Psoria'c  Arthri's  Clinical  Features  and  Epidemiology  

Dr.Sree  krishna  paturi    

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

Psoria'c  Arthri's  PaBerns  

Oligoarthritis Distal Arthritis

è è

Psoria'c  Arthri's  PaBerns  

Polyarticular Pattern

Psoria'c  Arthri's  PaBerns  

Arthritis Mutilans

Psoria'c  Arthri's  PaBerns  

Arthritis Mutilans Telescoping

Psoria'c  Spondyloarthropathy  

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Psoria'c  Spondyloarthropathy  

➨ ➨

Dactyli's  in  PsA    

Edema  in  PsA  

Heel  Lesions  in  PsA  

Achilles Tendon Insertion Erosion Plantar 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

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.