The diagnosis and treatment of early psoriatic arthritis

TNF-α Activating Osteoclasts in Patients with Psoriatic Arthritis Enhances the Recruitment of Osteoclast Precursors: A Plausible Role of WNT5A-MCP-1 in Osteoclast Engagement in Psoriatic Arthritis

Psoriatic arthritis (PsA) results from joint destruction by osteoclasts. The promising efficacy of TNF-α blockage indicates its important role in osteoclastogenesis of PsA. WNT ligands actively regulate osteoclastogenesis. We investigated how WNT ligands activate osteoclasts amid the TNF-α milieu in PsA. We first profiled the expression of WNT ligands in CD14⁺ monocyte-derived osteoclasts (MDOC) from five PsA patients and five healthy controls (HC) and then validated the candidate WNT ligands in 32 PsA patients and 16 HC. Through RNA interference against WNT ligands in MDOC, we determined the mechanisms by which TNF-α exerts its effects on osteclastogenesis or chemotaxis. WNT5A was selectively upregulated by TNF-α in MDOC from PsA patients. The number of CD68⁺WNT5A⁺ osteoclasts increased in PsA joints. CXCL1, CXCL16, and MCP-1 was selectively increased in supernatants of MDOC from PsA patients. RNA interference against WNT5A abolished the increased MCP-1 from MDOC and THP-1-cell-derived osteoclasts. The increased migration of osteoclast precursors (OCP) induced by supernatant from PsA MDOC was abolished by the MCP-1 neutralizing antibody. WNT5A and MCP-1 expressions were decreased in MDOC from PsA patients treated by biologics against TNF-α but not IL-17. We conclude that TNF-α recruits OCP by increased MCP-1 production but does not directly activate osteoclastogenesis in PsA.

Perceptions of Rheumatologists on Diagnosis of Psoriatic Arthritis in China

Objective

High prevalence of undiagnosed psoriatic arthritis (PsA) and prolonged diagnostic delay are key troubles in the appropriate management of PsA. To analyze the possible causes for this phenomenon, a web-based nationwide survey was conducted to investigate rheumatologists’ perceptions on PsA diagnosis in China.

Methods

The electronic questionnaire consisting of 38 questions were designed by an expert panel and distributed with the online survey tool Sojump, which is a professional online survey platform. The completed questionnaires by real-name rheumatologists were collected.

Results

A total of 1594 valid questionnaires were included. More than half of Chinese rheumatologists reported it was challenging to make a diagnosis of PsA. The four major challenges were “Difficulties in identification of atypical or hidden psoriasis”, “Absence of diagnostic biomarkers”, “No active self-report of history or family history of psoriasis” and “Various musculoskeletal manifestations”. In diagnosing PsA, minor participants had incorrect knowledge of inflammatory arthropathy (13.7%), acute phase reactant (23.8%), and rheumatoid factor (28.7%). There were no significant differences in the knowledge of PsA and practice habits in diagnosing PsA between modern western medicine (WM)- and traditional Chinese medicine (TCM)-rheumatologists. The part-time rheumatologists were not as good as full-time rheumatologists in diagnosing PsA.

Conclusions

About three quarters of Chinese rheumatologists are familiar with the elements in PsA diagnosis and have good practice habits in diagnosing PsA. Four main challenges in making PsA diagnosis are revealed. There was no significant difference in the knowledge of PsA between WM- and TCM-rheumatologists.

Alarmins/stressorins and immune dysregulation in intractable skin disorders

Unlike other barrier epithelia of internal organs, the stratified squamous epithelium of the skin is always exposed to the external environment. However, the robust barrier structure and function of the skin are highly resistant against external insults so as to not easily allow foreign invasions. Upon sensing danger signals, the innate immunity system is promptly activated. This process is mediated by alarmins, which are released passively from damaged cells. Nuclear alarmins or stressorins are actively released from intact cells in response to various cellular stresses. Alarmins/stressorins are deeply involved in the disease processes of chronic skin disorders of an unknown cause, such as rosacea, psoriasis, and atopic dermatitis. Furthermore, alarmins/stressorins are also induced in the congenital skin disorders of ichthyosis and keratoderma due to defective keratinization. Studies on alarmin activation and its downstream pathways may help develop novel therapeutic agents for intractable skin disorders.

Model to Determine the Cost-Effectiveness of Screening Psoriasis Patients for Psoriatic Arthritis

OBJECTIVE

Screening psoriasis patients for psoriatic arthritis (PsA) is intended to identify patients at earlier stages of the disease. Early treatment is expected to slow disease progression and delay the need for biologic therapy. Our objective was to determine the cost-effectiveness of screening for PsA in patients with psoriasis in Canada.

METHODS

A Markov model was built to estimate the costs and quality-adjusted life years (QALYs) of screening tools for PsA in psoriasis patients. The screening tools included the Toronto Psoriatic Arthritis Screen, Psoriasis Epidemiology Screening Tool, Psoriatic Arthritis Screening and Evaluation, and Early Psoriatic Arthritis Screening Questionnaire (EARP) questionnaires. States of health were defined by disability levels as measured by the Health Assessment Questionnaire. State transitions were modeled based on annual disease progression. Incremental cost-effectiveness ratios and incremental net monetary benefits were estimated. Sensitivity analyses were undertaken to account for parameter uncertainty and to test model assumptions.

RESULTS

Screening was cost-effective compared to no screening. The EARP tool had the lowest total cost ($2,000 per patient per year saved compared to no screening) and the highest total QALYs (additional 0.18 per patient compared to no screening). The results were most sensitive to test accuracy and the efficacy of disease-modifying antirheumatic drugs (DMARDs). No screening was cost-effective (at $50,000 per QALY) relative to screening when DMARDs failed to slow disease progression.

CONCLUSION

If early therapy with DMARDs delays biologic treatment, implementing screening in patients with psoriasis in Canada is expected to represent a cost savings of $220 million per year and improve the quality of life.

Upregulation of miR-941 in Circulating CD14+ Monocytes Enhances Osteoclast Activation via WNT16 Inhibition in Patients with Psoriatic Arthritis

Psoriatic arthritis (PsA) is a destructive joint disease mediated by osteoclasts. MicroRNAs (miRNAs) regulate several important pathways in osteoclastogenesis. We profiled the expression of miRNAs in CD14+ monocytes from PsA patients and investigated how candidate microRNAs regulate the pathophysiology in osteoclastogenesis. The RNA from circulatory CD14+ monocytes was isolated from PsA patients, psoriasis patients without arthritis (PsO), and healthy controls (HCs). The miRNAs were initially profiled by next-generation sequencing (NGS). The candidate miRNAs revealed by NGS were validated by PCR in 40 PsA patients, 40 PsO patients, and 40 HCs. The osteoclast differentiation and its functional resorption activity were measured with or without RNA interference against the candidate miRNA. The microRNA-941 was selectively upregulated in CD14+ monocytes from PsA patients. Osteoclast development and resorption ability were increased in CD14+ monocytes from PsA patients. Inhibition of miR-941 abrogated the osteoclast development and function while increased the expression of WNT16. After successful treatment, the increased miR-941 expression in CD14+ monocytes from PsA patients was revoked. The expression of miR-941 in CD14+ monocytes is associated with PsA disease activity. MiR-941 enhances osteoclastogenesis in PsA via WNT16 repression. The miR-941 could be a potential biomarker and treatment target for PsA.

Early diagnosis of psoriatic arthritis among psoriasis patients: clinical experience sharing

Background

The early detection of psoriatic arthritis (PSA) poses a challenge to rheumatologists, even when their diagnosis is aided by sonography. In order to facilitate early detection of PSA among patients with psoriasis (PSO), we retrospectively analyzed of the relationships between serological markers and comorbidities in 629 psoriatic patients, 102 of which had PSA, while the other 527 had PSO.

Results

Serological markers were found not to be useful in distinguishing between PSA and PSO (p > 0.05 for all comparisons). The prevalence rate of PSA among PSO patients was around 19.4%. Two components of metabolic syndrome—hyperlipidemia (2.94%) and gout (4.9%)—were significantly more prevalent in PSA patients than in PSO patients (p < 0.05). The odds ratio for PSA is 15.94 in patients with hyperlipidemia with a 95% confidence interval (CI) of 1.64–154.80; meanwhile, the odds ratio for PSA is 3.83 in patients with gout with a 95% CI of 1.19–12.31. Allergic rhinitis (5.88%) was more prevalent in PSA patients than in PSO patients (p < 0.01). The odds ratio was 8.17 in patients with allergic rhinitis with a 95% CI of 2.26–29.50. Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents (both p < 0.05).

Conclusions

No clinical available serology markers, but hyperlipidemia, gout, axial spondylopathy (inflammatory back pain), or allergic rhinitis, could differentiate between psoriatic arthritis from psoriasis. Plasma hs-miR-210-3p and comorbidities may differentiate psoriatic arthritis from psoriasis.

Key Points • Clinical manifestations and comorbidities are different between psoriatic arthritis and psoriasis only patients. • Traditional serology markers are similar between psoriatic arthritis and psoriasis-only patients. • Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents in our study.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05132-1) contains supplementary material, which is available to authorized users.

Traitor or warrior-Treg cells sneaking into the lesions of psoriatic arthritis

Regulatory T (Treg) cells have been recognized to maintain immune tolerance, which contributes to prevention of autoimmune diseases. However, recent evidence has demonstrated different characteristics of these cells between those that are in circulation compared to those in various local tissues. In addition, the ability of Treg cells to have plasticity in certain disease settings and in inflammatory lesions has been increasingly recognized. Herein we summarize updated knowledge of Treg biology and discuss the current understanding of tissue-resident Treg cells in psoriatic arthritis (PsA), attempting to provide new insights into precise role of Treg cells in the immune response and as a possible therapeutic intervention in patients with PsA.

Challenges in the clinical diagnosis of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic heterogeneous inflammatory musculoskeletal disease. The non-specific and often subtle manifestations make early diagnosis and subsequent treatment challenging. In the absence of diagnostic criteria and biomarkers, the diagnosis is often delayed leading to poor long-term outcomes. In addition, the differential diagnosis of a patient presenting with arthritis in the setting of skin psoriasis is wide due to symptom overlap with many other diseases. Peripheral arthritis, dactylitis, enthesitis and axial arthritis are the 4 domains of musculoskeletal involvement in PsA and careful examination of each domain by a rheumatologist is the first step for a correct diagnosis. Other extra-musculoskeletal features such as the presence of uveitis, inflammatory bowel disease, nail psoriasis and elevated acute phase reactants aid in the diagnosis of PsA. Screening patients with skin psoriasis using validated questionnaires might help in early diagnosis especially when coupled with imaging.

Expert Consensus on a Set of Outcomes to Assess the Effectiveness of Biologic Treatment in Psoriatic Arthritis: The MERECES Study

Objective.

To reach a consensus on the instruments to be used in clinical practice to evaluate the effectiveness of biological disease-modifying antirheumatic drug (bDMARD) treatment in patients with psoriatic arthritis (PsA) in the short to medium term (3–6 mos), and to establish the minimum health outcomes for treatment continuation.

Methods.

A 2-round Delphi questionnaire was developed based on both the information gathered in the literature review and 4 discussion groups. The suitability and feasibility of the proposed sets of instruments were assessed on a 7-point Likert scale. Consensus was established when at least 75% of healthcare professionals (HCP) reached agreement. To define a minimum health outcome to continue treatment, a combination of 4 disease activity states and 3 health-related quality of life states were defined for 3 hypothetical patient profiles. HCP were given a dichotomous choice (yes/no) to respond to whether they would continue treatment in each case.

Results.

The second round was completed by 106 HCP. Consensus was reached on the use of (1) Disease Activity in Psoriatic Arthritis + Psoriatic Arthritis Impact of Disease (PsAID12) or minimal disease activity + PsAID12 + C-reactive protein, in peripheral PsA; and (2) Ankylosing Spondylitis Disease Activity Score + PsAID12, in axial PsA. Health outcomes considered sufficient to continue treatment were stricter for bDMARD-naive patients than for patients who failed several bDMARD.

Conclusion.

To the best of our knowledge, this is the first multidisciplinary consensus on a set of outcomes for the evaluation of bDMARD effectiveness in PsA, in routine clinical practice.

Ultrasound assessment in psoriatic arthritis (PsA) and psoriasis vulgaris (non-PsA): which sites are most commonly involved and what features are more important in PsA?

Background

The aim of this study was to find out the most commonly involved sites and the most important ultrasonic features in psoriatic arthritis (PsA).

Methods

In total, 120 PsA patients and 320 psoriasis vulgaris (non-PsA) patients were assessed by grayscale and power Doppler (PD) ultrasound (US). Joints, tendons, enthesis, and bursa changes were observed. Weights of affected anatomical sites of PsA patients (overall weights >90%) were calculated. Affected anatomical sites between PsA and non-PsA patients were compared. Ultrasonic features of joint, tendon, entheses, and bursa changes between PsA and non-PsA patients were also compared. Finally, the test performance of ultrasonic features for the diagnosis of PsA was calculated.

Results

The anatomical sites with the highest weights were the Achilles tendon, quadriceps tendon, and knee; weights of these anatomical sites were all more than 5%. Among the affected anatomical sites of PsA patients, most of the anatomical sites were more greatly affected in the PsA patients than in the non-PsA patients (all P<0.05). The comparison of the affected Achilles tendon, quadriceps tendon, MTP1, subacromial-subdeltoid bursa, MCP4, and MCP3 showed no significance between PsA and non-PsA patients (all P>0.05). Joint synovial thickening, joint PD signal grades, joint bone erosions, tendon sheath synovial thickening, tendon sheath PD signals, enthesis bone erosions, and enthesis PD signals in PsA patients were higher than in non-PsA patients (all P<0.05). Joint PD signal grades, joint bone erosions, enthesis bone erosions, and enthesis PD signals showed the highest specificities, which were 96.06%, 95.15%, 96.93%, and 94.63% respectively.

Conclusions

The most common involvement sites of PsA were the Achilles tendon, quadriceps tendon, and knee, and some sites in non-PsA patients were also highly involved. The most important features in PsA included joint PD signal grades, joint bone erosion, entheses bone erosions, and entheses PD signals in US assessment.

Psoriatic arthritis screening: a systematic review and meta-analysis

OBJECTIVE

To systematically review the accuracy and characteristics of different questionnaire-based PsA screening tools.

METHODS

A systematic review of MEDLINE, Excerpta Medical Database, Cochrane Central Register of Controlled Trials and Web of Science was conducted to identify studies that evaluated the accuracy of self-administered PsA screening tools for patients with psoriasis. A bivariate meta-analysis was used to pool screening tool-specific accuracy estimates (sensitivity and specificity). Heterogeneity of the diagnostic odds ratio was evaluated through meta-regression. All full-text records were assessed for risk of bias with the QUADAS 2 tool.

RESULTS

A total of 2280 references were identified and 130 records were assessed for full-text review, of which 42 were included for synthesis. Of these, 27 were included in quantitative syntheses. Of the records, 37% had an overall low risk of bias. Fourteen different screening tools and 104 separate accuracy estimates were identified. Pooled sensitivity and specificity estimates were calculated for the Psoriatic Arthritis Screening and Evaluation (cut-off = 44), Psoriatic Arthritis Screening and Evaluation (47), Toronto Psoriatic Arthritis Screening (8), Psoriasis Epidemiology Screening Tool (3) and Early Psoriatic Arthritis Screening Questionnaire (3). The Early Psoriatic Arthritis Screening Questionnaire reported the highest sensitivity and specificity (0.85 each). The I2 for the diagnostic odds ratios varied between 76 and 90.1%. Meta-regressions were conducted, in which the age, risk of bias for patient selection and the screening tool accounted for some of the observed heterogeneity.

CONCLUSIONS

Questionnaire-based tools have moderate accuracy to identify PsA among psoriasis patients. The Early Psoriatic Arthritis Screening Questionnaire appears to have slightly better accuracy compared with the Toronto Psoriatic Arthritis Screening, Psoriasis Epidemiology Screening Tool and Psoriatic Arthritis Screening and Evaluation. An economic evaluation could model the uncertainty and estimate the cost-effectiveness of PsA screening programs that use different tools.

Cross-sectional multicenter observational study of psoriatic arthritis in Japanese patients: Relationship between skin and joint symptoms and results of treatment with tumor necrosis factor-α inhibitors

Psoriatic arthritis (PsA) is an inflammatory arthritis with as yet unclear pathophysiology. This retrospective, multicenter, cross-sectional study was conducted in 19 facilities in western Japan and aimed to identify patients' characteristics and factors that affect the results of treatment with biologic agents. Of 2116 patients with psoriasis, 285 (13.5%) had PsA. Skin manifestations preceded joint manifestations in 69.8%, the onset was simultaneous in 17.2%, whereas PsA preceded skin manifestations in 2.5%. Peripheral arthritis was most common, occurring in 73.7%, compared with axial disease in 21.8%, enthesitis in 23.5% and dactylitis in 35.4%. Patients with severe skin manifestations were significantly younger at onset (P = 0.02) and more frequently had axial disease (P < 0.01). Biologic agents were used in 206 patients (72.3%), anti-tumor necrosis factor (TNF)-α antibodies being prescribed first to 157 of them. Anti-TNF-α antibodies were continued by 105 participants and discontinued by 47, the remaining five patients being lost to follow up. Patients who discontinued anti-TNF-α antibodies were significantly older than those who continued (55 vs 51 years, P = 0.04) and significantly older at onset of joint manifestations (50 vs 44 years, P = 0.01). Multivariate analysis revealed that patients over 50 years significantly more frequently terminated anti-TNF-α antibodies (P < 0.01). In conclusion, patients with PsA and severe skin manifestations have earlier onset and axial disease, which seriously impacts on quality of life. Anti-TNF-α antibodies were generally effective enough to continue but less so in patients aged over 50 years. Further detailed research is needed.

Pathophysiology and inhibition of IL-23 signaling in psoriatic arthritis: A molecular insight

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis of unknown etiology, and currently the cellular and molecular interactions that dictate its pathogenesis remain elusive. A role of the interleukin-23 (IL-23)/IL-23R (IL-23 receptor) interaction in the development of psoriasis and PsA is well established. As IL-23 regulates the differentiation and activation of innate and adaptive immunity, it pertains to a very complex pathophysiology involving a plethora of effectors and transducers. In this review, we will discuss recent advances on the cellular and molecular pathophysiological mechanisms that regulate the initiation and progression of PsA as well as new therapeutic approaches for IL-23/IL-23R targeted therapeutics.

Delivering Precision Medicine and Patient-Centred Care Through a Multidisciplinary Approach

The current treatment strategy for patients with inflammatory bowel disease (IBD) aims to enable physicians to deliver optimal care and to improve the role that patients play in treatment decisions. The multidisciplinary team (MDT) approach integrates the patient’s perspective and sees the discussion of treatment options with both gastroenterologists and surgeons as early as possible. The MDT approach is also vital in managing the risk of IBD and cardiovascular-related comorbidities in patients with psoriasis (PsO) and psoriatic arthritis (PsA), where selection of appropriate medication may affect both the rheumatic condition and the associated comorbidity. Close interdisciplinary interactions between gastroenterologists, rheumatologists, and/or dermatologists are vital, and the ensuing knowledge transfer facilitates the provision of optimal patient care. Personalised medicine will have a profound impact on future treatment algorithms in IBD and other chronic inflammatory conditions. Owing to the complexity of these diseases, a novel approach is urgently needed that will aggregate data from multiple systems and integrate it into a so-called ‘IBD interactome’. This may help identify and target the key molecular components responsible for inflammation. Future treatment practices will also address the psychosocial aspects of IBD by empowering patients and integrating their perspective into the shared treatment decision-making process early on.

Patterns and predictors of long-term retention of inflammatory bowel or rheumatoid disease patients on innovator infliximab: an analysis of a Canadian prescriptions claims database

BACKGROUND

Long-term effectiveness is an important factor when considering treatment decisions.

OBJECTIVE

To determine the long-term retention patterns of Canadian inflammatory bowel disease (IBD) and rheumatologic disease (RD) patients, including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, treated with innovator infliximab (IFX) and to assess the impact of year-over-year cumulative IFX exposure on retention in both patient populations.

PATIENTS AND METHODS

This analysis used a Canadian longitudinal prescription claims database to measure retention on IFX over a period of 5 years. Twelve-month unadjusted odds ratios of retention by time on IFX were calculated for the overall cohort, and within-group comparisons evaluated differences according to age, sex, region, insurance coverage, use of concomitant immunosuppressant therapy, indication (RD cohort only), and previous biologic experience. Between-group analyses compared unadjusted 5-year retention among the same variables. Variables that were independently associated with longer retention on IFX were identified using multivariable regression.

RESULTS

Seven thousand eight hundred and six IBD patients and 2,935 RD patients on stable treatment with IFX were included in the analysis. Sixty-nine percent of IBD patients and 66% of RD patients were retained on IFX after 1 year and 33% and 29%, respectively, were retained after 5 years. Moreover, the probability of being retained on IFX significantly increased with cumulative time on IFX. Independent predictors of 5-year retention included sex, region, and type of insurance coverage among IBD patients and region, type of insurance, prior biologic therapy, and specific indication among RD patients. Patients with IBD were 17% more likely to be retained on IFX over 5 years compared to patients with RD.

CONCLUSION

Real-world Canadian IBD and RD patients on IFX have good overall long-term treatment retention. Previous duration of IFX treatment predicts better future retention, and this knowledge could help inform treatment decisions when patients have been stable on IFX treatment for varying periods of time.

Consensus document on the evaluation and treatment of moderate-to-severe psoriasis: Psoriasis Group of the Spanish Academy of Dermatology and Venereology

Psoriasis is a highly prevalent disease with a major impact on quality of life; therefore, appropriate patient management is mandatory. Given that many issues in psoriasis are controversial and not clearly defined by evidence-based medicine, management of psoriasis is very variable. Expert consensus can generate practical guidelines for optimization of patient care. Much has changed since 2009, when the Consensus Document on the Evaluation and Treatment of Moderate to Severe Psoriasis was published by the Spanish Psoriasis Group (GEP) of the Spanish Academy of Dermatology and Venereology (AEDV). The objective of the present consensus document is to provide the dermatologist with updated recommendations for the evaluation and treatment of patients with moderate-to-severe plaque psoriasis. All active members of the GEP of the AEDV were invited to participate in the survey. The final group comprised 46 members from various areas of Spain and with substantial experience in managing psoriasis. A 3-round Delphi process was used to reach consensus. Consistent agreement and consistent disagreement (consensus) required the achievement of at least two of the following three criteria: Criterion 1, which was based on the position occupied by the mean on a scale of 1-9 and an SD <2; Criterion 2, which was based on the median and interquartile range (IQR) on a scale of 1-9; Criterion 3, which considered the percentage of the voting experts on a scale of 1-9. The items studied were definition of severity, therapeutic objectives, indications for systemic treatment and biologic therapy, induction and maintenance periods, therapeutic failure, loss of response, relapse and rebound, continuous and intermittent therapy, screening of patients before treatment, adherence to therapy, follow-up of treatment outcome, combination of drugs, transitioning and associated comorbidities. Consistent agreement or disagreement (consensus) was achieved for 198 items (agreement, 3 criteria 146 items, 2 criteria 43 items; disagreement, 3 criteria 9 items, 2 criteria 0 items) based on the criteria described above. Completion of the Delphi consensus process enabled a broad and experienced group of Spanish psoriasis experts to provide useful and practical guidelines for the management and treatment of patients with moderate-to-severe psoriasis, particularly in areas where evidence is lacking.

Indirect comparisons of the efficacy of subsequent biological agents in patients with psoriatic arthritis with an inadequate response to tumor necrosis factor inhibitors: a meta-analysis

Significant portion of patients with psoriatic arthritis (PsA) could not tolerate or do not have a satisfactory response to either non-steroidal anti-inflammatory drugs (NSAIDs), non-biologic disease-modifying anti-rheumatic drugs (DMARDs), or even TNF inhibitors. Non-TNF inhibitor biologic agents have emerged as second-line therapy in such situation. However, the comparative efficacy of these agents remains unknown as head-to-head randomized controlled trials (RCTs) are not available. RCTs examining the efficacy of non-TNF inhibitor biologic agents in patients with PsA who experienced inadequate response or intolerance of TNF inhibitors were identified. If more than one RCT was available for a given biologic agent, the pooled odds ratio (OR) and 95 % confidence interval (CI) of achieving 20 % improvement according to American College of Rheumatology criteria (ACR20) response across trials were calculated. The pooled OR for each biologic agent was then compared using the indirect comparison technique. Five RCTs of four non-TNF inhibitor biologic agents, including abatacept, secukinumab, ustekinumab, and apremilast, with 675 participants were identified and included in the data analyses. We found no significant difference in any comparisons, with the p values ranging from 0.14 to 0.98. Our study demonstrates that the likelihood of achieving the ACR20 response in patients with TNF inhibitor experience is not significantly different between the four non-TNF biologic agents. However, the interpretation of this analysis is limited by the small sample sizes. Head-to-head comparisons are still required to confirm the comparative efficacy.

Indirect comparisons of the efficacy of biological agents in patients with psoriatic arthritis with an inadequate response to traditional disease-modifying anti-rheumatic drugs or to non-steroidal anti-inflammatory drugs: A meta-analysis

BACKGROUND

While the efficacy of biologic agents for the treatment of psoriatic arthritis (PsA) has been well demonstrated in randomized controlled trials (RCTs), the data on their relative efficacy is limited. This meta-analysis is aimed at assessing the comparative efficacy of these agents in patients who had persistently active disease despite traditional non-steroidal anti-inflammatory drugs (NSAIDs)/disease-modifying anti-rheumatic drugs (DMARDs), or who could not tolerate NSAIDs/DMARDs.

METHODS

RCTs examining the efficacy of biologic agents in patients with PsA who experienced inadequate response or intolerance of traditional DMARDs or NSAIDs were identified. If more than one RCT were available for a given biologic agent, the pooled risk ratio (RR) and 95% confidence interval (CI) of attaining a 20% improvement according to American College of Rheumatology criteria (ACR20) response across trials were calculated. The pooled risk ratios for each biologic agent were then compared using the indirect comparison technique.

RESULTS

A total of 12 RCTs were identified and included in the data analyses. We found that patients who received older TNF inhibitors (etanercept, infliximab, adalimumab, and golimumab) had a statistically significantly higher chance of achieving ACR20 response compared with apremilast, ustekinumab, and certolizumab. The likelihood of achieving ACR20 response among secukinumab users (at the dose of 150 mg and 300 mg weekly) was also higher compared with apremilast, ustekinumab, and certolizumab, though the relative risk did not always reach statistical significance.

CONCLUSIONS

Our study demonstrates that patients with PsA who experience inadequate response or intolerance of traditional DMARDs or NSAIDs have a higher probability of achieving the ACR20 response with older TNF inhibitors and secukinumab.

Assessments of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in Korean patients with psoriasis vulgaris and psoriatic arthritis

The objective of this retrospective study is to assess neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) as inflammatory markers in patients with psoriasis and psoriatic arthritis (PsA). A hundred and eleven psoriasis patients and 25 PsA patients were compared with 94 healthy controls. Demographic, clinical and laboratory information were collected and analyzed. NLR and PLR were calculated. White blood cell (WBC), neutrophils, eosinophils and NLR were increased in psoriasis patients compared with controls. WBC, neutrophils, NLR, monocytes, platelets and PLR were increased in PsA patients compared with both controls and psoriasis patients. Erythrocyte sedimentation rate (ESR) and C-reactive protein were significantly higher in PsA patients compared with psoriasis patients. Among psoriasis patients, Psoriasis Area and Severity Index (PASI) score correlated positively with platelets, NLR and PLR. These parameters were all significantly higher in moderate to severe psoriasis patients (PASI ≥ 10) compared with mild patients (PASI < 10). Elevated platelets, NLR and PLR were significantly associated with the increased PASI scores in multivariate analysis. NLR, PLR and ESR were statistically significant predictors for the presence of PsA in psoriasis patients. NLR was the strongest predictor (odds ratio = 3.351, P = 0.005). In conclusion, elevated NLR and PLR were significantly associated with psoriasis and PsA. Both NLR and PLR were strong predictors for the presence of PsA among psoriasis patients.

Psoriatic arthritis for the dermatologist

Psoriatic arthritis (PsA) is a chronic, progressive, inflammatory spondyloarthropathy that affects approximately one-third of patients with all types of psoriasis. Dermatologists are in a unique position to recognize early symptoms of PsA, initiate appropriate therapy, and prevent development of further disability. The course of PsA can be modulated by immunosuppressive therapy; patients with moderate-to-severe disease require aggressive management with medications proven to halt disease progression. It is essential for the dermatologist to understand the safety, tolerability, efficacy, cost, and potential to halt disease progression with available medications for this relatively common and potentially disabling disease.

Ultrasound composite scores for the assessment of inflammatory and structural pathologies in Psoriatic Arthritis (PsASon-Score)

Introduction

This study was performed to develop ultrasound composite scores for the assessment of inflammatory and structural lesions in Psoriatic Arthritis (PsA).

Methods

We performed a prospective study on 83 PsA patients undergoing two study visits scheduled 6 months apart. B-mode and Power Doppler (PD) findings were semi-quantitatively scored at 68 joints (evaluating synovia, perisynovial tissue, tendons and bone) and 14 entheses. We constructed bilateral and unilateral (focusing the dominant site) ultrasound composite scores selecting relevant sites by a hierarchical approach. We tested convergent construct validity, reliability and feasibility of inflammatory and structural elements of the scores as well as sensitivity to change for inflammatory items.

Results

The bilateral score (termed PsASon22) included 22 joints (6 metacarpophalangeal joints (MCPs), 4 proximal interphalangeal joints (PIPs) of hands (H-PIPs), 2 metatarsophalangeal joints (MTPs), 4 distal interphalangeal joints (DIPs) of hands (H-DIPs), 2 DIPs of feet (F-DIPs), 4 large joints) and 4 entheses (bilateral assessment of lateral epicondyle and distal patellar tendon). The unilateral score (PsASon13) compromised 13 joints (2 MCPs, 3 H-PIPs, 1 PIP of feet (F-PIP), 2 MTPs, 1 H-DIP and 2 F-DIPs and 2 large joints) and 2 entheses (unilateral lateral epicondyle and distal patellar tendon). Both composite scores revealed a moderate to high sensitivity (bilateral composite score 43% to 100%, unilateral 36% to 100%) to detect inflammatory and structural lesions compared to the 68-joint/14-entheses score. The inflammatory and structural components of the composite scores correlated weakly with clinical markers of disease activity (corr_coeffs 0 to 0.40) and the health assessment questionnaire (HAQ, corr_coeffs 0 to 0.39), respectively. Patients with active disease achieving remission at follow-up yielded greater reductions of ultrasound inflammatory scores than those with stable clinical activity (Cohen’s d effect size ranging from 0 to 0.79). Inter-rater reliability of bi- and unilateral composite scores was moderate to good with ICCs ranging from 0.42 to 0.96 and from 0.36 to 0.71, respectively for inflammatory and structural sub-scores. The PsASon22 and PsASon13 required 16 to 26 and 9 to 13 minutes, respectively to be completed.

Conclusion

Both new PsA ultrasound composite scores (PsASon22 and PsASon13) revealed sufficient convergent construct validity, sensitivity to change, reliability and feasibility.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-014-0476-2) contains supplementary material, which is available to authorized users.

Psoriasis

Psoriasis is a common chronic inflammatory skin disease with a spectrum of clinical phenotypes and results from the interplay of genetic, environmental, and immunological factors. Four decades of clinical and basic research on psoriasis have elucidated many of the pathogenic mechanisms underlying disease and paved the way to effective targeted therapies. Here, we review this progress and identify future directions of study that are supported by a more integrative research approach and aim at further improving the patients' life.

Serum kallikrein-8 correlates with skin activity, but not psoriatic arthritis, in patients with psoriatic disease

BACKGROUND

About 30% of cutaneous psoriasis (PsC) patients develop psoriatic arthritis (PsA) in the joint, which is under-recognized by dermatologists. Biomarkers for PsA are needed so that early referral to a rheumatologist is made. Kallikreins (KLKs) are secreted serine proteases implicated in skin desquamation and inflammation. This study examined KLK potential as serum biomarkers of PsA in cutaneous psoriasis patients.

METHODS

KLKs were measured by ELISAs in synovial fluids of three PsA patients and three control early osteoarthritis (OA) patients, as well as in a cohort of 152 serum samples collected from age- and sex-matched PsC patients, with (n=76) or without PsA (n=76). KLK expression in psoriatic plaques was examined by immunohistochemistry. Univariate and multivariate logistic regression analyses were conducted to analyze the association between serum KLK levels and disease class (PsC, PsA). Serum KLKs that associated with PsA were correlated with clinical parameters of skin and joint activity.

RESULTS

Among the seven KLKs tested, KLK6 and KLK8 were elevated in both PsA synovial fluids and psoriatic plaques, but only serum KLK8 levels were associated with psoriatic disease (odds ratio=2.56, p=0.03). Although significantly elevated in PsC and PsA sera compared to healthy controls, KLK8 did not discriminate PsA from PsC patients. KLK8 correlated positively with the psoriasis area and severity index (PASI) (r=0.43, p=0.001) independent of age, sex and psoriasis duration ( β=1.153, p=0.0003) and exhibited no correlations with tender or swollen joint counts.

CONCLUSIONS

Increased KLK8 serum level in PsA patients reflects disease activity in the skin but not in the joints. Serum KLK levels are not useful for screening psoriasis patients for PsA.

Recommendations for the coordinated management of psoriatic arthritis by rheumatologists and dermatologists: a Delphi study

Psoriatic arthritis, a chronic inflammatory musculoskeletal disease that is associated with psoriasis, causes joint erosions, accompanied by loss of function and quality-of-life. The clinical presentation is variable, with extreme phenotypes that can mimic rheumatoid arthritis or ankylosing spondylitis. Because psoriasis usually presents before psoriatic arthritis, the dermatologist plays a key role in early detection of the latter. As many treatments used in psoriasis are also used in psoriatic arthritis, treatment recommendations should take into consideration the type and severity of both conditions. This consensus paper presents guidelines for the coordinated management of psoriatic arthritis by rheumatologists and dermatologists. The paper was drafted by a multidisciplinary group (6rheumatologists, 6dermatologists, and 2epidemiologists) using the Delphi method and contains recommendations, tables, and algorithms for the diagnosis, referral, and treatment of patients with psoriatic arthritis.

IL-17A gene transfer induces bone loss and epidermal hyperplasia associated with psoriatic arthritis

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease characterised by clinical features that include bone loss and epidermal hyperplasia. Aberrant cytokine expression has been linked to joint and skin pathology; however, it is unclear which cytokines are critical for disease initiation. Interleukin 17A (IL-17A) participates in many pathological immune responses; however, its role in PsA has not been fully elucidated.

OBJECTIVE

To determine the role of IL-17A in epidermal hyperplasia and bone destruction associated with psoriatic arthritis.

DESIGN

An in vivo gene transfer approach was used to investigate the role of IL-17A in animal models of inflammatory (collagen-induced arthritis) and non-inflammatory (receptor activator of NF-κB ligand (RANKL)-gene transfer) bone loss.

RESULTS

IL-17A gene transfer induced the expansion of IL-17RA(+)CD11b(+)Gr1(low) osteoclast precursors and a concomitant elevation of biomarkers indicative of bone resorption. This occurred at a time preceding noticeable joint inflammation, suggesting that IL-17A is critical for the induction of pathological bone resorption through direct activation of osteoclast precursors. Moreover, IL-17A induced a second myeloid population CD11b(+)Gr1(high) neutrophil-like cells, which was associated with cutaneous pathology including epidermal hyperplasia, parakeratosis and Munro's microabscesses formation.

CONCLUSIONS

Collectively, these data support that IL-17A can play a key role in the pathogenesis of inflammation-associated arthritis and/or skin disease, as observed in PsA.

Clinical and Contrast-Enhanced Ultrasound Echography Outcomes in Psoriatic Arthritis Patients after One Year of Continuous Therapy with Anti-TNF Drugs

Background. We wanted to verify retrospectively the proportion of patients with psoriatic arthritis who were in remission after 1 year of continuous therapy with either etanercept or adalimumab. Remission was defined as the absence of both clinical and contrast-enhanced ultrasound (CEUS) findings suggestive of joint inflammation. Patients and Methods. The data of twenty-five patients with psoriatic arthritis were available for the clinical and CEUS evaluations before and after 1 year of continuous therapy with etanercept or adalimumab. The count of swollen (ACR66), tender (ACR68), and active inflamed joints (AJC) was used to measure the severity of joint involvement. PASI was used to score the severity of psoriasis. HAQ, DLQI, VAS pain, and VAS itching were administered to each patient before starting therapy and every 3 months, up to 1 year. Results. Eight (32%) out of twenty-five patients were in remission after 1 year of therapy with etanercept or adalimumab. A significant reduction of all clinical variables analysed was seen during the course of therapy. Conclusion. Although a significant proportion of patients achieved remission of arthritis after 1 year of effective anti-TNF therapy, the majority of them continued to have either clinical or CEUS findings suggestive of persistence of joint inflammation.

Non-biologic disease-modifying antirheumatic drugs (DMARDs) improve pain in inflammatory arthritis (IA): a systematic literature review of randomized controlled trials

Evidence supports early use of non-biologic DMARDs to prevent irreversible damage in inflammatory arthritides, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), and possibly ankylosing spondylitis (AS). However, there is a paucity of data exploring their effects on pain as a primary outcome in these conditions. This systematic literature review investigated the effect of non-biologic DMARDs on pain levels in IA and examined whether disease duration impacted efficacy. We searched Medline, Embase, Cochrane Central, and Cochrane Database of Systematic Reviews, abstracts from the 2008 to 2010 American College of Rheumatology annual congresses, and citation lists of retrieved publications. Only randomized, double-blind controlled trials were analyzed. Quality was assessed with the Risk of Bias tool. Descriptive statistics were used in meta-analysis. 9,860 articles were identified, with 33 eligible for inclusion: 8 in AS, 6 in PsA, 9 in early RA (ERA), and 10 in established RA. In ERA and established RA, all studies of DMARDs (monotherapy and combination therapies) consistently revealed statistically significant reductions in pain except three oral gold studies. In AS, sulfasalazine studies showed significant pain reduction, whereas use of other DMARDs did not. In PsA, 5 of 6 studies reported VAS-pain improvement. From the studies included, we were unable to assess the influence of disease duration on pain outcomes in these rheumatic conditions. DMARDs improve pain in early and established RA. Sulfasalazine may improve pain in AS and PsA. Further study is needed to assess the relationship between disease duration and DMARD efficacy in reducing pain in these conditions.

Early psoriatic arthritis

Psoriatic arthritis is an inflammatory musculoskeletal disease associated with psoriasis that is usually seronegative for rheumatoid factor. Psoriatic arthritis affects men and women equally, usually during the fourth decade, although it may affect children and octogenarians. Psoriatic arthritis may lead to deformities, joint damage, reduced quality of life and function. Early detection and treatment may prevent untoward outcomes.

FCGR2A/CD32AandFCGR3A/CD16AVariants and EULAR Response to Tumor Necrosis Factor-α Blockers in Psoriatic Arthritis: A Longitudinal Study with 6 Months of Followup

Objective.

The efficacy of antibody-based biological therapies currently used in psoriatic arthritis (PsA) depends not only on their blocking effect on the targeted molecule but also on their binding affinity to genetically defined variants of cell-surface Fc-γ receptors. Our objective was to assess the potential influence of functionally relevantFCGR2A/CD32A(H131R) andFCGR3A/CD16A(V158F) genetic polymorphisms on the EULAR response to tumor necrosis factor-α (TNF-α) blocker therapy in PsA.

Methods.

In total 103 patients with PsA starting anti-TNF-α therapy were included. The efficacy of therapy was evaluated according to EULAR response criteria at 3 and 6 months.FCGR2A-R131H andFCGR3A-F158V polymorphisms were genotyped. Potential correlations between clinical response and theFCGR2A-R131H andFCGR3A-F158V polymorphisms were evaluated.

Results.

EULAR response (moderate plus good) was 85.4% at 3 months and 87.4% at 6 months, while good EULAR response was 61.2% and 62.1%, respectively. More patients with high-affinityFCGR2Agenotypes (homozygous or heterozygous combinations) achieved a EULAR response at 6 months compared to patients with the low-affinity genotype (RR; p = 0.034, adjusted comparison error rate < 0.025). This association was due mainly to the group of patients treated with etanercept. No correlation was found for theFCGR3Apolymorphism. Similarly, no effect of C-reactive protein levels was observed.

Conclusion.

Our data indicate thatFCGR2Apolymorphism may influence the response to TNF-α blockers (namely etanercept) in PsA in a direction opposite to that previously found in patients with rheumatoid arthritis.

Presentation of psoriatic arthritis in the literature: a twenty-year bibliometric evaluation

Psoriatic arthritis is an inflammatory arthritis disabling patients with psoriasis. Bibliometric studies are tools for evaluating scientific productions in different countries, universities as well as publications related to a special topic. We aimed to perform a scientometric study to evaluate articles published under "Psoriatic arthritis" topic and also attempted to compare publications of different authors, countries, universities, and journals related to this topic. Study was performed on all articles published between 1989 and 2009. The ISI web of science was our main source. Two key words, "Psoriatic arthritis" and "Psoriatic arthropathy," were used to conduct search. Original articles were subject of further evaluation. A whole number of 3,727 article was result of our search. From this number, 1,961 (52.6 %) were original articles. Whole original articles were cited 38,613 times with average citations per item of 19.69. Gladman DD was the most popular author in this field. Articles were mostly in English (91.3 %). USA was the leading country in producing article under this topic with 463 (23.6 %) publications. University of Toronto was the first rank institution while publishing 125 (6.4 %) articles. More than half of articles were published under "Rheumatology" subject. "Journal of Rheumatology," "Annals of the Rheumatic Diseases," and "Arthritis and Rheumatism" were three journals with highest number of articles on this topic. There has been growing interest in psoriatic arthritis subject during these two decades. Between countries, institutions and journals; USA, university of Toronto, "Journal of Rheumatology," "Annals of The Rheumatic Diseases," and "Arthritis and Rheumatism" have special contributions to body of literature published under this topic, respectively.

Strategies for Biomarker Development in Psoriatic Disease: A Report from the GRAPPA 2010 Annual Meeting

Psoriatic disease includes psoriasis and associated comorbidities (arthritis, uveitis, inflammatory bowel disease, cardiovascular disease, metabolic syndrome, and anxiety/depression) and is remarkably diverse in disease presentation and course. The marked heterogeneity of musculoskeletal involvement in psoriatic arthritis (PsA) presents major challenges to clinicians regarding diagnosis, risk stratification, and management. Members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) have begun collaborative efforts to develop biomarkers that can assist in the diagnosis and management of patients with psoriasis and related comorbidities. This brief review provides a rationale for biomarker research in PsA, consideration of types and sources of biomarkers, and examples of important biomarker studies in PsA, followed by a review of trial designs for biomarker research and a discussion of potential funding sources.

125I-labeled gold nanorods for targeted imaging of inflammation

For better examination of inflammation, we designed inflammation-targeted nuclear and optical dual-modality contrast agents prepared by I-125 radiolabeling of gold nanorods (GdNRs) conjugated with anti-intercellular adhesion molecule 1 (ICAM-1) antibody. The bioactivity and specific binding of the PEGylated (125)I-ICAM-GdNR conjugates to the ICAM-1 was validated through ELISA testing. Inflammation-targeted imaging was then conducted on an adjuvant-induced arthritic rat model which demonstrated an elevation of ICAM-1 level in the affected ankle joints. Facilitated by the I-125 radioisotope and the whole-body imaging via the Gamma camera, the time-dependent distribution of the systemically injected agent as well as the uptake of the agent in the inflammatory articular tissues could be examined conveniently and quantitatively. The success in targeted delivery of gold nanoparticles to inflammatory tissue enables both nuclear and optical imaging of inflammation at molecular or cellular level. Other than diagnosis, radiolabeled gold nanoparticles also hold promise for targeted therapy of a variety of disorders.

Therapeutic considerations in spondyloarthritis patients who fail tumour necrosis factor antagonists

The tumour necrosis factor (TNF) antagonists have significantly improved quality of life and functional status in patients with spondyloarthritis (SpA). The excitement regarding the remarkable success of these agents is justified but challenges remain. In particular, alternative systemic therapies with proven efficacy for patients who fail TNF antagonists have been developed in rheumatoid arthritis but are not yet available in SpA. In this article, the approach to patients with psoriatic arthritis (PsA) or ankylosing spondylitis (AS) who fail TNF antagonists will be discussed with the goal of providing a path to the clinician, who must manage these patients amidst uncertainty. Three central questions will be addressed. Why does a particular SpA patient not respond to a TNF antagonist? How can the clinician improve the probability of treatment response in patients who fail a TNF antagonist? What specific approaches can be taken to control disease activity in PsA or AS following treatment failure with a TNF antagonist? Data from controlled trials, registries and pilot studies will be combined with expert opinion to address these important questions.

Emerging drugs for psoriatic arthritis

IMPORTANCE OF THE FIELD

The socioeconomic burden of psoriatic arthritis (PsA) is considerable and not different from that of rheumatoid arthritis. Current treatment options do not always allow reaching the therapeutic objectives consisting of the remission of symptoms and prevention of the appearance of damage in the early stage of PsA or the blocking of PsA progression in the established cases.

AREAS COVERED IN THIS REVIEW

After reviewing the current treatment choices, we examine the new drugs in clinical Phase II and III trials for PsA up to January 2010. Information was mainly obtained from the network of international clinical trial registries.

WHAT THE READER WILL GAIN

The current management of PsA includes NSAIDs, corticosteroids, disease-modifying antirheumatic drugs (DMARDs) and anti-TNF-alpha blocking agents. These last drugs are more effective than traditional DMARDs on symptoms/signs of inflammation, quality of life and function and can inhibit the progression of the structural joint damage. Recent advancement in the knowledge of the immunopathogenesis of PsA has permitted the development of novel drugs including new TNF-alpha blockers, IL-1, -6, -12, -23 and -17 inhibitors, co-stimulator modulation inhibitors, B-cell depleting agents, small molecules and receptor activator of NF-kappaB/receptor activator of NF-kappaB ligand inhibitors.

TAKE HOME MESSAGE

The currently available anti-TNF-alpha blocking agents have revolutionized the management of PsA. However, there is a need for more effective and safer drugs.