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. 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% bu t with other types in ~40%):  Spondylitis and sacroiliitis, usually HLA B27-positive      Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78

  3. Psoriatic arthritis: asymmetric synovitis

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

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

  6. Psoriatic arthritis: hands

  7. Axial PsA

  8. 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.

  9. Main Features and Their Frequency B ack 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 20 5Jiaravuthisan MM et al. JAAD 2007;57:1 27; 6Yamamoto Eur J Dermatol 2011;21:660 6 07;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 - – DIP: Distal interphalangeal - -

  10. 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 - - -

  11. 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“PsoriaticArthritis” inKelley’s Textbook of Rheumatology,2009 -

  12. 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. – –

  13. 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. – –

  14. Dactylitis/ Sausage Digit

  15. 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. – – –

  16. 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

  17. Psoriatic arthritis: nail pitting

  18. Psoriatic arthritis: nail dystrophy and arthritis

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

  20. Psoriatic Arthritis: Hand

  21. Psoriatic Arthritis: Feet

  22. Pencil-in-cup Deformity

  23. PsA: Progressive Joint Changes

  24. Juxta-articular Periostitis and Ankylosis

  25. Arthritis Mutilans

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

  27. Spurs/ Periosteal Reaction

  28. Sacroilitis

  29. Spinal Involvement: Syndesmophytes

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

  31. HIV Patients  Increased incidence  reactive arthritis  psoriasis  psoriatic ar  Explosive onset and more severe disease course  Testing for HIV indicated in newly diagnosed severe psoriatic or reactive arthritis thritis

  32. 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

  33. Classification Criteria of PsA How to diagnose PsA?

  34. 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 HLA: Human leucocytes antigen 1. Moll JMH, Wright V. Semin Arthritis Rheum 1973;3:55-78

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

  36. 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 -

  37. Assessment of PsA Disease Severity GRAPPA Disease Severity Table1