Psoriatic arthritis

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psoriatic arthritis, its types and management

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Psoriatic Arthritis:

Psoriatic Arthritis A complex and severe disabling disease Presented by: Dr. Kritika Pandey Government Medical College Amritsar

Interrelationship between diseases::

Interrelationship between diseases:

Psoriatic Arthritis::

Psoriatic Arthritis: Occurs in 4-6% up to 30% of patients with known psoriasis 60 – 70%: Skin psoriasis first 15-20%: Psoriatic arthritis first 16-21%: Skin and arthritis diagnosed at same time

Epidemiology::

Epidemiology: 4 th -5 th decade M=F Familial- HLA CW6, HLA B3, HLA B17, HLA B27, HLA DR3 Environmental factors: Increased immunoreactivity to streptococcal antigen. Increased prevalence among HIV & HCV. Koebner’s phenomenon- trauma- precipitating factor.

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Associations: Nail psoriasis (3/4 th vs 1/4 th in cutaneous psoriasis) Generalised pustular psoriasis Erythrodermic psoriasis. Eye involvement: uveitis , B/L chronic posterior. Aortic valve insufficiency: 4% after long standing cases.

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Moll and Wright criteria: An inflammatory arthritis. (peripheral arthritis/ sacroiliitis / spondylitis ) Presence of psoriasis. The (usual) absence of serological tests for rheumatoid arthritis.

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Psoriatic Arthritis A chronic and inflammatory arthritis in association with skin psoriasis Usually rheumatoid factor (RF) negative and ACCPA negative Distinct from RA Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies Characterized by synovitis , enthesitis , dactylitis , spondylitis , skin and nail psoriasis.

Clinical subgroups::

Clinical subgroups: Asymmetrical Oligoarthritis : Most common form (70%) Asymmetrical Similar to low grade gout Sausage like swelling of one or more digits ( dactylitis ) Flexor sheath synovitis Enthesitis

Definition of Enthesitis:

Definition of Enthesitis Entheses are the regions at which a tendon, ligament, or joint capsule attaches to bone Inflammation at the entheses is called enthesitis - is a hallmark feature of PsA Pathogenesis of enthesitis has not yet been defined Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients 1 McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58 –ii60 . 2 Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343. 3 Salvarani C. J Rheumatol. 1997;24:1106–1140.

Distal interphalangeal disease::

Distal interphalangeal disease: Classical form 16% Less common 30 pits with inflammatory arthritis of DIP joints considered diagnostic.

Symmetrical rheumatoid like::

Symmetrical rheumatoid like: 15% RA Factor- negative Less severe than RA PIP joint swollen, tender Swan neck deformity D/D from RA: Morning stiffness Fusiform swelling Wind swept deformity

Arthritis mutilans::

Arthritis mutilans : 5% Uncommon Severely deforming Fingers and toes May cause shortening or ankylosis

Axial arthritis::

Axial arthritis: 30% Spondylitis and/or sacroiliitis May be clinically silent Radiological examination: may affect 1/3 rd of cases of PsA

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Problems while distinguishing PsA from the other: Associations between psoriasis and RA. Some cases of RA will have coincidental psoriasis by chance alone. Psoriasis may precede, occur simultaneously, or follow the onset of arthritis. (In this situation, a family history of psoriasis may be an important clue.) Psoriasis may be present but may be hidden or may be misdiagnosed (by rheumatologists). The psoriasis may only be evident in the nails. In the true absence of psoriasis, a positive family history in a first degree relative may be of equal importance from a diagnostic point of view.

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Criteria for psoriatic arthritis ( PsA ) : Mandatory: Clinically apparent psoriasis (skin or nails) Pain and soft tissue swelling and/or limitation of motion in at least one joint observed by a physician for six weeks or longer Supportive: Pain and soft tissue swelling and/or limitation of motion in one or more other joints < 6 weeks. Presence of an inflammatory arthritis in a distal interphalangeal joint. Specific exclusions: Bouchard’s or Heberden’s nodes. Presence of ‘‘sausage’’ fingers or toes. An asymmetrical distribution of arthritis in the hands and feet. Absence of subcutaneous nodules. A negative test for rheumatoid factor in the serum. An inflammatory synovial fluid with a normal or increased C3 or C4 level and an absence of infection (including acid fast bacilli) and crystals of monosodium urate or pyrophosphate. A synovial biopsy showing hypertrophy of the synovial lining with a predominantly mononuclear cell infiltration and an absence of granuloma or tumour . Peripheral radiographs showing erosive arthritis of small joints with a relative lack of osteoporosis. Specific exclusion: erosive osteoarthritis Axial radiographs showing any of the following: sacroiliitis , syndesmophytes , paravertebral ossification Definite PsA : mandatory plus six supportive Probable PsA : mandatory plus four supportive Possible PsA : mandatory plus two supportive Bennett RM. Psoriatic arthritis. In: McCarty DJ, ed. Arthritis and RelatedConditions . Philadelphia: Lea & Febiger , 1979:645.

The Classification Criteria for Psoriatic Arthritis (CASPAR) Criteria :

The Classification Criteria for Psoriatic Arthritis (CASPAR) Criteria Inflammatory articular disease (joint, spine, or entheseal ) 2 points Evidence of current psoriasis, a personal history of psoriasis, or a family history of psoriasis (2 points) Typical psoriatic nail dystrophy including onycholysis , pitting, and hyperkeratosis observed on current physical examination (1 point) A negative test result for the presence of rheumatoid factor by any method except latex (1 point) Either current dactylitis , defined as swelling of an entire digit, or a history of dactylitis recorded by a rheumatologist (1 point) Radiographic evidence of juxta-articular new bone formation appearing as ill-defined ossification near joint margins (but excluding osteophyte formation) on plain radiographs of the hand or foot (1 point) CASPAR- diagnostic of PsA if ≥ 3 points Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis. 2005 Mar;64 Suppl 2:ii3-8.

Main Features and Their Frequency:

Main Features and Their Frequency 1 Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-1468 3 Gladman D et al. Ann Rheum Dis 2005; 64 :188–190; 4 Lawry M. Dermatol Ther 2007;20:60-67 5 Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6 Yamamoto 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 Skin Involvement 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

Comorbidities in PsA Patients:

Pso patients 6-8 Psychosocial burden Reactive depression Higher suicidal ideation Alcoholism  Metabolic Syndrome 3-5 Hyperlipidemia Hypertension Insulin resistent Diabetes Obesity  H igher risk of Cardiovascular disease (CVD) Ocular inflammation 1 (Iritis/Uveitis/ Episcleritis) IBD 2 Comorbidities in PsA Patients 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;6:383-392; 7 Naldi et al. Br J Dermatol 1992;127:212-217; 8 Mrowietz U et al. Arch Dermatol Res 2006;298(7): 309-319

Radiological findings::

Radiological findings: No or minimal juxta-articular osteoporosis : In RA, this is more prominent. Bony proliferation near joints and ligament and/or tendon insertion sites ( ie , enthesitis ): Enthesitis sites include the calcaneum , ischial tuberosities , femoral trochanters , ankle malleoli , anterior patella, ulnar olecranon , and condyles of the distal femur and proximal tibia. This is not a feature of RA.

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Bone erosion beginning in the periarticular region and progressing to more central areas Asymmetrical destruction of the DIP with bony ankylosis d/d: RA affects the metacarpal phalangeal joint and proximal interphalangeal joint [PIP] to a great extent.

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Resorption of terminal phalangeal tufts ( ie , the morning-star appearance ) Osteolysis of the bone with telescoping of the digits ( ie , the pencil-in-cup deformity ) extensive bony destruction around the interphalangeal joint of the second toe. There is associated widening of the joint space Pencil in cup deformity

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Periostitis along the shaft of a bone, often accompanied by soft tissue swelling Destruction/ resorption of the interphalangeal joint of the first toe, with periosteal reaction and bony proliferation at the distal phalangeal base: This finding is highly suggestive of PA. Arthritis mutilans

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Diffuse soft tissue swelling of an entire digit ( ie , sausage digit )

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Asymmetrical paravertebral ossification from the lower thoracic spine to the upper lumbar spine: This may be vertically directed and may not always be attached to the vertical margins, as in ankylosing spondylitis . Bony proliferation along anterior cervical spine and apophyseal joint-space narrowing Squaring of the lumbar vertebrae in L-spine: This occurs in ankylosing spondylitis but is uncommon in PA. Left, lateral radiograph of the dorsal spine of a 38-year-old man shows spondylitis in association with psoriasis. Note the squaring of the anterior vertebral bodies. Right, radiograph of the pelvis in the same patient shows sacroiliitis and erosive changes around both hip joints.

Characteristics of psoriatic arthritis::

Characteristics of psoriatic arthritis: *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

Patterns may Change Over Time and are Therefore not Useful for Classification:

Patterns may Change Over Time and are Therefore not Useful for Classification 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

Differential Diagnosis:

Differential Diagnosis Rheumatoid Arthritis Symmetric PIP, MCP, not distal Ulnar deviation, swan neck deformities Rheumatoid nodules Ankylosing Spondylitis Strong HLA B27 association Male predominance Axial skeletal involvement – sacroilitis Bamboo spine

Differential Diagnosis:

Differential Diagnosis Reactive Arthritis 1-4 weeks after an infection Infectious agents: Shigella Salmonella Yersinia Campylobacter Chlamydia Triad: urethritis , conjunctivitis, arthritis Keratoderma Blennorhagicum Inflammatory Bowel Disease Associated Crohn’s disease

Treatment General principles::

Treatment General principles: Goals: Relief of pain Reduction of inflammation Protection of articular surface Maintenance of function Control of systemic involvement Rest: splinting to reduce unwanted motion of inflamed parts. Exercise: directed at maintaining muscle strength and joint mobility without exacerbating joint inflammation.

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Disease Manifestation Initial Therapy Second Stage Third Stage Fourth Stage Peripheral arthritis NSAID Intra- articular steroids DMARDs: MTX, CsA , SSZ, LEF Biologicals Enthesitis NSAID Steroid injection Biologicals Dactylitis NSAID Steroid injection Biologicals Axial disease NSAIDS + physiotherapy Biologicals Skin and nail disease Topical PUVA/UVB Systemics : MTX, CsA , retinoids Biologicals Treatment: GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis)

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DMARDS MECHANISM OF ACTION DOSE MONITORING SIDE EFFECTS METHOTREXATE DHFRase , Adenosine -  anti inflammatory 7.5-25MG/WEEK CBC, LFT baseline and every 4 weeks for 3months, later every 8 weeks Nausea, fatigue, mouth ulcers, elevated LFTs SULPHASALAZINE Sulphonamide  sulphapyridine & ASA  immunomodulatory & antiinflammatory effect 2-3g/day CBC every 2-4 weeks, LFT 6 weekly for 3 months, then every 3 months Azoospermia , anaemia , neutropenia , elevated LFTs LEFLUNOMIDE Pyrimidine synthesis inhibitor  inh dihydroorate dehydrogenase  dec T Cells  antiinflammatory 100mg/d 3day Then 10-20mg/day CBC after 2 weeks, then after every 8 weeks GI intolerance, elevated LFTs, leukopenia , teratogenic CICLOSPORIN Macrolide antibiotic, Calcineurine inhibitor -  dec IL2 2.5-3mg/day S.Creatinine and BP evry 2 weeks till dose is stable, then monthly, CBC & LFT baseline and monthly till dose is stabilised then every 3 months, S.Lipid profile every 3 months Rise in BP, S. C reatinine >30%, hyperkalemia , S. lipid profile -  decrease dose/withhold

Biological therapies::

Biological therapies: Agent Action Dose Route Risk/side effect Infliximab Anti TNF α 5 mg @ 0, 2, 8 weeks and then 8 weekly Intravenous Infections Etanercept Anti TNF α 25 mg biweekly or 50 mg weekly Subcutaneous Infections Adalimumab Anti TNF α 40 mg once every 2 weeks Subcutaneous Infections Rituximab Anti CD 20 1000 mg @ 0, 2 weeks, can be repeated Intravenous Infusion reactions

Multiple choice questions::

Multiple choice questions : Skin psoriasis precedes PsA in: 60 – 70% 15-20% 25-40% 5-10% Most common form of PsA : Distal interphalangeal arthritis Asymmetrical oligoarthritis Arthritis mutilans Axial arthritis In PsA Low levels of RF and ACPA can be found in: 5-16% 40-45% 0 90-100% Which of the following is not a radiological finding of PsA : Morning star appearance Pencil in cup deformity Wind swept deformity Sacroiliitis Which of the following is a DMARD not used in PsA : HCQS Methotrexate Sulphasalazine Leflunomide RA is differentiated from PsA by: Symmetric PIP, MCP, not distal Ulnar deviation, swan neck deformities All of the above

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