Focus on CME at Memorial University Understanding and Managing Psoriatic Arthritis Title in All the Wrong Places Proton Rahman MD, MSc, FRCPC Although Baron Jean-Luis Aubert offered the first case description of psoriatic arthritis in 1818, it was not officially recognized by the American College of Rheumatology as a distinct clinical entity until 1964 due to some overlap- ping features with rheumatoid arthritis.1Since then, epidemiological studies have clearly demonstrated that psoriatic arthritis is a separate disease entity, with its own demographic, radio- logic, and clinical features.2Psoriatic arthritis is an inflammatory arthritis associated with psoria- sis.3The incidence of psoriatic arthritis varies between 0.3% to 1.0% and, to some extent, depends on the prevalence of psoriasis.4,5 Psoriatic arthritis usually occurs in patients with psoriasis or patients with a family history of pso- riasis or psoriatic arthritis.6The peak age of onset for psoriatic arthritis occurs in the late 30s and there is no predisposition to either sex. between genetic, immunological and environ- mental factors.7Multiple lines of evidence sup- port a genetic basis for psoriatic arthritis. This evidence is derived from family-based investiga- tions, association studies with human leukocyte antigens, and mounting evidence for the genetic basis of psoriasis, a related condition.8 The inflammatory nature of skin and joint manifestations of psoriatic arthritis has suggest- ed an immune mechanism. Humoral and cellular immune abnormalities have been detected in psoriasis and psoriatic arthritis. Environmental factors, including infection and trauma, have also been proposed as important factors in both the initiation and perpetuation of inflammation in the psoriatic arthritis condition in the setting of a susceptible individual.8 Clinical Features On the basis of clinical observations, Moll and Wright described five clinical patterns: symmetric polyarthritis, similar to rheumatoid arthritis; asym- metric oligoarthritis, four or less joints; spondy- loarthropathy, similar to ankylosing spondylitis; dis- tal pattern affecting the distal interphalangeal joints; Etiology of Psoriatic Arthritis The etiology of psoriatic arthritis remains unknown, but likely results from an interplay The Canadian J ournal of CME / October 2002 73
Psoriatic Arthritis and arthritis mutilans, a destructive form of arthritis leading to flail or ankylosed joints.6While these pat- terns may be clearly recognized at disease onset, they change over time and it has been difficult to ascertain whether they have prognostic implications. Table I Five clinical patterns of psoriatic arthritis in decreasing frequency • Symmetric polyarthritis • Asymmetric oligoarthritis Dr. Rahman is assistant professor, faculty of medicine, Memorial University of Newfoundland, staff, St. Clare’s Hospital, St. J ohn’s, NF. • Spondyloarthropathy • Distal interphalangeal pattern • Arthritis mutilans Table 2 Comparison of clinical features of psoriatic arthritis and rheumatoid arthritis Clinical feature Psoriatic arthritis Rheumatoid arthritis Peripheral joint involvement frequent frequent Asymmetric involvement frequent infrequent Distal interphalangeal involvement frequent infrequent Spondylitis frequent infrequent Sacroiliitis frequent infrequent Syndesmophytes frequent infrequent Iritis frequent infrequent Psoriasis frequent infrequent Nail lesions frequent infrequent Rheumatoid nodules infrequent frequent Rheumatoid factor infrequent frequent Bony erosions frequent frequent New bone formation frequent infrequent 74 The Canadian J ournal of CME / October 2002
Psoriatic Arthritis Periarticular involvement is also common in psoriatic arthritis, as patients may develop dactylitis, tendonitis and enthesitis. Dactylitis, or sausage digit, is an inflammatory process involving the whole digit. In dactylitis, arthritis is thought to affect all of the joints in the digit. Inflammation of the tendon sheath (either flex- ors or extensors) is called tenosynovitis. Common sites of involvement for tendonitis include the Achilles tendon and the plantar fas- cia. Enthesitis, or inflammation at sites of ten- don insertions, is a frequent finding in patients with psoriatic arthritis. It is especially common around the heel and is often associated with spur formation. Extra-articular manifestations of psoriatic arthritis, apart from psoriasis, include ocular involvement, particularly anterior uveitis, aortic insufficiency, mucus membrane lesions, and col- itis. no clear relationship between the extent of pso- riasis and severity of inflammatory arthritis. Inflammatory arthritis in the presence of pso- riasis usually prompts the physician into consid- ering the diagnosis of psoriatic arthritis. It should be noted, however, that the diagnosis of psoriasis is often overlooked as it may affect areas of the body not in plain view, such as scalp, buttocks, etc. A greater challenge ensues when one has to consider the diagnosis of psoriatic arthritis in the absence of psoriasis, as the arthritis can precede the psoriasis in 15% of cases. In such cases the physician has to be vigilant in searching for non-cutaneous features that will distinguish pso- riatic arthritis from rheumatoid arthritis. Relationship between skin and joints The majority of patients with psoriatic arthritis have the classic form of psoriasis vulgaris, although pustular psoriasis and erythroderma have also been reported.9 The relationship between skin and joint manifestations in psoriatic arthritis remains unclear. In approximately 70% of cases psoriasis precedes the onset of arthritis, but the interval in between is extremely variable. In approximately 15% of cases, psoriasis precedes the onset of arthritis. The interval between the onset of psoriasis and arthritis can be extremely variable. In another 15% of cases, the pso- riasis and inflammatory arthritis are diag- nosed together.2For the most part, there is MERCK FROSST CANADA LTD. P.O. BOX 1005, POINTE-CLAIRE DORVAL, QUEBEC H9R 4P8
Psoriatic Arthritis among first-degree relatives, should trigger con- sideration of a diagnosis of psoriatic arthritis. It is also important to search for rheumatoid nod- ules, vasculitis and pulmonary and renal mani- festations, as these extra-articulars are strongly suggestive of rheumatoid, rather than psoriatic, arthritis. Differences in radiographic features between these two inflammatory arthritides are described later. Practice Pointer • Inflammatory axial symptoms and/or sacroiliitis rarely occur in rheumatoid arthritis and strongly favor the diagnosis of a seronegative spondy- loarthropathy, such as psoriatic arthritis. • A strong family history of psoriasis or psoriatic arthritis, especially among first-degree relatives, should trigger consideration of a diagnosis of psoriatic arthritis. LABORATORY STUDIES There are no specific laboratory investigations that aid in the diagnosis of psoriatic arthritis. The abnormalities noted are similar to those of any chronic inflammatory process. Acute phase reactants, such as the erythrocyte sedimentation rate (ESR), are elevated in 40% to 60% of patients. Five to 16% of patients have a low titer of rheumatoid factor and 2% to 16% of patients test positive for anti-nuclear antibody. • The key radiographic features of psoriatic arthritis include soft-tissue swelling, minimal osteopenia, bone erosions, resorption of the distal phalanx, prominent new bone formation, asymmetric distribution, and paravertebral ossification. How do psoriatic arthritis and rheumatoid arthritis differ? Rheumatoid arthritis and psoriatic arthritis can both present with a symmetrical inflammatory polyarthritis. However, the presence of an inflammatory axial disease, the distribution of articular disease, the occurrence of periarticular and extra-articular features or characteristic radiographic changes may be more suggestive of psoriatic arthritis.8 Inflammatory axial symptoms and/or sacroili- itis rarely occur in rheumatoid arthritis and strongly favor the diagnosis of a seronegative spondyloarthropathy, such as psoriatic arthritis. Inflammatory axial symptoms and/or sacroiliitis also favors the presence of distal interphalangeal involvement, as this tends to occur in psoriatic arthritis and involvement of this joint is usually spared in rheumatoid arthritis. Psoriatic arthritis is more likely to be inherit- ed than rheumatoid arthritis. A strong family his- tory of psoriasis or psoriatic arthritis, especially RADIOGRAPHIC FINDINGS The key radiographic features of psoriatic arthritis include soft-tissue swelling, minimal osteopenia, bone erosions, resorption of the distal phalanx, prominent new bone formation, asymmetric distribution, and paravertebral ossification. Specific radiographic features that facilitate the diagnosis of psoriatic arthritis are the simultaneous appearance of joint erosions, such as “pencil-in-cup” changes, along with new bone formation in other joints. That is, psoriatic arthritis patients may demonstrate “pencil-in- cup” change in one joint and total ankylosis in an adjacent joint. Similar peripheral joints may be involved in rheumatoid arthritis and psoriatic arthritis, but X-rays of patients with psoriatic arthritis usually do not demonstrate the same degree of periarticular osteopenia. Psoriatic arthritis is associated with periosteal reaction and new bone formation.10 78 The Canadian J ournal of CME / October 2002
Psoriatic Arthritis Management The aims of therapy in psoriatic arthritis are to induce remission of the skin lesions, alleviate articular symptoms and prevent joint destruc- tion. At presentation it may be difficult to gauge how aggressively a patient should be treated. The clinical dilemma is that the majority of patients with psoriatic arthritis do well and can be treat- ed with just a nonsteroidal anti-inflammatory drug (NSAID). In up to 20% of patients, howev- er, joint destruction may develop. Unlike rheumatoid arthritis, where the institution of a dis- ease modifying anti-rheumatic drug (DMARD) is encouraged as soon as the diagnosis is confirmed, careful assessment and monitoring of clinical response with NSAID therapy is required prior to institution of DMARD therapy. NSAIDs are the initial drug of choice for pso- riatic arthritis. All NSAIDs, including the newer COX-2 selective agents, have similar efficacy for peripheral arthritis when administered in equivalent therapeutic doses. Indomethacin, diclofenac, tolmetin and sulindac may be more effective for treating axial symptoms than other NSAIDs. Practice Pointer The aims of therapy in psoriatic arthritis are to induce remission of the skin lesions, alleviate articular symptoms and prevent joint destruc- tion. In principle, medications capable of con- trolling both components of the disease should be favored. • NSAIDs are the initial drug of choice for psoriatic arthritis. All NSAIDs, including the newer COX-2 selective agents, have similar efficacy for peripheral arthritis when administered in equivalent therapeutic doses. • If NSAIDs do not control the inflammatory synovitis, a DMARD should be considered.The decision process in selecting a DMARD should include an assessment of the burden of skin disease, because certain DMARDs can improve both skin and joint manifestations. There is consensus that corticosteroids should be avoided in psoriatic arthritis as their discon- tinuation may exacerbate the skin disease. If NSAIDs do not control the inflammatory synovitis, a DMARD should be considered. The W W W . D I S C O V E R Y C A M P U S . C O M The Management of Chronic Obstructive Pulmonary Disease DiscoveryCampus is an innovative Web site offering high-quality education courses for physicians. DiscoveryCampus and Boehringer Ingelheim (Canada) Ltd. are pleased to offer a MAINPRO-M1 accredited course on Management of Chronic Obstructive Pulmonary Disease. The course is accredited by: The College of Family Physicians of Canada for 2 MAINPRO-M1 credits The Canadian Society of Respiratory Therapists American College of Chest Physicians. One credit hour in Category 1 of the Physician’s Recognition Award of the American Medical Association This course is sponsored by an unrestricted grant from Accreditation details available online. To take this complimentary course, go to www.discoverycampus.com and register for RSP 003. Registration is free.
Psoriatic Arthritis decision process in selecting a DMARD should include an assessment of the burden of skin dis- ease, because certain DMARDs can improve both skin and joint manifestations. In principle, medications capable of controlling both compo- nents of the disease should be favored. Many of the “classic” DMARDs used in the treatment of rheumatoid arthritis are also used in the treatment of psoriatic arthritis.8This includes methotrexate, sulfasalazine, intramuscular gold, azathioprine, and cyclosporine. The newer bio- logic agents (infliximab and etanercept) have also demonstrated great promise. 11 The most widely used agent is methotrexate. It is quite effective in reducing the inflammatory synovitis as well as the skin manifestations. The doses of methotrexate used in psoriatic arthritis are comparable to those in rheumatoid arthritis. Sulfasalazine has been used in the treatment of psoriatic arthritis with variable results. Reductions in the duration of morning stiffness, active joints and ESR following treatment with sulfasalazine have been noted. Intramuscular gold injections have been shown to be effective in treating active peripheral joints. Intramuscular gold injections’ role in treating symptoms of axial disease is limited. However, use of intra- muscular gold injections may cause psoriasis to flare. Small, randomized, controlled trials with both biologic agents directed at inhibiting tumor necrosis factor (infliximab and etanercept) have recently demonstrated a substantial reduction in active joints in patients with refractory psoriatic arthritis. If this trend is confirmed in larger stud- ies, these biologic agents will become a main- stay in the treatment of refractory psoriatic arthritis. rheumatoid arthritis, psoriatic arthritis is a dis- tinct clinical entity. In up to one-fifth of patients with psoriatic arthritis, the disease progressed from a benign condition to a disabling disease. Patients with mild disease can be managed sole- ly with NSAIDs, whereas those with severe dis- ease will require institution of DMARDs. CME References 1 O’Neil T, Silman A: Psoriatic arthritis: Historical back- ground and epidemiology. Baillieres Clin Rheumatol 1994; 245-48. 2 Gladman DD: The natural history of psoriatic arthritis. Baillière’s Clinical Rheumatology 1994; 8:379-94 3 Gladman DD: Criteria for psoriatic arthritis. Baillière’s Clinical Rheumatology 1995; 9:319-29. 4 Lawrence RC, Hochberg MC, Kelsey JL, et al: Estimates of the prevalence of selected arthritis and musculoskeletal dis- eases in the United States. J Rheumatol 1989; 16:427-41. 5 Uramoto KM, Shbeeb MI, Sunku J, et al. The epidemiology of psoriatic arthritis (PA) in Olmstead County 1980-91: Arthritis Rheum 1997; 40(Suppl 9): S214. 6 Moll JM, Wright V: Familial occurrence of PsA. Ann Rheum Dis. 1973; 32:181-201. 7 Gladman DD: Current concepts in psoriatic arthritis. Curr Opin Rheumatol 2002 ; 14(4): 361-6. 8 Gladman DD, Rahman P: Psoriatic arthritis. In: Harris ED, Ruddy S, Sledge CB (eds): Textbook of Rheumatology, Fifth Edition, 1997, pp. 1071-80. 9 Goodfield M: Skin lesions in psoriasis. Baillière’s Clinical Rheumatology 1994; 8:295-316. 10.Nguyen E, Rahman P, Schentag CT, et al: Comparison of radiographic features and severity in psoriatic arthritis (PsA) and rheumatoid arthritis (RA). J Rheumatol 1999; 26:1627. 11 Mease PJ: Etanercept: a new era in the treatment of psori- atic arthritis. Am J Manag Care 2002; 8(6):S194-2000. Suggested Readings 1 Gladman DD: Current concepts in psoriatic arthritis. Curr Opin Rheumatol 2002; 14(4):361-6. 2 Patel S, Veale D, Fitzgerald O, et al: Psoriatic arthritis: emerging concepts. Rheumatology 2001; 40(3):243-6 3 Gladman DD: Psoriatic arthritis. Rheum Dis Clin North America 1998; 24(4):829-44. 4 O’Neil T, Silman A: Psoriatic arthritis. Historical back- ground and epidemiology. Baillieres Clin Rheumatol 1994; 245-48. Conclusion Even though psoriatic arthritis may resemble 80 The Canadian J ournal of CME / October 2002