Subclinical carotid atherosclerosis in patients with psoriatic arthritis

OBJECTIVE: To examine the prevalence of subclinical atherosclerosis in patients with psoriatic arthritis (PsA) compared with healthy controls, and to identify clinical and biologic markers for atherosclerotic disease in this patient population. METHODS: Subclinical atherosclerosis was defined as the average of intima-media thickness (IMT) measures in the common carotid artery, bifurcation, and internal carotid artery on both sides above the 95th percentile of healthy controls. IMT was measured using carotid ultrasonography in 82 consecutive PsA patients and 82 healthy controls matched on age, sex, and ethnicity. We also ascertained traditional and novel cardiovascular (CV) risk factors, Framingham risk score (FRS), disease severity, treatment, and inflammatory markers in all PsA patients. RESULTS: No PsA patients had clinically overt CV diseases. After adjusting for traditional CV risk factors, PsA patients had a higher prevalence of subclinical atherosclerosis. PsA patients with subclinical atherosclerosis had significantly increased sugar, total triglyceride levels, total cholesterol/high-density cholesterol, white cell count, and patients' global assessment score compared with those without subclinical atherosclerosis. Using logistic regression analysis, independent explanatory variables associated with subclinical atherosclerosis in PsA included increased sugar and total triglyceride levels. The FRS was similar in PsA patients with or without subclinical atherosclerosis. Twenty-six (35%) of 74 patients had subclinical atherosclerosis despite having a low CV risk. CONCLUSION: PsA is associated with subclinical atherosclerosis after adjusting for traditional CV risk factors. Independent explanatory variables associated with subclinical atherosclerosis in PsA included increased sugar and total triglyceride levels. Carotid IMT can identify PsA patients with subclinical atherosclerosis who may benefit from early intervention.     

Immunopathology of psoriasis and psoriatic arthritis

Psoriatic arthritis (PsA) is characterised by several unique clinical features that differentiate it from rheumatoid arthritis (RA). Attempts to identify immunopathological mechanisms, some shared with psoriasis, that underlie these differences from RA have been most challenging. Recent research studies, however, highlight novel findings in PsA at the molecular, cellular, and tissue levels that form the basis for a new understanding of this relatively common form of inflammatory arthritis. In particular, the availability of new, biological antitumour necrosis factor alpha therapies have allowed further insight into the immunopathology of psoriasis and PsA. This brief review focuses on immunohistological studies in psoriatic skin, PsA synovium, and bone to demonstrate how these data advance our knowledge of disease pathogenesis.     

Cardiovascular comorbidities in psoriasis and psoriatic arthritis: pathogenesis, consequences for patient management, and future research agenda: a report from the GRAPPA 2009 annual meeting

Psoriasis is often associated with other diseases, substantially adding to the patient's burden of disease. Recent epidemiologic studies have demonstrated an increased cardiovascular morbidity among patients with psoriasis and psoriatic arthritis (PsA), which contributes to their reduced life expectancy. At the meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) adjacent to the International Federation of Psoriasis Associations (IFPA) congress, members discussed the pathogenetic aspects of this association and resulting consequences for the management of patients with psoriasis and PsA. A future research agenda was considered.     

Summary of minutes of the GRAPPA meeting adjacent to the American Academy of Dermatology 67th Annual Meeting

At a half-day meeting adjacent to the 67th annual meeting of the American Academy of Dermatology (AAD) in San Francisco, USA, in 2009, dermatology members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) met to discuss recognition of psoriatic arthritis (PsA) in the dermatology clinic; multidisciplinary management of psoriasis patients; examples of physician tiering; comparative treatments for psoriasis and PsA; and biomarkers as predictors of response to treatment. Key results and minutes of the San Francisco meeting were presented at the 2009 GRAPPA annual meeting in Stockholm, Sweden, and are summarized here.     

Decreased heart rate variability in patients with psoriatic arthritis

The purpose of this study was to investigate autonomous regulation of the cardiac activity by means of the heart rate variability (HRV) assessment and possible influence of conventional cardiovascular risk factors and disease activity parameters on it in patients with psoriatic arthritis (PsA). In total, 38 patients with the reliable diagnosis of PsA without clinically manifest cardiovascular pathology, known rhythm or conduction disturbances, diabetes mellitus, and hypercholesterolemia were included. In the control group, 25 age- and sex-matched healthy persons comparable with PsA patients in cardiovascular risk profile were included. For the HRV analysis, we used 5-min-long ECG records obtained at rest. Time and frequency domain parameters of HRV were calculated. Patients with PsA had decreased HRV in comparison to healthy controls as reflected by decrease of the standard deviation of normal R-R intervals (65.1?±?66.8 vs. 83.2?±?43.3?ms, respectively, p?=?0.011), of the percentage of normal R-R intervals that differ by more than 50?ms (12.9?±?15.4 vs. 20.6?±?17.1?%, respectively, p?=?0.035), and of the total power (2,069.4?±?1,537.8 vs. 2,942.5?±?1,734.2?ms², respectively, p?=?0.006). A significant correlation of HRV parameters with disease duration and parameters of disease activity in PsA was found. Patients with PsA had impaired autonomous regulation of the cardiac activity, which is likely to be related to the presence of systemic inflammation and which could contribute to the increase of cardiovascular risk in this disease.     

不同亚型银屑病关节炎的临床特征和实验室指标

目的分析不同亚型银屑病关节炎(PsA)临床特征、实验室指标的差异,以提高对该疾病的认识,为临床诊疗提供借鉴。方法对中国人民解放军264医院2005年1月至2011年12月住院诊治的PsA患者进行分型,并对不同亚型PsA患者首发症状、受累关节、类风湿因子(RF)、抗环瓜氨酸多肽抗体(抗CCP抗体)、人类白细胞抗原-B27(HLA-B27)进行比较分析。结果 82例PsA患者,皮疹先发于关节炎者60例(73%),皮疹和关节炎症状1个月内同时出现者9例(11%),关节炎先发于皮疹者13例(16%)。PsA临床分型:远端指(趾)间关节炎型10例(12.2%)、残毁型关节炎型6例(7.3%)、对称性多关节炎型19例(23.2%)、非对称性寡关节炎型20例(24.4%)、脊柱关节炎型27例(32.9%)。红细胞沉降率、C反应蛋白在PsA各亚型之间比较,差异无统计学意义(均P>0.05)。对称性多关节炎型RF或抗CCP抗体的阳性率为68%,远高于脊柱关节炎型(P<0.05)。脊柱关节炎型HLA-B27阳性率为37%,远高于远端指(趾)关节炎型、对称性多关节炎型、非对称性寡关节炎型(均P<0.05)。结论 PsA多以皮疹为首发,仍有部分患者以关节炎首发。临床分型以脊柱关节炎型多见。RF阳性或抗CCP抗体阳性PsA患者易出现对称性多关节受累,HLA-B27阳性PsA患者易出现中轴关节受累。     

Early psoriatic arthritis

In the majority of patients with psoriatic arthritis (PsA), it is a chronic progressive disease, and only 12% of patients with early PsA will be in disease-modifying antirheumatic drug-free remission at 2 years. Radiologic damage occurs in the early stages of PsA; up to 47% of patients with PsA have radiologic erosions after 2 years. This article reviews the clinical features of early PsA, pathologic insights into PsA gleaned from studies of early PsA, and the current state of diagnostic imaging and therapeutics in early PsA.     

Psoriatic arthritis as a mountain

The concept of psoriatic arthritis (PsA) is not yet universally accepted. Indeed, few of the features said to be characteristic for PsA are pathognomonic, and a same patient can be classified as RA, SpA or PsA depending on the physician seen. The heterogeneity of PsA, the lack of significant differences in early-arthritis with and without psoriasis, and a pathogenesis somewhat different in PsA and psoriasis, also argue against the originality of PsA. Nevertheless, although PsA is possibly "just" a syndrome depending on the combination of numerous co-factors (perhaps shared with SpA and/or RA), its more achieved forms deserve to be segregated from other SpA and RA. Indeed, PsA best bridges the gap with SAPHO syndromes. Moreover, the profile of synovial cytokines seems somewhat different in PsA as compared to RA and SpA, and a special pattern of vascularisation has been confirmed by several teams which could account for the demonstrated link between trauma and some PsA onsets. Both the greater familial risk for PsA than for RA or psoriasis alone and the excessive paternal transmission of PsA strongly suggest a genetic background, although so far only MICA-A9 (expressed on gut epithelial cells) seems to be associated with susceptibility to PsA independently from psoriasis. To make further genetics studies informative, a careful selection of unequivocal cases of PsA is needed, which requires criteria selecting patients at the "top of the mountain" of PsA. One can expect that the sets of criteria proposed by McGonagle or Fournié could satisfy this wish.     

Development and early experiences of a Swedish psoriatic arthritis register

OBJECTIVES: To present a programme for a psoriatic arthritis (PsA) register (SwePsA) and to report the early experiences of a test period. METHODS: Patients with symptoms and/or signs consistent with PsA or resembling PsA are enrolled into a follow-up programme, provided the disease duration at inclusion is not longer than two years. RESULTS: Ninety-two patients were included into the programme during the test period. Sixty patients were classified as having PsA, 39 mono/oligoarticular, 19 polyarticular and two predominant axial. Thirty-two patients were classified as possible PsA. Thirty-two of the 92 included patients were followed for one year. Seven of 18 with mono/oligoarticular PsA had advanced to polyarticular PsA. Four of nine patients initially classified as possible PsA evolved into definite polyarticular PsA. Patients with polyarticular PsA had evidence of more severe disease than had patients with mono/oligoarticular PsA. CONCLUSIONS: The programme was easy to administrate and not very time-consuming in daily clinical practice. The preliminary experiences emphasize the importance of early diagnosis and the need for reliable outcome predictors for this potentially severe disorder.     

Validity of the bath ankylosing spondylitis disease activity index for the evaluation of disease activity in axial psoriatic arthritis

Objective

To assess the validity of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for the evaluation and definition of disease activity of axial psoriatic arthritis (PsA).

Methods

Fifty‐four peripheral PsA, 46 axial PsA, and 103 primary ankylosing spondylitis (AS) patients were assessed. Patients were classified as having axial PsA if they had grade 2 or higher unilateral sacroiliitis in the presence of spinal symptoms. The 3 groups of patients were evaluated using several measurements for AS. Assessments of acceptability, data quality, internal consistency, construct validity, and responsiveness of the BASDAI were undertaken. Disease activity of the disease was assessed in peripheral PsA and axial PsA patients using the BASDAI, and compared with those with AS.

Results

For peripheral PsA patients, the Cronbach's alpha for the BASDAI was 0.783, for axial PSA patients it was 0.647, and for AS patients it was 0.786. The analysis of convergent validity showed that in peripheral PsA and axial PsA patients, the BASDAI was significantly correlated with other subjective disease activity parameters. For responsiveness, no association was found between changes in the BASDAI and changes in disease activity either in peripheral PsA or in axial PsA. BASDAI scores were similar in axial PsA and AS. Axial PsA patients with a BASDAI score >4 cm showed significant differences with peripheral PsA in terms of disease activity and were very similar to patients with AS.

Conclusion

The BASDAI performed similarly in evaluating disease activity in both axial and peripheral PsA. The BASDAI does not seem to be a good index for evaluating disease activity in axial PsA.     

A classification study of clinical subsets in an inception cohort of early psoriatic peripheral arthritis--'DIP or not DIP revisited'

INTRODUCTION: Multiple psoriatic arthritis (PsA) classification criteria exist, but these are based on established PsA when pre-existing joint damage and the effect of medication may confound their validity. This study examined the application of the Veale classification criteria in early PsA to determine the effect of disease progression and treatment on classification and to determine the effect of the number of involved joints and the presence of distal interphalangeal (DIP) joint involvement at initial presentation on clinical and radiological outcome. METHODS: A total of 129 patients presenting with PsA to an Irish early synovitis clinic were assessed at presentation and at 1- and 2-yr follow-up. The Veale criteria were used for PsA classification and the Sharp score of hands and feet was used to quantify radiological outcome. RESULTS: At presentation, 52 (40%) had oligoarticular PsA and 77 (60%) had polyarticular PsA. Patients with polyarticular PsA were administered disease-modifying anti-rheumatic drugs (DMARDs) more frequently than patients with oligoarticular PsA and this resulted in a significant number of polyarticular PsA patients being reclassified as oligoarticular PsA at 1- [27/70 (39%)] and 2-yr [26/53 (49%)] follow-up. Fewer patients initially classified with oligoarticular PsA were reclassified as polyarticular PsA. More patients with oligoarticular PsA at baseline were in DMARD-free remission and there was less radiological damage at 2-yr follow-up. DIP disease was associated with other classic seronegative disease features-enthesopathy and nail dystrophy-but did not influence clinical or radiological outcome and the separation of DIP disease as a distinct subgroup in classification criteria was not supported. Synovitis-acne-pustulosis-hyperostosis (SAPHO) syndrome was not observed as a separate subgroup. CONCLUSION: This study confirms that the application of classification criteria of PsA based on the pattern and number of involved joints may be confounded in established PsA by the effects of DMARDs. The application of classification criteria based on disease pattern prior to treatment may be more useful in studies of pathogenesis and long-term outcome in PsA.     

Evaluation of ankylosing spondylitis spinal mobility measurements in the assessment of spinal involvement in psoriatic arthritis

Objective

To determine the clinical usefulness of spinal mobility measurements used for ankylosing spondylitis (AS) to assess spinal involvement in patients with psoriatic arthritis (PsA).

Methods

We assessed 100 patients with PsA and 103 patients with AS. Patients were classified as having axial PsA if they had grade 2 or higher unilateral sacroiliitis in the presence of spinal symptoms. All PsA patients, without taking the degree of joint involvement into consideration, were evaluated using several measurements for AS. Spinal measurements were compared with axial and peripheral forms of PsA, and the ability of the techniques to discriminate between the 2 forms of PsA was analyzed using the Mann‐Whitney U test and the area under the receiver operating characteristic (ROC) curve. A logistic regression model was used to determine the best measurements for evaluating axial PsA. Finally, the results of measurements for axial PsA were compared with those for AS.

Results

Of the 100 PsA patients, 46 met the classification criteria for axial PsA, which presented more severe spinal measurement assessments compared with peripheral PsA. Modified Schober test, lumbar side flexion, chest expansion, and cervical rotation measurements performed best under the ROC curve. Modified Schober test, lumbar side flexion, and cervical rotation were the more suitable measurements for assessing axial PsA. There were only minor differences between axial PsA and AS.

Conclusion

The spinal measurements used to evaluate AS performed well to assess spinal involvement in PsA. These measurements, notably the modified Schober test, lumbar side flexion, and cervical rotation, should be used in daily clinical practice to assess PsA patients with spinal involvement.     

Evaluation of spinal mobility measurements in predicting axial psoriatic arthritis

Axial psoriatic arthritis (PsA) represents a more severe form of disease than peripheral PsA. We evaluate the usefulness of various spinal mobility measurements in predicting a radiographically defined axial PsA. A cross-sectional study on PsA patients with spinal mobility measurement performed. PsA were classified to axial or peripheral PsA by the presence of sacroiliitis. Three Bath Ankylosing Spondylitis Metrology Indexes (BASMIs) were calculated. The sensitivity, specificity, and area under receiver operator curves (AUC) of each spinal mobility measurement in prediction of axial PsA were analyzed. A total of 125 subjects studied (males 52%) with mean age and duration of illness of 47.5 ± 12.4 and 9.2 ± 6.7 years. Twenty-nine patients (17 males and duration of illness 12 females) had axial PsA. Axial PsA patients had longer disease duration (p = 0.05) and more limitation in spinal mobility. Axial PsA patients had higher inflammatory markers and a trend towards poorer global health, higher damaged joint count, and poorer physical function. The tragus-to-wall distance, modified schober test, and lumber side flexion had good sensitivity and specificity in predicting axial PsA. In the logistic regression model, the lumbar side flexion (OR 0.82, 95% CI 0.72–0.92) was independently associated with axial PsA. All three sets of composite scores BASMI₂, BASMI₁₀, and BASMI _lin had good prediction for axial PsA (AUC 0.619, 0.626, and 0.618). Spinal mobility measurements and BASMI were useful in differentiating axial and peripheral PsA. Lumber side flexion and modified schober test best differentiate axial and peripheral PsA.     

Developing classification criteria for peripheral joint psoriatic arthritis. Step I. Establishing whether the rheumatologist's opinion on the diagnosis can be used as the "gold standard"

OBJECTIVE: The study of psoriatic arthritis (PsA) is hampered by the absence of a widely accepted, validated case definition. We investigated whether the physician's opinion can be used as a gold standard when developing classification criteria for peripheral joint PsA. METHODS: UK rheumatologists who had published on PsA and attendees at 3 international meetings on PsA held in the UK were polled by questionnaire. There were 3 phases. The first questionnaire asked whether rheumatologists believed in the construct of PsA. The second survey developed a list of features thought to distinguish patients with PsA from other forms of peripheral arthritis. The final phase was development of a series of 61 "paper" patients with various combinations of the features of PsA. The paper patients were assessed by 15 rheumatologists who were asked whether, in their opinion, the patient had PsA. Latent class analysis was used to identify subgroups of patients and cross-tabulations were used to identify which clinical and laboratory features were associated with each subgroup. RESULTS: Rheumatologists agreed on the construct of PsA and that not all patients with psoriasis and an inflammatory polyarthritis have PsA. Latent class analysis identified 3 classes, corresponding to definite PsA; a middle group that was very likely to be given a diagnosis of PsA by some rheumatologists (high diagnosers), but unlikely to be given the diagnosis by others (low diagnosers); and a third group corresponding to "probably not PsA." CONCLUSION: For the group of patients with "definite PsA" the physician's opinion can be taken as the gold standard when developing classification criteria. However, for patients in the "middle group" there will always be disagreement with the gold standard whether the standard is based on the opinion of the high diagnosers or the low diagnosers.     

How Can Psoriatic Arthritis Be Diagnosed Early?

Psoriatic arthritis (PsA) is an inflammatory arthritis that usually develops after the onset of cutaneous psoriasis. Early diagnosis of PsA may lead to less joint damage and better long-term outcomes. Identifying inflammatory arthritis in individuals with psoriasis is the key to early diagnosis of PsA. Screening strategies targeted at individuals with psoriasis, as well as family members of patients with PsA will result in early identification of PsA. This article describes the various strategies that could be employed to identify inflammatory arthritis in patients with psoriasis so that appropriate referral to a rheumatologist for early diagnosis of PsA may be made.     

Genetic epidemiology of psoriatic arthritis

Psoriatic arthritis (PsA) is defined as an inflammatory arthritis (IA) associated with psoriasis and is usually negative for rheumatoid factor. This ambiguous definition has impeded research into this subject, but as yet no agreed definition or classification criteria exist for PsA. Furthermore, there are those who question whether PsA exists as a distinct disease, or is a mere coincidence of inflammatory arthritides such as rheumatoid arthritis or ankylosing spondylitis with psoriasis. The pathogenesis of both IA and psoriasis is complex, involving interactions between many different genes and environmental etiological factors. It is likely that PsA is also a complex disease. The identification of genetic susceptibility factors unique to PsA over and above those that contribute to IA or psoriasis alone would put an end to speculation as to whether PsA exists as a distinct disease. In addition, it may aid in the development of novel therapies which target PsA specifically. This review summarizes the approaches taken to identify PsA susceptibility genes, and outlines some interesting regions which may harbor PsA susceptibility genes.     

Axial involvement in psoriatic arthritis: An update for rheumatologists

Psoriatic arthritis (PsA) is a heterogenous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. Axial involvement occurs in 25% to 70% of patients with PsA, varying greatly depending on its definition, with the key manifestations being sacroiliitis and/or spondylitis. However, there are no agreed-upon classification or diagnostic criteria for axial involvement in PsA and no consensus on treatment paradigms, which complicates management of PsA. There have only been a few studies assessing biologics in patients with PsA with axial involvement, and most treatment plans are based on evidence from patients with axial spondyloarthritis. Rheumatologists therefore face many challenges in the management of axial PsA, including diagnosis, differential diagnosis, and choice of appropriate treatment. In this review, we summarize the clinical presentation, imaging characteristics, differential diagnoses, treatment options, and prognosis of axial PsA, with the aim of increasing rheumatologists’ knowledge of this phenotype of PsA and thereby aiding its optimal management.     

Clinical features of psoriatic arthritis in Korean patients with psoriasis: a cross-sectional observational study of 196 patients with psoriasis using psoriatic arthritis screening questionnaires

The prevalence and clinical features of psoriatic arthritis (PsA) in psoriasis patients vary widely in different countries, and studies on Korean population are rarely reported. The aim of this study was to investigate the clinical features of PsA in a Korean population of patients with psoriasis by using psoriatic arthritis screening questionnaires. A cross-sectional observational study was conducted, and consecutive psoriatic patients were evaluated for PsA by using two kinds of psoriatic arthritis screening questionnaires: Psoriatic Arthritis Screening and Evaluation tool (PASE) and Psoriasis Epidemiology Screening Tool (PEST). Psoriatic patients with higher score in screening questionnaires were referred to rheumatologist for confirmative diagnosis of PsA. Among 196 psoriasis patients screened by PASE and PEST, total prevalence of PsA was 11.2 % (n = 22/196) with 59.1 % of the cases being newly diagnosed. Compared with patients without PsA, patients with PsA had more extensive psoriasis, higher frequency of pustular and inverse type of psoriasis, and lower frequency of plaque type of psoriasis. Spondylitis was the most common manifestation pattern, followed by polyarthritis, oligoarthritis, predominant distal interphalangeal arthritis, and arthritis mutilans. Our findings are consistent with a low prevalence of PsA among patients with psoriasis in Asia. We also confirm a spondylitis as the most common pattern of PsA in Korea. PsA screening questionnaires can be a simple and useful tool to screen PsA in patients with psoriasis.     

Healthcare and burden of disease in psoriatic arthritis. A comparison with rheumatoid arthritis and ankylosing spondylitis

OBJECTIVE: To compare quality of life and treatment among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) treated by German rheumatologists. METHODS: Data for outpatients with PsA (n = 1863), RA (n = 9627), or AS (n = 1378) enrolled in the national database of the German collaborative arthritis centers in the year 2002 were analyzed. Among those with PsA, 2 subgroups with predominantly peripheral arthritis (n = 1612) and predominantly axial disease (n = 251) were distinguished. RESULTS: We found a high burden of illness in patients with PsA treated by rheumatologists. Among the 2 subgroups, those with axial PsA had worse outcomes (pain, function) than those with peripheral PsA. However, compared with RA and AS, physician ratings of disease activity and severity were lower in PsA. Concerning access to rheumatology care, there were similarities between AS and axial PsA, with very long disease duration at first visit (mean of about 6 yrs), versus RA and peripheral PsA, with shorter duration (1.6 and 2.5 yrs, respectively). A majority (84%) of patients with PsA were treated with disease modifying antirheumatic drugs. Thirty percent of the patients with PsA currently were under therapy with glucocorticoids, mainly (89%) with a dose < 7.5 mg. CONCLUSION: Patients with PsA seen in rheumatologic care have a burden of illness comparable to that of patients with RA or AS.     

Enhancing patient research partner engagement: Research in psoriatic arthritis

The perspective from individuals with psoriatic arthritis (PsA) can be beneficial to PsA research, increasing the likelihood that the results are meaningful and relevant to PsA patients. While there has been an advancement of patient research partner (PRP) involvement in PsA research over time, the effort is still in its infancy. Measures to ensure PRP engagement (PRPE) occurs and its impact evaluated need to be implemented routinely to increase PRPE in PsA research.