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

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

5 Pattern of Peripheral Synovitis in the Spondyloarthropathies Condition Ankylosing Spondylitis Reactive Arthritis Enteropathic Arthritis Psoriatic Arthritis 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

6 Psoriatic Arthritis- Epidemiology Prevalence of Psoriasis: 1 2% % develop arthritis Prevalence of PsA: % Peak age of onset: between years Highest incidence in patients with extensive skin involvement Males and females are equally affected In % of PsA, skin symptoms occur first 1Taylor WJ. Curr Opin Rheumatol. 2002;14:

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 patients 1 Joint tenderness sometimes less than in RA despite deformities 1 Ridging, pitting of nails, onycholysis in up to 90% of pts vs only 40% of pts with psoriasis 2,3 Dactylitis in >40% of pts 2,4 Eye inflammation (conjunctivitis, iritis, or uveitis) in 7 33% of pts; uveitis more commonly bilateral and chronic as compared to AS 2 Distal extremity swelling with pitting edema in 20% of pts as the first isolated manifestation of PsA 5 1 Gladman DD. In: Up To Date. Accessed December 3, Taurog JD. In: Harrison's Online McGrawHill. Accessed January 2, Gladman DD. Rheum Dis Clin N Amer. 1998;24: Veale D, et al. Br J Rheumatol. 1994;33: Cantini F, et al. Clin Exp Rheumatol. 2001;19:

14 Main Features and Their Frequency Back involvement (50%) 1 DIP involvement (39%) 2 Nail psoriasis (80%) 4, 5 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 Dactyilitis (48%) 3 Skin Involvement Enthesopathy (38%) 2 DIP: Distal interphalangeal 1 Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42: Gladman D et al. Ann Rheum Dis 2005;64: ; 4 Lawry M. Dermatol Ther 2007;20: Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6 Yamamoto Eur J Dermatol 2011;21:660-6

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

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: Helliwell PS. J Rheumatol. 2006;33:

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 inflammation 1 Also referred to as sausage digit 1 One of the cardinal features of PsA, in up to 40% of patients 1,2 Feet most commonly affected 1 Dactylitis involved digits show more radiographic damage 1 ACR Slide Collection on the Rheumatic Diseases; 3 rd edition Brockbank J, et al. Ann Rheum Dis. 2005;64: Veale D, et al. Br J Rheumatol. 1994;33:

19 Dactylitis/ Sausage Digit

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

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22 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

23 Psoriatic arthritis: nail pitting

24 Psoriatic arthritis: nail dystrophy and arthritis

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

26 Psoriatic Arthritis: Hand

27 Psoriatic Arthritis: Feet

28 Pencil-in-cup Deformity

29 PsA: Progressive Joint Changes

30 Juxta-articular Periostitis and Ankylosis

31 Arthritis Mutilans

32 Arthritis Mutilans Pencil-in-cup Osteolysis Gross Osteolysis

33 Spurs/ Periosteal Reaction

34 Sacroilitis

35 Spinal Involvement: Syndesmophytes

36 Differential Diagnosis Reactive (Reiter s) Arthritis Rheumatoid Arthritis with concomitant psoriasis Ankylosing Spondylitis Gouty Arthritis

37 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

38 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

39 Classification Criteria of PsA How to diagnose PsA?

40 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

41 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:

42 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:

43 Assessment of PsA Disease Severity GRAPPA Disease Severity Table 1

44 THANK YOU