Peripheral Joint Damage Research Articles

Pathogenesis of gout: Exploring more therapeutic target.

Gout is a chronic metabolic and immune disease, and its specific pathogenesis is still unclear. When the serum uric acid exceeds its saturation in the blood or tissue fluid, it is converted to monosodium urate crystals, which lead to acute arthritis of varying degrees, urinary stones, or irreversible peripheral joint damage, and in severe cases, impairment of vital organ function. Gout flare is a clinically significant state of acute inflammation in gout. The current treatment is mostly anti-inflammatory analgesics, which have numerous side effects with limited treatment methods. Gout pathogenesis involves many aspects. Therefore, exploring gout pathogenesis from multiple perspectives is conducive to identifying more therapeutic targets and providing safer and more effective alternative treatment options for patients with gout flare. Thus, this article is of great significance for further exploring the pathogenesis of gout. The author summarizes the pathogenesis of gout from four aspects: signaling pathways, inflammatory factors, intestinal flora, and programmed cell death, focusing on exploring more new therapeutic targets.

Risk factors for cervical instability in rheumatoid arthritis: a meta-analysis.

The aim of the study was to evaluate the risk factors for cervical instability in rheumatoid arthritis (RA). Computer searches were conducted in PubMed, Embase, Cochrane Library, the China National Knowledge Infrastructure (CNKI) database, the Wan Fang database, the Chinese Scientific Journal Databases (VIP) database, and the Chinese Biomedical Literature database (CBM) from their establishment until November 2022. A total of 8 articles were included in this study, including 1 cross-sectional study, 5 case-control studies, and 2 cohort study, including 3078 patients with RA. Meta-analysis results showed that: male sex (OR = 1.70, 95% CI: 1.19-2.42), course of disease (OR = 1.72, 95% CI: 1.29-2.28), long-term glucocorticosteroid use (OR = 2.84, 95% CI: 1.97-2.40), Steinbrocker staging (OR = 2.30, 95% CI: 1.61-3.28), disability at baseline (OR = 24.57, 95% CI: 5.51-109.60), peripheral joint destruction (OR = 2.24, 95% CI: 1.56-3.21), Steinbrocker stage I-IV progression to disability (OR = 20.08, 95% CI: 4.18-96.53), and previous joint surgery (OR = 1.54, 95% CI: 1.06-2.26) are the main risk factors for cervical instability in RA. There are many risk factors for cervical instability in RA. In clinical practice, special attention should be paid to patients who are male, have a longer course of disease, have long-term glucocorticosteroid use, have previous joint surgery, have peripheral joint damage, and develop disability in Steinbrocker stage I-IV. Attention should be paid to the high-risk groups mentioned above, and effective measures such as early screening and full monitoring should be taken to prevent the occurrence of cervical instability in RA.

Impact of hyperuricaemia on patients with psoriatic arthritis treated with secukinumab in the FUTURE 2–5 and MAXIMISE studies

ObjectivesPatients with psoriatic arthritis (PsA) are at a significantly increased risk of hyperuricaemia and development of gout, and those with hyperuricaemia have been found to respond poorly to PsA treatment...

P182 Real-world persistence and treatment patterns in psoriatic arthritis patients treated with anti-IL17 therapy: the PERFIL-17 study

Abstract Background/Aims Interleukin-17 inhibitors (anti-IL-17) have provided an additional treatment option in psoriatic arthritis (PsA). This study aims to describe the patient profile, treatment patterns and persistence in PsA patients treated with ixekizumab and secukinumab in a real-life setting. Methods A multicentre, retrospective study was conducted at 8 Spanish hospitals. Three cohorts of adult PsA patients, newly initiating treatment with an anti-IL-17A (secukinumab 150mg [SECU150], secukinumab 300mg [SECU300], ixekizumab [IXE]), between January 2019 and March 2020 were included. Data of patients exposed to anti-IL-17 drugs with a follow-up visit were collected until March 2021. Demographic and clinical characteristics, treatment patterns, and persistence were analysed descriptively. Continuous data were presented as mean (standard deviation [SD]) and categorical variables as frequencies with percentage. Persistence rates at 3/6/12 months were calculated. Results A total of 221 PsA patients were analysed (SECU150: 103 [46.6%], SECU300: 38 [17.2%] and IXE: 80 [36.2%]). Treatment patterns differed by clinical characteristics: SECU150 patients presented more moderate PsA and less peripheral joint damage, while SECU300 patients included a higher rate of enthesitis and active psoriasis. IXE patients showed a longer time since PsA diagnosis, with more frequent co-morbidities, joint damage and psoriasis diagnosed. 77.8% of patients were previously treated with csDMARDs in monotherapy and 72.9% with bDMARDs/tsDMARDs (93.8% IXE, 68.4% SECU300 and 58.3% SECU150). Mean number of previous bDMARDS/tsDMARDS were 2.4 (1.5), 1.7 (0.9) and 1.6 (1.0), respectively. Overall, persistence to anti-IL-17 treatments was found in 97.2%, 88.4% and 81.0% of patients at 3, 6 and 12 months, respectively, being 83.1% for SECU150, 64.5% for SECU300 and 86.4% for IXE at one year. The most frequent reason for discontinuation was lack of effectiveness (13.8%). Conclusion Most PsA patients treated with anti-IL-17 in Spain had a moderate to severe disease, high peripheral joint damage and skin involvement and had received at least 1 previous bDMARD/tsDMARD. More than 80% of patients with one year follow-up were persistent to anti-IL-17 treatments, observing the highest rate with IXE, followed by SECU150 and SECU300. Disclosure B. Ibañez: Consultancies; B.J.I. has received consulting fees from UCB, AMGEN, JANSSEN. Honoraria; B.J.I. has received honoraria from ABBVIE, LILLY, JANSSEN, NOVARTIS. Other; B.J.I. has received support for attending meetings and/or travel from NOVARTIS, UCB. C. Manteca: Other; C.F.M. has received support for attending meetings and/or travel from Inscripcion on line Congreso SER, EULAR. E. Rubio: None. E. Raya: None. A. Pérez-Linaza: None. R. Hernandez: Honoraria; R.H. has received honoraria from Lilly, Novartis, Janssen, Pfizer, Abbie. Grants/research support; R.H. has received support for the present manuscript from Lilly. Other; R.H. has received fee for expert testimony from Novartis, R.H. has received support for attending meetings and/or travel from NOVARTIS, UCB, R.H. has received fee for participation on a Data Safety Monitoring Board or Advisory Board from Novartis. S. Manrique-Arija: None. M. Núñez: Shareholder/stock ownership; M.N. is an employee and minor shareholder in Lilly. Grants/research support; M.N. has received support for the present manuscript from Lilly. S. Diaz: Shareholder/stock ownership; S.D. is an employee and minor shareholder in Lilly. Grants/research support; S.D. has received support for the present manuscript from Lilly. L. Trancho: Shareholder/stock ownership; L.T. is an employee and minor shareholder in Lilly. Grants/research support; L.T. has received support for the present manuscript from Lilly. R. García de Vicuña: Consultancies; R.G.D.V. has received consulting fees from Abbvie, Pfizer, Biogen, MSD. Honoraria; R.G.D.V. has received honoraria from Pfizer, Novartis, Sandoz. Grants/research support; R.G.D.V. has received funding for research from from Lilly, Novartis, Abbvie, Janssen, MSD, UCB. Other; R.G.D.V. has received support for attending meetings and/or travel from Abbvie, Pfizer, Novartis, MSD, Janssen, Lilly, UCB. A. Kiprianos (Non-author Presenter): Shareholder/stock ownership; A.P. is an employee and minor shareholder in Eli Lilly and Company.

Association between HLA-B27 and peripheral spondyloarthritis phenotype: results from the ASAS perSpA study

ObjectiveTo analyse the influence of HLA-B27 in the phenotypical expression of peripheral spondyloarthritis (pSpA).MethodThis is an observational cross-sectional study using data from the Assessment of SpondyloArthritis international Society perSpA registry,...

Plain Radiographic Instruments for Structural Damage in Peripheral Joints in Psoriatic Arthritis: A Report From the GRAPPA-OMERACT Working Group.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)-Outcome Measures in Rheumatology (OMERACT) Psoriatic Arthritis (PsA) Core Set working group is focused on the development of a core set of instruments used to assess the domains described in the 2016 PsA Core Domain Set. At the 2021 annual meeting, the group presented an update on the domain of structural damage. In this report, we discuss the steps taken to assess the domain match and feasibility of plain radiographic instruments in the assessment of structural damage in PsA.

Psoriatic arthritis with hyperuricemia: more peripheral, destructive, and challenging to treat

ObjectiveTo study the impact of hyperuricemia on clinical presentation, severity, and associated comorbidities of psoriatic arthritis (PsA).MethodsRetrospective bicentric case–control study performed in Strasbourg and Colmar, France, from 2009 to 2019. Patients with PsA (according to ICD-10 coding) and at least one available serum urate (SU) measurement were included. Demographic, comorbidities, clinical, and radiographic data were collected. Hyperuricemia was defined as SU level ≥ 360 µmol/L.ResultsWe included 242 patients: 73 (30.2%) had hyperuricemia and 15 (6.2%) met 2015 ACR/EULAR criteria for gout. On univariate analysis, as compared with normo-uricemic patients, hyperuricemic patients were more frequently male (72.6% vs 39.1%, p = 1.6 × 10−6) with higher body mass index (30.9 vs 28.7 kg/m2, p = 0.015) and more comorbidities (Charlson comorbidity index: 2.6 vs 1.8, p = 0.005). PsA started at an older age (47.5 vs 43 years, p = 0.016) was more polyarticular (56.2% vs 41.9%, p = 0.049) than axial (9.6% vs 22.8%, p = 0.019) and more destructive (52.8% vs 37.4%, p = 0.032). PsA patients with joint destruction more frequently had hyperuricemia than did others (37.6% vs 25.8%, p = 0.047). Multivariable analysis confirmed the association of hyperuricemic PsA with peripheral joint involvement (odds ratio 2.98; 95% confidence interval 1.15–7.75; p = 0.025) and less good response to treatment (0.35; 0.15–0.87; p = 0.024).ConclusionPatients with hyperuricemic PsA show poorer response to PsA treatment and have more peripheral and destructive joint damage than normo-uricemic patients.Key Points• Gout and psoriatic arthritis (PsA) can co-exist in the same patient.• Monosodium urate crystals might have a deleterious impact on PsA.• Hyperuricemic PsA is more polyarticular, less frequently axial, and more destructive than normo-uricemic PsA.• PsA with hyperuricemia should lead to more personalized medicine.

Relation of NSAIDs, DMARDs, and TNF Inhibitors for Ankylosing Spondylitis and Psoriatic Arthritis to Risk of Total Hip and Knee Arthroplasty.

Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) often affect the hip and/or knee. If effective, treatments might reduce risk of total hip or total knee arthroplasty (THA/TKA). We evaluated risk of THA/TKA related to use of medical therapies in AS/PsA. We conducted a nested case-control study using 1994-2018 data from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims, laboratory results, and enrollment records for commercial and Medicare Advantage enrollees. Among those with AS/PsA, THA/TKA cases were matched up to 4 controls by sex, age, AS/PsA diagnosis, diagnosis year, insurance type, obesity, and prior THA/TKA. We assessed AS/PsA treatment 6 months prior to THA/TKA, including disease-modifying antirheumatic drugs (DMARDs) and tumor necrosis factor inhibitors (TNFi), alone or in combination, stratified by nonsteroidal antiinflammatory drug (NSAID) use. We evaluated the relation of treatment to risk of THA/TKA using conditional logistical regression with adjustment for confounders. Among 16,748 adults with AS, there were 444 THA/TKA cases and 1613 matched controls. Among 34,512 adults with PsA, there were 1003 cases and 3793 controls. Adjusted ORs for treatment category and THA/TKA ranged from 0.60 to 1.92; however, none were statistically significant. Results were similarly null in several sensitivity analyses. Odds of THA/TKA were not reduced with any combinations of NSAIDs, DMARDs, or TNFi among persons with AS or PsA. Given current utilization patterns in this population of US adults with AS and PsA, these medical therapies did not appear to be associated with less end-stage peripheral joint damage.

Tumor necrosis factor inhibitors prevent structural damage in hips in ankylosing spondylitis-time to reconsider treatment guidelines? A case series and review of literature.

Tumor necrosis factor inhibitors (TNFi) are indicated to treat ankylosing spondylitis (AS), also termed radiographic axial spondyloarthritis (axSpA). The main indication for TNFi is symptom relief, and whether they retard spinal structural damage as assessed by radiography is debated. Hips are the most common "non-spinal" joints involved in AS patients leading to major incapacitation. No major treatment guidelines mention measures to prevent peripheral joint damage, especially hips, in individuals with AS. We present our experience of prevention of structural damage in hips by TNFi in 4 AS patients from our practice. We conducted a literature review looking for articles describing prevention of structural damage progression in hips by TNFi. Over a 10-year period, three out of four patients were treated with TNFi and had no progression in hip damage as assessed by imaging. Only one patient that withdrew the TNFi due to infectious complications developed rapid worsening and required hip arthroplasty. Our literature review showed multiple case series with similar results suggesting that use of TNFi in patients with AS may prevent structural damage and at least postpone a hip replacement at a young age. Based on our experience, as well as from the literature review, we believe that treatment guidelines in axSpA should recommend prompt institution of TNFi following identification of hip involvement in patients to prevent a major source of disability. Whether interleukin (IL)-17 inhibitors or targeted synthetic anti-rheumatic drugs have hip sparing effects in patients with AS should also be investigated. Key Points • Hip involvement in ankylosing spondylitis is a major source of disability. • TNFi prevent hip damage in ankylosing spondylitis. • Prompt institution of TNFi should follow suspicion of hip involvement in ankylosing spondylitis.

OP0057 SEX SPECIFIC DIFFERENCES IN EARLY PSORIATIC ARTHRITIS

Background:Although the prevalence of Psoriatic Arthritis (PsA) is the same in men and women, women experience a higher burden of disease (pain, disability, fatigue) (1).The persistent belief that women tend to over-report their symptoms compared to men may also contribute to under or delayed diagnosis in women. The clinical pattern of PsA also differs, with men presenting more commonly with peripheral and axial joint damage and women being affected more frequently by polyarthritis (2). Furthermore, most disease activity measures contain pain and quality of life measurement metrics that may perform differently by sex. As a result, this may affect the clinician’s perception of disease severity, influence management decisions and subsequently introduce sex bias in prescribing.Objectives:To assess sex-related differences in baseline demographics, disease characteristics and evolution over 1 year in patients with newly diagnosed PsA.Methods:Our study is embedded in the Dutch south-west Early Psoriatic Arthritis prospective cohort study. We described patient characteristics using simple descriptive analysis techniques. For the comparison across sexes and baseline and 1 year follow up, appropriate tests depending on the distribution were used.Results:273 men and 294 women with no significant differences in age and ethnicity were included. Women reported significantly longer duration of symptoms before diagnosis and significantly fewer of them were in paid employment at baseline. Oligoarthritis was the most common pattern of arthritis in both sexes. Polyarthritis and enthesitis were more prevalent in women who also presented at baseline a significantly higher tender joint count (Fig.1) than men but no difference in swollen joint count.Figure 1.Longitudinal evolution of TJC68, Pain, VAS global, BRAF for men and women in the first year of PsA.All composite indices (CPDAI, DAPSA, GRACE, MDA, Psoriatic ArthritiS Disease Activity Score) showed significantly worse results in women at baseline. Women also suffered more frequently from comorbid medical conditions, fatigue and anxiety, and reported more severe limitations in function and worse quality of life.At 12 months women, despite the improvement they made, reported significantly higher levels of pain compared to men. Although MDA rates increase over time for both sexes,(Fig.2), it remained significantly more prevalent among men (19.0% vs 11.1% at inclusion,p<0.05, and 58.1% vs 35.7%,p<0.00, at T12). DAPSA was significantly higher in women at both timepoints and a significantly higher percentage of men presented remission according to DAPSA score at 12 months.Figure 2.Longitudinal evolution of composite measures for men and women in the first year of PsA.Conclusion:After 1 year of follow-up women didn’t surpass their baseline disadvantages and despite the improvement, they still present higher disease activity, more pain and lower functional capacity than men. The nature of these findings may advocate a need for sex specific adjustment of treatment strategies and evaluation in psoriatic arthritis as sex-related difference in outcome persisted over time.

Osteophytes in the Joints of Patients with Ankylosing Spondylitis: Manifestation of Osteoarthritis or Underlying Disease?

Aim — to study the frequency of peripheral joint damage and the incidence of osteophytes in patients with ankylosing spondylitis. Materials and methods. 124 patients with ankylosing spondylitis corresponding to the international New York criteria of 1984 were examined; 84 men (67,7%). There are two groups of patients: patients aged under 40 years (n=61, men — 44 (72,1%) and over 40 years (n=63, men — 40 (63,5%). In the first group, the median age was 34 [29;38] years, in men — 34,5 [30;37,5] years, in women — 31 [27;38] year; in the second group — 50 [45;56] years, in men — 51,5 [46;54] year, in women — 48 [44;59] years. The activity of the disease was determined, and the results of radiography of the affected joints were evaluated. Results. Clinical and instrumental symptoms of arthritis at the time of study or in history had 82 (66,1%) of the 124 patients with ankylosing spondylitis. Among all patients 111 (89,5%) revealed osteophytes in the peripheral joints, of whom 72 (64,9%) patients had signs of arthritis. Patients with ankylosing spondylitis have both osteoresorption and osteoproliferation on the x-ray. Conclusion. Peripheral arthritis occurred in more than half of patients with ankylosing spondylitis and was associated with higher disease activity. Patients younger than 40 years of age are more likely to have asymmetric arthritis. Most patients had signs of osteoproliferation in the peripheral joints, and the defeat of large joints of the lower extremities prevails. In patients older than 40 years osteophytes are more often detected, more groups of joints are involved in the process, the joints of the hands and feet are affected.

The association between occupational-related mechanical stress and radiographic damage in psoriatic arthritis

ObjectiveTo assess the association between occupational-related mechanical factors and the severity of radiographic peripheral and axial joint damage in patients with longstanding Psoriatic Arthritis (PsA). MethodsPatients with longstanding PsA (disease duration≥10 years) were identified from a prospective longitudinal cohort. Using an occupation history questionnaire, patients were asked to report all paid employments since the age of 18. The key predictor variables included various occupational-related mechanical exposures. A job classification database was used to rate the level of exposure to various occupational physical activities. The outcomes were the extent of radiographic damage in the peripheral and axial joints, as measured by the modified Steinbrocker score (mSS), and the modified Stokes Ankylosing Spondylitis Spine Score (mSASSS). The association between the predictors and outcome variables was assessed by negative binomial regression models after adjusting for potential confounding variables. ResultsA total of 307 eligible patients were analyzed. In the multivariable analysis, exposure to prolonged repetitive hand movements (exp(β) 1.17 (95% 1.07, 1.28)) and occupations that required higher level of finger dexterity (exp(β) 1.27 (95% 1.09, 1.47)) were associated with a higher mSS. With regards to axial damage, none of the occupational exposures or workers abilities was associated with mSASSS. ConclusionHigh level of occupation-related mechanical stress is associated with increased radiographic peripheral joint damage among patients with longstanding PsA. This finding supports the potential role of micro-trauma in the pathogenesis of PsA.

The association between sonographic enthesitis and radiographic damage in psoriatic arthritis

BackgroundTo examine the association between sonographic enthesitis and the severity of radiographic features of damage in the peripheral and axial joints in psoriatic arthritis (PsA).MethodsA cross-sectional analysis was conducted in patients with PsA. The MAdrid Sonography Enthesitis Index (MASEI) scoring system was used to quantify the extent of sonographic entheseal abnormalities. Radiographic damage in the peripheral joints and spine was assessed by the modified Steinbrocker score (mSS), Modified New York Criteria for sacroiliitis, and the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The association between MASEI and the extent of radiographic damage was assessed using negative binomial and logistic regression. The results were expressed in terms of the regression coefficient estimates and their exponentiated values (eβ) or odds ratios (OR), and 95% confidence intervals (CI).ResultsTwo hundred and twenty three patients were analyzed; 58% were males, with mean ± SD age of 55.9 ± 12.9 years and PsA duration of 16.7 ± 12.4 years. Regression analyses yielded an association between higher MASEI scores (10 units increase) and peripheral joint damage including mSS (eβ = 1.42, 95% CI: 1.15, 1.72), joint ankylosis (OR = 1.93, 95% CI: 1.37, 2.72), arthritis mutilans (OR = 1.77, 95% CI: 1.23, 2.54), and periostitis (OR = 1.41, 95% CI: 1.08, 1.84). Similarly, an association was found between higher MASEI scores and axial damage as measured by mSASSS (eβ = 2.18, 95% CI: 1.16, 4.09) and sacroiliitis (OR = 1.33, 95% CI: 1.03, 1.72).ConclusionsThe severity of sonographic enthesitis is a potential marker of radiographic peripheral and axial joint damage in PsA.

Global epidemiology of gout: prevalence, incidence and risk factors.

Gout is a crystal-deposition disease that results from chronic elevation of uric acid levels above the saturation point for monosodium urate (MSU) crystal formation. Initial presentation is mainly severely painful episodes of peripheral joint synovitis (acute self-limiting 'attacks') but joint damage and deformity, chronic usage-related pain and subcutaneous tophus deposition can eventually develop. The global burden of gout is substantial and seems to be increasing in many parts of the world over the past 50 years. However, methodological differences impair the comparison of gout epidemiology between countries. In this comprehensive Review, data from epidemiological studies from diverse regions of the world are synthesized to depict the geographic variation in gout prevalence and incidence. Key advances in the understanding of factors associated with increased risk of gout are also summarized. The collected data indicate that the distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher burden of gout than developing countries, and seem to have increasing prevalence and incidence of the disease. Some ethnic groups are particularly susceptible to gout, supporting the importance of genetic predisposition. Socioeconomic and dietary factors, as well as comorbidities and medications that can influence uric acid levels and/or facilitate MSU crystal formation, are also important in determining the risk of developing clinically evident gout.

Progress of biological agents on psoriatic arthritis.

Psoriatic arthritis (PsA) is an inflammatory arthritis, characterized by mild arthralgia to severe joint deformities. Long term management of these diseases with nonsteroidal anti-inflammatory drugs (NSAIDs) and diseasemodifying antirheumatic drugs (DMARDs) is limited due to lack of efficacy and potential organ toxicity. Recently, the approval of injectable biologics, such as T cell inhibitors and TNF-α antagonist, has changed the treatment of moderateto- severe psoriasis and PsA. Unlike NSAIDs and DMARDs, TNF-α antagonists not only provide unambiguous benefits for the skin and joints, but also prevent the progression of structural damage in peripheral joints. Biological agents in the treatment of PsA have broad prospects. More and more biological agents are being developed for the treatment of PsA. In the current review, we will discuss the progress of biological agents on PsA.

Biological therapies for spondyloarthritis.

Biological therapies and new imaging techniques have changed the therapeutic and diagnostic approach to spondyloarthritis. In patients with axial spondyloarthritis, tumor necrosis factor α (TNFα) inhibitor treatment is currently the only effective therapy in patients for whom conventional therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) has failed. TNFα inhibitor treatment is more effective in preventing articular damage in peripheral joints than in axial ones. It is important to treat patients at an early stage of disease to reduce disease progression; moreover it is necessary to identify causes of therapy inefficacy in preventing joint damage in the axial subset.

Long-term follow-up of the cervical spine with conventional radiographs in patients with rheumatoid arthritis

Objectives: To investigate the prevalence of cervical spine damage due to rheumatoid arthritis (RA) in the long term and to investigate which disease-specific factors are related to this damage.Method: Patients with early RA from the Nijmegen inception cohort with 6 to 12 years of follow-up were included. Conventional radiographs of the cervical spine were obtained at baseline, 3, 6, 9, and 12 years and scored for erosions of C1 and C2, anterior atlantoaxial subluxation (AAS) and atlantoaxial impaction (AAI). Disease-specific factors, such as disease activity, functionality, and peripheral joint damage, at baseline, 3, 6, and 9 years, were compared between patients with and without cervical spine damage at 9 years.Results: A total of 196 patients were included, of whom 134 had radiographs at 9 years. Cervical spine damage was present in 16% (22/134) of the patients at 9 years. During the total 12 years of follow-up, AAS and erosions of C2 were observed most frequently. Erosions of C1 and AAI were very rare. Patients with cervical spine damage at 9 years had a higher number of erosions of the peripheral joints and failed more disease-modifying anti-rheumatic drugs (DMARDs) at 3, 6, and 9 years. Patients without peripheral erosive disease at 3 years were unlikely to develop cervical spine damage within 9 years of disease duration.Conclusions: The prevalence of cervical spine damage due to RA was 16% at 9 years. Patients without peripheral erosive disease at 3 years were unlikely to develop cervical spine damage at 9 years.

Clinical Differences between Men and Women with Psoriatic Arthritis: Relevance of the Analysis of Genes and Polymorphisms in the Major Histocompatibility Complex Region and of the Age at Onset of Psoriasis

It has been shown that males with spondyloarthritis tend to suffer from more severe spinal disease while females are more likely to have peripheral joint involvement. Nevertheless, gender-related differences have not been thoroughly explored in psoriatic arthritis (PsA). In PsA, males accumulate more peripheral and axial joint damage compared to women. However, it is not clear whether these findings are secondary to differences in occupational physical activity, hormonal changes, or other factors. The present study analyzed the differences in clinical expression of PsA between men and women. We have also evaluated the possible existence of gender-linked differences in the distribution of genes and polymorphisms within the major histocompatibility complex and whether patients' age at the onset of psoriasis established any differences in these aspects. Women suffered more polyarthritis, greater functional impairment, and a larger number of swollen joints during followup. We appreciated a differential expression of certain MHC genes according to gender and age at onset of psoriasis. Our results point to the need to include patient's age at the onset of psoriasis and gender as key stratification elements in future studies of genetic associations in PsA.

Pharmacoeconomic Issues in Psoriatic Arthritis

Therapies for psoriatic arthritis were inadequate until a short time ago. Nonsteroidal antiinflammatory drugs are helpful in relieving symptoms but do not prevent joint damage. Traditional disease-modifying antirheumatic drugs are used to control symptoms, but there is no evidence that they prevent or significantly slow the progression of structural damage in peripheral joints. The introduction of tumor necrosis factor-α (TNF-α) blocking agents has opened new horizons. These drugs lessen signs and symptoms of inflammation, enhance functional capacity and quality of life, and inhibit structural joint damage. On the other hand, TNF-α blockers are very costly and not easily available to all patients, whether they rely on a national health system or on private insurance. Pharmacoeconomic studies on these drugs so far have shown that they are cost-effective on both the musculoskeletal and skin manifestations of psoriatic disease, offering good value for money.

Classification and clinical assessment

There are at least nine classification criteria for psoriatic arthritis (PsA) that have been proposed and used in clinical studies. With the exception of the ESSG and Bennett rules, all of the other criteria sets have a good performance in identifying PsA patients. As the CASPAR criteria are based on a robust study methodology, they are considered the current reference standard. However, if there seems to be no doubt that they are very good to classify PsA patients (very high specificity), they might be not sensitive enough to diagnose patients with unknown early PsA. The vast clinical heterogeneity of PsA makes its assessment very challenging. Peripheral joint involvement is measured by 78/76 joint counts, spine involvement by the instruments used for ankylosing spondylitis (AS), dactylitis by involved digit count or by the Leeds dactylitis index, enthesitis by the number of affected entheses (several indices available) and psoriasis by the Psoriasis Area and Severity Index (PASI). Peripheral joint damage can be assessed by a modified van der Heijde-Sharp scoring system and axial damage by the methods used for AS or by the Psoriatic Arthritis Spondylitis Radiology Index (PASRI). As in other arthritides, global evaluation of disease activity and severity by patient and physician and assessment of disability and quality of life are widely used. Finally, composite indices that capture several clinical manifestations of PsA have been proposed and a new instrument, the Psoriatic ARthritis Disease Activity Score (PASDAS), is currently being developed.