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Recent Findings About Psoriatic Arthritis
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Multicenter cooperative psoriatic arthritis study group formed
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Conventional DMARDs may be excluded from psoriatic arthritis enthesitis guidelines
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
New guidelines proposed for nail involvement in psoriatic arthritis
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Patients with psoriatic arthritis perform accurate joint counts
NEW YORK – After instruction by a nurse, patients with psoriatic arthritis do at least as well as nurses but better than physicians in counting tender and swollen joints, according to a cross-sectional study that employed ultrasound as a gold standard.
"Patient counts of swollen joints correlated with both effusion and synovitis as detected by ultrasound, suggesting that patients can learn to monitor their own disease," reported Dr. Agnes Szentpetery of the department of rheumatology at St. Vincent’s Hospital, Dublin.
In this study, described as the first ever conducted in psoriatic arthritis to compare joint counts by patients, nurses, physicians, and ultrasound (US), 50 patients with a mean age of 50 years were enrolled. All received instruction from a nurse on how to assess and count tender and swollen joints. The major focus of the correlations was in 34 joints assessed with US, although further correlations were made between patients, nurses, and physicians for 28 (JC28) and 66 swollen and 68 tender (JC 66/68) counts.
"Joint counts [confirming active disease] were higher for patients and nurses than for physicians," reported Dr. Szentpetery, who presented these data at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network (SPARTAN). Doctor and nurse counts for swollen joints, unlike patient counts, did not correlate with US evidence of effusion, although they did for synovitis.
For tender joints, there was moderate or good agreement between patient and doctor for 11 joints, doctor and nurse for 12 joints, and patient and nurse for 19 joints. (This nurse was different from the one who provided instruction on joint counts.) However, correlation between any of these observers and US evidence of tender joints was uniformly poor.
Small joints in the hand, particularly the proximal interphalangeal joint, offered the best interobserver agreement for correlations, according to Dr. Szentpetery. Although no correlations rose above good and most were moderate between any two observers, Dr. Szentpetery stressed that patients performed at levels comparable with doctors and nurses, compared with US.
"Although this was a small study, the results support patient joint counts, and we have already begun routinely instructing patients in our clinic," Dr. Szentpetery reported.
Asked for a comment, Dr. John D. Reveille, professor of rheumatology and clinical immunogenetics at the University of Texas Health Sciences Center at Houston, said that he is remaining cautious until a larger study generates more data. He said that similar efforts to instruct patients to perform joint counts in rheumatoid arthritis failed to produce acceptable rates of accuracy.
"It may be possible to enlist patients to perform accurate joint counts if they are motivated and receive appropriate education, but you may need a special population and the right education," said Dr. Reveille, who is chair of SPARTAN’s executive committee.
However, joint counts are perceived to be so time consuming that many clinics do not perform them at all, according to Dr. Szentpetery. Moreover, she suggested that the absolute number of tender or swollen joints at any moment in time may be less important than the change in joint involvement after treatment is initiated, an outcome that may be best measured by patients.
"I agree that this is a small study, and more data are needed, but our data suggest patients may have a role in joint counts, which is an attractive strategy for reducing work for the clinicians," Dr. Szentpetery said.
Dr. Szentpetery and Dr. Reveille reported no relevant financial conflicts.
NEW YORK – After instruction by a nurse, patients with psoriatic arthritis do at least as well as nurses but better than physicians in counting tender and swollen joints, according to a cross-sectional study that employed ultrasound as a gold standard.
"Patient counts of swollen joints correlated with both effusion and synovitis as detected by ultrasound, suggesting that patients can learn to monitor their own disease," reported Dr. Agnes Szentpetery of the department of rheumatology at St. Vincent’s Hospital, Dublin.
In this study, described as the first ever conducted in psoriatic arthritis to compare joint counts by patients, nurses, physicians, and ultrasound (US), 50 patients with a mean age of 50 years were enrolled. All received instruction from a nurse on how to assess and count tender and swollen joints. The major focus of the correlations was in 34 joints assessed with US, although further correlations were made between patients, nurses, and physicians for 28 (JC28) and 66 swollen and 68 tender (JC 66/68) counts.
"Joint counts [confirming active disease] were higher for patients and nurses than for physicians," reported Dr. Szentpetery, who presented these data at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network (SPARTAN). Doctor and nurse counts for swollen joints, unlike patient counts, did not correlate with US evidence of effusion, although they did for synovitis.
For tender joints, there was moderate or good agreement between patient and doctor for 11 joints, doctor and nurse for 12 joints, and patient and nurse for 19 joints. (This nurse was different from the one who provided instruction on joint counts.) However, correlation between any of these observers and US evidence of tender joints was uniformly poor.
Small joints in the hand, particularly the proximal interphalangeal joint, offered the best interobserver agreement for correlations, according to Dr. Szentpetery. Although no correlations rose above good and most were moderate between any two observers, Dr. Szentpetery stressed that patients performed at levels comparable with doctors and nurses, compared with US.
"Although this was a small study, the results support patient joint counts, and we have already begun routinely instructing patients in our clinic," Dr. Szentpetery reported.
Asked for a comment, Dr. John D. Reveille, professor of rheumatology and clinical immunogenetics at the University of Texas Health Sciences Center at Houston, said that he is remaining cautious until a larger study generates more data. He said that similar efforts to instruct patients to perform joint counts in rheumatoid arthritis failed to produce acceptable rates of accuracy.
"It may be possible to enlist patients to perform accurate joint counts if they are motivated and receive appropriate education, but you may need a special population and the right education," said Dr. Reveille, who is chair of SPARTAN’s executive committee.
However, joint counts are perceived to be so time consuming that many clinics do not perform them at all, according to Dr. Szentpetery. Moreover, she suggested that the absolute number of tender or swollen joints at any moment in time may be less important than the change in joint involvement after treatment is initiated, an outcome that may be best measured by patients.
"I agree that this is a small study, and more data are needed, but our data suggest patients may have a role in joint counts, which is an attractive strategy for reducing work for the clinicians," Dr. Szentpetery said.
Dr. Szentpetery and Dr. Reveille reported no relevant financial conflicts.
NEW YORK – After instruction by a nurse, patients with psoriatic arthritis do at least as well as nurses but better than physicians in counting tender and swollen joints, according to a cross-sectional study that employed ultrasound as a gold standard.
"Patient counts of swollen joints correlated with both effusion and synovitis as detected by ultrasound, suggesting that patients can learn to monitor their own disease," reported Dr. Agnes Szentpetery of the department of rheumatology at St. Vincent’s Hospital, Dublin.
In this study, described as the first ever conducted in psoriatic arthritis to compare joint counts by patients, nurses, physicians, and ultrasound (US), 50 patients with a mean age of 50 years were enrolled. All received instruction from a nurse on how to assess and count tender and swollen joints. The major focus of the correlations was in 34 joints assessed with US, although further correlations were made between patients, nurses, and physicians for 28 (JC28) and 66 swollen and 68 tender (JC 66/68) counts.
"Joint counts [confirming active disease] were higher for patients and nurses than for physicians," reported Dr. Szentpetery, who presented these data at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network (SPARTAN). Doctor and nurse counts for swollen joints, unlike patient counts, did not correlate with US evidence of effusion, although they did for synovitis.
For tender joints, there was moderate or good agreement between patient and doctor for 11 joints, doctor and nurse for 12 joints, and patient and nurse for 19 joints. (This nurse was different from the one who provided instruction on joint counts.) However, correlation between any of these observers and US evidence of tender joints was uniformly poor.
Small joints in the hand, particularly the proximal interphalangeal joint, offered the best interobserver agreement for correlations, according to Dr. Szentpetery. Although no correlations rose above good and most were moderate between any two observers, Dr. Szentpetery stressed that patients performed at levels comparable with doctors and nurses, compared with US.
"Although this was a small study, the results support patient joint counts, and we have already begun routinely instructing patients in our clinic," Dr. Szentpetery reported.
Asked for a comment, Dr. John D. Reveille, professor of rheumatology and clinical immunogenetics at the University of Texas Health Sciences Center at Houston, said that he is remaining cautious until a larger study generates more data. He said that similar efforts to instruct patients to perform joint counts in rheumatoid arthritis failed to produce acceptable rates of accuracy.
"It may be possible to enlist patients to perform accurate joint counts if they are motivated and receive appropriate education, but you may need a special population and the right education," said Dr. Reveille, who is chair of SPARTAN’s executive committee.
However, joint counts are perceived to be so time consuming that many clinics do not perform them at all, according to Dr. Szentpetery. Moreover, she suggested that the absolute number of tender or swollen joints at any moment in time may be less important than the change in joint involvement after treatment is initiated, an outcome that may be best measured by patients.
"I agree that this is a small study, and more data are needed, but our data suggest patients may have a role in joint counts, which is an attractive strategy for reducing work for the clinicians," Dr. Szentpetery said.
Dr. Szentpetery and Dr. Reveille reported no relevant financial conflicts.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Key clinical point: Properly educated patients with psoriatic arthritis can count tender and swollen joints accurately, thereby saving time and effort by physicians or nurses.
Major finding: For tender joints, there was moderate or good agreement between the patient and the doctor for 11 joints, the doctor and the nurse for 12 joints, and the patient and the nurse for 19 joints, but correlations between any of these observers and ultrasound evidence of tender joints were uniformly poor.
Data source: A cross-sectional study of 50 patients with PsA.
Disclosures: Dr. Szentpetery and Dr. Reveille reported no potential conflicts of interest relevant to this study.
First comorbidity guidelines drafted for psoriatic arthritis
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
First comorbidity guidelines drafted for psoriatic arthritis
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
NEW YORK – For the first time, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis is preparing evidence-based treatment recommendations for the diagnosis and management of the comorbidities associated with psoriatic arthritis.
"I am really excited that we are taking the initiative to treat and manage the psoriatic arthritis [PsA] patient as a whole," reported Dr. Elaine Husni, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. The guidelines are meant to be a "platform on which to raise awareness" and foster education.
An initial set of guidelines on comorbidities was drafted at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Dr. Husni led the consensus group and fielded questions about key recommendations.
The first of these recommendations, which will undergo a process of discussion and review prior to formal adoption, states that all patients with PsA should be evaluated for cardiovascular (CV) disease. The consensus group labeled this recommendation "strong" even while conferring it with grade D evidence.
"The grade D was based on the fact that there are no outcomes data specifically in patients with psoriatic arthritis," observed Dr. Alexis R. Ogdie-Beatty, director of the Penn Psoriatic Arthritis Clinic at the University of Pennsylvania, Philadelphia. A member of the consensus group, Dr. Ogdie-Beatty suggested that benefit from CV screening is still a reasonable expectation "given the growing evidence that patients with PsA are at increased risk."
Similar "strong" recommendations but grade D evidence were given for screening for ophthalmic complications and inflammatory bowel disease. In these cases, there is good evidence for an association with PsA but limited evidence that screening will lead to improved outcome. The exception was obesity for which the group gave a B rating to the evidence for benefit from diagnosis and treatment.
Screening for diabetes was also included among recommendations, but it was given a "weak" rating and a grade D for supportive evidence.
Most of the other recommendations involved screening for various infections, such as hepatitis C virus (HCV), HIV, and tuberculosis, prior to initiating immunosuppressant therapies, particularly biologics. The level of evidence for these recommendations typically ranged between B and C even though all were given strong recommendations.
The consensus recommendations are not expected to include much detail about the specific management of comorbidities. The reason is concern about their applicability across various settings of care. It was thought that GRAPPA, as an international organization, should accommodate different types of practice. For example, the group cautioned against outlining steps of CV risk management, which may be managed by rheumatologists in some areas of the world but by specialists in others.
"We want to stay away from being minicardiologists," Dr. Husni explained. She indicated that the goal of the recommendations is to simply identify the specific types of comorbidity screening that should be considered "core recommendations" in the approach to PsA.
However, there is interest in creating a table regarding the use of specific medications for PsA treatment in the context of comorbidities. In a color-coded draft presented at the GRAPPA and SPARTAN meeting, some examples included caution in the use of NSAIDs in patients with CV disease, a need for monitoring when using cyclosporine in patients with chronic kidney disease, and a preference for etanercept over other tumor necrosis factor inhibitors in patients with HCV infection.
Overall, recommendations for comorbidities were identified as an important step in defining optimal care for PsA. According to Dr. Ogdie-Beatty, "the most important point may be to raise awareness." As these recommendations wend their way through an approval process at the organizational level, Dr. Ogdie-Beatty expressed hope that the final wording is specific enough to encourage attention to comorbidities without restricting a variety of valid approaches.
Dr. Husni reported a financial relationship with Celgene. Dr. Ogdie-Beatty had no potential conflicts of interest to report.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Putting Psoriatic Arthritis First
We are all aware of the burden of psoriatic arthritis (PsA). Although psoriasis is more common, the arthritic component is a major factor in the morbidity of psoriatic disease. Accordingly, the National Psoriasis Foundation (NPF) is taking steps to expand the focus on PsA.
Last month, the NPF launched the largest realignment and expansion of its PsA program since the organization began its services almost 20 years ago. The NPF’s PsA Project will focus on 4 major areas: (1) Decrease the time to diagnosis. (2) Help those with PsA better manage their disease. (3) Reduce barriers to health care and treatments. (4) Improve understanding of PsA symptoms, disease management, and impact on patient quality of life among health care providers.
Through the PsA Project, the NPF has the following specific goals: (1) Reduce the average time of diagnosis of PsA from 4 years to 1 year. (2) Increase by 50% the number of people with PsA who are receiving the right treatment to 62% total. (3) Reduce from 50% to 30% the number of people who report PsA is a problem in their everyday lives. (4) Double the number of health resources available to people diagnosed with PsA. (5) Increase by 50% the number of National Institutes of Health–funded scientists studying psoriatic disease to 42 scientists to boost care, improve treatment, and find a cure for PsA.
What’s the issue?
Our patients with PsA deserve more resources. The earlier we diagnose this condition the less likely an individual is to suffer pain and possible joint destruction. A project such as the one created by the NPF can only help to raise awareness among both patients and physicians. How will you contribute to expanding awareness of psoriatic arthritis in your community?
We are all aware of the burden of psoriatic arthritis (PsA). Although psoriasis is more common, the arthritic component is a major factor in the morbidity of psoriatic disease. Accordingly, the National Psoriasis Foundation (NPF) is taking steps to expand the focus on PsA.
Last month, the NPF launched the largest realignment and expansion of its PsA program since the organization began its services almost 20 years ago. The NPF’s PsA Project will focus on 4 major areas: (1) Decrease the time to diagnosis. (2) Help those with PsA better manage their disease. (3) Reduce barriers to health care and treatments. (4) Improve understanding of PsA symptoms, disease management, and impact on patient quality of life among health care providers.
Through the PsA Project, the NPF has the following specific goals: (1) Reduce the average time of diagnosis of PsA from 4 years to 1 year. (2) Increase by 50% the number of people with PsA who are receiving the right treatment to 62% total. (3) Reduce from 50% to 30% the number of people who report PsA is a problem in their everyday lives. (4) Double the number of health resources available to people diagnosed with PsA. (5) Increase by 50% the number of National Institutes of Health–funded scientists studying psoriatic disease to 42 scientists to boost care, improve treatment, and find a cure for PsA.
What’s the issue?
Our patients with PsA deserve more resources. The earlier we diagnose this condition the less likely an individual is to suffer pain and possible joint destruction. A project such as the one created by the NPF can only help to raise awareness among both patients and physicians. How will you contribute to expanding awareness of psoriatic arthritis in your community?
We are all aware of the burden of psoriatic arthritis (PsA). Although psoriasis is more common, the arthritic component is a major factor in the morbidity of psoriatic disease. Accordingly, the National Psoriasis Foundation (NPF) is taking steps to expand the focus on PsA.
Last month, the NPF launched the largest realignment and expansion of its PsA program since the organization began its services almost 20 years ago. The NPF’s PsA Project will focus on 4 major areas: (1) Decrease the time to diagnosis. (2) Help those with PsA better manage their disease. (3) Reduce barriers to health care and treatments. (4) Improve understanding of PsA symptoms, disease management, and impact on patient quality of life among health care providers.
Through the PsA Project, the NPF has the following specific goals: (1) Reduce the average time of diagnosis of PsA from 4 years to 1 year. (2) Increase by 50% the number of people with PsA who are receiving the right treatment to 62% total. (3) Reduce from 50% to 30% the number of people who report PsA is a problem in their everyday lives. (4) Double the number of health resources available to people diagnosed with PsA. (5) Increase by 50% the number of National Institutes of Health–funded scientists studying psoriatic disease to 42 scientists to boost care, improve treatment, and find a cure for PsA.
What’s the issue?
Our patients with PsA deserve more resources. The earlier we diagnose this condition the less likely an individual is to suffer pain and possible joint destruction. A project such as the one created by the NPF can only help to raise awareness among both patients and physicians. How will you contribute to expanding awareness of psoriatic arthritis in your community?
Axial involvement found common in psoriatic arthritis mutilans
NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.
In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.
"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.
The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.
In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.
Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.
Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.
When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.
The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.
Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.
Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.
Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.
Dr. Jadon reported no potential conflicts of interest.
NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.
In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.
"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.
The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.
In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.
Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.
Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.
When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.
The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.
Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.
Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.
Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.
Dr. Jadon reported no potential conflicts of interest.
NEW YORK – Unexpectedly and conflicting with previous reports, a careful analysis of a relatively large series of patients with psoriatic arthritis mutilans found that most had axial involvement.
In a series of 56 patients with psoriatic arthritis (PsA) mutilans drawn from 610 consecutive patients with PsA, 65% had evidence of axial disease on the most recent radiograph. Of these, 57% had radiographic sacroiliitis, which was bilateral in 80%.
"This proportion far exceeds the typical 25% incidence of axial disease reported in the literature," according to Dr. Deepak Jadon, a specialist registrar in rheumatology at the Royal National Hospital for Rheumatic Diseases, Bath, England.
The proportion of confirmed PsA mutilans cases, at 9%, was also higher than the 5% typically reported, according to Dr. Jadon, who presented these findings at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network (SPARTAN). Referral to a specialty clinic may explain the higher rate, but PsA mutilans could only be ruled out, because of inadequate radiographs, in 483 of the 610 patients, so the actual proportion could be even higher.
In 35 of the patients with PsA mutilans, defined as osteolysis involving at least 50% of the visualized articular surface on both sides of the joints, serial radiographs confirmed that this disease is progressive. In this series, 37% of the patients had PsA mutilans at the time of the first radiograph, but the rest developed PsA mutilans over the course of follow-up.
Of this second group, 84% had received a disease-modifying antirheumatic drug (DMARD) prior to developing PsA mutilans, an observation that "suggests DMARDs may not prevent the onset of this condition," Dr. Jadon reported, cautioning that there are other potential explanations.
Using a random-effects model, "different patterns of progression were observed in the feet and hands," Dr. Jadon reported. In both groups, the most common pattern was an initial surge of activity followed by a tapering of rate of progression. However, a second surge of activity in the hands was not observed in the feet.
When compared to unaffected PsA patients, those with PsA mutilans were on average younger (33 vs. 40 years; P = .039) and more likely to have nail dystrophy (83% vs. 45%; P = .0002). The severity of nail dystrophy appeared to correlate with the severity of joint involvement.
The most commonly affected joints in this series were the metatarsophalangeal joint of the big toe, the proximal interphalangeal joint of the thumb, and the metacarpophalangeal joint of the index finger. While many patients had monoarticular involvement at the time of diagnosis, 80% of patients in this series had polyarticular disease on the most recent radiograph.
Not surprisingly, functional limitations were significantly greater for patients with PsA mutilans on standardized health assessment questionnaire (HAQ) when compared with patients with PsA (P = .048). The differences involved functions affecting both the hands, such as those relevant to grip strength, and the feet.
Data from this series did not provide any insight on treatment efficacy. Biologic use in those with serial radiographs, which included a sizeable number of patients managed before the biologic era, was too infrequent to infer effect on disease progression. However, the frequent exposure to DMARDs in patients with documented progression suggests benefits may be limited.
Dr. Jadon suggested that prospective data for PsA mutilans, which is widely regarded as the least common but most severe form of PsA, are now needed to determine which treatments have the greatest potential to improve long-term outcome.
Dr. Jadon reported no potential conflicts of interest.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Key clinical point: In a review of a relatively large series of patients with PsA mutilans, radiographic evidence of axial disease was found in the majority, which conflicts with previous reports.
Major finding: Sixty-five percent of patients with PsA mutilans had axial disease and 57% of those had sacroiliitis.
Data source: A case series of 56 patients with PsA mutilans.
Disclosures: Dr. Jadon reported no potential conflicts of interest.
Patients become full partners in inflammatory arthritis and psoriasis research
NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.
"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.
The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.
"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.
At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).
"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."
The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.
"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.
PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.
In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).
According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.
"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.
Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.
NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.
"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.
The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.
"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.
At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).
"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."
The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.
"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.
PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.
In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).
According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.
"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.
Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.
NEW YORK – Improvements in clinical trial design for psoriasis, psoriatic arthritis, and other inflammatory diseases are being credited to a decision to enlist patients as full partners, not just advisors or consultants, in research initiatives.
"Rheumatologists, I think, have been leaders is recognizing that patients can bring an expertise to clinical research that is unique and ensure that study endpoints are relevant to outcomes important to them," reported Dr. William Tillett, a research fellow in the department of rheumatology at the Royal National Hospital for Rheumatic Diseases in Bath, England.
The value of patient research partners (PRP) was a recurring theme at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research & Treatment Network. GRAPPA, in particular, has been fostering research collaborations with patients since 2006.
"It has been an evolution. Patients were initially enlisted to sit in when trial designs were being discussed. Now, we are talking about full partnership so that they are involved at the inception with equal partnership that includes veto power and author credit," Dr. Tillett explained.
At the GRAPPA meeting, an afternoon symposium was devoted to optimal strategies for fostering collaboration with PRPs, which builds on work already initiated with a group called Patient Involvement for Outcome Measures in PsA (PIOMPsA). In turn, PIOMPsA, formed 2 years ago, was largely modeled on PRP initiatives led by OMERACT (Outcomes Measurement in Rheumatology).
"OMERACT has been involving patients in clinical research design for about 10 years," reported Dr. Philip J. Mease, director of rheumatology research at Swedish Medical Center, Seattle. "The idea of making patients full-blown partners is more recent, but I think there is increasing appreciation for what the right patients can contribute to improve study design."
The initiatives are spreading through rheumatology and other inflammatory diseases. At the GRAPPA meeting, updates on patient initiatives to influence clinical research were presented not only from the work of PIOMPsA and OMERACT but also from the International Dermatology Outcomes Measures (IDEOM) consortium. Created in collaboration with the National Psoriasis Foundation (NPF), IDEOM is bringing clinicians and patients together to define standard outcome measures.
"There are no really good measures to evaluate relative severity of psoriasis from the patient’s perspective," reported Dr. Alice Gottlieb, professor of dermatology at Tufts Medical Center, Boston. Tools traditionally used in clinical trials, such as the Psoriasis Area Severity Index (PASI) "are not practical in the clinic" and do not necessarily reflect the impact of psoriasis on quality of life when used as a study endpoint, she said.
PIOMPsA has now conducted several meetings, including one held in conjunction with OMERACT in Budapest, Hungary, in early May 2014. Like IDEOM, PIOMPsA has been focused on developing consensus on core symptoms of its target inflammatory disease. This is critical because the ability of clinical trials to generate relevant data is dependent on first defining meaningful endpoints, according to Dr. Tillett, who presented the PIOMPsA deliberations at the GRAPPA meeting.
In Budapest, for example, a vote was taken on whether to add fatigue to a list of core symptoms for PsA that includes impaired physical function, skin lesions, and joint pain. Fatigue was added to the list by a vote in which 70% supported it as a core PsA symptom, said Dr. Tillett, who recently published on the goals and underlying concepts of PIOMPsA (Curr. Rheumatol. Rep. 2014;16:418).
According to Dr. Tillett and Dr. Mease, PRPs are an answer to the repeatedly reported disconnect between physicians and patients in rating disease severity. By involving patients with interest in clinical research and collaborative skills, treatment trials have the potential to generate data more useful to practical patient management.
"It will be very difficult to show objectively that patient-aided trial design leads to better studies, but this is a reasonable expectation. I think that the contributions we have already seen from these collaborations bear this out," said Dr. Tillett, who expects the concept to spread to other fields of medicine.
Dr. Tillett reported financial relationships with AbbVie and Amgen. Dr. Mease reported financial relationships with AbbVie, Amgen, Biogen Idec, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, Janssen Pharmaceuticals, Lilly, Merck & Co, Novartis, Pfizer, UCB Pharma, and Vertex. Dr. Gottlieb reported financial relationships with Abbott, Actelion, Amgen, Bristol-Myers Squibb, Celgene, Centocor, Novo Nordisk, Teva, and UCB.
EXPERT ANALYSIS FROM THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
