Objectives Psoriatic Arthritis: a seronegative spondyloarthopathy - PDF Document

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  1. 4/7/15   Objectives Psoriatic Arthritis: a seronegative spondyloarthopathy Lindsey Clark, PA-C Mercy Arthritis and Osteoporosis Center — Identify clinical features of psoriatic arthritis — Discuss how the diagnosis is made — Recognize when referral is needed — Review approach to treatment Characteristics of seronegative spondyloarthropathy Extra articular manifestations: •  Skin disease: several clinical presentations- psoriasis vulgaris, guttate psoriasis •  Nail lesions ◦  Pitting, onycholysis, — Seronegative RF — Spinal involvement — Extra articular features — Association with HLA-B27 •  Inflammatory eye disease (iritis, episcleritis): common in all spondyloarthropathies •  Urethritis: feature of seronegative disease, less common in PSA Nail Pitting Nail Pitting 1  

  2. 4/7/15   Psoriatic Arthritis Demographics RA vs PSA Demographi cs Radiologic manifestations Joints involved Skin Labs —  Occurs in approx. 26% of patients with psoriasis (reports vary from 6%-50%) Rheumatoid arthritis Females> Males Prevalence 1-2% Most commonly small joints of hands (MCPs, PIPs) and feet (MTPs); axial skeleton is spared other than cervical spine -Juxtaarticular bony erosions -symmetric joint space narrowing -subluxation -periarticular osteopenia RF+/RF- ----- —  Affects men and women equally —  Skin involvement usually precedes joint involvement in majority of patients Psoriatic arthritis Females= Males Prevalence 0.1-1% Peripheral and/or axial joints; *DIP joints of hands -Erosive changes -new bone formation -“pencil in cup deformity” -lysis of terminal phalanges RF- Psoriasis- psoriasis vulgaris is most common type —  Age of onset usually 30-55 years Psoriatic Arthritis Clinical Features: Articular manifestations: • Dactylitis “sausage digit” o results from synovitis in the joints of the digit as well as tenosynovitis. • Tenosynovitis: o inflammation may affect flexor tendons (Achilles tendonitis and plantar fasciitis both common). o tendonitis may be associated with tendon nodules and significant functional limitation —  Pain, swelling, stiffness in affected joints —  Typically the psoriasis will appear prior to the arthritis, but in 15-25% of patients with PSA the arthritis will occur before or around the time of the skin involvement —  Predominantly distal joint disease- often affects all joints of one digit- “ray” pattern —  Both peripheral joint and axial skeleton- spinal involvement includes SI joints • Enthesitis: o inflammation of the enthesis (site of insertion of tendon into bone). o most commonly affects plantar fascia, Achilles tendon insertion, insertion of tendons at knee and shoulder, and pelvic bones. Dactylitis Dactylitis 2  

  3. 4/7/15   Achilles tendonitis Diagnosis *no specific lab marker for PSA (like RF in rheumatoid) —  Consider in patient with both inflammatory arthritis and diagnosis of psoriasis —  May have elevated CRP, ESR —  Distinguish from RA —  If RF negative, with DIP joint involvement, nail lesions, then consider PSA. —  Presence of spinal disease also points to PSA. C ACR Radiographic Features — “pencil in cup” deformity results from erosive changes and formation of hypertrophic bone in the phalanges — Soft tissue swelling, erosions, periostitis Treatment — Purpose of treating: ◦ decrease inflammation, improve discomfort, and prevent damage ◦ Recommend coordinating treatment with the rheumatologist and dermatologist to reduce adverse effects on the skin disease ; there are often different responses on skin vs joints 3  

  4. 4/7/15   Treatment Treatment — NSAIDs- alone and with other therapies — Methotrexate: ◦ Once weekly administration ◦ Oral or parenteral ◦ Adverse effects: liver toxicity, interstitial lung disease, bone marrow suppression ◦ *Avoid alcohol while on MTX ◦ Frequent labs to check CBC, LFTs (no less often than every 3 months) ◦ Hold medication with infection, surgery — Glucocorticoids- ◦  Occasional systemic glucocorticoids, however used less often than other inflammatory arthritis conditions due to effect on psoriasis skin lesions. ◦  intraarticular injections helpful in monoarticular disease — DMARDS: (Disease modifying agents) ◦  May improve joint/skin manifestations but have not been shown to slow or prevent radiographic damage ◦  Oral: methotrexate, sulfasalazine, cyclosporine, leflunomide Treatment Anti TNFs — Biologic Therapy- ◦  Shows greatest efficacy of any treatment ◦  Joint disease activity, inhibition of structural damage, function ◦  Treats skin disease — Hold with infections, surgery — Make sure patient up to date with vaccinations (influenza, pneumococcal- Pneumovax AND Prevnar ◦ http://www.cdc.gov/vaccines/vpd-vac/pneumo/ vac-PCV13-adults.htm — Can NOT receive live vaccines while on a biologic (ex. Zostavax) ◦ Anti-TNFs- approved for both psoriatic arthritis and psoriasis –  Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab) –  Increased risk for infection When to refer? Resources ◦ American College of Rheumatology ◦ www.rheumatology.org — Patient with joint pain who has diagnosis of psoriasis ◦ Gladman, Dafna. "Psoriatic Arthritis." Primer on the Rheumatic Diseases. 13th ed. New York, NY: Springer, 2008. 170-92. Print. — Patient with visible joint swelling — Joint pain and abnormal labs (elevated ESR, CRP) 4