EULAR: Arthralgia in psoriasis a risk factor for progression to psoriatic arthritis
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Key takeaways:
- New EULAR points to consider focus on preventing disease progression to psoriatic arthritis.
- Slowing disease progression will require collaboration between rheumatologists and dermatologists.
Among patients with psoriasis, arthralgia should be considered a risk factor predicting progression to psoriatic arthritis, according to new EULAR points to consider for suspicious features in early PsA development.
“In contrast to [rheumatoid arthritis], where revised classification criteria (American College of Rheumatology/EULAR 2010) allow for classification of patients with early disease, this is not the case for PsA, which thus hampers definitions of the evolution to early PsA as an outcome measure for prevention trials,” Alen Zabotti, MD, of the University Hospital of Udine, in Italy, and colleagues wrote in Annals of the Rheumatic Diseases. “Therefore, an unmet need exists to further explore and characterize the transition of PsO to PsA.”
To formulate a list of overarching principles and points to consider for both clinical trials and practice regarding the prevention of psoriatic disease progression to PsA, Zabotti and colleagues formed a EULAR task force representing multiple disciplines. The 30-member task force included representatives from 13 European countries and featured 16 rheumatologists, five dermatologists, two fellows, two patient research partners and one non-MD health care professional.
At the first meeting, the group designated three key objectives. Researchers conducted a systematic literature review where published evidence was evaluated. During the second cluster of meetings, members evaluated data and formulated overarching principles and points-to-consider. These were voted on, and upon reaching 75% or greater consensus, the principles and points were adopted.
Overall, the task force adopted five overarching principles and 10 points to consider regarding the prevention of psoriasis progression to PsA, as well as the management of patients who are at risk of progressing from psoriasis to PsA. The overarching principles follow:
- Patients with psoriasis may progress to PsA at varying times.
- Improving prevention strategies and early diagnosis will require collaboration between rheumatologists and dermatologists.
- When risk factors for PsA progression are present, those factors may change psoriasis treatment strategies.
- The role of the rheumatologist in the identification and treatment of PsA is “key.”
- Some systemic treatments for psoriasis may lower the risk for progression to PsA.
The adopted points to consider include:
- Among patients with psoriasis, arthralgia should be considered a risk factor for progression to PsA.
- Physicians should regularly assess patients with psoriasis for joint and entheseal pain. If present, these patients should be referred to a rheumatologist.
- Patients with psoriasis can undergo imaging evaluations — including MRI and ultrasound — to better determine risk factors for progression to PsA.
- If there are imaging anomalies but no musculoskeletal symptoms, physicians should consider symptoms carefully to avoid “inappropriate treatment.”
- Musculoskeletal symptoms alongside abnormal imaging findings in patients with psoriasis, but without a PsA diagnosis, should be standard inclusion criteria for trials looking to prevent disease progression.
Additionally, following the exclusion of other possible diagnoses, patients with psoriasis who demonstrate synovitis should be considered to have PsA in the context of clinical trials, according to the task force. If a patient with psoriasis needs systemic therapy, physicians should consider the risk for PsA development before choosing a therapy.
The task force also stated that patients with psoriasis who are obese, demonstrate nail disease or have “extensive” disease should be considered at higher risk for PsA. Patients with psoriasis should additionally be educated about their potential risk for progression. Lastly, patients with psoriasis at risk for PsA should be evaluated “regularly.”
“These [points to consider] will facilitate research investigating the stages preceding clinical PsA and the opportunity to prevent PsA development by modifying lifestyle habits or using systemic treatment that could act both on the skin and the joint to prevent PsA development,” Zabotti and colleagues wrote. “These findings set the scene for both PsA as an outcome in prevention studies and the regression of arthralgia and imaging abnormalities as bespoke strategy relevant to PsA cases, many of whom require chronic therapy for cutaneous [psoriasis].”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Exploring the intricacies of psoriasis (PsO) pathogenesis, we encounter a captivating blend of autoinflammatory and autoimmune elements, a relatively recent conceptualization in this field. Autoinflammatory aspects of psoriatic arthritis (PsA) underlie the potential role of biomechanical stress as an instigator or exacerbator of the disease. Additionally, the participation of innate immune response mediators in skin, synovial tissue and peripheral blood underscores its complexity.
The equitable gender distribution in PsA, a clinical course marked by intermittent remission and overlap with autoinflammatory syndromes, all lead to an innate immune system involvement. Conversely, the autoimmune aspect is emphasized by its association with class I major histocompatibility complex alleles, occasional parallels with rheumatoid arthritis (RA) in its polyarticular pattern and the presence of serum autoantibodies.
In the context of RA patients undergoing TNF inhibitor treatment, an enigmatic phenomenon surfaces ― paradoxical PsO that manifests at an estimated rate of 5%. This paradoxical condition encompasses a spectrum of cutaneous reactions, including plaque PsO, psoriasiform eruptions, palmoplantar pustular PsO, guttate PsO and inverse PsO. The growing body of evidence suggests that paradoxical PsO is not an isolated occurrence but rather a phenomenon observed across this class of treatments. Significantly, comprehending the pivotal role of the IL-23/Th-17 axis in paradoxical PsO has emerged as a critical element in managing these perplexing cases.
The existence of PsA without the concurrent PsO, known as “PsA sine PsO,” introduces another layer of complexity, impacting 10-15% of patients who develop arthritis before or without the onset of PsO.
Seronegative, symmetrical polyarthritis existing alongside PsO presents a diagnostic challenge. While coincidental cases of PsO and RA exist, clinicians rely on additional clinical features such as dactylitis, inflammatory spinal symptoms and enthesitis to differentiate and categorize patients within the PsA category. Nodules and extra-articular features lean toward a diagnosis of RA. The presence of rheumatoid factor, anti-CCP and radiological findings also play a role in the diagnostic process, although they may not manifest early in the disease course.
A common dilemma arises when encountering a patient with seronegative, symmetrical polyarthritis alongside PsO, where distinguishing features may not be immediately apparent.
Recent advancements lend credence to the idea that PsA should be considered a distinct entity from RA. This distinction gains support through synovial histopathology, which reveals significant differences between the two conditions. Conversely, there were no histopathological discrepancies between oligoarticular and polyarticular PsA.
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