{"id":225,"date":"2026-02-08T17:44:24","date_gmt":"2026-02-08T16:44:24","guid":{"rendered":"https:\/\/erlaxatu.fr\/index.php\/polyarthrite-rhumatoide-pr-memo-etudiant-item-196\/"},"modified":"2026-03-15T21:16:05","modified_gmt":"2026-03-15T20:16:05","slug":"polyarthrite-rhumatoide-pr-memo-etudiant-item-196","status":"publish","type":"page","link":"https:\/\/erlaxatu.fr\/index.php\/polyarthrite-rhumatoide-pr-memo-etudiant-item-196\/","title":{"rendered":"Polyarthrite rhumato\u00efde (PR)"},"content":{"rendered":"<p><strong>Polyarthrite rhumato\u00efde (PR) <\/strong><\/p>\n<p><strong>1) \u00c0 retenir d\u2019embl\u00e9e<\/strong><\/p>\n<ul>\n<li>La PR est le rhumatisme inflammatoire chronique le plus fr\u00e9quent (pr\u00e9valence ~0,3\u20130,8%). <\/li>\n<li>Objectif moderne : diagnostiquer t\u00f4t et traiter vite pour viser <strong>r\u00e9mission<\/strong> (ou faible activit\u00e9) et pr\u00e9venir <strong>\u00e9rosions<\/strong>, handicap et complications syst\u00e9miques. <\/li>\n<\/ul>\n<p><strong>2) \u00c9pid\u00e9miologie (rep\u00e8res rapides)<\/strong><\/p>\n<ul>\n<li>D\u00e9but typique vers 50 ans, possible \u00e0 tout \u00e2ge (formes juv\u00e9niles &lt;16 ans ; d\u00e9but tardif &gt;65 ans). <\/li>\n<li>Femme &gt; homme (\u2248 x3 avant 60 ans). <\/li>\n<li>Apparent\u00e9s du 1er degr\u00e9 : pr\u00e9valence ~2\u20134% (donc risque \u2191 mais la majorit\u00e9 ne d\u00e9veloppera pas de PR). <\/li>\n<\/ul>\n<p><strong>3) Physiopathologie <\/strong><\/p>\n<ul>\n<li>Terrain <strong>multifactoriel<\/strong> : g\u00e9n\u00e9tique (ex : HLA-DRB1\u2026) + environnement (notamment tabac, microbiotes\u2026). <\/li>\n<li>Activation immunitaire \u2192 <strong>auto-anticorps<\/strong> (FR, ACPA) + <strong>synovite<\/strong>. <\/li>\n<li>Cytokines majeures (TNF\u03b1, IL-1, IL-6) + pannus \u2192 <strong>chondrolyse<\/strong> (pincement) + activation ost\u00e9oclastique (RANK\/RANKL) \u2192 <strong>\u00e9rosions<\/strong>. <\/li>\n<li>Ces voies expliquent les cibles th\u00e9rapeutiques : anti-TNF, anti-IL-6R, abatacept (CTLA4-Ig), rituximab (anti-CD20), inhibiteurs de JAK. <\/li>\n<\/ul>\n<p><strong>4) Clinique : tableau typique de PR d\u00e9butante<\/strong><\/p>\n<p>Dans 70\u201380% : <strong>polyarthrite acrom\u00e9lique<\/strong>, bilat\u00e9rale, globalement sym\u00e9trique, \u00e9voluant &gt;6 semaines. <\/p>\n<ul>\n<li>Douleur <strong>inflammatoire<\/strong> : r\u00e9veils en fin de nuit + <strong>raideur matinale &gt;30 min<\/strong>. <\/li>\n<li>Atteinte pr\u00e9f\u00e9rentielle : <strong>poignets, MCP, IPP<\/strong>, mais aussi chevilles et MTP. <\/li>\n<li>Douleur \u00e0 la pression, <strong>squeeze test<\/strong> MCP\/MTP souvent positif. <\/li>\n<li>Gonflement parfois discret (synovite\/\u00e9panchement) \u00b1 limitation. <\/li>\n<li><strong>T\u00e9nosynovites<\/strong> possibles (extenseurs, ECU, fl\u00e9chisseurs \u2192 canal carpien, fibulaires\u2026). <\/li>\n<\/ul>\n<p><strong>Point important :<\/strong> les <strong>IPD<\/strong> sont habituellement respect\u00e9es (penser rhumatisme psoriasique, goutte, arthrose si IPD atteintes). <\/p>\n<p><strong>Formes possibles (20\u201330%)<\/strong> : rhizom\u00e9lique (sujet \u00e2g\u00e9), monoarticulaire, palindromique, polyarticulaire f\u00e9brile, forme arthralgique (\u00e0 risque si MCP + raideur \u226560 min + squeeze test + ATCD familiaux\u2026). <\/p>\n<p><strong>5) Biologie : quoi demander \/ comment interpr\u00e9ter<\/strong><\/p>\n<ul>\n<li><strong>CRP\/VS<\/strong> souvent \u2191 mais non sp\u00e9cifique ; une CRP normale n\u2019exclut pas. <\/li>\n<li>NFS : possible an\u00e9mie inflammatoire, thrombocytose, etc. <\/li>\n<\/ul>\n<p><strong>FR<\/strong><\/p>\n<ul>\n<li>Sensibilit\u00e9 ~60\u201380%, sp\u00e9cificit\u00e9 ~65\u201385%. <\/li>\n<li>Peut \u00eatre positif chez sujets sains (\u2191 avec l\u2019\u00e2ge) et dans beaucoup d\u2019autres situations (Sj\u00f6gren, lupus, infections, h\u00e9mopathies\u2026). <\/li>\n<\/ul>\n<p><strong>ACPA (anti-CCP)<\/strong><\/p>\n<ul>\n<li>Sensibilit\u00e9 ~60\u201375% ; <strong>sp\u00e9cificit\u00e9 \u00e9lev\u00e9e ~90\u201395%<\/strong>. <\/li>\n<li>Peuvent pr\u00e9c\u00e9der les sympt\u00f4mes ; pas totalement exclusifs de PR mais tr\u00e8s \u00e9vocateurs. <\/li>\n<\/ul>\n<p><strong>Ponction si possible<\/strong> (surtout moyenne\/grosse articulation)<\/p>\n<ul>\n<li>Liquide inflammatoire (&gt;2000 leucocytes\/mL), st\u00e9rile, sans cristaux dans la PR. <\/li>\n<\/ul>\n<p><strong>6) Imagerie : strat\u00e9gie pratique<\/strong><\/p>\n<ul>\n<li><strong>Radiographies de r\u00e9f\u00e9rence<\/strong> : mains\/poignets face, pieds (face + 3\/4), autres articulations douloureuses. Souvent normales au d\u00e9but. <\/li>\n<li>L\u00e9sions \u00e9vocatrices : <strong>\u00e9rosions<\/strong> + <strong>pincements<\/strong> (carpes, MCP, IPP, MTP, surtout 5e m\u00e9tatarsien). <\/li>\n<li><strong>Radio thorax<\/strong> : utile dans le bilan initial (DDx + avant m\u00e9thotrexate). <\/li>\n<li><strong>\u00c9chographie<\/strong> si doute\/activit\u00e9 : \u00e9panchement, synovite, Doppler (activit\u00e9), t\u00e9nosynovite, \u00e9rosions infraradiographiques. <\/li>\n<\/ul>\n<p><strong>7) \u00c9valuer l\u2019activit\u00e9 : DAS28 (rep\u00e8res)<\/strong><\/p>\n<ul>\n<li>Mesures : nb articulations douloureuses (28), gonfl\u00e9es (28), EVA patient, VS et\/ou CRP (et autres param\u00e8tres utiles comme raideur matinale). <\/li>\n<\/ul>\n<p><strong>8) Facteurs de mauvais pronostic (\u00e0 rep\u00e9rer t\u00f4t)<\/strong><\/p>\n<ul>\n<li>DAS28 &gt;3,2 persistant, inflammation biologique marqu\u00e9e, <strong>FR\/ACPA +<\/strong>, <strong>\u00e9rosions<\/strong>, HAQ \u00e9lev\u00e9, manifestations extra-articulaires, comorbidit\u00e9s (CV, infectieuses, tumorales\u2026). <\/li>\n<\/ul>\n<p><strong>9) Diagnostic diff\u00e9rentiel <\/strong><\/p>\n<p>Toujours v\u00e9rifier que les gonflements ne sont pas expliqu\u00e9s par autre chose : <\/p>\n<ul>\n<li><strong>Arthrite septique<\/strong>, <strong>microcristalline<\/strong> (ponction !)<\/li>\n<li><strong>Rhumatisme psoriasique<\/strong> \/ autres spondyloarthrites p\u00e9riph\u00e9riques<\/li>\n<li><strong>Connectivites<\/strong> : Sj\u00f6gren, lupus, scl\u00e9rodermie\u2026<\/li>\n<li><strong>Rhum paran\u00e9oplasique<\/strong><\/li>\n<li>Vascularites \/ granulomatoses \/ maladies auto-inflammatoires<br \/>Bilan orient\u00e9 : NFS (cytop\u00e9nies), BU\/cr\u00e9at, transaminases, ANA puis anti-ADN\/ENA si ANA+, radio thorax, ponction. <\/li>\n<\/ul>\n<p><strong>10) Prise en charge : principes (vision \u201ctreat-to-target\u201d)<\/strong><\/p>\n<ul>\n<li>Information et annonce : expliquer b\u00e9n\u00e9fice\/risque, observance, suivi r\u00e9gulier, ALD possible. <\/li>\n<li>Objectif : <strong>r\u00e9mission<\/strong> (ou faible activit\u00e9), pr\u00e9vention l\u00e9sions\/handicap\/comorbidit\u00e9s. <\/li>\n<li>Traitement de fond <strong>pr\u00e9coce<\/strong> si polyarthrite persistante &gt;6 semaines confirm\u00e9e par rhumatologue. <\/li>\n<\/ul>\n<p><strong>1re ligne : M\u00e9thotrexate (MTX)<\/strong><\/p>\n<ul>\n<li>D\u00e9marrage usuel 10\u201315 mg\/sem, augmentation progressive jusqu\u2019\u00e0 15\u201325 mg\/sem (\u22480,3 mg\/kg\/sem) en 4\u20138 semaines selon tol\u00e9rance. <\/li>\n<li>Folates \u22655 mg\/sem, 24\u201348 h apr\u00e8s MTX. <\/li>\n<li>Bilan pr\u00e9-MTX : NFS\/plaquettes, bilan h\u00e9patique, albumine, fonction r\u00e9nale, radio thorax, \u00b1 s\u00e9rologies h\u00e9patites si indiqu\u00e9. <\/li>\n<li>Surveillance : mensuelle 6 mois puis tous les 2\u20133 mois (NFS, enzymes h\u00e9patiques, rein + clinique). <\/li>\n<\/ul>\n<p><strong>Alternatives csDMARD si MTX impossible<\/strong><\/p>\n<ul>\n<li>L\u00e9flunomide 20 mg\/j, sulfasalazine (jusqu\u2019\u00e0 3 g\/j). <\/li>\n<\/ul>\n<p><strong>Si r\u00e9ponse insuffisante<\/strong><\/p>\n<ul>\n<li>Suivi rapproch\u00e9 (1\u20133 mois si active). Si pas d\u2019am\u00e9lioration \u00e0 3 mois ou cible non atteinte \u00e0 6 mois \u2192 ajuster. <\/li>\n<li>Selon pronostic : combinaisons csDMARD ou passage \u00e0 <strong>biotherapie ( Anti TNF souvent en premier)<\/strong> \/ <strong>JAKi<\/strong>, id\u00e9alement avec MTX (monoth\u00e9rapie plut\u00f4t si intol\u00e9rance MTX). <\/li>\n<li>Bilan pre biotherapie\u00a0: NFS CRP CREAT TGO TGP, Serologies HCV HBV HIV (eventuel avec accord patient) Quantiferon, ACAN ( possible rares lupus induit) et selon clinique pano dentaire, rx sinus, ELIMINER INFECTION PATENTE SELON TERRAIN)<\/li>\n<\/ul>\n<p><strong>11) PR \u201cphase d\u2019\u00e9tat\u201d (culture g\u00e9n\u00e9rale, complications)<\/strong><\/p>\n<p>Aujourd\u2019hui plus rare si strat\u00e9gie moderne, mais \u00e0 conna\u00eetre : d\u00e9formations (coup de vent ulnaire, col de cygne, boutonni\u00e8re\u2026), atteinte avant-pied, atteinte cervicale C1-C2, etc. <\/p>\n<p>Extra-articulaire : syndrome sec (Sj\u00f6gren secondaire), nodules rhumato\u00efdes, atteinte pleuro-pulmonaire (dont pneumopathies interstitielles), risque CV \u2191, infections \u2191 (maladie + traitements), etc<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Polyarthrite rhumato\u00efde (PR) 1) \u00c0 retenir d\u2019embl\u00e9e La PR est le rhumatisme inflammatoire chronique le plus fr\u00e9quent (pr\u00e9valence ~0,3\u20130,8%). Objectif [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-225","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/pages\/225","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/comments?post=225"}],"version-history":[{"count":1,"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/pages\/225\/revisions"}],"predecessor-version":[{"id":229,"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/pages\/225\/revisions\/229"}],"wp:attachment":[{"href":"https:\/\/erlaxatu.fr\/index.php\/wp-json\/wp\/v2\/media?parent=225"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}