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Transition Phase Towards Psoriatic Arthritis: Clinical and Ultrasonographic Characterisation of Psoriatic Arthralgia

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Transition Phase Towards Psoriatic Arthritis: Clinical and Ultrasonographic Characterisation of Psoriatic Arthralgia Psoriatic arthritis RMD Open: first published as 10.1136/rmdopen-2019-001067 on 23 October 2019. Downloaded from ORIGINAL ARTICLE Transition phase towards psoriatic arthritis: clinical and ultrasonographic characterisation of psoriatic arthralgia Alen Zabotti ,1 Dennis G McGonagle,2 Ivan Giovannini,1 Enzo Errichetti,3 Francesca Zuliani,1 Anna Zanetti,4 Ilaria Tinazzi,5 Orazio De Lucia,6 Alberto Batticciotto ,7 Luca Idolazzi,8 Garifallia Sakellariou,9 Sara Zandonella Callegher,1 Stefania Sacco,1 Luca Quartuccio,1 Annamaria Iagnocco,10 Salvatore De Vita1 To cite: Zabotti A, ABSTRACT McGonagle DG, Giovannini I, Objective Non-specific musculoskeletal pain is common Key messages et al. Transition phase in subjects destined to develop psoriatic arthritis (PsA). towards psoriatic arthritis: We evaluated psoriatic patients with arthralgia (PsOAr) What is already known about this subject? clinical and ultrasonographic compared with psoriasis alone (PsO) and healthy controls ► Patients with psoriasis have a period of non-specific characterisation of psoriatic joint symptoms (ie, arthralgia) before psoriatic ar- arthralgia. RMD Open (HCs) using ultrasonography (US) to investigate the anatomical basis for joint symptoms in PsOAr and the thritis (PsA) development, but the anatomical basis 2019;5:e001067. doi:10.1136/ for such arthralgia remains to be defined. rmdopen-2019-001067 link between these imaging findings and subsequent PsA transition. What does this study add? Methods A cross-sectional prevalence analysis of ► Tenosynovitis could be an important contributor to Received 25 July 2019 clinical and US abnormalities (including inflammatory non-specific musculoskeletal symptoms in psoriatic Revised 3 October 2019 and structural lesions) in PsOAr (n=61), PsO (n=57) and patients with arthralgia (PsOAr). Accepted 7 October 2019 HCs (n=57) was performed, with subsequent prospective ► Clinically, PsOAr patients were more prone to devel- follow-up for PsA development. op PsA with longitudinal evaluation and the baseline Results Tenosynovitis was the only significant sonographic detection of enthesitis was associated sonographic feature that differed between PsOAr and http://rmdopen.bmj.com/ with clinical PsA development. PsO (29.5% vs 5.3%, p<0.001), although synovitis and enthesitis were numerically more frequent in PsOAr. Five How might this impact on clinical practice? patients in PsOAr and one in PsO group developed PsA, ► PsOAr patients could be a subgroup of psoriatic pa- with an incidence rate of 109.2/1000 person-years in tients in which a strict rheumatological monitoring or PsOAr vs 13.4/1000 person-years in PsO (p=0.03). Visual disease interception with psoriasis directed therapy Analogue Scale pain, Health Assessment Questionnaire, could be envisaged. joint tenderness and US active enthesitis were baseline variables associated with PsA development. Conclusion Tenosynovitis was associated with arthralgia 2 on September 29, 2021 by guest. Protected copyright. in subjects with psoriasis. Baseline US evidence of PsA development. The incidence of PsA in enthesitis was associated with clinical PsA development different psoriasis cohorts is between 0.3% 2 3 in the longitudinal analysis. These findings are relevant and 3.5% per annum. In rheumatoid for enriching for subjects at risk of imminent PsA arthritis, anti citrullinated protein antibodies development. (ACPA)+ cases have a preclinical phase of disease characterised by clinically suspected arthralgia4 and imaging studies have shown that this phase of disease is associated with 5 6 © Author(s) (or their INTRODUCTION synovitis and tenosynovitis. employer(s)) 2019. Re-use Psoriatic arthritis (PsA) is a common and In PsA, it was clinically recognised that permitted under CC BY-NC. No commercial re-use. See rights potentially debilitating arthropathy that can the complex of symptoms, experienced and permissions. Published occur in up to a third of patients with psori- by patients in their preclinical phases of by BMJ. asis.1 It is well established that joint damage disease, is heterogeneous, from fatigue and For numbered affiliations see can occur early in the course of PsA, so early depressive symptoms to arthralgia. However, end of article. disease recognition is imperative. Given that prospective studies focussing on symptoms Correspondence to psoriasis predates PsA by a decade or more, suspicious for PsA development are still Dr Alen Zabotti; then skin involvement offers the opportunity lacking. Recently, Eder et al showed in a zabottialen@ gmail. com to investigate risk factors and predictors of longitudinal cohort of psoriasis that cases Zabotti A, et al. RMD Open 2019;5:e001067. doi:10.1136/rmdopen-2019-001067 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2019-001067 on 23 October 2019. Downloaded from destined to developed PsA had antedating non-spe- B ox 1 Inclusion and exclusion criteria cific musculoskeletal symptoms, without distinct find- 7 ings suggestive for PsA on physical examination. The Inclusion criteria anatomical basis for joint pain in the preclinical phase 1. Age ≥18 years of PsA is not yet understood, and musculoskeletal 2. Current cutaneous psoriasis and/or nail psoriasis diagnosed by a ultrasonography (US) could be a reliable modality to dermatologist detect musculoskeletal inflammatory lesions in these 3. Negative history of arthritis, dactylitis, enthesitis or inflammatory patients with psoriasis.8–11 Moreover, this sonograph- back pain ic-determined inflammation appears to regress under 4. Absence of clinical signs of osteoarthritis* and/or fibromyalgia† systemic therapy for skin disease raising the possibility 5. Absence of signs of active arthritis, dactylitis, enthesitis or inflam- that skin-directed therapy may prevent arthritis devel- matory back pain atenrolment, evaluated by rheumatologist 12 opment. However, the current inability to accurately Exclusion criteria enrich for imminent PsA means that the question of 1. Satisfaction of CASPAR criteria PsA prevention strategies remains in its infancy.13 2. Use of conventional synthetic DMARDs, steroid therapy (oral and In this study we explored, by means of US, the anatom- intra-articular), retinoids, non-steroidal anti-inflammatory drugs ical basis for arthralgia in subjects with psoriasis. We (chronically)within 3 months from enrolement followed up this patient group looking at the rate of PsA 3. Previous or actual use of bDMARDs or small molecules (eg, development in patients with psoriasis with and without Phosphodiesterase-4 inhibitor [PDE4i]) arthralgia and linked this to baseline imaging findings. *The clinical diagnosis of osteoarthritis was ruled out by a rheumatologist. Our findings confirmed that arthralgia in subjects with †Fibromyalgia was tested by ACR criteria (Wolfe et al. Arthritis Care Res psoriasis is associated with PsA development with our (Hoboken). 2010 May;62(5):600–10) imaging data showing important roles for baseline imag- ing-determined tenosynovitis or enthesitis on both symp- toms and disease evolution. Study design The study consisted of two phases: (a) cross-sectional prevalence analysis of clinical and US abnormalities in METHODS PsOAr compared with PsO and HCs; (b) prospective Study population analysis looking for the development of PsA. The diag- Patients with psoriasis and age-matched randomly nosis of PsA was clinical and made by rheumatologists, selected healthy controls (HCs) were recruited from blinded to previous US results, if CASPAR criteria were rheumatology and dermatology clinics from seven fulfilled. In the prospective follow-up, all psoriasis partic- centres in Italy. The HCs were non-blood relatives of ipants were reassessed every 6 months or according to enrolled patients or dermatological patients with other clinical practice. Patients were instructed to contact the http://rmdopen.bmj.com/ skin disease. Before enrolment all subjects were eval- rheumatologist prior to their scheduled assessment if uated by rheumatologists in order to exclude inflam- they developed inflammatory symptoms (eg, worsening matory arthritis and/or spondylitis, either current of joint pain, morning stiffness). In the prospective or in the past (ie, current or negative history of phase, only patients with psoriasis with a follow-up of at arthritis, dactylitis, enthesitis or inflammatory back least 3 months were included for final analysis. In order pain) (box 1). Patients with psoriasis were divided in to increase the validity and reliability of the results, the psoriasis cases with arthralgia (PsOAr) and without participants satisfied prerequisites: (1) expertise in early arthralgia (PsO). The PsOAr was defined as recent PsA and in combined dermatological-rheumatological on September 29, 2021 by guest. Protected copyright. onset (≤12 months) of non-inflammatory joint and/or assessment; (2) availability of a high-level US machine entheseal pain, without current or past inflammatory including high-level US probes (>14 MHz); (3) reliability signs/symptoms, and with Classification Criteria for exercise on US static images with a kappa statistics value Psoriatic Arthritis (CASPAR) criteria for a diagnosis of >0.7 compared with ‘gold-standard’ scorers (AZ, AI) PsA not being fulfilled (box 1).14 Concomitant osteo- (table 1). arthritis and fibromyalgia were also excluded. Previous or current use of biological disease-modifying antirheu- Clinical assessment matic drugs (DMARDs) or small molecules, and the For each patient, we recorded demographic data, use, within 3 months
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