reactive and undifferentiated spondyloarthropathies…are
TRANSCRIPT
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Psoriatic Arthritis
Ewa Olech, MD
Division of Rheumatology
University of Nevada School of Medicine
Las Vegas
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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
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Psoriatic arthritis: asymmetric synovitis
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Psoriatic arthritis: nail changes, rash, and arthritis
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Psoriatic arthritis: nail changes, rash, and arthritis
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Psoriatic arthritis: hands
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Axial PsA
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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.
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Main Features and Their Frequency
1Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-14683 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67
5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6
Enthesopathy (38%)2
Dactyilitis (48%)3
DIP involvement (39%)2
Back involvement (50%)1
Nail psoriasis (80%)4, 5
Sk
in In
vo
lve
me
nt
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: Distal interphalangeal
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PsA patients6-8
• Psychosocial burden• Reactive depression • Higher suicidal ideation• Alcoholism
Metabolic Syndrome3-5
• Hyperlipidemia
• Hypertension
• Insulin resistent
• Diabetes
• Obesity
Higher risk of
Cardiovascular disease (CVD)
Ocular inflammation1
(Iritis/Uveitis/ Episcleritis)
IBD2
Comorbidities in PsA Patients
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
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Main Features of PsA
Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8
Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009
*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
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Hallmark Clinical Features in PsA
Dactylitis Enthesitis
Psoriatic Arthritis
Ritchlin C. J Rheumatol. 2006;33:1435–1438.
Helliwell PS. J Rheumatol. 2006;33:1439–1441.
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Dactylitis
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.
• 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
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Dactylitis/ Sausage Digit
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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.
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Look for distal joint involvement in
asymmetric distribution
Look at the nails
Look in ears
Ask about family history
Look for dactylitis
How to Diagnose Those
Without Skin Findings
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Psoriatic arthritis: nail
pitting
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Psoriatic arthritis: nail dystrophy and arthritis
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PsA: Radiographic Characteristics
Erosive arthritis (usually asymmetric)
Pencil-in-cup deformity
Bony ankylosis
Arthritis mutilans
Spurs/ periosteal reaction
Non-marginal asymmetric syndesmophytes
Asymmetric sacroiliitis
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Psoriatic
Arthritis:
Hand
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Psoriatic Arthritis: Feet
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Pencil-in-cup Deformity
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PsA: Progressive Joint Changes
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Juxta-articular Periostitis and
Ankylosis
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Arthritis Mutilans
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Arthritis Mutilans
Pencil-in-cup Osteolysis Gross Osteolysis
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Spurs/ Periosteal Reaction
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Sacroilitis
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Spinal
Involvement:
Syndesmophytes
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Differential Diagnosis
Reactive (Reiter’s) Arthritis
Rheumatoid Arthritis with concomitant
psoriasis
Ankylosing Spondylitis
Gouty Arthritis
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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
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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
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Classification Criteria of
PsA
How to diagnose PsA?
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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
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Patterns may Change Over Time
McHugh et al. Rheum 2003;42:778-783
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
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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
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Assessment of PsA Disease Severity
GRAPPA Disease Severity Table1
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