1. A complex and severe disabling disease
Psoriatic Arthritis
A complex and severe disabling disease

2. Introduction to Psoriatic Arthritis (PsA)
Chronic progressive, inflammatory disorder of the joints and skin1
Characterized by osteolysis and bony proliferation1
Clinical manifestations include dactylitis, enthesitis, osteoperiostitis, large joint oligoarthritis, arthritis mutilans, sacroiliitis, spondylitis, and distal interphalangeal arthritis1
PsA is one of a group of disorders known as the spondyloarthropathies2
Males and females are equally affected3
PsA can range from mild nondestructive disease to a severely rapid and destructive arthropathy3
Usually Rheumatoid Factor negative3
Radiographic damage can be noted in up to 47% of patients at a median interval of two years despite clinical improvement with standard DMARD therapy4
PsA is one of a group of disorders known as the spondyloarthropathies. PsA is a chronic, progressive inflammatory disorder affecting the joints and skin characterized by osteolysis and bony proliferation. C
PsA can range from mild and non-destructive in nature to a severely rapid and destructive arthropathy. Radiographic damage can be noted in up to 47% of patients at a median interval of two years despite clinical improvement on standard DMARD therapy.
1Taylor WJ. Curr Opin Rheumatol. 2002;14:98– Mease P. Curr Opin Rheumatol. 2004;16:366– Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511– Kane D, et al. Rheumatology. 2003;42:1460–1468.

3. Spondyloarthritis, Psoriasis and PsA
Spondyloarthritis (SpA)
The prevalence of SpA is comparable to that of RA (0.5–1.9%)1,2
Psoriasis (Pso)
Psoriasis affects 2% of population
7% to 42% of patients with Pso will develop arthritis3
Psoriatic Arthritis
A chronic and inflammatory arthritis in association with skin psoriasis4
Usually rheumatoid factor (RF) negative and ACPA negative5
Distinct from RA
Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies
Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail psoriasis4
Juvenile SpA
Reactive
arthritis
Arthritis
associated with
IBD
PsA
Undifferentiated SpA (uSpA)
Ankylosing spondylitis (AS)
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1Rudwaleit M et al. Ann Rheum Dis 2004;63: ; 2Braun J et al. Scand J Rheumatol 2005;34:178-90;
3 Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009;
4Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77–i84. doi: /ard ;
5Pasquetti et al. Rheumatology 2009;48:315–325
RA: Rheumatoid arthritis

4. Psoriatic Arthritis
Psoriatic arthritis is an inflammatory disease, the manifestations of which may include:
Inflammatory arthritis which over time typically progresses to involve greater numbers of joints and can result in joint damage in over 40% of patients
Psoriasis
Diffuse swelling of the fingers and toes known as dactylitis
Enthesitis, which is the inflammation of the point of insertion of tendons, ligaments or joint capsules into bone. Shown here is swelling in the ankle region resulting from the inflammation of the Achilles tendon at the point of insertion into the heel. This is a common site of enthesopathy.
ACR Slide Collection on the Rheumatic Diseases; 3rd edition Data on file, Centocor, Inc.

5. Epidemiology of PsA Recent review undertaken to 20061,2 − Incidence
Europe+North America: 3 to 23.1 cases/105
Japan case/105
− Prevalence
Europe+North America 20 and 420 cases/105
Japan 1 case/105
Population-based study/Minnesota (CASPAR criteria)2,3
7.2 cases/105 (men 9.1, female 5.4)
158 cases/105
The prevalence of PsA is assumed to be larger than expected, since enthesitis associated with PsA can develop without symptoms or signs that are recognizable by patients themselves or the physicians4
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1 Alamos et al. J Rheumatol 2008;35:1354-8;
2Wilson F et al. J Rheumatol 2009;36:361-7;
3Editorial by Chaudran. J Rheumatol 2009;36:213-5;
4Takata et al. J Dermatol Sci Nov;64(2):144-7

6. Signs and Symptoms
Morning stiffness lasting >30 min in 50% of patients1
Ridging, pitting of nails, onycholysis – up 90% of patients vs nail changes in only 40% of psoriasis cases2,3
Patients may present with less joint tenderness than is usually seen in RA1
Dactylitis may be noted in >40% of patients2,4
Eye inflammation (conjunctivitis, iritis, or uveitis) — 7–33% of cases; uveitis shows a greater tendency to be bilateral and chronic when compared to AS2
Distal extremity swelling with pitting edema has been reported in 20% of patients as the first isolated manifestation of PsA5
Signs and symptoms of PsA in include morning stiffness lasting >30 minutes in 50% of patients, nail involvement in up to 90% of patients (as compared to 40% of psoriasis patients). Patients may present with joint deformity and less pain than is usually seen in RA. Dactylitis may be noted in >40% of patients, eye inflammation in 7-33% of cases. Finally, distal extremity swelling with pitting edema has been reported in 20% of patients as the first isolated manifestation of PsA.
1Gladman DD. In: Up To Date. Available at: Accessed December 3, 2004.
2Taurog JD. In: Harrison's Online McGrawHill. Available at: Accessed January 2, Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844.
4Veale D, et al. Br J Rheumatol. 1994;33:133–38. 5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296.

7. Main Features of PsA
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*Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA ***Spinal disease occurs in 40-70% of PsA patients
Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8
Fitzgerald “Psoriatic Arthritis” in Kelley’s Textbook of Rheumatology, 2009

8. Main Features and Their Frequency
Back involvement (50%)1
Skin Involvement
In nearly 70% of patients, cutaneous lesions precede the onset of joint pain, in 20% arthropathy starts before skin manifestations, and in 10% both are concurrent. 6
DIP involvement (39%)2
Enthesopathy (38%)2
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Nail psoriasis (80%)4, 5
Dactyilitis (48%)3
1Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:
3 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67
5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6
DIP: Distal interphalangeal 8

9. Comorbidities in PsA Patients
Ocular inflammation1
(Iritis/Uveitis/ Episcleritis)
Pso patients6-8
Psychosocial burden
Reactive depression
Higher suicidal ideation
Alcoholism
IBD2 
Metabolic Syndrome3-5
Hyperlipidemia
Hypertension
Insulin resistent
Diabetes
Obesity
 Higher risk of Cardiovascular disease (CVD)
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1Qieiro et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355; 4Neimann et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6: ;
7Naldi et al. Br J Dermatol 1992;127: ; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):

10. Hallmark Clinical Features in PsA
Two important features of PsA that cause significant problems for PsA patetients. Data to be shared later will show significant benefit of anti-tnf therapy in this regard.
Ritchlin C. J Rheumatol. 2006;33:1435–1438.
Helliwell PS. J Rheumatol. 2006;33:1439–1441.

11. Dactylitis
Diffuse swelling of a digit may be acute, with painful inflammatory changes, or chronic wherein the digit remains swollen despite the disappearance of acute inflammation1
Also referred to as “sausage digit”1
Recognized as one of the cardinal features of PsA, occurring in up to 40% of patients1,2
Feet most commonly affected1
Dactylitis involved digits show more radiographic damage1
Dactylitis is characterized by swelling of a digit and may be acute with painful inflammatory changes, or chronic changes where the digit remains swollen despite the disappearance of acute inflammation. Digits with dactylitis are referred to as sausage digits. Dactylitis is recognized as one of the cardinal features of PsA, occurring in up to 40% of patients. Feet are most commonly affected. Dactylitis-involved digits show more radiographic damage.
Shown here is psoriasis involving the first, third and fourth toes accompanied by PsA of the interphalangeal joints of the third and fourth toes and dactylitis. The “sausage shape” of these toes is caused by soft-tissue swelling.
ACR Slide Collection on the Rheumatic Diseases; 3rd edition Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190. 2Veale D, et al. Br J Rheumatol. 1994;33:133–38.

12. Definition of Enthesitis
Entheses are the regions at which a tendon, ligament, or joint capsule attaches to bone1
Inflammation at the entheses is called enthesitis and is a hallmark feature of PsA1,2
Pathogenesis of enthesitis has yet to be fully elucidated2
Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients3
Entheses are the regions at which a tendon, ligament, or joint capsule attaches to bone. The entheses act to dissipate biomechanical stress and are subjected to repeated microtraumas. Inflammation at the entheses is called enthesitis and is a hallmark feature of PsA. The pathogenesis of enthesitis has yet to be fully elucidated. Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients.
1McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60. 2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343. 3Salvarani C. J Rheumatol. 1997;24:1106–1140.

13. Classification Criteria of PsA
How to diagnose PsA?
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14. Classical Description of PsA Using the Diagnostic Criteria of Moll and Wright
Including 5 clinical patterns:
Asymmetric mono-/oligoarthritis (~30% [range 12-70%])1-4
Symmetric polyarthritis (~45% [range 15-65%])1-4
Distal interphalangeal (DIP) joint involvement (~5%)1
Axial (spondylitis and Sacroiliitis) (HLA-B27) (~5%)1,3
Arthritis Mutilans (<5%)1,3
1Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum 1973;3:55-78
2Gladman DD et al. Q J Med. 1987;62(238):127-41
3Torre Alonso JC et al. Br J Rheumatol. 1991;30(4):245-50
4Helliwell PS & Taylor WJ, Ann Rheum Dis 2005;64:3-8
5 Gladman et al. Derm therapy 2009;22:40-55
It is important to note that since the original Moll and Wright publication of 1973, the proportion of each subgroup has been changed. The symmetric polyarthritis in the original publication was only 15% and now was shown to be the predominant group. The last 3 bullet points are as in Moll&Wright’s ref.
Helliwell & Taylor, ARD, 2005: Fig.1 shows different distributions of Sym. PolyA and Asym. OligoA according to different references.
For a recent review on SUBTYPES of PsA, PsA classification and a suggestion for a NEW classification, check out Coates & Helliwell, Clinical Rheumatology, July 2008.
Ref Moll Gladman Torre
DIP <5% DIP involvement
found in all groups
Arth. Mutilans 5% %
Symmetric Arth. 15% (= PolyA?) 30.5% sym PolyA* 37% OligoA
+ 36% PolyA
No differentiation
between symA and
Asymmetric Arth. >70% OligoA 28% Asym. OligoA asymA.
+ MonoA % asym PolyA*
Ankyl.Arth. 5% % SpondA
HLA-B27 Not mentioned Not mentioned
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associated with SpondA
*Torre, 1991, talks about 61% PolyA, with equal repartition of sym.A and asymA.
However patterns may change over time and are therefore not useful for classification 5
HLA: Human leucocytes antigen
References see notes

15. Patterns may Change Over Time and are Therefore not Useful for Classification
Clinical subgroups at baseline and follow-up:
Monoarthritis Monoarthritis
Oligoarthritis Oligoarthritis
DIP DIP
Polyarthritis Polyarthritis
Spondyloarthritis Spondyloarthritis
Mutilans Mutilans
No clinical evidence of
joint disease
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McHugh et al. Rheum 2003;42:

16. CASPAR Criteria for the Classification of PsA
Inflammatory articular disease (joint, spine, or entheseal)
With 3 points from following categories:
− Psoriasis: current (2), history (1), family history (1)
− Nail dystrophy (1)
− Negative rheumatoid factor (1)
− Dactylitis: current (1), history (1) recorded by a rheumatologist
− Radiographs: (hand/foot) evidence of juxta-articular new bone formation
Specificity 98.7%, Sensitivity 91.4%
Juxtaarticular: The prefix "juxta-" comes from the Latin preposition meaning near, nearby, close.
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Taylor et al. Arthritis & Rheum 2006;54: 16

17. Spondyloarthritis and Classification Criteria
Spondyloarthropathies
Axial and Peripheral
AMOR criteria (1990)
ESSG criteria (1991)
Axial Spondyloarthritis
ASAS classification 2009
Peripheral Spondyloarthritis
ASAS classification 2010
Ankylosing spondylitis
Prototype of axial spondylitidis
Modified New York criteria 1984
Infliximab (IFX) and Golimumab (GLM)
indications
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Psoriatic arthritis
From Moll & Wright 1973 to CASPAR criteria 2006
ESSG: European Spondyloarthropathy Study Group
ASAS: Assessment of Spondyloarthritis International Society
CASPAR: Classification criteria for psoriatic arthritis
Sieper et al. Ann Rheum Dis 2009;68:ii1-ii44
Taylor et al. Arthritis & Rheum 2006;54:
Van der Heijde et al. Ann Rheum Dis 2011;70:905-8

18. Outcomes measurements
Treatment of PsA
Outcomes measurements

19. Clegg D.O. et al. Arthritis Rheum 1996;39:2013.
Outcome Measure in PsA
Psoriatic Arthritis Response Criteria (PsARC)
Clinical assessment of joint improvement, no skin assessment
Improvement in at least 2 of 4 criteria, one of which must be tender or swollen-joint score
Physician global assessment (> 1 unit)
Patient global assessment (> 1 unit)
Tender-joint score (> 30%)
Swollen-joint score (> 30%)
No worsening in any criterion
ACR response slide included in RA presentation
Clegg D.O. et al. Arthritis Rheum 1996;39:2013.