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Pain and photophobia
On the basis of the patient's medical history and presentation, this is probably a case of uveitis, a common extra-articular manifestation of psoriatic disease. In fact, the presence of uveitis can help distinguish PsA from osteoarthritis. Uveitis is characterized by inflammation of the uvea tract, with the retina, optic nerve, vitreous body, and sclera potentially becoming inflamed as well. Among patients with PsA, the prevalence of uveitis rises with ongoing disease duration, though the condition may also precede the development of PsA in patients with psoriasis, and is common among patients with severe psoriatic disease in Western and Asian populations. Overall, the prevalence of uveitis has been estimated to be 6%-9%. HLA-B27 genotype is strongly associated with uveitis in patients with concomitant PsA.
Symptoms of uveitis, as seen in the present case, include blurred vision, photophobia, pain, and ciliary flush. The condition is classified as anterior, intermediate, posterior, or panuveitis, with the majority of cases diagnosed as anterior. In anterior uveitis, the inflamed pupil may become constricted or take on an irregular shape caused by iris adhesions to the anterior lens capsule. Uveitis in PsA is bilateral and has a chronic relapsing course. Onset is typically insidious.
Workup for uveitis should comprise visual acuity testing, slit lamp biomicroscopy, measurement of intraocular pressures, and a dilated eye exam. Conditions in the differential which threaten a patient's sight include retinal vasculitis, vitritis, cystoid macular edema, Behçet disease, and tubulo-interstitial nephritis. Other autoimmune diseases which can cause uveitis with systemic manifestations (multiple sclerosis, sarcoidosis, lupus) should be investigated. Infectious causes must also be eliminated. However, considering this patient's history of psoriatic disease, uveitis should be highly suspected.
Uveitis demands urgent treatment to control ocular inflammation. Tumor necrosis factor (TNF) inhibitors are the recommended first-line and second-line treatment for PsA, including in patients with complications such as uveitis. However, etanercept should not be used as it is less effective than adalimumab or other TNF inhibitors for uveitis. Because uveitis may sometimes respond to MTX therapy, patients with severe PsA may use a biologic agent in combination with MTX if they have had a partial response to current MTX therapy, as recommended by the American College of Rheumatology.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
On the basis of the patient's medical history and presentation, this is probably a case of uveitis, a common extra-articular manifestation of psoriatic disease. In fact, the presence of uveitis can help distinguish PsA from osteoarthritis. Uveitis is characterized by inflammation of the uvea tract, with the retina, optic nerve, vitreous body, and sclera potentially becoming inflamed as well. Among patients with PsA, the prevalence of uveitis rises with ongoing disease duration, though the condition may also precede the development of PsA in patients with psoriasis, and is common among patients with severe psoriatic disease in Western and Asian populations. Overall, the prevalence of uveitis has been estimated to be 6%-9%. HLA-B27 genotype is strongly associated with uveitis in patients with concomitant PsA.
Symptoms of uveitis, as seen in the present case, include blurred vision, photophobia, pain, and ciliary flush. The condition is classified as anterior, intermediate, posterior, or panuveitis, with the majority of cases diagnosed as anterior. In anterior uveitis, the inflamed pupil may become constricted or take on an irregular shape caused by iris adhesions to the anterior lens capsule. Uveitis in PsA is bilateral and has a chronic relapsing course. Onset is typically insidious.
Workup for uveitis should comprise visual acuity testing, slit lamp biomicroscopy, measurement of intraocular pressures, and a dilated eye exam. Conditions in the differential which threaten a patient's sight include retinal vasculitis, vitritis, cystoid macular edema, Behçet disease, and tubulo-interstitial nephritis. Other autoimmune diseases which can cause uveitis with systemic manifestations (multiple sclerosis, sarcoidosis, lupus) should be investigated. Infectious causes must also be eliminated. However, considering this patient's history of psoriatic disease, uveitis should be highly suspected.
Uveitis demands urgent treatment to control ocular inflammation. Tumor necrosis factor (TNF) inhibitors are the recommended first-line and second-line treatment for PsA, including in patients with complications such as uveitis. However, etanercept should not be used as it is less effective than adalimumab or other TNF inhibitors for uveitis. Because uveitis may sometimes respond to MTX therapy, patients with severe PsA may use a biologic agent in combination with MTX if they have had a partial response to current MTX therapy, as recommended by the American College of Rheumatology.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
On the basis of the patient's medical history and presentation, this is probably a case of uveitis, a common extra-articular manifestation of psoriatic disease. In fact, the presence of uveitis can help distinguish PsA from osteoarthritis. Uveitis is characterized by inflammation of the uvea tract, with the retina, optic nerve, vitreous body, and sclera potentially becoming inflamed as well. Among patients with PsA, the prevalence of uveitis rises with ongoing disease duration, though the condition may also precede the development of PsA in patients with psoriasis, and is common among patients with severe psoriatic disease in Western and Asian populations. Overall, the prevalence of uveitis has been estimated to be 6%-9%. HLA-B27 genotype is strongly associated with uveitis in patients with concomitant PsA.
Symptoms of uveitis, as seen in the present case, include blurred vision, photophobia, pain, and ciliary flush. The condition is classified as anterior, intermediate, posterior, or panuveitis, with the majority of cases diagnosed as anterior. In anterior uveitis, the inflamed pupil may become constricted or take on an irregular shape caused by iris adhesions to the anterior lens capsule. Uveitis in PsA is bilateral and has a chronic relapsing course. Onset is typically insidious.
Workup for uveitis should comprise visual acuity testing, slit lamp biomicroscopy, measurement of intraocular pressures, and a dilated eye exam. Conditions in the differential which threaten a patient's sight include retinal vasculitis, vitritis, cystoid macular edema, Behçet disease, and tubulo-interstitial nephritis. Other autoimmune diseases which can cause uveitis with systemic manifestations (multiple sclerosis, sarcoidosis, lupus) should be investigated. Infectious causes must also be eliminated. However, considering this patient's history of psoriatic disease, uveitis should be highly suspected.
Uveitis demands urgent treatment to control ocular inflammation. Tumor necrosis factor (TNF) inhibitors are the recommended first-line and second-line treatment for PsA, including in patients with complications such as uveitis. However, etanercept should not be used as it is less effective than adalimumab or other TNF inhibitors for uveitis. Because uveitis may sometimes respond to MTX therapy, patients with severe PsA may use a biologic agent in combination with MTX if they have had a partial response to current MTX therapy, as recommended by the American College of Rheumatology.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
A 48-year-old male patient presents with blurred vision, pain, and photophobia. He recently had a routine visit with an ophthalmologist, which was normal. The affected pupil appears irregular in shape. The anterior chamber appears foggy. Local ciliary flush is observed on slit lamp exam. The physical examination is also notable for axial arthropathy. The patient has an 11-year history of moderate to severe psoriatic arthritis (PsA) which he typically manages with methotrexate (MTX) therapy, to which he has had a partial response. He was initially diagnosed when he presented with worsening psoriasis and enthesitis on the insertion sites of the plantar fascia, as well as dactylitis.
Psoriatic Arthritis Treatment Basics
Man with distal flexion deformities
On the basis of history and presentation, this patient's psoriatic disease has probably evolved to psoriatic arthritis mutilans (PAM). PAM is considered the most severe form of psoriatic arthritis (PsA), causing joint destruction and functional disability. It is estimated to affect about 5% of patients with PsA, with an equal sex distribution. Psoriatic nail dystrophy, a hallmark of PsA, appears to be a clinical biomarker of PAM development. Patients with PAM are generally younger at diagnosis than those with less severe forms of disease. Disease-modifying antirheumatic drugs and anti-TNF therapy do not appear to prevent the development of PAM, as evidenced by the present case.
In general, clinical presentation of PsA is heterogeneous and can be similar to that of other rheumatic diseases such as rheumatoid arthritis or osteoarthritis, complicating the differential diagnosis. The Classification Criteria for Psoriatic Arthritis (CASPAR) are considered the most sensitive diagnostic criteria, encompassing evidence of psoriasis; nail dystrophy; lab findings of typical autoantibodies (negative rheumatoid factor); and phenomena that are characteristic of PsA, like dactylitis.
Workup for PAM often includes radiography, ultrasound, and MRI or CT. With no established consensus, classification systems for the condition vary clinically and radiographically. Radiographic features suggestive of PAM include osteolysis or extended bone resorption; pencil-in-cup changes; joint subluxation; and, less often, ankylosis. Osteolysis has been defined as bone resorption with more than 50% loss of joint surface on both sides of the joint. Clinically, dissolution of the joint causes redundant, overlying skin with a telescoping motion of the digit. Other clinical features of PAM include digital shortening and flail joints. Of note, involvement of one small joint in the hands or feet is diagnostic of PAM.
In the setting of PsA, multiple genetic factors have been described, including presence of HLA-B27 and HLA-DRB1, but none are considered defining factors for the disease. A recent population-based study shows that presence of HLA-B27 was significantly increased among patients with PAM (45%) compared with patients with less severe PsA (13%) and healthy controls (13%).
According to the American College of Rheumatology guidelines, first-line therapy in adult patients who have active PsA and are treatment-naive is a TNFi biologic agent. For the patient in this case, who has active PsA despite treatment with TNFi biologic monotherapy, switching to a different TNFi biologic may be appropriate; however, switching to an interleukin-17 inhibitor may also be considered because this patient has severe disease. Data on the comparative efficacy of different biological agents for treatment of PAM are not yet available.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
On the basis of history and presentation, this patient's psoriatic disease has probably evolved to psoriatic arthritis mutilans (PAM). PAM is considered the most severe form of psoriatic arthritis (PsA), causing joint destruction and functional disability. It is estimated to affect about 5% of patients with PsA, with an equal sex distribution. Psoriatic nail dystrophy, a hallmark of PsA, appears to be a clinical biomarker of PAM development. Patients with PAM are generally younger at diagnosis than those with less severe forms of disease. Disease-modifying antirheumatic drugs and anti-TNF therapy do not appear to prevent the development of PAM, as evidenced by the present case.
In general, clinical presentation of PsA is heterogeneous and can be similar to that of other rheumatic diseases such as rheumatoid arthritis or osteoarthritis, complicating the differential diagnosis. The Classification Criteria for Psoriatic Arthritis (CASPAR) are considered the most sensitive diagnostic criteria, encompassing evidence of psoriasis; nail dystrophy; lab findings of typical autoantibodies (negative rheumatoid factor); and phenomena that are characteristic of PsA, like dactylitis.
Workup for PAM often includes radiography, ultrasound, and MRI or CT. With no established consensus, classification systems for the condition vary clinically and radiographically. Radiographic features suggestive of PAM include osteolysis or extended bone resorption; pencil-in-cup changes; joint subluxation; and, less often, ankylosis. Osteolysis has been defined as bone resorption with more than 50% loss of joint surface on both sides of the joint. Clinically, dissolution of the joint causes redundant, overlying skin with a telescoping motion of the digit. Other clinical features of PAM include digital shortening and flail joints. Of note, involvement of one small joint in the hands or feet is diagnostic of PAM.
In the setting of PsA, multiple genetic factors have been described, including presence of HLA-B27 and HLA-DRB1, but none are considered defining factors for the disease. A recent population-based study shows that presence of HLA-B27 was significantly increased among patients with PAM (45%) compared with patients with less severe PsA (13%) and healthy controls (13%).
According to the American College of Rheumatology guidelines, first-line therapy in adult patients who have active PsA and are treatment-naive is a TNFi biologic agent. For the patient in this case, who has active PsA despite treatment with TNFi biologic monotherapy, switching to a different TNFi biologic may be appropriate; however, switching to an interleukin-17 inhibitor may also be considered because this patient has severe disease. Data on the comparative efficacy of different biological agents for treatment of PAM are not yet available.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
On the basis of history and presentation, this patient's psoriatic disease has probably evolved to psoriatic arthritis mutilans (PAM). PAM is considered the most severe form of psoriatic arthritis (PsA), causing joint destruction and functional disability. It is estimated to affect about 5% of patients with PsA, with an equal sex distribution. Psoriatic nail dystrophy, a hallmark of PsA, appears to be a clinical biomarker of PAM development. Patients with PAM are generally younger at diagnosis than those with less severe forms of disease. Disease-modifying antirheumatic drugs and anti-TNF therapy do not appear to prevent the development of PAM, as evidenced by the present case.
In general, clinical presentation of PsA is heterogeneous and can be similar to that of other rheumatic diseases such as rheumatoid arthritis or osteoarthritis, complicating the differential diagnosis. The Classification Criteria for Psoriatic Arthritis (CASPAR) are considered the most sensitive diagnostic criteria, encompassing evidence of psoriasis; nail dystrophy; lab findings of typical autoantibodies (negative rheumatoid factor); and phenomena that are characteristic of PsA, like dactylitis.
Workup for PAM often includes radiography, ultrasound, and MRI or CT. With no established consensus, classification systems for the condition vary clinically and radiographically. Radiographic features suggestive of PAM include osteolysis or extended bone resorption; pencil-in-cup changes; joint subluxation; and, less often, ankylosis. Osteolysis has been defined as bone resorption with more than 50% loss of joint surface on both sides of the joint. Clinically, dissolution of the joint causes redundant, overlying skin with a telescoping motion of the digit. Other clinical features of PAM include digital shortening and flail joints. Of note, involvement of one small joint in the hands or feet is diagnostic of PAM.
In the setting of PsA, multiple genetic factors have been described, including presence of HLA-B27 and HLA-DRB1, but none are considered defining factors for the disease. A recent population-based study shows that presence of HLA-B27 was significantly increased among patients with PAM (45%) compared with patients with less severe PsA (13%) and healthy controls (13%).
According to the American College of Rheumatology guidelines, first-line therapy in adult patients who have active PsA and are treatment-naive is a TNFi biologic agent. For the patient in this case, who has active PsA despite treatment with TNFi biologic monotherapy, switching to a different TNFi biologic may be appropriate; however, switching to an interleukin-17 inhibitor may also be considered because this patient has severe disease. Data on the comparative efficacy of different biological agents for treatment of PAM are not yet available.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
A 43-year-old man presents with distal flexion deformities and telescoping of the digits. The patient was diagnosed with psoriasis at age 31 and he has several immediate family members who previously received the same diagnosis. He has been treated intermittently with tumor necrosis factor inhibitor (TNFi) biologic monotherapy but admits to nonadherence when disease activity seems to quiet down. Radiography shows osteolysis and dissolution of the joint.
Psoriatic Arthritis Workup
Painful swelling of fingers and toe
Although psoriatic arthritis is not the only disease associated with dactylitis — other culprits are sarcoidosis, septic arthritis, tuberculosis, and gout — dactylitis is one of the characteristic symptoms of psoriatic arthritis. Dactylitis is seen in as many as 35% of patients with psoriatic disease. Dactylitis clinically presents — as in this patient — with sausage-like swelling of the digits. It is included in the Classification Criteria for Psoriatic Arthritis (CASPAR) as one of the hallmarks of psoriatic arthritis.
Dactylitis has been thought to be a result of the concomitant swelling and inflammation of the flexor tendon sheaths of the metacarpophalangeal, metatarsophalangeal, or interphalangeal joints. Flexor tenosynovitis can be detected by examination with MRI and ultrasound. Dactylitis is associated with radiologically evident erosive damage to the joints.
Patients with psoriatic arthritis are typically seronegative for rheumatoid factor and antinuclear antibody; antinuclear antibody titers in persons with psoriatic arthritis do not differ from those of age- and sex-matched controls. C-reactive protein may be elevated but is often normal. Lack of C-reactive protein elevation, however, does not mean that systemic inflammation is absent, but rather indicates that different markers are needed that allow better quantification of systemic inflammation in psoriasis and psoriatic arthritis.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Although psoriatic arthritis is not the only disease associated with dactylitis — other culprits are sarcoidosis, septic arthritis, tuberculosis, and gout — dactylitis is one of the characteristic symptoms of psoriatic arthritis. Dactylitis is seen in as many as 35% of patients with psoriatic disease. Dactylitis clinically presents — as in this patient — with sausage-like swelling of the digits. It is included in the Classification Criteria for Psoriatic Arthritis (CASPAR) as one of the hallmarks of psoriatic arthritis.
Dactylitis has been thought to be a result of the concomitant swelling and inflammation of the flexor tendon sheaths of the metacarpophalangeal, metatarsophalangeal, or interphalangeal joints. Flexor tenosynovitis can be detected by examination with MRI and ultrasound. Dactylitis is associated with radiologically evident erosive damage to the joints.
Patients with psoriatic arthritis are typically seronegative for rheumatoid factor and antinuclear antibody; antinuclear antibody titers in persons with psoriatic arthritis do not differ from those of age- and sex-matched controls. C-reactive protein may be elevated but is often normal. Lack of C-reactive protein elevation, however, does not mean that systemic inflammation is absent, but rather indicates that different markers are needed that allow better quantification of systemic inflammation in psoriasis and psoriatic arthritis.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Although psoriatic arthritis is not the only disease associated with dactylitis — other culprits are sarcoidosis, septic arthritis, tuberculosis, and gout — dactylitis is one of the characteristic symptoms of psoriatic arthritis. Dactylitis is seen in as many as 35% of patients with psoriatic disease. Dactylitis clinically presents — as in this patient — with sausage-like swelling of the digits. It is included in the Classification Criteria for Psoriatic Arthritis (CASPAR) as one of the hallmarks of psoriatic arthritis.
Dactylitis has been thought to be a result of the concomitant swelling and inflammation of the flexor tendon sheaths of the metacarpophalangeal, metatarsophalangeal, or interphalangeal joints. Flexor tenosynovitis can be detected by examination with MRI and ultrasound. Dactylitis is associated with radiologically evident erosive damage to the joints.
Patients with psoriatic arthritis are typically seronegative for rheumatoid factor and antinuclear antibody; antinuclear antibody titers in persons with psoriatic arthritis do not differ from those of age- and sex-matched controls. C-reactive protein may be elevated but is often normal. Lack of C-reactive protein elevation, however, does not mean that systemic inflammation is absent, but rather indicates that different markers are needed that allow better quantification of systemic inflammation in psoriasis and psoriatic arthritis.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
A 35-year-old man presents with painful swelling of his right index and ring fingers as well as the fourth toe on his right foot, which has persisted for 5 days. He cannot perform his daily activities owing to severe pain in the affected fingers and toes. His medical history is unremarkable. His paternal uncle had psoriasis, which was successfully treated with adalimumab.
Physical assessment reveals tender, fusiform, swollen soft tissues in the affected fingertips, the fourth toe, and swollen palms. Nails are pitted. Hand radiography reveals mild edema of the soft tissue of the index and ring fingers but no significant joint abnormalities. Enthesitis is not present. Laboratory tests reveal a negative human leukocyte antigen B27 (HLA-B27) test, negative rheumatoid factor, negative antinuclear antibody, and normal C-reactive protein.
Dactylitis was diagnosed on the basis of clinical symptoms, radiographic results, and laboratory findings.
Intermittent joint aches
Fundamental changes in the initial pharmacologic approach to psoriatic arthritis were made in the 2018 American College Rheumatology/National Psoriasis (ACR/NPF) guidelines for the treatment of psoriatic arthritis. Previously, methotrexate had been widely used as the first-line agent. The 2018 guidelines recommend a tumor necrosis factor (TNF) inhibitor over methotrexate and other oral small molecules (leflunomide, cyclosporine, and apremilast).
Herein is a broad summary of the guidelines:
· Treat with TNF inhibitor over oral small molecule; may consider oral small molecule with mild psoriatic arthritis and psoriasis, patient preference, and/or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with oral small molecule over IL-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis and/or psoriatic arthritis
· Treat with oral small molecule over IL-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or psoriatic arthritis, or concomitant inflammatory bowel disease
· Treat with methotrexate over nonsteroidal anti-inflammatory drugs; may consider nonsteroidals for mild psoriatic arthritis and psoriasis
· Treat with IL-17 inhibitor over IL-12/23 inhibitor; may consider IL-12/23 inhibitor in a patient with concomitant inflammatory bowel disease
Note that these recommendations are based on conditional evidence (ie, low to very low quality). In fact, in the entire guideline document, only 6% of the recommendations are strong, whereas 96% are conditional. This emphasizes the importance of evaluating each patient individually and engaging in a discussion to choose optimal therapy.
Another set of guidelines, from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), was last updated in 2015. Since then, many of the agents above have been introduced. Updated GRAPPA guidelines are expected to be released later this year.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Fundamental changes in the initial pharmacologic approach to psoriatic arthritis were made in the 2018 American College Rheumatology/National Psoriasis (ACR/NPF) guidelines for the treatment of psoriatic arthritis. Previously, methotrexate had been widely used as the first-line agent. The 2018 guidelines recommend a tumor necrosis factor (TNF) inhibitor over methotrexate and other oral small molecules (leflunomide, cyclosporine, and apremilast).
Herein is a broad summary of the guidelines:
· Treat with TNF inhibitor over oral small molecule; may consider oral small molecule with mild psoriatic arthritis and psoriasis, patient preference, and/or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with oral small molecule over IL-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis and/or psoriatic arthritis
· Treat with oral small molecule over IL-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or psoriatic arthritis, or concomitant inflammatory bowel disease
· Treat with methotrexate over nonsteroidal anti-inflammatory drugs; may consider nonsteroidals for mild psoriatic arthritis and psoriasis
· Treat with IL-17 inhibitor over IL-12/23 inhibitor; may consider IL-12/23 inhibitor in a patient with concomitant inflammatory bowel disease
Note that these recommendations are based on conditional evidence (ie, low to very low quality). In fact, in the entire guideline document, only 6% of the recommendations are strong, whereas 96% are conditional. This emphasizes the importance of evaluating each patient individually and engaging in a discussion to choose optimal therapy.
Another set of guidelines, from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), was last updated in 2015. Since then, many of the agents above have been introduced. Updated GRAPPA guidelines are expected to be released later this year.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
Fundamental changes in the initial pharmacologic approach to psoriatic arthritis were made in the 2018 American College Rheumatology/National Psoriasis (ACR/NPF) guidelines for the treatment of psoriatic arthritis. Previously, methotrexate had been widely used as the first-line agent. The 2018 guidelines recommend a tumor necrosis factor (TNF) inhibitor over methotrexate and other oral small molecules (leflunomide, cyclosporine, and apremilast).
Herein is a broad summary of the guidelines:
· Treat with TNF inhibitor over oral small molecule; may consider oral small molecule with mild psoriatic arthritis and psoriasis, patient preference, and/or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with TNF inhibitor over interleukin (IL)-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or contraindication to TNF inhibitor
· Treat with oral small molecule over IL-17 inhibitor; may consider IL-17 inhibitor with severe psoriasis and/or psoriatic arthritis
· Treat with oral small molecule over IL-12/23 inhibitor; may consider IL-12/23 inhibitor with severe psoriasis or psoriatic arthritis, or concomitant inflammatory bowel disease
· Treat with methotrexate over nonsteroidal anti-inflammatory drugs; may consider nonsteroidals for mild psoriatic arthritis and psoriasis
· Treat with IL-17 inhibitor over IL-12/23 inhibitor; may consider IL-12/23 inhibitor in a patient with concomitant inflammatory bowel disease
Note that these recommendations are based on conditional evidence (ie, low to very low quality). In fact, in the entire guideline document, only 6% of the recommendations are strong, whereas 96% are conditional. This emphasizes the importance of evaluating each patient individually and engaging in a discussion to choose optimal therapy.
Another set of guidelines, from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), was last updated in 2015. Since then, many of the agents above have been introduced. Updated GRAPPA guidelines are expected to be released later this year.
Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.
Herbert S. Diamond, MD, has disclosed no relevant financial relationships.
A 56-year-old man presents because of intermittent joint aches and difficulty picking up his grandchild and cleaning his home. He has a 6-year history of scalp psoriasis that he has controlled with a salicylic acid shampoo. On physical examination, he has tenderness over both elbows and in his metacarpophalangeal and proximal interphalangeal (PIP) joints on both hands. Swollen joints are noted in the proximal and distal joints of the right hand. His fingernails show uniform pitting.
Neurologic examination shows no sensory deficits or hyperesthesia. Motor examination is unremarkable, and chest and abdominal findings are unremarkable. Blood pressure is 138/90 mm Hg. Radiographic imaging shows asymmetric erosive changes with very small areas of bony proliferation in the PIP joints.There is asymmetric narrowing of the joint space in the interphalangeal joints. Laboratory findings reveal an erythrocyte sedimentation rate of 35 mm/h, negative rheumatoid factor, negative antinuclear antibody, and C-reactive protein of 7 mg/dL.
These findings are consistent with a diagnosis of psoriatic arthritis. This patient has severe psoriatic arthritis based on radiographic evidence of erosive disease.
