Post on 16-Jul-2015
Psoria'c Arthri's
♦ An inflammatory arthri's ♦ Associated with psoriasis ♦ Usually seronega've for rheumatoid factor
Definition
Psoria'c Arthri's Clinical PaBerns
• Distal predominant (Distal inter-‐phalangeal joints of fingers and toes).
• Oligo-‐ar'cular (<5 joints) oKen in an asymmetric distribu'on.
• Poly-‐ar'cular (≥5 joints), rheumatoid arthri's-‐like. • Spinal Involvement. • ‘Arthri's Mu'lans’.
Moll & Wright, Seminars Arthritis Rheum 1973;32:181
PsA Reported Series*
Feature Roberts Kammer Gladman Torre-Alonso
Veale Jones
Year 1976 1979 1987 1991 1994 1994 Site Leeds Boston Toronto Spain Leeds Bath No. 168 100 220 180 100 100 M/F 67/101 45/55 104/116 99/81 59/52 43/57 Age 40 39 37 39 34 38 J < S ? 30 17 15 ? 18 SI NA 11 26 20 14 16 Asymm ? 53 21 45 43 26 Sym. 78 28 48 42 33 63 Distal 17 10 12 1 16 1 Back ? 2 3 7 4 6 Mutilans 5 7 16 5 2 4
*Includes only series with > 100 Patients
Psoria'c arthri's: A dis'nct en'ty ?
• Dutch study found no associa'on between psoriasis and polyarthri's.
• No associa'on between HLA an'gens and seronega've polyarthri's with psoriasis.
• No radiological features in seronega've polyarthri's with psoriasis. – van Romunde LKJ, et al.Rheumatology Interna'onal 1984;4:55-‐73.
• ? fortuitous associa'on – Cats A. Cu's 1990;46:323-‐329.
Psoria'c arthri's
• Prevalence of psoriasis in the general popula'on: 0.1-‐2.8%.
• Prevalence of psoriasis in arthri's pa'ents: 2.6-‐7.0%.
• Prevalence of arthri's in the general popula'on: 2-‐3%.
• Prevalence of arthri's in psoria'c pa'ents: 6-‐42%.
Epidemiological Evidence
Psoria'c arthri's: A dis'nct en'ty !
• Previous popula'on studies. • Epidemiological studies. • Dutch study found DIP joints disease more common in pa'ents with seronega've polyarthri's and psoriasis.
• A dis'nct form of arthri's, with different paBerns, associated with psoriasis.
A comparison between Psoria'c Arthri's and Rheumatoid Arthri's
Psoriatic Arthritis
Rheumatoid Arthritis
DIP Involvement Common Uncommon Symmetry Less Common Common Erythema of joint Common Uncommon Back Involvement Common Uncommon Skin Lesions Always Uncommon Nail Lesions Common Uncommon Dactylitis Common Uncommon Enthesitis Common Uncommon Rheumatoid nodules Never Common Rheumatoid Factor Uncommon Common HLA-B*27 40-50% 4-8%
Assessment of Tenderness
RA N=51
PsA N=50
Test P Value
Fibromyalgia (N) 29 12 Χ2=9.99 0.0016 Dolorimeter (Kg) Tender Points
4.77 6.60 t=5.23 <0.0001
Dolorimeter (Kg) Control Points
5.99 7.58 t=5.18 <0.0001
Dolorimeter (Kg) Active Joints
4.19 6.78 t=10.18 <0.0001
Psoriatic Arthritis Vs. Rheumatoid Arthritis
Buskila D, et al. J Rheumatol 1992;19:1115-9.
Psoria'c Arthri's
Classified with the Seronega've Spondyloarthropathies: – It is usually seronega've for rheumatoid factor.
– It may be associated with a spondyloarthropathy.
– It is associated with HLA-‐B27.
Classification
Differen'a'ng PsA from other SpA
Feature PsA AS ReA IBDM:F 1:1 9:1 8:1 1:1Age onset 35-45 20 20 AnyPeripheral 96% 25% 90% CommonDistribution Any Axial
Lower limbsLowerlimbs
Lowerlimbs
Dactylitis 35% Uncommon Common UncommonEnthesitis Common Common Common UnommonSacroiliitis 40% 100% 80% 20%HLA-B*27 ~50% >90% 80% 40%
Psoria'c Arthri's Prevalence
• Exact prevalence unknown. • Es'mated figures vary from 0.1% in Rochester Minnesota to 1.4% in the Faroe Islands.
• Recent Survey by Na'onal Psoriasis Founda'on suggests prevalence of 1.4% of general popula'on in the US.
• Recent study from Toronto suggests a prevalence of 2.5%.
Psoria'c Arthri's Prevalence among people with psoriasis
Author (yr) Centre No. Ps. Pts. % PsA Leczinsky (1948) Sweden 534 7
Vilanova (1951) Barcelona 214 25
Little (1975) Toronto 100 32
Scarpa (1984) Napoli 180 34
Stern (1985) Boston 1285 20
Zaneli (1992) Winston-Salem 459 17
Barisic-Drusko (1994) Osijek region 553 10
Salvarani (1995) Regio Emilia 205 36
Shbeeb (2000) Mayo Clinic 1056 6.25
Brockbank (2001) Toronto 126 31
NPF (2002) US 4.4 m 23
Psoria'c arthri's
♦ PsA is much more serious than previously recognized.
♦ 20% of pa'ents with PsA develop clinical deformi'es and damage, resul'ng in func'onal disability.
♦ ≥5 deformi'es were detected in 55% of pa'ents aKer 10 years of follow-‐up.
Gladman DD et al. Quart J Med 1987;62:127. Torre Alonso et al. Brit J Rheumatol 1991;30:245.
Clinical Outcome
The University of Toronto Psoria'c Arthri's Program
Duration <1 yr 1-5 yr 6-10 yr >10 yr Visit 1st Last 1st Last 1st Last 1st Last No Deformities 53% 51% 70% 50% 64% 35% 59% 22% < 5 deformities 28% 30% 20% 28% 17% 28% 26% 23% ≥5 deformities 19% 19% 10% 22% 19% 37% 15% 55%
Development of Deformities during follow-up
Gladman DD. Baillière’s Clinical Rheumatology1994;8:379.
Prognos'c Indicators in PsA
• Progression of damage defined by a change in damage state: – State 1 = 0 damaged joints – State 2 = 1-‐4 damaged joints – State 3 = 5-‐9 damaged joints – State 4 = ≥ 10 damaged joints
• Analysis by model for rate of transi'on between damage states.
Clinical Indicators of Progression
Gladman DD et al. J Rheumatology 1995;22:675.
Prognos'c Indicators in PsA
Relative Risk Variable 1 to 2 2 to 3 3 to 4 Χ2 P value > 4 Effusions 1.6 1.6 1.6 5.7 0.017 ESR < 15 0.61 0.61 - 6.68 0.01 Rx 1.78 1.78 1.78 7.8 0.005 Steroids 1.55 1.55 1.55 5.46 0.019
Multivariate model for Clinical Indicators of Clinical Progression*
Gladman DD et al. J Rheumatology 1995;22:675. *Based on clinical features at presentation
Prognos'c Indicators in PsA
Variable Relative Risk X2 P value 1 to 2 2 to 3 3 to 4 B22 0.19 0.19 0.19 0.002 B27 1.06 1.06 1.06 0.06 0.81 B27xDR7 2.47 2.47 2.47 5.39 0.02 B39 7.05 - - 16.40 <0.001 DR7 0.83 0.83 0.83 0.63 0.43 DQw3 1.63 0.63 1.63 6.86 <0.001 DQw3xDR7 0.54 0.54 0.54 3.09 0.08 > 4 Efusions 1.27 1.27 1.27 1.18 0.28 ESR < 15 0.83 0.83 0.83 1.91 0.17 High Past Rx 2.25 2.25 2.25 8.10 0.004 Steroids 1.58 1.58 1.58 6.73 0.0001
Multivariate Model for Clinical Damage
Gladman DD & Farewell VT. Arthritis Rheum 1995;38:845. Gladman DD, et al. J Rheumatol 1998;25:730.
Prognos'c Indicators in Psoria'c Arthri's
Factor Relative Damage Rate
95% CI P value
No. AJ 1.04 1.02,1.07 <0.001 ↓ FC 1.86 1.05,2.16 0.027 Male gender 0.65 0.47,0.92 0.013 Current Damage 3.95 2.52,6.20 <0.001 Initial ESR 0.61 0.42,0.90 0.013 Pre Clinic Rx 1.83 1.20,2.79 0.005
Final Multivariate Model for Time Varying Clinical Indicators
Gladman DD, Farewell VT. J Rheumatol 1999;26:2409
Outcome in Psoria'c arthri's
♦ PsA pa'ents are at an increased risk of death. ♦ Overall risk is 1.62 that of Ontario Residents.
• 1.66 for women, 1.59 for men
♦ Causes of Death are similar to general popula'on.
♠ Risk of death is related to previously ac've and severe disease.
Wong K, et al. Arthritis Rheum 1997;40:1868-7. Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Mortality Studies
Mortality in Psoria'c Arthri's
Primary Cause N (%) Circulatory system 17 (36.2) Myocardial Infarction 13 (27.6) Cerebrovascular accident 2 ( 4.3) CHF/arteriosclerosis 2 ( 4.3) Respiratory system 10 (21.3) Pneumonia 7 (14.9) COPD 3 ( 6.4) Digestive system (liver) 4 ( 8.5) Malignant neoplasms 8 (17.0) Injuries/poisoning 7 (14.9) Other 1 ( 2.1) Total known cause 47 ( 100)
Primary causes of death in 53 patients
Survival in Psoriatic Arthritis
Time Since Clinic Entry (Years)
Surv
ival
Pro
babi
lity
0 5 10 15 20
0.5
0.6
0.7
0.8
0.9
1.0
All patients
Mortality in Psoria'c Arthri's
Factor Relative risk
Confidence interval
P value
Prior Medication
1.83
0.93, 3.60
0.079
Radiological damage 3.88 1.32,11.35 0.014 ESR > 15 3.77 1.31,10.83 0.013 Nail changes 0.33 0.14, 0.76 0.009
Prognostic Factors: Final Multivariate Model
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Remission in Psoria'c Arthri's
Summary ♦ Remission occurred in 17.6% of our PsA pa'ents.
♦ Male gender and less ac've and severe arthri's at presenta'on to Clinic were associated with remission.
♦ Only 6 (8.7%) of the PsA pa'ents sustained “true remission”,
♦ 35 (52%) had subsequent flares.
Gladman DD et al. J Rheumatol 2001;28:1045-8.
Psoria'c Arthri's Prognos'c Factors
☛ Progression of Damage: ✦ High effusion count at presenta'on ✦ High joint count at each visit ✦ High medica'on level at presenta'on ✦ Low ESR is “protec've”
☛ Death: 8 Elevated ESR 8 High prior medica'on level 8 Radiological Damage
☛ Remission 8 Male Gender 8 Low joint count at presenta'on
Psoria'c Arthri's
Not just skin and joints! • An inflammatory arthri's associated with psoriasis.
• More common than previously thought. • About one fiKh of the pa'ents have a severe debilita'ng disease, although some pa'ents achieve remission.
• Earlier studies sugges'ng that PsA was a mild disease included pa'ents with early disease.