AB0531 THERAPIES FOR PERIPHERAL JOINT INVOLVEMENT IN PSORIATIC ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Much new information has been reported since the last evidence-based GRAPPA recommendations for the treatment of psoriasis and psoriatic arthritis (PsA).

Objectives:

We aimed to compile the evidence for the efficacy and safety of established and newly developed drugs targeting the peripheral arthritis domain in PsA so as to provide information for the revised GRAPPA treatment recommendations.

Methods:

A working group consisting of clinicians and patient research partners (PRPs) was convened. We performed an updated systematic literature review (SLR) of randomized controlled trials (RCTs) for the treatment of PsA, including peripheral arthritis, from the date of the last GRAPPA SLR, from February 19, 2013 to August 28, 2020. The working group reviewed the evidence supporting the efficacy on peripheral arthritis for each class of drug, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, for three patients groups: 1) naïve to treatment; 2) refractory to conventional (-c)DMARDs; and 3) with prior biological (-b)DMARD experience. We also evaluated the evidence for non-pharmacological treatments. A set of important outcomes for the peripheral arthritis domain was assessed for each class of medication. The certainty of evidence supporting each class of drugs for each patient group was evaluated. Recommendations were derived through consensus meetings.

Results:

87 articles from 52 RCTs were included. For patients with mild disease who are naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and PDE4i, and weakly recommends them for severe disease, where TNFi are preferred over csDMARDs. Other bDMARDs (IL-17i, IL-12/23i, IL-23i) and JAKi are strongly recommended to treat peripheral arthritis for treatment naïve patients. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i and JAKi. Certainty of evidence (GRADE) and recommendations for peripheral arthritis domain of PsA for different population groups are shown in Table 1. While the evidence supporting non-pharmacological treatments was low, we derived the recommendations from clinician/PRP expert opinion, included advocating an increase in physical activity, smoking cessation and a healthy diet to control weight gain.

Conclusion:

Evidence supporting drug treatment for the peripheral arthritis domain of PsA was compiled, providing required information for the revised GRAPPA treatment recommendations. Further work seeking agreement from a broader group of stakeholders is in progress.

Table 1.

Certainty of evidence (GRADE) and Recommendation for peripheral arthritis of PsA

Treatment naivecsDMARD inadequate responsebDMARD inadequate responseDrug classevidence (GRADE)Recom-mendationevidence (GRADE)Recom-mendationevidence (GRADE)Recom-mendationPDE-4iMod to highStrong for(mild/ mod disease)Conditional for(severe disease)Mod to HighStrong forbDMARD exp: ModbDMARD IR: Mod (NS)Conditional for (bDMARD exp)Conditional against (bDMARD IR)TNFiHighStrong forHighStrong forModStrong fora 2ndTNFiTNFiVs. MTXHighStrong for TNFi as 1st line for severe disease----IL-17iHighStrong forHighStrong forMod to highStrong forIL-12/23iMod to highStrong forMod to HighStrong forLowConditional forIL-23iHighStrong forHighStrong forModStrong forJAKiMod*Strong forHighStrong forMod to HighStrong forCTLA4iVery LowConditional for†LowConditional for†Mod (NS)Conditional for†Dual TNFi/ IL17iModerateNA¥ModNA¥NANA¥IL-6iVery LowConditional againstVery low to lowConditional againstNAConditional against

NS: not statistically significant; *included data from abstract; ¥ not making recommendation due to not approved and not available in market; †reserve for no alternatives. Mod: Moderate; exp: experienced; IR: inadequate response.

Acknowledgements:

We are grateful to the contribution of our patient research partner, Rodrigo Firmino.

Disclosure of Interests:

None declared.

[Secondary hypertrophic osteoarthropathy in a patient with pulmonary carcinoma]

BACKGROUND

Hypertrophic osteoarthropathy (HOA) is a syndrome that manifests itself by clubbing of fingers, periosteal and osteal neoformation in acral bones and oligo- or polysynovitis. It may occur as primary form (mostly hereditary) or secondary form, associated with various diseases, especially neoplastic or infectious diseases.

PURPOSE

The purpose of the study was to point out that when the symptoms of HOA occur, it is necessary to search for the primary disease, which is usually represented by tumor.

METHODS

The study reports a case of a patient with symptoms of HOA, pulmonary adenocarcinoma confirmed by histological examination, and with metastases spread into peripheral lymph nodes. The examination of symptomatology of HOA indicated that to pulmonary carcinoma.

RESULTS

The medical history of the patient shows that if there is, at an early stage, little attention paid to the fact that HOA represents a paraneoplastic syndrome, cancer is then confirmed later at a more advanced stage. Neglection of this fact delays the primary diagnosis, deteriorates the prognosis and limits the treatment by the extent of the cancerous process.

CONCLUSION

In practice, manifestations of HOA may point to the primary cancerous disease. When the symptomatology of HOA appears, radiograms usually pick up tumours at their early stages, which is important for the prognosis and the strategy of their treatment. The situation was different with the case reported in the study, because the disease was diagnosed at a more advanced stage, which unfavourably affected the prognosis and the treatment of the disease. (Tab. 1, Fig. 4, Ref. 15.)

Low serum hyaluronan in psoriatic arthritis patients in comparison to rheumatoid arthritis patients

OBJECTIVE

Serum hyaluronan (HA) was determined in 37 patients suffering from psoriatic arthritis (PSA), 39 patients with rheumatoid arthritis (RA), 31 with osteoarthritic joint disease (OA) and 26 healthy controls (C) in order to examine earlier reports that HA levels are increased in the serum of RA and to assess whether this finding is also relevant for PSA, another inflammatory joint disease, since HA in serum is considered a sign of inflammation in general.

METHOD

HA in the serum samples was measured with an enzyme linked microplate assay.

RESULTS

Sera from PSA, RA and OA patients showed a significantly higher HA concentration than those of healthy controls (56.0 +/- 16.0 micrograms/l). The serum HA concentration in PSA patients amounted to 107.8 +/- 57.2 micrograms/l, which was not significantly different from OA patients (104.9 +/- 16 micrograms/l). A significant difference, however, could be observed between the HA concentrations of the PSA subgroups: the mean HA level of patients suffering from symmetrical polyarthritis was 134 +/- 79.6 micrograms/l, which turned out to be significantly higher than in patients suffering from symmetrical oligoarthritis (89.9 +/- 42.8 micrograms/l; P < 0.04), but was insignificantly increased in comparison to patients with ankylosing spondylitis as the predominant feature (109 +/- 27.8 micrograms/l; P = 0.49). The mean HA concentration for RA sera was 197.1 +/- 122.9 micrograms/l, which was statistically significantly increased compared to PSA (P < 0.001) and OA (P < 0.001) sera. The sera of seropositive RA patients showed significantly higher HA levels than PSA patients with symmetrical polyarthritis (P < 0.04).

CONCLUSION

The data obtained support recent studies which have shown HA levels to be higher in RA patients than in OA patients. Seronegative and seropositive RA patients showed the same HA concentrations, while patients suffering from "seronegative" PSA were found to have lower HA concentrations. Therefore, HA serum levels may reflect cartilage degradation in general or the degree of articular inflammatory processes, indicating different pathogenetic pathways.