Chronic Inflammatory Arthropathy Research Articles

Physiopathological Aspects of Synovial Fluid and Membrane in Psoriatic Arthritis

Background: Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy characterized by a variety of clinical manifestations, mainly affecting joints and entheses, but also skin, nails, the eye, and the intestine. Objectives: In this review, we describe the essential characteristics of both synovial membranes and synovial fluid (SF) in PsA. Similarly to other inflammatory arthritis, the histological peculiarities in PsA synovitis are lining hyperplasia, neoangiogenesis, and sublining infiltration by immune cells and inflammatory mediators. Synovial effusions are frequent in PsA patients and SF analysis allows us to determine the pathological process occurring in the joint. Routine examinations help clinicians in defining the inflammatory status and possibly the detection of specific cell subsets. In addition, pathogenic crystals including monosodium urate and calcium pyrophosphate may be found in PsA SF. Conclusions: SF represents a potential substrate to identify the biomarkers that are useful to predict disease progression and response to medications in PsA patients, thus guiding the choice of appropriate and tailored pharmacological treatment.

B-078 Serodiagnosis of Rheumatoid Arthritis Using the New Accentis Chemiluminescence Immunoassay Platform for Anti-CCP Antibody Detection

Abstract Background Rheumatoid arthritis (RA) is one of the most common autoimmune diseases and the most frequent chronic inflammatory arthropathy. Reliable diagnosis at the earliest possible stage is indispensable to keep the disease under control with suitable therapy and to prevent irreversible joint damage. Autoantibodies against cyclic citrullinated peptides (CCP) are a highly specific marker for RA with relevance for (differential) diagnosis, prediction and prognosis. In this study, we investigated the clinical and analytical performance of a newly developed anti-CCP chemiluminescence immunoassay (ChLIA) system. Methods Serum samples from 170 patients with clinically confirmed RA and from a control panel of 274 patients with other diseases were analyzed using the EUROIMMUN Anti-CCP ChLIA (IgG), which was processed on the fully automated random-access system Accentis (EUROIMMUN). The results were compared with those obtained with the EUROIMMUN Anti-CCP ELISA (IgG) with regard to sensitivity, specificity and inter-assay concordance. Results The ChLIA achieved a sensitivity of 71.2% (121/170) and a specificity of 97.4% (267/274), while the ELISA was less sensitive (67.5%, 114/170) and specific (96.4%, 264/274). The qualitative results showed positive and negative agreement rates between the two assays of 92.7% (115/124) and 95.9% (307/320), respectively, resulting in 95.0% (422/444) overall agreement and a kappa score (0.878) indicating near perfect agreement. Conclusions The new Accentis ChLIA showed improved sensitivity and specificity for the detection of anti-CCP antibodies compared to the corresponding ELISA. Given the enhanced clinical performance and the practical benefits of using a random-access system, this ChLIA platform can effectively support the diagnosis of RA.

P046 The influence of deprivation in the outcomes of Psoriatic Arthritis within the UK - utilising Outcomes of Treatment in Psoriatic Arthritis Study Syndicate data

Abstract Background/Aims Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy, which affects approximately 30% of patients with psoriasis and is associated with a high degree of morbidity. The introduction of biological disease-modifying antirheumatic drugs (bDMARDs) revolutionised treatment strategies for patients with PsA, however response is not universal. Deprivation and its associated risk factors may impact the initiation of and response to treatment with bDMARDs. There is limited data exploring the effect of deprivation on disease response to biologics in PsA. Psoriasis patients with a higher socioeconomic status have been shown to be more likely to respond to biologics, to our knowledge this has not been investigated in PsA. This study aimed to assess the impact of deprivation on initiation of and clinical response to biologic DMARDs. Methods Patients commencing a bDMARD were recruited to the UK prospective observational study Outcome of Treatment in Psoriatic Arthritis Studies Syndicate (OUTPASS REC ref:13/NW/0068). Index of Multiple Deprivation (IMD), the official measure of relative deprivation in England, was the exposure of interest. Subjects were ranked based on their IMD and split into the 20% most deprived (deciles 1-2), middle 40% (deciles 3-6) and 40% least deprived (deciles 7-10). This was done to aid analysis as IMD weightings provide greater differentiation among the least advantaged areas with fewer distinctions for less deprived areas. Treatment response was measured using changes in DAS28/PsARC, analysed using multivariate linear regression and multivariate logistic regression, respectively. Response was measured at three months as NICE guidance advises review of biological therapies at this time. Results There was no difference in the distribution of patients between the three groups (most deprived=138, middle deprived=207, least deprived=193). There were no statistically significant differences in the time from diagnosis to starting biologics in the most deprived group compared to the middle (p = 0.62) or least deprived p = 0.42) groups. There was no statistically significant difference in treatment responses between the groups. DAS28 change and PsARC improvement at three months remained similar between the most deprived, the middle deprived (p = 0.71, p = 0.08) and least deprived groups (p = 0.81, p = 0.22). Conclusion There was no difference in the distribution of IMD in patients recruited to OUTPASS, suggesting that the study is inclusive in recruiting across IMD subgroups. There was no difference in time from diagnosis to starting bDMARD therapy or response to treatment across the deprivation spectrum. These findings suggest that the NHS in England is performing its role of providing care according to need and regardless of circumstance. The study assesses deprivation in the context of free healthcare and may not be applicable to fee-paying healthcare systems. Further research is required to determine the relationship between deprivation and other outcomes, including work instability, in PsA. Disclosure M. Lyon: None. S. Zhao: None. A. Barton: Member of speakers’ bureau; speaker fees from Chugai-Roche and Galapagos. Grants/research support; grant funding from BMS, Pfizer, all unrelated to the work presented. H. Chinoy: Corporate appointments; Advisory Board member for Astra Zeneca, Pfizer, Argenx, Galapagos; Data and Science Monitoring Board chair for Horizon Therapeutics.. Consultancies; Consulting for PTC Therapeutics. Member of speakers’ bureau; fees as a speaker for GSK, UCB. M. Jani: None. J. Bluett: Grants/research support; research grant award from Pfizer and travel/conference fees from UCB, Fresenius Kabi, Pfizer and Eli Lilly.

The use of anakinra in a patient with gout and long-term follow-up of rheumatoid arthritis

Gout is a chronic inflammatory arthropathy, caused by articular and periarticular sodium monourate (MUN) crystals deposition on the background of chronic hyperuricemia. Gout belongs to the group of autoinflammatory diseases characterized by activation of the innate immune system. In some cases, especially in women, with a long course of the disease and absence of adequate therapy, chronic arthritis is detected, which has little difference from that in rheumatoid arthritis (RA). At the same time, until recently, the combination of RA and gout was considered casuistry due to the inhibition of crystal formation by specific factors associated with RA, what is more mechanisms of inflammation development characteristic of these diseases are completely different. However, according to the latest data, the coexistence of these two diseases in one patient is possible, and the therapy of both, gout and RA (in some patients) can be successful when prescribing biological disease modifying antirheumatic drugs, in particular inhibitors of the interleukin 1 receptor (IL1r).The article presents a rare clinical case of chronic tophi gout in an elderly patient who was followed up for a long time with a diagnosis of RA, a significant improvement was achieved on therapy with the IL1r antagonist anakinra.

Clinical practice guideline for the treatment of psoriatic arthritis in Colombia

IntroductionPsoriatic arthritis is a chronic inflammatory arthropathy characterized by subtypes with distinct phenotypes and variable clinical course, which requires optimal management of joint manifestations and skin involvement. ObjectivesThis study aims to provide recommendations for the pharmacological treatment of psoriatic arthritis based on evidence and applicability to the Colombian health system. Methodology and methodsThese guidelines were developed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Clinical experts, rheumatologists, and dermatologists formulated the recommendations based on clinical evidence, the disease's impact, patient values and preferences, and the resource availability in the country. ResultsThe guideline includes 12 recommendations related to the use of anti-inflammatory drugs, glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs), including conventional synthetics, biologics, and targeted synthetic DMARD, for the PsA domains: peripheral disease, axial disease, enthesitis, and dactylitis. ConclusionsThis document presents a set of updated and evidence-based recommendations that guide decision-making about pharmacological management of psoriatic arthritis in adults in Colombia. They constitute general guidelines that should be interpreted and implemented according to the individualized evaluation of the patient and the medical criteria in the different clinical settings.

Clinical practice guideline for the treatment of psoriatic arthritis in Colombia

IntroductionPsoriatic arthritis is a chronic inflammatory arthropathy characterized by subtypes with distinct phenotypes and variable clinical course, which requires optimal management of joint manifestations and skin involvement. ObjectivesThis study aims to provide recommendations for the pharmacological treatment of psoriatic arthritis based on evidence and applicability to the Colombian health system. Methodology and methodsThese guidelines were developed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Clinical experts, rheumatologists, and dermatologists formulated the recommendations based on clinical evidence, the disease's impact, patient values and preferences, and the resource availability in the country. ResultsThe guideline includes 12 recommendations related to the use of anti-inflammatory drugs, glucocorticoids, and disease-modifying antirheumatic drugs (DMARDs), including conventional synthetics, biologics, and targeted synthetic DMARD, for the PsA domains: peripheral disease, axial disease, enthesitis, and dactylitis. ConclusionsThis document presents a set of updated and evidence-based recommendations that guide decision-making about pharmacological management of psoriatic arthritis in adults in Colombia. They constitute general guidelines that should be interpreted and implemented according to the individualized evaluation of the patient and the medical criteria in the different clinical settings.

Palmoplantar pustulosis and pustulotic arthro-osteitis associated with multiple venous occlusion: A case report and literature review.

Pustulotic arthro-osteitis (PAO) is a rare chronic inflammatory arthropathy associated with palmoplantar pustulosis. The pathogenesis of PAO remains unclear. The most common musculoskeletal involvement in PAO is ossification of the sternoclavicular joints. A combination of parietal inflammation and hyperostosis-induced mechanical compression in this region is hypothesized to contribute to multiple venous thrombosis. Here, we present a 66-year-old man with PAO-associated multiple venous occlusion who was successfully treated with guselkumab. We also discuss its clinical manifestation and cause by reviewing the literature.

DEGENERATIVE ARTICULAR CARTILAGE DISEASE, OSTEOARTHROSIS

Introduction: Osteoarthrosis (OA), degenerative articular cartilage disease is a chronic inflammatory arthropathy involving joint elements (subchondral bone, synovial membrane, hyaline cartilage and others). It is due to a disorder in the regulation between degradation and synthesis of the extracellular matrix of cartilage, involving bone and synovial membrane in a biochemical process mediated by growth factors and cytokines which, in turn, intervene in the course of bone remodeling and joint destruction. Objective: to detail the current information related to osteoarthrosis, description, etiology, classification, imaging classification, management and current treatments. Methodology: a total of 52 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 38 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: arthrosis, osteoartrose, bones, osteoartrosis, articular cartilage. Results: The prevalence of osteoarthrosis increases directly with age 25-35 years 0.1 % 35-65 years 30 % and over 80 years 80-100 %. An improvement of pain and sensitivity is observed with local treatment with capsaicin. Paracetamol can be considered as the basic analgesic in the treatment of most chronic osteoarticular pain in doses of 1 gram four times/day. Opioids have an analgesic effect that almost completely eliminates all kinds of pain regardless of its intensity or site of affection. Short-term and long-term parenteral corticosteroid use is effective in controlling pain and stiffness. Systemic use of corticosteroids in OA is not warranted and only intra-articular injections are advised. Diacerein decreases IL 1Beta production in cartilage as well as nitric oxide levels by antagonizing the catabolic process and stimulates the anabolic process of cartilage. Chondroitin sulfate does not present a clinically relevant effect on joint pain or joint space reduction. Conclusions: osteoarthritis should be considered as a chronic, irreversible and progressive lesion. There are factors that aggravate its prognosis. Many measures are recommended to the patient and his family, especially if it is an elderly patient, in order to avoid the progression of joint damage. Surgical treatment is reserved for patients with severe pain or marked deformity, which occurs in advanced OA. Among the most frequently used procedures are: valgus osteotomy of the proximal tibia, arthroplasty, arthrodesis and amniotic membrane implantation. Bone tissue regenerative currents using tetracyclines that prevent the activation of metalloproteases, autologous chondrocyte implants, hypoxia inducible factor (HIF-1/2a), parathyroid hormone that stimulates chondrocyte multiplication and the use of in situ stem cells, cartilage regeneration and a better understanding of the developmental protein ancestor of osteogenesis, will be part of the medical management protocol, being a promising therapy for future therapy. KEY WORDS: Osteoarthrosis, osteoartrose, bones, osteoartrosis, articular cartilage.

An intra‐articular injectable phospholipids‐based gel for the treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory and destructive arthropathy with a high deformity rate. Despite numerous studies and clinical trials, no curative treatment is available for large weight-bearing joints. Intra-articular (IA) injections could deliver high concentrations of drug to the afflicted joint and improve the drug efficacy while reducing systemic toxicity. However, free drugs are rapidly cleared from synovial fluid and do not significantly halt the progression of joint disease. Herein, a phospholipids-based controlled-release gel was prepared for sustained IA delivery of celastrol (CEL) and the therapeutic efficiency was evaluated in a rheumatoid arthritis rabbit model. The CEL-loaded gel (CEL-gel) contained up to 70% phospholipids yet was easy to inject. After injecting into the joint cavity, CEL-gel achieved sol to gel phase transition without special stimuli and gelling agent. In vitro release and in vivo pharmacokinetic studies evidenced the stable and sustained release action of CEL-gel. A single IA injection of CEL-gel could maintain therapeutic efficiency for about 25 d and showed much better anti-arthritic efficacy compared to repeated injections of free drug solution (CEL-sol). Furthermore, the IA injection of CEL-gel greatly reduced the systemic toxicity of CEL. With good biocompatibility and biodegradability, CEL-gel might be a promising IA drug delivery system.

Consistency of recommendations for pharmacotherapy of rheumatoid arthritis.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory arthropathy. Recommendations for RA, specifically on pharmacotherapy, are essential in clinical practice. However, the direction and strength of recommendations are controversial across current clinical practice guidelines (CPGs) of RA. Objective: To systematically analyze the consistency of recommendations regarding pharmacotherapy of RA across CPGs. Methods: 11 electronic databases and websites were comprehensively searched from inception to 14 March 2022, to identify CPGs for diagnosis, therapy, and management of RA. Unambiguous and discrete specifications of the population-intervention-comparison (PIC) framework were used to classify the recommendations. Based on the PIC framework, consistency analyses across CPGs on pharmacotherapy of RA were performed. Two researchers reached a consensus on coding the direction and strength of each recommendation. Results: Finally, 26 CPGs were included in this study, and 14 of them, which included pharmacotherapy, were performed consistency analysis. 1) 64 recommendations from 14 CPGs were classified into 18 PICs. 2) Seven PICs (38%) were consistent in direction and strength, 10 PICs (56%) were consistent in direction but inconsistent in strength, and one PIC (6%) was inconsistent in direction (hydroxychloroquine, HCQ). 3) Sensitivity analysis tested the robustness, and the inconsistency remained high. Conclusion: The direction was highly consistent among the recommendations of pharmacotherapy for RA, but the strength was highly inconsistent. Reasons for the inconsistency need to be further investigated, and consistent recommendations could guide the pharmacotherapy of RA in clinical practice.

Consensus statements for evaluation and nonpharmacological Management of Psoriatic Arthritis in UAE.

ObjectivePsoriatic arthritis (PsA), a chronic inflammatory arthropathy, is often underdiagnosed in Middle Eastern countries, substantially impacting the treatment of affected individuals. This article aims to highlight current unmet clinical needs and provide consensus recommendations for region‐specific evaluation methods and nonpharmacological therapies in the United Arab Emirates (UAE).MethodAn extensive literature review was conducted, focusing especially on global and regional guidelines for the evaluation and treatment of PsA. These form the basis of the consensus statements formulated. Additionally, an expert panel of key opinion leaders from the UAE reviewed these guidelines and available literature at an advisory board meeting to identify unmet needs, bridge clinical gaps in the UAE, and develop consensus statements for the evaluation and treatment of PsA.ResultThe consensus statements were developed based on overarching principles for the management of PsA, evaluation of patients with PsA, and nonpharmacological approaches for the management of PsA. The overarching principles included adopting a targeted, multidisciplinary approach, along with collaboration between rheumatologists and dermatologists in cases of clinically significant skin involvement. The panel also highlighted the value of composite disease severity measures for characterizing clinical manifestations of PsA. In terms of nonpharmacological management approaches, lifestyle modification (comprising dietary change, exercise, and cessation of smoking) and psychotherapy were recommended.ConclusionThe consensus statements will aid healthcare professionals in clinical decision‐making in the context of PsA.

P021 Development of a Rheumatology Hot Clinic in the Midst of a Pandemic

Background/AimsThe COVID-19 pandemic has had a significant impact on emergency and scheduled care, affecting both inpatient and outpatient services for all specialities, including Rheumatology. During the first pandemic peak, rheumatology outpatient clinics all became virtual (i.e. telephone or video), except for a single emergency clinic per week. However, this face-to-face clinic, quickly became oversaturated resulting in a waiting list extending above 4 weeks for our patients.MethodsIn the lead-up to the second COVID-19 peak during the winter, we developed a novel, urgent, hot Rheumatology Clinic within our Ambulatory Emergency Care (AEC) department. This whole-day weekly clinic was delivered by a Rheumatology registrar, with consultant support. Its purpose was to provide a service for patients who did not require hospitalisation but required urgent face-to-face Rheumatology speciality review that could not wait for an outpatient appointment. Referrals came from General Practice, Urgent Care (i.e. Emergency Care, Acute Medicine and AEC) and from the Rheumatology department. Pathologies reviewed included vasculitides, inflammatory arthritis and inflammatory connective tissue diseases. The clinic facilitated for patients with suspected new diagnoses or flares of established rheumatological diseases. Furthermore, patients could also undergo urgent joint and soft tissue procedures. All referrals were directed to the Rheumatology registrar to triage. Because of the success of the clinic, it continued beyond the second peak with data gathered from its inception.ResultsData was collected between November 2020 and June 2021, covering 23 hot clinics. A total of 118 patients were reviewed during this period. The highest number of referrals occurred during the second peak of the pandemic (38 patients over seven clinics compared to 48 patients over ten clinics post-peak). The majority of referrals were from Rheumatology directly (70%) compared with Urgent Care (14%) and General Practice (12%). Most (60%) were seen within 7-days of referral; a further 27% were seen within 7- 14 days. The main reasons for review delays beyond seven-days were lack of available clinic (46%) or lack of space (29%). The most common disease encountered was a chronic inflammatory arthropathy (48 patients).ConclusionThe service has generated positive feedback from all patients. Furthermore, this clinic has benefited both Rheumatology and AEC. Firstly, it ensured timely face-to-face reviews of patients requiring urgent Rheumatology assessments. Secondly, it eased pressure on the Rheumatology department, particularly the outpatient emergency clinic. Thirdly, it ensured that the Rheumatology registrar continued to have Rheumatology training opportunities, particularly when redeployed during the Winter wave on other days of the week. Fourthly, the AEC department have had easier access to Rheumatology reviews. Finally, it has empowered the registrar to manage their own workload and organise the clinic enhancing management and leadership experience. The success of the clinic has resulted in its ongoing continuation.Disclosure A. Khan: None. C. Murdoch: None. I. Wamuo: None.

Artritis psoriásica

Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy linked to the presence of cutaneous psoriasis and usually-negative rheumatoid factor (RF). The development of this disease depends on predisposing genetic factors, immunological determinants that perpetuate the local inflammatory cycle, and the participation of the Th1/Th17 pathways and those of the IL-9, IL-12/23 and IL-17 interleukins. Part of PsA genesis has been explained by association studies, but knowledge about the mechanisms that make it possible is currently incomplete. There are no specific diagnostic tests; diagnosis is based on the Classification Criteria for Psoriatic Arthritis (CASPAR) scheme, backed by imaging techniques. The last few years have seen great strides in immunosuppressive therapy for PsA, with the development of new treatments against different targets.

THE MANAGEMENT OF AMAVATA (RHEUMATOID ARTHRITIS) WITH VATARI GUGGULU AND BRIHAT SIMHANADA GUGGULU

The detail knowledge on Amavata was first explained by Madhavakar, whereas Chakrapani Dutta first gave knowledge about principle and management of the disease. Amavata is a clinical entity very much similar to the chronic but active inflammatory arthropathy, the Rheumatoid arthritis. Till now, the etio-pathogenesis of Rheumatoid arthritis is not known precisely but among the hypothesis, entero-pathy along with autoimmune have important role regarding this disease. In Amavata, due to impaired functioning of 'Kayagni' the anna-rasa undergoes fermentation resulted formation of ama (biotoxin) which combines with vitiated Vata (biophysical force for movement) to form Amavata.(1) So, two important entities one is toxin and other is movement, when comes together kha vaigunya concept the disease formed which is worst one. That’s why swelling, severe pain, and restricted movements are the main features of Amavata. Severe pain, difficulty in movements, and swelling on the joints along with fever etc makes the patient’s life miserable. Although Ama and Vata are chiefly pathogenic factors, Kapha and Pitta are also invariably involved in its pathogenesis (Samprapti). The therapeutic approach should be on Vata dosha, Kapha dosha and correction of Amadosha and of Agni viz. Pitta. The line of treatment for amavata also includes langhanam, swedanam, tiktam, deepana, katu drugs and sodhana treatment like virechana, basti etc. The shamana drugs which are having Vatashamaka, Amapachaka, Ama Shoshaka, and Deepniya properties can be used in the treatment of this disease. Vatari Guggulu and Brihat simhanada guggulu carries indication for Amavata according to Bhaisajya Ratnavali. The compositions in it are approachable lieu of principles of treatment of Amavata. The clinical research shows that in TG I, 7 (46.67%) patients were got Moderate im-provement while 8 (53.33%) patients were got Mild improvement. In TG II 10 (66.67%) patients were get Moderate improvement while 5 (33.33%) patients were got Mild improvement.

Shoulder and Elbow Surgery in Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory arthropathy that manifests itself prior to the age of sixteen years with symptoms lasting six weeks or longer. As JIA frequently effects the upper extremities, activities of daily living become compromised during the stages of development when young adults are striving for independence. Symptomatology includes ankylosing, pain and early growth plate closure. Patients with joint involvement prior to growth plate closure have the most destruction in terms of joint abnormality and surgical complexity.Medical management of JIA has allowed for better non-surgical management, yet, there is a continued need to understand the appropriate surgical intervention and order for the greatest functional gains. Comparative studies have shown that varied results as to whether the shoulder replacement should supersede the elbow replacement or should that be reversed or both joint replacements done simultaneously. Our experience found a more significant functional improvement after total elbow replacement due to the unpredictable nature from the shoulder replacement outcomes and an inability for patients to do simple tasks such as bringing a cup to their mouths or handling a toothbrush. The exception to this occurs if the ipsilateral shoulder joint is severely limited to the point that the stressors placed on the elbow due to compensation will lead to early loosening or failure of the elbow joint replacement.Various methods for performing joint replacement of the shoulder and elbow in the JIA population will be discussed. Soft tissue integrity including the functional status of the rotator cuff will be a consideration for which surgical procedure should be considered. Surgical approaches for the elbow present fewer options for improving pain and function in this patient population. Pre, peri and postoperative management is reviewed as careful attention to irregular bony dimensions and dysmorphic anatomy precludes the use of standard implants.Total shoulder and total elbow arthroplasty should be considered in the JIA population where pain and significant functional compromise are present. The order of procedures is dependent on multiple factors and expected outcomes. Educating patients on postoperative expectations over the lifespan is an important part of surgical management for patients with JIA.

An Update for the Clinician on Biologics for the Treatment of Psoriatic Arthritis.

Psoriatic arthritis (PsA) is a chronic inflammatory arthropathy typically associated with psoriasis (PsO). The pathogenesis is strictly related to the association among the presence of genetic risk alleles and innate and acquired immune response with dramatic consequences on bone remodeling. Clinically, PsA patients may present heterogenicity of articular and periarticular manifestations that may be associated with the presence of comorbidities making treatment decision challenging in patients management. The identification of patient-targeted therapies is still a critical issue. Actually, several biological and synthetic drugs are promising in terms of efficacy and safety profile. National and international treatment recommendations support clinicians in the decision of the best treatment, although they may have limits basically related to updates and different outcomes included in the clinical studies evaluated. The aim of this narrative review is therefore to give guidance for clinicians for PsA patients treatment. For this purpose, we evaluated evidence on biological therapies efficacy used for PsA treatment. Specifically, we reviewed data on biological therapies, Janus kinases (JAK) inhibitors, and drugs with a new mechanism of action that are part of the treatment pipeline. The concept of “switching” and “swapping” is also described, as well as data concerning special populations such as pregnant women and elderly patients.

Biological therapy safety in chronic inflammatory arthropathy patients.

The marketing of biological therapies transformed the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. But there is still concern about patient safety and management in daily clinical practice. The aim of this study was to estimate risk factors of the adverse effects in a cohort of Spanish patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. A single institution, descriptive, retrospective, cohort study was developed from January 2009 to December 2016. Patients diagnosed with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis on biological therapies were included. Undesirable events affecting patients during biological therapy, their clinical implications and the use of health resources related to adverse effects were collected. Three hundred and sixty-two patients corresponding to 478 biological therapy lines were analysed. It implied 1192 years of monitoring. There were 57 adverse effects per 100 biological patient-years and 4.8 serious adverse effects per 100 biological patient-years. The only significant factor for a likely serious adverse effect was having a Charlson Index ≥10, OR of 6.2 (CI 95%: 3.4-11.1, p<0.001). Around 15 % of patients with adverse effects were admitted to hospital and 25% received attention at the Emergency Department. Over half of the patients with arthropathies on biological therapy can suffer adverse effect during treatment but only 8.5% of these effects are serious. Special vigilance must be paid to patients with a higher number of comorbidities because they are more likely to experience serious adverse effects.

Biological therapy safety in chronic inflammatory arthropathy patients.

The marketing of biological therapies transformed the treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. But there is still concern about patient safety and management in daily clinical practice. The aim of this study was to estimate risk factors of the adverse effects in a cohort of Spanish patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. A single institution, descriptive, retrospective, cohort study was developed from January 2009 to December 2016. Patients diagnosed with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis on biological therapies were included. Undesirable events affecting patients during biological therapy, their clinical implications and the use of health resources related to adverse effects were collected. Three hundred and sixty-two patients corresponding to 478 biological therapy lines were analysed. It implied 1192 years of monitoring. There were 57 adverse effects per 100 biological patient- years and 4.8 serious adverse effects per 100 biological patient-years. The only significant factor for a likely serious adverse effect was having a Charlson Index ≥10, OR of 6.2 (CI 95%: 3.4-11.1, p<0.001). Around 15 % of patients with adverse effects were admitted to hospital and 25% received attention at the Emergency Department. Over half of the patients with arthropathies on biological therapy can suffer adverse effect during treatment but only 8.5% of these effects are serious. Special vigilance must be paid to patients with a higher number of comorbidities because they are more likely to experience serious adverse effects.

Clinical-therapeutic and recuperatory features in a patient with pluripatology: ischemic stroke, ischemic heart disease (sechelar myocardial infarction), chronic kidney disease and monstrous gout

Introduction: gout is a chronic inflammatory arthropathy produced by depositing crystals of monosodium uric acid (in joints and tissues) following an anomaly (genetics or acquired) in the purine metabolism (1,2). The manifestations of the disease are: hyperuricemia, recurrent episodes of acute arthritis, the presence of tophi, chronic kidney disease, urinary lithiasis(2). Stroke represents„ the rapid development of localized or global clinical signs of cerebral dysfunction with symptoms exceeding 24 hours, leading to death, without any other cause, except for vascular origin”. (3) Materials and Methods: with the permission of the THEBA Ethics Commission ( no.17464/14.06.2019), we will present the clinical case of a 57-year-old patient admitted to the TEHBA Neuromuscular Recovery Clinic presenting a right hemiplegia and mixed aphasia after an ischemic stroke in the territory of the left middle cerebral artery, on the background of complex polypathology (monstrous gout arthropathy, chronic smoking, arterial hypertension, myocardial infarction with coronary artery stenosis, chronic kidney disease). Results: the patient did in our clinic a neuro-muscular recovery treatment, adapted to his needs,which consisted of kinetotherapy and speech therapy and received appropriate medical treatment. The clinical evolution of the patient was slowly favorable, with improvement in language disorders and motor control of paralyzed limbs. Conclusions: the case of this patient has several particularities. This is a patient with a vicious life style, with a severe arthropathy, with severe cardio-vascular sufferers, hospitalized for recovering neuro-muscular deficits after an ischemic stroke. Despite limited prognosis, the patient has improved ADL and the quality of life after recovery treatment. Key words: stroke, hemiplegia, poly-pathologic, ischemic,

The correlation between interleukin-34 and bone erosion under ultrasound in rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is a chronic inflammatory arthropathy characterized by excessive synovial hyperplasia and progressive joint destruction. Pro-inflammatory cytokines play major roles in the regulation of synovial inflammation. The contribution of interleukin-34 (IL-34) in RA pathogenesis has been strongly suggested in clinical studies.Aim: To investigate the correlation between plasma IL-34 and disease parameters in RA patients including disease activity score (DAS28), receptor activator of NF-B ligand (RANKL) concentration, synovitis and bone erosions under ultrasound.Methods: 60 RA patients and 20 healthy controls were from Huashan Hospital, patient's medical history, physical examination, laboratory examination and ultrasound data were collected and recorded, respectively. Blood samples of all participants were collected and the levels of IL-34 and RANKL were tested. The levels of IL-34 and RANKL in RA patients were compared with those of healthy controls. Furthermore, the correlation between IL-34, RANKL and disease parameters in RA patients was analyzed.Results: Both plasma levels of IL-34 and RANKL in RA patients were significantly higher than the healthy controls (p < .05). IL-34 was significantly related to disease activity scores (r = 0.43, p = .001); RANKL (r = 0.46, p = .0003) and bone erosions by ultrasound (r = 0.38, p = .002).Conclusions: The plasma IL-34 concentration in RA was significantly higher than the healthy controls and was significantly correlated with RANKL, as well as disease activity score and bone erosions by ultrasound. The IL-34 may be a new biological marker for disease activity and predictor for bone erosions in RA. Targeting IL-34 holds promise in the management of RA and, potentially, other osteoclasts driven diseases (erosive osteoarthritis and psoriatic arthritis for example).