PsoriaticArthritisLAURIE HUGHELL, MSPA-C, MPHIOWA ARTHRITIS & OSTEOPOROSIS CENTER

Seronegative Spondyloarthropathies

uPsoriatic Arthritis

u Ankylosing Spondylitis

u Reactive Arthritis

u Enteropathic ArthritisuCrohn’s DiseaseuUlcerative Colitis

SeronegativeSpondyloarthropathiesu Propensity for axial arthritis

u Sacroiliitis and spondylitis

u Peripheral arthritis

u Enthesitis – inflammation of tendons, ligaments or fascial insertions

u Familial pattern with HLA-B27 associationu Positive result is a 20 fold increased risk of developing

a spondyloarthropathy

Psoriatic Arthritis (PsA)

Psoriatic Arthritis (PsA)u Inflammatory arthritis associated with psoriasis

u Nail changes can be present

u Originally considered a variant of rheumatoid arthritis

u Seronegativity of rheumatoid factor (RF) was an original requirement but no longer

u 10% of patients with psoriasis have a + RF

Pathogenesis of PsAu Genetic factors:

u 40% of patients with psoriasis or PsA have a family history of these disorders

u PsA is 55 times more likely to occur among first-degree relatives

u Paternal transmission bias for psoriasis and PsA has been found

Pathogenesis of PsA

u Environmental factors:u Infections – association with streptococcal infection has been

proposedu One study showed improvement in psoriasis after having

tonsillectomyu Trauma

u Koebner phenomenon – psoriasis forms at sites of traumau Emotional stress

u Obesity – risk factor for psoriasis

Epidemiology of PsA

u Affects men and women equally

u Age of onset usually 30-55 years

u 1-2 per 1000 in the general population

PsA & Psoriasisu PsA prevalence estimates are 4-30% of patients with psoriasis

u Skin involvement precedes joint involvement in the majority of patients

u Study showed psoriasis patients more likely to develop PsA:u Higher skin burdenu nail lesionsu scalp and intergluteal lesions

u Weak relationship between the severity of skin disease and arthritic involvement

Differential Diagnosis

u Rheumatoid Arthritisu Reactive Arthritisu Arthritis of inflammatory bowel disease (enteropathic

arthritis)u Ankylosing Spondylitisu Goutu Osteoarthritis

Psoriasis

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Psoriasis

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PsA: Presentation

PsA: Cardinal Findings

} Spinal stiffness, pain or limited range of motion

} Asymmetric peripheral joint stiffness, pain and swelling

} Dactylitis◦ “sausage”-like swelling of the fingers or toes◦ Uniform swelling of the soft tissues between the MCP and interphalangeal

joints such that there is diffuse swelling of the digits◦ Occur in ½ of PsA patients and are associated with an increased risk of

progressive radiographic damage

Dactylitis

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PsA: Cardinal Findings

} Enthesitis

} Inflammation of the tendons, ligaments and synovium into bone

} Achilles tendon, plantar fascia & the pelvic bones are most common areas

} Tenosynovitis

} May involve flexor tendons of the hands

Achilles tendonitis

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PsA: Cardinal Findings

} Pitting Edema} Swelling of the hands or feet

} Often asymmetrical and occasionally precedes joint involvement

} Ocular inflammation} Conjunctivitis present in 20% of PsA patients} Uveitis in 7% of PsA patients

PsA: Pitting Edema

PsA: Nail Changes

u Nail lesions occur in 80-90% of patients compared vs. 46% of those with psoriasis

u Pits – depressions in the nail plateu Usually occur in large numbers and involve several nails

u Onycholysisu Separation of the nail from its bed

u Can be difficult to distinguish from Onychomycosis (fungal infection) –should send nail scrapings for fungal culture

u Severity of nail involvement may correlate with the severity of both skin and joint diseaseu Most common in patients with DIP arthritis

Nail pitting

Onycholysis

Onycholysis

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PsA: CASPAR Classification Criteriau Skin psoriasis

u Present – 2 points

u Previous history – 1 point

u Family history – 1 point

u Nail lesions – 1 point

u Dactylitis – 1 point

u Negative rheumatoid factor – 1 point

u X-rays changes – 1 point

3+ points makes the diagnosis of PsA

PsA: Comorbidities

u Risk of cardiovascular disease is increased in patients with PsA, especially those not on treatment

u Psoriasis associated with:u Metabolic syndrome

u Hypertension

u Diabetes

u Atherosclerosis

u Malignancy

u Hepatic and pulmonary disorders

u Psychiatric disease (depression & Anxiety)

PsA: Diagnostic Testing

PsA: Laboratory

u Lab findings in PsA are nonspecific

u Rheumatoid factor – in 2-10% of patients with PsA

u ANA – found at low titer (less than 1:40) in ~50% of patients

u Anti-cyclic citrullinated peptide (Anti-CCP) found in 8-16% of patients with PsA

u HLA-B27 –genetic marker that may indicate higher risk of developing PsA

u Acute Phase reactants elevated in 40% of patientsu C-reactive protein and Erythrocyte sedimentation rate

PsA: Imaging

u Unique in inflammatory arthritisu erosive changes & new bone formation occur in the same joint or same

digit

u “pencil and cup” deformity results from erosive changes and formation of hypertrophic bone in the phalanges

u Presence of early radiologic changes in course of PsA suggest aggressive disease

u MRI can be used to look for sacroiliitis u Correlates with decreased spinal mobility and longer duration of

disease

Arthritis Mutilans

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PsA: Treatment Options

PsA Treatment Options

u Physical Therapyu Occupational Therapyu Weight reductionu Exerciseu Patient Educationu Medications

u DMARDS

u Biologics

PsA Treatment - NSAIDs

} NSAIDs } May be helpful for inflammatory back pain & peripheral joint pain

} OTC vs. Prescription} Ibuprofen, naproxen sodium, etodolac, nabumetone, meloxicam, etc.

} Cox 2 Inhibitor – celecoxib may be better tolerated from GI standpoint

} Side effects:

} Renal insufficiency, GI ulceration, cardiovascular disease

PsA Treatment - Corticosteroids} Corticosteroids◦ Use of oral, low-dose prednisone should be reserved

for severe, peripheral arthritis

◦ Use caution when prescribing high dose steroids◦ Withdrawal of oral steroids may cause worsening of

psoriasis

◦ Corticosteroid joint injections can reduce swelling/pain of single joint◦ Avoid injecting directly into a psoriasis plaque

PsA Treatment - DMARDs

u Disease modifying anti-rheumatic drugs (DMARDs)

u May be used for peripheral arthritis

u May continue NSAIDs as “bridging therapy” until DMARD becomes effective

u Commonly used DMARDs

u Methotrexate

u Leflunomide

u Sulfasalazineu Cyclosporineu Azathioprine

PsA: DMARDsu METHOTREXATE

u 2.5 mg tablets

u 2-10 tablets (5-25 mg) once weekly

u 25 mg/mlu 0.5 – 1.0 cc once weekly

u Side effects: Hepatoxicity, pancytopenia, oral ulcers, GI upset, nausea

u Gold standard treatment

u Patients take folic acid(800-2,000 mcg) daily

u LEFLUNOMIDEu Dosing 10-20 mg once daily

u Side effects: Hepatoxicity, pancytopenia, GI upset, nausea

u Loading dose is 100 mg daily x 5 days

u Can cause vomiting and diarrhea

Otezla (Apremilast)

u 30 mg twice dailyu Starter titration pack

u Has not been shown to stop radiographic changes of erosionu Excellent safety profile so good for those with comorbiditiesu Potential side effects: Unexplained weight loss, depression

Biologics: TNF Inhibitors

TNF Inhibitors:} Have shown excellent

efficacy in treating skin disease as well as joint disease and preventing x-ray erosions

} FDA Black Box Warnings:} Opportunistic

infections including tuberculosis, histoplasmosis, etc.

} Malignancy risk is slightly increased for lung cancer, skin cancer, lymphoma

Biologics: TNF Inhibitors

u Enbrel (etanercept)u 50 mg SC once weekly

u Cimzia (certolizumab)u 400 mg SC once monthly

u Simponi (golimumab)u 50 mg SC monthly

u Humira (adalimumab)u 40 mg SC every other week

u Remicade (infliximab)

u 5 mg/kg at weeks 0, 2 and 8 weeks then 5 mg/kg every 8 weeks

u Biosimilar TNF Inhibitors for Infliximab:u Inflectrau Renflexis

Other Biologicsu Stelara (ustekinumab)

u Human interleukin 12 and 23 antagonist

u Initial is week 0 and 4 thenu Injectable q 3 months

u Abatacept (Orencia)u T-cell modulatoru FDA approved for PsA in

2017u IV or Injectable q month

u Cosentyx (secukinumab)u Human interleukin-17A

antagonist u Injectable q monthu Titration dose at weeks 0,

1, 2, 3 & 4

u Taltz (ixekizumab)u Human Interleukin-17

antagonistu Injectable q month

Oral Biologic

u Tofacitinib (Xeljanz, Xeljanz XR)

u Oral inhibitor or Janus Kinase (JAK)u FDA approved for PsA in patients with inadequate

response or intolerance to Methotrexate

PsA: Prognosisu Risk factors for progressive joint damage/ poor prognosis:

u Increased numbers of actively inflamed joints

u Elevated CRP or ESR (sed rate)

u Failure of previous medication trials

u Presence of joint damage (clinically or radiographically)

u Loss of function (by Health Assessment Questionnaire)

u Diminished quality of life

Health Assessment Questionnaire