Comorbidities associated with psoriatic arthritis: Review and update

HDL regulates the risk of cardiometabolic and inflammatory-related diseases: Focusing on cholesterol efflux capacity

Dyslipidemia, characterized by higher serum concentrations of low-density lipoprotein cholesterol (LDL-C), very low-density lipoprotein cholesterol (VLDL-C), triglyceride (TG), and lower serum concentrations of high-density lipoprotein cholesterol (HDL-C), is confirmed as a hallmark of cardiovascular diseases (CVD), posing serious risks to the future health of humans. Aside from the role of HDL-C concentrations, the capacity of cholesterol efflux to HDL is being identified as an enssential messurement for the dyslipidemic morbidity. Through inducing the progression of reverse cholesterol transport (RCT), the HDL-related cholesterol efflux plays a vital role in atherosclerotic plaque formation. In addition, increasing results demonstrated that the relationships between cholesterol efflux and cardiovascular events might be influenced by multiple factors, such as atherosclerosis, diabetes, and, inflammatory diseases. These risk factors could affect the intracellular composition of HDL, which might subsqently influence the cholesterol efflux process induced by HDL particle. In the present comprehensive article, we summarize the latest findings which described the modulatory roles of HDL in cardiometabolic disorders and inflammatory related diseases, focusing on its capacity in mediating cholesterol efflux. Moreover, the potential mechanisms whereby HDL regulate the risk of cardiometabolic disorders or inflammatory related diseases, at least partly, via cholesterol efflux pathway, are also well-listed.

Complementary and Alternative Therapies for Psoriasis

Despite recent advancements in psoriasis treatment, challenges in management persist. Recently, there has been a rising interest amongst patients in complementary and alternative medicines (CAM), driven by the desire for more natural, holistic approaches and dissatisfaction with conventional treatments. Up to 41% of patients with psoriasis reported using alternative therapies and 39.5% use complementary therapies (Murphy EC, Nussbaum D, Prussick R, Friedman AJ (2019) Use of complementary and alternative medicine by patients with psoriasis. J Am Acad Dermatol 81:280-283). Despite their rapidly growing prevalence, literature on CAM therapies for psoriasis is lacking, making their recommendation difficult. Since the last systematic review on this topic published in 2018, evidence for new alternative therapies has emerged, promoting a further investigation of their efficacy (Gamret AC, Price A, Fertig RM, Lev-Tov H, Nichols AJ (2018) Complementary and Alternative Medicine Therapies for Psoriasis: A Systematic Review. JAMA Dermatol 154:1330-1337). This systematic review aims to compile recent literature on the most studied alternative therapies for psoriasis and further discuss their effectiveness in order to counsel clinicians in guiding patients on the use of these non-standard approaches. A literature search was conducted in the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov databases for randomized controlled trials (RCT) on complementary and alternative therapies in psoriasis from March 2018 through April 2024, resulting in 12 studies being included in this review. The preliminary results for many treatments such as curcumin, dietary modification and additions, indigo naturalis, meditation, acupuncture, and balneotherapy showed positive clinical effects. However, additional well-designed randomized trials are needed to confirm the potential beneficial effects and to establish safety of use.

The impact of serum uric acid on psoriasis: NHANES 2005-2014 and Mendelian randomization

Background

Psoriasis is a chronic systemic inflammatory disease, and hyperuricemia is a common comorbidity in patients with psoriasis. However, the exact relationship between uric acid levels and psoriasis remains unclear. This study aimed to explore the association between uric acid levels and psoriasis.

Methods

Observational study participant data (≥16 years, n = 23,489) from NHANES 2003-2014. We conducted analyses using a weighted multiple logistic regression model. Genetic data sets for uric acid levels and psoriasis were obtained from the IEU database. We selected genetically independent loci closely associated with serum uric acid levels as instrumental variables and performed Mendelian randomization analyses using five complementary methods: inverse variance weighting (IVW), MR-Egger, weighted median, simple mode, and weighted mode.

Results

After adjusting for other covariates, the results revealed no significant association between serum uric acid levels and psoriasis (b = 0.999, 95% CI: 0.998, 1.001, p = 0.275). Subgroup analyses stratified by gender and ethnicity showed no significant association between sUA and psoriasis in any of the subgroups. Furthermore, the MR analysis involved the selection of 227 SNPs that were associated with both sUA and psoriasis. IVW results demonstrated no causal relationship between sUA and psoriasis (OR = 0.282, 95% CI: -0.094-0.657, p = 0.142).

Conclusion

Our study suggests that uric acid levels are not significantly causally related to psoriasis. This finding provides valuable insights for the treatment and prevention of psoriasis, indicating that merely reducing uric acid levels may not be an effective strategy to reduce the risk of psoriasis onset.

Risk of serious infection associated with different classes of targeted therapies used in psoriatic arthritis: a nationwide cohort study from the French Health Insurance Database (SNDS)

OBJECTIVE

To assess the risk of serious infection associated with different targeted therapies for psoriatic arthritis (PsA) in real-world settings.

METHODS

This nationwide cohort study used the administrative healthcare database of the French health insurance scheme linked to the hospital discharge database to identify all adults with PsA who were new users of targeted therapies (adalimumab, etanercept, golimumab, certolizumab pegol, infliximab, secukinumab, ixekizumab, ustekinumab, and tofacitinib) from 1 January 2015 to 30 June 2021. The primary outcome was a serious infection (ie, requiring hospitalisation), in a time-to-event analysis using propensity score-weighted Cox models, with adalimumab as the comparator, estimating weighted HRs (wHRs) and their 95% CIs.

RESULTS

A total of 12 071 patients were included (mean age 48.7±12.7 years; 6965 (57.7%) women). We identified 367 serious infections (3.0% of patients), with a crude incidence rate of 17.0 per 1000 person-years (95% CI, 15.2 to 18.7). After inverse propensity score weighting and adjustment for time-dependent covariates and calendar year, risk of serious infection was significantly lower for new users of etanercept (wHR 0.72; 95% CI, 0.53 to 0.97) or ustekinumab (wHR, 0.57; 95% CI, 0.35 to 0.93) than adalimumab new users. This risk was not statistically modified with the other targeted therapies.

CONCLUSIONS

The incidence of serious infection was low for PsA patients who were new users of targeted therapies in real-world settings. Relative to adalimumab new users, this risk was lower among new users of etanercept and ustekinumab and unmodified for the other molecules.

The risk factors for uveitis among psoriatic arthritis patients: a population-based cohort study

OBJECTIVE

To assess the frequency of uveitis in patients with psoriatic arthritis (PsA) in the era of biologics and to identify risk factors associated with uveitis.

METHODS

A retrospective matched cohort study was conducted within the database of a large healthcare provider. Newly diagnosed 6147 adult PsA patients between 2005 and 2020 were matched by the index date of PsA diagnosis, age, sex, and ethnicity to 23,999 randomly selected controls. This cohort was used to examine the association between PsA and uveitis. An additional analysis was conducted within the PsA group to identify uveitis risk factors, using two analytic approaches: a retrospective cohort study and a nested case-control study.

RESULTS

Uveitis was diagnosed in 107 patients in the PsA group (1.7%) vs 187 (0.8%) patients in the control group (adjusted HR, 2.38, 95% CI 1.80-3.15, p<0.005) and was similar when the analysis was confined to patients without past uveitis. Uveitis was diagnosed more in females (2.1% vs 1.3%, HR 1.61, 95% CI 1.09-2.40, p<0.05), and was acute in all cases. Anterior uveitis was documented in 41.1% of the cases, 64.5% unilateral, and 9.3% bilateral. In the PsA group, using nested case control approach, only past uveitis [adjusted OR 136.4 (95% CI 27.38-679.88), p<0.005] and treatment with etanercept [adjusted OR 2.57 (95% CI 1.45-4.57), p=0.001] were independently associated with uveitis. Only one PsA patient with uveitis (out of 107) required systemic oral treatment with prednisone, while the rest of the patients were treated with topical glucocorticosteroids only.

CONCLUSION

PsA is associated with increased risk of uveitis. Past uveitis and treatment with etanercept were associated with higher risk of uveitis. Key Points • Psoriatic arthritis (PsA) is a major risk factor for uveitis with hazard ratio of 2.38 compared to healthy individuals without PsA. • Among PsA patients, the past event of uveitis and treatment with etanercept are risk factors for uveitis. • Uveitis in patients treated with biologics for their PsA requires topical therapy only in most of the cases.

Comparison of metabolic and neurological comorbidities in Asian patients with psoriasis and atopic dermatitis

Although various comorbidities have been noted to be associated with atopic dermatitis (AD) and psoriasis, few studies have compared comorbidities between the two diseases, and little is known about whether these comorbidities vary by the subtypes of psoriasis. In this study of 1:1 age- and sex-matched pair analysis between patients diagnosed with either psoriasis or AD at Asan Medical Center between 1991 and 2020, comorbidities, as determined by the International Classification of Diseases-10 codes, and likelihood ratios of metabolic and neurologic comorbidities in psoriasis compared with AD were studied using a logistic regression model. Among a total of 14,128 patients, the psoriasis group had higher odds of obesity (odds ratio [95% confidence interval]: 1.49 [1.34-1.66]), hypertension (1.14 [1.03-1.26]), diabetes mellitus (1.46 [1.29-1.66]), chronic kidney disease (1.59 [1.22-2.08]), and Parkinson's disease (2.1 [1.15-3.83]) than the AD group. Subgroup analysis revealed that patients with plaque psoriasis had higher odds of obesity (1.18 [1.05-1.33]), hypertension (1.18 [1.06-1.32]), diabetes mellitus (1.53 [1.34-1.75]), chronic kidney disease (1.66 [1.26-2.17]), and Parkinson's disease (2.12 [1.16-3.88]) compared with AD. Meanwhile, guttate psoriasis was associated with higher odds of dementia (3.63 [1.06-12.40]) and patients with generalized pustular psoriasis showed higher odds of diabetes mellitus (5.42 [1.56-18.83]) compared with AD. In conclusion, Asian patients with all types of psoriasis should be closely monitored for the development of metabolic and neurologic diseases, especially men and those aged ≥ 40 years.

Influence of the HLA-Cw6 Allele and IFIH1/MDA5 Gene Variants on the Cardiometabolic Risk Profile of Patients with Psoriatic Disease

BACKGROUND

Cardiovascular comorbidity is a common companion of psoriasis and psoriatic arthritis (PsA). Recently, a significant link has been found between the HLA-Cw6 allele and a better cardiometabolic profile in these patients. We aimed to check this finding in our setting.

METHODS

A cross-sectional observational study (n: 572 psoriasis patients, 30% with PsA) was conducted. Different study variables were collected in detail, as well as classic cardiometabolic risk factors. The distribution of the HLA-Cw6 allele and the IFIH1/MDA5 gene variants previously linked to disease risk were determined in the study cohort and stratified according to the cardiometabolic comorbidity. Linear and logistic regression models were constructed to analyze these associations.

RESULTS

The study cohort included 309 men and 263 women, with a mean age of 46.7 years (SD 14.5) and a mean disease duration of 19.4 years (SD 14.8). We confirmed the known association between HLA-Cw6 and type I psoriasis (familial, severe, and early onset). Psoriasis severity (OR: 2.14), female sex (OR: 1.63), and the IFIH1/MDA5 rs1990760 TT genotype (OR: 1.62) were significantly related to PsA, while HLA-Cw6 was protective (OR: 0.65). HLA-Cw6 carriers showed a lower waist perimeter, lower BMI, and lower risk of both hypertension (OR: 0.52, p < 0.001) and diabetes (OR: 0.36, p < 0.001), but these findings were no longer apparent upon adjusting the regression models. No IFIH1/MDA5 gene variant was associated with any cardiometabolic risk factor.

CONCLUSIONS

The influence of HLA-Cw6 on the cardiometabolic risk profile of psoriatic patients seems to be explained by other factors (age, sex, duration of the disease or arthritis) and not by this biomarker itself.

Long-Term Safety of Guselkumab in Patients with Psoriatic Disease: An Integrated Analysis of Eleven Phase II/III Clinical Studies in Psoriasis and Psoriatic Arthritis

INTRODUCTION

The benefit/risk profiles of biologics can be affected by comorbidities, certain demographic characteristics, and concomitant medications; therefore, it is important to evaluate the long-term safety profiles of biologics across broad patient populations. Guselkumab was well tolerated and efficacious across individual pivotal clinical studies in adults with moderate-to-severe psoriasis and/or active psoriatic arthritis (PsA).

OBJECTIVES

The objective of the current analysis was to evaluate guselkumab safety in a large population of patients with psoriatic disease by pooling adverse event (AE) data from 11 phase II/III studies (seven in psoriasis; four in PsA).

METHODS

Guselkumab was generally administered as 100 mg subcutaneous injections at Week 0, Week 4, then every 8 weeks (Q8W) in psoriasis studies and at Week 0, Week 4, then every 4 weeks (Q4W) or Q8W in PsA studies. Safety data were summarized for the placebo-controlled period (Weeks 0-16 in psoriasis; Weeks 0-24 in PsA) and through the end of the reporting period (up to 5 years in psoriasis; up to 2 years in PsA). Using the integrated data, incidence rates of key AEs were determined post hoc, adjusted for duration of follow-up, and reported per 100 patient-years (PYs). AE rates were also determined in subgroups of patients defined by sex, age, body mass index (BMI), and prior biologic use.

RESULTS

During the placebo-controlled period, 1061 patients received placebo (395 PYs) and 2257 received guselkumab (856 PYs). Through the end of the reporting period, 4399 guselkumab-treated patients contributed 10,787 PYs of follow-up. During the placebo-controlled period, in the guselkumab and placebo groups, respectively, rates of AEs were 281 versus 272/100 PYs, and infections were 76.0 versus 72.2/100 PYs. Rates of serious AEs (5.6 vs. 7.8/100 PYs), AEs leading to discontinuation (4.9 vs. 6.6/100 PYs), serious infections (1.0 vs. 2.3/100 PYs), malignancy (0.59 vs. 0.25 patients/100 PYs), and major adverse cardiovascular events (MACE; 0.35 vs. 0.25/100 PYs) were low and comparable between guselkumab and placebo. Among guselkumab-treated patients, safety event rates through the end of the reporting period were numerically lower than or comparable with rates observed during the placebo-controlled period: AEs, 164/100 PYs; infections, 61.2/100 PYs; serious AEs, 5.4/100 PYs; AEs leading to discontinuation, 1.8/100 PYs; serious infections, 1.0/100 PYs; malignancy, 0.6/100 PYs; and MACE, 0.3/100 PYs. No AEs of Crohn's disease, ulcerative colitis, or active tuberculosis were reported among guselkumab-treated patients. In the psoriasis studies, no opportunistic infections were reported among guselkumab-treated patients. Three AEs of opportunistic infections were reported in guselkumab-treated patients with PsA (0.14/100 PYs; all after Week 52 in DISCOVER-2). AE rates were largely consistent across subgroups of guselkumab-treated patients defined by sex, age, BMI, and prior biologic use.

CONCLUSIONS

In this analysis of 4399 guselkumab-treated patients with psoriatic disease followed for 10,787 PYs, guselkumab had a favorable AE profile. AE rates were similar between guselkumab- and placebo-treated patients and were consistent throughout long-term guselkumab treatment and across broad subgroups of patients with psoriatic disease.

CLINICAL TRIALS REGISTRATIONS

Clinicaltrials.gov identifiers: NCT01483599, NCT02207231, NCT02207244, NCT02203032, NCT02905331, NCT03090100, NCT02325219, NCT02319759, NCT03162796, NCT03158285, and NCT03796858.

Machine learning identifies right index finger tenderness as key signal of DAS28-CRP based psoriatic arthritis activity

Psoriatic arthritis (PsA) is a chronic inflammatory systemic disease whose activity is often assessed using the Disease Activity Score 28 (DAS28-CRP). The present study was designed to investigate the significance of individual components within the score for PsA activity. A cohort of 80 PsA patients (44 women and 36 men, aged 56.3 ± 12 years) with a range of disease activity from remission to moderate was analyzed using unsupervised and supervised methods applied to the DAS28-CRP components. Machine learning-based permutation importance identified tenderness in the metacarpophalangeal joint of the right index finger as the most informative item of the DAS28-CRP for PsA activity staging. This symptom alone allowed a machine learned (random forests) classifier to identify PsA remission with 67% balanced accuracy in new cases. Projection of the DAS28-CRP data onto an emergent self-organizing map of artificial neurons identified outliers, which following augmentation of group sizes by emergent self-organizing maps based generative artificial intelligence (AI) could be defined as subgroups particularly characterized by either tenderness or swelling of specific joints. AI-assisted re-evaluation of the DAS28-CRP for PsA has narrowed the score items to a most relevant symptom, and generative AI has been useful for identifying and characterizing small subgroups of patients whose symptom patterns differ from the majority. These findings represent an important step toward precision medicine that can address outliers.

Management of psoriatic arthritis: a consensus opinion by expert rheumatologists

Background

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disease involving several articular and extra-articular structures. Despite the important progresses recently made in all of the aspects of this disease, its management is still burdened by unresolved issues. The aim of this exercise was to provide a set of statements that may be helpful for the management of PsA.

Methods

A group of 38 Italian rheumatologists with recognized expertise in PsA selected and addressed the following four topics: "early PsA," "axial-PsA," "extra-articular manifestations and comorbidities," "therapeutic goals." Relevant articles from the literature (2016-2022) were selected by the experts based on a PubMed search. A number of statements for each topic were elaborated.

Results

Ninety-four articles were selected and evaluated, 68 out of the 1,114 yielded by the literature search and 26 added by the Authors. Each of the four topic was subdivided in themes as follows: transition from psoriasis to PsA, imaging vs. CASPAR criteria in early diagnosis, early treatment for "early PsA"; axial-PsA vs. axialspondyloarthritis, diagnosis, clinical evaluation, treatment, standard radiography vs. magnetic resonance imaging for "axial PsA"; influence of inflammatory bowel disease on the therapeutic choice, cardiovascular comorbidity, bone damage, risk of infection for "comorbidities and extra-articular manifestations"; target and tools, treat-to-target strategy, role of imaging for "therapeutic goals." The final document consisted of 49 statements.

Discussion

The final product of this exercise is a set of statements concerning the main issues of PsA management offering an expert opinion for some unmet needs of this complex disease.

Impact of hyperuricaemia on patients with psoriatic arthritis treated with secukinumab in the FUTURE 2-5 and MAXIMISE studies

OBJECTIVES

Patients with psoriatic arthritis (PsA) are at a significantly increased risk of hyperuricaemia and development of gout, and those with hyperuricaemia have been found to respond poorly to PsA treatment and have more peripheral and destructive joint damage. We present a comprehensive post hoc analysis using pooled data from the FUTURE 2-5 studies and the MAXIMISE study to further evaluate the impact of hyperuricaemia on clinical presentation/disease severity and response to secukinumab in patients with PsA.

METHODS

Patients were stratified into two groups based on baseline serum uric acid (SUA) level (threshold of 360 µmol/L). A sensitivity analysis was also performed based on SUA thresholds of 300 µmol/L and 420 µmol/L. Demographics, clinical, radiological characteristics and comorbidities data were collected.

RESULTS

At baseline, patients with hyperuricaemia were mostly male, reported a higher prevalence of hypertension, with more clinical dactylitis, more psoriasis and more severe skin disease compared with patients with normouricaemia. A similar proportion of patients in the normouricaemic and hyperuricaemic cohorts achieved American College of Rheumatology responses, resolution of enthesitis and dactylitis, inhibition of structural damage progression and improvement in health-related quality of life across all secukinumab doses at week 52.

CONCLUSION

Patients with PsA and hyperuricaemia have different clinical characteristics from patients with PsA and normouricaemia. Identification of these patients at an early stage may facilitate a personalised treatment approach and improved management of comorbidities. Furthermore, secukinumab provided a rapid and sustained response across all manifestations of PsA up to week 52, irrespective of baseline uricaemia status.

Serum and Synovial Levels of Cathepsin G and Cathepsin K in Patients with Psoriatic Arthritis and Their Correlation with Disease Activity Indices

This retrospective case-control study examined the relationship between the serum and synovial levels of cathepsin G (CatG) and cathepsin K (CatK) in patients with psoriatic arthritis (PsA) and their association with disease activity. Methods: This case-control study involved 156 PsA patients, 50 patients with gonarthrosis (GoA), and 30 healthy controls. The target parameters were measured using enzyme-linked immunosorbent assay (ELISA) kits. The serum levels of CatG and CatK were found to be significantly higher in PsA patients compared to both control groups (p < 0.001). Moreover, they could distinguish PsA patients from healthy controls with 100% accuracy. Synovial fluid CatG and CatK were positively associated with the following indicators of disease activity: the VAS (rs = 0.362, rs = 0.391); the DAPSA (rs = 0.191, rs = 0.182); and the mCPDAI (rs = 0.378, rs = 0.313). Our results suggest that serum and synovial fluid CatG and CatK levels could serve as biomarkers for PsA. In PsA patients with synovial fluid crystals, elevated synovial CatG levels demonstrated a sensitivity of 89.54% and a specificity of 86.00% in distinguishing them from PsA patients without crystals. Similarly, elevated synovial CatK levels had a sensitivity of 93.67% and a specificity of 94.34% for distinguishing PsA patients with synovial fluid crystals from those without. Furthermore, the synovial fluid levels of both CatG and CatK showed positive associations with key indicators of disease activity, including the visual analog scale (VAS) (rs = 0.362, rs = 0.391), the disease activity in psoriatic arthritis (DAPSA) (rs = 0.191, rs = 0.182), and the modified composite psoriatic disease activity index (mCPDAI) (rs = 0.378, rs = 0.313). In conclusion, our findings suggest that the serum and synovial fluid levels of CatG and CatK hold promise as potential biomarkers for assessing disease activity in psoriatic arthritis.

Epidemiological analysis of patients with psoriatic arthritis in follow-up at the brazilian Unified Health System

INTRODUCTION/OBJECTIVES

Psoriatic arthritis (PsA) is a chronic multisystem osteoarticular disease that requires specialized care. Most Brazilians depend on the public healthcare provided by the Unified Health System (Sistema Único de Saúde, SUS). This study aimed to describe the epidemiological characteristics of patients with PsA in follow-up in SUS, focusing on the incidence and prevalence of the disease, comorbidities, and hospitalizations.

METHODS

We collected data from the Outpatient Data System of SUS (Sistema de Informações Ambulatoriais do SUS, SIA/SUS) regarding outpatient visits and hospitalizations in the Brazilian public healthcare system from January 2008 to March 2021 using the Techtrials Disease Explorer® platform and the medical code related to PsA were selected.

RESULTS

We evaluated 40,009 patients and found a prevalence of 24.4 cases of visits due to PsA per 100,000 patients in follow-up in SUS. Female patients were predominant (54.38%). The incidence of visits due to PsA has been increasing in recent years and we observed an incidence of 8,982 new visits in 2020. The main comorbidities of these patients were osteoarthritis, lower back pain, shoulder injuries, oncological diseases, crystal arthropathies, and osteoporosis. Hospitalizations were mainly due to treating clinical or cardiovascular conditions and performing orthopedic procedures.

CONCLUSION

The number of visits due to PsA in SUS has increased in recent years, mainly on account of new diagnoses of the disease, although the prevalence found in this study's population was lower than that observed in the general population.

Lifestyle Modifications and Nonpharmacologic Interventions to Improve Outcomes in Psoriatic Arthritis: A Systematic Review

PURPOSE

Psoriatic arthritis (PsA) is a multisystem inflammatory disorder associated with significant mortality and morbidity, including functional impairment and psychological disability. Although evidence-based treatment recommendations are available for the use of drug treatments in PsA, there is little guidance for health professionals on nonpharmacologic and psychological interventions that may be useful in PsA. The objective of this systematic review (SR) was to identify how lifestyle modifications and the use of nonpharmacologic and psychological interventions may improve the outcomes of patients with PsA.

METHODS

Studies were included if they evaluated adults diagnosed with PsA and included exposure to nonpharmacologic interventions, psychological interventions, and lifestyle modifications. The outcomes used needed to have been validated in PsA. A systematic literature search was run on May 28, 2021, in the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), EMBASE, Global Health, MEDLINE, and PsycINFO databases to identify articles related to lifestyle modifications and nonpharmacologic or psychological interventions for adults with PsA published between 2010 and 2021. Two review authors independently screened and selected full-text studies for inclusion in the SR. Risk of bias was assessed with either the Risk of Bias 2 (ie, RoB 2) tool or Critical Appraisal Skills Program checklist depending on the study type.

FINDINGS

The search strategy identified 26,132 references. Eight studies examining lifestyle modifications and the effect on PsA were eligible to be included in the SR. Three of the 8 studies were randomized controlled trials, and 5 were nonrandomized studies. Three studies assessed physical activity, 3 assessed diet, 1 study assessed smoking, and another study assessed mud bath therapy. There was large heterogeneity between studies, and the measures of disease activity, and psychological and functional outcomes varied widely between studies.

IMPLICATIONS

Although this SR identified 8 relevant studies, these studies did not provide high-quality evidence to guide patients for non-drug treatments of PsA. The effectiveness of these interventions has therefore not been established. We found that physical activity seems to have a positive impact on disease activity and psychological well-being. Further well-designed research studies are needed to develop treatment recommendations. PROSPERO identifier: CRD42021257404.

Pregnancy & neonatal outcomes in spondyloarthritis

Limited research has been conducted on the impact of spondylitis (SpA) on fertility, but some studies suggest a higher risk of subfertility in women with SpA compared to the general population. Factors associated with impaired fertility in SpA include pain, fatigue, stiffness, functional disorders, depression, anxiety, negative body image, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) preconceptionally, while TNF alpha inhibitors may play a role in improving fertility in certain cases. There has been a recent increase in clinical research focused on pregnancy outcomes in SpA. However, clear trends in terms of risk of pregnancy and fetal complications have been slow to emerge and many questions remain for women with SpA planning a pregnancy. This article discusses the current evidence for risk of specific pregnancy and fetal complications in women with axial and psoriatic SpA.

The Combination of IL-6, PLR and Nail Psoriasis: Screen for the Early Diagnosis of Psoriatic Arthritis

Background

Early screening or timely prediction of psoriatic arthritis (PsA) are crucial. The study aimed to compare the clinical characteristics, cytokines and inflammation index between plaque psoriasis and PsA to explore their values in the early diagnosis of PsA.

Methods

This was a case-control study in a single center from January 2021 to February 2023. The differences in clinical characteristics and laboratory examinations between PsA and plaque psoriasis were conducted. Patients with rheumatoid arthritis (RA) were used as a positive control. The correlation between variables were analyzed and multivariable logistic regression were performed by using the 10-fold cross-validation to find independently risk factors of plaque psoriasis that are developing PsA.

Results

A total of 109 patients with plaque psoriasis (without joint damage), 47 patients with PsA and 41 patients with RA were enrolled in this study. The study found that the proportion of patients with elevated serum IL-6 levels, as well as the value of platelet to lymphocyte ratio (PLR) and systemic immune-inflammation index (SII), were significantly higher in patients with PsA and early PsA (PsA course ≤2 years) compared to those with plaque psoriasis (p<0.05). After adjusting for age, gender, severity of skin lesions, and comorbidities (diabetes, hypertension, hyperlipidemia, hyperuricemia, and overweight/obesity), the study identified nail psoriasis (OR=4.35, 95% CI 1.67-11.29, p<0.002), elevated serum IL-6 (OR=6.78, 95% CI 2.34-19.67, p<0.001), and PLR (OR=8.37, 95% CI 2.97-23.61, p<0.001) as independent risk factors for PsA. A multivariable logistic regression analysis employing 10-fold cross-validation assessing the predictive association between the diagnosis of early PsA and the combination of IL-6, PLR, and nail psoriasis demonstrated that the area under the curve (AUC) was 0.84 (95% CI 0.77-0.90) and the F1-score was 0.67 (95% CI 0.54-0.80).

Conclusion

The combination of elevated serum IL-6, PLR, and nail psoriasis can help to predict and screen the early stage of PsA.

Racial disparities in comorbidities of patients with psoriatic arthritis

There have been significant advances in the treatment of psoriatic arthritis (PsA). Despite these advances, racial and ethnic disparities in clinical outcomes may still exist in patients with PsA. We aimed to examine the racial differences in clinical characteristics, medication usage and comorbidities in PsA patients. This retrospective study was conducted using the IBM Explorys platform. Search criteria included ICD diagnosis code for PsA and at least two visits with a rheumatologist, between 1999 and 2019. We further stratified by adding the following variables to the search: race, sex, laboratory data, and clinical characteristics, medication use, and comorbidities. Data sets were recorded as proportions and compared using chi-squared tests (p < 0.05). We identified 28,360 patients with PsA. AAs had a higher prevalence of hypertension (59% vs 52%, p < 0.0001), diabetes (31% vs 23% p < 0.0001), obesity (47% vs 30%, p < 0.0001), and gout (12% vs 8%, p < 0.0001). Caucasian patients were more likely to have cancer (20% vs 16%, p = 0.002), anxiety (28% vs 23%, p < 0.0001), and osteoporosis (14% vs 12%, p = 0.001). NSAIDs were used in 80% of Caucasians and 78% of AAs (p < 0.009), TNFs in 51% of Caucasians and 41% of AAs, and DMARDs in 72% of Caucasians and 98% of AAs (p < 0.0001). Our findings from a large US real-world database revealed that certain comorbidities were more frequent in AA patients with PsA, which warrants increased risk stratification. There was increased biologic use in Caucasians with PsA compared to AA who were more commonly on DMARDs.

Psoriatic Arthritis: Pathogenesis and Targeted Therapies

Psoriatic arthritis (PsA), a heterogeneous chronic inflammatory immune-mediated disease characterized by musculoskeletal inflammation (arthritis, enthesitis, spondylitis, and dactylitis), generally occurs in patients with psoriasis. PsA is also associated with uveitis and inflammatory bowel disease (Crohn's disease and ulcerative colitis). To capture these manifestations as well as the associated comorbidities, and to recognize their underlining common pathogenesis, the name of psoriatic disease was coined. The pathogenesis of PsA is complex and multifaceted, with an interplay of genetic predisposition, triggering environmental factors, and activation of the innate and adaptive immune system, although autoinflammation has also been implicated. Research has identified several immune-inflammatory pathways defined by cytokines (IL-23/IL-17, TNF), leading to the development of efficacious therapeutic targets. However, heterogeneous responses to these drugs occur in different patients and in the different tissues involved, resulting in a challenge to the global management of the disease. Therefore, more translational research is necessary in order to identify new targets and improve current disease outcomes. Hopefully, this may become a reality through the integration of different omics technologies that allow better understanding of the relevant cellular and molecular players of the different tissues and manifestations of the disease. In this narrative review, we aim to provide an updated overview of the pathophysiology, including the latest findings from multiomics studies, and to describe current targeted therapies.

Identification of PsA phenotypes with machine learning analytics using data from two phase III clinical trials of guselkumab in a bio-naïve population of patients with PsA

Objectives

Psoriatic arthritis (PsA) phenotypes are typically defined by their clinical components, which may not reflect patients’ overlapping symptoms. This post hoc analysis aimed to identify hypothesis-free PsA phenotype clusters using machine learning to analyse data from the phase III DISCOVER-1/DISCOVER-2 clinical trials.

Methods

Pooled data from bio-naïve patients with active PsA receiving guselkumab 100 mg every 8/4 weeks were retrospectively analysed. Non-negative matrix factorisation was applied as an unsupervised machine learning technique to identify PsA phenotype clusters; baseline patient characteristics and clinical observations were input features. Minimal disease activity (MDA), disease activity index for psoriatic arthritis (DAPSA) low disease activity (LDA) and DAPSA remission at weeks 24 and 52 were evaluated.

Results

Eight clusters (n=661) were identified: cluster 1 (feet dominant), cluster 2 (male, overweight, psoriasis dominant), cluster 3 (hand dominant), cluster 4 (dactylitis dominant), cluster 5 (enthesitis, large joints), cluster 6 (enthesitis, small joints), cluster 7 (axial dominant) and cluster 8 (female, obese, large joints). At week 24, MDA response was highest in cluster 2 and lowest in clusters 3, 5 and 6; at week 52, it was highest in cluster 2 and lowest in cluster 5. At weeks 24 and 52, DAPSA LDA and remission were highest in cluster 2 and lowest in clusters 4 and 6, respectively. All clusters improved with guselkumab treatment over 52 weeks.

Conclusions

Unsupervised machine learning identified eight PsA phenotype clusters with significant differences in demographics, clinical features and treatment responses. In the future, such data could help support individualised treatment decisions.

The Clinical Characteristics of Psoriatic Arthritis: A Cross-Sectional Study Based on the Psoriatic Arthritis Cohort of West China Hospital

INTRODUCTION

This study aims to describe the demographic, clinical, laboratory, and ultrasonic characteristics of patients with psoriatic arthritis (PsA) in the Psoriatic Arthritis cohort of West China Hospital.

METHODS

In this cross-sectional study, we included patients diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis, collected their demographic information, medical histories, and treatments, evaluated all domains (skin and nail lesions, tenderness, swelling, enthesitis, dactylitis, and axial arthritis) related to PsA, and then performed descriptive statistical analyses of all data.

RESULTS

A total of 275 patients with PsA were included in this study. The ratio of male to female patients was 2.16:1. Skin lesions preceded arthritis in 86.5% of these patients with PsA with a mean interval of 10.1 years. The metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints of fingers, and sacroiliac joints are the most commonly involved sites of tenderness, swelling, and the spine, respectively. Among all comorbidities, fatty liver has the highest incidence with 33.1%. Finally, we noted that the mean disease duration of PsA was 4.2 years, suggesting a delay in the diagnosis of PsA.

CONCLUSION

Our study proposes that the prevalent population of PsA are male patients with psoriasis over 40 years of age who have a long disease course. For patients with PsA, MCP, PIP joints of fingers, and sacroiliac joints are the most frequently affected anatomical sites. With respect to comorbidities, the association between PsA and fatty liver and the underlying molecular mechanisms are worthy of further exploration.

Safety profile of upadacitinib over 15 000 patient-years across rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and atopic dermatitis

OBJECTIVE

To evaluate the long-term safety profile for upadacitinib across rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and atopic dermatitis (AD).

METHODS

Safety data from clinical trials of upadacitinib 15 mg and upadacitinib 30 mg (AD only) for treating RA, PsA, AS and AD as of 30 June 2021 were analysed; some RA and PsA studies included adalimumab and methotrexate as active comparators. Treatment-emergent adverse events (TEAEs) were presented by disease as exposure-adjusted event rates per 100 patient years (E/100 PY).

RESULTS

The analysis included 6991 patients (RA, n=3209; PsA, n=907; AS, n=182; AD, n=2693) who received at least one dose of upadacitinib, representing 15 425 PY of exposure (maximum duration 2.75-5.45 years) across diseases. Rates (E/100 PY) of any TEAE (205.5-278.1) and TEAE leading to discontinuation (4.5-5.4) were similar across diseases; serious TEAEs were numerically higher in patients with RA and PsA. Rates of herpes zoster (1.6-3.6), non-melanoma skin cancer (0-0.8) and elevations in creatine phosphokinase levels (4.4-7.9) were higher with upadacitinib than with active comparators in the RA and PsA populations. Deaths (0-0.8), serious infections (0-3.9), major adverse cardiovascular events (0-0.4), venous thromboembolism (<0.1-0.4) and malignancies (0.3-1.4) were observed, with rates generally lowest in AS and AD. Increased rates of acne were observed in patients with AD only.

CONCLUSIONS

Findings from this analysis demonstrate that upadacitinib is generally well tolerated with observed differences in safety profiles likely reflective of varying patient characteristics across RA, PsA, AS and AD populations.

TRIAL REGISTRATION NUMBERS

NCT02675426, NCT02706951, NCT02706847, NCT02629159, NCT02706873, NCT03086343, NCT03104374, NCT03104400, NCT03178487, NCT03569293, NCT03568318 and NCT03607422.

Serum Calprotectin as a Promising Inflammatory Biomarker in Psoriatic Arthritis: a 1-Year Longitudinal Study

INTRODUCTION

There are few biomarkers correlated with psoriatic arthritis (PsA). We aimed to explore the clinical value of calprotectin (CLP) in PsA in disease activity and treatment targets.

METHODS

Serum CLP was detected by enzyme-linked immunosorbent assay (ELISA) in 71 patients with PsA, 55 patients with psoriasis (PsO), and 10 healthy controls. The association of serum CLP with disease activity index at baseline and follow-up was analyzed. Cox regression and receiver operating characteristic (ROC) analysis were used to evaluate the potential of CLP for predicting the achievement of treatment targets, including low disease activity (LDA), remission, and minimal disease activity (MDA).

RESULTS

Serum CLP levels (μg/ml) were significantly increased in patients with PsA/PsO compared with healthy controls (p < 0.001). Serum CLP levels were positively associated with psoriasis area and severity index (PASI), disease activity in psoriatic arthritis (DAPSA), and its components [including tender joint count (TJC), swollen joint count (SJC), patient's global assessment (PGA), and visual analog scale (VAS)-pain, r 0.290-0.601, all p value < 0.05]. After 1-year follow-up, the number of patients with PsA in remission and MDA increased [17 (23.9%) versus 47 (66.1%) and 21 (29.5%) versus 52 (73.2%) respectively, all p value < 0.001]. Cox regression and Kaplan-Meier survival analysis indicated that patients with lower CLP obtain LDA, MDA, and remission earlier, including remission and MDA within a year (all p-value < 0.05). ROC analysis showed the ability of serum at baseline to predict the achievement of the treatment target in 3 months [area under the curve (AUC) 0.663-0.691, all p-values < 0.05].

CONCLUSIONS

Serum CLP level was correlated with disease activity in PsA. It also possessed the ability to predict the achievement of the therapeutic target. These features of CLP would make it a useful tool in clinical work.

Treatment in Patients with Psoriatic Disease and Rheumatoid Arthritis: Seven Case Reports

The incidence of psoriasis, an intractable long-lasting inflammatory skin disease, is increasing and has many complications and comorbidities. Approximately 14% of patients have psoriatic arthritis (PsA). Rheumatoid arthritis (RA) is not a rare disease worldwide, and some patients may have both PsA and RA. In the present study, we encountered seven patients with concurrent diagnoses of RA and psoriatic disease and reported the details of clinical data, treatment efficacy, and X-ray findings. The diagnosis may require not only classification criteria but also a comprehensive judgment in collaboration with rheumatology over time. In addition to methotrexate as an anchor drug, anti-tumor necrosis factor-α agents are the first choice of biological agents for treatment, and interleukin (IL)-17 inhibitors may be effective, as IL-17 is also involved in the pathogenesis of RA. When treating patients with both PsA and RA, it may be essential to consider the treatment strategy, depending on which disease is more active.

Seronegative spondyloarthropathy-associated inflammatory bowel disease

Seronegative spondyloarthropathy (SpA) usually starts in the third decade of life with negative rheumatoid factor, human leukocyte antigen-B27 genetic marker and clinical features of spinal and peripheral arthritis, dactylitis, enthesitis and extra-articular manifestations (EAMs). Cases can be classified as ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis, or juvenile-onset spondyloarthritis. Joint and gut inflammation is intricately linked in SpA and inflammatory bowel disease (IBD), with shared genetic and immunopathogenic mechanisms. IBD is a common EAM in SpA patients, while extraintestinal manifestations in IBD patients mostly affect the joints. Although individual protocols are available for the management of each disease, the standard therapeutic guidelines of SpA-associated IBD patients remain to be established. Nonsteroidal anti-inflammatory drugs are recommended as initial therapy of peripheral and axial SpA, whereas their use is controversial in IBD due to associated disease flares. Conventional disease-modifying anti-rheumatic drugs are beneficial for peripheral arthritis but ineffective for axial SpA or IBD therapy. Anti-tumor necrosis factor monoclonal antibodies are effective medications with indicated use in SpA and IBD, and a drug of choice for treating SpA-associated IBD. Janus kinase inhibitors, approved for treating SpA and ulcerative colitis, are promising therapeutics in SpA coexistent with ulcerative colitis. A tight collaboration between gastroenterologists and rheumatologists with mutual referral from early accurate diagnosis to appropriately prompt therapy is required in this complex clinical scenario.

Uveitis in psoriatic arthritis: study of 406 patients in a single university center and literature review

BACKGROUND/PURPOSE

The manifestations of uveitis are well established in axial spondyloarthritis (ax-SpA), but not in psoriatic arthritis (PsA). We aimed to assess, in a large unselected series of PsA: (A) the frequency and clinical features of uveitis; (B) its association with PsA activity, the impact of disease and functional disability, and (C) its relationship with the biological treatment. In addition, a literature review was performed.

METHODS

Retrospective longitudinal study of PsA patients from a single referral hospital. PsA was classified according to the CASPAR criteria, and uveitis was diagnosed by experienced ophthalmologists.

RESULTS

We studied 406 patients with PsA (46.3±12.3 years). Uveitis was observed in 20 (4.9%). Uveitis was acute in all cases, anterior (80%), unilateral (80%) and recurrent (50%). Patients with uveitis had a higher prevalence of HLA-B27 (45% vs 7.5%, p<0.0001), sacroiliitis on MRI (25% vs 8.3% p=0.027), ocular surface pathology (10% vs 0.8%, p=0.021), and median PsA impact of Disease Score (5.9 (2.1-6.8) vs 1.25 (0.0-3.0), p=0.001) and Bath Ankylosing Spondylitis Functional Index (4 (1.6-5) vs 1.0 (0.0-3.5), p=0.01) than patients without uveitis.The exposure adjusted incidence rate (episodes/100 patients-year) of uveitis before versus after biological treatment decreased with anti-TNFα monoclonal antibodies (56.3 vs 9.4) and increased with etanercept (ETN) (6.03 vs 24.2) and secukinumab (SECU) (0 vs 50) (including only one patient treated in the last two cases).

CONCLUSION

The prevalence of uveitis in patients with PsA was about 5%. The pattern was similar to that observed in ax-SpA. Uveitis was associated with a worse quality of life and greater functional disability. The uveitis exposure adjusted incidence rate decreased with anti-TNFα monoclonal antibodies and increased with ETN and SECU.

Do genetics contribute to TNF inhibitor response prediction in Psoriatic Arthritis?

Psoriatic arthritis (PsA) is a heterogeneous chronic musculoskeletal disease, affecting up to 30% of people with psoriasis. Research into PsA pathogenesis has led to the development of targeted therapies, including Tumor Necrosis Factor inhibitors (TNF-i). Good response is only achieved by ~60% of patients leading to 'trial and error' drug management approaches, adverse reactions and increasing healthcare costs. Robust and well-validated biomarker identification, and subsequent development of sensitive and specific assays, would facilitate the implementation of a stratified approach into clinical care. This review will summarise potential genetic biomarkers for TNF-i (adalimumab, etanercept and infliximab) response that have been reported to date. It will also comment upon the importance of managing clinical confounders when understanding drug response prediction. Variants in multiple gene regions including TNF-A, FCGR2A, TNFAIP3, TNFR1/TNFR1A/TNFRSF1A, TRAIL-R1/TNFRSF10A, FCGR3A have been reported to correlate with TNF-i response at various levels of statistical significance in patients with PsA. However, results were often from heterogenous and underpowered cohorts and none are currently implemented into clinical practice. External validation of genetic biomarkers in large, well-documented cohorts is required, and assessment of the predictive value of combining multiple genetic biomarkers with clinical measures is essential to clinically embed pharmacogenomics into PsA drug management.

Are Janus kinase inhibitors safe and effective in treating the key clinical domains of psoriatic arthritis? A systematic review and meta-analysis

OBJECTIVES

Psoriatic arthritis (PsA), is a complex inflammatory arthropathy with a heterogenous spectrum of disease presentation. Despite the vast therapeutic armamentarium, disease control in a considerable proportion of patients is suboptimal. The aim of this study was to assess the safety and efficacy of Janus kinase inhibitors (JAKi), in the management of key clinical domains of PsA including peripheral arthritis, psoriasis, enthesitis and dactylitis.

METHOD

Randomized placebo-controlled trials (RCTs) of JAKi in PsA were identified by a systematic literature search using EMBASE, PubMed and CENTRAL. All included studies underwent meta-analysis.

RESULTS

A total of 5 RCTs were included. Patients were randomized to tofacitinib (n = 474), filgotinib (n = 65), upadacitinib (n = 1281) or placebo (n = 937). JAKi treatment was associated with superior efficacy across all primary outcome measures vs placebo: American College of Rheumatology (ACR) 20 (risk ratio [RR] 2.10, [95% CI 1.86-2.37], P < .00001, I2 = 19%); ACR 50 (RR 3.43, [95% CI 2.37-4.96], P < .00001, I2 = 66%); ACR 70 (RR 4.57, [95% CI 1.83-11.44], P = .001, I2 = 82%); Psoriasis Area and Severity Index 75 (RR 2.96, [95% CI 2.44-3.58], P < .00001, I2 = 0%); enthesitis resolution (RR 1.82, [95% CI 1.56-2.12], P < .00001, I2 = 0%); and dactylitis resolution (RR 1.85, [95% CI 1.57-2.16], P < .00001, I2 = 0%). JAKi were associated with an overall increased risk of adverse events (RR 1.14, [95% CI 1.07-1.21], P = .0001, I2 = 0%) with increased risk of infection (RR1.23, [95% CI 1.08-1.39], P = .001, I2 = 0%) vs placebo.

CONCLUSION

This pooled analysis demonstrates the efficacy of JAKi in treating key clinical domains of PsA. However, they are associated with an increased risk of adverse events, including infection. Further studies are required to corroborate these findings and further elucidate the safety profile.

The Prevalence of Asymptomatic Hyperuricemia in Patients with or Without Psoriatic Arthritis is Associated with a Similar Cardiovascular Risk

Aim: To investigate the association between cardiovascular burden and monosodium urate (MSU) deposits in the joints of patients with asymptomatic hyperuricemia and no evidence of arthritis and subjects with psoriatic arthritis and hyperuricemia.

Patients and methods: A single-center, cross-sectional study including 52 individuals: 39 with asymptomatic hyperuricemia and 13 with psoriatic arthritis and hyperuricemia. All patients underwent ultrasound of the joints by which the presence or absence of MSU crystal deposits was assessed. Subjects underwent transthoracic echocardiography by which left ventricular mass index (LVMI) was estimated. Intima-media thickness (IMT) of the common carotid arteries was measured and the presence of atherosclerotic plaques was registered.

Results: We found no difference in the distribution of cardiovascular risk factors between the two groups. Further, no difference in their distribution was found between those who were not treated and those who were treated with urate-lowering medications. The frequency of articular MSU deposits was similar between non-allopurinol-treated and allopurinol-treated individuals (p = 0.554). There was no difference in the frequency of articular deposits between benzbromarone recipients and non-recipients (p = 0.396). We observed no connection between articular MSU deposits and LVMI (p = 0.625), IMT (p = 0.117) and atherosclerotic plaques (p = 0.102). Among untreated and treated with urate-lowering drugs there was no difference in LVMI (p = 0.063), IMT (p = 0.975) and plaque distribution (p = 1.000).

Conclusion: We can assume that in patients with asymptomatic hyperuricemia and no evidence of arthritis and in subjects with psoriatic arthritis and asymptomatic hyperuricemia, only the prescription of urate-lowering medications for reduction of urate load and cardiovascular risk is not sufficient.

Acute joint swelling in psoriatic arthritis: Flare or "psout"-A 10-year-monocentric study on synovial fluid

Psoriatic arthritis (PsA) is a multifaceted inflammatory disease associated with psoriasis that can affect peripheral joints, entheses, and the axial skeleton with a variable clinical course. Acute episodes of joint swelling in PsA patients can have different causes and require specific treatments. We aimed to describe the acute joint swelling in PsA patients via synovial fluid (SF) analyses, assessing in particular the presence of pathogenic crystals, to determine whether it is a flare or an acute episode of gout ("psout") during the course of the disease. This retrospective study was based on the results of SF analysis of samples collected from unselected adult PsA patients referred to our clinic for acute joint swelling. Demographic characteristics, disease involvement, laboratory findings on SF, and treatment options were recorded and reviewed. Among 5,478 SF samples analyzed in a 10-year time span, 213 complete SF records from PsA patients were evaluated. Overall, after adjustment for the degree of synovial inflammation, significant differences were observed in term of sex (p = 0.0017) and ongoing therapy (p = 0.0246). Non-inflammatory SFs, indeed, were mainly described for female PsA patients under therapy. Regarding serum uric acid levels, there were 19/213 (8.9%) PsA with hyperuricemia (HU), who were older, mostly male, patients with mild articular involvement and rare pathogenic crystals in their SF. Although it is known that the risk of gout is higher among patients with PsA ("psout"), monosodium urate crystals were reported only in 5/213 SFs (2.4%) of our cohort and in 2/19 SFs (10.5%) of HU PsA patients. Moreover, hyperuricemia seems not to modify the SF features in PsA patients. This study results seem to suggest that the convergence of gout and PsA, involving the role of urate crystals, is a more intricate relationship, which needs further insights to be unraveled.

Epidemiology and clinical characteristics of psoriatic arthritis-related uveitis in Madrid, Spain

PURPOSE

To describe the epidemiology and clinical characteristics of psoriatic arthritis (PsA) related uveitis in Madrid, Spain.

METHODS

A case series nested in a retrospective single-center cohort of 494 patients with PsA was performed. Patients older than 18 years old whit a clinical diagnosis PsA-related uveitis who attended the Ramon y Cajal University Hospital in Madrid, Spain, between 1st January 2017 and 31st December 2019 were included in the study. Epidemiological and clinical data were retrieved from the electronic medical records.

RESULTS

Thirteen cases of psoriatic arthritis-related uveitis (6 men and 7 women) were included. PsA-related uveitis showed an incidence of 0.05 cases per 100,000 persons/year (CI95 0.00-0.35), and a prevalence of 2.19 cases per 100,000 persons (CI95 1.24-3.79). The prevalence of active uveitis in the cohort of PsA patients was 2.6%. The first episode of uveitis (mean age of 48.15 ± 15.41 years) was anterior and unilateral in 92.31% of the cases. Most of the patients had a recurrent course (69.2%) with 0.92 flare-ups per patient/year (CI95 0.85-0.96). The uveitis preceded the diagnosis of psoriatic arthritis in 62.5% of the patients. In patients with PsA-related uveitis, HLA-B27 was present in 23.1%, HLA-Cw6 in 7.7%.

CONCLUSIONS

Uveitis is a PsA manifestation that affects roughly 1 in 37 PsA patients, and that may precede the articular symptoms. It generally presents as a unilateral acute anterior uveitis and has a recurrent course. The most frequent observed complications are elevated intraocular pressure and cataracts.

Sex- and gender-related differences in psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory musculoskeletal disease with a chronic, progressive course. Various aspects of PsA, including its clinical features, disease course and response to treatment, are influenced by sociodemographic characteristics of the patient. This includes patient sex, the biological attributes associated with being male or female, and gender, a sociocultural construct that comprises attitudes, traits and behaviours associated with being a man or a woman. An understanding of sex- and gender-related differences in PsA, as well as their underlying mechanisms, is therefore important for individualized care. In this narrative review, the influence of sex and gender on PsA manifestation and course, patient function and quality of life, and their association with comorbidities are described. Sex- and gender-related disparities in response to advanced therapies and their potential underlying mechanisms are delineated. Differences in pathophysiological mechanisms between male and female patients including genetics, immune and hormonal mechanisms are discussed. Finally, fertility and pregnancy outcomes in PsA are outlined. By adopting sex and gender lenses, this review is aimed at highlighting key differences between male and female patients with PsA and uncovering mechanisms underlying these differences, ultimately promoting individualized care of men and women with PsA and informing future research in this area.

Immunological risk factors for nonalcoholic fatty liver disease in patients with psoriatic arthritis: New predictive nomograms and natural killer cells

Objective

To search for the immunological risk factors of Psoriatic arthritis (PsA) combined with nonalcoholic fatty liver disease (NAFLD), development and assessment of predictive nomograms for NAFLD risk in patients with PsA, and to further explore the correlation between risk factors and dyslipidemia.

Methds

A total of 127 patients with PsA (46 with NAFLD and 81 without NAFLD) were included in this retrospective study. The clinical and serological parameters of the patients were collected. The percentage and the absolute number of lymphocytes and CD4+T cells were determined by Flow cytometry. Univariate and multivariate binary logistic regression analysis was used to screen independent risk factors of PsA complicated with NAFLD in the model population, and a nomogram prediction model was developed and assessed.

Results

(1) Univariate and multivariate logistic regression analysis of the modeling population showed that the percentage of peripheral blood T helper 1 cells (Th1%) (OR=1.12, P=0.001), body mass index (BMI) (OR=1.22, P=0.005) and triglycerides (TG) (OR=4.78, P=0.003) were independent risk factors for NAFLD in patients with PsA, which were incorporated and established a nomogram prediction model. The model has good discrimination and calibration, and also has certain clinical application value. (2) The number of peripheral blood NK cells in PsA patients was significantly positively correlated with serum triglyceride (TG) (r=0.489, P<0.001), cholesterol (CHOL) (r=0.314, P=0.003) and low-density lipoprotein (LDL) (r=0.362, P=0.001) levels.

Conclusions

Our study shows that the novel NAFLD nomogram could assess the risk of NAFLD in PsA patients with good efficiency. In addition, peripheral blood NK cell levels may be associated with dyslipidemia in patients with PsA.

Pregnancy, delivery, and neonatal outcomes among women with psoriatic arthritis, a population based study

OBJECTIVES

Many autoimmune diseases negatively affect pregnancies. Studies report conflicting data about the effects of psoriatic arthritis (PsA) in pregnancy. We sought to evaluate the pregnancy, delivery, and neonatal outcomes among women with PsA.

METHODS

We conducted a retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-HIS). Cases of PsA were identified using the ICD code 696.0. Pregnancies complicated with PsA were compared with the other pregnancies. A multivariate logistic regression was used to adjust for confounding variables.

RESULTS

A total of 9,096,369 control births and 419 with PsA occurred during the study period. Women with PsA were more likely to be older, Caucasian, obese, have a higher income, and private insurance (p-value <0.0001 all). Also, they were more likely to start their pregnancy with chronic hypertension, pregestational diabetes, thyroid disorders, inflammatory bowel disease, and depression. Rates of pregnancy induced hypertension (PIH) (aOR 1.58, 95% CI 1.13-2.21) and small for gestational age (SGA) (aOR 2.42, 95% CI 1.49-3.93) were higher in PsA. There were no differences in the rates of most outcomes including: preeclampsia, gestational diabetes, preterm delivery, preterm premature rupture of membranes (PPROM), placenta previa, abruption, modes of delivery, hemorrhage, deep vein thrombosis (DVT), pulmonary embolism (PE), chorioamnionitis, intrauterine fetal death, or congenital anomalies (p>0.05 all).

CONCLUSIONS

Women with PsA should be reassured about their pregnancy outcomes as only PIH and SGA were more common. Healthcare providers should take appropriate surveillance and preventive methods to mitigate the effect of these two complications in pregnancies complicated with PsA.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Validity and psychometric characteristics of the self-administered comorbidity questionnaire in patients with psoriatic arthritis

The study aimed to translate and cross-culturally adapt the self-comorbidity questionnaire (SCQ) into Turkish and investigate the validity and reliability of SCQ and its modified version (mSCQ) in psoriatic arthritis (PsA). Psoriatic arthritis quality of life (PsAQoL) and short form 36 (SF-36) were used to assess the quality of life. The physical disability was evaluated with the health assessment questionnaire (HAQ). The reliability of the SCQ scale was assessed by test-retest reliability. For construct validity, the correlations of SCQ with the HAQ, SF-36, PsAQoL, age, body mass index (BMI), disease duration, disease activity in psa (DAPSA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Psoriasis Area and Severity Index (PASI), dactylitis and enthesitis were evaluated. The mSCQ was also used by removing the items related to rheumatic conditions. For the test-retest reliability of the Turkish version of SCQ, the intraclass correlation coefficient was 0.965, p < 0.001. The SCQ and mSCQ had significant correlations with HAQ, PsAQoL, some subscales of SF-36, and age (p < 0.05), but not with disease duration, BASDAI, PASI and dactylitis (p > 0.05). Although SCQ had a low correlation with DAPSA (rho = 0.262, p = 0.031), mSCQ was not correlated with DAPSA (p > 0.05). mSCQ was significantly correlated with BMI (rho = 0.233, p = 0.016), but SCQ was not (p > 0.05). The Turkish version of SCQ had adequate reliability and validity, and the mSCQ improved the validity of the scale in patients with PsA.

The effects of custom-made foot orthoses on foot pain, foot function, gait function, and free-living walking activities in people with psoriatic arthritis (PsA): a pre-experimental trial

Introduction

Foot involvement is a significant concern in psoriatic arthritis (PsA) as it can lead to severe levels of foot pain and disability and reduced mobility and quality of life. Previous studies have shown moderate efficacy for custom-made foot orthoses (CFO) in reducing foot pain and disability in people with rheumatoid arthritis. However, evidence on the efficacy of CFO in people with PsA is lacking.

Objectives

To explore the effects of CFO on foot function, foot and lower limb pain, gait function, and free-living walking activities (FWA) in people with PsA.

Methods

A pre-experimental study including twenty participants with PsA (mean age: 54.10 ± 9.06 years and disease duration: 11.53 ± 10.22 years) was carried out. All the participants received and wore CFO for 7 weeks. Foot and lower limb pain and foot function were measured before and after the intervention using the numerical rating scale (NRS) and the foot function index (FFI). Gait function was assessed by recording spatiotemporal parameters (STPs) during a 10-m walk test using an instrumented gait analysis system (Mobility Lab). Free-living walking activities (step count, free-living cadence, time spent in different ambulatory physical activities (APA)) were recorded over 7 days using an accelerometer-instrumented sock.

Results

The FFI reported scores demonstrated severe baseline levels of foot pain (54.46 ± 14.58 %) and disability (46.65 ± 16.14%). Statistically and clinically significant improvements in foot pain and foot function and large effect sizes (Cohen’s effect size > 1, p < 0.005) were observed after the intervention period. A strong correlation (r = −0.64, p < 0.01) between the CFO wearing time and foot function was demonstrated. However, no significant changes were found for gait STP or free-living walking activities after 7 weeks of CFO use.

Conclusion

Results support the clinical and biomechanical plausibility of using CFO in people with PsA to reduce pain and improve foot function. Large-scale and controlled studies are needed to confirm these findings. Moreover, a multidisciplinary approach including the prescription of exercise therapy and physiotherapy combined with CFO could be required to improve STP and promote APA in people with PsA.

Trial registration

ClinicalTrials.gov, NCT05075343. Retrospectively registered on September 29, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02808-8.

Assessment of Crystals in the Synovial Fluid of Psoriatic Arthritis Patients in Relation to Disease Activity

Background: This study examines the relationship between the presence of crystals in the synovial fluid of patients with psoriatic arthritis (PsA) and disease activity. Methods: The synovial fluid of 156 PsA patients was analyzed and compared to 50 patients with gonarthrosis (GoA). The Leica DM4500P polarization microscope was used for crystal detection. Results: The presence of crystals was observed in 23.71% of PsA patients and none of the GoA patients, p < 0.001. Monosodium urate crystals (67.58%) and calcium pyrophosphate crystals (21.62%) were prevalent. The presence of crystals in the synovial fluid of PsA patients was associated with high disease activity according to the Composite Psoriatic Disease Activity Index (OR = 18.75, 95%; CI: 7.13 to 49.25) and the Disease Activity for Psoriatic Arthritis (OR = 15.96, 95%; CI: 5.76 to 44.23), with severe disability according to the Health Assessment Questionnaire Disability Index (OR = 13.60, 95%; CI: 5.09 to 36.31), and with severe pain on the Visual Analog Scale (OR = 157.25, 95%; CI: 39.50 to 625.94). Conclusion: Our results suggest that synovial fluid examination should be included in the treatment pathway for PsA patients with active disease, to aid in determining whether urate-lowering therapy is required.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a type of inflammatory arthritis that is included within the spondyloarthritis, a group of rheumatological diseases characterized by different clinical manifestations and associated comorbidities, that can compromise the quality of life of patients. The diagnosis of PsA is sometimes difficult due to an enormous clinical and radiological variability, including six different domains of involvement: peripheral joint, axial skeleton, skin psoriasis, nail psoriasis, enthesitis and dactylitis. Currently, there are no biomarkers that allow the detection of PsA in patients with psoriasis, so a high level of suspicion is important, mainly by dermatologists, but also by other specialists, such as family doctors. Advances in the knowledge of new immunological mechanisms and joint management by rheumatologists and dermatologists have made it possible to improve the therapeutic approach in patients with PsA.

The clinical and molecular cardiometabolic fingerprint of an exploratory psoriatic arthritis cohort is associated with the disease activity and differentially modulated by methotrexate and apremilast

OBJECTIVES

(1) To evaluate clinical and molecular cardiovascular disease (CVD) signs and their relationship with psoriatic arthritis (PsA) features and (2) to identify a clinical patient profile susceptible to benefit from methotrexate (MTX) and/or apremilast regarding CVD risk.

METHODS

This cross-sectional study included 100 patients with PsA and 100 age-matched healthy donors. In addition, an exploratory cohort of 45 biologically naïve patients treated for 6 months with apremilast, MTX or combined therapy according to routine clinical practice was recruited. Extensive clinical and metabolic profiles were obtained. Ninety-nine surrogate CVD-related molecules were analysed in plasma and peripheral blood mononuclear cells (PBMCs). Hard cluster analysis was performed to identify the clinical and molecular phenotypes. Mechanistic studies were performed on adipocytes.

RESULTS

Cardiometabolic comorbidities were associated with disease activity and long-term inflammatory status. Thirty-five CVD-related proteins were altered in the plasma and PBMCs of PsA patients and were associated with the key clinical features of the disease. Plasma levels of some of the CVD-related molecules might distinguish insulin-resistant patients (MMP-3, CD163, FABP-4), high disease activity (GAL-3 and FABP-4) and poor therapy outcomes (CD-163, LTBR and CNTN-1). Hard cluster analysis identified two phenotypes of patients according to the rates of cardiometabolic comorbidities with distinctive clinical and molecular responses to each treatment.

CONCLUSIONS

(1) Novel CVD-related proteins associated with clinical features could be emerging therapeutic targets in the context of PsA and (2) the pleiotropic action of apremilast could make it an excellent choice for the management of PsA patients with high CVD risk, targeting metabolic alterations and CVD-related molecules.

Long-term Safety of Secukinumab Over Five Years in Patients with Moderate-to-severe Plaque Psoriasis, Psoriatic Arthritis and Ankylosing Spondylitis: Update on Integrated Pooled Clinical Trial and Post-marketing Surveillance Data

Secukinumab, a selective interleukin (IL)-17A inhibitor, is approved for use in adult and paediatric psoriasis, psoriatic arthritis, ankylosing spondylitis and non-radiographic axial spondyloarthritis. The aim of this study was to report the long-term safety of secukinumab in pooled data from 28 clinical trials and a post-marketing safety surveillance in psoriasis, psoriatic arthritis and ankylosing spondylitis patients. Analyses included 12,637 secukinumab-treated patients, corresponding to 15,063, 5,985 and 3,527 patient-years of exposure in psoriasis, psoriatic arthritis and ankylosing spondylitis patients, respectively. Incidences of serious adverse events were low, with no identifiable patterns across indications. Active tuberculosis or latent tuberculosis infections were rare. The incidence of opportunistic infections was < 0.2/100 patient-years, the incidence of malignancy was ≤ 1/100 patient-years, and the incidence of major adverse cardiovascular events was < 0.7/100 patient-years, with no apparent increases over time. Secukinumab demonstrated a favourable safety profile for up to 5 years of treatment across the 3 indications, and no new safety signals were identified.

Psoriatic arthritis: prospects for the future

Psoriatic arthritis (PsA) is a form of chronic inflammatory arthritis associated with psoriasis and a multitude of other symptoms, most commonly arthritis, dactylitis, enthesitis and axial involvement. PsA is significantly heterogeneous, with a highly variable clinical course of PsA. Patients may experience significant or mild skin and joint symptoms, with some patients developing rapidly progressing joint destruction and skin symptoms. Despite the range of symptom severity, PsA is frequently associated with significantly impaired quality of life from joint destruction, as well as chronic pain and a range of comorbidities such as depression and cardiovascular disease. Currently, there are no definitive diagnostic tests for PsA, with diagnosis remaining challenging owing to the heterogeneous presentation and course of the disease. Presently, the CASPAR criteria are often used to aid rheumatologists in distinguishing PsA from other inflammatory arthritides. Treatment options for patients have been expanded over the last two decades with the emerging clinical utility of biological therapies. However, early identification and diagnosis of patients and effective disease control remain unmet medical needs within the PsA community. In addition, predicting response to treatment also remains a challenge to rheumatologists. This review highlights the current hurdles faced by healthcare professionals in the diagnosis and management of PsA patients and provides future action points for consideration by the members of the multidisciplinary team who treat PsA patients.

Association Between Atopic Dermatitis, Asthma, and Serum Lipids: A UK Biobank Based Observational Study and Mendelian Randomization Analysis

Background

Both atopic diseases and dysregulation of serum lipids (SLs) add to significant health burden, but evidences about their association are inconsistent.

Objective

This work is to evaluate the association between asthma/atopic dermatitis (AD) and SLs and investigate the potential causal relationship.

Methods

A large-scale cross-sectional study based on the UK Biobank (UKB) and then examined the casual relationships between SLs with asthma/AD based on a Mendelian randomization (MR) analysis.

Results

A total of 502,505 participants were included in analysis. After full adjustment, AD was associated with lower TG (β = −0.006; 95%CI, −0.010 to −0.002; P = 0.006), lower LDL (β = −0.004; 95%CI, −0.006 to −0.002, P < 0.001), and lower TC (β = −0.004; 95%CI, −0.005 to −0.002; P < 0.001) but insignificantly correlated to HDL (P = 0.794). Asthma was also inversely correlated to TG (β = −0.005; 95%CI, = −0.007 to −0.003; < 0.001), LDL (β = −0.003; 95%CI, −0.004 to −0.002; P < 0.001), and TC (β = −0.002; 95%CI, −0.003 to −0.002; P < 0.001), but was positively correlated to HDL (β = 0.004; 95%CI, 0.003 to 0.005; P < 0.001), respectively. In subsequent MR analysis, both allergic diseases and asthma showed a protective effect on TC. Allergic diseases, asthma, and AD all showed a negative effect on LDL.

Conclusion

Collectively, we identify a protective causal effect of allergic diseases on serum lipids, as well as a potentially positive association of HDL with asthma. Owing to the largest sample size and the application of IVs in causal inference, this study will provide a robust evidence for the management of asthma and AD and the prevention of dyslipidemia.

Current Medication Practices and Preferences Among Patients With Psoriatic Arthritis

OBJECTIVE

The aim of this study was to evaluate real-world psoriatic arthritis (PsA) medication use and patient medication preferences.

METHODS

This is a cross-sectional survey of Classification for Psoriatic Arthritis criteria defined PsA patients recruited from a single-center PsA registry from June to September 2020. Preferences were ranked on a 5-point Likert scale ranging from "not at all important" to "extremely important."

RESULTS

One hundred thirty-seven patients (29%) responded. The median duration (years) of PsA skin and joint symptoms was 19 (interquartile range, 10-34) and 12 (interquartile range, 8-21), respectively. The most common initial immunomodulatory medications were anti-tumor necrosis factor α (35%), methotrexate (19%), and anti-phosphodiesterase 4 (anti-PDE4) (12.4%). At survey administration, the most common immunomodulatory therapies were anti-tumor necrosis factor α (30%), anti-interleukin 17 (IL-17) (20.4%), and methotrexate (10.2%). After 2018, when updated guidelines from the American College of Rheumatology/National Psoriasis Foundation were published, a significantly higher percentage of patients' first medication was an anti-IL-17 compared with 2018 or earlier (30% vs 3.5%, p < 0.001), a pattern also seen with anti-PDE4 (40% vs 11.5%, p < 0.012). Medication preferences most ranked as "extremely" important were prevention of joint damage (80%), ability to perform daily activities (71%), prevention of pain (70.1%), rheumatologist recommendation (63%), and medication adverse effects (62%).

CONCLUSIONS

The significant increase of anti-IL-17 and anti-PDE4 medications as initial treatment after 2018 may reflect their inclusion as potential initial therapy in updated guidelines, along with the importance placed by patients on medication adverse effects. Given the expanding armamentarium of PsA medications, it is increasingly important to align patient preferences and therapeutic options to ensure durable use of effective therapy.

Choosing the Appropriate Target for the Treatment of Psoriatic Arthritis: TNFα, IL-17, IL-23 or JAK Inhibitors?

Psoriatic arthritis (PsA) is a highly heterogenous disease. Apart from arthritis and psoriasis, other manifestations can also occur, including enthesitis, dactylitis, axial-, nail-, eye- and bowel- involvement. Comorbidities are also frequent in the setting of PsA, with cardiovascular disease and mental-health disorders being the most frequent. The Rheumatologist's arsenal has many different treatment options for treating PsA. Despite their effectiveness, there are some differences in terms of efficacy and safety that might affect clinician's decision for one or the other drug. Comparing biologic DMARDs and JAK-inhibitors, one could say that they have similar effectiveness in terms of musculoskeletal manifestations. However, anti-IL-17 and anti-IL-23 drugs seem to be more effective for skin manifestations. In contrast, JAK-inhibitors and etanercept might be less effective for these manifestations. Inflammatory bowel disease and uveitis are non-responsive to etanercept and anti-IL-17 drugs. As regards to comorbidities, data are scarce, but future studies will shed light on possible differential effect of bDMARDs or JAK-inhibitors. Safety is always an important drive for choosing the appropriate treatment. Infections are the most common adverse event of these drugs. Etanercept and anti-IL-17 drugs are safer for patients having latent tuberculosis, while herpes zoster is more common in individuals receiving JAK-inhibitors. Finally, venous thromboembolism risk, should be taken into account when JAK-inhibitors are used. In this review, we comparatively present, as outlined above, the various aspects that could affect the choice of the appropriate bDMARD or JAK-inhibitor for the treatment of a PsA patient.

Cardiovascular Implications of Immune Disorders in Women

Immune responses differ between men and women, with women at higher risk of developing chronic autoimmune diseases and having more robust immune responses to many viruses, including HIV and hepatitis C virus. Although immune dysregulation plays a prominent role in chronic systemic inflammation, a key driver in the development of atherosclerotic cardiovascular disease (ASCVD), standard ASCVD risk prediction scores underestimate risk in populations with immune disorders, particularly women. This review focuses on the ASCVD implications of immune dysregulation due to disorders with varying global prevalence by sex: autoimmune disorders (female predominant), HIV (male-female equivalent), and hepatitis C virus (male predominant). Factors contributing to ASCVD in women with immune disorders, including traditional risk factors, dysregulated innate and adaptive immunity, sex hormones, and treatment modalities, are discussed. Finally, the need to develop new ASCVD risk stratification tools that incorporate variables specific to populations with chronic immune disorders, particularly in women, is emphasized.