Psoriatic arthritis for dermatologists

Dermoscopic features of nail psoriasis: a systematic review

INTRODUCTION

Nail psoriasis is common in psoriasis vulgaris and even more prevalent in psoriatic arthritis. Dermatoscopy of the nail proves helpful in enhancing the visualization of psoriatic nail lesions.

OBJECTIVE

This systematic review aimed to summarize the existing studies published in the literature that reported the various dermoscopic features of nail psoriasis.

MATERIALS AND METHODS

A systematic search of two medical databases, PubMed and Scopus, was conducted in April 2023. In total, 11 records were included. The number of reported cases in the included studies was 723.

RESULTS

The average age was 42.39 years. Sixty percent of patients were males, and 40% were females. Pitting constituted the most common onychoscopic feature indicating nail matrix involvement, followed by various other features such as leukonychia, nail plate thickening, transverse and longitudinal ridges, and different lunula abnormalities. The predominant onychoscopic feature indicating nail bed involvement was onycholysis, followed by splinter hemorrhages, oil drop sign, subungual hyperkeratosis, dilated capillaries, agminated capillary dots, erythematous border, and pustules. Vascular abnormalities observed in all locations were present in 52% of patients.

CONCLUSIONS

The clinical signs of nail psoriasis are diverse, and for the majority, they are nonspecific. Nail dermoscopy is a noninvasive tool that enhances the visualization of the nail manifestations of psoriasis. It may facilitate the establishment of diagnostic criteria for this pathology without resorting to more invasive procedures, such as nail biopsy.

Impact of periodontitis on oral health-related quality of life of patients with psoriatic arthritis

BACKGROUND

Since oral health issues can have a negative influence on a person's physical functioning, social status, and wellbeing, oral health-related quality of life (OHRQoL) becomes an indispensable part of overall health. Previous published studies report that periodontitis (PD) and psoriatic arthritis (PsA) have a significant negative impact on OHRQoL. Based on these findings, it would be reasonable to assume that patients with coexisting PsA and PD would see a comparable or maybe synergistic effect on their OHRQoL. Hence, the aim of the present study is to evaluate the OHRQoL and its impact among subjects with concurrent PsA and PD.

MATERIAL AND METHODS

The present study was a comparative, cross-sectional investigation. A total of 200 participants were categorized into four groups- PD-PsA (n = 50), PsA (n = 50), PD (n = 50), and healthy controls (n = 50). Demographic data and periodontal parameters-plaque index, sites with gingival bleeding, probing pocket depth, gingival recession, and clinical attachment level were recorded for all the four groups. Number of mobile teeth due to periodontitis was recorded for the PSA-PD and PD groups. OHIP-14 questionnaire was administered to all the four groups. Collected data was then subjected to statistical analysis.

RESULTS

The severity of OHIP-14 summary scores was highest in the PsA-PD group (18.06 ± 11.22) followed by the PD group (17.02 ± 9.99) and lowest in the healthy group (6.32 ± 5.59) (p < .0001). The scores of all the domains- oral pain, oral function, orofacial appearance and psychological impact were highest among the PsA-PD group followed by the PD group (p < .0001). The combined interaction of PsA and PD on the OHRQoL was statistically significant (F = 6.33, p = .012). Results of the multiple linear regression analysis indicated that there was a moderate collective significant effect between age, past dental visit, frequency of daily tooth brushing, use of other oral hygiene aids, and OHIP-14 (F(3,196) = 13.08, p < .001, R2 = 0.17, adjusted R2 = 0.15).

CONCLUSION

The negative impact on OHRQoL was highest in the patients with concurrent presence of PD with PsA followed by those with PD alone. While the summary scores and dimensional scores of OHIP-14 were insignificant when patients with PsA-PD and PD alone were compared, these scores were significantly higher in patients with PsA-PD than patients with PsA alone.

Danish translation and cultural adaptation of the Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) scale

OBJECTIVES

Screening tools are needed to help to identify psoriatic arthritis in patients with psoriasis. The Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) questionnaire was developed for this purpose and has been shown to perform very well. The aim of this study was to translate and culturally adapt the PURE-4 scale into the Danish language.

METHOD

The translational process followed the guidelines provided by the Mapi Research Trust, which include the following steps: forward translation, backward translation, cognitive interviews, and proofreading. Following the guidelines helps to maintain the content validity of the questionnaire and secures a translation that is both literally and culturally appropriate for the target population.

RESULTS

All four items were modified throughout the translation process, involving mainly minor changes such as the addition of more colloquial words in the Danish version. The new Danish version of PURE-4 was reviewed and approved by the original developers.

CONCLUSIONS

A Danish version of the PURE-4 questionnaire was produced. The translation and cultural adaptation of PURE-4 constitute the first step in the validation of the questionnaire in Danish patients with psoriasis.

Nail psoriasis in China: A prospective multicentre study

BACKGROUND

Data on nail psoriasis (PsO) in China are scarce.

OBJECTIVES

To provide nail PsO-related data regarding epidemiologic characteristics, manifestations, fungal infections, arthritic complaints and treatments that may facilitate improved patient management globally.

METHODS

From August 2021 to August 2022, patients with nail PsO were enrolled in a prospective multicentre observational study at 25 hospitals in China. We collected and analysed data concerning nail PsO demography, clinical signs, fungal detection, arthritic symptoms and treatment.

RESULTS

A total of 817 patients with nail PsO were involved, with a mean body mass index of 24.13 ± 2.93. In addition, 71.41% of the patients were male. The Nail PsO Severity Index score was weakly positively correlated with body surface area. The percentage of nail involvement was 95.29% for fingernails and 57.18% for toenails, with pitting (67.11%) and subungual hyperkeratosis (60.40%) being the most prevalent manifestations, respectively. Toenails showed a significantly higher frequency of nailfold scales, subungual hyperkeratosis and nail plate crumbling and a lower frequency of splinter haemorrhages, pitting and erythema of the lunula. A total of 13.26% of the PsO patients had onychomycosis, and 77.08% were observed in the toenails. Articular symptoms were reported by 12.17% of the patients, with the peripheral type being predominant. Significant associations between articular symptoms and nailfold swelling, subungual hyperkeratosis, nailfold scales, onycholysis and longitudinal ridges were found. Only 2.30% (20 out of 871) of patients with nail PsO received treatment. The most frequently employed therapy for cutaneous PsO with nail involvement was biologic therapy (n = 366).

CONCLUSIONS

PsO showed distinct manifestations in the toenails and fingernails. Additionally, toenail PsO combined with onychomycosis requires special attention. Articular symptoms in psoriatic patients are associated with specific nail changes. It is important to research and advocate for more potent treatments for nail PsO.

Podcast on Cross-speciality Perspectives on Practical Management of Atopic Dermatitis-Associated Ocular Surface Diseases

There is a growing awareness among dermatology providers of ocular comorbidities in patients with the chronic inflammatory skin disease atopic dermatitis (AD). For example, the prevalence of ocular surface diseases (OSD) such as conjunctivitis is higher in patients with AD than in the general population, and the use of some AD treatments may be associated with OSD. In a recent review published in the Journal of the American Academy of Dermatology, dermatologists and ophthalmologists provided an overview of the different types, etiology, pathophysiology, and practical management of OSD associated with AD. This review included a suggested treatment algorithm that champions a partnership between dermatology providers and eye care providers for optimal screening, diagnosis, and care. In this podcast article, a dermatologist and ophthalmologist who were authors on this review are joined by a nurse practitioner moderator to discuss how these concepts can be adapted to clinical practice, inclusive of dermatologists, eye care providers, and relevant advanced practice providers. This podcast focuses on the authors' clinical experiences and highlights the key aspects of optimal care, including exploring additional questions to answer with future research.

A clinical review of structural damage in psoriatic arthritis for dermatologists: From pathogenesis to ongoing controversies

Psoriatic arthritis (PsA) is a chronic inflammatory disease that often goes unrecognized in patients with psoriasis. As a result, patients may develop significant structural damage before diagnosis and initiation of adequate treatment. Dermatologists are in an unique position to identify early signs and symptoms of PsA. Here, we briefly review the pathogenesis of PsA, differences in PsA presentation within real-world dermatology practice versus rheumatology clinical trials, and imaging modalities that can be used to assess structural damage. We then discuss several ongoing controversies related to prediction, assessment, and treatment of PsA-related structural damage. Debated questions include the following: (1) Does subclinical enthesitis predict progression from psoriasis to PsA?, (2) Does methotrexate inhibit progression of structural damage?, (3) Does structural damage correlate with clinical disease activity?, and (4) Can progression from psoriasis to PsA be prevented? Evidence presented herein suggests that dermatologists, together with rheumatologists, can play important roles in the early diagnosis and treatment of PsA, thereby potentially preventing irreversible structural damage.

Psoriatic arthritis increases the risk of venous thromboembolism following degenerative lumbar spine surgery: An analysis of U.S. Nationwide Inpatient Sample 2005-2018

Background

This retrospective study aimed to determine the risk of venous thromboembolism (VTE) in patients with PsA after surgery for lumbar degenerative disease (LDD).

Methods

The study data of adults aged ≥20 years admitted to U.S. hospitals with diagnoses of LDD and undergoing spinal decompression or fusion between 2005 and 2018 were extracted from the National Inpatient Sample (NIS) database. Patients were further divided into two groups based on a diagnosis of PsA or not via codes ICD-9: 696.0 and ICD-10: L40.50. Patients with missing information were excluded. Propensity score matching (PSM) was employed to enhance comparability between groups. Logistic regression was used to determine associations between PsA and various outcomes, including complications, unfavorable discharge, and prolonged length of stay (LOS).

Results

Data on 471,283 patients with LDD was extracted from the NIS database.from 2005 to 2018. Before propensity score matching, patients with PsA had higher proportions of overall morbidity (8.8 % vs. 6.9 %), VTE (1.4 % vs. 0.7 %), and unfavorable discharge (20.8 % vs. 16.9 %). After matching, patients with PsA still had higher VTE incidence and unfavorable discharge proportions. After adjustments, multivariable regression analysis indicated that patients with PsA had a higher risk of unfavorable discharge (aOR: 1.26, 95 % CI: 1.03-1.55) and VTE (aOR: 1.99, 95 % CI: 1.05-3.75).

Conclusions

Among patients undergoing surgery for LDD, pre-existing PsA may be associated with increased risks of unfavorable discharge and VTE occurrence. The findings may benefit preoperative risk stratifications before LDD surgeries.

Comorbidity Burden and Treatment Patterns of Psoriasis in Vietnam: Real-World Data from the EXPAND Study

INTRODUCTION

Psoriasis is a multi-faceted, immune-mediated inflammatory disease associated with a wide range of comorbidities. Real-world data on treatment patterns, comorbidities, and economic burden in patients with psoriasis are needed for comprehensive patient care in Vietnam.

METHODS

A retrospective chart review study was conducted using secondary data extracted from patients' medical records of two hospitals in Vietnam, with the aim of identifying adult patients with a confirmed diagnosis of psoriasis. The index date was defined as the date of first diagnosis between 1 January 2020 and 31 October 2021. Sociodemographic factors, disease characteristics, comorbidities, medication usage, drug survival, and medication costs were analyzed.

RESULTS

A total of 661 patients were identified (mean ± standard deviation [SD] age 43.5 ± 14.8 years). The most prevalent comorbidity was dyslipidemia (49.6% of patients), followed by hypertension (23.4%), and psoriatic arthritis (10.4%). In total, 44% of patients received biologic therapies. Overall, 66.7% and 54.3% of patients receiving biologic and non-biologic therapies, respectively, had ≥ 1 comorbidity. Only 23.2% of patients with psoriasis-related comorbidities stopped therapy with biologics. Biologics had a longer retention time (17.0 months) than non-biologics (6.0 months) in patients with comorbidities. Patients with comorbidities had significantly higher total annual healthcare costs than those without comorbidities (in US dollars: USD901 vs. USD304; p < 0.001), mainly due to the relatively higher costs associated with the use of biologics.

CONCLUSION

Patients with psoriasis in Vietnam experience a high disease and economic burden due to comorbidities. Evidence from this real-world study supports the need for routine monitoring of and an appropriate treatment course for psoriasis-related comorbidities.

Prevalence of Musculoskeletal Symptoms in Patients with Psoriasis and Predictors Associated with the Development of Psoriatic Arthritis: Retrospective Analysis of a US Claims Database

INTRODUCTION

Psoriasis (PsO) is associated with the development of psoriatic arthritis (PsA). Patients with PsO often experience pre-PsA musculoskeletal (MSK) symptoms, leading to potential structural damage and substantial disease burden with impact on function. The objective of this study is to describe prevalence rates and evidence of MSK symptoms, including incidence of comorbid PsA diagnosis, in patients newly diagnosed with PsO and identify factors associated with PsA diagnosis.

METHODS

This retrospective analysis included administrative claims from the Optum Research Database for adult patients with a new PsO diagnosis between January 2008 and February 2019. Eligible patients had ≥ 2 claims for PsO on unique dates, were aged ≥ 18 years at the date of the first claim with a diagnosis of PsO (index date), and had continuous enrollment with medical and pharmacy coverage for 12 months before (baseline period) and ≥ 12 months following the index date. Primary outcomes were incidence of comorbid PsA diagnosis, prevalence of MSK symptoms other than PsA, and evidence of MSK symptoms collected at baseline and assessed in 12-month intervals through 60 months.

RESULTS

Of the 116,203 patients with newly diagnosed PsO, 110,118 were without baseline comorbid PsA. High prevalence rates of MSK symptoms among patients with only PsO were seen at baseline (47.1%), 12 months (48.2%), and 60 months (82.1%). Patient age, baseline MSK symptoms, and baseline MSK symptom-related healthcare utilization were associated with increased hazard of a PsA diagnosis.

CONCLUSION

Increased prevalence rates of MSK symptoms and burden are experienced by patients newly diagnosed with PsO through 60 months of follow-up. Several baseline factors were associated with increased risk of PsA diagnosis.

Challenges in Diagnosing Psoriatic Arthritis in Primary Care: A Meta-Ethnographic Study

Psoriatic arthritis (PsA) is a complex and debilitating chronic inflammatory joint disorder that is often associated with psoriasis and presents significant challenges in its early diagnosis and management. Therefore, this study aimed to investigate the diagnostic intricacies of PsA in primary care settings to shed light on the prevalence, barriers, and implications of delayed diagnosis. To achieve our research objectives, we conducted a qualitative synthesis using the meta-ethnographic method, which is a robust approach for synthesizing qualitative data. We systematically searched the PubMed, Web of Science, and Embase databases for relevant articles using predefined search terms such as "psoriatic arthritis," "diagnosis," and "primary care." The inclusion criteria were narrative articles in English that provided insights into the diagnostic challenges of PsA in primary care. Conference presentations, original articles, and duplicate articles were excluded. Our analysis revealed four key themes that elucidated the multifaceted nature of PsA diagnosis in primary care: (1) a variety of initial and non-specific symptoms, highlighting the diverse clinical presentations that can mimic other conditions; (2) the lack of experience with PsA among primary care professionals, underscoring the importance of education and training; (3) the lack of skin lesions, which can complicate diagnosis when not present; and (4) a delay in diagnosis, with potentially severe consequences for patients' health and quality of life. This study highlights the challenges inherent in the diagnosis of PsA in primary care settings. The multifaceted nature of the disease, coupled with limited experience among primary care providers, often results in delayed diagnosis and subsequent treatment initiation. Early recognition and intervention are pivotal for optimizing patient outcomes. Addressing these challenges necessitates a comprehensive approach involving heightened clinical suspicion, continuous medical education, interdisciplinary collaboration, and utilization of standardized diagnostic criteria. Collaboration between primary care physicians and specialists is crucial for enhancing the accuracy and timeliness of PsA diagnosis and ultimately improving patient well-being and quality of life.

Report of the Skin Research Workgroups From the IDEOM Breakout at the GRAPPA 2022 Annual Meeting

The International Dermatology Outcome Measures (IDEOM) organization presented an update on its progress related to patient-centered outcome measures for psoriasis (PsO) and psoriatic arthritis (PsA) at the 2022 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). The Musculoskeletal (MSK) Symptoms working group presented an update on the development of the IDEOM Musculoskeletal Questionnaire (IDEOM MSK-Q). The IDEOM MSK-Q is a patient-reported outcome measure intended to capture MSK symptoms and describe their intensity and impact on health-related quality of life in patients with psoriatic disease. IDEOM also presented the progress of the integration of the Psoriasis Epidemiology Screening Tool (PEST) and Psoriatic Arthritis Impact of Disease (PsAID) questionnaires into the Epic electronic health record system. This will allow for automated PsA screening and symptom measurement in the hopes of improving disease detection and treat-to-target strategies. The Treatment Satisfaction working group discussed the development of the DermSat-7, a 7-item treatment satisfaction questionnaire specific for dermatological conditions. The DermSat-7 is currently being validated in a multicenter study of patients with PsO.

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

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATIONS

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

Effect of guselkumab on serum biomarkers in patients with active psoriatic arthritis and inadequate response to tumor necrosis factor inhibitors: results from the COSMOS phase 3b study

BACKGROUND

Guselkumab is a selective interleukin (IL)-23 inhibitor targeting the IL-23p19 subunit. In the phase 3b COSMOS trial, guselkumab demonstrated efficacy in treating participants with active psoriatic arthritis (PsA) and inadequate response (IR; lack of efficacy or intolerance) to tumor necrosis factor inhibitors (TNFi).

METHODS

Adults with active PsA (≥ 3 swollen joints,  ≥ 3 tender joints) and IR to one or two TNFi (TNFi-IR) were randomized 2:1 to guselkumab at Weeks 0, 4, then every 8 weeks (Q8W) or placebo➔guselkumab Q8W at Week 24 with possible early escape at Week 16. Levels of serum cytokines, including interferon ɣ (IFNɣ), IL-10, and tumor necrosis factor α (TNFα); T helper 17 (Th17) effector cytokines IL-17A, IL-17F, and IL-22; and acute phase proteins C-reactive protein (CRP), IL-6, and serum amyloid A (SAA), were assessed and compared with matched healthy controls; guselkumab pharmacodynamics through Week 24 were also assessed. Associations between baseline biomarker levels and 1) baseline disease activity (28-joint disease activity score using CRP [DAS28-CRP], psoriasis area and severity index [PASI], and % body surface area [BSA] affected by psoriasis) and 2) clinical response (including  ≥ 20% improvement in American College of Rheumatology criteria [ACR20] response) at Week 24 were assessed.

RESULTS

Baseline serum levels of IL-6, IL-10, IL-17A, IL-17F, IL-22, TNFα, and IFNɣ were significantly higher in COSMOS TNFi-IR participants than in matched healthy controls. Baseline IL-6, CRP, and SAA levels were associated with baseline DAS28-CRP. IL-17A and IL-17F levels were associated with baseline PASI score and psoriasis BSA. Baseline swollen or tender joint counts did not associate with baseline biomarker levels. At Week 24, significant decreases from baseline in CRP, SAA, IL-17A, IL-17F, and IL-22 levels were seen in guselkumab, but not placebo-, treated participants. IL-17F and IL-22 levels at Week 24 in guselkumab-treated participants did not significantly differ from those of matched healthy controls. Guselkumab-treated participants achieving ACR20 response at Week 24 exhibited higher baseline IL-22 and IFNɣ levels versus nonresponders.

CONCLUSIONS

Results from COSMOS participants with active, TNFi-IR PsA suggest guselkumab reduces levels of effector cytokines associated with the IL-23/IL-17 pathway, including those associated with baseline arthritis and skin disease activity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03796858.

Disease modification in inflammatory skin disorders: opportunities and challenges

Progress in understanding of the mechanisms underlying chronic inflammatory skin disorders, such as atopic dermatitis and psoriasis vulgaris, has led to new treatment options with the primary goal of alleviating symptoms. In addition, this knowledge has the potential to inform on new strategies aimed at inducing deep and therapy-free remission, that is, disease modification, potentially impacting on associated comorbidities. However, to reach this goal, key areas require further exploration, including the definitions of disease modification and disease activity index, further understanding of disease mechanisms and systemic spillover effects, potential windows of opportunity, biomarkers for patient stratification and successful intervention, as well as appropriate study design. This Perspective article assesses the opportunities and challenges in the discovery and development of disease-modifying therapies for chronic inflammatory skin disorders.

IL36G genetic variant is independently associated with susceptibility, severity and joint involvement in psoriasis

Psoriasis (PsO) is a chronic, immune-mediated, inflammatory and polygenic dermatosis associated with both physical and psychological burden that can be triggered by injury, trauma, infections and medications. The etiology of PsO is not fully elucidated but genetic, epigenetic and environmental factors are all likely to play a role. A case-control study was carried out to evaluate the frequency of the IL36G C>T (rs13392494) and the IL36G A>G (rs7584409) variants and their association with susceptibility, joint involvement and severity of PsO. The study included 154 patients with PsO and 154 controls from Brazilian population. The severity of PsO was assessed by the Psoriasis Area and Severity Index (PASI). The IL36G (rs13392494 and rs7584409) variants were genotyped by allelic discrimination assay using the real-time polymerase chain reaction. The association between the IL36G genetic variants and the study variables was analyzed in allelic, dominant, codominant, overdominant, recessive, and haplotype models. The main results were that PsO patients were older (p < 0.001) and had higher body mass index (p < 0.001) than controls; 95.8% of the patients had plaque PsO, 16.1% had psoriatic arthritis (PsA), and 27.9% had PASI > 10. The IL36G rs1339294 variant showed no association with PsO in all genetic models while the IL36G rs7584409 variant showed a protective effect in PsO. However, the G allele of the IL36G rs7584409 in the dominant model was positively associated with PASI > 10 (p = 0.031). Moreover, patients with the GG genotype of the IL36G rs7584409 variant had about 5.0 times more chance of PsA than those with the AA genotype (p = 0.014). Regarding the haplotypes, the C/A in a recessive model (CACA versus C/G and T/A carriers) was associated with PsO (p = 0.035) while the C/G haplotype in a dominant model (C/A carriers versus C/G and T/A carriers) showed a protective effect for PsO (p = 0.041). In conclusion, the G allele of the IL36G rs7584409 variant was associated with protection to PsO; however, in patients with PsO, this same allele was associated with moderate to severe disease and PsA. These results suggest that the IL36G rs7584409 variant may be used as a possible genetic biomarker to predict severity and joint involvement of PsO.

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

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

The Psoriatic Arthritis Experience in Saudi Arabia from the Rheumatologist and Patient Perspectives

BACKGROUND

Psoriatic arthritis (PsA) is a musculoskeletal disease that adversely affects physical mobility and quality of life. It is challenging to manage because of the heterogeneous nature of the symptoms and the current treatment options.

PURPOSE

To explore the patient and rheumatologist perspectives of PsA to help improve understanding of the disease experience and improve disease management.

METHODS

A descriptive, observational cross-sectional study of Saudi Arabian dermatologists and rheumatologists and patients with psoriasis or PsA was conducted. Questionnaire data were collected from 31 dermatologists, 34 rheumatologists, 90 patients with psoriasis, and 98 patients with PsA and analysed using descriptive statistics. Here, data from rheumatologists and patients with PsA are presented.

RESULTS

The results revealed similarities and differences in the rheumatologist and patient perspectives of PsA. Rheumatologists and patients agreed on the impact that PsA had on patients' quality of life and that more education was needed. However, they differed on several aspects of disease management. Rheumatologists estimated the time to diagnosis as four times shorter than what patients experienced. Patients accepted their diagnosis more than rheumatologists perceived them to; rheumatologists perceived patients to be worried or fearful. Patients perceived joint pain as their most severe symptom, in contrast to rheumatologists, who presumed skin appearance was the most severe symptom. Reported input into PsA treatment goals differed significantly. More than half of the rheumatologists reported equal patient-physician input into goal development as opposed to <10% of patients reporting the same. Almost half of patients reported no input into the development of their treatment goals.

CONCLUSION

The management of PsA could benefit from enhanced screening and re-evaluation of what PsA outcomes have the most value to patients and rheumatologists. A multidisciplinary approach is recommended with increased patient involvement in disease management and individualized treatment options.

Current and emerging biologic and small molecule systemic treatment options for psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis are chronic inflammatory diseases affecting the skin and joints, respectively. Psoriasis and psoriatic arthritis are associated with a high comorbidity burden as well as negative impact on quality of life. Impact on health-related quality of life is optimized when both skin and joint manifestations are effectively treated. The identification of key cytokines involved in disease pathogenesis has led to the development of several therapeutic options for psoriatic disease. When selecting a therapy, it is important to consider disease severity, psoriasis disease subtypes or domains of psoriatic arthritis, comorbidities, patient preference for treatment, among other factors. This review summarizes current biologic and small molecule treatment options as well as emerging therapies for moderate-to-severe adult plaque psoriasis and psoriatic arthritis.

A consensus-based approach on the management of patients with both psoriasis and psoriatic arthritis in the dermatological and rheumatological settings in Italy: The ADOI PSO-Amore Project

Psoriasis is a complex disease often needing a multidisciplinary approach. In particular, the collaboration between dermatologist and rheumatologist is crucial for the management of patients suffering from both psoriasis (PSO) and psoriatic arthritis (PsA). Here we report a series of recommendations from a group of experts, as a result of a Consensus Conference, defining the circumstances in which it is preferable or even mandatory, depending on the available settings, to rely on the opinion of the two specialists, jointly or in a deferred manner. Indications are given on how to organize a 3^rd level joint Dermatology- Rheumatology care unit, in connection with 1^st and 2^nd level clinicians of both specialties, GPs, and other specialists involved in the management of psoriasis. A potential patient journey is suggested, that can be used as a basis for future design and validation of national and/or local diagnostic therapeutic and assistance pathways.

Altered Fecal Metabolomics and Potential Biomarkers of Psoriatic Arthritis Differing From Rheumatoid Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory joint disease, and the diagnosis is quite difficult due to the unavailability of reliable clinical markers. This study aimed to investigate the fecal metabolites in PsA by comparison with rheumatoid arthritis (RA), and to identify potential diagnostic biomarkers for PsA. The metabolic profiles of the fecal samples from 27 PsA and 29 RA patients and also 36 healthy controls (HCs) were performed on ultra-high-performance liquid chromatography coupled with hybrid triple quadrupole time-of-flight mass spectrometry (UHPLC-Q-TOF-MS). And differentially altered metabolites were screened and assessed using multivariate analysis for exploring the potential biomarkers of PsA. The results showed that 154 fecal metabolites were significantly altered in PsA patients when compared with HCs, and 45 metabolites were different when compared with RA patients. A total of 14 common differential metabolites could be defined as candidate biomarkers. Furthermore, a support vector machines (SVM) model was performed to distinguish PsA from RA patients and HCs, and 5 fecal metabolites, namely, α/β-turmerone, glycerol 1-hexadecanoate, dihydrosphingosine, pantothenic acid and glutamine, were determined as biomarkers for PsA. Through the metabolic pathways analysis, we found that the abnormality of amino acid metabolism, bile acid metabolism and lipid metabolism might contribute to the occurrence and development of PsA. In summary, our research provided ideas for the early diagnosis and treatment of PsA by identifying fecal biomarkers and analyzing metabolic pathways.

Cost per Responder Analysis of Secukinumab versus Adalimumab in the Treatment of Psoriatic Disease

BACKGROUND

The EXCEED study evaluated the efficacy and safety of secukinumab versus adalimumab in psoriatic arthritis, but it did not include a pharmacoeconomic analysis. The objective of this study was to compare the cost per responder of secukinumab versus adalimumab in patients with psoriatic disease.

METHODS

The cost per responder was calculated by multiplying the cost of treatment by the number needed to treat for each therapy. The 52-week primary endpoint was the American College of Rheumatology response rate (ACR) 20; secondary endpoints were ACR 50, Psoriasis Area and Severity Index (PASI) 90, and minimal disease activity (MDA).

RESULTS

The cost per responder for ACR 20 was €19,846 versus €19,766 for secukinumab and adalimumab, respectively, whereas the costs per responder for ACR 50 and PASI 90 were €27,820 versus €27,384 and €22,102 versus €32,375 for secukinumab and adalimumab, respectively. The cost per MDA responder was €34,072 and €38,906 for secukinumab versus adalimumab.

CONCLUSIONS

The costs per responder associated with the psoriatic arthritis end points were similar for adalimumab and secukinumab; conversely, the costs for psoriasis and composite end points were lower for secukinumab.

Potential Impact of Sex and Body Mass Index on Response to Therapy in Psoriatic Arthritis: Post-hoc Analysis of Results From the SEAM-PsA Trial

Objective

In this post-hoc analysis, we examined the potential impact of sex and body mass index (BMI) on response in the SEAM-PsA trial (NCT02376790), a 48-week, phase 3, randomized controlled trial that compared outcomes with methotrexate monotherapy, etanercept monotherapy, and methotrexate+etanercept combination therapy in patients with psoriatic arthritis (PsA) naïve to methotrexate and biologics.

Methods

We evaluated key outcomes at Week 24 stratified by sex (male vs female) and BMI (≤30kg/m2 vs >30kg/m2), including the American College of Rheumatology 20 (ACR20), minimal disease activity (MDA), very low disease activity (VLDA), and Psoriatic Arthritis Disease Activity Score (PASDAS). We analyzed data using descriptive statistics, normal approximation, logistic model, and analysis of covariance.

Results

A total of 851 patients completed the SEAM-PsA trial. Higher proportions of men than women who received methotrexate+etanercept combination therapy achieved ACR20 (71.5% vs 58.3%; P=0.0194), MDA (45.8% vs 25.2%; P=0.0003), and VLDA (19.1% vs 9.4%; P=0.0273), and men achieved better PASDAS (–3.0 vs –2.3; P=0.0004). Patients with BMI≤30kg/m2 generally had better outcomes than those with BMI>30kg/m2 in some treatment arms for ACR20, MDA, VLDA, and PASDAS; however, there was no consistent pattern regarding the treatment arm in which the difference occurred.

Conclusion

Improved outcomes were observed more in men than in women for MDA and PASDAS with methotrexate+etanercept combination therapy. Patients with BMI≤30kg/m2 had better outcomes than those with BMI>30kg/m2 with no clear pattern regarding treatment received. These findings suggest that contextual factors such as sex and BMI may affect response to PsA therapy.

Related Risk Factors and Treatment Management of Psoriatic Arthritis Complicated With Cardiovascular Disease

Psoriatic arthritis (PsA) is a chronic autoimmune inflammatory joint disease related to psoriasis (PsO). The risk of PsA patients with cardiovascular disease (CVD) is significantly higher than that of the general population. At present, the relevant mechanism is not clear, chronic inflammation and traditional cardiovascular risk factors are the most important factors for the increased risk of CVD in PsA patients. Early assessment of the risk of PsA patients with CVD, and active control of the disease activity of PsA patients and intervention of traditional cardiovascular risk factors can delay the progression of CVD risk. This article reviews the epidemiology and pathogenesis between PsA and CVD, and reviews the latest developments in the risk assessment and management of CVD in PsA patients.

Clinical Specialty Setting as Determinant of Management of Psoriatic Arthritis: A Cross-Sectional Brazilian Study

OBJECTIVE

The aim of this study was to examine the effect of clinical specialty setting on the management of psoriatic arthritis (PsA) as well as disease activity/burden in Brazil.

METHODS

This study is a post hoc analysis of the Brazilian population in a cross-sectional, observational study conducted in 17 countries. Patients were 18 years or older with suspected or confirmed PsA attending routine visits at participating sites. Primary end points were time from symptom onset to PsA diagnosis, from diagnosis to first conventional systemic disease-modifying antirheumatic drug (DMARD) or first biologic DMARD, and from first conventional systemic DMARD to first biologic DMARD. Potential associations were assessed using the Student t test or the Mann-Whitney U nonparametric test. Normality was tested using the Shapiro-Wilk and Kolmogorov-Smirnov tests. For qualitative variables, the χ2 test was adopted.

RESULTS

Patients (n = 130) visited dermatology (n = 75) or rheumatology (n = 55) sites. All primary end points were similar between the 2 settings; however, dermatology patients had significantly greater enthesitis counts (2.1 vs 0.6; p = 0.002), absenteeism at work (Work Productivity and Activity Impairment, 19.7% vs 5.2%; p = 0.03), and pain (Health Assessment Questionnaire-Disability Index pain scale, 1.39 vs 1.01; p = 0.032), as well as worse quality of life related to psoriasis (Dermatology Life Quality Index total score, 8.5 vs 5.0; p = 0.019) and mental health (12-item Short-Form Health Survey, version 2.0 subscale, 42.4 vs 47.4; p = 0.029).

CONCLUSIONS

In Brazil, PsA disease burden and disease activity were influenced by clinical specialty. Irrespective of setting, patients experienced a delay in being diagnosed with PsA, reinforcing the need for collaborative management of PsA by rheumatologists and dermatologists for better outcomes in these patients.

Efficacy and safety of selective TYK2 inhibitor, deucravacitinib, in a phase II trial in psoriatic arthritis

Objective

To evaluate the efficacy and safety of an oral selective tyrosine kinase 2 (TYK2) inhibitor, deucravacitinib, in patients with active psoriatic arthritis (PsA).

Methods

In this double-blind, phase II trial, 203 patients with PsA were randomised 1:1:1 to placebo, deucravacitinib 6 mg once a day or 12 mg once a day. The primary endpoint was American College of Rheumatology-20 (ACR-20) response at week 16.

Results

ACR-20 response was significantly higher with deucravacitinib 6 mg once a day (52.9%, p=0.0134) and 12 mg once a day (62.7%, p=0.0004) versus placebo (31.8%) at week 16. Both deucravacitinib doses resulted in significant improvements versus placebo (p≤0.05) in the multiplicity-controlled secondary endpoints of change from baseline in Health Assessment Questionnaire-Disability Index and Short Form-36 Physical Component Summary score and in Psoriasis Area and Severity Index-75 response. Improvements were also seen in multiple exploratory endpoints with deucravacitinib treatment. The most common adverse events (AEs) (≥5%) in deucravacitinib-treated patients were nasopharyngitis, upper respiratory tract infection, sinusitis, bronchitis, rash, headache and diarrhoea. There were no serious AEs and no occurrence of herpes zoster, opportunistic infections and major adverse cardiovascular events, or differences versus placebo in mean changes in laboratory parameters with deucravacitinib treatment.

Conclusions

Treatment with the selective TYK2 inhibitor deucravacitinib was well tolerated and resulted in greater improvements than placebo in ACR-20, multiplicity-controlled secondary endpoints and other exploratory efficacy measures in patients with PsA. Larger trials over longer periods of time with deucravacitinib are warranted to confirm its safety profile and benefits in PsA.

Trial registration number

NCT03881059.

Telemedicine and psoriatic arthritis: best practices and considerations for dermatologists and rheumatologists

Telemedicine encompasses a variety of modalities that allow for the remote assessment and treatment of patients. The technologies, services, and tools available for telemedicine in the USA are increasingly becoming an integral part of the healthcare system to bridge the gaps in care that can arise from geographic and/or socioeconomic obstacles and provider shortages. Telemedicine can be applied to a spectrum of clinical areas, including rheumatic diseases. Psoriatic arthritis (PsA) is a chronic, inflammatory, multisystem disease with predominately skin and joint manifestations. PsA is often misdiagnosed and/or undiagnosed, which can lead to worse patient outcomes, including irreversible joint erosion and damage. The difficulties in diagnosing and managing PsA are confounded by the emergence and increased use of telemedicine because of the COVID-19 pandemic. Telemedicine presents the opportunity to increase access to healthcare by rheumatologists and dermatologists to improve training and education regarding PsA and to decrease time attributed to office visits associated with PsA. However, challenges in diagnosing PsA without a thorough in-person physical examination by a trained rheumatologist or dermatologist exist. We provide an overview of the ways telemedicine can be incorporated into clinical care and optimized for patients with PsA; characteristic clinical features of PsA, with a focus on skin and joint signs and symptoms; screening tools to be used in routine clinical care; assessments that can be used to evaluate quality of life, functional ability, and disease activity in PsA; and resources and recommendations for the development of future telemedicine use in rheumatology and dermatology.

Key Points • Patients with psoriatic arthritis (PsA) are often misdiagnosed and/or undiagnosed. • Telemedicine can improve access to healthcare by rheumatologists and dermatologists. • Telemedicine can be incorporated into clinical care and optimized for managing PsA.

New-Onset Psoriatic Arthritis under Biologics in Psoriasis Patients: An Increasing Challenge?

Psoriasis and psoriatic arthritis (PsA) development is sustained by tumor necrosis factor (TNF)α, interleukin (IL)17, and IL23; hence, biologics targeting those cytokines represent useful therapeutic weapons for both conditions. Nevertheless, biologics strongly reduce PsA risk; several studies reported the possibility of new-onset PsA during biologic therapy for psoriasis. The aim of this 1-year prospective study is to evaluate the prevalence of paradoxical PsA in psoriasis patients under biologic therapy and review the existing literature. For each patient, age, sex, psoriasis duration, psoriasis severity, comorbidities, and previous and current psoriasis treatments were collected, and each subject was screened for PsA using the Early ARthritis for Psoriatic patient (EARP) questionnaire every 3 months for 1 year. New-onset PsA was diagnosed in 10 (8.5%) out of 118 patients (three male, 30.0%; mean age 44.5 years) involving every different biologic class (anti-TNF, anti-IL12/23, anti-IL17, and anti-IL23). No significant risk factor for new-onset PsA was identified; no significant difference was found comparing patients who developed PsA and subjects who did not develop PsA regarding psoriasis severity, past/current therapies, and comorbidities. Clinicians must keep in mind the possibility of PsA onset also in patients undergoing biologics so that PsA screening should be strongly recommended at each follow-up.

Differentiating Psoriatic Arthritis from Osteoarthritis and Rheumatoid Arthritis: A Narrative Review and Guide for Advanced Practice Providers

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects multiple organ systems and is characterized by skin and joint manifestations. PsA is frequently undiagnosed and/or misdiagnosed, especially because of the similarities in clinical presentation shared with other arthritic diseases, including rheumatoid arthritis (RA) and osteoarthritis (OA). An accurate and timely diagnosis of PsA is crucial to prevent delays in optimal treatment, which can lead to irreversible joint damage and increased functional disability. Patients are usually seen by a number of different healthcare providers on their path to a diagnosis of PsA, including advanced practice providers (APPs). This review provides a comprehensive overview of the characteristic features that can be used to facilitate the differentiation of PsA from RA and OA. Detailed information on clinical manifestations, biomarkers, radiologic features, and therapeutic recommendations for PsA included here can be applied in routine clinical settings to provide APPs with the confidence and knowledge to recognize and refer patients more accurately to rheumatologists for management of patients with PsA.

A clinical perspective on risk factors and signs of subclinical and early psoriatic arthritis among patients with psoriasis

Psoriasis is a chronic, immune-mediated disease that includes a broad spectrum of systemic manifestations, complications, and comorbidities. Approximately 20%-30% of patients with psoriasis eventually develop psoriatic arthritis, and up to half of those without psoriatic arthritis experience subclinical musculoskeletal abnormalities. Recognition of early musculoskeletal inflammatory signs in patients with psoriasis is important to understand the extent and severity of this systemic disease, assess the risk of structural joint damage, and ensure timely and effective treatment of the complete spectrum of psoriatic disease. Delayed or ineffective treatment can lead to decreased quality of life, irreversible musculoskeletal damage, and loss of function. In this review, we highlight features of subclinical or early psoriatic arthritis among patients with psoriasis of which dermatologists should be aware. Recent knowledge of features of preclinical psoriatic arthritis in patients with psoriasis is presented. We briefly discuss important risk factors, clinical features, and other characteristics of patients likely to progress from psoriasis to psoriatic arthritis that should be known by dermatologists. Screening tools commonly used in the dermatology clinic to detect psoriatic arthritis are also critically reviewed. Finally, we provide expert commentary for dermatologists concerning the treatment of patients with psoriasis and subclinical signs of early psoriatic arthritis.

Axial involvement in psoriatic arthritis: An update for rheumatologists

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

Validation of Sinhala version of Psoriasis Epidemiology Screening Tool

INTRODUCTION/OBJECTIVES

Psoriatic arthritis (PsA) occurs in one-third of patients with psoriasis and mostly remains undetected leading to debilitating deforming arthritis, eventually. The Psoriasis Epidemiology Screening Tool (PEST) is a quick and valid tool, widely used to detect PsA in clinical practice, and it has been validated to many languages. In this study, we intended to validate a Sinhala version of the PEST and assess its psychometric properties.

METHODS

The Sinhala version of the questionnaire was tested on 199 patients with psoriasis attending the dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients who were detected to have PsA previously (n = 5) and those with other rheumatologic conditions (n = 12) were excluded. All patients were examined by a dermatologist, and demographic and disease characteristics were obtained. All patients were assessed by two rheumatologists who were blinded to the answers provided in the questionnaire. The diagnosis of PsA was made based on the CASPAR criteria.

RESULTS

We observed the total PEST score of 3 or more to be the best cutoff value to screen for PsA. This cutoff value showed the highest Youden index (sensitivity = 0.89, specificity = 0.95). In the ROC analysis, the area under the curve of the PEST_sv was 0.95 (SE 0.02, p < 0.001). PEST_sv total score showed a significant correlation with body surface area involved but not with Dermatology Life Quality Index or Psoriasis area and severity index score.

CONCLUSION

The Sinhala version of PEST demonstrated satisfactory performance as a screening tool for PsA. Key Points • Psoriatic arthritis (PsA) is the most debilitating complication of psoriasis and lack of quick, valid screening tool is a limiting factor for early identification in Sri Lankan context. • Sinhala version of the Psoriasis Epidemiology Screening Tool (PEST_sv) was tested on 199 patients with psoriasis and examined for the diagnosis of PsA according to Classification of Psoriatic Arthritis (CASPAR) criteria. • PEST_sv score of 3 or more was observed to be the best cutoff value to screen for PsA with sensitivity and specificity of 0.89 and 0.95 respectively. • PEST_sv demonstrated satisfactory performance as a screening tool for PsA.

A Systematic Review With Network Meta-Analysis of the Available Biologic Therapies for Psoriatic Disease Domains

Introduction: Several new treatments have been developed for psoriatic disease, an inflammatory condition that involves skin and joints. Notwithstanding, few studies have made direct comparisons between treatments and therefore it is difficult to select the ideal treatment for an individual patient. The aim of this systematic review with network meta-analysis (NMA) was to analyze available and approved biologic therapies for each domain of psoriatic disease: skin, peripheral arthritis, axial arthritis, enthesitis, dactylitis, and nail involvement. Methods: Data from randomized clinical trials (RCTs) were included. A systematic review was performed using the MEDLINE database (July 2020) using PICO criteria. Bayesian NMA was conducted to compare the clinical efficacy of biological therapy in terms of the American College of Rheumatology criteria (ACR, 24 weeks) and Psoriasis Area and Severity Index (PASI, 10-16 weeks). Results: Fifty-four RCTs were included in the systematic review. Due to the design of the RCTs, namely, outcomes and time points, network meta-analysis was performed for skin and peripheral arthritis domains. For the skin domain, 30 studies reporting PASI100 were included. The peripheral arthritis domain was analyzed through ACR70 in 12 studies. From the therapies approved for both domains, secukinumab and ixekizumab were the ones with the highest probability of reaching the proposed outcomes. There is a lack of outcome uniformization in the dactylitis, enthesitis, and nail domains, and therefore, an objective comparison of the studies was not feasible. Nevertheless, secukinumab was the treatment with the best compromise between the number of studies in each domain and the results obtained in the different outcomes. Conclusion: Secukinumab and ixekizumab were the treatments with the highest probability of reaching both PASI100 and ACR70 outcomes. Due to the lack of a standard evaluation of outcomes of the other psoriatic disease domains, a network meta-analysis for all the domains was not possible to perform.

Validation of the Toronto Psoriatic Arthritis Screen II (ToPAS II) questionnaire in a Brazilian population

The Toronto Psoriatic Arthritis Screen II (ToPAS II) was developed as a tool to screen patients with probable psoriatic arthritis. We aimed to evaluate the validation of the ToPAS II questionnaire in a Brazilian population. The Portuguese translation of the ToPAS II was sent to us by the developer authors of the original index, and adapted to Brazilian Portuguese. Subjects were recruited from dermatology, general, and rheumatology outpatient clinics. After patients completed the questionnaire, they were assessed by a rheumatologist, according to standard protocol. Receiver operating characteristics (ROC) was used to obtain the sensitivity and specificity of the Brazilian Portuguese version of the ToPAS II questionnaire. One hundred and eighty-four subjects were recruited in the study. There were 70 subjects from the psoriasis group, 44 subjects from the psoriatic arthritis (PsA) group, 40 subjects from the rheumatology (non-PsA) group, and 45 healthy controls. Twenty-four patients (34.3%) in the psoriasis group had inflammatory pain and met the CASPAR classification criteria. The area under the ROC curve was 0.96, which indicates that an excellent predictor and optimum cutoff threshold to discriminate patients diagnosed with PsA used was eight as originally chosen. The overall sensitivity and specificity based on the cutoff threshold of eight were 91.3 and 90.9%, respectively. The Portuguese Brazilian version of the ToPAS II has good sensitivity and specificity and is a useful tool to screen for PsA. Key Points • Among these psoriasis patients, almost 35% in fact had psoriatic arthritis without correct diagnosis. Keeping alert of the need to disclose screening tool's use. • The TOPAS II can facilitate the screening of patients suggestive of inflammatory joint disease (with high probability of rheumatologic diagnosis) decreasing morbidity of these patients.

A head-to-head comparison of ixekizumab vs. guselkumab in patients with moderate-to-severe plaque psoriasis: 24-week efficacy and safety results from a randomized, double-blinded trial

Background

Significantly more patients with moderate‐to‐severe plaque psoriasis treated with the interleukin (IL)‐17A inhibitor ixekizumab vs. the IL‐23p19 inhibitor guselkumab in the IXORA‐R head‐to‐head trial achieved 100% improvement in Psoriasis Area and Severity Index (PASI 100) at week 12.

Objectives

To compare skin and nail clearance and patient‐reported outcomes for ixekizumab vs. guselkumab, up to week 24.

Methods

IXORA‐R enrolled adults with moderate‐to‐severe plaque psoriasis, defined as static Physician’s Global Assessment ≥ 3, PASI ≥ 12 and involved body surface area ≥ 10%. Statistical comparisons were performed using the Cochran–Mantel–Haenszel test stratified by pooled site. Time‐to‐first‐event comparisons were performed using Kaplan–Meier analysis, and P‐values were generated using adjusted log‐rank tests stratified by treatment group. Cumulative days at clinical and patient‐reported responses were compared by ancova. The trial was registered with ClinicalTrials.gov (NCT03573323).

Results

Of the 1027 patients randomly assigned, 90% completed the trial (465 of 520 ixekizumab and 459 of 507 guselkumab). As early as week 2 and through week 16, more patients on ixekizumab achieved PASI 100 (P < 0·01). At week 24, ixekizumab was noninferior to guselkumab (50% vs. 52%, difference −2·3%), with no statistically significant difference in PASI 100 (P = 0·41). More patients receiving ixekizumab showed completely clear nails at week 24 (52% vs. 31%, P = 0·007). The median time to first PASI 50/75/90 and PASI 100 were 2 and 7·5 weeks shorter, respectively, for patients on ixekizumab vs. guselkumab (P < 0·001). Patients on ixekizumab also had a greater cumulative benefit, with more days at PASI 90 and 100, with Dermatology Life Quality Index of 0 or 1, and itch free (P < 0·05). The frequency of serious adverse events was 3% for each group, with no new safety signals.

Conclusions

Ixekizumab was noninferior to guselkumab in complete skin clearance and superior in clearing nails at week 24. Ixekizumab cleared skin more rapidly in patients with moderate‐to‐severe plaque psoriasis, with a greater cumulative benefit, than guselkumab. Overall, the safety findings were consistent with the known safety profile for ixekizumab.

What is already known about this topic?

Patients with plaque psoriasis desire both high levels of clearance and rapid onset of treatment effects.

Ixekizumab is a high‐affinity monoclonal antibody that selectively targets interleukin (IL)‐17A.

In the 12‐week report of the IXORA‐R study, ixekizumab demonstrated significantly higher efficacy at early timepoints than the IL‐23p19 inhibitor guselkumab, with more patients achieving 100% improvement in Psoriasis Area and Severity Index (PASI 100) and improved quality of life as early as week 4.

What does this study add?

Patients on ixekizumab vs. guselkumab achieved similar levels of skin clearance and superior efficacy in the resolution of nail psoriasis at week 24.

Patients on ixekizumab vs. guselkumab had a greater cumulative benefit, with more days at PASI 90 and 100, more days when psoriasis did not impact their quality of life, and more itch‐free days.

The safety profiles of both drugs were consistent with those in previous studies.

Linked Comment: Puig. Br J Dermatol 2021; 184:992–993.

Guselkumab in biologic-naive patients with active psoriatic arthritis (DISCOVER-2): a double-blind, randomised, placebo-controlled phase 3 trial

BACKGROUND

The interleukin-23 (IL-23)/T-helper 17 cell pathway is implicated in psoriatic arthritis pathogenesis. Guselkumab, an IL-23 inhibitor that specifically binds the IL-23 p19 subunit, significantly and safely improved psoriatic arthritis in a phase 2 study. DISCOVER-2 was a phase 3 trial to assess guselkumab in biologic-naive patients with psoriatic arthritis.

METHODS

This phase 3, double-blind, placebo-controlled study was done at 118 sites in 13 countries across Asia, Europe, and North America. We enrolled biologic-naive patients with active psoriatic arthritis (at least five swollen joints, at least five tender joints, and C-reactive protein ≥0·6 mg/dL) despite standard therapies. Patients were randomly assigned (1:1:1, computer-generated permuted blocks; stratified by baseline disease-modifying antirheumatic drug use and C-reactive protein concentration) to subcutaneous injections of guselkumab 100 mg every 4 weeks; guselkumab 100 mg at weeks 0, 4, then every 8 weeks; or placebo. The primary endpoint was American College of Rheumatology 20% improvement (ACR20) response at week 24 in all patients per assigned treatment group. Safety was assessed in all patients per treatment received. This trial is registered at ClinicalTrials.gov, NCT03158285 (active, not recruiting).

FINDINGS

From July 13, 2017, to Aug 3, 2018, 1153 patients were screened, of whom 741 were randomly assigned to receive guselkumab every 4 weeks (n=246), every 8 weeks (n=248), or placebo (n=247). One patient in the every 4 weeks group and one in the placebo group did not start treatment, and the remaining 739 patients started treatment; 716 patients continued treatment up to week 24. Significantly greater proportions of patients in the guselkumab every 4 weeks group (156 [64%] of 245 [95% CI 57-70]) and every 8 weeks group (159 [64%] of 248 [58-70]) than in the placebo group (81 [33%] of 246 [27-39]) achieved an ACR20 response at week 24 (percentage differences vs placebo 31% [95% CI 22-39] for the every 4 weeks group and 31% [23-40] for the every 8 weeks group; both p<0·0001). Up to week 24, serious adverse events occurred in eight (3%) of 245 patients receiving guselkumab every 4 weeks (three serious infections), three (1%) of 248 receiving guselkumab every 8 weeks (one serious infection), and seven (3%) of 246 receiving placebo (one serious infection). No deaths occurred.

INTERPRETATION

Guselkumab, a human monoclonal antibody that specifically inhibits IL-23 by binding the cytokine's p19 subunit, was efficacious and demonstrated an acceptable benefit-risk profile in patients with active psoriatic arthritis who were naive to treatment with biologics. These data support the use of selective inhibition of IL-23 to treat psoriatic arthritis.

FUNDING

Janssen Research and Development.