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psoriatic arthritis

Psoriatic arthritis develops in <30% of patients with psoriasis. Classification: 5 clinical groups: 1) predominant distal interphalangeal joint (DIP) arthritis in hands & feet associated with nail involvement 2) arthritis mutilans, severely destructive athritis involving the hands with shortening of the digits [2] 3) symmetrical polyarthritis involving both large & small joints, resembling seronegative rheumatoid arthritis 4) asymmetrical oligoarthritis involving large joints primarily in the lower extremities 5) psoriatic spondylitis (HLA-B27 positive 50-75%) Epidemiology: - 15-20% of patients with psoriasis [2]; < 30% [14] Pathology: - inflammation involves the tenosynovial junction causing edema beyond the affected joints (sausage digits) - erosions can be much more destructive than osteoarthritis - HIV1 infection associated with increased severity of psoriatic arthritis [2] Genetics: - mutations or gene deletions of junB [4] - polymorphisms in TNF-alpha are a cause of susceptibility psoriatic arthritis - polymorphisms in lymphotoxin-alpha (LTA) are a cause of susceptibility psoriatic arthritis - other implicated genes: MICA Clinical manifestations: 1) a prodromal phase of nonspecific musculoskeletal symptoms with visits to primary care or emergency department [20] 3) cutaneous psoriasis a) generally precedes arthritis [2] - arthritis may precede cutaneous psoriasis by up to 10 years [2] b) strong confirmatory sign, but may not be present c) plaque psoriasis on extensor surfaces, scalp, posterior auricular region, umbilicus, gluteal fold d) pustular psoriasis on palms & soles e) nail pitting, onycholysis [2] 3) asymmetric oligoarthritis or symmetric polyarthritis - asymmetric lower extremity oligoarthritis - symmetric arthritis of DIP joints in hands & feet - DIP involvement associated with nail involvement [2] - arthritis mutilans - symmetric arthritis of PIP joints, MCP joints & MTP joints - may be diffuse dactylitis (sausage digits) - dactylitis predicts a more severe disease phenotype in early disease [22] - predicts more swollen joints, higher serum CRP, synovitis & bone erosions [22] 4) tendonitis, tenosynovitis & enthesitis (heel pain) 5) axial involvement a) spondylitis may occur at any level - may skip regions, may be asymmetric [2] b) sacroiliitis is a strong confirmatory sign - may not be present c) may start in cervical spine 6) extent of skin disease does NOT correlate with severity of arthritis 7) explosive onset or severe flare of arthritis suggests HIV1 infection 8) conjunctivitis more common than anterior uveitis [2] - 80% of uveitis is anterior (iritis), 20% posterior 9) no relationship between extent of skin & joint disease [2] * see classification for different patterns Diagnostic criteria: - arthritis: asymmetric oligoarthritis or symmetric polyarthritis - plus >= 3 of the following - psoriasis - psoriatic nail dystrophy - rheumatoid factor negative - dactylitis - radiographic evidence of juxta-articular new bone formation (joints of hands &/or foot) [2] Laboratory: 1) erythrocyte sedimentation rate (ESR) is increased 2) rheumatoid factor (RF) a) generally negative or low titer b) positive RF with high titer suggest coexistant rheumatoid arthritis 3) association with HLA-B27; however, HLA-B27 is negative in most patients 4) serum uric acid may be elevated because of rapid turnover of skin cells 5) HIV serology [2] Radiology: 1) X-ray of hands a) destructive arthritis with erosions & osteophytes b) arthritis multilans - distal interphalageal joint involvement c) lysis of terminal phalanges d) marked osteolysis & ankylosis e) new bone formation at proximal head of distal phalanx - 'pencil in a cup' appearance 2) X-ray of spine, sacrum, ilium a) bone spurs (osteophytes) b) syndesmophytes c) sacroiliitis Differential diagnosis: - rheumatoid arthritis - ankylosing spondylitis - reactive arthritis - enteropathic arthritis - gout, pseudogout - inflammatory erosive osteoarthritis - explosive onset or severe flare of psoriatic arthritis suggests comorbid HIV1 infection [2] Complications: - increased risk of fracture [2] - prevalence of osteopenia & osteoporosis similar to that of the general population [24] - hyperuricemia & gout are comorbidities associated with psoriasis & psoriatic arthritis [2] - infectious arthritis is less common than gout [2] - increased risk of cardiovascular disease [9] - increased risk for cardiovasacular mortality (RR=1.2) [23] - increased risk of respiratory mortality (RR=3.4) & infection (RR=2.4) [23] - no increased risk of overall mortality [23] Management: 1) ibuprofen, indomethacin or other NSAID a) may be useful for mild forms of psoriatic arthritis b) does not alter course of disease 2) glucocorticoid injections for limited arthritis 3) DMARDS useful for treating arthritis & enthesitis a) methotrexate, start with 7.5 mg PO QD (hepatotoxic, avoid in alcoholics) [26] b) auranofin, start with 3 mg PO QD c) hydroxychloroquine unlikely to benefit psoriatic arthritis & may exacerbate psoriasis [25] d) azathioprine 4) TNF-alpha inhibitor for methotrexate-resistant disease a) etanercept b) infliximib [2] c) adalimumab [5] d) certolizumab [2] e) golimumab [2] f) TNF-alpha inhibitor + methotrexate [21] 5) brodalumab (Siliq) or secukinumab (IL17RA inhibitors) [2,8] - secukinumab (Cosentyx) may be of benefit [17] 6) ustekinumab (IL12 & IL23 inhibitor) [2] - not recommended (NICE) 6) tofacitinib (Xeljanz) FDA approved [2] a) symptomatic benefit b) effect on radiologic progression unclear c) may be of benefit in patients with inadequate response to TNF-alpha inhibitor [16] 8) guselkumab (Tremfya) 9) NSAIDs, antimalarials & withdrawal from glucocorticoids may aggravate psoriasis [2] 10) tight control of psoriatic arthritis with DMARDs +/- TNF-alpha inhibitor more effective than standard care but with more serious adverse effects & expense [12] 11) weight reduction & smoking cessation may reduce disease activity

Interactions

disease interactions

Related

sacroiliitis

Specific

arthritis mutilans

General

chronic inflammation psoriasis spondyloarthropathy (HLA B27-associated arthritis, seronegative spondyloarthropathy)

References

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  3. Weiner S, In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. Zenz R et al. Psoriasis-like skin disease and arthritis caused by inducible epidermal deletion of Jun proteins. Nature 2005 Sep 15; 437:369-75. PMID: 16163348
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  12. Rudwaleit M, Taylor WJ. Classification criteria for psoriatic arthritis and ankylosing spondylitis/axial spondyloarthritis. Best Pract Res Clin Rheumatol. 2010 Oct;24(5):589-604. PMID: 21035082
  13. Coates LC et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): A UK multicentre, open-label, randomised controlled trial. Lancet 2015 Sep 30; PMID: 26433318
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  15. Walsh N. FDA Panel Says Yes to Tofacitinib for PsA. Clear efficacy for symptoms, but radiographic progression benefit remains unclear. MedPage Today, August 03, 2017 https://www.medpagetoday.com/Rheumatology/Arthritis/67064
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  17. Kuznar W PsA Structural Damage Inhibited with Secukinumab - Loading dose appears to improve outcomes, researchers say. MedPage Today. Nov 9, 2017 https://www.medpagetoday.com/meetingcoverage/acr/69156 - Mease PJ et al Subcutaneous Secukinumab Inhibits Radiographic Progression in Psoriatic Arthritis: Primary Results from a Large Randomized, Controlled, Double-Blind Phase 3 Study American College of Rheumatology (ACR) 2017; Abstract 17L. - Janeczko LL Secukinumab Improves Active Psoriatic Arthritis. Medscape - Apr 10, 2018. https://www.medscape.com/viewarticle/895030
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  21. Zoler ML TNF Inhibitor Plus Methotrexate Surpassed Monotherapy in PsA Medscape - Jun 10, 2020. https://www.medscape.com/viewarticle/932074
  22. Dubash S, Alabas OA, Xabier Michelena X et al Dactylitis is an indicator of a more severe phenotype independently associated with greater SJC, CRP, ultrasound synovitis and erosive damage in DMARD-naive early psoriatic arthritis. Annals of Rheumatic Diseases. 2021. Dec 10 PMID: 34893470 https://ard.bmj.com/content/early/2021/12/09/annrheumdis-2021-220964
  23. Harris S Mortality in Ankylosing Spondylitis and Psoriatic Arthritis. AS alone linked with greater all-cause mortality; CV deaths elevated with both diseases. MedPage Today April 15, 2022 https://www.medpagetoday.com/reading-room/acrr/psoriaticarthritis/98224 - Chaudhary H, Bohra N, Syed K et al All-Cause and Cause-Specific Mortality in Psoriatic Arthritis and Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken). 2021 Nov 17 PMID: 34788902 https://onlinelibrary.wiley.com/doi/10.1002/acr.24820
  24. Harris S Osteopenia, Osteoporosis Rates Similar Between PsA and General Populations. MedPage Today October 14, 2022 https://www.medpagetoday.com/reading-room/acrr/psoriaticarthritis/101219 - Kwok TSH, Sutton M, Yang Ye J et al Prevalence and Factors Associated With Osteoporosis and Bone Mineral Density Testing in Psoriatic Arthritis. Arthritis Care & Research. 2020. Dec 16 PMID: 33326187 https://onlinelibrary.wiley.com/doi/abs/10.1002/acr.24538
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