Psoriatic Arthritis Clinical 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 Toronto Western Hospital

Psoriatic Arthritis Definition An inflammatory arthritis Associated with psoriasis Usually seronegative for rheumatoid factor

Psoriatic Arthritis Clinical Patterns Distal predominant (Distal inter-phalangeal joints of fingers and toes). Oligo-articular (<5 joints) often in an asymmetric distribution. Poly-articular (5 joints), rheumatoid arthritis-like. Spinal Involvement. ‘Arthritis Mutilans’. Moll & Wright, Seminars Arthritis Rheum 1973;32:181

Psoriatic Arthritis Patterns   Oligoarthritis Distal Arthritis

Psoriatic Arthritis Patterns Polyarticular Pattern

Psoriatic Arthritis Patterns Arthritis Mutilans

Psoriatic Arthritis Patterns Arthritis Mutilans Telescoping

Psoriatic Spondyloarthropathy 

Psoriatic Spondyloarthropathy  

Dactylitis in PsA

Edema in PsA

Heel Lesions in PsA Achilles Tendon Spur Achilles Tendon Insertion Erosion Plantar Spur

Other Radiological Features of PsA Periostitis Tuft resorption

Hidden Psoriasis

PsA Reported Series* *Includes only series with > 100 Patients

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 1984;4:55-73. ? fortuitous association Cats A. Cutis 1990;46:323-329.

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%.

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.

A comparison between Psoriatic Arthritis and Rheumatoid Arthritis

Assessment of Tenderness Psoriatic Arthritis Vs. Rheumatoid Arthritis Buskila D, et al. J Rheumatol 1992;19:1115-9.

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.

Differentiating PsA from other SpA

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%.

Psoriatic Arthritis Prevalence 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) 126 31 NPF (2002) US 4.4 m 23

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 1987;62:127. Torre Alonso et al. Brit J Rheumatol 1991;30:245.

The University of Toronto Psoriatic Arthritis Program Development of Deformities during follow-up Gladman DD. Baillière’s Clinical Rheumatology1994;8:379.

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 1995;22:675.

Prognostic Indicators in PsA Multivariate model for Clinical Indicators of Clinical Progression* *Based on clinical features at presentation Gladman DD et al. J Rheumatology 1995;22:675.

Prognostic Indicators in PsA Multivariate Model for Clinical Damage Gladman DD & Farewell VT. Arthritis Rheum 1995;38:845. Gladman DD, et al. J Rheumatol 1998;25:730.

Prognostic Indicators in Psoriatic Arthritis Final Multivariate Model for Time Varying Clinical Indicators Gladman DD, Farewell VT. J Rheumatol 1999;26:2409

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 1997;40:1868-7. Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.

Mortality in Psoriatic Arthritis Primary causes of death in 53 patients

Survival in Psoriatic Arthritis 0.5 0.6 0.7 0.8 0.9 1.0 Survival Probability All patients 5 10 15 20 Time Since Clinic Entry (Years)

Mortality in Psoriatic Arthritis Prognostic Factors: Final Multivariate Model Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.

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 2001;28:1045-8.

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

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.

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

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