Does age matter in Psoriatic arthritis? A narrative review

Determinants of health-related quality of life and global functioning and health in axSpA, pSpA and PsA: results from the ASAS-PerSpA study

OBJECTIVES

We aimed to identify determinants of health-related quality of life (HRQoL) and global functioning and health (GH) in axial SpA (axSpA), peripheral SpA (pSpA) and (PsA).

METHODS

The ASAS-perSpA study data were analysed. Models for the three patient groups were run separately to explore factors associated with HRQoL and GH, assessed by EQ-5D and ASAS-HI, respectively.

RESULTS

The analyses included 4185 patients: 2719 with axSpA, 433 with pSpA, and 1033 with PsA.In axSpA, disease activity (β = -0.061), physical function (β = -0.041), female sex (β = -0.019) and fibromyalgia (FM) (β = -0.068) were associated with worse HRQoL; age (β = 0.001) and university education (β = 0.014) were associated with better HRQoL. In pSpA, disease activity (β = -0.04) and physical function (β = -0.054) were associated with worse HRQoL. In PsA, disease activity (β = -0.045), physical function (β = -0.053), axial disease (β = -0.041) and female sex (β = -0.028) were associated with worse HRQoL. In axSpA, disease activity (β = 0.889), physical function (β = 0.887), peripheral disease (β = 0.564), female sex (β = 0.812) and FM (β = 1.639) were associated with worse GH; age (β = -0.013) and university education (β = -0.274) were associated with better GH. In pSpA, physical function (β = 1.142) and female sex (β = 1.060) were associated with worse GH; university education (β = -0.611) was associated with better GH. In PsA, disease activity (β = 0.703), physical function (β = 1.025), axial involvement (β = 0.659), female sex (β = 0.924) and FM (β = 1.387) were associated with worse GH; age (β = -0.024) and university education (β = -0.856) were associated with better GH.

CONCLUSION

Disease activity and physical function are major HRQoL and GH determinants across SpA types, and clinical characteristics and sociodemographic factors play an important role, highlighting the importance of a holistic approach for individual patients.

Rasmussen S, Lindström U, Askling J, Michelsen B, Di Giuseppe D, Wallman JK, Gudbjornsson B, Love TJ, Nordström DC, Yli-Kerttula T, Nekvindová L, Vencovský J, Iannone F, Cauli A, Loft AG, Glintborg B, Laas K, Rotar Z, Tomšič M, Macfarlane GJ, Möller B, van de Sande M, Codreanu C, Nissen MJ, Birlik M, Erten S, Santos MJ, Vieira-Sousa E, Hetland ML, Østergaard M. Predictors of DAPSA28 remission in patients with psoriatic arthritis initiating a first TNF inhibitor: results from 13 European registries

OBJECTIVES

In bio-naïve patients with PsA initiating a TNF inhibitor (TNFi), we aimed to identify baseline predictors of Disease Activity index for PsA in 28 joints (DAPSA28) remission (primary objective) and DAPSA28 moderate response at 6 months, as well as drug retention at 12 months across 13 European registries.

METHODS

Baseline demographic and clinical characteristics were retrieved and the three outcomes investigated per registry and in pooled data, using logistic regression analyses on multiply imputed data. In the pooled cohort, selected predictors that were either consistently positive or negative across all three outcomes were defined as common predictors.

RESULTS

In the pooled cohort (n = 13 369), 6-month proportions of remission, moderate response and 12-month drug retention were 25%, 34% and 63% in patients with available data (n = 6954, n = 5275 and n = 13 369, respectively). Five common baseline predictors of remission, moderate response and 12-month drug retention were identified across all three outcomes. The odds ratios (95% CIs) for DAPSA28 remission were: age, per year: 0.97 (0.96-0.98); disease duration, years (<2 years as reference): 2-3 years: 1.20 (0.89-1.60), 4-9 years: 1.42 (1.09-1.84), ≥10 years: 1.66 (1.26-2.20); men vs women: 1.85 (1.54-2.23); CRP of >10 vs ≤10 mg/l: 1.52 (1.22-1.89) and 1 mm increase in patient fatigue score: 0.99 (0.98-0.99).

CONCLUSION

Baseline predictors of remission, response and adherence to TNFi therapy were identified, of which five were common for all three outcomes, indicating that the predictors emerging from our pooled cohort may be considered generalizable from country level to disease level.

Current Pharmacological Therapies for the Management of Spondyloarthritis: Special Considerations in Older Patients

Spondylarthritis (SpA) is generally observed in young male patients but can be diagnosed in older patients. These cases correspond to late-onset SpA (LoSpA) with two main clinical presentations, axial and peripheral SpA. Another increasingly common situation is that of older patients who have had SpA for many years. The therapeutic management of LoSpA is quite smilar to the management of patients with an early-onset disease, combining both non-pharmacological and pharmacological treatments. The treatments that can be used in LoSpA include non-steroidal anti-inflammatory drugs (NSAIDs) and biological agents targeting TNFα or IL-17A. Janus kinase inhibitors (JAKi) were recently introduced on the market for SpA. TNF inhibitors and IL-17inhibitors are very effective drugs in early-onset SpA. The effectiveness and safety of targeted therapies have not been specifically evaluated in LoSpA or older patients, and thus caution is required for these patients with comorbidities and/or polymedication. According to indirect data, biological agents seem to be less effective in LoSpA compared with early-onset disease. In parallel, a careful evaluation for the risk of infection, malignancy and cardiovascular events is recommended before initiating these drugs in this age category. JAKi may be used in LoSpA, but only in selected patients according to recent recommendations from the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). When considering that the prevalence of such situations is expected to increase as ageing progresses, it is certainly time to consider this patient category as a distinct subgroup within the spectrum of SpA. Specific studies evaluating targeted agents in this age category are thus desirable.

Retention rate of tumor necrosis factor inhibitors, anti-interleukin 17, and anti-interleukin 12/23 drugs in a single-center cohort of psoriatic arthritis patients

The objective of this study was to evaluate biological disease-modifying anti-rheumatic drugs (bDMARDs) survival in several therapy courses of patients affected by psoriatic arthritis (PsA) and to compare tumor necrosis factor inhibitors (TNFi) and non-TNFi retention rates. A total of 241 bDMARD therapy courses (155 TNFi drugs, 65 anti-interleukin (IL)-17 drugs, and 21 anti-IL12/23) were analyzed. Bivariate analyses were performed to assess the presence of demographic and clinical features, as well as comorbidities, associated with bDMARD discontinuation in TNFi and non-TNFi groups. In the bivariate analyses of TNFi and non-TNFi groups, we found a lower age at the start of TNFi therapy in the former group [46 years, interquartile range (IQR) 45-54 vs 50.5 years, IQR 42-61; p=0.004] as well as a lower proportion of patients with skin psoriasis (65.8% vs 88.4%; p<0.001). Survival analysis showed no significant differences between TNFi and non-TNFi groups. Cox regression found fibromyalgia as a predictor of drug failure [hazard ratio (HR) 3.40, confidence interval (CI) 1.92-6.03; p<0.001] and first-line bDMARDs as a protective factor (HR 0.46, CI 0.25-0.88; p=0.019). Lastly, among TNFi courses, fibromyalgia was associated with drug suspension (HR 6.52, CI 3.16-13.46; p<0.001), while only a trend of significance for skin psoriasis as a risk factor for drug failure was shown (HR 2.38, CI 1.00-5.66, p=0.05). This study provides information about clinical and demographic factors associated with retention rates of bDMARDs from a real-life, single-center cohort of PsA patients.

[A new integral enthesial-comorbididity index of psoriatic arthritis activity]

AIM

To develop an integral index of psoriatic arthritis (PsA) activity.

MATERIALS AND METHODS

117 patients with PsA (M/F - 63/54) were included. Patients' age 44±11 years, psoriasis (Ps) duration - 213±153 months, PsA duration - 73.4±78.5 months. Patients underwent standard clinical examination of PsA activity: tender (out of 68) and swollen (out of 66) joint counts (TJC, SJC), LEI, tenderness of the plantar fascia (PF), skin lesion severity (BSA), presence of nail Ps, body mass index (BMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), DAPSA, FACIT-F. Parametric and nonparametric statistic methods, correlation and ROC analysis were used.

RESULTS

Mean DAPSA was 38±21, TJC - 14.2±10.6, SJC - 10.6±8.3, ESR - 30.5±29.5 mm/h, CRP - 23.3±29 mg/l, LEI - 1.2±1.5, FACIT-F - 32±11, BMI - 27.4±6.2 kg/m2. The following significant positive correlations were revealed: between DAPSA and BMI, patients' age, ESR, PsA and Ps duration, TJC, SJC, LEI, presence of PF enthesitis, skin lesion severity, presence of nail Ps. A negative correlation between FACIT-F and male sex was found. Based on the predictive model of parameters, the Entesial-Comorbid Index of PsA (ECIPsA) was created: 3.81×LEI+13.72×PF+0.54×Age-0.25×FACIT-F+7.36×BSA+7.94×PsA duration+5.5×Nail Ps+0.32×BMI-3.52, namely LEI - Leeds Enthesial Index; PF - pain in the PF; patient's age; FACIT-F - fatigue scale; BSA<3%=0, ≥3%=1; PsA duration≤2 years=0, >2 years=1; presence of nail Ps=1, absence=0; ECIPsA≥28 corresponds with high PsA activity according to DAPSA≥28. ROC analysis of sensitivity and specificity of the prognostic model demonstrated high correctness of the index: the area under the ROC curve was 0.768, 95% confidence interval (0.624-0.913).

CONCLUSION

The new PsA activity index corresponds to the existing ones and takes into consideration the clinical heterogeneity and comorbidity of the disease.

Differences between early vs. late-onset of psoriatic arthritis: Data from the RESPONDIA and REGISPONSER registries

OBJECTIVES

The objective was to evaluate the association between the age at onset of psoriatic arthritis (PsA) symptoms with the characteristics and burden of the disease.

METHODS

This was an observational and cross-sectional study that included a subgroup of 231 patients with PsA with < 10 years of disease duration from the REGISPONSER and RESPONDIA registries. Patients were divided into two groups according to the age of PsA symptom onset (early onset: ≤ 40-years-old and late onset: ≥ 60-years-old). The characteristics and burden of the disease were compared between the two groups, and multivariate logistic regression was performed to determine the factors independently associated with late-onset PsA.

RESULTS

Patients from the early-onset group showed a significantly lower prevalence of males [94 (62.3%) vs. 38 (86.4%)] and a higher prevalence of enthesitis [44 (24.6%) vs. 5 (9.8%)] and sacroiliitis [30 (16.8%) vs. 4 (7.7%)]. Additionally, the early-onset group showed lower scores on the BASFI [2.2 (2.2) vs. 3.3 (2.5)] and minor structural damage (BASRI) in both the spine [1.6 (2) vs. 2.9 (3)] and whole axial skeleton (total BASRI) [1.9 (2.4) vs. 3.4 (3.4)]. In contrast, no statistically significant differences were found between the groups in disease activity evaluated by the BASDAI and ASDAS. Logistic regression analysis showed that late-onset PsA was independently associated with being male (OR 4.4, 95% CI: 1.3, 16.3), greater structural damage (total BASRI) (OR 3.3, 95% CI: 1.3, 8.1), a higher frequency of arthritis in the upper limbs (OR 2.8, 95% CI: 1, 7.7), and greater loss of function (BASFI) (OR 1.3, 95% CI: 1, 1.6).

CONCLUSIONS

Patients with late-onset PsA showed different clinical characteristics and greater disease severity than those with early-onset PsA.

Response to treatment in psoriatic arthritis, the effect of age: analysis of patients receiving ustekinumab in the PsABio real-world study

BACKGROUND

This post-hoc analysis of PsABio (NCT02627768) evaluated safety, effectiveness and treatment persistence in patients < 60 and ≥ 60 years of age receiving ustekinumab over 3 years.

METHODS

Measures included adverse events (AE), clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) low disease activity (LDA) including remission, Psoriatic Arthritis Impact of Disease-12 (PsAID-12), Minimal Disease Activity, dactylitis, nail/skin involvement and time to treatment stop. Data were analysed descriptively.

RESULTS

Overall, 336 patients < 60 and 103 ≥ 60 years received ustekinumab, with a similar gender balance. A numerically lower proportion of younger patients reported at least one AE: 124/379 (32.7%) vs 47/115 (40.9%) for patients < 60 and ≥ 60 years, respectively. Serious AEs were low (< 10%) in both groups. At 6 months, the proportion of patients with cDAPSA LDA was 138/267 (51.7%) and 35/80 (43.8%) for patients < 60 and ≥ 60 years, respectively, with the effectiveness being maintained through 36 months. PsAID-12 mean scores reduced for both groups from a baseline mean of 5.73 and 5.61 for patients < 60 and ≥ 60 years, respectively, to 3.81 and 3.88, respectively, at 6 months, and 2.02 and 3.24, respectively, at 36 months. Regarding treatment persistence, 173/336 (51.5%) vs 47/103 (45.6%) patients < 60 and ≥ 60 years, respectively, stopped or switched treatment.

CONCLUSION

Fewer AEs were observed over 3 years for younger versus older patients with PsA. There were no clinically meaningful treatment response differences. Persistence was numerically higher in the older age group.

Late-Onset Psoriatic Arthritis: Are There Any Distinct Characteristics? A Retrospective Cohort Data Analysis

As life expectancy increases, psoriatic arthritis (PsA) in older individuals becomes more prevalent. We explored whether late-onset versus earlier-onset PsA patients display different clinical features at diagnosis and/or during the disease course, as well as different treatment approaches and comorbidity profiles. We retrospectively collected data from consecutive PsA patients attending two rheumatology centers (December 2017–December 2022). Late-onset PsA patients (diagnosis-age: ≥60 years) were compared to those diagnosed before 60 years old. Univariate analyses and logistic regression were performed to examine for factors associated with late-onset PsA. For sensitivity analyses, the cohort’s mean diagnosis age was used as the cut-off value. Overall, 281 PsA patients were included (mean ± SD diagnosis-age: 46.0 ± 13.3 years). Of them, 14.2% (N = 40) had late-onset PsA. At diagnosis, after controlling for confounders, no demographic and clinical differences were identified. During the disease course, the late-onset group exhibited 65% fewer odds of manifesting enthesitis (adjusted Odds-ratio—adOR 0.35; 95% confidence interval 0.13–0.97), but higher frequency of dyslipidemia (adOR 3.01; 1.30–6.95) and of major adverse cardiovascular events (adOR 4.30; 1.42–12.98) compared to earlier-onset PsA group. No differences were found in the treatment approaches. In sensitivity analyses, PsA patients diagnosed after 46 (vs. ≤46) years old had an increased frequency of hypertension (adOR 3.18; 1.70–5.94) and dyslipidemia (adOR 2.17; 1.25–3.74). The present study underpins that late-onset PsA is not uncommon, while the age at PsA onset may affect the longitudinal clinical expression of the disease. Patients with late-onset PsA were less likely to manifest enthesitis but displayed increased cardiovascular risk.

Comorbidities in Psoriatic Arthritis: A Narrative Review

PURPOSE

Psoriatic arthritis (PsA) is a common type of inflammatory arthritis. Patients with PsA present with certain extra-articular manifestations and comorbidities (often collectively called psoriatic disease). The purpose of the present review was to highlight the main comorbidities in the setting of PsA.

METHODS

A narrative review was performed using data from articles found in a search of PubMed and Scopus using the terms psoriatic arthritis and comorbidities.

FINDINGS

Cardiovascular disease (CVD), as well as metabolic and mental health disorders, are the most common comorbidities in patients with PsA. In most cases, underlying inflammation seems to be involved in the increased risk for CVD in PsA, while a bidirectional relationship seems to operate between mental health disorders and psoriatic disease. The treatment of patients with PsA, especially with biologic disease-modifying antirheumatic drugs, has been shown to lead to favorable outcomes regarding the CVD risk. However, it is debatable whether specific drug classes are more effective than others or should be avoided in patients with CVD risk factors. Comorbidity of mental health disorders is even more complex, given the difficulties in measuring and reporting these comorbidities in clinical trials and in clinical practice.

IMPLICATIONS

Future studies are needed for a better understanding of the pathogenic mechanisms of, and the development of better protocols for the identification and treatment of patients with, comorbidities in patients with PsA. The education of clinicians, health care professionals in rheumatology, and patients could be useful in achieving this goal.

Validity and psychometric characteristics of the self-administered comorbidity questionnaire in patients with psoriatic arthritis

The study aimed to translate and cross-culturally adapt the self-comorbidity questionnaire (SCQ) into Turkish and investigate the validity and reliability of SCQ and its modified version (mSCQ) in psoriatic arthritis (PsA). Psoriatic arthritis quality of life (PsAQoL) and short form 36 (SF-36) were used to assess the quality of life. The physical disability was evaluated with the health assessment questionnaire (HAQ). The reliability of the SCQ scale was assessed by test-retest reliability. For construct validity, the correlations of SCQ with the HAQ, SF-36, PsAQoL, age, body mass index (BMI), disease duration, disease activity in psa (DAPSA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Psoriasis Area and Severity Index (PASI), dactylitis and enthesitis were evaluated. The mSCQ was also used by removing the items related to rheumatic conditions. For the test-retest reliability of the Turkish version of SCQ, the intraclass correlation coefficient was 0.965, p < 0.001. The SCQ and mSCQ had significant correlations with HAQ, PsAQoL, some subscales of SF-36, and age (p < 0.05), but not with disease duration, BASDAI, PASI and dactylitis (p > 0.05). Although SCQ had a low correlation with DAPSA (rho = 0.262, p = 0.031), mSCQ was not correlated with DAPSA (p > 0.05). mSCQ was significantly correlated with BMI (rho = 0.233, p = 0.016), but SCQ was not (p > 0.05). The Turkish version of SCQ had adequate reliability and validity, and the mSCQ improved the validity of the scale in patients with PsA.

Different systemic rheumatic diseases as risk factors for COVID-19-related mortality

COVID-19 has been associated with increased morbidity and mortality, globally. Whether COVID-19-related mortality is increased in patients with systemic rheumatic diseases (SRDs) is still debatable. Although results are somewhat conflicting, there are a handful of nationwide studies published indicating that, in individuals with SRD, there is signal for increased adverse COVID-19-related outcomes and higher mortality. It appears that there are differences in COVID-19-related mortality across various SRDs. Besides, certain disease-specific (disease activity, disease duration, medication received) and/or other features (e.g. comorbidities) seem to also affect COVID-19-related mortality in SRD patients. Herein, we wanted to highlight that a more individualized approach taking into consideration the effect of the aforementioned factors into the risk calculation for COVID-19 adverse outcomes, including mortality, in SRD patients is warranted. A multinational study based on nationwide data, examining all common SRDs and stratifying accordingly, would be of interest, toward this direction.

Key Points • It is still debatable whether Covid-19-related mortality is increased in patients with sytemic rheumatic diseases (SRD). • Disease-specific risk factors (e.g. type of SRD, disease activity) should be taken into account in risk assessment for Covid-19-releted outcomes in SRD patients.