Overlap in PsA, nonradiographic axSpA, reactive arthritis make for ‘challenging’ diagnosis
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Shared features and clinical presentations can make diagnosis and management of psoriatic arthritis, non-radiographic axial spondyloarthritis and reactive arthritis particularly challenging, according to a speaker at the 2021 Rheumatology Nurses Society annual conference.
“When we talk about spondyloarthritis, we talk about a group of inflammatory arthropathies that include psoriatic arthritis, ankylosing spondylitis, nonradiographic axSpA, reactive arthritis and enteropathic arthritis,” Amanda M. Mixon, PA-C, physician assistant in rheumatology at the Arthritis and Rheumatology Clinic of Northern Colorado, told attendees.
Mixon added that there can be overlap between all these conditions. Patients with any of these conditions may have skin, nail, scalp or joint involvement, uveitis, inflammatory bowel disease or other inflammatory manifestations like Crohn’s disease. “Patients can have any or all of these features, which can make things challenging to decipher and decide what treatments are appropriate for that patient,” she said. “This can help or hinder us.”
Looking at PsA, Mixon noted that psoriasis precedes arthritis in many cases. “Women and men are equally impacted, usually in the fourth decade of life,” she said.
Both genetic and environmental factors can play a role in PsA, according to Mixon. “We do not know what it is in the environment that tips the scale,” she said.
What is clear is that patients often find themselves in an “inflammatory feedback loop,” according to Mixon. “You can’t turn it off until you give medicines.”
Regarding the treatments, Mixon highlighted the broad array of options that are available to rheumatologists today. NSAIDs can be used to control pain, while traditional disease-modifying anti-rheumatic drugs like methotrexate and sulfasalazine can have efficacy. Regarding biologics, TNF inhibitors can be a mainstay, while IL-6, IL-12/23, and IL-17 inhibitors all can work in various aspects of PsA patients, from joints to skin and nails.
“When you are first treating a patient with psoriatic arthritis, treat what you are up against,” she said. “Really just hone in on what is the biggest issue for the patient. Is it their skin? Is it their peripheral arthritis? Is it their nails?”
Specifically, Mixon suggested that biologics can be particularly useful in aggressive skin, nail and scalp disease, while NSAIDs can be useful for mild pain. Above all, Mixon stressed that there is no guarantee that the first option will be the right choice. “If you are not getting what you need, you can switch,” she said.
The next topic Mixon tackled was nonradiographic axSpA. “The thing to remember about these patients is their disease burden is same as those with patients who have clear sacroiliac disease on radiograph,” she said.
Most patients with nonradiographic axSpA have had back pain for more than 3 months and an age of onset younger than 45 years. Often, lab results will show positivity for the HLA-B27 polymorphism. C-reactive protein may be elevated, they may respond poorly to NSAIDs and they may have skin involvement, decreased spinal mobility, Crohn’s disease, uveitis or dactylitis.
“Hip involvement is most associated with poor prognosis in nonradiographic axSpA,” Mixon said.
She added that women often present differently, with less pronounced clinical features and, often, more neck involvement. “Women may have slower progression on radiographic changes,” she said.
In addition, women may not voice concerns as commonly as men. “Women are pretty stoic,” Mixon said. “They don’t like to complain.”
Early and aggressive treatment is essential in nonradiographic disease, according to Mixon. But there is also a key non-pharmacotherapeutic approach for these patients: “Exercise, exercise, exercise,” she said. “There is no cure, but it is definitely treatable.”
The final condition Mixon discussed was reactive arthritis, which often occurs within 4 weeks of an infection elsewhere in the body. “This can be a challenging conversation because reactive arthritis is often associated with [sexually transmitted infections],” she said.
If the patient has been impacted for less than 6 months, NSAIDs may be effective, according to Mixon. For patients impacted longer than 6 months, methotrexate, sulfasalazine or TNF inhibitors are useful. “Sometimes these patients are hard to treat,” she said.
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Mixon AM. Latest Treatments and Guidelines on Psoriatic Arthritis (PsA) and Spondyloarthropathies (SpA) for the Nurse and Advanced Practice Provider (APP). Presented at: Rheumatology Nurses Society annual conference; August 4-7, 2021 (virtual meeting).
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