dr.

Nanang Sukmana, SpPD-KAI

KONAS VIII PERALMUNI
Tempat, Tgl Lahir : Pegaden Baru Subang,
3 Agustus 1948
Jabatan : Ketua PB Peralmuni

Pekerjaan : SP Penyakit Dalam

Konsultan Alergi Imunologi
 KONAS VIII PERALMUNI
BANDUNG : 21 23 November 2014

Nanang Sukmana
Divisi Alergi - Imunologi Klinik
Departemen Ilmu Penyakit Dalam FKUI / RSCM - Jakarta
Defining Autoimmune Disease
An autoimmune disease is a condition in
which tissue injury is caused by T-cell or
antibody reactivity to self
self.. The immune
activation may be initiated by infection, but
must persist in the absence of any detectable
microbial antigen
antigen..
(Davidson and Diamond, 2001
2001)).
CD4+25+
Treg cells

Doan T, Melvold
R, Viselli S,
Waltenbaugh .
Immunology.
Lippincotts
Illustrated
Reviews. 2008
Female: Male ratios in Autoimmune Diseases

Yehuda Schoenfeld, Gisele Zandman-Goddard. Autoimmune diseases

The enemy from within. 2003
 Autoimmune disease in the United States by immunological
mediator & percentage of female patients
Autoimmune Disease Immunological Female patient, %
Mediator
Hashimoto thyroiditis Th2 95

Sjogren syndrome Th2 94

Addison disease Unknown 93

Scleroderma Th2 92

Systemic lupus erythematosus Th2 89

Primary biliary cirrhosis Unknown 89

Graves disease Th2 88

Rheumatoid arthritis Th1 75

Myasthenia gravis Unknown 73

Polymyositis/dermatomyositis Unknown 67

Multiple sclerosis Th1 64

Vitiligo Unknown 52

Type 1 diabetes mellitus Th1 48

Lindsay S. Ackerman. Sex hormones & the genesis of autoimmunity.

Arch Dermatol. 2006;142:371-76
ANTIBODIES IN S L E
AUTOANTIBODIES PRECEDE
DISEASE BY YEARS
Some Auto Ab
before Dx: 80%

ANA: 3 yrs Anti-DNA: 2 yrs Anti-Sm: 1 yr

Anti-Ro/La Anti-PL: Anti-RNP
MCTD, Overlap, UCTD RRC

Early Undifferentiated Connective

Tissue Disease
Undifferentiated Connective
Tissue Disease
Mixed Connective Tissue Disease
Some features of > 2 of DCTD
High titer Anti-
Anti-U1RNP
Overlap Syndrome
Rhupus(RA+SLE)
Psupus(Psoriatic A.+ SLE)
I. Salehi
MCTD, Overlap, UCTD

Diseases Classification:
Six major Rheumatic diseases
Systemic Lupus Erythematosus(SLE)
Scleroderma(Scl)
Polymyositis(PM)
Dermatomyositis(DM)
Rheumatoid Arthritis(RA)
Primary Sjogrens syndrome
Infections in S L E
 Infections related to the
development of autoantibodies
Hepatitis A Measles Chickenpox

Hepatitis B Rubella Trypanosoma

cruzi
Hepatitis C HIV HTLV
HTLV--1

Mumps Influenza
virus

Yehuda Schoenfeld, Gisele Zandman-Goddard. Autoimmune diseases

The enemy from within. 2003
Cytokines In S L E
Treatment of SLE: Into the 21st Century
Proteasome
inhibitors PC BAFF
inhibitors
Anti-B cell
Anti--B cell
Anti pDC
antibodies
antibodies BR3 sBAFF mBAFF IFN
IFN

IFN
IFN
TLR cytokines blockade
inhibitors DC
TLR9
TLR
IFN
IFN
blockade
B B7.1/2 B7.1/2

CTLA4-Ig
CTLA4-
TLR2
TLR4
TLR6
inhibitors
TLR7
CD28
Abatacept TLR8
CD40
IFN
IFN IL-2, 4
IL-10 CXCL13
TNF CD40L CXCR4

pDC
IFN
IL-12p40 T IP-10
S1P M TNF
blockade

TNF
Cytokine IFN- IL-1
Lymphocyte inhibitors
IL-12 IL-6

signaling
IL-23
TNF
Chemokine -
inhibitors Lymphocyte IL-6
IL-
trafficking blockade
Adapted from Martin & Chan, 2006. modulators
Annu. Rev. Immunol. 24:467-96
Gilliam classification
Disease Mechanism
 Take Home Points

Neuropsychiatric manifestations of SLE are very

common.
Clinical diagnosis can be elusive.
Presentations are varied.
Diagnostic testing is often unreliable.
Prolonged immune suppression is the mainstay of
therapy.
 Drugs In Pregnancy and Lactation
Pregnancy Lactation
NSAIDs Yes (avoid after 32 weeks) Yes
Antimalarials Yes Yes
Corticosteroids Yes Yes
Azathioprine Yes Yes?
Mycophenolate No No
Methotrexate No No
Cyclophosphami No No
de
Anti-TNF No No
Warfarin No (with caution after first Yes
trimester)
Heparin Yes Yes
AAS (low dose) Yes Yes
NSAIDS, non-
non-steroidal anti-
anti-inflammatory drugs; AAS, aspirin
Lupus and Pregnancy : ten questions and some answers. Gruiz-Irastorza and MA Khamashta. Lupus (2008)17, 416-420
http://myastheniagravistreatment.net/wp-
conloads/2012/01/myasthenia-gravis-
treatment2.jpg
Sjogrens Syndrome with parotid enlargement
indicates lymphoproliferative tendency
Principles of therapy

1. Remission
2. Organ Survival
3. Patient Survival
4. Complication/
Comorbid
5. Quality of Life
(Cost)
Ann Rheum Dis 2010;69:1603-1611 doi:10.1136/ard.2010.135186
Review 2010
Therapeutic opportunities in systemic lupus erythematosus: state of the art and prospects for the new decade
1.George K Bertsias1, Jane E Salmon2, Dimitrios T Boumpas1
 Therapy

Induction

Maintenance

Prednison Cyclo MM

Prednison AZT MM
Thank You