Managing Psoriatic Arthritis With Inflammatory Bowel Disease and/or Uveitis

Early psoriatic arthritis: clinical and therapeutic challenges

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic immunoinflammatory disease of the enthesis and adjacent synovium, skin, and nail, which early diagnosis may be crucial for starting a prompt therapeutic intervention. Theoretically, early treatment offers the advantage of acting on the reduction of the articular damage progression since initial phases of the disease.

AREAS COVERED

This review explores the challenges of clinical-diagnostic aspects and the underlying pathophysiology of early PsA phases, as well as the evidence evaluating the impact of early intervention on disease outcomes.

EXPERT OPINION

Main instruments for early PsA diagnosis include recognizing synovial-entheseal inflammatory signs at onset, improving screening PsA high-risk subjects, and increasing disease knowledge of physicians and patients with psoriasis or familial history.PsA continues to significantly impact on the Quality of Life of patients affected by the disease, making necessary to deeply study clinical manifestations, risk factors and underlying immunoinflammatory mechanisms, as well as to identify biomarkers for early identification. Additionally, it remains a need to increase more evidence on understanding how early treatment of PsA and of psoriasis might influence the course of the disease.

Biologic therapies for psoriasis and eyes

Psoriasis is a systemic inflammatory disorder, manifested mainly by skin lesions, but the inflammation also may affect the joints and eye. Many comorbidities have been described in association with psoriasis, including metabolic syndrome and coronary plaques. The pathomechanism of psoriasis is multifaceted. Both genetic and immunologic aspects play a role in stimulating inflammation. Genetic susceptibility is conditioned by presence of the human leukocyte antigen-C*06:02 risk allele and the inflammatory reaction secondary to cytokines, such as tumor necrosis factor α, interleukin 17 (IL-17), IL-20, IL-23, and interferon alfa. Besides the conventional therapy of topical steroids and immunosuppressants, biologic therapies are widely used in the treatment of psoriasis, psoriatic arthritis, and coexisting uveitis. In the majority of cases, biologic therapy has a beneficial effect on uveitis, but in some cases, some of these drugs can lead to serious side effects threatening vision.

Seronegative spondyloarthropathy-associated inflammatory bowel disease

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

Mechanisms of Tumor Necrosis Factor-Alpha Inhibitor-Induced Systemic Lupus Erythematosus

Systemic lupus erythematosus induced by biologics mainly results from tumor necrosis factor-alpha remains unclear. The objectives of the study were to investigate the mechanisms of tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus. Peripheral blood mononuclear cells obtained from thirteen psoriasis patients were cultured and treated with the following: untreated control, Streptococcus pyogenes with or without different biologics. The supernatants were collected for cytokines assay. Analysis of cytokine expression revealed that IL-2 and IL-10 levels decreased only in the TNF-α inhibitor-treated groups but not in the groups treated with biologics involving IL-17, IL-12/IL-23 or IL-23 inhibitor mechanisms (p < 0.001, p < 0.05). The IFN-γ/IL-13 ratio increased significantly in patients with SLE inducing biologics to S. pyogenes induction only compared with non-SLE inducing biologics to S. pyogenes induction only (p = 0.001). IL-2 and IL-10 depletion and a shift to the Th-1 pathway in the innate response are the correlated mechanism for tumor necrosis factor-alpha inhibitor-induced systemic lupus erythematosus.

Reflecting on the immunopathology of arthritis associated with inflammatory bowel disease: what do we know and what should we know?

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is clinically closely associated with arthritis. Three major arthritis clinical subtypes have been described, peripheral arthritis type 1 (PeA1), peripheral arthritis type 2 (PeA2), and axial spondyloarthritis (axSpA). While genetic overlaps between IBD and arthritis have been defined, detailed pathophysiology for these three major subtypes of arthritis in patients with IBD has only recently begun to be established. The genetic and molecular mechanisms distinguishing axial and peripheral arthropathies in patients with UC and CD need to be better described. Understanding the pathophysiology for PeA1, PeA2, and axSpA in the settings of both UC and CD is necessary to provide the fundamental biology underlying the clinical phenotypes in IBD arthritis. This has been attempted for CD-associated spondyloarthritis, differentiating this from both CD and axSpA, while observing unique peripheral blood mononuclear cells linking gut inflammation to joint disease. We should know more about the processes by which immune cells are perturbed in these disorders, how they translocate to joints, how they are activated, what other molecules and mediators are involved, and how gut microbes and microbial products damage joints. Information from such studies are needed to elucidate whether distinctions between IBD-related peripheral and axSpA are clinically meaningful. IBD-related peripheral and axSpA studies are needed to elucidate whether distinctions between peripheral and axSpA are clinically meaningful, to better understand immunopathogenesis, and to develop novel targeted therapies.

Enthesitis in Bowel-Associated Dermatosis-Arthritis Syndrome in an Ulcerative Colitis Patient

Bowel-associated dermatosis-arthritis syndrome (BADAS) is a rare and recurrent neutrophilic dermatosis condition. Due to the rarity of this syndrome and the difficulty of the disease recognition and management, there was no clear reported incidence rate of this syndrome. 20% of patients after ileojejunal bypass surgery for morbid obesity were reported, by Jorizzo et al., to have BADAS. The underlying etiology of BADAS is not fully understood; therefore, the diagnosis of this condition is difficult and the approach for the management as well. Herein, we report a case of BADAS with unusual musculoskeletal presentation.

Parental uveitis causes elevated hair loss in offspring of C57BL/6J mice

Our previous study demonstrated that parental uveitis in a susceptible population can cause hair loss and increase the susceptibility to experimental autoimmune uveitis (EAU) in offspring. However, it is unclear whether parental uveitis affects the development of offspring in an EAU-moderate-susceptible population. Herein, moderate-susceptible C57BL/6J mice were immunized with inter-photoreceptor retinoid binding protein (IRBP) 651-670 to develop EAU and were kept together for mating. Gross examination and histopathological changes of the offspring gestated with parental uveitis were observed to evaluate the impact of parental uveitis on the development of the offspring. Differentially expressed genes (DEGs) were screened by RNA sequencing in the affected skin and eyeball of the offspring on postnatal day 27. Adult offspring were injected 75 μg IRBP_651-670 to evaluate their susceptibility to EAU. Gross examination in the offspring revealed hair loss on postnatal days 11-31. Histopathological observation showed increased melanin granules and hair follicles of skin in the affected offspring with hair loss. Gene Ontology (GO) analysis in the skin revealed differential expression of genes involved in the mitotic cell cycle, response to endogenous stimulus, hair follicle development, and hair cycle. The DEGs in the skin were predominately associated with the cell cycle and peroxisome proliferator-activated receptor (PPAR) signaling pathway. The GO enrichment analysis in the eyeball showed differential expression of genes involved in the nervous system development, camera-type eye photoreceptor cell differentiation, neuron projection morphogenesis, axon development, and calcium-induced calcium release activity; enriched pathways included the circadian entrainment and glutamatergic synapses. No increased susceptibility to EAU in offspring gestated from parental remitting EAU was observed at a low-dose 75 μg IRBP induction. These results suggested that parental uveitis in a moderate-susceptible population could affect the skin development and DEG profiles of skin and eyeball related to the response to endogenous stimulus, the PPAR signaling pathway, and glutamatergic synapse, which provides the molecular evidence to explain the influence of parental uveitis on offspring development.