ ouмPaível мe та кAnpovoмlкa auтoфAeYMovшбn voon-мата тnQ па^га^ nAiKiaQ, Yi' аито Kai n ^NIA 9ewpei-тal onмepa wq eva пoAuYovlбlaк6 auтoфAeYMovшбeQ V6onмa/oйvбpoмo 34.

Neeq GepaneuTiKeq Taaeiq: Та тeAeuтaía 15 xp6via eпnA9e eпavaoтaon oto бla9¿olмa 9epaпeuтlкa мeoa Yia ^nv avтlмeтшпlon тnQ NIA, мe aпoт¿Aeoмa тnv eпí-тeu^n avevepYoй v6oou Kai пeploploмoй тnQ мaкpo-xp6viaQ a9polOтlкnQ PAaPnQ, oтnv пAel0V6тnтa тwv ao9evwv 6-11. Iтo avaoкoпlK6 аито ap9po, пapouola-Zovтal oi тp¿xouoeQ ouoтaoelQ тou ACR Ka9wQ Kai oi oмoфwvíeQ aAAwv eпloтnмovlкшv фop¿wv Yia тnv avтl-Meтшпlon ^nQ NIA. ria тnv кaAйтepn кaтav6non тwv ou-oтaoewv auтшv, 9a пpoтax9oйv oi oйYXPovol oploмoí (definitions) Kai та «epYaAeia» eктíмnonQ тои ao9evoйQ (assessment tools), пou xpnolMoпoloйvтаl onмepa 6ie-9vwq oтnv пalбopeuмaтoAoYlкn KAiviKn пpa^n.

OPIZMOI

Evepyoq NIA: Qq «evepY6Q NIA» opíZeтal n пapouoía 6i6YKwonQ oe кaпola ap9pwon, пou 6ev oфeíAeтal oe oornn aй^non /бleйpuvon Kai ouvoбeйeтal ouvn9wQ апо aй^non тnQ 9epмoкpaoíaQ тотака (xwpiQ epu9p6-тпта) Kai пepюplOM6 тnQ кlvnтlK6тnтaQ A6yw П6Vou. Oтav aпouolaZel n 6i6YKWon n 6ev eivai opaтn (п.x. ap9píтlбa ioxiou, мeoooпovбuAíwv ap9pwoewv), n пapouoía evepYoй ap9píтlбaQ кa9opíZeтal апо тov пepюplOM6 тnQ кlvnтlK6тnтaQ тnQ ap9pwonQ, тои ouvoбeйeтal апо п6vo oтnv Kivnon n апо euaio9noia oтnv e^aon/ пíeon тnQ ap9pwonQ Kai 6ev aпoбí-бeтal oe aAAn, мп peuмaтlкn alTloAoYÍa. H ap9píтlбa Mпopeí va ouvoбeйeтal n 6xi апо пp6o9la paYoelбíтl-ба (lplбoкuкAíтlбa). le кaпola фaon тnQ пopeíaQ ^Q NIA, мпopeí va ¿xouмe e^apon n uпoтpoпn M6Vo тnQ

of rheumatology 1

EAAHNIKH PEYMATQAOriA 2015

ipiôoKUKÀÎTiôaç xwpíQ ouvoSó ap9píTiSa, onóTe Kai náÁi n vóooq xapaKTnpíZeTai wq evepYóQ1-3.

Avevepyôç NIA (KAivikh ú$eon)

Qq «avevepYóQ NIA» H «NIA oe kàivikh ú0eon» opíZeTai n KaTáoTaon tou ao6evoúQ nou xapaKTnpíZeTai anó:

12,13

1. Anouoía evepYoú ap9píTiSaQ, nupeToú*, e£av9H-paToQ, opoYovÍTióaQ, peYaÁoonÁnvíaQ h YeviKeu-pévnQ Áep0aSevoná9eiaQ nou anoóíóeTai oTn NIA

2. Anouoía evepYoú paYoeiSíTiSaQ

3. OuoioÁoYiKá eníneSa TKE H CRP

4. To KaÁúTepo SuvaTó score (aváÁoYa pe to epYa-Áeío nou xpnoiMonoieÍTai) oTn o0aipiKH eKTípnon tou iaTpoú Yia Tn SpaoTnpióTnTa TnQ vóoou n.x. £e onTiKn avaÀoYiKH KÁípaKa (Visual Analogue Scale H VAS anó 1-10, score <1)

5. AiápKeia npwivHQ SuoKap^íaQ <15min *Anouoía SiaÁeínovToQ nupeToú, xapaKTnpioTiKoú TnQ INIA (1-2 KúpaTa u^nÁoú nupeToú > 38o npepnoí-wq Kai oTa peooSiaoTHpaTa, noÁú KaÀH YeviKH KaTáoTaon tou naiSioú) KaTá Tn SiápKeia TnQ nponYoúpe-vnQ eßôopáôaQ (ßÀéпe nív.1).

KAivikh ú$ean unó Gepaneía: AvevepYÓQ vóooQ ení 6 SiaSoxiKoúQ pHveQ unó 9epaneía. KAivikh ú$eon ektôç Gepaneiaç: AvevepYóQ vóooQ ení 12 SiaSoxiKoúQ pHveQ eKTóQ 9epaneíaQ Yia NIA H Yia paYoeiSíTiSa.

EAáxioTa evepyôç NIA (NIA pe eÁáxioTn SpaoTnpióTnTa) 14

OAiyoapGpiKn NIA: I0aipiKH eKTípnon iaTpoú oe OnTiKH AvaÀoYiKH KÁípaKa (VAS) anó 1-10, score <2.5/10 Kai api9póQ SioYKwpévwv ap9púoewv 0. noÁuapdpiKq NIA: I0aipiKH eKTípnon iaTpoú: VAS <3.4/10 Kai api9póQ SioYKwpévwv ap9púoewv <1. ZuoTqyariKq NIA: Sev éxouv aKópn Ka9opioTeí Kpi-THpia.

EPrAAEIA nOZOTIKHZ EKTIMHZHZ THZ APAZTHPIOTHTAZ (ACTIVITY) THZ NIA

H eKTípnon TnQ SpaoTnpióTnTaQ (evepYóTnTaQ) TnQ vóoou anoTeÁeí 9epeÀiùSn npoünó9eon Yia tov Ka-9opiopó TnQ kàivikHq KaTáoTaonQ evóQ ao9evoúQ pe NIA, SeSopévou óti, n napouoía enípovnQ SpaoTnpióTnTaQ oSnYeí ouvH9wq oe KaTaoTpo0iKH ap9poná-9eia Kai oe 0uoiKH ÀeiToupYiKH peioveKTiKóTnTa. Eni-nÀéov, n noooTiKH eKTípnon TnQ SpaoTnpióTnTaQ TnQ vóoou SiaxpoviKá, eívai anapaíTnTn Yia Tnv eKTípnon tou anoTeÀéopaToQ Ká9e 9epaneuTiKoú oxHpaToQ/ npwToKóÁÁou, óxi póvo oTnv Ka9npepivH kàivikh npá-^n aÁÁá Kai oe óÁeQ tiq KÀiviKéQ peÀéTeQ. Ynápxouv Siá0opa «epYaÁeía» eKTípnonQ tou eniné-Sou SpaoTnpióTnTaQ TnQ NIA, nou пeplÀapßávouv: KÁípaKeQ ouvoÀiKHQ eKTípnonQ TnQ KaTáoTaonQ tou

ao9evoÜQ, KAipaKeQ peTpnonQ tou növou, npooßoAH ouYKeKpipevwv ap9pwoewv (n.x. npooßoAH loxiou, auxeviKHQ poipaQ onovSuAiKiiQ ot|ahq kA), ep№T|-paToÄöYia AeiToupYiKHQ iKavöTHTaQ, epYacnrpaKoüQ SeiKTEQ (SeiKTEQ o^eiaQ 0äonQ, enineSa Hb, api9pö AeuKOKUTTäpwv/ou5eTepo0iAwv Kai aiponeTaAiwv), ßäpoQ owpaTOQ K.ä. napa9eToupe auTä nou xpnoi-MonoiouvTai nepiooöTepo Sie9vüQ, Töoo othv Ka9n-pepivH KAiviKiH npa^n, öoo Kai othv kAivikH epeuva 12.

A) JADAS (Juvenile Arthritis Disease Activity Score)*15,16: AdKTHQ öpaCTinpiöxnTaQ thq Neavi-khq Ap0piTi8aQ Me ßa0MoAöynan (score)

1. Z^aipiKn SKTÎinan t|q auvoÀiKriQ Spaainpioiniaç ir|ç vôaou (overall disease activity) anô tov laxpô, |is Pâan onTiKn avaÀoyiKn KÀÎ^aKa (MDVAS global) anô 0-10 cm

2. Z^aipiKn SKTÎ^nan t|Q auvoÀiKriQ susÇiaç (overall wellbeing) anô tov yovsa/aa9svr| |S Pâan to auvoAiKô score tou axsTiKoù nsôiou anô to spwTniaToÀôyio CHAQ (Childhood Health Assessment Questionnaire. BAsns SKTÎ^nan aw|jaTiKr|Q AsnroupyiKriQ iKavôT|TaQ Kai auvoÀiKHQ susÇiaç)

3. Api9|iôQ ap9pwaswv |is svspyô ap9pÎTi5a (api9|nan anô 0-71)

4. TKE [TpononoiniJsvn Ti|jr| WQ sÇr|Q: (TKE-20)/10**]

ZuvoAikô Score: 0-101

*To JADAS xpnoiMonoieÍTai Yia tf|v eKTípnon THQ SpaoTnpióTnTaQ TnQ vóoou oe ouYKeKpiMévn xPOViKñ OTiYMñ.

**Ze TKE<20mm/h, n TiMñ unoAoYÍZeTai wq 20.

npoTEivóyeva KaTÚTepa ópia tou JADAS (cut off levels) yia tov opioyó avevepyoü Kai eXáxiora evepyoü oAiyoapdpiKqq (PÁéne Ta£ivóyqon aoGe-vúv ye NIA) Kai noXuapOpiKqq NIA ye fiáoq Tqv Tiyq tou score)16

AvevepYÓQ oAiYoap9piKñ NIA: JADAS=1, EAáxioTa evepYóQ: JADAS=2

AvevepYÓQ noAuap9piKñ NIA: JADAS=2,EAáxioTa evepYÓQ: JADAS=3.8

Ra T| ouoT|MaTiKñ NIA, aváAoYa ópia Sev éxouv aKÓ-Mn opio9eí.

B) ACRpedi=American College of Rheumatology Pediatric (ACRpedi) criteria of JIA improvement: Kpixnpia Pa0MoAóynonQ thq KaxaCTiaanQ SpaCTin-pióxnxaQ inQ NIA yia inv EKiÍMnon inQ PeAiiwonQ inQ vóoou, SiaxpoviKá.17,18 Ta ACRpedi nepiAapPávouv é^i PaoiKéQ napapé-TpouQ (core set of variables) nou Ka9iepú9|Kav anó to ACR Yia T|v eKTípnon T|Q KaTáoTaonQ SpaoTnpióTnTaQ T|Q NIA, npoKeiMévou va Ka9opioToúv KpiTñpia

Pa9joÁóYnonQ THQ PeÁTÍwonQ TnQ vóoou je to eKá-otote 9epaneuTiKó oxñja. Me Tn xpñon auTúv twv PaoiKúv napajéTpwv opÍo9nKav Ta ACRpedi 30, ACRpedi 50, ACRpedi 70, 90, 100 KpiTñpia.

BaoiKÉQ napá^expoi (core set of variables) ektí-MHOHQ thq SpaoTnpiÓTHTaQ KaTá ACRpedi

1. I0aipiKií eKTÍjnon thq ouvoÁiKñQ SpaoTnpiÓTHTaQ thq vóoou (overall disease activity) anó tov iaTpó, je Páon onTiK| avaÁoYiKñ KÁÍjaKa (MDVAS global) anó 0-10 cm

2. I0aipiK| eKTÍjnon TnQ ouvoÁiKñQ eue^ÍaQ (overall wellbeing) anó tov Yovéa/ao9evñ je páon to ou-voáikó score tou oxetikoú neSÍou anó to epwTn-jaToÁóYio CHAQ (Childhood Health Assessment Questionnaire. BÁéne eKTÍjnon owjaTiKÍQ ÁeiToup-YiKñQ iKavóTnTaQ Kai ouvoÁiKñQ eue^ÍaQ)

3. Api9jóQ ap9púoewv je evepYó ap9pÍTi5a*

4. Api9jóQ ap9púoewv je nepiopiojévn KivnTiKóTn-Ta**

5. EpYaoTnpiaKóQ SeÍKTnQ SpaoTnpióTnTaQ (TaxúTn-Ta Ka9íZnonQ epu9púv)

*,**: BÁéne opiojoúQ.

BaGMoAóynon PeÁTÍwonQ

ACRpedi30:

BeÁTÍwon anó Tnv évap^n TnQ 9epaneÍaQ KaTá >30% oe TouÁáxioTov 3/6 PaoiKéQ napajéTpouQ Kai oe ne-pínjwon ouoTnjaTiKñQ NIA, TauTóxpovn anouoÍa tou XapaKTnpioTiKoú SiaÁeÍnovToQ nupeToú KaTá Tn 5iáp-Keia TnQ nponYoújevnQ epSojáSaQ (PÁéne opiojoúQ, avevepYóQ vóooq), x^pÍQ TauTóxpovn eniSeÍvwon KaTá 30% oe nepiooóTepeQ anó jÍa napajéTpouQ. ACRpedi50:

BeÁTÍwon anó Tnv évap^n TnQ 9epaneÍaQ KaTá >50% oe TouÁáxioTov 3/6 PaoiKéQ napajéTpouQ Kai oe ne-pÍnrwon ouoTnjaTiKñQ NIA, TauTóxpovn anouoÍa tou XapaKTnpioTiKoú SiaÁeÍnovroQ nupeToú KaTá Tn 5iáp-Keia TnQ nponYoújevnQ epSojáSaQ (PÁéne opiojoúQ, avevepYóQ vóooq), x^pÍQ TauTóxpovn eniSeÍvwon KaTá 30% oe nepiooóTepeQ anó jÍa napajéTpouQ. ACRpedi70:

BeÁTÍwon anó Tnv évap^n TnQ 9epaneÍaQ KaTá >70% oe TouÁáxioTov 3/6 PaoiKéQ napajéTpouQ Kai oe ne-pÍnrwon ouoTnjaTiKñQ NIA, TauTóxpovn anouoÍa tou XapaKTnpioTiKoú SiaÁeÍnovroQ nupeToú KaTá Tn 5iáp-Keia TnQ nponYoújevnQ ePSojáSaQ (PÁéne opiojoúQ, avevepYóQ vóooq), x^pÍQ TauTóxpovn eniSeÍvwon KaTá 30% oe nepiooóTepeQ anó jÍa napajéTpouQ. ACRpedi90:

BeÁTÍwon anó Tnv évap^n TnQ 9epaneÍaQ KaTá >90% oe TouÁáxioTov 3/6 PaoiKéQ napajéTpouQ Kai oe ne-pÍnjwon ouoTnjaTiKñQ NIA, TauTóxpovn anouoÍa tou

XapaKTnpioTiKoú SiaÁeÍnovroQ nupeToú KaTá Tn 5iáp-Keia TnQ nponYoújevnQ ePSojáSaQ (PÁéne opiojoúQ, avevepYóQ vóooq), x^pÍQ TauTóxpovn eniSeÍvwon KaTá 30% oe nepiooóTepeQ anó jÍa napajéTpouQ. ACRpedi100:

BeÁTÍwon anó Tnv évap^n TnQ 9epaneÍaQ KaTá 100% oe TouÁáxioTov 3/6 PaoiKéQ napajéTpouQ Kai oe ne-pÍnjwon ouoTnjaTiKñQ NIA, TauTóxpovn anouoÍa tou XapaKTnpioTiKoú SiaÁeÍnovroQ nupeToú KaTá Tn 5iáp-Keia TnQ nponYoújevnQ ePSojáSaQ (PÁéne opiojoúQ, avevepYóQ vóooq), x^pÍQ TauTóxpovn eniSeÍvwon KaTá 30% oe nepiooóTepeQ anó jÍa napajéTpouQ.

Ynorponq (flare) NeaviKqq lóionaGoüq ApGpíri-óaq oóyQwva ye Ta ACRpedi19

EniSeÍvwon KaTá TouÁáxioTov 40% oe 2 anó tiq 6 PaoiKéQ napajéTpouQ, x^pÍQ TauTóxpovn PeÁTÍwon KaTá TouÁáxioTov 30% oe nepiooóTepeQ anó 1 na-pajéTpouQ.

nOZOTIKH EKTIMHZH AElTOYPriKHZ IKANOTHTAZ KAI rENIKHZ EYEEIAZ

ria Tnv eKTÍjnon TnQ owjaTiKÍQ ÁeiToupYiKñQ iKavóTnTaQ Kai TnQ ouvoÁiKñQ eue^ÍaQ anó tov Yovéa/ao9evñ XpnoijonoieÍTai to naiSiaTpiKó epwTnjaToÁóYio noi-óTnTaQ Z^ÍQ C-HAQ (Childhood Health Assessment Questionnaire) 20, 21

To C-HAQ (Yia ouvrojÍa CHAQ) eKTijá noooTiKá Tn AeiroupyiKórqra tou oúyaroq tou naióioüleQq-Pou, a&oAoyúvraq 8 neóia ópaorqpiórqraq rqq Kadqyepivqq fyqq: a) To vTúoijo Kai Tnv nepinoÍn-on, P) Tnv éYepon oTnv óp9ia 9éon, Y) to Yeúja, 5) to PáSioja, e) Tn 0povTÍ5a TnQ uyieivíq tou oújaTOQ, ot) Tnv npooéYYion avTiKeijévwv, Z) Tnv iKavóTnTa va o0ÍYYei Ta SáKTuÁa Kai n) KánoieQ áÁÁeQ SpaoTnpió-TnTeQ. To Ká9e neSÍo nepiÁajPávei anó 2-5 epwTñ-oeiQ ava0opiKá je Tnv iKavóTnTa eKTéÁeonQ KánoiaQ SpaoTnpióTnTaQ, tiq onoÍeQ KaÁeÍTai va anavTñoei o YovéaQ/naiSÍ, Pa9joÁoYwvraQ anó 0 to ápioro éwq 3 ro xeipórepo. ria Ká9e neSÍo ÁajPáveTai unó^n to u^nÁóTepo score. O jéooQ ópoQ tou a9poÍojaToQ twv 8 scores avTioToixeÍ oto AeÍKTn MeioveKTiKóTnTaQ (Disability Index, DI).

EninÁéov, to C-HAQ, eKTijá je 2 omiKéQ avaÁoYiKéQ KÁÍjaKeQ (VAS 0-10cm) rq oQaipiKq eKTÍyqoq rou yovéalaadevq yia rov nóvo rqq npoqyoóyevqq epóoyáóoq (ónou 0= Ka9óÁou nóvoQ Kai 10=noÁú SuvaTóQ nóvoQ) Kai rq ouvoAiKq aftoAóyqoq rqq eue&aq (ónou 0=jéYioTn eue^Ía Kai 10= Ka9óÁou eu-e^Ía).

TAEINOMHZH AZGENfiN ME NIA

Me páor¡ tov káivikó Qaivóruno évapfyq rqq vóoou (napouoÍa ouoTnjaTiKúv, e£wap9piKúv etónÁúoewv, api9jóQ npooPePÁnjévwv ap9púoewv otouq npú-

of rheumatology 1

E Л Л H N I K H PEYMATOЛOПA 2015

touç б pПveQ anó T|v évap^n t|Q vóoou), бlaкpÍvovтal 3 Túnoi évap^nQ: Q ouoтпyaтlкóç, о QÀlYQapвplкóç (<5 apвpwoelç) Kai о пQÀuapвplкóç (> 5 apвpwoelç), evw pe ßáoп óxi ¡Jóvo тQv шпо évapÇqç aÁÁá Kai тпv rnpeía тпç vóoou, кавwç Kai тпv пapQuoía opioyé-vwv QpoÀQYiKùv ôe^wv Kai áÁÁwv KÁiviKwv eKôn-Awoewv (п.x. ßÀáßeç), бlaкpívQvтal erná

urn^rni /кaтnYQpíeç тпç vóoou (nÍv.1) oúpфwva pe T|v raTá ILAR raTáTa^n (2001). 2 H Ta^ivópnon twv aoGevúv pe NÍA otiq кaтпYopÍeQ auTéç, éxei oкoпó va бeíÇel tiq opoióTnTeQ кal tiq бга-фopéç peTa^ú touq, úoTe va бleuкoÀúveтal п enirai-vwvÍa peTa^ú twv na^opeupaTC^óYwv naYraopÍWQ (va piAoúv бпЛaбП T|v Íбla Y^wooa), pe anoTéAeopa T|v кaЛúтepп бle^aYШYП t|Q épeuvaQ (пoЛuкevтplкéQ peXéTeQ) кal T|v кaЛúтepп кaтavóпoп t|q npóYvwonQ кal t|Q GepaпeuтlкПQ avnpeTúnionQ t|Q vóoou.4,12

ЛYZMENEIZ nPOrNQZTIKOI nAPArONTEZ KAI EПIПEЛA ЛPAZTHPIOTHTAZ THZ NIA ZE nENTE (5) OMAAEZ AZOENQN (OEPAnEYTIKEZ OMA-ЛEZ) KATA ACR 201112 /201310

H пoooтlкП eктÍpпoп T|Q бpaoтпplóтптaQ T|Q NIA, oe ouvбuaopó pe T|v napouoÍa opiopévwv бuope-vwv пpoYvшoтlкшv napaYóvTwv, anoTeAoúv raGopi-oTiraúQ napáYovTeQ Yia T|v eпlЛoYП T|Q кaтáЛЛпAпQ GepaneÍaQ otiq бláфopeQ popфéQ t|Q vóoou. Ztiq ou-oTáoeiQ tou ACR Yia тп GepaneÍa T|Q NIA 2011, eктÓQ anó Ta eпÍпeбa бpaoтпplóтптaQ t|Q vóoou, raGopÍ-oтпкav opiopévoi бuopeveÍQ npoYvwoTiraÍ napáYovTeQ Yia 5 opáбeQ aoGevúv (ßЛéпe «GepaпeuтlкéQ opáбeQ aoGevúv pe NIA»), pe ßáoп Ta ßlßЛlOYpaфlкá бeбopéva кal T|v npoownirai epneipÍa twv epneipo-Yvwpóvwv T|Q EпlтpoпПQ tou ACR (Experts' opinion). Oi бuopeveÍQ npoYvwoTiraÍ napáYovTeQ rai Ta enÍne-бa бpaoтпplóтптaQ t|Q vóoou (xapпЛП, péTpia, uфп-Лп), Yia кáGe pÍa anó tiq opáбeQ auTéQ, avaфépovтal otouq nÍvaraQ 2-б.

ANTIMETQnIZH THZ NIA

H avTipeTúnion T|Q NÍA eÍvai Yevirá пoЛúпЛeupп бга-бlкaoÍa. ПeplЛapßável:

1. T| фappaкeuтlкП aYWYП pe ouvGeTirá кal ßloЛoYlкá тpoпoпolптlкá t|Q vóoou фáppaкa (Disease Modifying Antirheumatic Drugs п DMARDS, ПÍvакаQ 7), pn oTe-poelбП avтlфЛeYPOvшбп (NSAID п MZAФ, ПÍvaкaQ 8) кal YЛuкoкopтlкooтepoelбП (GCS п KZ, ПÍvaкaQ 9) ouoTnpaTirá кal тoпlкá (evбoapGplкá, evбoфGaЛplкá, ПÍvaкaQ 10).

2. T| pn фappaкeuтlкП aYWY^ ónwQ, tiq opGonatói-кéQ кal opGoтexvlкéQ пapepßáoelQ, Ta фuolкá péoa GepaneÍaQ (фuolкoGepaпeÍa, uбpoGepaпeÍa), T|v ep-YaoioGepaneÍa, кal T|v фuxo-кolvwvlкП unooTípi^n tóoo twv natôiùv, óoo кal twv Yovéwv touq (e^Íoou oipav^raí).1,3

rENIKEZ ОйНПЕЕ Г1А ТН ФАРМАКЕУТ1КН АГОГН

1. Ta DMARDs, бю^^ут^ oTa ouvGeтlкá rai Ta ßloЛoYlкá DMARDs п ßloЛoYlкoÚQ napáYovTeQ. Ta DMARDs eпlßpaбúvouv T|v aктlvoЛoYlкП eí^i^n T|Q vóoou rai eÍvai anapaÍT|Ta тouЛáxloтov oTa 2/3 twv nepinTúoewv.3

2. То DMARD екЛоуqç yia тп NIA eívai n уево-TpeÇâTq. EnapraíQ GepaneuTiwí бoкlpП twv DMARDs GewpeÍTai п GepaneÍa бlápкelaQ тouЛáxloтov 3 pnvúv otiq ouvioTúpeveQ бóoelQ (nÍv. 7). Oi ouvбuaopoÍ twv DMARDs Ga npénei va xpnoiponoioúvTai enÍ anoTuxÍ-aQ t|Q povoGepaneÍaQ pe peGoTpe^áTn, eктóQ кal av unápxouv avтevбeÍ^elQ Yia тп xopПYПoП touq.

3. H xopПYПOП ßloЛoYlкшv napaYóvTwv Yia тп GepaneÍa T|Q ôiayvwoyévnç NIA ouoтПveтal:

Ze óЛeQ кaтпYopÍeQ twv aoGevúv pe пoЛuapGplкП nopeÍa, ave^ap^TWQ t|Q napouoÍaQ п pn RF, aЛЛá pe napouoÍa бuopevúv npoYvwomúv napaYóvTwv кal uфпЛП бpaoтпplóтптa T|Q vóoou (ßЛéпe nívaraQ 3,4), oe aoGeveÍQ pe ouoTnpaTiräQ eкбпЛúoelQ pe п xwpÍQ apGpnrôa raGúQ кal oe enÍpova evepYó paYoelбÍтlбa, (e^wapGpiraí eкбПЛwoп t|Q NIA) nou eÍvai avGeктlкП oTa áЛЛa DMARDs, ave^ápT|Ta anó T|v napouoÍa п pn apGpÍтlбaQ 7,12 ка1 еф0аоу éxouv anoTúxei ot| GepaneÍa:

pe 32 nAaooirá DMARDs п ouvбuaopoÚQ auTúv enÍ anouoÍaQ бuopevúv npoYvwomúv napaYóvTwv, п pe 31 DMARD enÍ napouoÍaQ бuopevúv npoYvwoTi-^v napaYóvTwv,

п oe nepÍnTwon aпoбeбelYpévпQ avтévбel^ПQ п бuoa-ve^ÍaQ п To^iráTiTaQ T|Q GepaneÍaQ pe DMARDs

4. Oi ey^wi^évoi (кат' aЛфaßnтlкq oeipá) ßio-\оуко1 napâyovTeç Yia тп GepaneÍa T|Q NIA ot|v Eupúnn (EMA)22 eÍvai péxpi oтlYpПQ to Abatacept, to Adalimumab, to Canakinumab, to Etanercept, rai to Tocilizumab (nÍv. 8). Qotóoo, éxouv xpnoiponoinGeÍ pe eniTuxÍa rai ouoTívovTai anó epneipoYvúpoveQ кal áЛЛol ßloЛoYlкoÍ napáYovTeQ nou éxouv nápei npoQ to napóv évбel^п póvo oe evПЛlкeQ pe apGpÍтlбeQ бlaфópwv popфúv, (ónwQ PeupaтoelбП ApGpÍтlбa, oпovбuЛoapGpÍтlбa п apGpÍтlбa oTa пЛaÍola фЛeYpo-vú6ouq vóoou tou evTépou). Autoí eÍvai (кaт' aЛфa-ßПTlкП oeipá) to Anakinra, to Infliximab, to Rilonacept ^ev кuкЛoфopeÍ ot|v EЛЛáба) кal to Rituximab (póvov enÍ anoTuxÍaQ twv пpoavaфepGévтwv napaYóvTwv).

3,б-8,22,23

5. Ze aoGeveÍQ pe avтévбel^п, бuoave^Ía п тo^lкóтптa oTa DMARDs (rapÍWQ ot| peGoTpe^áTn, кuкЛooпopÍ-vn п ЛeфЛouvopÍбп) evбeÍкvuтal п XopПYПOП, wq povo-GepaneÍa, twv ßloЛoYlкшv napaYóvTwv Adalimumab, Anakinra, Canakinumab, Etanercept rai Tocilizumab, raTá nepÍnTwon.12

6. MeTa^ú twv ßloЛoYlкшv napaYóvTwv unápxouv eni-pépouQ бlaфopéQ ot|v aпoтeЛeopaтlкóтптa, aoфá-

Àera Kai otov тропо xopnYHonQ (avâÀOYa je Tnv ка-THYopia TnQ NIA) пои npénei va ouveKTijwvTai ката Tnv eniÀoYH TnQ 9epaneiaç. H eniÀoYH тои Pi0À0YiK0Û napâYOVTa OTnpiZeTai OTnv nAiKÎa тои ao9evn, OTnv KaTHYopia thq NIA, oe ouvunâpxovTEQ napâYOVTeç Kivôûvou Kai ÇeKivâ je фâpJaкa пои éxouv napei év-Sei^n отп NIA.24

7. Ao9eveÎQ пои пaípvouv aYwYn je ouv9eTiKâ n/Kai PюЛoYlкâ DMARDs пpéпel va пapaкoЛou9oûvтal je eupéwQ aTOSeKTa Sie9vn epYaÀeia eKTÎjnonQ TnQ Ka-TâoraonQ SpaoTnpiÔTnTaQ TnQ vôоou (п.х. JADAS, ACRpedi) ка9е 1-3 jnveQ мета Tnv évap^n TnQ 9epa-пeíaQ Kai ка9е 3-6 jnveQ мета Tnv ertTeu^n ûфeоnQ H xajn^ÎQ SpaoTnpiÔTnTaQ TnQ vôоou. H 9epaTOÎa auTn ouvexiZeTai, eфôоov о1 ao9eveÎQ éхouv TOuAâxi-otov ACRpedi 30 jeTâ a™ 3jnveQ 9epaTOÎaQ Ka9wQ Kai oe ao9eveÎQ je ouoTnjaTiKn NIA пои je Tn 9epa-пeía eÀéYx9nKav о1 ouoTnjaTiKéQ тouQ eKSnAwoeiQ. ПpoQ то пapôv Sev uпâpхouv KaTeu9uvTnpieQ oSnYÍ-eQ Yia тov Tpô™ eAâTTwonQ n то xpôvo 6laкoпnQ twv PюÀoYlкшv пapaYôvтwv. H eAâTTwon TnQ SôonQ n n 6laкoпn auTwv twv 9epaTOiwv eÇaTOjiKeûeTai, avâ-ЛoYa je Tnv ^pim-won, Kai ouvH9wq Sev eпlхelpeíтal пplv a™ Tn 2eTÎa ûфeоnQ ито 9epaпeía.24

8. О отôхOQ TnQ оÛYXPOvnQ avтlJeтwпlоnQ TnQ NIA eivai n ôоo то SuvaTôv TaxûTepn eraTeu^n avevepYoû H eÀâxiOTa evepYoû vôоou (PAéTO ^юмо!^») Yia va aпoфeux9oûv jôvijeQ JuoокeЛeтlкéQ PAâPeQ Kai jeA-ЛovтlкéQ ava^pieQ. le ao9eveÎQ пои Sev eraTUYXâve-Tai о отôxoQ auTôQ, ouvioTâTai aAAaYn TnQ 9epa^u-TiKHQ aYWYHQ.

Me pâon пpôофaтa PlPAюYpaфlKâ SeSoJéva, n Tâon, wq пpoQ Tn фapJaкeuтlкn aYwYn, eivai n, ôоo то SuvaTôv evwpÎTepa, évap^n TnQ aYWYHQ. EпlпAéov, otiq JopфéQ пои éxouv пoAuap9plкn пopeía, n aYwYn пpéпel va eivai eÇapxnQ eпl9eтlкn. 25,26

9. H aTOTeAeojaTiKôTnTa twv PюAoYlкwv пapaYôvтwv avajéveTai otiq ^WTeQ 16-24 epSoJâSeQ aYWYHQ. TôTe пpéпel va пoоoтlкoпoleíтal то aroTéAeoja KaTâ ACRpedi Kai va AajPâveTai 9epaпeuтlкn aпôфaоn (п.x. eâv то score ACRpedi < 30, aAAaYn 9epaпeíaQ).12,17

10. Era aпoтuxíaQ тои пpwтоu avTÎ-TNF пapâYOvтa, 9ewpoûvтal, wq a^Seno^ пpaктlкéQ, n aAAaYn oe 2°v avTÎ-TNF n oe âAAov PюAoYlKô пapâYOvтa, KaTâ пepíптwоn (PAéTO 9epaпeuтlкéQ 0JâSeQ ao9evwv).12

ЛОЮЛОПА ФАPMАKQN nOY XPHZIMOnOlOYNTAI ZTH NIA

Mg oTEpoeiôq аутфАеууоуыбц фаруака (М1АФ):

Kavéva Sev uTOpTepei évavTi twv âAAwv. H eпlAoYn PaoiZeTai oe âAAouQ пapâYovтeQ, ôпwQ n ouxvôTnTa XopnYnоnQ, n JopФn тои фapJâкou oe uyph JopФn (evaiwpnja) Yia Ta jiKpâ пalSlâ, то kôotoq, Kai n eÇa-тoJlкeuJévn avoxn тои OKeuâojaTOQ. H тauтôXpovn XopnYnоn 2 n TOpiooôTepwv М1АФ Sev ouoTnveTai.

Та МЗДФ, avaкouфíZouv м6vo апо miv пpwlvn би-oкaмфía Kai tov tovo, aAAa 6ev кaтaoт¿AAouv тп xp6via фAeYMovшбn 6iepYaoia, 6ev eпnpeaZouv бп-Aa6n тnv ¿KPaon тnQ v6oou (niv. 8).3,4

Kopтlкooтepoelбn

'Exouv a^Au^ ev6ei^n oтn ouoтnмaтlкn Mopфn тnQ NIA (niv. 9), ouYKeKp^eva Yia тnv кaтaсттоAn тои пи-peтoй, тnQ opoYovíтlбaQ Kai тои ouvбp6Mou evep-YoпoínonQ тои мaкpoфaYou (macrophage activation syndrome, MAS). 1та пайга 6ev eivai aпapaíтnтn n ouYxopnYnon YaoтpoпpooтaoíaQ. 4 12 27 28

nPOTEINOMENA 0ЕРАПЕУТ1КА ZXHMATA/ nPQTOKOAAA ZTIZ 5 OMAAEZ AZOENQN ME NIA ZYMФQNA ME TIZ ZYZTAZEIZ TOYACR 2011/2013 10'12

H ouoTO9eioa Eпlтpoпn тои ACR Yia пpoтaoelQ 9e-paTOu™^ oxnмaтwv oтlQ 6^opeQ кaтnYopíeQ тnQ NIA eTOAe^e 5 oмaбeQ ao9evwv мe Paon KupiwQ тov apl9м6 (oAiYoap9pm6a, пoAuap9píтlбa) n/Kai тo ei-6oq тwv пpooPePAnмevwv ap9pwoewv (п.x iepoAa-Y6vieQ), тnv пapouoía n мп бuoмevшv пpoYVwoтlкшv пapaY6vтwv мaZÍ мe тп oфalplкn eкгíмnon тou laтpoй Yia тп ouvoAiKn бpaoтnpl6тnтa ^Q v6oou oe oптlкn avaAoYiKn кМмака 0-10 (9a avaф¿peтal oтo e^nQ wq MDVAS global) Kai ^v пapouoía n мп ouoтnмaтlкшv eK6nAwoewv. ria ouvтoмía, oi 5 arn'EQ oмaбeQ кaAoй-vтal «9epaпeuтlк¿Q oмaбeQ (treatment groups) ao9e-vwv мe NIA». Пapaкaтw, пapaтí9evтal oi oмaбeQ au-т¿Q мe та пpoтelV6мeva 9epaпeuтlкa oxnмaтa (niv. 7-11) Kai ^nv пapaкoAoй9non тnQ aoфaAelaQ touq (niv. 12), oймфwva мe ^v пpoo9nкn мeтaYev¿oтepwv бnмooleuмevwv бeбoмevwv.29-32 ria ^nv 4H Kai 5n oмaбa, пou aфopoйv тп ouoтnмaтlкn NIA, o пpшnv бlaxwplOM6Q (2011) onQ oмaбeQ auт¿Q мe Paon w пapouoía n тnv aпouoía ouoтnмaтlкшv eK6nAwoewv Kai evepYoй ap9pin6aQ (ave^apтnтa апо тov apl9м6 тwv пpooPePAnмevwv ap9pwoewv) тpoпoпoln9nкe onQ ouoтaoelQ tou ACR 2013, Kai o бlaxwploм6Q Yiverai тшpa мe Paon tov apl9м6 тwv пpooPePAnмevwv ap9pwoewv, (0=a™uoia ap9pin-6aQ, <4 = oAiYoap9pm6a, >4 = пoAuap9píтlбa), тo eпíпeбo бpaoтnpl6тnтaQ тnQ v6oou мe W MDVAS global <5 n >5 Kai ^v пapouoía n W aпouoía ouoтn-мaтlкшv eK6nAwoewv. Me та Kpmipia auтa oi «9epa-пeuтlк¿Q oмaбeQ» тnQ ouoтnмaтlкnQ NIA 6iaKpivovTOi oe «ouoтnмaтlкn NIA мe evepYeiQ ouoтnмaтlк¿Q eK-6nAwoeiQ Kai мe бlaф6pou Pa9мoй evepY6 ap9pm6a (бlaф6pou apl9мoй пpooPePAnмeveQ ap9pwoeiQ)» Kai oe «ouoтnмaтlкn NIA xwpiQ ouoтnмaтlк¿Q eK6nAwoeiQ Kai мe бlaф6pou Pa9мoй evepY6 ap9pin6a (бlaф6pou apl9мoй пpooPePAnмeveQ ap9pwoeiQ)».

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1H 0ЕРАПЕУТ1КН OMAAA: AZOENEIZ ME IZTOPIKO APQPITIAAZ ZE 4 H Л1rOTEPEZ AP0PQZEIZ (ОЛ1ГОАР0Р1Т1ЛА)

EvTáooovTai ao6eveÍQ pe enípovn oAiYoap9píTiSa, Kánoioi anó touq ao6eveÍQ pe фшр1ао1кп ap9píTiSa, Kánoioi pe ap9píTiSa nou oxeTíZeTai pe ev9eoíTiSa Kai opiopévoi pe aTaíivópnTn ap9píTiSa, oi onoíoi, o' óAn тп SiápKeia thq vóoou, éxouv npooPoAn péxpi 4 ap-9púoeiQ.

H Siapá9pion SpaoTnpióTnTaQ thq vóoou oe 3 ení-neSa Kai oi SuopeveíQ npoYvwoTiKoí napáYovTeQ yi' auTn тп «9epaneuTiKn opáSa» ao9evwv pe NIA, na-paTÍ9eTai otov nívaKa 2. ZxnpaTiKá, п óAn oTpaTnYi-кп thq 9epaneíaQ фaíveтal otov aAYópi9po/oxnpa 1.

©epaneía

Qq apxiKn 9epaneía othv opáSa auTn twv ao9evúv npoTeívovTai, povo9epaneía pe М1АФ (a) п evSoap-9piKn éYxuon KopTiKooTepoeiSúv (P) п pe9oTpeíáTn (y) a. Movo0epaneía pe МЕАФ (xwpíQ ev6oap9piKñ éYxuon KZ) ouoTnveTai:

• ria ao9eveÍQ pe xapnAn SpaoTnpióTnTa thq vóoou, xwpíQ póvipn oúYкapфп ap9púoewv Kai pe anouoÍa Suopevwv npoYvwoTiKúv napaYóvTwv. Ení na-papovnQ evepYoú ap9píTiSaQ Yia nepínou 2 pnveQ Sev ouvexÍZeTai п povo9epaneía pe М1АФ aAAá npoTeÍveTai aAAaYn oe áAAn opáSa фappáкwv.

p. Ev6oap0piKñ ¿YXuan K0pxiK0CTrep0ei6úv (KZ) (pe п xwpíQ eninpóo9eTn 9epaneía) ouoTnveTai:

• ria óAouq touq ao9eveÍQ pe evepYó ap9píTiSa ave^ápTHTa anó to eníneSo SpaoTnpióTnTaQ thq vóoou Kai napouoía п anouoÍa Suopevwv npoYvwoTiKúv napaYóvTwv п oÚYкapфп twv ap9pw-oewv (niv.10). To 9epaneuTiKó anoTéAeopa (KAivi-Kñ PeATÍwon) avapéveTai va SiapKéoei TouAáxioTov 4 pпveQ. Eáv n SiápKeia eívai ouvTopóTepn TóTe npooTÍ9eTai Kai ouoTHpaTi^ 9epaneía. Eáv to 9e-paneuTiKó anoTéAeopa SiapKéoei > 4 pпveQ TóTe П evSoap9piraí éYxuon KZ pnopeí va eпavaAпф9eÍ pe п XwpÍQ ouoTnpaTi^ 9epaneía aváAoYa Kai pe Tnv KaTáoTaon twv áAAwv ap9pwoewv.

Y. Me0OTpe£árn. H X0PПYП0П pe9oTpeíáTHQ ouo^í-veTai:

• Qq apxi^ 9epaneía (eáv Sev éxei nponYn9eÍ áAAn 9epaneía) Yia ao9eveÍQ pe uфпAп SpaoTnpióTnTa thq vóoou Kai napouoía Suopevwv npoYvwoTiKúv napaYóvTwv.

• Eáv éxei nponYn9eÍ evSoap9plкп éYxuon KZ, ou-oi^eTai Yia ao9eveÍQ pe uфпAп SpaoTnpióTnTa thq vóoou xwpÍQ napouoía Suopevwv npoYvwoTiKúv napaYóvTwv Ka9úQ Kai Yia ao9eveíQ pe pé-Tpia SpaoTnpióTnTa thq vóoou Kai napouoía Su-opevúv npoYvwoTiKúv napaYóvTwv.

• Eáv éxouv nponYH9eí enaveiAnppéveQ evSoap9pi-KéQ eYxúoeiQ KZ, п X0PПYП0П pe9oTpeíáTHQ ou-

o^íveTai Yia ao9eveíQ pe péTpia SpaoTnpióTnTa thq vóoou Kai anouoía Suopevúv npoYvwoTiKúv napaYóvTwv Ka9úQ Kai Yia ao9eveíQ pe xapпAп SpaoTnpióTnTa thq vóoou aAAá pe napouoía Suopevúv npoYvwoTiKúv napaYóvTwv.

ria ao9eveíQ nou avпкouv othv KaTnYopía thq apdpí-Ti6aq nou oxeTÍ&Tai ye evdeomda ouo^veTai п X0PПYП0П ооиАфаоаАа^м^ otiq eí^Q nepimúoeiQ:

• Eáv éxei nponYn9eí evSoap9plкп éYxuon п povo9e-paneía pe М1АФ SiápKeiaQ 2 pnvúv, Kai, napóAa auTá, unápxei péTpia п uфпAп SpaoTnpióTnTa thq vóoou aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv. Aev ouo^veTai oouAфaoaAaZÍvп otouq ao9eveíQ nou Sev avпкouv o' au^v Tnv KaTnYopía thq vóoou.

AvaoToAeíq tou TNF-a (TNF-a inhibitors, TNFai). Xo-PПYП0П evóQ TNF-ai ouo^veTai:

• ria ao9eveíQ, oi onoíoi éxouv Kávei evSoap9piKéQ eYxúoeiQ KZ Kai éxouv nápei pe9oTpeíáTn oth pé-Yíoth ouvioTúpevn Sóon Yia TouAáxioTov 3 pпveQ Kai napóAa auTá éxouv péTpia п uфпAп SpaoTnpióTnTa thq vóoou Kai napouoía Suopevúv npoYvwoTiKúv napaYóvTwv.

• ria ao9eveíQ nou éxouv Kávei evSoap9piKéQ eYxúoeiQ KZ Kai éxouv nápei pe9oTpeíáTn Yia 6 pпveQ Kai napóAa auTá éxouv uфпAп SpaoTnpióTnTa thq vóoou xwpíQ va éxouv SuopeveíQ npoYvwoTiKoúQ napáYovTeQ.

• ria ao9eveíQ nou avпкouv othv KaTnYopía thq ap-9píTiSaQ nou oxeTíZeTai pe ev9eoíTiSa, oi onoíoi éxouv Kávei evSoap9piKéQ eYxúoeiQ KZ Kai éxouv nápei oouAфaoaAaZÍvп ení 3pnvo, (xwpíQ va éxei nponYn9eí anapaíTHTa pe9oTpeíáTn), Kai napóAa auTá eíaKoAou9oúv va éxouv péTpia п uфпAп SpaoTnpióTnTa thq vóoou, aveíápTnTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

To anoTéAeopa thq X0PПYП0ПQ áAAwv PioAoyikúv napaYóvTwv (nx Abatacept), п áAAwv ouv9eTiKúv DMARDs (uSpoíuxAwpoKívnQ, AeфAouvopíSпQ) o' au^ Tnv opáSa Sev eívai pépaio.

2H GEPAnEYTIKH OMAAA: AZOENEÍZ ME IZTOPIKO APQPITIAAZ ZE 5 TOYAAXIZTON AP0PQZEIZ (ПOЛYAPQPITIAA):

EvTáooovTai ao9eveíQ pe noAuap9píTiSa (RF 9eTiKoí п apvnTiKoí), Kánoioi anó touq ao9eveíQ pe фwplaol-кп ap9píTiSa, Kánoioi pe ap9píTiSa nou oxeTíZeTai pe ev9eoíTiSa Kai opiopévoi pe aTaíivópnTn ap9píTiSa, oi onoíoi, o' óAn тп SiápKeia thq vóoou, éxouv пpooPoAп TouAáxioTov 5 ap9púoewv. H Siapá9pion SpaoTnpióTnTaQ thq vóoou oe 3 ení-neSa Kai oi SuopeveíQ npoYvwoTiKoí napáYovTeQ Yi'

Зг'вЕРАПЕУТ1КНОМДДА Аэвртба kiu шраХвутгЬпба

VIIАФ ±EE ÍVLM 1 ^T"'1-'

MTX EouXoaaaXa^ivri (VKi 3 wi'tt;)

TNF-ai

(Adalimumah, Etanarrapt, Infliximab)

М1А.Ф : Mq cntpoEitr^ iTVTir^^itфаррака MTX : MíflcnpEÍnni

*MdWQ yia ŒJOÛEYÊCÇ FIÛU ÜVIÍKÍJUY drr^v KatrlyöpLa apÔpnLfinÇ núu C^ETL^ÉIÚL |JE £V€ÉCÍELÍÜ : EvÉiOnpGpucií ¿v^uciri И

KI : KopTLKûaiipoELÈ^ CSA : KuKAocTropivri A

ZxПмa 1. ZтpaтпYlкП GepaneÍaQ ot|v 1|, 2| кal 3| GepaпeuтlкП opáбa

auтП тп «GepaпeuтlкП opáбa» aoGevúv pe NÍA, na-paTÍGeTai otov ПÍvaкa 3. Zxпpaтlкá, п óЛп OTpaTnY^ii t|Q GepaneÍaQ фaÍveтal otov aЛYÓplGpo/oxПpa 1.

Oepaneía

Моуоверапе1а ye МЕЛФ: H évap^n povoGepaneÍ-aQ pe MZAФ кal xwpÍQ evбoapGplкП éYxuon KZ, бev aпoбÍбel ouvПGwQ otouq aoGeveÍQ pe evepYó пoЛu-apGpÍтlбa. EпlпЛéov, ave^ápT|Ta anó T|v napouoÍa п óxi бuopevшv npoYvwoT^wv napaYóvTwv, п ouvé-xion t|Q GepaneÍaQ pe MZAФ Yia nepiooóTepo anó 2 pПveQ, oe napapévouoa evepYó apGpÍтlбa бev éxei Géon.

Корткоотерое^ф: MnopeÍ va xopnYlGoúv ouot|-paтlкá ßpaxuxpóvla, péxpi va бpáoouv Ta DMARDS. ZuvGeтlкá DMARDs

Мевотре&тп : H xopПYПOП peGoTpe^áT|Q oucmîveTai:

• Qq apxlкП GepaneÍa oe aoGeveÍQ pe uфпЛП бpa-oTnpióT|Ta t|Q vóoou, ave£ápT|Ta anó T|v napouoÍa п óxi бuopevшv npoYvwomwv napaYóvTwv

• Qq apxiraí GepaneÍa oe aoGeveÍQ pe péTpia бpa-oTnpióT|Ta t|Q vóoou rai napouoÍa бuopevшv пpoYvwoтlкшv napaYóvTwv.

• MeTá anó évav nepÍnou pПva GepaneÍaQ pe MZAФ oe aoGeveÍQ pe xapпЛП бpaoтпplóтптa t|Q vóoou rai napouoÍa бuopevшv пpoYvwoтlкшv napaYóvTwv.

• MeTá anó 1 - 2 nepÍnou pПveQ GepaneÍaQ pe MZAФ xwpÍQ aпoтéЛeopa, oe aoGeveÍQ pe péTpia бpaoтпplóтптa t|Q vóoou xwpÍQ napouoÍa бuope-vúv npoYvwornwv napaYóvTwv.

ЛeфÀоuvоyíön:: H eпlтpoпП tou ACR ei<Tipá óti п peGoTpe^áTn unepéxei t|Q ЛeфЛouvopÍбпQ, ßáoel t|Q пpoowпlкПQ aЛЛá кal t|q ouvoЛlкПQ бпpooleupévпQ epneipÍaQ. H xopПYПoП T|Q ouoтПveтal:

• Qq apxlкП povoGepaneÍa oe aoGeveÍQ pe uфпЛп бpaoтпplóтптa t|Q vóoou кal napouoÍa бuopevшv napaYóvTwv.

• Qq apxlкП povoGepaneÍa oe aoGeveÍQ pe uфпЛп бpaoтпplóтптa t|Q vóoou enÍ anouoÍaQ бuopevшv пpoYvwoтlкшv napaYóvTwv, eфóoov пpoпYПGпкe GepaneÍa pe MZAФ.

• Qq apxi^i povoGepaneÍa oe aoGeveÍQ pe péTpia бpaoтпplóтптa t|Q vóoou кal pe napouoÍa бuope-vúv npoYvwornwv napaYóvTwv, eфóoov пpoпYП-Gпкe GepaneÍa pe MZAФ.

YöроÇuxЛwрокívn:: XopПYПOП uбpo^uxЛwpoкÍvпQ eÍTe wq povoGepaneÍa п pe/xwpÍQ ouYXopПYПOп MZAФ бev GewpeÍTai oПpepa кaтáЛЛпЛп Yia aoGeveÍQ pe evepYó пoЛuapGpÍтlбa.

ЕоиЛфаоаЛа^мп: To Gepaпeuтlкó aпoтéЛeopa T|Q oouЛфaoaЛaZÍvпQ eÍvai aßéßalo Yi' au^í T|v opáбa. EпlпЛéov, бev éxei a£^oY|GeÍ oe aoGeveÍQ nou av^ кouv oT|v кaтпYopÍa t|Q apGpnrôaQ nou oxeTÍZeTai

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E Л Л H N I К H РЕУМАТОЛОГ1А 2015

pe ev9eoíTiSa Kai éxouv ioTopiKó пpooPoAпQ > 5 ap-9púoeiQ.

Zuv6uaoyoí ouvderiKwv DMARDs: O ouvSuaopóQ nou xpnoiponoieíTai oe apKeTá naiSopeupaToAoYi-Ká KévTpa thq EupúnnQ pe noAú KaAá 9epaneuTiKá anoTeAéopaTa (Snpooieupévn epneipía) eívai thq pe-9oTpeíáTnQ pe KuAoonopívn. O ouvSuaopóQ pe9o-TpeíáTnQ pe oouAфaoaAaZÍvп Kai/п uSpoíuxAwpowívn éxei apépaio anoTéAeopa.

BioÁoYiKoí napáYovTeQ (KaTá aAфaPптlкп oeipá, nívaKaQ 11)

AvaoroAeíq rqq ouv6iéyepoqq (Abatacept) ouorq-vovrai:

• Ze ao9eveíQ nou éxouv nápei évav TNF-ai Yia 4 pпveQ Kai éxouv uфпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

• Ze ao9eveíQ nou éxouv nápei SiaSoxiKá nepio-oóTepouQ anó évav TNF-ai Kai éxouv péTpia п uфпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

• Ze ao9eveíQ nou éxouv nápei SiaSoxiKá nepiooó-TepouQ anó évav TNF-ai Kai éxouv xapпAп SpaoTnpióTnTa thq vóoou pe napouoía Suopevúv npoYvwoTiKúv napaYóvTwv.

AvaoroAeíq тои TNF-a (TNF-ai , Adalimumab, Etanercept, Infliximab) ouorqvovrai:

• Ze ao9eveíQ nou éxouv nápei pe9oTpeíáTn п Ae-фAouvopíSп Yia 3 pпveQ oth peYaAúTepn npoPAe-nópevn Sóon Kai éxouv péTpia п uфпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

• Ze ao9eveíQ nou éxouv nápei pe9oTpeíáTn п Ae-фAouvopíSп Yia 6 pпveQ Kai éxouv xapпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

MeTaKívqoq anó évav TNF-ai oe áAAov ouo^ve-Tai, wq evaAAaктlкп 9epaneía:

• Ze ao9eveíQ nou éxouv nápei évav TNF-ai Yia 4 pпveQ Kai napapévouv oe péTpia п uфпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

• Ze ao9eveíQ nou éxouv nápei Abatacept Yia 3 p^ veQ Kai éxouv uфпAп SpaoTnpióTnTa thq vóoou Kai napouoía Suopevúv npoYvwoTiKúv napaYóvTwv.

• Ze ao9eveíQ nou éxouv nápei Abatacept Yia 6 p^ veQ Kai éxouv péTpia п uфпAп SpaoTnpióTnTa thq vóoou, aveíápTHTa anó Tnv napouoía п óxi Suopevúv npoYvwoTiKúv napaYóvTwv.

AvaoroAeíq rqq IL-6 (IL-6i) Tocilizumab:

Пpóoфaтa eYKpí9nKe п X0PПYП0П Tocilizumab Kai Yia naiSiá ávw twv 2 eTúv pe пoAuap9plкп veaviwi iSi-oпa9п ap9píTiSa, av9eктlкп oTa áAAa DMARDs. 29,30

AvaoroAeíq rwv В Kurrápwv (Rituximab) ouorq-vovrai:

• Ze ao9eveíQ nou éxouv nápei évav TNF-ai Kai oth ouvéxeia Abatacept п Tocilizumab Kai éxouv napa-pévouoa uфпAп SpaoTnpióTnTa thq vóoou, ave-íápTnTa anó Tnv napouoía Suopevúv npoYvwoTiKúv napaYóvTwv,

• Ze ao9eveíQ nou éxouv nápei évav TNFi Kai oth ouvéxeia Abatacept п Tocilizumab Kai éxouv péTpia SpaoTnpióTnTa thq vóoou Kai napouoía Suopevúv npoYvwoTiKúv napaYóvTwv.

Ynápxouv npúipeQ evSeííeiQ óTi to Rituximab pnopeí va eívai KaTaAAnAóTepo Yia RF opo9eTiwoúQ ao9eveíQ, ouYKpiTiwá pe touq opoapvnTiwoúQ.

AvaoroAeíq rqq IL-1 (IL-1i Anakinra/Canakinumab):

Ae ouoтпvovтal Yia au^ Tnv opáSa twv ao9evúv.

3H QEPAnEYTIKH OMAAA: AZQENEIZ ME ENEPrO APQPITIAA TQN IEPOAArONIQN

EvTáooovTai ao9eveíQ pe KAiviiéQ Kai aneiKovioTiKéQ evSeííeiQ evepYoú iepoAaYovíTiSaQ, ónwQ eívai ouv^ 9wq oi ao9eveíQ pe ap9píTiSa nou oxeTíZeTai pe ev-9eoíTiSa Kai pe фwplaolкп ap9píTiSa, pnopeí ópwQ va evTáooovTai Kai ao9eveíQ pe oпolaSппoтe áAAn pop-фп thq vóoou Kai evepYó iepoAaYovíTiSa. 12 ZxnpaTiKá, п óAn oTpa^^ thq 9epaneíaQ фaíveтal otov aAYÓpl9po/oxпpa 1.

©epaneía

H 9epaneía oTnpíZeTai KupíwQ othv avTíoToixn Snpooieupévn epneipía Yia evпAlкeQ ao9eveíQ pe onoSuAo-ap9píTiSa, Aóyw éAAelфПQ Tuxaionoinpévwv peAeTúv oTa naiSiá au^Q thq opáSaQ.12,31 Ta nepiooóTepa KévTpa xPnoiponoioúv Ta М!АФ, tiq evSoap9piwéQ eYxúoeiQ KopTiKooTepoeiSúv, Kai тп pe9oTpeíáTn п oouAфaoaAaZÍvп Yia piipó SiáoTnpa. H eniTpo^ Tou ACR aíioAóYnoe póvo тп 9éon twv PioAoyikúv napaYóvTwv othv opáSa au^.12

MZAФ: XpnoiponoioúvTai Yia 4-8 ePSopáSeQ.

Ev6apdpiKéq eyxúoeiq KopriKoorepoei6wv: KaTá nepínTwon

ZuvderiKá DMARDs

Me9oTpeíáTn Yia SiáoTnpa péxpi 3pпveQ Kai enave-KTípnon.

ZouAфoaAaZÍvп Yia SiáoTnpa péxpi 3pпveQ Kai ena-veKTípnon. AnoTeAeí Kai au^ pía anoSen^ eпlAoYП peTá anó Ta М!АФ Kai /п tiq evSoap9piwéQ eYxúoeiQ KopTiKooTepoeiSúv.

ВloЛoYlкoí napáYovreQ 6-8,12 TNF-ai ouoтqvQvтal:

• Ze aoGeveÍQ pe evepYó lepoЛaYOvÍтlбa nou бev avтaпoкpíGпкav oe MZAФ, éxouv uфпЛП бpaoтп-pióT|Ta t|Q vóoou кal napouoÍa бuopevúv npo-Yvwoti^v napaYóvTwv.

• Ze aoGeveÍQ nou бev éxouv aпavтПoel oe 3pnvn XopПYПOП peGoTpe^áT|Q кal éxouv uфпЛП бpaoтп-pióT|Ta t|Q vóoou, ave^ápT|Ta anó T|v napouoÍa п óxi бuopevúv npoYvwoTi^v napaYóvTwv.

• Ze aoGeveÍQ nou бev éxouv aпavтПoel oe 6piv| XopПYПOп peGoTpe£áT|Q, éxouv péTpia бpaoтпpl-óT|Ta t|Q vóoou кal anouoía бuopevúv npoYvw-ot^úv napaYóvTwv.

• Ze aoGeveÍQ nou бev éxouv aпavтПoel oe 3pnvn XopПYПOП oouЛфaoaЛaZÍvпQ, éxouv péTpia п uфп-Лп бpaoтпplóтптa t|Q vóoou кal napouoÍa бuope-vúv npoYvwoTi^v napaYóvTwv.

• Ze aoGeveÍQ nou бev éxouv пЛéov evepYó lepoЛaYO-vÍтlбa, aЛЛá éxouv nep^epiraî apGpÍтlбa (nou npo-ßáЛЛel eÍTe wq oЛlYoapGpÍтlбa п wq пoЛuapGpÍтlбa), peTá anó aveпapкП anávTnon oe 3pnvn п 6piv| GepaneÍa pe peGoTpe^áTn, pe loтoplкó npo|Y|GeÍ-oaQ GepaneÍaQ pe MZAФ enÍ 1-2 pПveQ кal ouxvéQ evбoapGplкéQ eYXúoeiQ rapTiraoTepoe^úv.

•

4H GEPAnEYrIKH ОМЛЛЛ: AZ0ENEIZ ME LYZ^MA^KH NIA nOY EXOYN ENEPrEIZ ZYZ^MAnKEZ E^HAQZEIZ KAI ЛIAФOPOY BA0MOY ENEPrO APOP^^ (APIOMOZ ПPOZBEBЛHMENQN APOPQZEQN: O, 1-4, >4) EvTáooovTai óЛol oi aoGeveÍQ nou ^npoúv Ta ^пп-pia ILAR Yia тп ouoTipaTiraî popфП T|Q NIA (ZNÍA), nou éxouv ouoтпpaтlкéQ eкбпЛúoelQ aЛЛá anouoía evepYoú apGpÍтlбaQ (n.x. aoGeveÍQ nou п apGpÍтlбá touq uфéGпкe xwpÍQ GepaneÍa п eЛéYxGпкe pe pn oтepoelбП avтlфЛeYpovшбп фáppaкa aЛЛá o nupeTóQ enipévei) п nou éxouv ouoтпpaтlкéQ eкбпЛúoelQ pe бlaфópou ßaGpoú evepYó apGpÍтlбa 11,12. Ta Gepaпeuтlкá пpwтóкoЛЛa Yia touq aoGeveÍQ t|Q opáбaQ auтПQ ouoтПvovтal pe ßáoп T|v napouoÍa ouoTnpamùv eкбпЛúoewv, to eпÍпeбo бpaoтпpl-óT|TaQ T|Q vóoou pe T|v MDVAS global <5 каl >5 (ónou G=anouoÍa бpaoтпplóтптaQ кal 1G= péYioTn бpaoтпplóтптa) кal tov apiGpó twv пpooßeßЛпpévwv apGpúoewv (G, 1-4, >4). Ze ráGe nepÍnTwon, pnopeÍ va npoTeÍvovTai nepiooóTepa anó éva GepaneuTirá povonáTia, onóTe, evaпóкelтal ot|v !pÍon tou iaTpoú va en^é^ei to кaтáЛЛпЛo Yia T|v nepÍnTwon povonáTi, oúpфwva pe Ta xapaктпploтlкá tou aoGevoúQ кal tiq пpoтlpПoelQ auToú кal t|Q olкoYévelaQ. Zto GepaneuTirá oxПpa pnopeÍ va npooTeGoúv oe oпoloбПпoтe oтáбlo кopтlкooтepoelбП (ouoTnpaTirá п evбoapGpl-кá), oúpфwva pe T|v кpÍoп tou iaTpoú. 'СЛа Ta DMARDs (ouvGeтlкá кal ßloЛoYlкá) nou ava-

фépovтal otiq GepaneuTiráQ eпlЛoYéQ/povoпáтla ava-Ypáфovтal кaтá G^aßn^^ oeipá. 'CTav unápxei rá-GeToQ (/) peTa^ú 2 DMARDs onpaÍvei óti apxÍZoupe pe to npúTo eÍTe ЛÓYW tou óti éxei aпoбelxтeÍ wq фáppa-кo 1nQ eкЛoYПQ (n.x. peGoтpe^áтп/ЛeфЛouvopÍбп) eÍTe ЛÓYW кóoтouQ (n.x. Anakinra/Canakinumab ) п ЛÓYW áЛЛпQ alтÍaQ/avтévбel^ПQ.

Ta oтáбla ot|v пpóoбo t|Q GepaneÍaQ pnopeÍ va eÍvai пpooGПкп п бlaбoxlкП xopПYПOП фappáкwv, eктÓQ anó touq ßloЛoYlкoÚQ napáYovTeQ nou n XopПYПOП eÍvai návTa бlaбoxlкП.

Eáv anavToúv ot| GepaneÍa oi ouoTnpaTiráQ erá|-ЛúoelQ aЛЛá óxi rai п apGpÍтlбa, TÓTe n enópevn Ge-paпeuтlкП aпóфaoп Ga npénei va ßaoiZeTai otiq ou-oTáoeiQ nou aфopoúv тп «ZNIA pe evepYó apGpÍтlбa aЛЛá xwpÍQ ouoтпpaтlкéQ eкбпЛúoelQ».

Oepaneía

1. MDVAS global <5 каi a^uoía eveрyоú арврí-nöaç

XopnYoúvTai MZAФ Yia 1 pПva. Eáv бev aпavтПoel o aoGevПQ, npoTeÍvovTai 3 eпlЛoYéQ/povoпáтla: a. napapévouv MDVAS global <5 каl anouoía evepYoú apGpnrôaQ: XopnYoúvTai avaoTC^eÍQ T|Q IL-1 (IL-1i Anakinra/Canakinumab) Yia ^va. Eáv бev ana-vтПoel npoTeÍvovTai 2 eпlЛoYéQ /povonáTia: a1. Eáv unápxei evepYÓQ apGpnrôa oe G-4 apGpú-oeiQ, ave^ápT|Ta anó T|v MDVAS global, XopnYoúvTai avaoтoЛeÍQ T|Q IL-б (IL-6í Tocilizumab), п MeGoTpe^á-тп / ЛeфЛouvopÍбп.

a2. Eáv unápxei evepYÓQ apGpnrôa oe >4 apGpúoeiQ, ave^ápT|Ta anó T|v MDVAS global, XopnYoúvTai ava-oтoЛeÍQ T|Q IL-б (IL-6í, Tocilizumab) п MeGoTpe^áTn / ЛeфЛouvopÍбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

ß. napapévei п MDVAS global <5 rai unápxei evepYÓQ apGpnrôa oe >0 apGpúoeiQ: npoTeÍvovTai 2 eni-ЛoYéQ/povoпáтla:

ß1. XopnYoúvTai KZ anó to OTópa п evбoфЛéßla Yia 2 eßбopáбeQ. Eáv бev anavi^oei o aoGevПQ npoTeÍvovTai 2 en^oYéQ/povonáTia:

• MDVAS global >5 ave^ápT|Ta anó tov apiGpó twv apGpúoewv pe evepYó apGpÍтlбa п MDVAS, <5 pe anouoía evepYoú apGpnrôaQ : XopnYoúvTai IL-1i (Anakinra/ Canakinumab) п IL-6í (Tocilizumab)

• MDVAS global <5 rai apiGpóQ apGpúoewv pe evepYó apGpnrôa >0 : XopnYoúvTai IL-1i (Anakinra/ Canakinumab) п IL-6í (Tocilizumab) п MeGoTpe^á-т|/ ЛeфЛouvopÍбп

ß2. XopnYoúvTai IL-1i (Anakinra/ Canakinumab) Yia 1 pПva. Eáv бev aпavтПoel o aoGevПQ npoTeÍvovTai 2 eпlЛoYéQ/povoпáтla:

• ApiGpóQ apGpúoewv pe evepYó apGpÍтlбa 0-4, ave^ápT|Ta anó T|v MDVAS global: XopnYoúvTai

of rheumatology 1

E Л Л H N I К H PEYMATOЛOПA 20"1б

IL-6i (Tocilizumab) п Me9oтpeÇáтп /ЛeфЛouvopíбп

• Api9póQ ap9púoewv pe evepYó ap9píтlбa >4, ave^áp^a aпó тг^ MDVAS global: XopпYOÚvтаl IL-6i {rocilizumab) п Me9oтpe^áтп/ЛeфЛouvopíбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

Y. Eáv п MDVAS global >б ave^áp^a aró тov api9-pó ap9púoewv pe evepYó ap9píтlбa, пpoтeívovтal 3 eпlЛoYéç/povoпáтra:

Y1. XopпYOÚvтal KZ aпó то oropa п evбoфЛéßla Yia 2 eßбopáбeç. Eáv бev aпavтПoel o ao9evПç пpoтeívo-vтal 2 eпlЛoYéç/povoпáтra:

• MDVAS global >б ave^áp^a aпó тov api9pó ap-9púoewv pe evepYó ap9píтlбa п MDVAS global <б pe апouoíа evepYoú ap9píтlбaQ : XopпYOúvтal IL-1i (Anakinra/ Canakinumab) п IL-6i (Tocilizumab)

• MDVAS global <б Kai api9póq ap9púoewv pe evepYó ap9píтlбa >0 : XopпYOÚvтal IL-1i (Anakinra/ Canakinumab) п IL-6i (Tocilizumab) п Me9oтpeÇá-тп /ЛeфЛouvopíбп.

Y2. XopпYOÚvтal IL-1i (Anakinra/ Canakinumab) Yia 1 pПva. Eáv бev aпavтПoel o ao9evПç, пpoтeívovтal 2 eпlЛoYéQ/povoпáтla:

• Api9póQ ap9púoewv pe evepYó ap9píтlбa 0-4, ave^áp^a aпó тпv MDVAS global : XopпYOÚvтаl IL-6i (Tocilizumab) п Me9oтpeÇáтп /ЛeфЛouvopíбп

• Api9póQ ap9púoewv pe evepYó ap9píтlбa >4, ave^áp^a aпó тпv MDVAS global: XopпYOÚvтаl IL-6i (Tocilizumab) п Me9oтpe^áтп/ЛeфЛouvopíбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

Y3. XopпYOÚvтal IL-1i (Anakinra/ Canakinumab) п IL-6i (Tocilizumab) Yia éva pПva. Eáv бev aпavтПoel o ao9e-vПQ oтov éva пapáYOvтa хopпYeíтal o áAAoQ.

2. MDVAS global <5 ка1 1-4 арвр^е^ ye evepyó арвра^а

XopпYOÚvтal MZAФ (а) п IL-1i (Anakinra/ Canakinumab) (ß) Yia 1 pПva.

a. Eáv бev aпavтПoel o ao9evПQ oтa MZAФ пpoтeívo-vтal 3 eпlЛoYéç/povoпáтra óпwç Kai oтпv пepíптwoп 1(a,ß,Y)

ß. Eáv бev aпavтПoel o ao9evПç oтouQ IL-1i (Anakinra/ Canakinumab)) пpoтeívovтаl 2 eпlЛoYéQ/povoпáтla:

• Api9póQ ap9púoewv pe evepYó ap9píтlбa 0-4, ave^áp^a aпó тпv MDVAS global : XopпYOÚvтаl IL-6i (Tocilizumab) п Me9oтpeÇáтп /ЛeфЛouvopíбп

• Api9póQ ap9púoewv pe evepYó ap9píтlбa >4, ave^áp^a aпó тпv MDVAS global: XopпYOÚvтаl IL-6i (Tocilizumab) п Me9oтpe^áтп /ЛeфЛouvopíбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

3. MDVAS global <5 ка1 >4 арвр^е^ ye evepyó

арвр^^а

XopпYOÚvтal MZAФ (а) п KZ (ß) aпó то oтópa п

evбoфЛéßla Yia 2 eßбopáбeQ п IL-1i (Anakinra/

Canakinumab) (y) Yia 1 jñva.

a. Eáv 5ev anavTñoei o ao9evñQ oTa MZAO npoTeÍvo-vTai 3 eniÁoYéQ/jovonáTia ónwQ Kai oTnv nepÍrnwon

1 (a,P,Y)

p. Eáv 5ev anavTñoei o ao9evñQ oTa KZ npoTeÍvovTai

2 eniÁoYéQ/jovonáTia:

• MDVAS global <5 Kai api9jóQ ap9púoewv je evepYó ap9pÍTi5a >0 : XopnYoúvTai IL-1i (Anakinra/ Canakinumab) ñ IL-6i (Tocilizumab) ñ Me9oTpe^á-Tn /Ae0ÁouvojÍ5n

• MDVAS global >5 ave^ápTnTa anó tov api9jó ap-9púoewv je evepYó ap9pÍTi5a ñ MDVAS global <5 je anouoÍa evepYoú ap9pÍTi5aQ : XopnYoúvTai IL-1i (Anakinra/ Canakinumab) ñ IL-6i (Tocilizumab)

Y. Eáv 5ev anavTñoei o ao9evñQ otouq IL-1i (Anakinra/ Canakinumab) npoTeÍvovTai 2 eniÁoYéQ/jovonáTia:

• Api9jóQ ap9púoewv je evepYó ap9pÍTi5a 0-4, ave^ápTnTa anó Tnv MDVAS global : XopnYoúvTai IL-6i (Tocilizumab) ñ Me9oTpe^áTn / Ae0ÁouvojÍ5n

• Api9jóQ ap9púoewv je evepYó ap9pÍTi5a >4, ave^ápTnTa anó Tnv MDVAS global: XopnYoúvTai IL-6i (Tocilizumab) ñ Me9oTpe^áTn/Ae0ÁouvojÍ5n ñ TNF-ai (Adalimumab, Etanercept, Infliximab)

4. MDVAS global >5 ave£áprqra anó rov apiGyó apQpúoewv ye evepyó apGpírióa

XopnYoúvTai KZ anó to oTója ñ ev5o0ÁéPia (a) Yia 2 ePSojáSeQ ñ IL-1i (Anakinra/ Canakinumab) (P) Yia 1 jñva a. Eáv 5ev anavTñoei o ao9evñQ oTa KZ, npoTeÍvovTai 2 eniÁoYéQ/jovonáTia ónwQ Kai oTnv nepÍnTwon 3(P) p. Eáv 5ev anavTñoei o ao9evñQ otouq IL-1i (Anakinra/ Canakinumab) npoTeÍvovTai 2 eniÁoYéQ/jovonáTia ónwQ otiq nepinTúoeiQ 2 (P) Kai 3 (y) ZxnjaTiKá, n óÁn oTpaTnYiKñ TnQ 9epaneÍaQ 0aÍveTai otouq aÁYópi9jouQ/oxñjaTa 2-5.

5H OEPAnEYTIKH OMAAA: AZ0ENEIZ ME ZYZTHMATIKH NIA ZTOYZ OnOIOYZ nPOEXEI H ENEPrOZ AP0PITIAA KAI AnOYZIAZOYN OI ZYZTHMATIKEZ EKAHAQZEIZ

EvTáooovTai óÁoi oi ao9eveÍQ nou nÁnpoúv Ta KpiTñ-pia ILAR Yia Tn ZNIA, Kai oi onoÍoi éxouv evepYó ap9pÍ-Ti5a x^pÍQ ouoTnjaTiKéQ eKSnÁúoeiQ. (n.x. ao9eveÍQ je káivikó 0aivóTuno ZNIA otouq onoÍouQ u0é9nKav oi ouoTnjaTiKéQ eKSnÁúoeiQ auTójaTa ñ jóvo je Tn Áñ^n MZAO aÁÁá napajévei evepYóQ ap9pÍTi5a). 12 Ta 9epaneuTiKá npwTóKoÁÁa Yia touq ao9eveÍQ TnQ ojáSaQ auTñQ ouoTñvovTai jóvo je Páon rov pad-yó evepyoü apGpírióaq (0, 1-4, >4) Kai óxi ro ení-neóo ópaorqpiórqraq rqq vóoou (MDVAS global <5 q >5). Ze Ká9e nepÍnTwon jnopeÍ va npoTeÍvovTai nepiooóTepa anó éva 9epaneuTiKá jovonáTia, onó-te, evanóKeiTai oTnv KpÍon tou iaTpoú va eniÁé^ei to KaTáÁÁnÁo jovonáTi oúj0wva je Ta xapaKTnpioTiKá tou ao9evñ Kai tiq npoTijñoeiQ auToú Kai TnQ oiko-

ZxПнa 2. ZтpaтпYlкП OepaneÍaQ OT|v 4| GepaпeuтlкП opáбa ZuoтпpaтlкП NIA : MDVAS global <5 rai anouoÍa evepYoú apGpnrôaq

ZxПмa 3. ZipaTiYi^l OepaneÍaQ ot|v 4| GepaпeuтlкП opáбa ZuoтпpaтlкП NIA : MDVAS global <5 rai 1-4 apGpúoeiQ pe evepYÓ apGpÍтlбa

of rheumatology

EAAHNIKH PEYMATQAOriA

ZxnMa 4. ZTpaTHYiKH OepaneiaQ OTqv 4n 9epaneunKii opaSa ZuoTHMaTiKn NIA : MDVAS global <5 Kai >4 ap9pwoeiQ pe evepYO ap9pm6a

IL-li fAiDkinrj/ConakiruTabJ IL-Ei (TociNiumab)

IL-li (Anaklnra/Canaklnumab) IL-61 (TociMzumab) MTX / Af c|iAtJuiro|ji6n

AEA = QuLU^O':, vVtpyLv OpOptildELiJV

MT>! = MfOcipEiiin

ZxnMa 5. ZTpaTHYiKH OepaneiaQ OTn 4r| 9epaneuTiKii opaSa

ZuoTnpaTiKn NIA : MDVAS global >5 av£^aprqra and tov apidyo apdptioswv ys svspyd apdpmSa

Yéveiaç.

'ОЛа та DMARDs (ouv9eтlкá Kai ßюЛoYlкá) пou ava-фépovтal cmç 9epaпeuтlкéQ eпlЛoYéQ/povoпáтla avaYpáфovтal кaтá aЛфaßптlкП oeipá. 'C^av uпápхel кá9eтoQ (/) peтaÇú 2 DMARDs, oпpaível, ón apxíZou-pe pe то пpштo eíтe ЛÓYW тou óтl éxei aпoбelхтeí wq фáppaкo eкЛoYПQ (п.х. pe9oтpe^áтп/ЛeфЛouvopí-бп) eíтe ЛÓYW кóoтouQ (п.х. Anakinra/Canakinumab ) п ЛÓYШ áЛЛпQ alтíaQ/avтévбel^ПQ. Та oтáбla oтпv пpóoбo тпQ 9epaпeíaQ prapeí va eívai пpoo9Пкп п бгабох^п хopПYПOП фappáкwv, eiKTOQ ará тouQ ßюЛoYlкoúQ пapáYOvтeQ пou п XopПYПOп eívai пávтa бгабох^п.

Oepaпeía:

1. Api6póq apGpwaewv pe evepYó ap0píтlбa 1-4

XopпYOÚvтal KZ evбoap9plкá (а) п MZAФ (ß) Yia 1 pПva.

a. Eáv бev aпavтПoel o ao9evПQ o^v evбoap9plкП éYXUOП KZ, пpoтeívovтal 2 eпlЛoYéQ/povoпáтla: Eáv uпápхel evepYóQ ap9píтlбa oe 1-4 ap9púoeiQ :

• XopпYOÚvтal Me9oтpe^áтп/ЛeфЛouvopíбп. Eáv пáЛl бev aпavтПoel o ao9evПQ Kai uпápхel evepYóQ ap9píтlбa oe >0 ap9púoeiQ peтá 3 pПveQ хо-pПYПOПQ тwv avwтépw фappáкwv ouvexíZoupe pe Abatacept п IL-1i (Anakinra/Canakinumab) п IL-6i (Tocilizumab) п TNF-ai (Adalimumab, Etanercept, Infliximab)

Eáv uпápхel evepYóQ ap9píтlбa oe >4 ap9púoeiQ пpoтeívovтal 2 eпlЛoYéQ/povoпáтla:

• XopпYOÚvтal Me9oтpeÇáтn/ЛeфЛouvopíбn. Eáv п6Л1 бev aпavтПoel o ao9evПQ Kai uпápхel evepYóQ ap9píтlбa oe >0 ap9púoeiQ peтá 3 pПveQ хо-pПYПOПQ тwv avwтépw фappáкwv ouvexíZoupe pe Abatacept п IL-1i (Anakinra/Canakinumab) п IL-6i (Tocilizumab) п TNF-ai (Adalimumab, Etanercept, Infliximab)

• XopпYOÚvтal IL-1i (Anakinra/ Canakinumab) Yia 1 pПva. Eáv п6Л1 бev aпavтПoel o ao9evПQ Kai uпápхel evepYóQ ap9píтlбa oe >0 ap9púoeiQ peтá 1 pПva хopПYПOПQ тwv avwтépw пapaYÓvтwv ouvexíZoupe pe Abatacept п IL-6i (rocilizumab) п Me-9oтpe^áтп/ЛeфЛouvopíбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

ß. Eáv бev aпavтпoel o ao9evПQ ота MZ^ peтá aпó 1 pПva 9epaпeíaQ пpoтeívovтal 2 eпlЛoYéQ/povoпáтla: Eáv uпápхel evepYÓQ ap9píтlбa oe 1-4 ap9púoeiQ:

• XopпYOÚvтal Me9oтpe^áтп/ЛeфЛouvopíбп. Eáv п6Л1 бev aпavтПoel o ao9evПQ Kai uпápхel evepYÓQ ap9píтlбa oe >0 ap9púoeiQ peтá 3 pПveQ хо-pПYПOПQ тwv avwтépw фappáкwv ouvexíZoupe pe Abatacept п IL-1i (Anakinra/Canakinumab) п IL-6i (rocilizumab) п TNF-ai (Adalimumab, Etanercept, Infliximab)

Eáv uпápхel evepYÓQ ap9píтlбa oe >4 ap9púoeiQ пpoтeívovтal 2 eпlЛoYéQ/povoпáтla:

• XopпYOÚvтal IL-1i (Anakinra/Canakinumab) Yia 1 pПva Kai av п6Л1 бev aпavтПoel o ao9evПQ Kai uпápхel evepYÓQ ap9píтlбa oe >0 ap9púoeiQ peтá 1 pПva хopПYПOПQ тwv avwтépw пapaYÓvтwv ouvexíZoupe pe Abatacept п IL-6i (Tocilizumab) п Me-9oтpe^áтп /ЛeфЛouvopíбп п TNF-ai (Adalimumab, Etanercept, Infliximab)

• XopпYOÚvтal Me9oтpe^áтп/ЛeфЛouvopíбп. Eáv п6Л1 бev aпavтПoel o ao9evПQ Kai uпápхel evepYÓQ ap9píтlбa oe >0 ap9púoeiQ peтá 3 pПveQ хо-pПYПOПQ тwv avwтépw фappáкwv ouvexíZoupe pe Abatacept п IL-1i (Anakinra/Canakinumab) п IL-6i (Tocilizumab) п TNF-ai (Adalimumab, Etanercept, Infliximab)

2. Api6póq ap6pwoewv pe evepYó ap6píтlбa >4

XopпYOÚvтal MZAФ (a) Yia 1 pПva п Me9oтpeÇáтп / ЛeфЛouvopíбп (ß) Yia 3 pПveQ. a. Eáv бev aпavтПoel o ao9evПQ oтa MZAФ peтá aпó éva pПva 9eparaíaQ пpoтeívovтal 2 eпlЛoYéQ/povo-пáтla óпwQ Kai oтпv пepíптwoп 1(ß): ß. Eáv бev aпavтПoel o ao9evПQ oтп хopПYПOп Me-9oтpe^áтпQ /ЛeфЛouvopíбпQ peтá aпó 3 pПveQ 9epaTOíaQ Kai uпápхel aкópп evepYÓQ ap9píтlбa oe >0 ap9púoeiQ, хopПYOúvтal Abatacept п IL-1i (Anakinra/Canakinumab) п IL-6i (Tocilizumab) п TNF-ai (Adalimumab, Etanercept, Infliximab).

Zхпpaтlкá, п óЛп oтpaтпYlкП тпQ 9epaпeíaQ фaíveтal oтouQ aЛYÓpl9pouQ/oхПpaтa 6-7.

QEPAnEIA EEQAP0PIKQN EKЛHЛQZEQN THZ NIA

1. Xpóvia пpóa6la paYoelбíтlбa (lplбoкuкЛíтlбa,

nivaraç 13) 3433-36 Пpóкelтal Yia pп кoккlшpaтшбп фЛeYPOvП тou ^ó-o9iou 9aЛápou тou oф9aЛpoú, п oпoía eívai тeЛeíwQ aoupптшpaтlкП Kai п oпoía av бev бraYvwo9eí Kai avтlpeтшпloтeí éYKaipa pпopeí va oбпYПoel oe peiw-pévп ópaoп п Kai ^J^WO^ H éYKa^ бráYvwoп Kai évapí^ тпQ 9epaTOíaQ Ka9opíZei Kai тпv éкßaoП ^Q. ri auтó п oпpavтlкóтepп evépYeia Yia тпv awipe^-пюп ^Q eívai п пpoЛпптlкП eÇéтaoп oe oxiopoe^ Лuхvía aпó épпelpo oф9aЛpíaтpo oe тaкгá xpoviKá бlaoтПpaтa.

Eívai ouхvóтepп oe кopíтola <6xpovúv tou éxouv ANA 9enKá, пpooßoЛП péxpi 4 ap9púoewv Kai RF apvптlкó. H aпouoía evepYoú ap9píтlбaQ бev ouve-пáYeтal Kai avevepYó paYoetônrôa.

Oepaпeía

H 0epaпeía кa9opíZeтal ará тov oф9aЛpíaтpo Kai apxíZei pe ^v aveúpeoп Kai evóQ а^п кuттápou

of rheumatology

EAAHNIKH PEYMATOAOriA

ZxnMa 6. ZTpaTHYiKH 0epaneiaQ oth 5n 9epaneuTiKii opaSa

ZuoTnpaTiKn NIA pe npoexouoa evepYO ap9pmSa Kai anouoia ouoTqpaTiKwv eKSqAwoewv Api9poQ ap9pwoewv pe evepYO ap9piTiSa 1-4

ZxnMa 7. ZTpaTHYiKH 9epaneiaQ oth 5n 9epaneuTiKii opaSa

ZuoTnpaTiKn NIA pe npoexouoa evepYO ap9piTiSa Kai anouoia ouoTqpaTiKwv eKSqAwoewv Api9poQ ap9pwoewv pe evepYO ap9piTiSa >4

otov npoo9io 9aAapo. AiaKpiveTai oe ToniKii Kai ou-oTqpaTiKn 9epaneia.

ToniKq depaneia:

EvoraAAa^eiQ KopTiKooTepoeiSwv Kai KuKAonAnYiKwv (evSo09aApiKi eveon onavia xpnoiponoieiai ora nai-Sia). H ouxvoTnTa evoToAAa^ewv Ka9opiZeTai ano Tn PapuTnTa TnQ 0AeYpov|Q Kai xpeiaZeTai TaKTiKn napaKoAou9non Yia to evSexopevo avanTu^nQ eni-nAoKwv (KaTappaKTn, evSo<t>9aApiaQ unepTaonQ, YAauKwpaToQ). O anoYaAaKTiopoQ (tapering) ano Ta KopTiKooTepoeiSn eivai e^iKioQ e0ooov KaTaoTaAei n paYoeiSiTiSa, e^aTopiKeueTai, Kai npenei va YiveTai apYa Kai oTaSiaKa. H npoAnnTiKii e^ETaon ouvexiZeTai Kai peTa Tn SiaKonn TnQ 9epaneiaQ Yia to evSexopevo unoTpon|Q.

ZuarqyariKq depaneia:35,36

le enipovn evepYO IK n ToniKii 9epaneia ouvSuaZeTai

Kai pe ouornpaTiKi xopnYnon KI.

AvGektikh ara KopriKoarepoeiSn npoaGia payo-ei6ii6a

AvTipeTwniZeTai pe eninAeov ouoTnpaTiKn xopnYnon ouv9eTiKwv Kai PioAoyikwv DMARDS. Medorpe^arq: AnoTeAei to 0appaKo npwTnQ eKAo-YIQ xopnYoupevo otiq Ka9iepwpeveQ S6oeiQ, pe to evSexopevo unoTponnQ (nepinou oto 50% twv nepi-rnwoewv) peTa Tn SiaKonn TnQ, Yi auTo anoTpeneTai n SiaKonn TnQ npiv Tnv napeAeuon 3eTiaQ. le anoTuxia povo9epaneiaQ pe pe9oTpe£aTn, pnopei va npooTe9ei 2o avoooTpononoinTiKO 0appaKo, onwQ n KUKAoanopivq, to MMF, q ¿vaq TNF-i. EnionQ, oe Suoavoxn oTn pe9oTpe£aTn, pnopei va xpnoiponoin-9ei, wq povo9epaneia, n KuKAoonopivn n Kanoio aAAo anO Ta npoava0ep9evTa DMARDS.

BioAoyiKoi napayovreQ: 34-36 XpnoiponoiouvTai oe enipoveQ nepinTwoeiQ nou Sev anavTouv oTa Ka9iepwpeva avoooTpononoinTiKa n eivai au^npevoQ o KivSuvoQ anwAeiaQ TnQ OpaonQ, Ka9wQ Kai oe ouxva unoTponiaZouoa IK.

XpnoiponoiouvTai oi TNF-ai, KupiwQ to adalimumab Kai to infliximab

To adalimumab, xopnYeiTai unoSOpia otiq ouv|9eiQ SOoeiQ. Ynapxouv npoQ to napOv nepiopiopeva KAivi-Ka SeSopeva Yia to oti to adalimumab unepTepei anO to infliximab orn SiaT|pnon avevepYou IK Kai oTnv ano0uYH unoTponwv.

To infliximab xopnYeiTai evSo0AePia paZi pe pe9oTpe-£aTn Yia KaAuTepn anoTeAeopaTiKOTnTa. le av9eKTiKeQ nepinTwoeiQ, pnopei va xpnoiponoi-n9ei oupnAnpwpaTiKa oto 9epaneuTiKO oxnpa, to abatacept Kai to rituximab, aAAa eivai nepiopiopevn aKOpn n Sie9v|Q epneipia. To auvSpoMo evepyonoinonQ MaKpoQayou (macrophage activation syndrome, MAS) 37 EioPaAAei pe eiKOva «unep0AeYpov|Q», ouxvOTepa oTn INIA, oTnv evap^n n oTnv nopeia TnQ vOoou n oe aAAaYi rou 9epaneuTiKou oxnpaToQ. XapaKTnpiZeTai anO enipovo nupeTo, av9eKTiKO oTn xopiYnon avri-Piotikwv, Kai npwipo eupnpa-KAeiSi, Tnv napaSo^n oTaSiaK| nrwon TnQ TKE.

Oepaneia: Mexpi onpepa Sev unapxei opo0wvia Yia tov Ka9opiopou evOQ anoSeKiou 9epaneuTiKou npw-tokoAAou Yia to MAS. le noAAa KevTpa xpnoiponoi-ouv Ta 9epaneuTiKa npwTOKoAAa tou oiKoYevouQ ai-po^aYoKuTTapiKou ouvSpopou. Oi nepioooTepoi xpnoiponoiouv wq 0appaKo eKAo-YIQ ra KopTiKooTepoeiSn, apxiKa oe evSo0AePieQ woeiQ pe pe9uAnpeSviZoAOvn wq povo9epaneia (oxi Yia nepioooTepeQ ano 2 ePSopaSeQ) n oe ouvSuaopo pe KuKAoonopivn n pe Anakinra Kai oTn ouvexeia ano tou oTopaToQ npeSviZovn, oe Soon 2 mg/kg/H. le ne-pinTwon av9eKTiKnQ oTa KopTiKooTepoeiSn IK xpnoi-ponoieiTai n KuKAoonopivn Kai wq povo9epaneia. Oi ooPapeQ nepinTwoeiQ anaiTouv eioaYWYn oe EvTaTiKn MovaSa.

of rheumatology

EAAHNIKH PEYMATQAOriA

nivaKaQ 1. KaTOTa^n thq NeaviKi^Q ISiona9ouQ Ap9pm5aQ (NIA) KaTa ILAR 2001 oe 7 KaTnYopieQ pe Paon opi-opeva KAiviKa Kai epYaoTnpiaKa xapaKTnpioTiKa 13

Kaxnyopia NIA

Kpixqpia Kaxaxa^nQ

1. OXiyoap9piKq NIA

1a. Eni|jovr| oAiyoapGpiKri

NIA m£ npoopoXq 4 q XiyOxepuv ap9puoeuv oxo npuxo e^a^nvo anO xnv cvapift xnQ vOoou

NIA me npoopoXq 4 q XiyOxepuv ap9puoeuv oe ¿An Tn SiapKeia xnQ vooou

1p. EnsKTaGsioa oAiyoapGpiKri

2. noXuap9piKq NIA, opo9exiKq uq npoq xov peuMaxoeiSq napayovxa (RF)

3. noXuap9piKq NIA, opoapvnxiKq uq npoQ xov peuMaxoeiSq napayovxa (RF)

4. ZuoxnMaxiKn NIA

5. ^upiaoiKq ap9pixi6a

6. Ap9pixi6a nou oxexiZexai me ev9eoixiSa

7. ASia^oponoinxn q axa^ivOMnxn ap9pixi6a

NIA nou apxiZet uq oXiyoap9pixiSa, aXXa eneKxeivexai oe> 4 ap9puoeiQ Mexa xo npuxo e^aMnvo ano xnv cvap^n xnQ vOoou

NIA me npoopoXq xouXaxioxov 5 ap9puoeuv oxo npuxo e^aMnvo anO xnv cvapift xnQ vOoou Kai RF oxov opO 9exiKO

NIA me npoopoXq xouXaxioxov 5 ap9puoeuv oxo npuxo e^aMnvo anO xnv evap^n xnQ vOoou Kai RF oxov opO apvnxiKO

NIA nou apxiZet Me xapaKxnptoxiKO nupexO*, nou ouvoSeuexai anO 1 q nepiooOxepa anO xa napaKaxu:

1. Ap9pixi5a**

2. OeuyaXeo epu9nMaxu6eQ e£av9nMa

3. AeM$aSevona9eia

4. AiOyKuon qnaxoQ q /Kai onXqva

5. OpoyovixiSa

H ouoxnMaxiKn NIA jnopsi va sninAaKsi ot|v svapijr H ot|v nopsia t|Q js to Ii>v5pojo EvspyonoinonQ MaKpo^ayou (Macrophage Activation Syndrome n MAS, pAsns sijttiapGpi-K£Q SninAoKEQ NIA).

* Y^hAoq nupsTOQ (>380C), 5iaAAsintt>v (1-2 KujaTa rjsproittic;), sni 3 5ia5oxiKsc; njspsQ Kai ouvoAiKHQ 5iapKsiaq TouAaxioTov 2 sp5oja5tt>v. iTa jsoo5iaoTr|jaTa anupsijiac;, xapaKTnpioTiKa, r| ysviKH KaTaoTaon tou nai5ioi> sivai s^aipsTiKn.

** H apGpiTi5a jnopsi va j|v sivai sK5rAr ot|v svap^r H/Kai ot|v npwijr nopsia T|Q vooou (<6 jnvsq)

Ap9pixiSa Kai tyupiaon q ap9pixiSa Kai xouXaxtoxov 2 anO xa napaKaxu:

1. AaKxuXixiSa

2. EvxunuMaxa ovuxuv q ovuxOXuon

3. ^upiaon oe ouyyevq npuxou pa9Mou

Ap9pixiSa Kai ev9eoixiSa q ap9pixiSa q ev9eoixiSa Kai xouXaxtoxov 2 anO xa napaKaxu:

1. Euaio9noia oxnv lepoXayOvia ap9puon q nOvoQ oxnv oo$uoiepq nepioxq

2. napouoia xou HLAB27 avxiyOvou

3. Evapijn ap9pixiSaq oe ayOpia nXiKiaq >6 exuv.

4. O^eia (ouMnxuMaxiKq) npOo9ia payoeiSixiSa (ipiSoKuKXixiSa)

5. IoxopiKO vooqMaxoQ nou ouoxexiZexai Me xo avxiyOvo HLAB27 oe ouyyevq npuxou pa9Mou*

* AyKuXonoinxiKq onovSuXoap9pixiSa,

ap9pixiSa nou oxexiZexai Me ev9eoixiSa, iepoXayovixiSa Me $XeyMovu5n vOoo xou evxepou, ouvSpoMo Reiter

Ap9pixiSa nou Sev eKnXnpuvei OXa xa Kpixqpia KanoiaQ anO xiQ nponyouMeveQ 6 KaxnyopieQ q eKnXnpuvei xa Kpixqpia anO 2 q nepiooOxepeQ Kaxnyopieq

nívaraq 2. ЛuopeveÍQ пpoYvwoтlкoÍ пapáYOvтeQ Kai eпíпeбa бpaoтпplóтптaQ oe ao9eveíQ pe oЛlYoap9pÍтlбa

Дuopeveíç пpoYvыoтlкoí пapáYOvтeç (e^X^^on тouЛáxloтov 1 aпó тa пapaкáты)

• Ap6píтlбa ioxíou п auxevi^Q poípaQ oпovбuЛlкпQ отпЛпс

• Ap0píтlбa пoбoкvnplкпQ п ^xeoraprn^Q кal uфnЛoí бeíктeç фЛeYpovпQ fax TKE, CRP) п пapaтeтapcvn aùÇnon auráv.

• A^ivoAoYi^ eupпpaтa ap6plкпQ ßЛáßnQ ßiaßpwoeiQ п отеуыоп peoap6píou бlaoтпpaтoQ)

Eпíпeбa бpaoтnplóтnтaç тпс vóoou Xapn^n бpaoтnPlóтnтa ^кпЛнршоп óЛшv) < 1 apGpwosiç ps svspyó ap9píтl5a TKE (s 20mm) п CRP фuoloЛoYlкп

Zфalplкп eктípnon тou laтpoú Yia тп ouvoЛlкп бpaoтnplóтnтa тпс vóoou: MDVAS global<3 Zфalplкп eктípnon тou Yovca/ao6evñ Yia тп ouvoЛlкп eue^ía: VAS<2

Mcrpia бpaoтnplóтnтa (бev eкпЛnpйvovтal тa ^i^pia oúтe xapn^Q oúтe uфnЛпQ бpaoтnplóтnтaç тпс vóoou)

1 | пsplooóтspa Kpn:npia ps >score/np£ç anó aur£ç тп^ xap^nç, Kai < 3 крптфю ps < oKop/np£ç anó auréç тп^ ифиЛг^ 5paoтr|pютr|тaç тп^ vóoou

YфnЛп бpaoтnplóтnтa ^кпЛнршоп тouЛáxloтov 3 кргтнрш^ TouЛáxloтov 2 ap6púoeiQ pe evepYó ap6píтlбa

Eпíпeбa TKE п CRP тouЛáxloтov 2пЛáola aпó тa av^repa фuoloЛoYlкá ópia Zфalplкп eктípnon тou laтpoú Yia тп ouvoЛlкп бpaoтnplóтnтa тпс vóoou: MDVAS

global >7

Zфаlplкп e^rípnon тou Yovca/ao6evñ Yia тп ouvoЛlкп eue^ía: VAS a4

nívaraq 3. ЛuopeveÍQ пpoYvwoтlкoÍ пapáYOvтeQ Kai eпíпeбa бpaoтпplóтптaQ oe ao9eveÍQ pe пoЛuap9pÍтlбa

ДuopeveíQ пpoYvыoтlкoí пapáYOvтeQ (eкпЛпpыon тouЛáxloтov 1 aпó тa пapaкáты)

• Ap0píтlбa ioxíou п auxevi^Q poípaQ oпovбuЛlкпQ oтпЛnQ

• OenráQ peuparoetóñQ пapáYOvтaç п 6eтlкá avтlKlтpouЛЛlVlкá avтloыpaтa (anti-CCP)

• AктlvoЛoYlкá eupпpaтa ap6plкпQ ßЛáßnQ ßiaßpwoeiQ п oтcvыon peoap6píou бlaoтпpaтoQ)

Eпíпeбa бpaoтnplóтnтaç тпс vóoou

XapnЛп бpaoтnplóтnтa ^кпЛпршон óЛшv)

<4 ap9pwosiç ps svspyó ap9píтl5a гата тp£xouoa sKrip^!

TKE п CRP oe фuoloЛoYlкá eпíпeбa

Zфalplкп eктípnon тou laтpoú Yia тп ouvoЛlкп бpaoтnplóтnтa тпс vóoou: MDVAS global <4 Zфalplкп eктípnon ^u Yovca/ao6evñ Yia тп ouvoЛlкп eue^ía:VAS<2

Mcrpia бpaoтnplóтnтa (5sv sкпЛr|pшvovтal тa Kpn:npia oúтs xap^nç oúтs ифг|Лгк 5paoтr|pютr|тaç vóoou) 1 | пsplooóтspa Kpn:npia ps psYaЛúтspo score/npéç anó auréç xap^nç, Kai < 3 Kpn:npia ps plкpóтspo oKop/np£ç an' auréç ифг|Лгк 5paoтr|pютr|тaç vóoou

УФпЛп бpaoтnPlóтnтa ^кпЛпршон тouЛáxloтov 3 кргтнрш^ TouЛáxloтov 8 ap6púoeiQ pe evepYó ap6píтlбa

Eпíпeбa TKE п CRP тouЛáxloтov 2пЛáola aпó тa av^repa фuoloЛoYlкá ópia

Zфalplкп eктípnon тou laтpoú Yia тп ouvoЛlкп бpaoтnplóтnтa тпс vóoou: MDVAS global >7

Zфalplкп eктípnon тou Yovca/ao6evñ Yia ^v ouvoЛlкп eueíjía: VAS a5

of rheumatology

EAAHNIKH PEYMATOAOriA

nivaKaq 4. AuopeveiQ npoYvwoTiKoi napaYovTeQ Kai enineSa SpaoTnpiOTnTaQ oTn NIA pe evepYO iepoAaYoviTiSa

Auoueveiq npoyvuonKoi napayovreq

AKrivoXoyiKa eupnuara ap9piKnq PXaPnq (SiaPpuoeiq n orevuon ueoap9piou Siaornuaroq)

EnineSa Spaornpiornraq rnq vooou

XaunXn Spaornpiornra (sKnAnp^on oAoiv) OuoioXoyiKH Kau^n rnq onovSuXiKnq ornXnq TKE n CRP oe QuoioXoyiKa enineSa

ZQaipiKn eKriunon rou iarpou yia rn ouvoXiKn Spaornpiornra rnq vooou: MDVAS

global <4

ZQaipiKn eKriunon rou yovea/ao9evn yia rn ouvoXiKn eue^ia: VAS<2

Merpia Spaornpiornra(5sv SKnAnp^vovrai Ta KpiT|pia outs xapHAnQ outs u^AHc; 5paoTr|pi6Tr|Tac; thq vooou)

1 | nspioooTspa KpiT|pia ps psyaAinrspo score/Tipsc; ano auTSQ t|q xapHAriQ 5paoTrpi6TrTaQ, Kai <2 KpiT|pia ps piKpoTspo oKop/Tipsc; ano auTSQ t|q 5paoTipi6Tr|Tac; t|q vooou

Y^nXn Spaornpiornra (sKnAnpuoH TouAaxioTov 2 KpiT|piwv)

EnineSa TKE n CRP rouXaxiorov 2nXaoia ano ra avurepa QuoioXoyiKa opia

ZQaipiKn eKriunon rou iarpou yia rn ouvoXiKn Spaornpiornra rnq vooou: MDVAS

global >7/10

ZQaipiKn eKriunon rou yovea/ao9evn yia rn ouvoXiKn eue^ia: VAS>4

nivaKaq 5. AuopeveiQ npoYvwoTiKoi napaYovTeQ Kai enineSa SpaoTnpiOTnTaQ oTn ouoTnpaTiKn NIA pe evepYeiQ ouoTnpaTiKeQ eKSnAwoeiQ Kai Sia0Opou Pa9pou evepYO ap9piTiSa

Auo^eveiq npoyvuoriKoi napayovreq

napapevouoa eni 6unvo ooPapn evepyoq ouornuariKn voooq nou opi£erai ano rnv napapovn nuperou Kai auSftuevuv SeiKruv o^eiaq Qaonq n ano rnv avayKn ouvexouq xopnvnonc KopriKoorepoeiSuv

EnineSa Spaornpiornraq rnq vooou

XaunXn Spaornpiornra' MDVAS global <5 + anouoia svspyoi) ap9pm5ac;. Merpia Spaornpiornra: MDVAS global <5 + oAiyoap9pm5a (1-4 ap9priosic;).

Y^nXn Spaornpiornra' MDVAS global >5 avs^apTiTa ano tov api9po twv npoopspAnpsvwv ap9pwosa>v

nivaKaq 6. AuopeveiQ npoYvwoTiKoi napaYovTeQ Kai enineSa SpaoTnpiOTnTaQ oTn ouoTnpaTiKn NIA pe evepYO ap9piTiSa aAAa xwpiQ ouoTnpaTiKeQ eKSnAwoeiQ3

Auoueveiq npoyvuoriKoi napayovreq ( eKnXnpuon 1 Kpirnpiou)

• Ap9piriSa ioxiou

• AKrivoXoyiKa eupnuara ap9piKnq PXaPnq (SiaPpuoeiq n orevuon Meoap9piou Siaornuaroq)

EnineSa Spaornpiornraq rnc vooou (ouuQuva pe riq ouoraoeiq rou ACR 2011)

XaunXn Spaornpiornra (sKnArpmori oAmv) < 4 ap9pwosiq ps svspyo ap9piTi5a KaTa t|v Tpsxouoa sKTipror TKE n CRP oe QuoioXoyiKa enineSa

ZQaipiKn eKriunon rou iarpou yia rn ouvoXiKn Spaornpiornra rnq vooou:MDVAS global < 4 ZQaipiKn eKriunon rou yovea/ao9evn yia rn ouvoXiKn eue^ia: VAS <2

Merpia Spaornpiornra (5sv sKnArpwvovTai Ta KpiT|pia outs t|q xaprAHQ outs t|q u^hAHq 5paoтr|pl6тr|тac; t|q vooou) 1 H nspioooTspa KpiTrpia ps >score/TipsQ ano auTSQ t|q xaprAHQ, Kai < 3 KpiT|pia ps < score /TipsQ ano auTSQ t|q u^hAHq 5paoтr|pl6-TrTaQ t|q vooou

Y^nXn Spaornpiornra (sKnArpwor TouAaxioTov 3 KpiTrpiwv)

EnineSa TKE n CRP rouXaxiorov 2nXaoia ano ra avurepa QuoioXoyiKa opia

ZQaipiKn eKriunon rou iarpou yia rn ouvoXiKn Spaornpiornra rnq vooou: MDVAS global >7

ZQaipiKn eKriunon rou yovea/ao9evn yia rn ouvoXiKn eue^ia: >5

nivaKaq 7. Mn OTepoeiSii avTi0AeYjovw6n 0äpjaKa (MIAO) nou xPnoijonoiouvTai OTn NeaviKii I5iona0ii Ap9piTi5a

MIAO H^epnoia 6oon (ano tou otömotoq) MeyioTH H^epnoia Aöon

Diclofenac* 50-100 mg os 2 ööosiQ /H 200 mg

Ibuprofen * 30-50 mg/kg ,os 3-4 ööosiq/H 2400 mg

Indomethacin* 1-2 mg/kg os 3 ööosic;/H 200 mg

Naproxen* 10-20mg/kg,os 2 ööosiQ /H 1000 mg

Celecoxib** 10-25 kg: 50 mg os 2 ööosiQ /H > 25 kg: 100 mgos 2 ööosiq/H 100 mg 200 mg

Meloxicam** 0.125-0.25 mg/kg/ IE 1 ööon/H 15 mg

*Ta ouxvÖTspa xpnoijonoioujsva MIAO.

**Oi COX-2 avaoToAsiq ösv xpnoijonoiouvTai os naiöia, napa jövo os nspinTtiosiQ ooßaptiv yaoTpsvTspiKtiv svoxAnjamiv oTa aAAa MIAO Kai ^Asyjovwöouc; vöoou tou svTspou

nivaKaq 8. KopTiKoorepoeiSn

KopTiKOOTcpociSn H^epnoia Söon MeyioTn H^epnoia Aöon

EvSoapSpiKeq eyxüoeiq KopTiKOOTepoeiSüv* BAene nivaKa 8a

Me0uAnpe5vi?oAövn** (svöo^Asßisc; wosiq) 30mg/kg/H 1g/H

npe5vi?oAövn*** anö tou oTÖ^aToq 0.5-2mg/kg/H 40-60 mg/H

* H E^aKETOviKn TpiajoivoAövn (triamcinolone hexacetonide) 0so)psiTai oti unspsxsi 0spansuTiKa anö iqv aKSToviKr) (triamcinolone acetonide). H 6is0vnQ sjnsipia unooTHpiZsi tqv 24aipn avanauon jstö tqv sv6oap0piKn 0spansia snsiSn ßsATidivsi tqv anoTsAsojaTiKÖTnTä TnQ. ** ria 3 SiaöoxiKEQ njspsQ Kai snavsKTijnon os 1-2 sßöojäösQ.

*** iTa naiöia ouvii0o)Q n sni0ujnTn jsyiOTn njspiioia Soon sivai Ta 40mg/H s0ana£; to npaii, (ano0uyn nAqpouQ KaTaoToAqQ TnQ svSoysvouQ EKKpionQ KopTiZöAnQ)

nivaKaq 9. npoTeivöjevo eiSoQ Kai Söon KopTiKooTepoeiSoüQ Yia tiq ev6ap0piKEQ eyxüoeiq, ava0opiKä je Tnv TonoYpa0ia TnQ npooßoÄqQ

Tonoypa$ia äp0puonQ n eiöoq nepiap0piKOü ^opiou EiSoq KopTiKO-oTepoeiöoüq Aöoq

'O^OQ E^aKeToviKn TpiajoivoAövn 1mg/kg (MeyioTn ööon 40mg)

AyKÜvaq E^aKeToviKn TpiajoivoAövn 0.75mg/kg (jsyioTn ööon 30mg)

Kapnöq E^aKeToviKn TpiajoivoAövn 0.25-0.5mg/kg (jsyioTn ööon 20mg)

MeTaKapno^aAayyiKeq/ Meoo$aAayyiKCQ xepioü Me0uAnpe6viZoAövn 5-10mg

loxio E^aKeToviKn TpiajoivoAövn 1mg/kg (jsyioTn ööon 40mg)

rövaTO E^aKeToviKn TpiajoivoAövn 1mg/kg (jsyioTn ööon 40mg)

noSoKvnM'KH EijaKeTOviKn TpiajoivoAövn 0.75mg/kg (jsyioTn ööon 30mg)

AoTpäyaAoq/nTepva Me0uAnpe6viZoAövn 20-40mg

MeTaTapoia n Meoo^aAayyiKeq noSiuv Me0uAnpe6viZoAövn 5-10mg

Ev0eoeiq n eAuTpa TevövTuv Me0uAnpe6viZoAövn 20-40mg

of rheumatology

EAAHNIKH PEYMATOAOriA

nivaKaq 10. Kupia ouv9eTiKa TpononoinTiKa TnQ vooou avTipeupaTiKa 0appaKa (Disease Modifying Antirheumatic Drugs, DMARDs )

OapuaKo

Apaon

ZuvoXiKn Soon (ueyiorn)

OSoq xopnvnonq

AZa9eionpiun* KuKXoonopivn

AeQXouvopiSn

Me9orpe5arn*

ZouXQaoaXaZivn

Kupiuq eniSpaon orn Xeiroupyia ruv T-XeuQoKurrapuv

Kupiuq eniSpaon orn Xeiroupyia ruv avriyovonapouoiaoriKuv Kurrapuv

Kupiuq eniSpaon orn Xeiroupyia ruv avriyovonapouoiaoriKuv Kurrapuv

Ayvuorn, ni9avn avriQXeyuovuSnq Spaon ueou KaraoroXnq npoorayXavSivuv Kai XeuKorpieviuv

3-5mg/kg/H os 2 5oosiQ

<20 kg BI: 100 mg yia t|v

np^T! rpspa Kai ot| ouvsxsia

10 mg naprpspa

20-40 kg BI: 100mg yia tiq

np^Tsq 2 rpspsQ Kai psTa 10

mg/H

>40 kg BI: 100 mg yia tiq np^Tsq 3 rpspsQ Kai psTa 20mg/H

15mg/H os 1 | 2 ouvsxopsvsQ H/Ep5 (25mg)

50 mg/kg/H os 2 |3 5oosiQ (2000 mg)

Ano rou orouaroq n evSoQXepia Ano rou orouaroq

Ano rou orouaroq n unoSopia

Ano rou orouaroq

YSpo^uxXupoKivn*

* Aev xpnoiponoieirai onpepa orn Gepaneia rnQ NIA

**Me9orpe£arn ano rou oroparoQ n unoSopiwQ Kai n nAnpnQ anoreAeopariKornra rnQ eivai ep0avi|Q pera ano 6-12 epSopaSeQ 9epaneiaQ. H unoSopia xopiYnon rnQ 0aiverai va au^avei rn plo6laGeolp6rnra rnQ Kai evSeiKvurai oe ao9eveiQ pe Suoavoxn ornv ano rou oroparoQ xopiYnon I pe povo YaorpiKi Suoavoxn Kai oe nrwxn ouppop0won rou ao9evouQ. ***Xpnoiponoieirai onavia oe ouvSuaopo pe peGorpe£arn pe apepaia anoreAeopara

nivaKaq 11. BioAoYiKa TpononoinTiKa TnQ vooou avTipeupaTiKa 0appaKa n PioAoYiKoi napaYovTeQ

napayuv Mnxaviouoq Spaonq Aoon (ueyiorn) OSoq xopnvnonq

Abatacept AvaoroXeaq rnq ouvSieyeponq ruv T-Kurrapuv 10 mg/kg (1000 mg) otiq 0, 2 Kai 4 epS Kai uera ava 4 epS EvSoQXepia

Adalimumab E^av9punonoinuevo avriouua Kara rou TNF 24mg/m2 / ava 2 epS n<30 kg BZ*, 20 mg / ava 2 epS >30Kg BI, 40 mg / ava 2 epS YnoSopia

Anakinra Avrayuviornq rou unoSoxea rnq IL-1 2 mg/kg/H (100 mg) YnoSopia

Canakinumab E^av9punonoinuevo avriouua Kara rnq IL-1P 4 mg/kg/H (150 mg) ava p|va YnoSopia

Etanercept AiaXuroq unoSoxeaq rou TNF 0.8 mg/kg/epS,(50mg/epS) YnoSopia

Infliximab XiuaipiKo uovokXuviko avriouua Kara rou TNF-a 5-10mg/kg otiq 0, 2, 6 epS Kai uera ava 4-8 epS EvSoQXepia

Rituximab Avriouua Kara rou eniQaveiaKou uopiou CD20 Aev exei Ka9opiorei n naiSiarpiKn Soon, (ueyiorn Soon 1000mg 0,2 epS Kai 6 unveq uera) EvSoQXepia

Tocilizumab Avriouua Kara rou unoSoxea rnq IL-6 <20 kg, 12 mg/kg/ ava 2-4sp5** >20 kg, 8 mg/kg ava 2-4sp5 EvSoQXepia

"BI=BapoQ IdiparoQ, " Ava 2 epSopaSeQ orn ouornpariKi NIA Kai ava 4 epSopaSeQ ornv noAuap9piKn

nivaKaQ 12. napaKoAoú9non thq аоф6Ле1ад twv ouv9etikúv Kai ßioAoYiKWV DMARDS oe ao9eveÍQ pe NIA

rsVlKÉQ 0U0Tá0SiQ

• Aev snnpénsTai évapíjn GspansíaQ os aoGsvsÍQ ps Koivri svspyó Aoípa>í;n, фupaтíшоn (svspyó r| AavGávouoa), avoooavsnápKsia r| npo-KapKiviKn катаотаоп.

• Is KáGs snsioööio Aoípa>í;nQ npénsi va a^ioAoysÍTai n niGavÓTnTa napoöiKriQ öiaKonriQ TnQ GspansíaQ éoiq ótou sAsyxGsí n Aoípa>í;n.

• Na YÍvovTai TaKTiKá spYaoTnpiaKEQ síjsTáosiQ yia Tnv napaKoAoúGnon TnQ фио1оАоу1к|^ aiponoínonQ (ysviKÍ aípaTOQ), TnQ nnaTiKriQ Kai TnQ vsфplкrQ AsiToupyíaQ.

• Na aпoфsÚYOvтal spßoAiaopoi ps spß0Aia пои nspiéxouv íwvtsq síjaoGsvnpsvouQ piKpoopYaviopoÚQ ката Tn 0iápKsia TnQ GspansíaQ.

• EpßoAiaopoi ps vsKpá spß0Aia pnopsí va 0isvspYnGoúv. Ynápxsi ßsßaia то svósxópsvo xapnAÓTspnQ avnottipaTiKriQ anávrnonQ aAAá n SisGvíq spnsipía ösixvsi, óti ouvr|Gtt>Q о títAoq síjaKoAouGsí va sívai npooTaTSUTiKÓQ. O stioioq avTiYpiniKÓQ spßoAiaop0Q ösv avrsvösi-KVUTai, ansvavTÍaQ ouoTr|VSTai.

• H ouoTnpaTiKr avaZ|Tnon avsпlGúpnтшv svspYsiwv aпóтокшv TnQ avoooTpononoinTiKriQ GspansíaQ, oupnspiAapßavopsvaiv тшv vsu-poAoYiK^v Kai vsupофuxlaтplкшv öiaTapaxwv, KaGwQ Kai TnQ spфávlоnQ véoiv auтоávоошv naGriosoiv Kai vsonAaoiwv, sпlßáAAsтal va YÍvsTai TaKTiKá.

luoTáosiQ Yia ouYKSKpipéva фáppaкa

• MsGoTps^áTn

XoprYnon фоAAlVlкоú o^éoq 24-48 wpsQ npiv | psTá Tn xoprYnon psGoTps^áTnQ Yia tov nspiopiopó тшv YaoTpsvrspiKwv Kai áAAoiv avsпlGúpnтшv svspYsiwv

ria Tn ßsA™on TnQ avoxiQ Kai ßioöiaGsoip0TnTaQ, npoTsívsTai n napsvTspiKr o0óq ÓTav xopnYoúvrai uфnA£Q 0óosiq psGoTps^áTnQ

• ЛsфAоuvоpíön Kai KUKAoonopívn: TaKTiKr péTpnon TnQ apTnpiaKiQ nísonQ

nívaKaq 13. luxvÓTqTa o09aÁjoAoYiKnQ e^ÉTaoriQ oe naiSiá je NIA (o6r|YÍeQ thq American Academy of Pediatrics)

Kaxnyopia NIA HAiKÍa ¿vapínQ ANA ZuxvÓTHTa o06aAHoAoyiKHQ c^CTaanQ

OAiyoapGpiKn П noAuapGpiKq <6ЕТП белка Avá 3-4pnvo

OAiyoapGpiKn П noAuapGpiKq avc^äpTHTa ApvnTiKá Avá 6nnvo

OAiyoapGpiKn П noAuapGpiKq >7ЕТП avc^äpTHTa Avá 6nnvo

ZuornnaTiKn avc^äpTHTa avc^äpTHTa Avá12nnvo

EuxapiorͣQ

Oi оuYYPафeÍQ e^páZouv tiq 9eppéQ euxapioTÍeQ отг| ßi0A0Y0 тои naSiaTpiKoú Kai avoooAoYiKoú KévTpou к. Avva TanápKou Yia Tqv noAÚTipn oupßoAii thq отг| 5гар0рфшог| Kai enipeAeia twv oxnpáTwv aAYopí9pwv

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35. Gregory AC,Kempen JH, Daniel E, Ka§maz RO, Foster CS, Jabs DA, et al. Risk factors for loss of visual acuity among patients with uveitis associated with juvenile idiopathic arthritis: the Systemic Immunosuppressive Therapy for Eye Diseases Study. Ophthalmology 2013; 120:186-92.

36. Heiligenhaus A, Michels H, Schumacher C, Kopp I, Neudorf U, Niehues T, et al. Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int 2012; 32:1121-33.

37. Ravelli A. Macrophage activation Syndrome. emedicine.med-scape.com /article/1380671-overview. Accessed: 20 July 2012