Psoriatic Arthritis Clinical Features and Epidemiology

1
Psoriatic ArthritisClinical Features and
Epidemiology

• Dafna D. Gladman MD, FRCPC
• Director, Psoriatic Arthritis Program,
• University Health Network
• Centre for Prognosis Studies in the Rheumatic
  Diseases
• Toronto Western Hospital

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Psoriatic Arthritis
Definition

• An inflammatory arthritis
• Associated with psoriasis
• Usually seronegative for rheumatoid factor

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Psoriatic Arthritis Clinical Patterns

• Distal predominant (Distal inter-phalangeal
  joints of fingers and toes).
• Oligo-articular (lt5 joints) often in an
  asymmetric distribution.
• Poly-articular (?5 joints), rheumatoid
  arthritis-like.
• Spinal Involvement.
• Arthritis Mutilans.

Moll Wright, Seminars Arthritis Rheum
197332181
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Psoriatic Arthritis Patterns
?
?
Oligoarthritis
Distal Arthritis
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Psoriatic Arthritis Patterns
Polyarticular Pattern
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Psoriatic Arthritis Patterns
Arthritis Mutilans
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Psoriatic Arthritis Patterns
Arthritis Mutilans
Telescoping
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Psoriatic Spondyloarthropathy
?
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Psoriatic Spondyloarthropathy
?
?
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Dactylitis in PsA
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Edema in PsA
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Heel Lesions in PsA
Achilles Tendon Insertion Erosion Plantar Spur
Achilles Tendon Spur
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Other Radiological Features of PsA
Periostitis
Tuft resorption
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Hidden Psoriasis
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PsA Reported Series
Includes only series with gt 100 Patients
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Psoriatic arthritis A distinct entity ?

• Dutch study found no association between
  psoriasis and polyarthritis.
• No association between HLA antigens and
  seronegative polyarthritis with psoriasis.
• No radiological features in seronegative
  polyarthritis with psoriasis.
• van Romunde LKJ, et al.Rheumatology
  International 1984455-73.
• ? fortuitous association
• Cats A. Cutis 199046323-329.

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Psoriatic arthritis
Epidemiological Evidence

• Prevalence of psoriasis in the general
  population 0.1-2.8.
• Prevalence of psoriasis in arthritis patients
  2.6-7.0.
• Prevalence of arthritis in the general
  population 2-3.
• Prevalence of arthritis in psoriatic patients
  6-42.

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Psoriatic arthritis A distinct entity !

• Previous population studies.
• Epidemiological studies.
• Dutch study found DIP joints disease more common
  in patients with seronegative polyarthritis and
  psoriasis.
• A distinct form of arthritis, with different
  patterns, associated with psoriasis.

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A comparison between Psoriatic Arthritis and
Rheumatoid Arthritis
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Assessment of Tenderness
Psoriatic Arthritis Vs. Rheumatoid Arthritis
Buskila D, et al. J Rheumatol 1992191115-9.
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Psoriatic Arthritis
Classification

• Classified with the Seronegative
  Spondyloarthropathies
• It is usually seronegative for rheumatoid factor.
• It may be associated with a spondyloarthropathy.
• It is associated with HLA-B27.

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Differentiating PsA from other SpA
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Psoriatic Arthritis Prevalence

• Exact prevalence unknown.
• Estimated figures vary from 0.1 in Rochester
  Minnesota to 1.4 in the Faroe Islands.
• Recent Survey by National Psoriasis Foundation
  suggests prevalence of 1.4 of general population
  in the US.
• Recent study from Toronto suggests a prevalence
  of 2.5.

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Psoriatic ArthritisPrevalence among people with
psoriasis
Author (yr) Centre No. Ps. Pts. PsA
Leczinsky (1948) Sweden 534 7
Vilanova (1951) Barcelona 214 25
Little (1975) Toronto 100 32
Scarpa (1984) Napoli 180 34
Stern (1985) Boston 1285 20
Zaneli (1992) Winston-Salem 459 17
Barisic-Drusko (1994) Osijek region 553 10
Salvarani (1995) Regio Emilia 205 36
Shbeeb (2000) Mayo Clinic 1056 6.25
Brockbank (2001) Toronto 126 31
NPF (2002) US 4.4 m 23
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Psoriatic arthritis
Clinical Outcome

• PsA is much more serious than previously
  recognized.
• 20 of patients with PsA develop clinical
  deformities and damage, resulting in functional
  disability.
• ?5 deformities were detected in 55 of patients
  after 10 years of follow-up.

Gladman DD et al. Quart J Med 198762127. Torre
Alonso et al. Brit J Rheumatol 199130245.
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The University of Toronto Psoriatic Arthritis
Program
Development of Deformities during follow-up
Gladman DD. Baillières Clinical
Rheumatology19948379.
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Prognostic Indicators in PsA
Clinical Indicators of Progression

• Progression of damage defined by a change in
  damage state
• State 1 0 damaged joints
• State 2 1-4 damaged joints
• State 3 5-9 damaged joints
• State 4 ? 10 damaged joints
• Analysis by model for rate of transition between
  damage states.

Gladman DD et al. J Rheumatology 199522675.
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Prognostic Indicators in PsA
Multivariate model for Clinical Indicators of
Clinical Progression
Based on clinical features at presentation
Gladman DD et al. J Rheumatology 199522675.
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Prognostic Indicators in PsA
Multivariate Model for Clinical Damage
Gladman DD Farewell VT. Arthritis Rheum
199538845. Gladman DD, et al. J Rheumatol
199825730.
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Prognostic Indicators in Psoriatic Arthritis
Final Multivariate Model for Time Varying
Clinical Indicators
Gladman DD, Farewell VT. J Rheumatol 1999262409
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Outcome in Psoriatic arthritis
Mortality Studies

• PsA patients are at an increased risk of death.
• Overall risk is 1.62 that of Ontario Residents.
• 1.66 for women, 1.59 for men
• Causes of Death are similar to general
  population.
• Risk of death is related to previously active and
  severe disease.

Wong K, et al. Arthritis Rheum 1997401868-7. Gla
dman DD, et al. Arthritis Rheum 1998411103-10.
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Mortality in Psoriatic Arthritis
Primary causes of death in 53 patients
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Survival in Psoriatic Arthritis
Survival Probability
All patients
Time Since Clinic Entry (Years)
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Mortality in Psoriatic Arthritis
Prognostic Factors Final Multivariate Model
Gladman DD, et al. Arthritis Rheum
1998411103-10.
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Remission in Psoriatic Arthritis

• Summary
• Remission occurred in 17.6 of our PsA patients.
• Male gender and less active and severe arthritis
  at presentation to Clinic were associated with
  remission.
• Only 6 (8.7) of the PsA patients sustained true
  remission,
• 35 (52) had subsequent flares.

Gladman DD et al. J Rheumatol 2001281045-8.
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Psoriatic Arthritis Prognostic Factors

• Progression of Damage
• High effusion count at presentation
• High joint count at each visit
• High medication level at presentation
• Low ESR is protective
• Death
• Elevated ESR
• High prior medication level
• Radiological Damage
• Remission
• Male Gender
• Low joint count at presentation

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Psoriatic Arthritis

• Not just skin and joints!
• An inflammatory arthritis associated with
  psoriasis.
• More common than previously thought.
• About one fifth of the patients have a severe
  debilitating disease, although some patients
  achieve remission.
• Earlier studies suggesting that PsA was a mild
  disease included patients with early disease.

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Psoriatic Arthritis Program
Dr. Dafna Gladman - Director
Cathy Schentag MsC Research Associate CPSRD, TWH
Nicole Anderson, BSc Research Assistant CPSRD, TWH
Vern Farewell, PhD Biostatistician MRC,
Cambridge, UK
Fawnda Pellett, BSC Research Technologist CPSRD,
TWH
Richard Cook, PhD Biostatistician Waterloo,
Ontario
Janice Husted, PhD Epidemiologist Waterloo,
Ontario
Research Fellows, Rheumatology Residents,
Students,Patients
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Psoriatic Arthritis Program - Support

• Ontario Ministry of Health
• Medical Research Council / Canadian Institutes of
  Health Research
• The Arthritis Society
• Centre for Prognosis Studies in The Rheumatic
  Diseases
• University of Toronto / University Health Network
  Arthritis Centre of Excellence
• Krembil Foundation
• PsA Patients