Kembara Xtra - Medicine - Psoriatic Arthritis
ESSENTIAL DESCRIPTIONS a persistent, harmful, seronegative arthropathy that most commonly affects people with severe psoriasis Psoriatic arthritis (PsA) is a spondyloarthropathy that is seronegative and is characterized by enthesitis and inflammatory arthritis. ● There are five types of arthritis in PsA: - Five joints have asymmetric oligoarthritis. - Predominant osteoarthritis-like condition in the distal interphalangeal joint (DIP), which is linked to nail psoriasis - Symmetric polyarthritis: usually milder than rheumatoid arthritis (RA), but may be difficult to discern. - Spondyloarthritis is discontinuous and asymmetric, in contrast to ankylosing spondylitis (AS). - Arthritis mutilans: resorptive, destructive arthritis that causes "telescoping" or "opera-glass" digits. Psoriasis might not be severe. - The progression of arthritis and the severity of psoriasis are unrelated. – Iritis and other extra-articular characteristics are less frequent. – 40% to 60% of people may have debilitating joint illness. Periostitis and the "pencil-in-cup" deformity are two distinctive radiologic alterations. Anti-cyclic citrullinated peptide (anti-CCP) and rheumatoid factor (RF) antibodies are typically negative. Potentially positive HLA-B27. EPIDEMIOLOGY Peak onset age is between 30 and 50 years, and females outnumber men. In women, polyarthritis is more prevalent. 25% of people have spondylitis, which is more common in men. In most cases, psoriasis develops 12 years before arthritis does. 15% of people with psoriasis, mainly children, have arthritis first. Psoriasis and arthritis can appear at the same time. 2-3% of Americans with psoriasis, and 6-42% will also acquire PsA (1). Prevalence 1 to 2 cases per 1,000 people are present. Etiology and pathophysiology include the presence of matrix metalloproteases in synovial fluid, tumor necrosis factor (TNF-), interleukins 1 (IL-1), 6, 8, and 10, and CD4+/CD8+ T cells. Upregulation of osteoclast precursor cells Unknown. Environmental, genetic, and immunologic variables are likely complex. Genetics: 30–40% concordance in identical twins; 15–50% of PsA (spondylitis pattern) cases had HLA-B27, compared to 90% of AS cases; other HLA correlations with PsA include HLA-B7, HLA-B38, HLA-B39, and HLA–Cw6. RISK FACTORS: Obesity, Psoriasis, and PsA in the family DURATIONAL PREVENTION No proven preventative methods exist, and it is unclear if early psoriasis treatment can stop the development of Ps. A COMBINATION OF RELATED CONDITIONS Psoriasis DIAGNOSIS In patients with psoriasis already present, a history of inflammatory arthritis, dactylitis, or enthesitis aids in making the diagnosis. Differentiating PsA from other inflammatory arthropathies might be challenging. Screen patients for PsA using the Classification of Psoriatic Arthritis (CASPAR) criteria (91% sensitivity; 99% specificity). Joint, spine, or entheseal inflammation with fewer than three points in each of the following five categories: - Current psoriasis evidence and psoriasis in one's own or one's family (2 points) Onycholysis, pitting, and hyperkeratosis are all common features of psoriatic nail dystrophy (1 point). - Negative RF (1 point, ELISA preferable) - Dactylitis currently or in the past (1 point) - Plain radiographs of the hand or foot that show radiologic evidence of new bone development (apart from osteophyte production) (1 point) HISTORY The history and physical exam aid in making the PsA diagnosis. (Typically) long-standing psoriasis history Morning stiffness for more than 30 minutes in the hands, foot, or low back discomfort in the affected joints Swelling or redness in the peripheral joints Ankle or heel discomfort Dactylitis or uniform swelling of a whole digit Physical examination may reveal erythema, warmth, and edema overlaying affected peripheral joints. - Synovitis - Dactylitis - Tendon swelling (such as the Achilles tendon) and discomfort at the sites of insertion (such as the calcaneus) - Limited axial skeleton range of motion - Stress-related sacroiliac joint pain Well-defined pink to red erythematous plaques with a white silvery scale; common sites include the scalp, ears, trunk, buttocks, gluteal cleft, elbows and forearms, knees and legs, and palms and soles; dystrophic nails with pits, oil spots, crumbling, leukonychia, and red lunulae; and nails with pits and oil spots. DISTINCTIVE DIAGNOSIS Reactive arthritis, polyarticular gout, psoriasis, osteoarthritis, psoriasis and RA, and psoriasis DETECTION & INTERPRETATION OF DIAGNOSIS Initial examinations (lab, imaging) Serum RF, which is often negative Anti-CCP (generally unfavorable) Antinuclear antibodies, which are typically negative ESR and C-reactive protein may be high acute-phase reactants. Baseline radiographs of the afflicted joints show that 50–70% of patients with axial disease and 15% of patients with peripheral disease had HLA-B27. Plain radiographs can help in diagnosis and evaluation of joint damage, disease progression, and therapeutic response. Characteristic radiographic findings include centrally progressing marginal joint erosions (referred to as "pencil-incup" erosions) and juxta-articular new bone growth (periostitis). Tests in the Future & Special Considerations Radiographs taken later; frequency determined by severity Clinical diagnostic procedures and other diagnoses are typical. Interpretation of Tests Skin or synovium biopsies are not frequently necessary. GENERAL MEASURES/TREATY All illness phases benefit from physical treatment and/or occupational therapy. The degree of structural damage, the severity of the psoriasis, and the severity of joint pain all factor into treatment strategies for PsA. Disease-modifying antirheumatic medications (DMARDs) should be started in patients with moderate to severe arthritis to minimize or prevent joint deterioration and preserve joint integrity and function. Patients should also receive education about lifestyle changes such quitting smoking, losing weight, protecting their joints, engaging in physical activity, exercising, and learning stress management techniques in addition to pharmacotherapy. First Line: MEDICATION NSAIDs to manage moderate illness symptoms. Injections of glucocorticoids into the joints on occasion might be helpful. ● There are no organized NSAID trials for PsA. Use an NSAID dose to reduce minor irritation. The choice of an NSAID depends on the patient's preferences and ease of administration. Ibuprofen 400–800 mg PO TID–QID, naproxen 250–500 mg PO BID–TID, diclofenac 100–150 mg QD, and indomethacin 100–150 mg QD are a few examples of NSAIDs. ● A combination of two analgesics, NSAIDs, opioids, opioid-like medicines, and neuromodulators (antidepressants, anticonvulsants, and muscle relaxants) is just as effective as monotherapy. Next Line Leflunomide, methotrexate, and sulfasalazine are among the suggested DMARDs. The use of combined DMARD therapy is not backed by any data. Initial doses of DMARDs include the following: sulfasalazine (2 to 3 g/day PO divided in BID dosing), leflunomide (20 mg/day PO after a loading dose of 100 mg/day PO for three days), methotrexate (1 test dose of 2.5 to 5.0 mg PO to assess for significant bone marrow suppression and then 15 to 25 mg once weekly), and azathioprine (0.5 mg/kg/day, with a Avoid using systemic corticosteroids if you can (they may be useful temporarily for severe flares when using a biologic treatment). For patients who do not react to at least one standard DMARD or in patients with a poor prognosis, even if they have not failed a standard DMARD, biologic treatments, in particular anti-TNF-agents, are recommended. Anti-TNF-agent dosage schedules include: - Adalimumab 40 mg SC every two weeks - Infliximab 5 mg/kg at 0, 2, and 6 weeks, then every eight weeks following; - Certolizumab pegol 200 mg every two weeks; for maintenance dose, or 400 mg every four weeks; - Etanercept 50 mg SC weekly; - Golimumab 50 mg SC monthly; - Some anti-IL-17 medications are: - Ixekizumab 80 mg every two weeks (6) - Secukinumab 150 mg per week for the first four weeks, then monthly (6) - Brodalumab 210 mg SC 1 time every week from 0 to 2, then every 2 weeks. - Ustekinumab is being dosed at 45 or 90 mg (depending on weight) at 0, 4, and 12 weeks, and then every 12 weeks after that. IL-23 selective inhibitors include: Guselkumab 100 mg SC, given once every 0 and 4 weeks, followed by every 8 weeks. PDE4 inhibitors include the following: - Arimidex 30 mg PO BID Selective T-cell costimulation blockers include Abatacept, which is dosed at 125 mg once weekly SC or in accordance with body weight. JAK1 and JAK3 inhibitors include Tofacitinib citrate, which is dosed at 5 mg PO BID immediate release or 11 mg once daily extended release. Repeat IV infusions using the same weight-based dose following the initial IV infusion should be given q2 weeks, q4 weeks, and then q4 weeks later. The drugs mentioned above have FDA approval for PsA. Use of anti-TNF medications should be avoided in cases of active infection, such as TB and hepatitis B. Use of anti-TNF medications is contraindicated in patients who are receiving concurrent live vaccines, have congestive heart failure classified by the New York Heart Association as classes III or IV, have cancer, or have a history of demyelinating disease. Ustekinumab should not be administered to patients who are actively unwell, have mycobacterial or Salmonella infections, are receiving concurrent live vaccines, such as the bacillus Calmette-Guérin vaccine, or have a history of cancer. Considerations for Pregnancy Steer clear of teratogenic drugs like leflunomide and methotrexate while you're pregnant. Currently, Category B drugs include adalimumab, etanercept, golimumab, infliximab, ustekinumab, and certolizumab pegol, secukinumab. As Category C medications during pregnancy, apremilast, abatacept, tofacitinib citrate, ixekizumab, and guselkumab are all included. QUESTIONS FOR REFERENCE Dermatology and rheumatology SURGICAL AND OTHER PROCEDURE Joint replacement or fusion for advanced destruction CONTINUING CARE AFTERCARE RECOMMENDATIONS The metabolic syndrome, myocardial infarction, stroke, and psoriasis may all be related, according to epidemiologic studies. It is advised to keep your glucose, cholesterol, blood pressure, and weight under control. PROGNOSIS Prognosis is better than for RA (apart from those who develop arthritis mutilans), course is often insidious with persistent joint disease and recurring/remitting skin disease. Complications include disability and the psychosocial effects of PsA, such as anxiety and sadness.
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