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Title of Program OVERVIEW OF PSORIATIC ARTHRITIS: CLINICAL CONSIDERATIONS FOR HEALTHCARE PROFESSIONALS JAMIE L. MCCONAHA, PHARMD, NCTTP, BCACP, CDE FACULTY DISCLOSURES I have no conflicts of interest to disclose. I do not intend to discuss non-FDA approved drugs or investigational use of any product/device. OBJECTIVES Describe the epidemiology and pathophysiology of PsA List the clinical features and manifestations of PsA that may aid in diagnosis and assessment of disease severity Describe screening tools for patients suspected of having PsA Discuss the importance of early detection of PsA and methods and tests used to diagnose the disease Review treatment and management strategies for patients with PsA PSORIATIC ARTHRITIS (PSA) WHAT IS PSORIATIC ARTHRITIS? Chronic, progressive, inflammatory arthritis Considered a type of spondyloarthropathy Swelling, stiffness, and pain in and around the joints, as well as overall fatigue Early recognition, diagnosis and treatment is crucial to prevent permanent damage INCIDENCE Prevalence in patients with psoriasis ranges between 6-42% Affects approximately 1% of the general population Estimates vary due to delayed or missed diagnoses Psoriatic arthritis. National Psoriasis Foundation. Available at:https://www.psoriasis.org/about-psoriatic-arthritis. Gelfand JM, et al. Epidemiology of psoriatic arthritis in the population of the United States. J Am Acad Dermatol. 2005. Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis. Drugs. 2014. EPIDEMIOLOGY Affects both men and women equally Usually occurs between 30-50 years, but can affect any age Relationship to psoriasis (skin): 85% of patients present with skin psoriasis first 10-37% have skin and joint disease simultaneously 6-18% have arthritis preceding psoriasis Liu JT, Yeh, HM, Liu SY, Chen KT. Psoriatic arthritis: epidemiology, diagnosis, and treatment. World J Orthop. 2014. Sep 18; 5(4):537-543. INCIDENCE AND PREVALENCE COMPARISON Country Incidence (1/100000) Prevalence China NA 0.02% Japan 0.1 0.001% Greece 3 0.17% France NA 0.19% Italy NA 0.42% Germany NA 0.29% Finland 23.1 NA United States 7.2 0.16% Mexico NA 0.02% Liu JT, Yeh, HM, Liu SY, Chen KT. Psoriatic arthritis: epidemiology, diagnosis, and treatment. World J Orthop. 2014. Sep 18; 5(4):537-543. PATHOPHYSIOLOGY Exact cause is unknown Complex interplay of genetic, environmental, and immunologic factors Genetics: strong familial association Environmental: may trigger immune response (viruses or physical trauma) Immunologic: activated T cells in joint tissue; TNF-α guides inflammatory process Husni ME. Psoriatic arthritis. Cleveland Clinic. Oct 2016. FitzGerald O, Winchester R. Psoriatic arthritis: from pathogenesis to therapy. Arthritis Res Ther. 2009; 11(1): 214. COMORBID CONDITIONS Psoriasis and psoriatic arthritis comorbidities: Cancer Cardiovascular disease Crohn’s Disease Depression Diabetes Metabolic syndrome Obesity Osteoporosis Uveitis Liver disease Treatment of the underlying condition (psoriasis/arthritis) often alleviates comorbid condition symptoms or reduces risk National Psoriasis Foundation. Comorbidities associated with psoriatic arthritis. https://www.psoriasis.org/about- psoriasis/related-conditions SIGNS AND SYMPTOMS Painful, swollen joints Stiffness Dactylitis (sausage-like swelling) Enthesitis (tendon or ligament pain) Nail and skin changes Fatigue SIGNS AND SYMPTOMS Back Involvement (40%) DIP involvement (39%) Nail psoriasis (67%) Dactylitis (48%) Enthesopathy (38%) http://www.discoverpsa.com/ SIGNS AND SYMPTOMS Many patients experience nonspecific musculoskeletal symptoms before diagnosis In a 2017 study by Eder et al, the following preclinical symptoms predicted the development of psoriatic arthritis: Arthralgia in women (hazard ratio [HR] 2.59, P=0.02) Heel pain (HR 4.18, P=0.02) High fatigue score (HR 2.36, P=0.007) High stiffness score (HR 2.03, P=0.045) Eder L, et al. The development of psoriatic arthritis in patients with psoriasis is preceded by a period of nonspecific musculoskeletal symptoms: a prospective cohort study. Arthritis Rheumatol. 2017; Mar. 69(3):622-629. PSORIATIC ARTHRITIS VS RHEUMATOID ARTHRITIS PsA RA Sex Distribution Males = Females Females > Males Symptoms Swelling, pain and Swelling, pain and stiffness stiffness Joint Involvement Ray pattern distribution Symmetrical distribution Extra-Articular Rheumatoid nodules Rheumatoid nodules Manifestations absent present Nail involvement ~20 nail pits Absent Blood Tests Seronegative Seropositive Gladman DD, et al. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005; 64(Suppl II). DIAGNOSIS Imaging Laboratory X-Rays: Rheumatoid Factor (RF): Pinpoint changes in the Usually absent in psoriatic affected joints arthritis Synovial Fluid: CT or MRI: Aspiration and examination of Identify changes in tendons or synovial fluid of an affected ligaments or otherwise more joint revealing uric acid crystals detailed examination of joints to rule out gout There is no single test to confirm a psoriatic arthritis diagnosis. CLASSIFICATION OF PSORIATIC ARTHRITIS Moll and Wright Classification Criteria for PsA Proposed in 1973 Oldest and best-known Simple to use diagnostic criteria Inflammatory arthritis (peripheral arthritis and/or sacroiliitis or spondylitis) Presence of psoriasis Absence of serological tests for rheumatoid factor Classifies patients with PsA into 5 subgroups Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005; 64(Suppl II). MOLL AND WRIGHT CLASSIFICATION SYSTEM 5 subgroups: Polyarticular, symmetric arthritis Oligoarticular and asymmetric Distal interphalangeal joint (DIP) predominant Spondylitis predominant Arthritis mutilans https://psoriatic-arthritis.com/diagnostic-criteria/ CLASSIFICATION OF PSORIATIC ARTHRITIS (CASPAR) Patient must have inflammatory articular disease (joint, spine, or entheseal) and >3 points Category Description Points Current psoriasis Current psoriasis: skin or plaque 2 (current) or disease confirmed by a Personal or family history of rheumatologist or dermatologist or psoriasis Family history: in 1st or 2nd degree relative 1 (history) Nail psoriasis Onycholysis, pitting, or 1 hyperkeratosis Negative rheumatoid factor 1 Dactylitis (current or history) Swelling of entire digit 1 Radiographic evidence of Found on x-rays of hand or foot 1 periarticular new bone (excludes osteophytes) formation https://www.hopkinsarthritis.org/arthritis-info/psoriatic-arthritis/diagnosis/ CASE STUDY: CLASSIFICATION CASE STUDY: CLASSIFICATION Kim is a 38 year old white woman you have treated in your practice for five years. Kim has a 3-year history of mild scalp psoriasis but is an otherwise healthy mother of two who works as an attorney. At the end of her most recent annual physical, she mentions she has been experiencing intermittent low back and right sided hip pain with difficulty bending over when picking up her kids or cleaning around the house. Kim notes that the pain began about six months ago without injury and comes and goes without any obvious trigger, although the pain seems to be worse when she gets up in the morning. Kim states that she thinks it is normal “wear and tear” from years of running and standing long periods in court, but would like to know if there are any at- home or OTC remedies she can take when the pain begins. She denies fever, swelling and pain in other joints or worsening of her scalp psoriasis. Clinical case: psoriatic arthritis. American College of Rheumatology. CASE STUDY: CLASSIFICATION Moll and Wright CASPAR Psoriasis Inflammatory articular disease (-) RF Current psoriasis (2) Inflammatory arthritis Nail psoriasis (0) Meets 1 of 5 subgroup types Polyarticular, symmetric arthritis Negative rheumatoid factor (1) Oligoarticular and asymmetric Dactylitis (0) Distal interphalangeal joint predominant (DIP) Radiographic evidence (0) Spondylitis predominant Arthritis mutilans ASSESSMENT OF PSA ASSESSMENT OF PSA Requires consideration of all major disease domains Peripheral arthritis Axial disease Enthesitis Dactylitis Psoriasis Nail disease Impact of disease on quality of life Structural damage Relevant comorbidities PSORIASIS ASSESSMENT (SKIN) General Principles Assessment Methods Body surface area (BSA) involvement Psoriasis Area and Severity Index Palm size = 1% BSA (PASI) Rule of Tens Physician Global Assessment (PGA) Handprint = 1% BSA ACR JOINT COUNT American College of Rheumatology (ACR) uses joint counts in assessment of rheumatoid arthritis Several types of joint count methods: 66/68 Joint Count Ritchie Articular Index Thompson-Kirwan Index 44-Swollen Joint Count 28-Joint Count ACR JOINT COUNT Stekhoven D, et al. Hypothesis-free analysis from a large psoriatic arthritis cohort support merger to consolidated peripheral arthritis definition without subtyping. Clinical Rheumatology. 2017; 36(9):2035-2043. JOINT COUNTS IN PSA ACR Joint Counts originally developed for RA Limitations to use for patients with PsA Modified ACR Count developed for PsA Reproducibility verified by studies Not tested specifically for sensitivity to change over time Miedany Y. Recent developments in management of psoriatic arthritis. Current Rheumatology Reviews. 2005; 1:9-19. DISEASE ACTIVITY INDEX FOR PSORIATIC ARTHRITIS (DAPSA) Originally developed for reactive arthritis Validated
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