Magnetic Resonance Imaging in Psoriatic Arthritis: A Descriptive Study of Indications, Features and Effect on Treatment Change

Magnetic resonance imaging characteristics in patients with psoriatic arthritis and axial manifestations from the MAXIMISE cohort

OBJECTIVE

The current analysis of the MAXIMISE trial was conducted to investigate the presence of post-inflammatory and degenerative spinal changes and inflammatory changes in spinal processes identified in baseline MRIs and their potential for predicting differential treatment effects in a cohort of PsA patients with axial manifestations.

METHODS

Baseline spinal MRIs from the MAXIMISE trial were re-read to identify additional inflammatory (spinal process), post-inflammatory, and degenerative changes, and investigate the differential treatment effect of these imaging features using logistic regression modelling.

RESULTS

In addition to bone marrow oedema assessed at primary analysis, spinal process inflammation and post-inflammatory changes evaluated by FAt Spondyloarthritis Spine Score were documented in 11.1% and 20.2% patients, respectively. At least one type of degenerative change was noted in 64% patients, with Pfirrmann grade ≥3 (51.1%) being the most common. Combining primary and re-read MRI findings, 67.1% of patients presented with inflammatory or post-inflammatory changes while 21.2% had degenerative changes alone. Although not statistically significant, post-inflammatory changes were associated with a trend for better efficacy outcomes in terms of ASAS20, ASAS40 and BASDAI50 responses; a trend for worse outcomes was observed in the presence of degenerative changes.

CONCLUSION

The current analysis revealed the occurrence of additional inflammatory and post-inflammatory changes suggestive of axial PsA (axPsA) and a trend for better clinical outcomes for patients treated with secukinumab. These results elucidate the imaging characteristics and improve our current understanding of axPsA thereby supporting the interpretation of future trials.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02721966.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Axial involvement in psoriatic arthritis

Among the variety of clinical manifestations of psoriatic arthritis (PsA) – including peripheral arthritis, dactylitis, enthesitis, and axial disease – spondylitis is the least studied. There is no generally accepted definition of axial PsA (axPsA), nor is there any common terminology or diagnostic criteria for it. In the rheumatology community, there is also no consensus regarding radiological and MRI assessment of axial involvement in PsA patients, while disease activity indexes and the therapeutic tactics are borrowed from those used in treating axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS). However, despite a range of similarities in immunopathogenetic mechanisms of axPsA and axSpA, there are also certain differences that may affect the treatment response in these patients. The aim of this review is the analysis of data on axial disease in PsA. The article discusses the genetic features, clinical presentations, imaging techniques, differential diagnostics and treatment options of axPsA.

Psoriatic Spondylitis: A Disease Manifestation in Debate: Evidences to Know for the Clinical Rheumatologist

ABSTRACT

With the advent of classification criteria for psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), patients with axial manifestations associated with psoriasis, initially described in the l950s as a specific entity termed psoriatic spondylitis (PS), are now categorized within PsA, ankylosing spondylitis (AS), and axSpA. Thus, different terms are used to describe axial disease in patients with PsA including PS, axial psoriatic arthritis (axPsA), and psoriatic spondyloarthritis. Patients with PS may present with inflammatory and/or mechanical back pain, but also may display axial disease on imaging despite not complaining of back pain. Cervical spondylitis has been reported in 35% to 75% of patients with PsA. Axial disease is silent in 20% and 25% of patients with axial PsA and PsA, respectively. The majority of axPsA patients have peripheral arthritis alongside the axial involvement, whereas only 2% to 5% of PsA patients have solely axial arthritis with no peripheral arthritis.A debate is currently underway as to whether inflammatory axial disease and psoriasis represent axSpA with psoriasis or a subset of PsA named axPsA. Studies have recognized that axial disease in PsA patients seems to be different demographically, genetically, clinically, and radiographically when compared with AS with or without psoriasis. This narrative review summarizes current knowledge regarding axial involvement of PsA in terms of history, terminology, classification, epidemiology, clinical presentation, imaging, diagnosis, and treatment, with the aim of providing advice for management of PS in clinical evidence-based practice. Data-driven studies are needed to develop clear, nonoverlapping classification criteria for spinal involvement in PsA.

Axial Psoriatic Disease: Clinical and Imaging Assessment of an Underdiagnosed Condition

The frequent involvement of the spine and sacroiliac joint has justified the classification of psoriatic arthritis (PsA) in the Spondyloarthritis group. Even if different classification criteria have been developed for PsA and Spondyloarthritis over the years, a well-defined distinction is still difficult. Although the majority of PsA patients present peripheral involvement, the axial involvement needs to be taken into account when considering disease management. Depending on the definition used, the prevalence of axial disease may vary from 25 to 70% in patients affected by PsA. To date, no consensus definition has been reached in the literature and the definition of axial involvement in PsA has varied from isolated sacroiliitis to criteria used in ankylosing spondylitis. This article reviews the unmet needs in the clinical and radiological assessment of axial PsA, reporting the various interpretations of axial involvement, which have changed over the years. Focusing on both imaging and clinical standpoints, we reported the prevalence of clinical and radiologic features, describing the characteristics of axial disease detectable by X-rays, magnetic resonance imaging, and PET-CT, and also describing the axial symptoms and outcome measures in patients affected by axial disease.

Disease activity indices in psoriatic arthritis: current and evolving concepts

Psoriatic arthritis (PsA) is a highly heterogenous disease, with many different clinical manifestations inside or outside of the musculoskeletal system and the skin. It is often accompanied by comorbidities like cardiovascular diseases and mental health disorders. Acute phase reactants are not always elevated and specific markers for diagnosis and/or monitor the disease are lacking thus far. These characteristics possibly reflect the difficulty in agreement about a disease activity index for PsA. Many indices have been proposed over the last years, each of them considering different combinations of disease characteristics. We performed a literature search for relevant articles using PubMed and Embase. No data limits were applied. The keywords "Psoriatic arthritis" OR "PsA" AND "disease activity" AND "index" OR "indices" were used. Reference lists of relevant articles were also reviewed. Articles were also identified through searches of the authors' own files. In this review, we comparatively present the available indices (simple or composite) used for measuring activity in PsA, highlighting their weaknesses, strengths, and disparities. We comment also on the caveats and pitfalls that are encountered in assessment of disease activity, in relation to clinical practice and research. A widely accepted index for measuring disease activity in PsA is lacking. Other parameters, mostly related to patient-reported outcomes and to novel biomarkers might be included in the future, in such indices. Key points • Disease activity in PsA is multiparametric and its assessment is challenging due to many different phenotypes. • Many different indices are currently in use of PsA disease activity assessment. • Each PsA disease activity index has specific pros and cons.

Imaging in psoriatic arthritis: Status and recent advances

The heterogeneous nature of psoriatic arthritis (PsA), encompassing several domains, with varied presentations brings about considerable challenges in disease evaluation. Prompt diagnosis and targeted therapy have resulted in disease remission being accepted as an attainable goal in PsA. Imaging has played a pivotal role in early diagnosis, better understanding of pathogenesis, monitoring of disease, and as an outcome measurement tool in clinical trials in PsA. Conventional radiography has been the cornerstone of assessing structural damage. With the advent of ultrasound and magnetic resonance imaging, better delineation of the various structures involved in the disease process is possible, thus enabling sensitive assessment of inflammatory and structural pathologies together. In this review, imaging modalities used in routine assessment and clinical trials in PsA will be discussed in detail, focusing on advances over the past 5 years.

Recent Advances in Imaging for Diagnosis, Monitoring, and Prognosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory condition characterized by a strong heterogeneity and multifaceted behavior. PsA manifests in two types—axial and peripheral—which may be present at the same time. Peripheral manifestations can be further divided into the articular (arthritis) and extra-articular (i.e., enthesitis and dactylitis) subgroups. In such a complex disease, imaging is often required to characterize the type of involvement and to evaluate the radiological damage and progression of PsA. In addition, imaging plays a pivotal role in clinical practice; that is, for axial involvement. Conventional radiology has been the main standard of reference for many years. However, in recent years, there has been growing interest in different imaging modalities, such as ultrasonography (US) and magnetic resonance imaging (MRI). All these techniques play a role in the diagnosis and follow-up of patients with PsA and cover all the types of the disease. US and MRI have good sensitivities and specificities for detecting synovitis, and this may be helpful for differential diagnosis with other musculoskeletal diseases and useful in the early or preclinical phases of the disease. However, US is not useful in the diagnosis of axial PsA. In addition, other modalities have been investigated in the field of PsA imaging. Computed tomography (CT), in particular, dual energy-CT and high-resolution peripheral CT (HRpQ-CT) might play an important role in the assessment of bone damage, erosions, and new bone formation. Regarding advanced functional imaging, FDG PET/CT is another interesting technique for exploring disease activity.

Axial Psoriatic Arthritis: A Distinct Clinical Entity in Search of a Definition

Axial involvement in psoriatic arthritis is a well-recognized manifestation with a prevalence between 12.5% and 78%. This huge heterogeneity is due to the different criteria used by authors to define psoriatic arthritis with axial involvement combining clinical features with radiographic evidence of disease. Specific genetic and clinical attributes of axial psoriatic arthritis might differentiate it from axial spondyloarthritis with concurrent skin psoriasis. Few studies address the specific management. The purpose of this review is to acknowledge the current understanding of axial involvement in psoriatic arthritis and highlight the need for a definition to facilitate research and clinical recognition.

Definition of Remission and Disease Activity Assessment in Psoriatic Arthritis: Evidence and Expert-Based Recommendations

OBJECTIVE

We aimed to reach a consensus on the best instruments to monitor disease activity in patients with psoriatic arthritis (PsA) and to develop a consensus definition of remission.

METHODS

A modified Delphi approach was used. A scientific committee provided statements addressing the definition of remission and the monitoring of PsA in clinical practice. The questionnaire was evaluated in 2 rounds by rheumatologists with experience in managing PsA patients.

RESULTS

A panel of 77 rheumatologists reached agreement on 62 out of the 86 proposed items (72.0%). The most recommended index for monitoring disease activity was DAPSA (cut-off values: ≤4 for remission and >4-14 for low disease activity ([LDA]), MDA (at least 5/7 criteria). In cases with axial involvement, ASDAS was the preferred index (cut-off values: <1.3 for remission and <2.1 for LDA). BASDAI (cut-off values: ≤2 for remission and ≤4 for LDA) may be used as an alternative. PsAID was the preferred tool to assess disease impact.

CONCLUSION

We propose a definition of remission in PsA as the absence of disease activity evaluated by DAPSA or MDA (ASDAS and/or BASDAI in patients with axial involvement), which would imply absence of signs or symptoms of inflammation, physical well-being, lack of disease impact, and absence of inflammation as measured by biological markers.

Axial disease in psoriatic arthritis and ankylosing spondylitis: a critical comparison

Ankylosing spondylitis (AS) was first identified in the late 17th century. 250 years later, inflammatory spine disease was recognized to be one of the patterns of psoriatic arthritis (PsA). Isolated spondylitis is rare among patients with PsA, occurring in less than 5% of patients; however, many patients with PsA have axial disease that is concurrent with peripheral arthritis. At the other end of the spondyloarthritis spectrum, psoriasis is observed in 10% of patients with AS. Although axial involvement in PsA can be indistinguishable from axial disease in AS, it can also differ in several respects, raising the question of whether axial PsA and AS (with or without psoriasis) are different clinical presentations of the same disease, or whether they are separate diseases that have overlapping features. In this Review, the clinical presentation, metrology, radiographic characteristics, genetic factors, treatment options and axial prognosis of the two diseases are addressed. The aim of this Review is to capture all available comparisons made to date, to highlight the similarities and differences between AS and axial PsA and to propose a research agenda.