Early psoriatic arthritis

Four-year effectiveness, safety and drug retention rate of secukinumab in psoriatic arthritis: a real-life Italian multicenter cohort

OBJECTIVES

to evaluate over a 48-month follow-up period the: 1) long-term effectiveness and safety; 2) drug retention rate (DRR); 3) impact of comorbidities and bDMARDs line on MDA and DAPSA remission/low disease activity (LDA) of secukinumab in a multicenter Italian cohort of PsA patients.

METHODS

Consecutive PsA patients receiving secukinumab were followed prospectively in Italian centers between 2016 and 2023. Disease characteristics, previous/ongoing treatments, comorbidities and follow-up duration were recorded. Treatment response was evaluated at 6 and 12 months after initiation, and every year up to 48 months (T48). DRR was assessed according to clinical and demographic features, comorbidities and bDMARDs line. Adverse events (AE) were recorded.

RESULTS

Six hundred eighty-five patients [42.5% male] were enrolled; 32.9% naïve received secukinumab; 74.2% had ≥ 1 comorbidity. Overall, secukinumab yielded improved outcomes at T48: naïve maintained lower disease activity vs. non-naïve [DAPSA 4.0 (1.4-8.1) vs. 6.0 (2.2-10.4);p = 0.04]; 76.9% naïve and 66.2% non-naïve achieved MDA; MDA no comorbidities vs. 1-3 comorbidities 78.8% vs. 73.3% (p < 0.05), and MDA no comorbidities vs. > 3 comorbidities 78.8% vs. 48.7% (p < 0.001). DAPSA-REM and DAPSA-LDA rates were higher in naïve patients, albeit similar between those without comorbidities vs. 1-3 comorbidities, and slightly lower in those with > 3 comorbidities. Treatment was discontinued in 233 patients due to loss of effectiveness, and in 41 due to AE. The overall DRR at T48 was 66%, with differences according to bDMARDs line (p < 0.001), use of combined csDMARDs (p = 0.016), BMI (p = 0.037) and mono/oligoarthritis vs. polyarthritis (p = 0.012).

CONCLUSIONS

Secukinumab proved safe and effective, and patients achieved sustained remission with a notable drug retention rate at 4 years.

Screening of psoriatic arthritis by dermatologists - a German nationwide survey

BACKGROUND AND OBJECTIVES

Up to 30% of psoriasis (PsO) is clinically associated with psoriatic arthritis (PsA). A large proportion of new onset of PsA is diagnosed at a later stage, despite the necessity of early effective treatment to prevent structural damage. This study aimed to identify the routine screening practices used for PsA in patients with PsO.

PATIENTS AND METHODS

This non-interventional, prospective, epidemiological, cross-sectional study conducted in Germany focuses on screening activity and treatment selection of dermatological practices in suspected PsA. Descriptive statistics and patient characteristics were analyzed for different center types.

RESULTS

One hundred ninety-five patients from 34 office-based physicians, five non-university hospitals, and nine university hospitals were included. Questionnaires or imaging techniques were not routinely used (< 45%). Especially, ultrasounds (≤ 5%) and MRIs (< 6.3%) were rarely performed. Between 30% and 75% of suspected PsA could be confirmed. Referral to rheumatologists and/or appropriate therapy initiation were the most frequent consequences.

CONCLUSIONS

Results of this study reflect the status of PsA screening activity by dermatologists. Imaging techniques, particularly ultrasound or MRIs to detect early forms of PsA, were inadequately used, which may have contributed to continued underdiagnoses. Collaboration between dermatologists and rheumatologists should be reviewed with a view to improving effective PsA screening.

Window of opportunity in psoriatic arthritis: the earlier the better?

OBJECTIVES

To investigate whether there is a window of opportunity for psoriatic arthritis (PsA) patients and to assess which patient characteristics are associated with a longer diagnostic delay.

METHODS

All newly diagnosed, disease-modifying antirheumatic drug-naïve PsA patients who participated in the Dutch southwest Early PsA cohoRt and had ≥3 years of follow-up were studied. First, total delay was calculated as the time period between symptom onset and PsA diagnosis made by a rheumatologist and then split into patient and physician delays. The total delay was categorised into short (<12 weeks), intermediate (12 weeks to 1 year) or long (>1 year). These groups were compared on clinical (Minimal Disease Activity (MDA) and Disease Activity index for PSoriatic Arthritis (DAPSA) remission) and patient-reported outcomes during 3 years follow-up.

RESULTS

708 PsA patients were studied of whom 136 (19%), 237 (33%) and 335 (47%) had a short, intermediate and long total delay, respectively. Patient delay was 1.0 month and physician delay was 4.5 months. Patients with a short delay were more likely to achieve MDA (OR 2.55, p=0.003) and DAPSA remission (OR 2.35,p=0.004) compared with PsA patients with a long delay. Patient-reported outcomes showed numerical but non-significant differences between the short and long delay groups. Female patients and those presenting with enthesitis, chronic back pain or normal C-reactive protein (CRP) had a longer delay.

CONCLUSIONS

In PsA, referral and diagnosis within 1 year is associated with better clinical outcomes, suggesting the presence of a window of opportunity. The most gain in referral could be obtained in physician delay and in females, patients with enthesitis, chronic back pain or normal CRP.

Management der Psoriasisarthritis durch Dermatologen - eine deutschlandweite Umfrage: Management of psoriatic arthritis by dermatologists - a German nationwide survey

Hintergrund und Zielsetzung

Die Psoriasisarthritis (PsA) erfordert für bestmögliche therapeutische Ergebnisse eine frühzeitige Diagnose und den Einsatz adäquater antirheumatischer Therapien sowie der regelmäßigen Überprüfung des Therapieerfolges. Ziel dieser Studie war es, die routinemäßigen Überwachungsmaßnahmen für Patienten mit gesicherter PsA und Psoriasis vulgaris (PsO) durch Dermatologen zu untersuchen und Daten zu generieren, wie die Bedingungen für ein optimales Therapiemanagement bei Dermatologen sichergestellt werden können.

Patienten und Methodik

Diese nichtinterventionelle, prospektive, epidemiologische Querschnittsstudie (2016–2019) umfasste Patienten mit bestätigter PsA, die sich bei einem Dermatologen in Behandlung befanden. Für Zentrums‐ und Patientencharakteristika sowie die Daten zur PsA‐Überwachung und ‐Behandlung, stratifiziert nach verschiedenen Zentrumsarten, wurden deskriptive statistische Analysen durchgeführt.

Ergebnisse

212 Patienten von 34 niedergelassenen Ärzten, 5 nichtuniversitären Krankenhäusern und 9 Universitätskliniken wurden eingeschlossen. Die Mehrheit der PsA‐Patienten wurde von Rheumatologen (> 55% in jedem Zentrumstyp) in einem frühen oder mittleren Stadium (> 59%) diagnostiziert. Die Behandlung der PsA wurde hingegen am häufigsten von Dermatologen eingeleitet (niedergelassene Ärzte: 69,6%, Krankenhäuser: 60,9%, Universitätskliniken: 82.9%). In Universitätskliniken wurden die Patienten häufiger mit Biologika behandelt (alleinige Therapie: 43,9%, in Kombination mit weiteren systemischen Therapien: 26,8%) als bei niedergelassenen Ärzten (alleinige Therapie: 44,6%, Kombinationstherapie: 13,5%) und in nichtuniversitären Krankenhäusern (alleinige Therapie: 34,8%, Kombination: 8,7%).

Schlussfolgerungen

Da die PsA‐Diagnose am häufigsten von Rheumatologen gestellt wurde, während hingegen die Behandlung von mild bis moderater PsA hauptsächlich von Dermatologen eingeleitet wird, ist eine optimale Zusammenarbeit zwischen diesen Fachärzten von entscheidender Bedeutung.

Management of psoriatic arthritis by dermatologists - a German nationwide survey

BACKGROUND AND OBJECTIVES

Psoriatic arthritis (PsA) warrants early diagnosis and treatment for optimal results. This study aimed to elucidate routine monitoring activities for PsA with concurrent psoriasis (PsO) by dermatologists to gather data on how conditions for optimal treatment are ensured.

PATIENTS AND METHODS

This non-interventional, prospective, epidemiological, cross-sectional study (2016-2019) included patients with confirmed PsA from dermatologists. Descriptive statistics were conducted for center and patient characteristics as well as for data of PsA monitoring and treatment stratified by different center types.

RESULTS

212 patients from 34 office-based physicians, five non-university hospitals, and nine university hospitals were included. The majority of the PsA patients were diagnosed by a rheumatologist (> 55% in each center type) at an early or intermediate stage (> 59%). Treatment was initiated most frequently by a dermatologist (office-based physicians: 69.6%, hospitals: 60.9%, university hospitals: 82.9%). Patients were treated with biologics more frequently in university hospitals (single therapy: 43.9%, in combination with systemic therapy: 26.8%) compared to private practices (single: 44.6%, combination: 13.5%) and non-university hospitals (single: 34.8%, combination: 8.7%).

CONCLUSIONS

As PsA diagnosis was performed most frequently by rheumatologists whereas treatment was primarily initiated by dermatologists, an optimal collaboration between these specialists is crucial.

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.

Early intervention in psoriasis: Where do we go from here?

Patients with psoriasis often have comorbidities and are at increased risk of developing several complications compared with the general population. Knowledge on the role of immune mediators and systemic inflammation in psoriasis has led to the hypothesis that early intervention with systemic therapy has the potential to modify the course of the disease and reduce the risk of long-term adverse outcomes. In this article, we address some potential issues that need to be considered before early intervention can be implemented routinely. The first is determining what constitutes "early" intervention for psoriasis. A second point is whether the intervention should be considered for patients with early disease or for selected subsets based on risk stratification. A third important consideration is defining success for early intervention. Finally, adoption of early and effective intervention should be based on high-level evidence. Ideally, randomized trials would be the best strategy to compare early vs. late systemic treatment in patients with psoriasis, probably using the frequency of long-term outcomes as primary endpoint, with cutaneous and pharmacoeconomic outcomes assessed secondarily.

Clinical Characteristics of Potential "Difficult-to-treat" Patients with Psoriatic Arthritis: A Retrospective Analysis of a Longitudinal Cohort

Introduction

The EULAR group recently published the definition of difficult-to-treat (D2T) patients for rheumatoid arthritis. However, a similar definition is lacking for patients with psoriatic arthritis (PsA), in which its multi-domain expression may impact the treatment response. The aim of the study was to characterize the potential D2T PsA patients, to assess the risk factors, and to determine the burden of disease.

Methods

Retrospective analysis of a longitudinal cohort of PsA patients attending a tertiary care center. At each visit, the patients underwent a complete physical examination and the clinical/laboratory data were collected. Data on comorbidities with the assessment of different comorbidity indices were also collected. Disease activity was assessed by using the DAPSA score and the MDA. The PsAID and HAQ-DI were also collected. We use the previous identified definition of D2T patients, applied to our PsA group and modified for this study.

Results

A total of 106 patients fulfilled the inclusion criteria and were evaluated. Of these, 36 (33.9%) patients fulfilled the criteria for the potential D2T patients. D2T patients showed a significantly higher BMI and higher prevalence of fibromyalgia. Furthermore, D2T patients showed a significantly higher median Functional Comorbidity Index and a significantly higher BSA, LEI, pain level, PsAID score, and HAQ-DI than non-D2T patients. Potential D2T patients also showed a significant delay in the time from diagnosis to first b/ts DMARDs treatment.

Conclusions

Our study firstly evaluated the presence of clinical characteristics of potential D2T patients and may contribute to future research on this intriguing aspect.

Real world effectiveness and satisfaction with secukinumab in the treatment of patients with psoriatic arthritis: a population survey in five European countries

OBJECTIVES

To describe the effectiveness of secukinumab in the treatment of psoriatic arthritis (PsA) and associated physician satisfaction with secukinumab treatment, in routine clinical practice across five European countries.

METHODS

A retrospective analysis of PsA patients receiving secukinumab for ≥4 months in France, Germany, Italy, Spain and the UK from March to December 2018. Data based on physician-completed questionnaires at initiation of treatment and at the data collection consultation were collected and used to assess effectiveness.

RESULTS

572 PsA patients with a mean age of 47.9 years, 57.0% were male, with 5.6% of patients with mild, 55.2% with moderate and 38.1% severe PsA prior to treatment initiation were included. 33.0% of patients received a dosage of 150 mg and 67.0% a dosage of 300 mg secukinumab. Around 84% of patients received secukinumab for 6 months or longer. Symptoms seen at current assessment in over 20% of patients were tender or swollen joints or psoriatic skin lesions. Between initiation of treatment and the current consultation, improvements in skin, joint and overall severity were reported. Physician satisfaction with secukinumab's ability to control disease was very high during the study period, greater than 90%, and was seen irrespective of disease severity at initiation, prior biologic use, treatment duration, time since diagnosis or onset of symptoms, treatment history, and BMI.

CONCLUSION

Physicians were satisfied with the ability of secukinumab to control disease and it was effective in the treatment of PsA patients in routine clinical settings.

Real-life efficacy of guselkumab in patients with early psoriatic arthritis

OBJECTIVES

To assess the efficacy of the novel anti-IL-23 monoclonal antibody Guselkumab in a real-life observational cohort of patients with early Psoriatic arthritis (PsA).

METHODS

We conducted an observational study on patients with early PsA followed by the joint dermatology-rheumatology clinics of two Italian centres starting therapy with guselkumab for severe skin involvement. Each patient was evaluated at baseline and every 24 weeks for one year, recording DAPSA, PASI, VAS Pain, VAS Prutitus, Patient's Global Assessment (PtGA) and assessing DAPSA response.

RESULTS

Twenty-four patients were recruited (16 women). The mean duration of skin disease was 12.5 years [CI 8; 17], but all patients had a shorter articular disease duration, 21.29 months [CI 15.9; 26.68]. At baseline, all patients displayed a moderate cutaneous disease with a mean PASI of 15.2 [CI 11.7-18.6] and high disease activity, characterized by mean DAPSA of 26.84 (CI 22.49-31.19). An inflammatory low back pain ware reported by five patients (20%) with a mean BASDAI 5.1 [4,38-5,85] at baseline. The majority of guselkumab-treated patients (N = 18; 75%) reached DAPSA remission or DAPSA low disease activity (LDA) after six months. Seventeen out of 24 patients completed 12 months of treatment, 11 of them (65%) in LDA, 6 (35%) in remission. All patients with axial disease reported improvement of inflammatory low back pain at week 24 with a mean BASDAI 2.98 [2,18- 3,77]. No significant side effects were reported.

CONCLUSIONS

Real-life data on a cohort of early PsA patients confirm the efficacy and safety of Guselkumab on peripheral and axial manifestations.

Treatment Persistence and Adherence Among Patients With Psoriatic Arthritis Who Initiated Targeted Immune Modulators in the US: A Retrospective Cohort Study

Introduction

This study compared treatment persistence and adherence among psoriatic arthritis (PsA) patients in the US who initiated an interleukin-12/23 inhibitor (IL-12/23i) versus those who initiated tumor necrosis factor inhibitors (TNFis), targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs), or interleukin-17 inhibitors (IL-17is).

Methods

Adults diagnosed with PsA with ≥ 1 claim for a targeted immune modulator were selected from the IBM MarketScan^® Commercial and Medicare Supplemental databases (October 1, 2013–October 31, 2018). The date of the first claim was the index date. Patients had continuous health plan enrollment for ≥ 12 months pre-index and ≥ 12-month post-index period. Pairwise propensity score matching with nearest-neighbor technique was performed. Persistence duration, discontinuation rate, and the proportion of days covered (PDC) were evaluated in biologic/tsDMARD naïve patients who initiated TNFis, IL-17is, tsDMARDs, or IL-12/23i (reference group).

Results

There were 238 matched patient pairs for TNFi versus IL-12/23i, 238 pairs for tsDMARD versus IL-12/23i, and 189 pairs for IL-17is versus IL-12/23i. Duration of persistence was longer for the IL-12/23i cohort than for the TNFi (269 vs. 215 days, p < 0.001) or tsDMARD (269 vs. 213 days, p < 0.001) cohorts, but comparable between the IL-12/23i and IL-17i cohorts (267 vs. 246 days, p = 0.199). Fewer patients in the IL-12/23i cohort discontinued their index medication than in the TNFi (53.4% vs. 73.9%, p < 0.001) or tsDMARD (53.4% vs. 71.8%, p < 0.001) cohorts, but no significant difference was observed between the IL-12/23i and IL-17i cohorts (52.9% vs. 58.2%, p = 0.288). During the 12-month follow-up, adherence (i.e., PDC) was higher among those who initiated an IL-12/23i than among those who initiated TNFis (0.64 vs. 0.56, p = 0.004) or tsDMARDs (0.64 vs. 0.58, p = 0.027), but similar to those who initiated IL-17is (0.64 vs. 0.65, p = 0.589).

Conclusion

In this real-world study of PsA therapies with differing mechanisms of action, the IL-12/23i demonstrated longer persistence and higher adherence than either TNFis or tsDMARDs, and comparability to IL-17is.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01687-w.

Early psoriatic arthritis in Japan: Post-hoc analyses from a survey by the Japanese Society of Psoriasis Research

To determine the characteristics of the early phase of psoriatic arthritis (PsA), we conducted a subanalysis of a retrospective survey of Japanese patients. In this study, we enrolled patients with early onset within either 2 years or 1 year from onset among the 1282 patients with PsA that had previously been reported. Among the total reported PsA patients, 304 (23.7%) were diagnosed with less than 2 years of onset of joint manifestation. The male : female ratio was 1.9:1, mean age at onset of cutaneous psoriasis 40.2 years, and that of joint manifestation 50.3 years. Age of less than 20 years at cutaneous psoriasis onset was observed in 22 cases, while that at joint manifestation was observed in two cases. Plaque-type psoriasis accounted for 90.1%, followed by psoriasis erythroderma (3.9%), pustular psoriasis (3.9%), and nail psoriasis (1.3%). Polyarthritis was the most common joint manifestation (32.9%), followed by distal interphalangeal (DIP) type (29.6%), oligoarthritis type (27.3%), and ankylosing spondylitis type (4.9%). Enthesitis was observed in 27.3% and dactylitis in 61.8%. Biologics were used in 168 cases (55.3%). By contrast, 199 patients (15.5%) were diagnosed within 1 year of onset of joint manifestation, among whom polyarthritis was the most common (30.7%). Biologics were used in 50.8%. In conclusion, the present study showed that the frequency of early PsA within 2 years of onset accounted for 23.7%, and those within 1 year of onset was 15.5% among the Japanese patients with PsA. Polyarthritis was the most common in early PsA patients.

PsART-ID inception cohort: clinical characteristics, treatment choices and outcomes of patients with psoriatic arthritis

OBJECTIVES

Our aim is to understand clinical characteristics, real-life treatment strategies, outcomes of early PsA patients and determine the differences between the inception and established PsA cohorts.

METHODS

PsArt-ID (Psoriatic Arthritis- International Database) is a multicentre registry. From that registry, patients with a diagnosis of PsA up to 6 months were classified as the inception cohort (n==388). Two periods were identified for the established cohort: Patients with PsA diagnosis within 5-10 years (n = 328), ≥10 years (n = 326). Demographic, clinical characteristics, treatment strategies, outcomes were determined for the inception cohort and compared with the established cohorts.

RESULTS

The mean (s.d.) age of the inception cohort was 44.7 (13.3) and 167/388 (43.0%) of the patients were male. Polyarticular and mono-oligoarticular presentations were comparable in the inception and established cohorts. Axial involvement rate was higher in the cohort of patients with PsA ≥10 years compared with the inception cohort (34.8% vs 27.7%). As well as dactylitis and nail involvement (P = 0.004, P = 0.001 respectively). Both enthesitis, deformity rates were lower in the inception cohort. Overall, 13% of patients in the inception group had a deformity. MTX was the most commonly prescribed treatment for all cohorts with 10.7% of the early PsA patients were given anti-TNF agents after 16 months.

CONCLUSION

The real-life experience in PsA patients showed no significant differences in the disease pattern rates except for the axial involvement. The dactylitis, nail involvement rates had increased significantly after 10 years from the diagnosis and the enthesitis, deformity had an increasing trend over time.

DGEMRIC in the Assessment of Pre-Morphological Cartilage Degeneration in Rheumatic Disease: Rheumatoid Arthritis vs. Psoriatic Arthritis

Background: Even though cartilage loss is a known feature of psoriatic (PsA) and rheumatoid arthritis (RA), research is sparse on its role in the pathogenesis of PsA, its potential use for disease monitoring and for differentiation from RA. We therefore assessed the use of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) to evaluate biochemical cartilage changes in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in PsA patients and compared these to RA patients. Materials and Methods: A total of 17 patients with active PsA and 20 patients with active RA were evaluated by high-resolution 3 Tesla dGEMRIC using a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices and joint space width (JSW) at MCP and PIP joint levels. Results: No significant differences of dGEMRIC values could be found between both study populations (PsA 472.25 ms, RA 461.11 ms; p = 0.763). In all RA and most PsA patients, PIP joints showed significantly lower dGEMRIC indices than MCP joints (RA: D2: p = 0.009, D3: p = 0.008, D4: p = 0.002, D5: p = 0.002; PsA: D3: p = 0.001, D4: p = 0.004). Most joint spaces had similar widths in both disease entities and no significant differences were found. Conclusions: As evaluated by dGEMRIC, the molecular composition of the MCP and PIP joint cartilage of PsA patients is similar to that of RA patients, demonstrating the scientific and clinical feasibility of compositional magnetic resonance (MR) imaging in these disease entities. Patterns and severity of compositional cartilage degradation of the finger joints may therefore be assessed beyond mere morphology in PsA and RA patients.

Differentiating rheumatoid and psoriatic arthritis: a systematic analysis of high-resolution magnetic resonance imaging features-preliminary findings

BACKGROUND

Because of overlapping phenotypical presentations, the diagnostic differentiation of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) remains challenging. Thus, this study aimed to examine the diagnostic value of distinct imaging features obtained by high-resolution 3-T MRI for the diagnostic differentiation.

MATERIALS AND METHODS

Seventeen patients with PsA and 28 patients with RA were imaged at high resolution using 3-T MRI scanners and a dedicated 16-channel hand coil. All images were analyzed according to the outcome measures in rheumatology clinical trials' (OMERACT) RAMRIS (Rheumatoid Arthritis Magnetic Resonance Imaging Score) and PsAMRIS (Psoriatic Arthritis Magnetic Resonance Imaging Score) for the presence and intensity of synovitis, flexor tenosynovitis, bone edema, bone erosion, periarticular inflammation, bone proliferation, and joint space narrowing. Next, odds ratios (OR) were calculated to determine the strength of the associations between these imaging features, demographic characteristics, and the outcome RA vs. PsA.

RESULTS

PsA could be differentiated from RA by extracapsular inflammatory changes (PsAMRIS sub-score "periarticular inflammation"), with low odds for the presence of RA (OR of 0.06, p < 0.01) at all metacarpophalangeal (MCP) joints. A prediction model informed by the items that were strongest associated with the presence of RA or PsA demonstrated excellent differentiating capability with an area under the curve of 98.1%.

CONCLUSION

High-resolution imaging is beneficial for the identification of relevant imaging features that may assist the clinical differentiation of inflammatory conditions of the hand. At the MCP level, extracapsular inflammatory changes were strongly associated with PsA and may consequently allow the imaging differentiation of PsA and RA.

Interleukin-17A biomarker as a predictor for detection of early axial spondyloarthritis changes in patients with psoriasis

AIM

Although the pathogenic mechanisms of psoriatic arthritis (PsA) are not completely clarified, evidence suggests that interleukin 17A (IL-17A)-mediated immune responses play a pivotal role in the disease. This is best underscored by the important clinical effectiveness of IL-17A inhibitors in psoriasis treatment. We aim to investigate the predictive value of IL-17A in detecting the early axial spondyloarthropic (SpA) changes in psoriatic patients.

METHODS

The study enrolled 100 patients with psoriasis, classified into group 1, included 62 patients with only psoriatic skin lesions (Ps), and group 2 included 38 patients with PsA, and 100 age and gender matched healthy volunteers. All participants were subjected to general and local clinical examination, laboratory assessment including IL-17A in the serum by means of enzyme-linked immunosorbent assay, and axial joint radiological assessment.

RESULTS

Our study included 60 males (60%) and 40 females (40%).The positive radiological findings of early axial SpA changes were found among 30.6% of the Ps group and among 84.2% of the PsA group. There were significant differences between patients with positive magnetic resonance imaging (MRI) findings of early axial SpA and patients with negative MRI findings in both groups regarding IL-17A levels. There was a significant association between IL-17A level and early axial SpA changes in psoriatic patients with a clear cutoff point (222.5).

CONCLUSION

Our study can imply that IL-17A is a valuable, useful and low-cost biomarker in detecting early axial SpA changes in asymptomatic and nonradiographic axial SpA (nr-axial SpA) psoriatic patients that helps early management and prevent progressive axial involvement and disabilities.

The gut microbiome in psoriasis and psoriatic arthritis

This review summarizes existing research on the gut microbiome composition and function in psoriasis and psoriatic arthritis, exploring potential roles in disease pathogenesis, progression, and management. A strong relationship between skin, joint, and gastrointestinal inflammation exists, as demonstrated by an increased prevalence of psoriasis, psoriatic arthritis, and inflammatory bowel disease co-occurring together; however, the link between them has not been fully elucidated. Studies analyzing the gut microbiome in psoriasis and psoriatic arthritis reveal a unique pattern of dysbiosis. With regard to the gut microbiome's role in psoriasis and psoriatic arthritis pathogenesis, we discuss several theories including intestinal permeability, altered immune homeostasis, and imbalance of short- and medium-chain fatty acid-producing bacteria. We also discuss how the gut microbiome affects patient risk of psoriatic arthritis and other serious comorbidities, and how fecal microbes could be used clinically as therapeutic targets or markers of disease.

Long-term efficacy and safety of secukinumab in patients with psoriatic arthritis: 5-year (end-of-study) results from the phase 3 FUTURE 2 study

BACKGROUND

Secukinumab is an interleukin-17A inhibitor used in the treatment of patients with active psoriatic arthritis. In the phase 3 FUTURE 2 trial, secukinumab showed sustained improvement in clinical outcomes over 2 years. Because scarce data exists on the long-term treatment with biological therapies in patients with psoriatic arthritis, we aimed to assess and describe the 5-year (end-of-study) results on the efficacy and safety of secukinumab 300 mg and 150 mg doses, as well as dose escalation, from the FUTURE 2 study.

METHODS

FUTURE 2 is a phase 3, double-blind, placebo-controlled study done at 76 centres in Asia, Australia, Canada, Europe, and the USA. Patients with active psoriatic arthritis aged 18 years or older were randomly assigned to either secukinumab (300 mg, 150 mg, or 75 mg) or placebo weekly from baseline and then every 4 weeks from week 4. Secukinumab dose was escalated from 150 mg to 300 mg and from 75 mg to 150 mg or 300 mg starting at week 128, if active signs of disease were observed in patients, on the basis of the physician's assessment, with the escalated dose maintained thereafter. We assessed key efficacy endpoints at week 260 (5 years) for secukinumab 300 mg and 150 mg, including American College of Rheumatology (ACR) and Psoriasis Area and Severity Index (PASI) responses. The safety analysis included all patients who received one or more doses of secukinumab. We report data as observed. This study is registered with ClinicalTrials.gov, NCT01752634.

FINDINGS

At randomisation, 65% of patients were naive to tumour necrosis factor inhibitors and 47% were receiving concomitant methotrexate. Of 397 patients randomly assigned in FUTURE 2, 248 (62%) completed 5 years of treatment, including 64 (64%) of 100 patients in the original secukinumab 300 mg group, 65 (65%) of 100 in the 150 mg group, 59 (60%) of 99 in the 75 mg group, and 60 (61%) of 98 in the placebo group. Overall, 127 (52%) of 242 patients required dose escalation during the study. ACR responses at 5 years were 71 (74%; ACR20), 50 (52%; ACR50), and 31 (32%; ACR70) of 96 evaluable patients in the secukinumab 300 mg group, and 67 (70%; ACR20), 41 (43%; ACR50), and 28 (29%; ACR70) of 96 evaluable patients in the secukinumab 150 mg group. From 24 to 32 weeks and from 48 to 84 weeks after dose escalation from secukinumab 150 mg to 300 mg, the proportions of ACR and PASI non-responders decreased, whereas the proportions of ACR and PASI responders increased. During the entire treatment period, the most frequent treatment-emergent serious adverse event was serious infection (exposure-adjusted incidence 1·7, 95% CI 1·1-2·5; n=25) in the any secukinumab group. No new or unexpected safety signals were reported.

INTERPRETATION

Secukinumab 300 mg and 150 mg provided sustained improvement in the signs and symptoms of psoriatic arthritis, with consistent safety over 5 years. This study supports the clinical benefit and safety of long-term treatment with secukinumab in patients with psoriatic arthritis.

FUNDING

Novartis.

High-resolution MRI of flexor tendon pulleys using a 16-channel hand coil: disease detection and differentiation of psoriatic and rheumatoid arthritis

Background

To evaluate the value of 3 Tesla (T) magnetic resonance imaging (MRI) changes of flexor tendon pulleys for the differentiation of psoriatic (PsA) and rheumatoid arthritis (RA), using a novel 16-channel high-resolution hand coil.

Methods

Seventeen patients with active PsA, 20 patients with active RA, and 16 healthy controls (HC) underwent high-resolution 3 T MRI using the dedicated 16-channel hand coil. Images were analyzed by three independent readers for the degree of inflammatory changes, thickness of flexor tendon pulleys, and comparison to the outcome measures for RA clinical trials (OMERACT) PsA MRI score (PsAMRIS) and to its sub-scores. For correlation analyses, Spearman rho correlation was calculated.

Results

Flexor tendon pulleys were thicker in PsA than in RA patients (mean difference 0.16 mm, p < 0.001) and HC (mean difference 0.2 mm, p < 0.001) and showed a higher degree of associated inflammatory changes (mean difference from RA 4.7, p = 0.048; mean difference from HC 14.65, p < 0.001). Additionally, there was a strong correlation of accessory pulley inflammation and PsAMRIS and its acute-inflammatory sub-scores, flexor tenosynovitis, synovitis, and periarticular inflammation (for the second digit synovitis ρ = 0.72, flexor tenosynovitis ρ = 0.7, overall PsAMRIS ρ = 0.72, p < 0.01). Similar robust correlations were evident in digits 3–5. Weaker correlations were evident in RA (synovitis ρ = 0.49, flexor tenosynovitis ρ = 0.49, periarticular inflammation ρ = 0.4).

Conclusion

The assessment of MRI changes of flexor tendon pulleys is potentially beneficial for disease detection in PsA, as well as for its distinction from RA and HC.

Trial registration

2014123117, December 2014.

Disease interception with interleukin-17 inhibition in high-risk psoriasis patients with subclinical joint inflammation-data from the prospective IVEPSA study

BACKGROUND

A specific subset of psoriasis patients is characterized by subclinical inflammatory changes. These patients frequently present with arthralgia and have a higher risk to develop psoriatic arthritis (PsA). We hypothesized that IL-17A inhibition in this subset of patients can intercept the link between skin and joint disease and resolves pain and inflammatory changes.

METHODS

Psoriasis, but no PsA, patients were included in the open prospective exploratory Interception in very early PsA (IVEPSA) study. Patients had to have nail or scalp involvement or a high psoriasis area severity index (PASI) (> 6) as well as inflammatory or erosive changes in MRI or CT. Patients received treatment with the anti-interleukin (IL)-17A antibody secukinumab over 24 weeks. Clinical assessments of skin and joint disease were done at baseline and after 12 and 24 weeks, MRI and CT at baseline and after 24 weeks.

RESULTS

Twenty patients were included, 85% of them reporting arthralgia and 40% had tender joints at the examination. Eighty-three percent had at least one inflammatory lesion in the MRI, most of them synovitis/enthesitis. Skin disease (PASI: p < 0.002; BSA: p < 0.003) and arthralgia (VAS pain: p < 0.003) significantly improved after 24 weeks. Total PsAMRIS (p = 0.005) and synovitis subscore (p = 0.008) also significantly improved. Erosions and enthesiophytes did not progress, while bone mass in the distal radius significantly (p = 0.020) increased after 24 weeks.

CONCLUSIONS

These data suggest that very early disease interception in PsA is possible leading to a comprehensive decline in skin symptoms, pain, and subclinical inflammation. IVEPSA therefore provides rationale for future early interventions with the concept to prevent the onset of PsA in high-risk individuals.

TRIAL REGISTRATION

Trial registry name PSARTROS; trial registry number: NCT02483234; June 26, 2015.

PsA-Disk, a novel visual instrument to evaluate psoriatic arthritis in psoriatic patients: an Italian derma-rheuma multicentre study

Background:

Consensus among dermatologists and rheumatologists in the diagnosis and assessment of musculoskeletal diseases in psoriasis (PsO) patients is needed. This study assesses characteristics of musculoskeletal pain in patients with PsO for the presence of psoriatic arthritis (PsA) and evaluation of a novel 16-item visual instrument (PsA-Disk).

Methods:

Data were collected from eight dermatological/rheumatological centres across Italy. Patients with PsO completed PEST (Psoriasis Epidemiology Screening Tool) and PsA-Disk questionnaires during the first visit. A rheumatological visit was performed to confirm the presence of PsA. Both validity and reliability of PsA-Disk were assessed.

Results:

A total of 573 patients with PsO were examined at the first visit, and 120 (21%) were diagnosed with PsA. Patients with PsA compared with patients with PsO (n = 119) presented statistically significant differences for: nail involvement, PEST score ⩾3, higher erythrocyte sedimentation rate (ESR), Nail Psoriasis Severity Index (NAPSI)-feet, NAPSI-(hands + feet) and PsA-Disk scores (73.9 ± 32.1 versus 58.1 ± 39.8, p < 0.001). Patients with PsA with knee arthritis had higher PsA-Disk scores (98.4 ± 26 versus 71.5 ± 31.9, p = 0.006) that were also correlated with number of swollen (r = 0.2, p < 0.05) and tender joints (r = 0.24, p = 0.021), patient (r = 0.4, p < 0.001) and physician-pain-visual analogue scale (VAS; r = 0.33, p < 0.001), patient global assessment (PGA)-VAS (r = 0.23, p = 0.025), physician-health assessment questionnaire (HAQ; r = 0.38, p = 0.011), Disease Activity Score (DAS)-44 (r = 0.25, p = 0.023) and Disease Activity in Psoriatic Arthritis (DAPSA; r = 0.31, p = 0.005). The instrument had excellent reliability in terms of internal consistency (Cronbach’s alpha = 0.90) and stability (intraclass correlation = 0.98). Moderate agreement between PsA-Disk and PEST (Cohen’s kappa = 0.46) was observed, while construct validity appeared appropriate [PsA + patients: PsA-Disk score (interquartile range; IQR) =71 (50–96); PsA-patients: PsA-Disk score (IQR)=50 (20–90); p < 0.001].

Conclusion:

PsA-Disk may be considered a valid novel instrument aiding both dermatologists and rheumatologists in the rapid detection and assessment of musculoskeletal disease characteristics.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

Objective:

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

Methods:

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

Results:

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

Conclusion:

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

The GOLMePsA study protocol: an investigator-initiated, double-blind, parallel-group, randomised, controlled trial of GOLimumab and methotrexate versus methotrexate in early diagnosed psoriatic arthritis using clinical and whole body MRI outcomes

Background

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis which impacts significantly on the quality of life and work capacity of affected individuals. Recent evidence has shown that early control of inflammation in PsA leads to improved long-term outcomes. It is postulated that prompt intervention after diagnosis using a remission-induction treatment strategy will lead to improved outcomes and optimal disease control of PsA.

The aim of the present study was to compare the clinical efficacy of a treatment strategy in newly diagnosed, treatment naïve PsA subjects, using the combination of golimumab (GOL), methotrexate (MTX) and steroids versus standard care (MTX monotherapy plus steroids).

Methods/design

GOLMePsA is an investigator initiated, phase IIIb, single-centre, randomised, double-blind, placebo-controlled, two-armed, parallel-group, imaging-supplemented study. Eighty-eight PsA patients, diagnosed within 24 months prior to screening and treatment naïve, will be randomised at baseline to receive: (arm 1) the combination of intramuscular/intra-articular prednisolone, MTX and GOL or (arm 2) the combination of intramuscular/intra-articular prednisolone, MTX and placebo for 24 weeks (interventional period). Primary outcome measure is clinical improvement (at least 1 unit difference) in the Psoriatic ArthritiS Disease Activity Score (PASDAS) composite index.

Reflecting a “step down” therapeutic approach, all participants successfully completing the interventional period will be followed up for a further 28 weeks. During this observational period, stable maintenance MTX monotherapy will continue for both arms, unless in case of intolerance or PsA relapse. In the latter case, additional treatment will be provided. Overall, the GOLMePsA study length is planned to be 52 weeks.

Discussion

The hypothesis underlining this study is that very early treatment with first-line GOL reduces disease activity in PsA, in comparison to conventional therapy.

Trial registration

EudraCT 2013–004122-28. 24/09/2013.

The effect of smartphone addiction on hand joints in psoriatic patients: an ultrasound-based study

BACKGROUND

Distal interphalangeal (DIP) arthritis is a frequent form of psoriatic arthritis being often linked to nail psoriasis. Modern society is characterized by overuse of smartphones. Indeed, literature has recently focalized on research into smartphone addiction and health-related problems.

OBJECTIVES

As smartphone addiction is able to determine overuse and repeated movements of DIP joints and nails, the aim of this study was to evaluate the impact of smartphone use on hand joints of young psoriatic patients.

METHODS

An observational study involving four different groups such as non-smartphone-addicted (SA) psoriatic patients, SA psoriatic patients, non-SA controls and SA controls was performed. Each subject underwent an ultrasound examination of both hands by three independent and blinded to group assignment radiologists. A specific score was used to evaluate the inflammatory state of the analysed joints.

RESULTS

The total ultrasound score was statistically significantly higher in SA controls respect to non-SA controls (3.4 vs. 1.4; P < 0.05) as well as in SA psoriasis patients compared to non-SA psoriatic subjects (15.2 vs. 6.7; P < 0.01). Higher mean of ultrasound score was found for left hand in controls (both SA or not) and for right hand in psoriatic subjects (both SA or not), however without reaching statistical significance.

CONCLUSIONS

Smartphone overuse was found to be linked with higher signs of inflammation of musculoskeletal structures of hands joints in both psoriasis and controls through ultrasound examination. Therefore, smartphone overuse may be a factor which facilitate or speed up the possible development of psoriatic arthritis.

Tumor necrosis factor inhibitors in psoriatic arthritis

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory disease that can result in significant disability. With the emergence of tumor necrosis factor inhibitors (TNFi), therapeutic outcomes in PsA have improved substantially. The clinical efficacy and the inhibition of radiographic progression demonstrated by TNFi have transformed the management of PsA. However, there is still an unmet need for a subset of patients who do not respond adequately to TNFi. Areas covered: This review provides an overview of the pharmacokinetics of TNFi, the efficacy of TNFi in PsA, and the role of immunogenicity of TNFi in the treatment of PsA. In addition, we address the use of TNFi in the setting of other medications utilized in the treatment of PsA and the potential future role of biosimilars. Expert commentary: Monoclonal antibodies exhibit complex and widely variable pharmacokinetics. The study of factors that can affect the pharmacokinetics, such as immunogenicity, is valuable to further define and understand the use of TNFi in PsA, especially in the subset of patients who do not respond adequately to these agents or lose effectiveness over time.

Screening of Patients with Psoriasis for Psoriatic Arthritis in the Slovak Republic

Global prevalence of psoriasis is ranging from 0.91 % to 8.5 % [1]. Exact numbers are missing for Slovakia. 1-5% range is the most probable while 2 % is also mentioned as an average prevalence for the European population. There is approximately 110 thousand patients suffering from psoriasis when extrapolating from total population of 5.5 million [2]. Extracutaneous manifestation is observed in 11–30 % of patients after years of solely skin symptoms presentation [3, 4, 5, 6].

Objective: To estimate prevalence of psoriatic arthritis among psoriatic patients population visiting dermatology out-patient irrelevant of the disease duration and the treatment regimen. To compare the sensitivity of both tests (ToPAS and PASE) used, evaluate possible PsA risk factors.

Methods: This was a prospective, non-interventional, epidemiological, observational study conducted using a survey administered to psoriatic patients by their dermatologists. 10–20 consequent outpatients with psoriasis in each center in 43 regional dermatology officies were screened for the presence of extra-cutaneous symptoms (i.e. joint pain, enthesitis, dactylitis, nail involvement) using questionnaire, developed specificaly for this study, and by the PASE and ToPAS questionnaires. Patients without personal history of PsA and „positivity“ of PASE and/or ToPAS were sent to the center for confirmation / exclusion of the diagnosis by applying CASPAR criteria. Outcomes were statistically processed.

Results: 177 (21.8 %) of total of 831 psoriatic patients had PsA. 9 of 177 (5.35 %) has been newly diagnosed. There was almost equal number of men (50.5 %) and women (49.5 %).

Plaque psoriasis has been most frequent type – 76.9 %. 43.2 % of PsA patients reported the onset of the disease after 40 years of life. Time interval between onset of psoriasis and PsA has been less than 10 years in 20.2 %, 10–20 years in 20.8 % and more than 20 years in 16.1 %. Most frequent co-morbidity in the study population was hypertension 23.2 %, asthma 3 % and diabetes 2.4 %. Average value of BSA and PASI was higher in PsA vs. non-PsA group: 24 vs. 20 and 10 vs 9, respectively. The sensitivity (72.6 % vs 58.9 %, P=0.01) and specificity (81.3 % vs 80.5 %) of ToPAS was higher compared to PASE.

Conclusion: 21.8 % PsA prevalence in psoriatic population in Slovakia is within the range observed in other studies. ToPAS test showed comparable results in terms of specificity, but significantly better results in terms of sensitivity and its early application should be of major importance because of the diagnostic process acceleration. The effect of an early diagnosis on the total patient outcome should be an objective of further research. This project was supported from educational grant of Pfizer Inc.

Psoriatic arthritis and psoriasis: differential diagnosis

Psoriasis frequency ranges from 1 to 3 % in white population, and arthritis occurs in 10-40 % of psoriasis patients, representing a relevant health issue. Psoriatic arthritis (PsA) is an inflammatory arthropathy, associated with psoriasis, in which ocular-, intestinal-, metabolic-, and cardiovascular-related manifestations can variably coexist. In order to favor early PsA and psoriasis diagnosis, it is crucial to rule out other conditions that can resemble the disease and delay appropriate therapeutic approach. Therefore, the aim of this review is to focus on PsA and psoriasis differential diagnosis.

Clinical and Demographic Characteristics of Erosion-free and Erosion-present Status in Psoriatic Arthritis in a Cohort Study

OBJECTIVE

Psoriatic arthritis (PsA) has been recognized as a severe erosive disease. However, some patients do not develop erosions. We aimed to determine the prevalence, characteristics, and predictors of erosion-free patients (EFP) as compared with erosion-present patients (EPP) among patients with PsA followed prospectively.

METHODS

This is a retrospective analysis conducted on patients from the Toronto PsA cohort. Patients with at least 10 years of followup and radiographs were analyzed. Radiographs were scored with the modified Steinbrocker method. Baseline (first visit to clinic) characteristics were used to predict the development of erosions with logistic regression models. To examine the effect of time-varying covariates, Cox regression models were fit for the time to development of erosions from baseline.

RESULTS

Among 290 patients, 12.4% were EFP and 87.6% were EPP over the study period. The mean time to development of erosion in the EPP over the course of followup was 6.8 ± 6.1 years. EFP were diagnosed with psoriasis at a younger age compared with EPP. In both models, actively inflamed joints and clinically damaged joints were predictive of the development of erosion, whereas a longer duration of psoriasis at baseline decreased the odds of developing erosion. EPP had a higher percentage of unemployment as compared with EFP at baseline and followup visits.

CONCLUSION

Among patients with PsA followed for at least 10 years, 12.4% never develop erosions. The clinical and radiographic findings can ultimately assist in the stratification of a patient's prognosis regarding the development of erosions.

An evidence-based review of certolizumab pegol in the treatment of active psoriatic arthritis: place in therapy

Certolizumab pegol (CZP) is a pegylated humanized tumor necrosis factor-α inhibitor (TNFi) approved for the treatment of psoriatic arthritis (PsA) in Europe, the USA, and Latin American countries. CZP neutralizes TNF-α at its soluble and membrane portions. Due to the lack of Fc region, it does not induce complement or antibody-dependent cytotoxicity in vitro, unlike other TNFi. RAPID-PsA study, the only randomized clinical trial performed in PsA, is a Phase III clinical trial conducted in 409 PsA patients during 24 weeks. Patients were randomized to CZP (200 mg every 2 weeks or 400 mg every 4 weeks) or placebo. Patients in CZP arms reported improvements in skin disease, joint involvement, dactylitis, enthesitis, and quality of life. Safety profile was similar to that reported for other TNF-α inhibitors in PsA patients. This article summarizes the pharmacology and reviews the efficacy and tolerability of this drug in PsA. CZP is the newest TNFi with proved efficacy in all manifestations of psoriasis disease, except for axial involvement where the evidence has been derived from response to axial spondyloarthritis.

Emerging drugs for psoriatic arthritis

INTRODUCTION

The majority of Psoriatic Arthritis patients experience a good clinical response to anti-Tumor Necrosis Factor (TNF)-α therapies. However, treatment failure with anti-TNF-α can represent a relevant clinical problem.

AREAS COVERED

We review the efficacy and safety profile of biological therapies that have been reported from randomized, controlled trials in phase II and phase III available in Pubmed Database for agents targeting IL-12/23p40 antibody (ustekinumab) and IL-17 (secukinumab), inhibitor of phosphodiesterase 4, (apremilast), and of JAK/STAT pathways (tofacitinib) and CTLA4 co-stimulation (abatacept) in Psoriatic Arthritis.

EXPERT OPINION

In Psoriatic Arthritis, main emerging drugs are represented by the fully human monoclonal IL-12/23p40 antibody, ustekinumab, the agent targeting IL-17, secukinumab, and the inhibitor of phosphodiesterase 4, apremilast. Results on T cell co-stimulation inhibition by abatacept are insufficient both in psoriasis and in PsA. In vitro investigations on JAK/STAT pathways in PsA suggest that tofacitinib could represent a further valuable therapeutic option. Emerging biological treatments other than anti-TNF agents, ustekinumab, secukinumab and apremilast appear promising for Psoriatic Arthritis and recent studies have showed a good efficacy and an acceptable safety profile; however, further and long-term studies are advocated.

Short-Term Total Hip Arthroplasty Outcomes in Patients With Psoriatic Arthritis or Psoriatic Skin Disease Compared to Patients With Osteoarthritis

OBJECTIVE

Outcomes of total hip arthroplasty (THA) in patients with psoriasis have been poorly studied. This study was undertaken to assess whether patients with psoriatic arthritis (PsA) or those with cutaneous psoriasis (PsC) without evidence of inflammatory joint disease are at an increased risk for worse outcomes after THA as compared to patients with osteoarthritis (OA).

METHODS

Among subjects in a prospective THA registry, PsA and PsC cases were identified by International Classification of Diseases, Ninth Revision codes, and all cases were matched with patients with OA as controls. Analyses were performed to identify predictors of poor postoperative pain or function.

RESULTS

Of the 289 potential cases of PsA or PsC, 63 with PsA and 153 with PsC were validated. Self-report data were available postoperatively from 75% of PsA patients, 69% of PsC patients, and 94% of OA controls. In total, 51% of PsA patients and 56% of PsC patients were male, compared to 45% of OA controls (P = 0.04). Body mass index was higher in those with PsA or PsC (P = 0.002 versus controls). There were no differences in race or education between the 3 groups. PsA patients and PsC patients had more comorbidities than OA controls. PsA patients were more likely than PsC patients and OA controls to be current or previous smokers. Moreover, 54% of PsA patients were being treated with biologics or nonbiologic disease-modifying antirheumatic drugs, compared to 8% of PsC patients. There were no significant differences in pre- or postoperative Western Ontario and McMaster Universities OA Index scores for pain or function between the 3 groups. Short-Form 36 mental component summary scores were significantly better in the OA controls, both pre- and postoperatively (P = 0.006 and P < 0.001, respectively, versus PsA or PsC). EuroQol 5-domain health-related quality of life scores were significantly worse postoperatively for those with PsA or PsC (P < 0.0001 versus OA controls). In regression analyses, neither PsA nor PsC were risk factors for worse THA outcomes. Satisfaction with the outcomes of THA was similarly high among all 3 groups (P = 0.54).

CONCLUSION

Neither PsA nor PsC are risk factors for poor outcomes after THA. This is important information to convey to patients with either PsA or PsC who are contemplating surgical intervention with THA.

Progress in understanding and utilizing TNF-α inhibition for the treatment of psoriatic arthritis

The improved recognition of pathogenetic molecular mechanisms has led to the use of drugs targeting cytokines in different inflammatory arthropathies as well psoriatic arthritis (PsA). In particular, the progress in knowledge on tumor necrosis factor (TNF)-α in the pathogenesis of PsA has changed the therapeutic approach by use of direct and receptor cytokine antagonists. Currently, infliximab (IFX), adalimumab, etanercept, golimumab and certolizumab pegol represent the five anti-TNF-α available for the treatment of PsA. This review describes evidence on treatment aimed at neutralizing TNF-α in PsA patients, from the first study in 2000 until today, mainly derived from randomized clinical trials. In comparison with traditional therapies, anti-TNF-α agents have shown to have more efficacy both in treating clinical aspects, including enthesitis, dactylitis, joint pain and swelling, axial involvement, nail and skin lesions, and in reducing radiographic progression. Moreover, anti-TNF-α agents have been demonstrated to be reasonably safe in PsA, as confirmed by data derived by different registries.

New treatment paradigms in psoriatic arthritis: an update on new therapeutics approved by the U.S. Food and Drug Administration

PURPOSE OF REVIEW

The purpose of this study is to give an overview of the new treatments approved by the U.S. Food and Drug Administration (FDA) for use in psoriatic arthritis (PsA).

RECENT FINDINGS

FDA has approved three new drugs for PsA: Certolizumab-pegol: a PEGylated Fc-free tumour necrosis factor inhibitor (TNFi); ustekinumab: an anti interleukin (IL)-12 and IL-23 mAb; and apremilast and oral phosphodiesterase 4 inhibitor. On well designed and extensive developing programmes, all three drugs proved to be effective for the treatment of most PsA manifestations, including peripheral arthritis, skin involvement, enthesitis, dactylitis, quality of life and radiographic progression in patients failing traditional disease modifying drugs (DMARDs) and TNFi. Safety profile of all three drugs seems to be reassuring until now, although long-term data are still not available. Although Certolizumab-pegol is likely to be placed among the other TNFi, ustekinumab and apremilast, due to lower efficacy on arthritis, are being more frequently used as second-line therapy after TNFi failure, especially among rheumatologists.

SUMMARY

There are new therapeutic options approved for the treatment of PsA. For the first time, well proved effective therapies with a different mechanism of action than the inhibition of TNF alpha are available for the treatment of this progressive disease.

The Epidemiology of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by joint and entheseal inflammation with a prevalence of 0.05% to 0.25% of the population and 6% to 41% of patients with psoriasis. PsA is a highly heterogeneous inflammatory arthritis. In this review, current knowledge is discussed regarding the epidemiology of PsA, including disease manifestations, classification criteria for adult and juvenile PsA, methods for recognizing early PsA, including use of screening tools and knowledge of risk factors for PsA, and medical comorbidities associated with PsA.

Treat-to-target and Improving Outcomes in Psoriasis: A Report from the GRAPPA 2014 Annual Meeting

Treat-to-target strategies are part of routine clinical practice in cardiovascular medicine. This approach, however, is relatively new in rheumatology and dermatology and has not been widely applied to the management of psoriatic diseases. At the 2014 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in New York, New York, USA, several GRAPPA members summarized and participated in a panel discussion on the treat-to-target concept as it applies to psoriasis, its potential role in improving treatment outcomes, identification of specific treatment targets for psoriasis, and future directions for research.

Simple clinical indicators for early psoriatic arthritis detection

Background

Diagnosis of psoriatic arthritis (PsA), in a period of 12 months from the onset of the first articular episode, permits of identifying the early form defined as “early PsA”. The recognition of the disease in this phase leads to better outcome.

The aim of this study was to identify peculiar clinical and/or laboratory findings that could be useful for the diagnosis of “early PsA”.

Findings

Thirty-five patients with early onset of arthritis were observed. The following data were collected for each patient: family and personal history, physical examination, tender and swollen joint counts (TJC, SJC), tender entheseal count, presence of dactylitis and low back pain (LBP), and laboratory tests.

Among the 35 total patients, 24 showed skin and/or nail psoriasis or a family history of psoriasis.

The remaining 11 patients showed absence of concomitant or previous psoriasis and/or familiarity for psoriasis. The comparison between the two groups showed that patients with psoriasis had a significant presence of LBP, dactylitis and enthesitis than patients with psoriasis.

Conclusions

The study confirms that the distinctive clinical findings of PsA is psoriasis, but also LBP, dactylitis and enthesitis have a relevant role in early identification. A low number of SJC and TJC are frequently observed in early phases of PsA than in other forms of early arthritis. These aspects could be mostly helpful when psoriasis is not detected or can follow arthritis in absence of familiar positivity, making difficult PsA diagnosis.

In conclusion, careful medical history, clinical examination and first-level laboratory investigations are useful to characterize early phases of PsA.

Análisis Costo-Utilidad Del Uso De Adalimumab, Etanercept E Infliximab Para El Tratamiento De La Artritis Psoriásica En Uruguay

OBJECTIVE

To support an evidence-based decision regarding the inclusion of the anti TNF's adalimumab, etanercept or infliximab to the National Formulary of Uruguay for the treatment of psoriatic arthritis, in patients who did not respond to first-line treatment.

METHODS

We perform a cost-utility evaluation using a Markov model, to estimate the incremental costs and quality-adjusted life years (QALY) gained with each of these biologic drugs compared with palliative care only. The model considered the perspective of the National Health System, with a time horizon of 40 years.

RESULTS

Under base-case assumptions, infliximab results in an incremental cost-effectiveness ratio (ICER) of United States Dollars (USD) 47,294 compared to palliative care only. Adalimumab was extendedly dominated and etanercept was dominated. However, infliximab requires intravenous administration which could significantly reduce access to treatment, thus producing inequities for patients from different regions. The probabilistic sensitivity analysis shows that all biologics had null probabilities of being cost-effective considering a willingness-to-pay (WTP) threshold of one time the gross domestic product per capita of Uruguay per QALY.

CONCLUSIONS

In our analysis from the perspective of the National Health System, the use of biologic drug treatments for psoriatic arthritis results in an ICER above the WTP ceiling proposed by the World Health Organization. Reduction of drug prices could bring more favorable cost-effectiveness results.

Therapeutic strategies in psoriasis patients with psoriatic arthritis: focus on new agents

Psoriatic arthritis affects approximately 6-42 % of patients with psoriasis. It is useful for physicians or dermatologists managing psoriasis patients to be aware of how to concurrently manage the joint manifestations, as it is preferable and convenient to use a single agent in such patients. However, only certain therapies are effective for both. Systemic agents, which can be used for both skin and joint manifestations, include methotrexate and ciclosporin. For the group of biologic agents, the tumor necrosis factor inhibitors such as adalimumab, etanercept, infliximab, golimumab and certolizumab are effective. Ustekinumab is a more recently developed agent belonging to the group of anti-IL-12p40 antibodies and has been shown to be efficacious. Newer drugs in the treatment armamentarium that have shown efficacy for both psoriasis and psoriatic arthritis consist of the anti-IL-17 agent, secukinumab, and a phosphodiesterase-4 inhibitor, apremilast. The other anti-IL-17 agents, ixekizumab and brodalumab, as well as the oral Jak inhibitor, tofacitinib, have very limited but promising data. This review paper provides a good overview of the agents that can be used for the concurrent management of skin and joint psoriasis.

Dermatology Screening Tools: Project Update from the GRAPPA 2012 Annual Meeting

Several screening tools for early identification of psoriatic arthritis (PsA) have been developed. While these tools had high sensitivity and specificity during their development and initial validation, it remained to be determined how they would function with widespread use. At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in Stockholm, Sweden, these tools were compared for their utility when used to screen patients for PsA in clinics other than those in which they were developed. The screening tools did not perform as well as previously published, and members suggested new tools may need to be developed. An additional study of the prevalence of PsA in a large cohort of psoriasis patients, the PREPARE study, which investigated the use of screening questionnaires, was also presented.