Management Of Psoriatic Arthritis Research Articles

The interpretation of European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies:2019 update

The interpretation of European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies:2019 update

Management of Patients with Psoriatic Arthritis – Analysis and Discussion of the Main Points of the EULAR Recommendations 2019

Updated recommendations of the European League Against Rheumatism (EULAR) on the pharmacological management of psoriatic arthritis (PsA) 2019 were presented in May 2020. The recommendations are compiled in accordance with the standardized EULAR operating procedures, a systematic review of the literature, followed by a consensus meeting of 28 international members of the task force for guideline development.Updated recommendations include 6 general principles and 12 recommendations. General principles relate to the nature of PsA and the diversity of both musculoskeletal and non-musculoskeletal manifestations; emphasizes the need for joint decision-making by the patient and the doctor. The recommendations represent treatment strategies for pharmacological therapy. Nonsteroidal anti-inflammatory drugs and local injections of glucocorticoids are offered as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis, accompanied by dactylitis or joint damage, it is recommended that the usual synthetic disease-modifying antirheumatic drugs (DMARD) be started quickly. If the treatment objective is not achieved using this strategy, biological DMARD (bDMARD) should be initiated, targeting tumor necrosis factor (TNF), interleukin (IL)-17A, or IL-12/23 taking into account skin lesions. If axial disease predominates, an TNF inhibitor or an IL-17A inhibitor should be started as a first-line DMARD.The use of Janus kinase inhibitors is considered primarily after the ineffectiveness of bDMARD. Inhibition of phosphodiesterase-4 is proposed for patients who are not suitable for other drugs, usually in the context of a mild disease. The switching of drugs and dose tapering in the phase of sustained remission are considered. This guideline provides an updated consensus on the pharmacological treatment of PsA based on a combination of evidence and expert opinion.

Pharmacological treatment of psoriatic arthritis: a systematic literature research for the 2019 update of the EULAR recommendations for the management of psoriatic arthritis

ObjectiveTo perform an update of a review of the efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) in psoriatic arthritis (PsA).MethodsThis is a systematic literature research of 2015–2018 publications on...

Case Study: Water-Only Fasting and an Exclusively Whole Plant Foods Diet in the Management of Psoriatic Arthritis

Psoriatic Arthritis (PsA) is a unique form of inflammatory arthritis associated with psoriasis. The current pharmacological management approach to treating PsA is often not successful in isolation. Here, the case of a 46-year-old woman with PsA is presented. The patient underwent a medically supervised, water-only fast and began an exclusively whole plant foods diet free of added sugar, oil, and salt. The patient discontinued the use of corticosteroids and achieved a significant reduction and eventual elimination of PsA symptoms. This case demonstrates the need for further research on the effects of medically supervised water-only fasting in cases of psoriatic arthritis.

EP43 Biologic retention in psoriatic arthritis: a real world study

Abstract Background Biologics have led to a sea change in the management of psoriatic arthritis (PsA) with unprecedented improvement in the signs, symptoms and radiographic damage, resulting in improvement in functionality and quality of life. However longitudinal data for their retention and tolerability is sparse. Our objective was to evaluate real-world biologic therapy duration and reasons for discontinuing treatment. Methods We conducted a retrospective analysis of our PsA electronic register from 1994 up to and including April 2019 at our university teaching hospital. We had access to full patient records including details on co-morbidities, drugs and disease management. Results 335 patients were identified with PsA. 58% were female with mean age 46 yr (13-81). 113 (33.7%) patients had been treated with a biologic with 105 (93%) continuing at the time of analysis. 60 individuals were prescribed combination therapy with DMARDs. Mean age was 43.3 (13-81) with 56% women. The biologics sample was ethnically diverse including 80% White Caucasian patients, 17% Asian and others (3%). Significant co-morbidities included cardiovascular disease (18.6%) and diabetes (4.4%). Eight different biologics were in use with adalimumab being the most prescribed (67%). 35 (30.9%) patients had stopped biologics at some point with 76 episodes of cessation. 6% of our sample had discontinued two or more biologic treatments. The mean duration before biologic therapy was discontinued was 18.2 months (8 days to 9.5 years), which was almost twice as long as the average period before discontinuing a DMARD (9.9 months). Main reasons for stopping treatment included 23% each due to GI symptoms, neurological causes, cutaneous symptoms and other side effects. The remaining 8% reported fatigue as the reason for stopping therapy. Conclusion To our knowledge this is the first dedicated retrospective review of a large real world PsA cohort comparing drug survival and tolerability of biologics against DMARDs. Biologic therapies are well tolerated in psoriatic arthritis. There is no significant difference amongst various modes of action. Over a quarter of the patients discontinue the drug owing to intolerance with mean drug survival of 18 months. In contrast nearly two-thirds were intolerant of DMARDs and stopped within ten months. Thus both the rate and duration of biologic retention is significantly better than conventional DMARDs. This has significant economic impact as NICE guidelines require an adequate trial of two DMARDs for six months prior to advanced therapy. However, this approach is unlikely to be cost effective as the disease progresses whilst patients struggle with DMARDs prescription and thus delay biologics which are more likely to be tolerated and retained longer. Hence there is an urgent need to review NICE guidelines to allow earlier employment of biologics in the treatment paradigm with significant benefits to both patients and the health economy. Disclosures: I. Jawad: None. M.K. Nisar: None.

Psoriatic arthritis in developing and resource-poor countries.

Published literature regarding the prevalence, incidence, management, and outcomes for psoriatic arthritis from developing countries and under-resourced regions is scarce. Most of the data available are from developed countries, especially European countries, the USA, and Canada. The European League Against Rheumatism (EULAR) and Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) have developed recommendations for the treatment of psoriatic arthritis based on data from developed countries. 1 , 2 These recommendations are often later tailored to suit patients and health-care settings in developing countries, but to date there have been no guidelines specifically looking at the management of psoriatic arthritis in resource-poor countries.

International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings

BackgroundPsoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR).ProcessThe ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production).ResultILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature.ConclusionThe ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.Key Points• The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings.• The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa.• The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.

An ayurvedic approach to diagnosis and management of psoriatic arthritis on principles of Vatarakta: A review

Psoriatic arthritis (PsA) is inflammatory arthritis usually occurring in patients with psoriasis. Even though skin disease and joint involvement are linked in PsA, they can occur irrespective of each other. An equivalent entity in Ayurvedic literature, Vatarakta is a disabling illness occurring due to the concurrent aggravation of Vata and Rakta. Its Moolasthana (~primary site) of manifestation is joints of hands and feet. With this article, we aim to develop a clinical approach to PsA on the principles of Vatarakta. Relevant information from authentic texts of Ayurveda and contemporary medical literature is gathered, and facts are analyzed to find similarities and dissimilarities between PsA and Vatarakta's etiology, pathogenesis, clinical features, prognosis, and management principles. It was seen that PsA bears similarity to Vatarakta on grounds of etiology, pathogenesis, and clinical features. The few differences seen are not found to be conceptually contradictory. Concepts of Vatarakta can explain the vascular, dermal, musculoskeletal, and systemic changes seen in PsA. The differential of Asthimajjagata Kushtha, Kushtha Updrava, and Aamvata is mandatory to rule out any diagnostic dilemma. Often the patients with psoriasis and/or PsA have hyperuricemia, which has been long viewed and treated on principles of Vatarakta. Hence, Vatarakta may be seen as an umbrella term for immune-mediated or inflammatory musculoskeletal disorders with dermal and systemic manifestations. Clinically, PsA can be understood and managed on principles of Vatarakta.

A Case of Widespread Dermatophytosis during Interleukin-17A Inhibitor Treatment in Psoriasis Patient with Tinea Unguium

Interleukin-17 (IL-17) is secreted by a class of helper T cells called Th17 cells, which stimulates keratinocytes to secrete proinflammatory mediator and to recruit other inflammatory cells in psoriatic skins. IL-17A inhibitor was approved for the management of psoriatic arthritis by FDA. It is the one of the biologics approved as first-line therapy for the management of psoriasis. But several studies show some side effects of IL-17A inhibitor such as upper respiratory infection and fungal infection like Candida albicans. Herein we report a widespread dermatophytosis during IL-17A inhibitor treatment. A 66-year-old male patient, with tinea unguium and chronic plaque psoriasis for several decades, presented with multiple erythematous scaly macules and patches for 2 weeks. He medicated IL-17A inhibitor for treating psoriasis total 3 times and last injection was 1 week ago. Dermatological examination revealed the involvement of 20% body surface area in the form of erythematous scaly macules and patches. KOH mount revealed the presence of numerous hyphae. The patient was started on oral terbinafine, topical isoconazole and efinaconazole. His skin lesions were improved after 1 month of anti-fungal therapy. IL-17 plays an important role in mucocutaneous microbial defense. So, fungal infection should be checked in using IL-17A inhibitor patients periodically.

835 Can Ustekinemab Relieve the Symptoms of IBD-Associated Arthropathy?

INTRODUCTION: Arthropathy is the most common extra intestinal manifestation observed in patients with Inflammatory Bowel Disease (IBD). Various studies have shown that up to 40% or more of patients with IBD may experience arthropathy. Ustekinemab is a relatively new drug approved for the management of moderate to severe Crohn’s disease (Oct 2016) and phase 3 trials for ulcerative colitis have now been completed. It is also FDA approved for management of psoriatic arthritis. The purpose of this study was to determine if a small cohort of patients with enteroarthropathy had symptom improvement while receiving ustekinemab in a longitudinal retrospective cohort. METHODS: Adult patients with IBD and arthropathy with who were treated with ustekinumab were included in the cohort. We followed the minimal disease activity index (MDA) which includes 7 broadly accepted parameters. We chose to collect data on 5 of those parameters including 1) joint tenderness, 2) swollen joint count, 3) tender points, 4) standardized graphic pain scales (VAS or GRS), and 5) a global assessment score from 0-5 (GAS). Two parameters (psoriatic area and severity index and health disability index) were not assessed. At each visit outcome measures were evaluated for changes in arthritic symptoms. RESULTS: 15 patients were included for review. 11 had Crohn’s disease and 4 had ulcerative colitis. Patients were followed for an average of 12 months (range 9-16). Eleven of 15 patients had joint tenderness on palpation at the start of therapy with 1 to 3 affected joints per patient while the others had subjective tenderness. Five patients had visibly swollen joints and 1 had both. The mean GAS was 3 with a range of 2 to 4. The pain GRS had a mean score of four out of 10 with a range of 2 to 8. The mean number of tender points was 3. After ustekinumab therapy, 14 of 15 patients had a drop in the global assessment score and the pain GRS score. Fourteen patients had resolution of joint swelling and tenderness. At the conclusion of the study, 6 of 15 patients complete resolution of all five scales. Four patients had resolution in three of the five scales, while 4 patients had resolution of two of the five scales. 1 patient did not exhibit improvement in any area. CONCLUSION: In this small observational cohort, ustekinumab improved arthropathy in 14 of 15 patients. We hope this stimulates interest in trials observing larger number of patients with this debilitating extra international manifestation of IBD.

Secukinumab in the Management of Psoriatic Arthritis: Current Perspectives

Psoriatic arthritis (PsA) is a seronegative, inflammatory arthritis associated with cutaneous psoriasis. This disease is associated with significant morbidity, thus requiring early treatment initiation and reduction of disease activity. Anti-cytokine therapies are increasingly being used for the treatment of PsA. In addition to the anti-TNF agents, monoclonal antibodies targeting IL-17 have been approved for the treatment of PsA. Secukinumab is a monoclonal antibody against IL-17 and is currently approved for the management of PsA. In this literature-based review, the current status of secukinumab for the management of PsA is discussed.

The Management of Psoriatic Arthritis in Italy: Organizational Impact Analysis of Optimized Pathwaystimized pathways

BACKGROUND: The management of psoriatic arthritis requires competencies in the fields of both rheumatology and dermatology, and a multidisciplinary approach.AIM: To propose an effective pathway for the diagnosis, monitoring and treatment of psoriatic arthritis in the Italian context, and to assess its organizational impact on the Regional Health Service of Lombardy Region.METHODS: The analysis was performed through interviews conducted with two key opinion leaders in the areas of dermatology and rheumatology. The current pathway of patients who present symptoms that might be related to psoriatic arthritis was defined and an optimized pathway was then proposed on the basis of the clinical practice, considering the implementation of a dermatology and rheumatology shared outpatient service. The organizational impact of the optimized pathway was then assessed from both the hospital and that of the Regional Health Service of Lombardy Region perspectives.RESULTS: The implementation of the service would have a positive impact on patients’ experience, improving the quality of the service provided, thanks to the multidisciplinary approach adopted, limiting the patients’ resources needed for the diagnosis, reducing the number of visits and time loss. The optimized pathway, therefore, would have a limited impact on the marketing mix, while potentially improving patients satisfaction, increasing the possibility of patients’ retention. To successfully implement the dermatological and rheumatologic multidisciplinary service, a precise communication strategy is mandatory.CONCLUSIONS: The optimized pathway for the diagnosis and management of psoriatic arthritis proposed would have a limited organizational impact at both hospital and Regional Health Service levels, while leading to theoretical benefits in terms of a prompt diagnosis of the pathology.

Düzeltme: Türkiye Romatoloji Derneği psoriyatik artrit ulusal tedavi önerileri

Düzeltme: Türkiye Romatoloji Derneği psoriyatik artrit ulusal tedavi önerileri

Management of psoriatic arthritis

The treatment of psoriatic arthritis (PsA) makes use of many agents. Most of them are used for the treatment of other forms of inflammatory arthritis or the management of cutaneous manifestations of psoriasis. Although a number of medications are effective in the treatment of both rheumatoid arthritis (RA) and PsA, trials involving some classes of biologic agents indicate that patients with RA and PsA may show different responses to certain drug classes. Treatment of the different elements of PsA includes coordinated interventions to address the major domains of the disease, including peripheral and axial arthritis, enthesitis, dactylitis, and skin and nail involvement.

Classical Ashtavaidyan Ayurvedic Therapy in the functional improvement of patients of Psoriatic Arthritis - An open label, single arm exploratory clinical study

Background: Arthritis and various musculoskeletal disorders are the leading cause of disability in persons between 18 to 65 years of age. Psoriatic arthritis simulates Ayurvedic descriptions of the clinical syndrome - Vatarakta. The study has been designed to evaluate the effectiveness of classical Ashtavaidyan methods of Ayurvedic intervention in the management of psoriatic arthritis and to assess the safety of the therapy. Methodology: Diagnosed cases of psoriatic arthritis (n=30) (20-60 yrs) have undergone the prescribed classical Ashtavaidyan Ayurvedic therapies. The total study period was 57 days which included 21 days each at inpatient and outpatient basis and 15 days of follow up. Initially modified Takradhara was performed along with internal medications for first 14 days; later same internal medication was continued with Sarvanga Abhyanga (therapeutic massage) with Pinda Taila and Vajraka Ghrita in 3:1 ratio externally and Amalaki Thalam for next 7 days. Same internal medicines and oil application were continued for next 21 days as outpatient. Results: The response to treatment was assessed periodically with respective parameters and showed highly significant improvement (P less than 0.001). There was significant reduction in PASI score and also significant changes in functional parameters related to psoriatic arthritis evaluated by using the visual analogue pain scale, DAS score, disability index scores and SF-36 (quality of life Index). The laboratory parameters used to evaluate the liver and renal functions did not show any significant changes that indicate the prescribed treatment is safe. Conclusion: Traditional Ashtavaidyan Ayurveda therapy is effective in reducing the skin lesions and improving functional ability in Vatarakta vis-à-vis psoriatic arthritis over a period of 42 days. Moreover, there was no adverse drug reaction recorded as well no significant change observed in liver and renal function tests.

Multidisciplinary Management of Psoriatic Arthritis: The Benefits of a Comprehensive Approach.

Psoriatic arthritis (PsA) is a lifelong disease associated with extra-articular manifestations and several comorbidities, as well as reduced quality of life and psychosocial burden. Diagnostic delay is associated with poorer outcomes, while a short delay between symptom onset and diagnosis is linked with preservation of function. Overcoming the barriers to early diagnosis of PsA is often difficult to achieve in the absence of well-characterized disease markers and/or a definitive screening procedure. Once a diagnosis is made, approaches to care may differ between countries, but a treat-to-target approach can be advocated, with constant patient follow-up visits and specialist monitoring and treatment of comorbidities. Adequately addressing all aspects of care can help to drive patient-centered care and encourage better adherence. Given the mounting number of therapeutic options and the complexity of management of PsA, the disease can be optimally treated by a multidisciplinary approach, and a collaborative approach between rheumatologists and dermatologists can be advocated. The need for multidisciplinary management is reinforced by consensus among experts. Patient satisfaction has emerged as a central indicator of quality, and patient-centered care must remain a central goal for the care of patients with PsA. Definition of a minimum set of standards for care will help to achieve the goal of multidisciplinary care for patients with PsA. Optimal care of PsA and greater collaboration among clinicians should always be encouraged so that patients can receive the best possible quality of care.Funding: Pfizer Italy.

Evolution of psoriatic arthritis study patient population characteristics in the era of biological treatments

ObjectivesPsoriatic arthritis is a chronic inflammatory disease that affects the musculoskeletal system. It can include arthritis, spondylitis, dactylitis and enthesitis, and is strongly associated with the presence of psoriasis. The...

Türkiye Romatoloji Derneği psoriyatik artrit ulusal tedavi önerileri

Türkiye Romatoloji Derneği psoriyatik artrit ulusal tedavi önerileri

Role of Methotrexate in the Management of Psoriatic Arthritis.

Methotrexate is known to be safe and efficacious in the management of rheumatoid arthritis and psoriasis and thus has been used for the management of psoriatic arthritis despite a lack of evidence to support efficacy in psoriatic arthritis from randomized controlled trials. Although the largest randomized trial to date did not support its use as a disease-modifying therapy, observational studies have supported its role, and current treatment recommendations approve of its use as a first-line agent for the management of psoriatic arthritis with predominant peripheral arthritis. The first treat-to-target study in psoriatic arthritis, comparing tight control with standard care, has shown the efficacy of methotrexate as monotherapy in the first 12weeks. This trial demonstrated the effectiveness of methotrexate with improvement in peripheral arthritis, skin and nail disease, enthesitis, and dactylitis over the course of 12weeks. There is conflicting evidence about the role of combination (concomitant methotrexate and anti-tumor necrosis factor) therapy. However, drug survival and immunogenicity of certain anti-tumor necrosis factors seem to be better when used in combination with methotrexate. This report reviews the available evidence on the efficacy and effectiveness of methotrexate in psoriatic arthritis and its role in treating psoriatic arthritis to target, as well as in combination with biologic agents. Ideally, randomized placebo-controlled clinical trials evaluating methotrexate (using subcutaneous route of delivery) would provide much-needed clarity on the role of methotrexate in the management of psoriatic arthritis; however, issues around using a placebo in patients with active psoriatic arthritis may render such a trial unfeasible.

E33 An experience of tight control in psoriatic arthritis management within the Belfast Trust

e33 An experience of tight control in psoriatic arthritis management within the Belfast Trust