Psoriatic ArthritisClinical Features and

Epidemiology

Dafna D. Gladman MD, FRCPC

Director, Psoriatic Arthritis Program,

University Health Network

Centre for Prognosis Studies in the Rheumatic Diseases

Toronto Western Hospital

Toronto Western Hospital

Psoriatic Arthritis

An inflammatory arthritis Associated with psoriasis Usually seronegative for

rheumatoid factor

Definition

Psoriatic Arthritis Clinical Patterns

Distal predominant (Distal inter-phalangeal joints of fingers and toes).

Oligo-articular (<5 joints) often in an asymmetric distribution.

Poly-articular (5 joints), rheumatoid arthritis-like.

Spinal Involvement. ‘Arthritis Mutilans’.

Moll & Wright, Seminars Arthritis Rheum 1973;32:181

Psoriatic Arthritis Patterns

Oligoarthritis Distal Arthritis

Psoriatic Arthritis Patterns

Polyarticular Pattern

Psoriatic Arthritis Patterns

Arthritis Mutilans

Psoriatic Arthritis Patterns

Arthritis Mutilans Telescoping

Psoriatic Spondyloarthropathy

Psoriatic Spondyloarthropathy

Dactylitis in PsA

Edema in PsA

Heel Lesions in PsA

Achilles Tendon Insertion ErosionPlantar Spur

Achilles Tendon Spur

Other Radiological Features of PsA

Tuft resorption

Periostitis

Hidden Psoriasis

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

Psoriatic arthritis: A distinct entity ? Dutch study found no association

between psoriasis and polyarthritis. No association between HLA antigens and

seronegative polyarthritis with psoriasis. No radiological features in seronegative

polyarthritis with psoriasis.– van Romunde LKJ, et al.Rheumatology

International 1984;4:55-73.

? fortuitous association – Cats A. Cutis 1990;46:323-329.

Psoriatic arthritis

Prevalence of psoriasis in the general population: 0.1-2.8%.

Prevalence of psoriasis in arthritis patients: 2.6-7.0%.

Prevalence of arthritis in the general population: 2-3%.

Prevalence of arthritis in psoriatic patients: 6-42%.

Epidemiological Evidence

Psoriatic arthritis: A distinct entity !

Previous population studies. Epidemiological studies. Dutch study found DIP joints disease

more common in patients with seronegative polyarthritis and psoriasis.

A distinct form of arthritis, with different patterns, associated with psoriasis.

A comparison between Psoriatic Arthritis and Rheumatoid Arthritis

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 2=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.

Psoriatic Arthritis

Classified with the Seronegative Spondyloarthropathies:– It is usually seronegative for

rheumatoid factor.

– It may be associated with a spondyloarthropathy.

– It is associated with HLA-B27.

Classification

Differentiating PsA from other SpA

Feature PsA AS ReA IBDM:F 1:1 9:1 8:1 1:1

Age onset 35-45 20 20 AnyPeripheral 96% 25% 90% Common

Distribution Any AxialLower limbs

Lowerlimbs

Lowerlimbs

Dactylitis 35% Uncommon Common Uncommon

Enthesitis Common Common Common Unommon

Sacroiliitis 40% 100% 80% 20%HLA-B*27 ~50% >90% 80% 40%

Psoriatic Arthritis Prevalence

Exact prevalence unknown. Estimated figures vary from 0.1% in

Rochester Minnesota to 1.4% in the Faroe Islands.

Recent Survey by National Psoriasis Foundation suggests prevalence of 1.4% of general population in the US.

Recent study from Toronto suggests a prevalence of 2.5%.

Psoriatic ArthritisPrevalence 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

Psoriatic arthritis

PsA is much more serious than previously recognized.

20% of patients with PsA develop clinical deformities and damage, resulting in functional disability.

5 deformities were detected in 55% of patients after 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 Psoriatic Arthritis 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.

Prognostic 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 transition between damage states.

Clinical Indicators of Progression

Gladman DD et al. J Rheumatology 1995;22:675.

Prognostic Indicators in PsA

Relative Risk Variable 1 to 2 2 to 3 3 to 4 2 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 Indicatorsof Clinical Progression*

Gladman DD et al. J Rheumatology 1995;22:675.

*Based on clinical features at presentation

Prognostic 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.

Prognostic Indicators in Psoriatic Arthritis

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 Psoriatic arthritis

PsA patients 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 population.

Risk of death is related to previously active 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 Psoriatic Arthritis

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)

Su

rviv

al P

rob

abili

ty

0 5 10 15 20

0.5

0.6

0.7

0.8

0.9

1.0

All patients

Mortality in Psoriatic Arthritis

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 Psoriatic Arthritis

Summary Remission occurred in 17.6% of our PsA

patients. Male gender and less active and severe

arthritis at presentation to Clinic were associated with remission.

Only 6 (8.7%) of the PsA patients sustained “true remission”,

35 (52%) had subsequent flares.

Gladman DD et al. J Rheumatol 2001;28:1045-8.

Psoriatic Arthritis Prognostic Factors

Progression of Damage: High effusion count at presentation High joint count at each visit High medication level at presentation Low ESR is “protective”

Death: Elevated ESR High prior medication level Radiological Damage

Remission Male Gender Low joint count at presentation

Psoriatic Arthritis

Not just skin and joints! An inflammatory arthritis associated with

psoriasis. More common than previously thought. About one fifth of the patients have a

severe debilitating disease, although some patients achieve remission.

Earlier studies suggesting that PsA was a mild disease included patients with early disease.

Psoriatic Arthritis Program

Cathy Schentag MsC Research AssociateCPSRD, TWH

Richard Cook, PhDBiostatisticianWaterloo, Ontario

Vern Farewell, PhDBiostatisticianMRC, Cambridge, UK

Dr. Dafna Gladman - Director

Janice Husted, PhD EpidemiologistWaterloo, Ontario

Nicole Anderson, BScResearch AssistantCPSRD, TWH

Fawnda Pellett, BSCResearch TechnologistCPSRD, TWH

Research Fellows, Rheumatology Residents, Students,Patients

Psoriatic Arthritis Program - Support Ontario Ministry of Health Medical Research Council / Canadian

Institutes of Health Research The Arthritis Society Centre for Prognosis Studies in The

Rheumatic Diseases University of Toronto / University Health

Network Arthritis Centre of Excellence Krembil Foundation PsA Patients