Profile of Psoriatic Arthritis: What to expect as a typical patient Dr Deepak Jadon

Profile of Psoriatic Arthritis: What to expect as a typical patient Dr Deepak Jadon Rheumatology Specialist Registrar & PhD Research Fellow

2 Overview Back ground on psoriatic arthritis (PsA) Epidemiology Disease course & prognosis Management overview Features of PsA Arthritis Tendons & ligament Skin Nails Eyes Fatigue Other Summary Questions

3 Psoriatic arthritis (PsA) is a chronic inflammatory condition of the musculoskeletal system Psoriasis + Arthritis PsA presents with a varied pattern of joint inflammation & extra-articular manifestations Including Arthritis (joint inflammation) Spondylitis (spinal inflammation) Skin psoriasis Nail psoriasis Dactylitis ( sausage finger / toe) Enthesitis (tendon / ligament insertion inflammation) Uveitis (eye inflammation) Metabolic syndrome (diabetes, obesity, high BP, angina, MI)

4 Epidemiology Prevalence of PsA in the UK population estimated to be 0.19% Men & women equally affected 14% of psoriasis patients affected by a PsA in a U.K. primary care study Estimates vary from 8-43%

5 Disease course PsA was once considered a mild disease that didn t warrant DMARD use. In the late 1980s it became apparent that PsA should be treated intensively A study in Toronto in 1987 showed that 2 years after PsA diagnosis 47% had erosions visible on x-rays of hands / feet 56% were taking DMARDs A study in Bath in 2003 showed that over a 5 year periods Majority of patients showed progression in the number of joints affected 68% had erosions visible on x-rays of hands / feet

6 What are my chances of remission? A study of 391 patient in Toronto in 2001 18% of patients achieved remission with use of DMARDs Period of remission lasted 2.5 years But most patients had a relapse at 2.6 years Patients most likely to achieve remission Men Fewer inflamed joints at presentation Fewer erosions on x-ray at presentation Less disability at presentation Other predictors of good outlook Low CRP / ESR at presentation Good response to initial medications

7 Morbidity & mortality Mortality Study in Bath of 453 PsA patients seen between 1985-1997 [Buckley 2010] No increased risk of death in the PsA patients compared to the general UK population PsA patients are at greater risk of [Gladman 2009] Myocardial infarction x2.57 Angina x1.97 High BP x1.90 Not stroke / heart failure All risks greater if concomitant Diabetes High cholesterol Severe psoriasis

Features of PsA 8

9 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

10 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

11 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

12 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

13 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

14 Arthritis Pain, swelling & >30min early morning stiffness 5 patterns (subsets) of presentation (often migrate between the subsets) Distal predominant Oligoarthritis Polyarthritis Arthritis mutilans Psoriatic spondyloarthropathy

15 Polyarthritis subset 5 joints affected by arthritis Symmetrically affects proximal interphalangeal joints (PIPJ) distal interphalangeal joints (DIPJ) wrist knees ankles Can be indistinguishable from rheumatoid arthritis Unless x-rays extra-articular features

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18 Oligoarthritis subset 4 joints affected by arthritis Asymmetrically Most frequent sites Proximal interphalangeal joints (PIPJ) Wrist Knees Ankles

19 Distal interphalangeal joint subset DIPJs affected Bulbous drumstick appearance to the ends of finger Symmetrically Several joints DIPJ involvement alone occurs in <20% of cases Mimics osteoarthritis calcium pyrophosphate deposition disease complicating nodal osteoarthritis Clubbing Can significantly impair hand dexterity

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21 Arthritis mutilans Features destruction of bone in finger / toes marked deformity telescoping (skin folds, like opera glasses) X-ray: pencil in cup bone deformity

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23 Examination of joints Often pronounced joint deformity, but perhaps limited pain. Pain on stressing the joint Joint line tenderness Fluid in the knee (effusion) Redness overlying the joint (erythaema)

24 Psoriatic spondyloarthropathy (PsSpA) Males > females How common is it? 25% of PsA patients 4% of PsA patients experience only spinal disease, and no peripheral problems Symptoms inflammatory spinal pain / stiffness worse in the morning on waking / 5am worsened by rest improved by activity improved by NSAIDs lasts >6 weeks Sites Cervical & Lumbar spine vertebrae (spondylitis) Sacro-iliac joints (sacroiliitis)

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27 Examination of the spine Painful range of movement Looking over one s shoulder (cervical spine) Forward curvature of neck with difficult straightening (cervical spine) Picking a pen up of the floor without bending one s legs (lumbar spine) Alternating buttock pain during prolonged rest (sacro-iliac joints) Putting on socks (hips) Tenderness of sacroiliac joints on stressing

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33 Dactylitis Sausage toe / finger uniform swelling along the length of the finger / toe red shiny stretched appearance Pathology Inflammation of joint, tendons, ligament & skin Site Feet 65% Hands 24% Affects 50% of PsA at some time point in their life (usually early on) Can indicate more severe disease X-ray damage worse in affected joints

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36 Enthesitis = inflammation at the site where a tendon / ligament inserts into bone Sites Tennis / golfer s elbow (edges of elbows) Achilles insertion (calcaneum) Sole of foot (plantar fascia) Knee cap (patella ) Pelvic bone Often worst in the morning, improves with movement responds well to stretching exercises & steroid injections

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43 Tenosynovitis Inflammation of the lining around tendons (sheath) Sites flexor tendons of the hands extensor carpi ulnaris of the forearm / wrist Symptoms swollen fingers on palm side curling of fingers on waking difficulty straightening fingers improved by warmth & gentle stretching

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Trigger Finger 45

46 Extra-articular articular manifestations

47 Skin Psoriasis 2 common forms of psoriasis seen in PsA 1. Plaque psoriasis red base + fish-like surface scaling 2. Pustular psoriasis affects palms & soles Is skin disease present at time of arthritis diagnosis? 70% yes 15% yes, but not seen by doctor 15% no, but develops later (nail, dactylitis, FHx, genes) Skin psoriasis onset age 28y PsA onset age 38y (10y later) Conflicting data whether arthritis flares at same time as skin skin severity correlates with arthritis severity

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52 Psoriatic nails More common in PsA (90%) than psoriasis (46%) More common in DIPJ subset Nail severity correlates with arthritis severity (tender / swollen joint counts) skin severity Features Lifting of nail (onycholysis) Crumbling Thickening (hyperkeratosis) Pitting Whitening (leuconychia) Red spot lunula Black lines (splinter haemorrhages)

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57 Uveitis = Acute red painful eye 7% of PsA patients affected Symptoms Red painful eye Reduced vision Dislike of bright light Can be both sides Lasts for several days / weeks Very important to seek medical attention Steroid eyedrops Steroid tablets

58 Pitting oedema = excess water under the skin 21% of PsA patients affected Often precedes arthritis Sites hands & feet Cause uncertain

59 Metabolic Syndrome Greater cardiovascular disease in PsA patients High blood pressure Type 2 diabetes High cholesterol Angina Myocardial infarction Especially in people with Obese Severe skin disease NSAID use Kidney impairment Prevention Don t smoke Keep to optimum body weight (body mass index; BMI) Balanced diet Limit alcohol consumption Regular exercise

60 Fatigue Very common Often people are bothered more by fatigue than swollen / tender joints Causes Underlying PsA inflammation Poor sleep due to PsA pain Symptoms profound lack of energy sensation of muscle weakness slowed reaction time poor concentration poor memory

61 Other impacts of PsA Family life Relationships Having & caring for children Being a carer to older relatives Daily chores Employment Sports & hobbies Mood Quality of life

62 Management overview Education & support Physiotherapy, occupational therapy, podiatry, orthotics, hydrotherapy, aids Reduce risk factors for secondary problems smoking, alcohol, diabetes, high BP, cholesterol Joint injections Steroids) NSAIDs Naproxen, ibuprofen, diclofenac, meloxicam, celecoxib DMARDs (disease modifying anti-rheumatic drugs) Methotrexate, sulfasalazine, leflunomide Biologicals TNF inhibitors: Etanercept, adalimumab, infliximab, golimumab IL12/23 inhibitors: Ustekinumab Future medications IL-17 inhibitors: Secukinumab JAK inhibitors: Tofacitinib PDE4 inhibitors: Apremilast

63 Summary PsA is a complex multifaceted condition Spectrum of severity from mild to severe Not just skin & joints several sites affected some which one might not think to be connected Tailored therapy to the individual Lifelong condition, without a cure we can help you on that journey Please let us know we can help!

64 Thank you for listening - Any Questions? -

Profile of Psoriatic Arthritis: What to expect as a typical patient Dr Deepak Jadon Rheumatology Specialist Registrar & PhD Research Fellow