Psoriatic Arthritis - PDF Document

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  1. Psoriatic Arthritis Ewa Olech, MD Division of Rheumatology University of Nevada School of Medicine Las Vegas

  2. The Spectrum of Spondyloarthritis

  3. Characteristics of the Spondyloarthritis ? Sacroiliac & spinal joint involvement ? Peripheral arthritis ? Enthesopathy ? Common spectrum of extra-articular features (especially mucocutaneous, ocular) ? Negative rheumatoid factor ? Familial clustering ? Association with HLA-B27 ? Potential infectious trigger

  4. HLA-B27 and the Seronegative Spondyloarthritides Disorder Ankylosing spondylitis Reactive arthritis Psoriatic arthritis Psoriatic spondylitis Enteropathic arthritis Enteropathic Spondylitis Juvenile Spondyloarthropathy Undifferentiated Spondyloarthropathy 70% Acute Anterior Uveitis HLA-B27 frequency (%) 95% 70% 25% 60% 7% 70% 70% 50%

  5. Pattern of Peripheral Synovitis in the Spondyloarthropathies Condition Pattern of Involvement • Asymmetric large-joint oligoarthritis, primarily lower extremities • Asymmetric large-joint oligoarthritis, primarily lower extremities • Asymmetric large-joint oligoarthritis, primarily lower extremities • Oligoarticular disease: Asymmetric large-joint oligoarthritis, primarily lower extremities • Polyarticular disease: Symmetric polyarthritis involving large and small joints resembling RA • DIP joint disease: Associated with nail involvement • Arthritis mutilans: Severely destructive arthritis involving the hands with shortening of the digits Ankylosing Spondylitis Reactive Arthritis Enteropathic Arthritis Psoriatic Arthritis

  6. Psoriatic Arthritis- Epidemiology ? Prevalence of Psoriasis: 1–2% ? 20 – 40 % develop arthritis ? Prevalence of PsA: 0.04-1.2% ? Peak age of onset: between 30-55 years ? Highest incidence in patients with extensive skin involvement ? Males and females are equally affected ? In 70-80 % of PsA, skin symptoms occur first 1Taylor WJ. Curr Opin Rheumatol. 2002;14:98–103. 2Mease P. Curr Opin Rheumatol. 2004;16:366–370. 3Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511–1522. 4Kane D, et al. Rheumatology. 2003;42:1460–1468.

  7. Pathogenesis of Ps and PsA ?Nograles KE, et al. Clin Pract Rheumatol 2009,5:83-91

  8. Historical Patterns of PsA ? Oligo/ monoarticular disease (~ 30-70%): ? Asymmetric, <5 joints, usually large, primarily LEs ? Polyarticular disease (~15-45%): ? Symmetric, large & small joints, resembling RA ? DIP joint disease (~5%): ? Associated with nail involvement ? Arthritis mutilans (~5%): ? Severely destructive arthritis involving the hands with shortening of the digits ? Axial (sole in ~5% but with other types in ~40%): ? Spondylitis and sacroiliitis, usually HLA B27-positive Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78

  9. Psoriatic arthritis: asymmetric synovitis

  10. Psoriatic arthritis: nail changes, rash, and arthritis

  11. Psoriatic arthritis: nail changes, rash, and arthritis

  12. Psoriatic arthritis: hands

  13. Signs and Symptoms ? Morning stiffness >30 min in 50% of patients1 ? Joint tenderness sometimes less than in RA despite deformities1 ? Ridging, pitting of nails, onycholysis in up to 90% of pts vs only 40% of pts with psoriasis2,3 ? Dactylitis in >40% of pts2,4 ? Eye inflammation (conjunctivitis, iritis, or uveitis) in 7– 33% of pts; ? uveitis more commonly bilateral and chronic as compared to AS2 ? Distal extremity swelling with pitting edema in 20% of pts as the first isolated manifestation of PsA5 1Gladman DD. In: Up To Date. Accessed December 3, 2004. 2Taurog JD. In: Harrison's Online McGrawHill. Accessed January 2,2005. 3Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844. 4Veale D, et al. Br J Rheumatol. 1994;33:133–38. 5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296.

  14. Main Features and Their Frequency Back involvement (50%)1 Skin Involvement In nearly 70% of patients, cutaneous lesions precede the onset of joint pain, in 20% arthropathy starts before skin manifestations, and in 10% both are concurrent. 6 DIP involvement (39%)2 Nail psoriasis(80%)4, 5 Dactyilitis (48%)3 Enthesopathy (38%)2 1Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-1468 3 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67 5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6 DIP: Distal interphalangeal

  15. Comorbidities in PsA Patients Ocular inflammation1 (Iritis/Uveitis/ Episcleritis) PsA patients6-8 • Psychosocial burden • Reactive depression • Higher suicidal ideation • Alcoholism ? ? IBD2 Metabolic Syndrome3-5 • Hyperlipidemia • Hypertension • Insulin resistent • Diabetes • Obesity ? ? Higher risk of Cardiovascular disease (CVD) 1Qieiro et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355; 4Neimann et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6:383-392; 7Naldi et al. Br J Dermatol 1992;127:212-217; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319

  16. Main Features of PsA *Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA ***Spinal disease occurs in 40-70% of PsA patients Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8 Fitzgerald  “Psoriatic  Arthritis”  in  Kelley’s  Textbook  of  Rheumatology,  2009

  17. Hallmark Clinical Features in PsA Psoriatic Arthritis Dactylitis Enthesitis Ritchlin C. J Rheumatol. 2006;33:1435–1438. Helliwell PS. J Rheumatol. 2006;33:1439–1441.

  18. Dactylitis • Diffuse swelling of a digit may be acute, with painful inflammatory changes, or chronic wherein the digit remains swollen despite the disappearance of acute inflammation1 • Also referred to as “sausage  digit”1 • One of the cardinal features of PsA, in up to 40% of patients1,2 • Feet most commonly affected1 • Dactylitis involved digits show more radiographic damage1 ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994. 1Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190. 2Veale D, et al. Br J Rheumatol. 1994;33:133–38.

  19. Dactylitis/ Sausage Digit

  20. Definition of Enthesitis ?Entheses - the regions at which a tendon, ligament, or joint capsule attaches to bone1 ?Enthesitis -inflammation at the entheses1,2 ?Pathogenesis of enthesitis has yet to be fully elucidated2 ?Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients3 1McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60. 2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343. 3Salvarani C. J Rheumatol. 1997;24:1106–1140.

  21. How to Diagnose Those Without Skin Findings Look for distal joint involvement in asymmetric distribution Look at the nails Look in ears Ask about family history Look for dactylitis

  22. Psoriatic arthritis: nail pitting

  23. Psoriatic arthritis: nail dystrophy and arthritis

  24. PsA: Radiographic Characteristics ? Erosive arthritis (usually asymmetric) ? Pencil-in-cup deformity ? Bony ankylosis ? Arthritis mutilans ? Spurs/ periosteal reaction ? Non-marginal asymmetric syndesmophytes ? Asymmetric sacroiliitis

  25. Psoriatic Arthritis: Hand

  26. Psoriatic Arthritis: Feet

  27. Pencil-in-cup Deformity

  28. PsA: Progressive Joint Changes

  29. Juxta-articular Periostitis and Ankylosis

  30. Arthritis Mutilans

  31. Arthritis Mutilans Pencil-in-cup Osteolysis Gross Osteolysis

  32. Spurs/ Periosteal Reaction

  33. Sacroilitis

  34. Spinal Involvement: Syndesmophytes

  35. Differential Diagnosis Reactive  (Reiter’s)  Arthritis Rheumatoid Arthritis with concomitant psoriasis Ankylosing Spondylitis Gouty Arthritis

  36. HIV Patients ? Increased incidence ? reactive arthritis ? psoriasis ? psoriatic arthritis ? Explosive onset and more severe disease course ? Testing for HIV indicated in newly diagnosed severe psoriatic or reactive arthritis

  37. Course and Prognosis 20% of patients have a severe an debilitating form of arthritis originally thought to be more benign course than RhA progression of clinical damage occurs in a majority of patients radiologic changes occur over time despite treatment

  38. Classification Criteria of PsA How to diagnose PsA?

  39. Classical Description of PsA Using the Diagnostic Criteria of Moll and Wright ? Including 5 clinical patterns: ? Asymmetric mono-/oligoarthritis (~30%)1-4 ? Symmetric polyarthritis (~45%)1-4 ? Distal interphalangeal (DIP) joint involvement (~5%)1 ? Axial (spondylitis and sacroiliitis) (HLA-B27) (~5%)1,3 ? Arthritis Mutilans (<5%)1,3 • However patterns may change over time and are therefore not useful for classification 5 1. Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78 HLA: Human leucocytes antigen

  40. Patterns may Change Over Time Clinical subgroups at baseline and follow-up: Monoarthritis Oligoarthritis DIP Polyarthritis Spondyloarthritis Mutilans Monoarthritis Oligoarthritis DIP Polyarthritis Spondyloarthritis Mutilans No clinical evidence of joint disease McHugh et al. Rheum 2003;42:778-783

  41. CASPAR Criteria for the Classification of PsA ? Inflammatory articular disease (joint, spine, or entheseal) ? With ?3 points from following categories: −  Psoriasis: current (2), history (1), family history (1) −  Nail dystrophy (1) −  Negative rheumatoid factor (1) −  Dactylitis: current (1), history (1) recorded by a rheumatologist −  Radiographs: (hand/foot) evidence of juxta-articular new bone formation ? Specificity 98.7%, Sensitivity 91.4% Taylor et al. Arthritis & Rheum 2006;54: 2665-73

  42. Assessment of PsA Disease Severity GRAPPA Disease Severity Table1

  43. THANK YOU