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| __NOTOC__ | | __NOTOC__ |
| {{SI}}
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| {{CMG}}; {{CK}} | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| ==Overview==
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| ==Historical Perspective==
| | {{Psoriatic arthritis}} |
| *[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
| | {{CMG}}; {{AE}} {{CK}} |
| *In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
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| *In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
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| ==Classification==
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| *[Disease name] may be classified according to [classification method] into [number] subtypes/groups:
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| :*[group1]
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| :*[group2]
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| :*[group3]
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| *Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
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|
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| ==Pathophysiology==
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| *The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
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| *The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
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| *On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
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| *On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
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| ==Clinical Features==
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| ==Differentiating psoriatic arthritis from other Diseases== | | ==[[Psoriatic arthritis overview|Overview]]== |
| *Psoriatic arthritis must be differentiated from other arthritides including rheumatoid arthritis, reactive arthritis, ankylosing spondylitis, arthritis associated with inflammatory bowel disease, osteoarthritis, and gout.<ref name="pmid15708931">{{cite journal |vauthors=Helliwell PS, Taylor WJ |title=Classification and diagnostic criteria for psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=64 Suppl 2 |issue= |pages=ii3–8 |date=March 2005 |pmid=15708931 |pmc=1766878 |doi=10.1136/ard.2004.032318 |url=}}</ref><ref name="pmid5562018">{{cite journal |vauthors=McEwen C, DiTata D, Lingg C, Porini A, Good A, Rankin T |title=Ankylosing spondylitis and spondylitis accompanying ulcerative colitis, regional enteritis, psoriasis and Reiter's disease. A comparative study |journal=Arthritis Rheum. |volume=14 |issue=3 |pages=291–318 |date=1971 |pmid=5562018 |doi= |url=}}</ref><ref name="pmid9640127">{{cite journal |vauthors=Helliwell PS, Hickling P, Wright V |title=Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis? |journal=Ann. Rheum. Dis. |volume=57 |issue=3 |pages=135–40 |date=March 1998 |pmid=9640127 |pmc=1752543 |doi= |url=}}</ref><ref name="pmid4604133">{{cite journal |vauthors=Moll JM, Haslock I, Macrae IF, Wright V |title=Associations between ankylosing spondylitis, psoriatic arthritis, Reiter's disease, the intestinal arthropathies, and Behcet's syndrome |journal=Medicine (Baltimore) |volume=53 |issue=5 |pages=343–64 |date=September 1974 |pmid=4604133 |doi= |url=}}</ref>
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| <small>
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| {| class="wikitable"
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| ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Arthritis Type
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| ! colspan="7" align="center" style="background:#4479BA; color: #FFFFFF;" ! + |Clinical Features
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| ! colspan="4" align="center" style="background:#4479BA; color: #FFFFFF;" ! + |Body Distribution
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| ! colspan="4" align="center" style="background:#4479BA; color: #FFFFFF;" ! + |Key Signs
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| ! colspan="4" align="center" style="background:#4479BA; color: #FFFFFF;" ! + |Laboratory Abnormalities
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| |-
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| |'''History of Psoriasis'''
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| |'''Symmetric [[joint]] involvement'''
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| |'''Asymmetric [[joint]] involvement'''
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| |[[Enthesopathy|'''Enthesopathy''']]
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| |'''[[Dactylitis]]'''
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| |'''[[Nail (anatomy)|Nail]] [[Dystrophy]]'''
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| |'''[[Human Immunodeficiency Virus (HIV)|Human immunodeficiency virus]] association'''
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| |'''[[Upper extremity]]-hands'''
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| |'''[[Lower extremity]]'''
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| |'''[[Sacroiliac joint|Sacroiliac joints]]'''
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| |'''[[Spine]]'''
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| |'''[[Osteopenia]]'''
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| |'''[[Joint]] Space'''
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| |'''[[Ankylosis]]'''
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| |'''[[Periostitis]]'''
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| |'''[[Soft tissue]] swelling'''
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| |'''[[ESR]]'''
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| |'''[[Rheumatoid factor]] ([[Rheumatoid factor|RF]])'''
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| |'''[[HLA-B27]]'''
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| |-
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| |'''[[Psoriatic arthritis]]'''
| |
| | +
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| | +
| |
| | ++
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| | +
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| | +
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| | +
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| | +
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| | +++ ([[Distal interphalangeal joints|DIP]]/[[Proximal interphalangeal joints|PIP]]) | |
| | +++
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| | ++ (Unilateral)
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| | ++
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| | -
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| | ++ (Widening)
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| | ++
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| | +++ (Fluffy)
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| | ++
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| | +
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| | -
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| |30-75%
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| |-
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| |'''[[Rheumatoid arthritis]]'''
| |
| | -
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| | ++
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| | +
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| | -
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| | -
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| | -
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| | -
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| | +++
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| ([[MCP joints|MCP]]/[[wrist]])
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| | +++
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| | + (Unilateral)
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| | ++([[Cervical spine|Cervical]])
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| | +++
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| | +++ (Narrowing)
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| | +
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| | + (Linear)
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| | +++
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| | +++
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| | +++
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| |6-8%
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| |-
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| |'''[[Ankylosing spondylitis]]'''
| |
| | -
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| | +++
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| | -
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| | +
| |
| | -
| |
| | -
| |
| | -
| |
| | +
| |
| | +
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| | +++ (Bilateral)
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| | +++
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| | +++
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| | ++ (Narrowing)
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| | +++
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| | +++ (Fluffy)
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| | +
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| | +++
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| | -
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| |90%
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| |-
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| |'''[[Reactive arthritis]] ([[Reiter's syndrome]])'''
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| | -
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| | +++
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| | -
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| | +
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| | +
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| | -
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| | -
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| | ++
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| | +++
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| | ++ (Unilateral)
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| | +
| |
| | +
| |
| | + (Narrowing)
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| | -
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| | +++ (Fluffy)
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| | ++
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| | ++
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| | -
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| |75%
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| |}
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| | ==[[Psoriatic arthritis historical perspective|Historical Perspective]]== |
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| Key:+ : Infrequently present, ++ : Frequently present, +++ : Always present, - : Absent
| | ==[[Psoriatic arthritis classification|Classification]]== |
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| ==Epidemiology and Demographics== | | ==[[Psoriatic arthritis pathophysiology|Pathophysiology]]== |
| * The [[prevalence]] of psoriatic arthritis in general population ranges from 6,000 - 25,000 cases per 100,000 individuals in United states.<ref name="pmid16198775">{{cite journal |vauthors=Gelfand JM, Gladman DD, Mease PJ, Smith N, Margolis DJ, Nijsten T, Stern RS, Feldman SR, Rolstad T |title=Epidemiology of psoriatic arthritis in the population of the United States |journal=J. Am. Acad. Dermatol. |volume=53 |issue=4 |pages=573 |date=October 2005 |pmid=16198775 |doi=10.1016/j.jaad.2005.03.046 |url=}}</ref>
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| * The prevalence of psoriatic arthritis ranges in genreal population from 5,000 - 21,000 cases per 100,000 individuals in Europe.<ref name="pmid20476864">{{cite journal |vauthors=Hanova P, Pavelka K, Holcatova I, Pikhart H |title=Incidence and prevalence of psoriatic arthritis, ankylosing spondylitis, and reactive arthritis in the first descriptive population-based study in the Czech Republic |journal=Scand. J. Rheumatol. |volume=39 |issue=4 |pages=310–7 |date=August 2010 |pmid=20476864 |doi=10.3109/03009740903544212 |url=}}</ref>
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| * The [[prevalence]] of psoriatic arthritis among psoriasis patients is 11,000 per 100,000 individuals.
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| * The [[incidence]] of psoriatic arthritis is 3.6-6 per 100,000 individuals.<ref name="pmid20476864">{{cite journal |vauthors=Hanova P, Pavelka K, Holcatova I, Pikhart H |title=Incidence and prevalence of psoriatic arthritis, ankylosing spondylitis, and reactive arthritis in the first descriptive population-based study in the Czech Republic |journal=Scand. J. Rheumatol. |volume=39 |issue=4 |pages=310–7 |date=August 2010 |pmid=20476864 |doi=10.3109/03009740903544212 |url=}}</ref>
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| ===Age===
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| * Psoriatic arthritis may commonly occur in age groups 40-50 yrs with mean age at diagnosis is 40.7 years.<ref name="pmid10813295">{{cite journal |vauthors=Shbeeb M, Uramoto KM, Gibson LE, O'Fallon WM, Gabriel SE |title=The epidemiology of psoriatic arthritis in Olmsted County, Minnesota, USA, 1982-1991 |journal=J. Rheumatol. |volume=27 |issue=5 |pages=1247–50 |date=May 2000 |pmid=10813295 |doi= |url=}}</ref>
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| ===Gender===
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| * In general, there is no gender predilection to psoriatic arthritis.<ref name="pmid4715537">{{cite journal |vauthors=Moll JM, Wright V |title=Familial occurrence of psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=32 |issue=3 |pages=181–201 |date=May 1973 |pmid=4715537 |pmc=1006078 |doi= |url=}}</ref>
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| ===Race=== | | ==[[Psoriatic arthritis causes|Causes]]== |
| * There is insufficient data to support racial dominance of psoriatic arthritis.
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| ==Risk Factors== | | ==[[Psoriatic arthritis differential diagnosis|Differentiating Psoriatic arthritis from Other Diseases]]== |
| *Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
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|
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| == Natural History, Complications and Prognosis==
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| *The majority of patients with [disease name] remain asymptomatic for [duration/years].
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| *Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
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| *If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
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| *Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
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| *Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
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|
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| == Diagnosis ==
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| ===Diagnostic Criteria===
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| *The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
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| :*[criterion 1]
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| :*[criterion 2]
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| :*[criterion 3]
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| :*[criterion 4]
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|
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| === Symptoms ===
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| *[Disease name] is usually asymptomatic.
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| *Symptoms of [disease name] may include the following:
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| :*[symptom 1]
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| :*[symptom 2]
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| :*[symptom 3]
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| :*[symptom 4]
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| :*[symptom 5]
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| :*[symptom 6]
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|
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| === Physical Examination ===
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| *Patients with [disease name] usually appear [general appearance].
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| *Physical examination may be remarkable for:
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| :*[finding 1]
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| :*[finding 2]
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| :*[finding 3]
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| :*[finding 4]
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| :*[finding 5]
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| :*[finding 6]
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|
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| === Laboratory Findings ===
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| *There are no specific [[Medical laboratory|laboratory]] findings associated with [[Psoriatic arthritis (patient information)|psoriatic arthritis]] and most the tests are non-specific.
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| *However, there are certain [[Medical laboratory|laboratory]] tests that can check for markers of [[inflammation]] and to exclude other [[Disease|diseases]]. These include:<ref name="pmid17828345">{{cite journal |vauthors=Punzi L, Podswiadek M, Oliviero F, Lonigro A, Modesti V, Ramonda R, Todesco S |title=Laboratory findings in psoriatic arthritis |journal=Reumatismo |volume=59 Suppl 1 |issue= |pages=52–5 |date=2007 |pmid=17828345 |doi= |url=}}</ref>
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| ** [[Complete blood count|CBC]] with differential count
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| *** [[Leukocytosis]]
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| *** [[Anemia|Anaemia]]
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| ** Elevated [[Erythrocyte sedimentation rate|ESR]]
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| ** Elevated [[C-reactive protein|CRP]] (C- reactive protein)
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| ** [[Autoantibody|Autoantibodies]]: The following [[Autoantibody|autoantibodies]] may be found in patients with [[Psoriatic arthritis (patient information)|psoriatic arthritis]].<ref name="pmid15834057">{{cite journal |vauthors=Johnson SR, Schentag CT, Gladman DD |title=Autoantibodies in biological agent naive patients with psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=64 |issue=5 |pages=770–2 |date=May 2005 |pmid=15834057 |pmc=1755477 |doi=10.1136/ard.2004.031286 |url=}}</ref>
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| *** [[Rheumatoid factor]]
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| *** [[Antinuclear antibodies|ANA]] ([[Antinuclear antibodies]])
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| *** Anti-citrullinated peptide antibodies (ACPA)
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| ** Genetic markers:<ref name="pmid23916976">{{cite journal |vauthors=Chandran V, Bull SB, Pellett FJ, Ayearst R, Rahman P, Gladman DD |title=Human leukocyte antigen alleles and susceptibility to psoriatic arthritis |journal=Hum. Immunol. |volume=74 |issue=10 |pages=1333–8 |date=October 2013 |pmid=23916976 |doi=10.1016/j.humimm.2013.07.014 |url=}}</ref><ref name="pmid21900282">{{cite journal |vauthors=Eder L, Chandran V, Pellet F, Shanmugarajah S, Rosen CF, Bull SB, Gladman DD |title=Human leucocyte antigen risk alleles for psoriatic arthritis among patients with psoriasis |journal=Ann. Rheum. Dis. |volume=71 |issue=1 |pages=50–5 |date=January 2012 |pmid=21900282 |doi=10.1136/ard.2011.155044 |url=}}</ref>
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| *** [[HLA-B27]]
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| *** [[HLA-C]]*06
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| ** [[Synovial fluid]] analysis: Elevated [[White blood cells|WBC]] count suggestive of [[inflammation]].
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| ===Imaging Findings=== | | ==[[Psoriatic arthritis epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[X-rays|X-ray]] of digits:<ref name="pmid25231177">{{cite journal |vauthors=McGonagle D, Hermann KG, Tan AL |title=Differentiation between osteoarthritis and psoriatic arthritis: implications for pathogenesis and treatment in the biologic therapy era |journal=Rheumatology (Oxford) |volume=54 |issue=1 |pages=29–38 |date=January 2015 |pmid=25231177 |pmc=4269795 |doi=10.1093/rheumatology/keu328 |url=}}</ref><ref name="pmid16126794">{{cite journal |vauthors=Siannis F, Farewell VT, Cook RJ, Schentag CT, Gladman DD |title=Clinical and radiological damage in psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=65 |issue=4 |pages=478–81 |date=April 2006 |pmid=16126794 |pmc=1798082 |doi=10.1136/ard.2005.039826 |url=}}</ref><ref name="pmid23430715">{{cite journal |vauthors=Haddad A, Chandran V |title=Arthritis mutilans |journal=Curr Rheumatol Rep |volume=15 |issue=4 |pages=321 |year=2013 |pmid=23430715 |doi=10.1007/s11926-013-0321-7 |url=}}</ref>
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| ** Bone destructive changes including formation of subchondral cyst and erosions
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| ** Fluffy periostitis
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| ** [[Ankylosis]]
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| ** [[Phalanx bones|Phalangeal]] tuft [[acroosteolysis]]
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| ** New [[bone]] formation: Perisoteal and endosteal [[bone]] formation may result in increased [[bone density]] of an entire phalanx resulting in so called ivory phalanx.
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| ** Pencil-in-cup deformity (osteolytic lesions) usually involving [[Interphalangeal articulations of hand|DIP joints]] but also affects [[Interphalangeal articulations of hand|PIP joints]]
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| ** [[Osteolysis]] and [[ankylosis]] both coexists in the same [[Joint|joints]] of [[Hand|hands]] and [[foot]]
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| ** [[Enthesopathy|Enthesitis]]
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| ** [[Dactylitis]] (sausage digit)
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| ** Gross finger [[deformity]]
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| ** [[Arthritis]] mutilans: It may lead to "telescoping of fingers" caused by marked bony resorption and the subsequent collapse of soft tissue
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| ** Asymmetrical [[sacroiliitis]]
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| ** [[Spondylitis]]: Asymmetric paravertebral ossifications and relative sparing of the facet joints
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| [[File:Psoriatic-arthritis of hands.jpg|centre|thumb|Psoriatic-arthritis of hands showing pencil-in-cup deformity - By Case courtesy of Dr Jeremy Jones, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/8798">rID: 8798</a>]]
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| * MRI: MRI may reveal the following findings:<ref name="pmid20966327">{{cite journal |vauthors=Spira D, Kötter I, Henes J, Kümmerle-Deschner J, Schulze M, Boss A, Horger M |title=MRI findings in psoriatic arthritis of the hands |journal=AJR Am J Roentgenol |volume=195 |issue=5 |pages=1187–93 |date=November 2010 |pmid=20966327 |doi=10.2214/AJR.10.4281 |url=}}</ref>
| | ==[[Psoriatic arthritis risk factors|Risk Factors]]== |
| ** [[enthesitis]]
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| ** [[Periostitis]]
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| ** Joint erosions
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| ** Synovitis (articular or flexor tendon sheath)
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| ** Ankylosis
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| ** Bone marrow edema
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| * Ulrasonography: Ultrasonography may reveal following findings.<ref name="pmid10451072">{{cite journal |vauthors=Kane D, Greaney T, Bresnihan B, Gibney R, FitzGerald O |title=Ultrasonography in the diagnosis and management of psoriatic dactylitis |journal=J. Rheumatol. |volume=26 |issue=8 |pages=1746–51 |date=August 1999 |pmid=10451072 |doi= |url=}}</ref>
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| ** Joint effusions and widening of joint space
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| ** Synovitis (articular and flexor tenosynovitis)
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| ** Dactylitis
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| ** Thickening of the joint capsule
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|
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| === Other Diagnostic Studies === | | ==[[Psoriatic arthritis screening|Screening]]== |
| * [[Bone mineral density]] (BMD) testing: [[Bone density]] may be decreased in [[psoriatic arthritis]] resulting in [[osteoporosis]] and increased risk for [[Bone fracture|fractures]]. <ref name="pmid11196516">{{cite journal |vauthors=Frediani B, Allegri A, Falsetti P, Storri L, Bisogno S, Baldi F, Filipponi P, Marcolongo R |title=Bone mineral density in patients with psoriatic arthritis |journal=J. Rheumatol. |volume=28 |issue=1 |pages=138–43 |date=January 2001 |pmid=11196516 |doi= |url=}}</ref>
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| == Treatment == | | ==[[Psoriatic arthritis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| === Medical Therapy ===
| |
| * Medical therapy for [[psoriatic arthritis]] is according to the guidelines proposed by
| |
| ** European League Against Rheumatism (EULAR): Guidelines were first proposed in 2012 and they were updated in 2015.<ref name="pmid26644232">{{cite journal |vauthors=Gossec L, Smolen JS, Ramiro S, de Wit M, Cutolo M, Dougados M, Emery P, Landewé R, Oliver S, Aletaha D, Betteridge N, Braun J, Burmester G, Cañete JD, Damjanov N, FitzGerald O, Haglund E, Helliwell P, Kvien TK, Lories R, Luger T, Maccarone M, Marzo-Ortega H, McGonagle D, McInnes IB, Olivieri I, Pavelka K, Schett G, Sieper J, van den Bosch F, Veale DJ, Wollenhaupt J, Zink A, van der Heijde D |title=European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update |journal=Ann. Rheum. Dis. |volume=75 |issue=3 |pages=499–510 |date=March 2016 |pmid=26644232 |doi=10.1136/annrheumdis-2015-208337 |url=}}</ref><ref name="pmid21953336">{{cite journal |vauthors=Gossec L, Smolen JS, Gaujoux-Viala C, Ash Z, Marzo-Ortega H, van der Heijde D, FitzGerald O, Aletaha D, Balint P, Boumpas D, Braun J, Breedveld FC, Burmester G, Cañete JD, de Wit M, Dagfinrud H, de Vlam K, Dougados M, Helliwell P, Kavanaugh A, Kvien TK, Landewé R, Luger T, Maccarone M, McGonagle D, McHugh N, McInnes IB, Ritchlin C, Sieper J, Tak PP, Valesini G, Vencovsky J, Winthrop KL, Zink A, Emery P |title=European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies |journal=Ann. Rheum. Dis. |volume=71 |issue=1 |pages=4–12 |date=January 2012 |pmid=21953336 |doi=10.1136/annrheumdis-2011-200350 |url=}}</ref>
| |
| ** Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)<ref name="pmid18952643">{{cite journal |vauthors=Ritchlin CT, Kavanaugh A, Gladman DD, Mease PJ, Helliwell P, Boehncke WH, de Vlam K, Fiorentino D, Fitzgerald O, Gottlieb AB, McHugh NJ, Nash P, Qureshi AA, Soriano ER, Taylor WJ |title=Treatment recommendations for psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=68 |issue=9 |pages=1387–94 |date=September 2009 |pmid=18952643 |pmc=2719080 |doi=10.1136/ard.2008.094946 |url=}}</ref>
| |
| ** American College of Rheumatology (ACR)
| |
| ** National Psoriasis Foundation (NPF)
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| ** American Academy of Dermatology (AAD) Psoriasis Guidelines of Care<ref name="pmid21306785">{{cite journal |vauthors=Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R |title=Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions |journal=J. Am. Acad. Dermatol. |volume=65 |issue=1 |pages=137–74 |date=July 2011 |pmid=21306785 |doi=10.1016/j.jaad.2010.11.055 |url=}}</ref>
| |
| ** British Society of Rheumatology (BSR)<ref name="pmid23887065">{{cite journal |vauthors=Coates LC, Tillett W, Chandler D, Helliwell PS, Korendowych E, Kyle S, McInnes IB, Oliver S, Ormerod A, Smith C, Symmons D, Waldron N, McHugh NJ |title=The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics |journal=Rheumatology (Oxford) |volume=52 |issue=10 |pages=1754–7 |date=October 2013 |pmid=23887065 |doi=10.1093/rheumatology/ket187 |url=}}</ref>
| |
| * Pharmacologic therapy for [[psoriatic arthritis]] include, [[Non-steroidal anti-inflammatory drug|non-steroidal anti-inflammatory drugs]] ([[Non-steroidal anti-inflammatory drug|NSAID]]<nowiki/>s), conventional synthetic [[Disease-modifying antirheumatic drug|DMARDs]] (eg, [[methotrexate]], [[sulfasalazine]], [[Cyclosporine|cyclosporin A]], [[leflunomide]]), biologic[[Disease-modifying antirheumatic drug|DMARD]]<nowiki/>s<nowiki/> including, [[TNF inhibitor|TNF inhibitors]] (eg, [[etanercept]], [[infliximab]], [[adalimumab]], [[golimumab]]), [[Phosphodiesterase inhibitors|phosphodiesterase (PDE) inhibitors]] (eg, [[apremilast]]), interleukin(IL) inhibitors (eg, [[secukinumab]], [[ixekizumab]], [[abatacept]]) and [[Joint|intraarticular]] [[Glucocorticoids|glucocorticoid]] injections.
| |
| * '''Peripheral [[arthritis]]''':
| |
| ** '''Mild disease''': [[Non-steroidal anti-inflammatory drug|Nonsteroidal antiinflammatory drugs]] ([[Non-steroidal anti-inflammatory drug|NSAID]]<nowiki/>s) are the most commonly used drugs for the management of mild active [[psoriatic arthritis]].<ref name="pmid15708943">{{cite journal |vauthors=Nash P, Clegg DO |title=Psoriatic arthritis therapy: NSAIDs and traditional DMARDs |journal=Ann. Rheum. Dis. |volume=64 Suppl 2 |issue= |pages=ii74–7 |date=March 2005 |pmid=15708943 |pmc=1766880 |doi=10.1136/ard.2004.030783 |url=}}</ref><ref name="pmid11296544">{{cite journal |vauthors=Sarzi-Puttini P, Santandrea S, Boccassini L, Panni B, Caruso I |title=The role of NSAIDs in psoriatic arthritis: evidence from a controlled study with nimesulide |journal=Clin. Exp. Rheumatol. |volume=19 |issue=1 Suppl 22 |pages=S17–20 |date=2001 |pmid=11296544 |doi= |url=}}</ref>
| |
| *** '''Preferred regimen (1)''': [[Naproxen sodium|Naproxen]]: 375-500 mg/twice a day
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| *** '''Preferred regimen (2):''' [[Celecoxib]]: 200 mg/twice a day
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| *** '''Preferred regimen (3)''': [[Nimesulide]]: 200 and 400 mg/day
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| *** '''Preferred regimen (4)''': [[Ibuprofen]]: Max dose of up to 2400 mg/day
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| **** [[Adverse effect (medicine)|Adverse effects]] of [[Non-steroidal anti-inflammatory drug|non-steroidal anti-inflammatory drugs]] include increased cardiovascular risk, [[gastritis]], [[Peptic ulcer|ulcers]] and [[Renal insufficiency|low renal clearance]].
| |
| ** '''Moderate to severe disease''': Conventional synthetic [[Disease-modifying antirheumatic drug|disease-modifying antirheumatic drugs]] ([[Disease-modifying antirheumatic drug|DMARD]]<nowiki/>s) may be considered in [[Patient|patients]] with moderate to severe active peripheral [[arthritis]]. These are also considered in [[Patient|patients]] who are resistant or not responding to [[Non-steroidal anti-inflammatory drug|NSAIDs]], and local [[corticosteroid]] injections.
| |
| *** Preferred regimen (1): [[Methotrexate]]<ref name="pmid24219040">{{cite journal |vauthors=Mease P |title=Methotrexate in psoriatic arthritis |journal=Bull Hosp Jt Dis (2013) |volume=71 Suppl 1 |issue= |pages=S41–5 |date=2013 |pmid=24219040 |doi= |url=}}</ref><ref name="pmid7868484">{{cite journal |vauthors=Singh YN, Verma KK, Kumar A, Malaviya AN |title=Methotrexate in psoriatic arthritis |journal=J Assoc Physicians India |volume=42 |issue=11 |pages=860–2 |date=November 1994 |pmid=7868484 |doi= |url=}}</ref>: 15 to 25 mg/week
| |
| **** [[Adverse effect (medicine)|Adverse effects]] of [[methotrexate]]: Liver toxicity, [[immunosuppression]], interstitial [[pneumonitis]], increased infection risk.
| |
| **** [[Folic Acid|Folic acid]] supplementation should be given to all patients taking [[methotrexate]].
| |
| *** Preferred regimen (2): [[Leflunomide]]: 20 mg/day
| |
| **** [[Adverse effect (medicine)|Adverse effects]] of [[Leflunomide]]: Liver toxicity, [[diarrhea]], [[rash]], [[alopecia]], [[pneumonitis]].
| |
| *** Preferred regimen (3): [[Sulfasalazine]]<ref name="pmid7868484">{{cite journal |vauthors=Singh YN, Verma KK, Kumar A, Malaviya AN |title=Methotrexate in psoriatic arthritis |journal=J Assoc Physicians India |volume=42 |issue=11 |pages=860–2 |date=November 1994 |pmid=7868484 |doi= |url=}}</ref>: 2-3 gms/day
| |
| **** [[Adverse effect (medicine)|Adverse effects]] of [[sulfasalazine]]: [[Nausea and vomiting|Nausea]], [[diarrhea]], abdominal pain, [[rash]], and [[neutropenia]].
| |
| *** Preferred regimen (4): [[Cyclosporine]] A: 3.5 mg/kg per day<ref name="pmid2396865">{{cite journal |vauthors=Steinsson K, Jónsdóttir I, Valdimarsson H |title=Cyclosporin A in psoriatic arthritis: an open study |journal=Ann. Rheum. Dis. |volume=49 |issue=8 |pages=603–6 |date=August 1990 |pmid=2396865 |pmc=1004173 |doi= |url=}}</ref>
| |
| **** [[Adverse effect (medicine)|Adverse effects]] of [[Cyclosporine]] A: [[Hypertension]], [[Renal insufficiency|kidney damage]].
| |
| ** '''Severe disease''' '''and the presence of adverse prognostic factors''': [[TNF inhibitor|TNF inhibitors]] (eg, [[etanercept]], [[infliximab]], [[adalimumab]], [[golimumab]]), interleukin(IL) inhibitors (eg, [[secukinumab]], [[ixekizumab]], [[abatacept]]).
| |
| *** Biologic DMARDs are considered for patients who fail to respond or contraindication to conventional synthetic DMARDs. It is also administered in patients with presence of poor prognosis factors, even if they have not failed a standard DMARDs therapy.
| |
| **** TNF inhibitors:
| |
| ***** Preferred regimen (1): [[Adalimumab]]<ref name="pmid16200601">{{cite journal |vauthors=Mease PJ, Gladman DD, Ritchlin CT, Ruderman EM, Steinfeld SD, Choy EH, Sharp JT, Ory PA, Perdok RJ, Weinberg MA |title=Adalimumab for the treatment of patients with moderately to severely active psoriatic arthritis: results of a double-blind, randomized, placebo-controlled trial |journal=Arthritis Rheum. |volume=52 |issue=10 |pages=3279–89 |date=October 2005 |pmid=16200601 |doi=10.1002/art.21306 |url=}}</ref>: It is a human anti-[[Tumor necrosis factor-alpha|TNF alpha]] monoclonal [[antibody]]. Dosage: 40 mg can be given s.c every 2 weeks
| |
| ***** Preferred regimen (2): [[Etanercept]]<ref name="pmid15248226">{{cite journal |vauthors=Mease PJ, Kivitz AJ, Burch FX, Siegel EL, Cohen SB, Ory P, Salonen D, Rubenstein J, Sharp JT, Tsuji W |title=Etanercept treatment of psoriatic arthritis: safety, efficacy, and effect on disease progression |journal=Arthritis Rheum. |volume=50 |issue=7 |pages=2264–72 |date=July 2004 |pmid=15248226 |doi=10.1002/art.20335 |url=}}</ref>: It is a [[Tumor necrosis factors|TNF]] receptor p75-IgG1 fusion [[protein]]. Dosage: 50 mg can be given s.c every week.
| |
| ***** Preferred regimen (3): [[Infliximab]]<ref name="pmid15677701">{{cite journal |vauthors=Antoni C, Krueger GG, de Vlam K, Birbara C, Beutler A, Guzzo C, Zhou B, Dooley LT, Kavanaugh A |title=Infliximab improves signs and symptoms of psoriatic arthritis: results of the IMPACT 2 trial |journal=Ann. Rheum. Dis. |volume=64 |issue=8 |pages=1150–7 |date=August 2005 |pmid=15677701 |pmc=1755609 |doi=10.1136/ard.2004.032268 |url=}}</ref>: It is a chimeric [[Monoclonal antibodies|monoclonal antibody]] against [[Tumor necrosis factor-alpha|TNF alpha]]. Dosage: 5 mg/kg at weeks 0, 2, and 6 and after that 5 mg/kg every 6-8 weeks.
| |
| ***** Preferred regimen (4): [[Golimumab]]<ref name="pmid19333944">{{cite journal |vauthors=Kavanaugh A, McInnes I, Mease P, Krueger GG, Gladman D, Gomez-Reino J, Papp K, Zrubek J, Mudivarthy S, Mack M, Visvanathan S, Beutler A |title=Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four-week efficacy and safety results of a randomized, placebo-controlled study |journal=Arthritis Rheum. |volume=60 |issue=4 |pages=976–86 |date=April 2009 |pmid=19333944 |doi=10.1002/art.24403 |url=}}</ref>: it is a human IgG1k anti-[[Tumor necrosis factor-alpha|TNF alpha antibody]]. Dosage: 50 mg can be given s.c and monthly.
| |
| ***** Preferred regimen (5): [[Certolizumab pegol]]<ref name="pmid23942868">{{cite journal |vauthors=Mease PJ, Fleischmann R, Deodhar AA, Wollenhaupt J, Khraishi M, Kielar D, Woltering F, Stach C, Hoepken B, Arledge T, van der Heijde D |title=Effect of certolizumab pegol on signs and symptoms in patients with psoriatic arthritis: 24-week results of a Phase 3 double-blind randomised placebo-controlled study (RAPID-PsA) |journal=Ann. Rheum. Dis. |volume=73 |issue=1 |pages=48–55 |date=January 2014 |pmid=23942868 |pmc=3888622 |doi=10.1136/annrheumdis-2013-203696 |url=}}</ref>: It is a Fab fragment of anti-[[Tumor necrosis factor-alpha|TNF alpha monoclonal antibody]]. Dosage: 400 mg at 0, 2, and 4 weeks can be given s.c and then 200 mg every 2 weeks sub cutaneously.
| |
| ****** Adverse effects: Reactivation of latent Tuberculosis, increased risk for infections including bacterial and opportunistic infection. Therefore, before starting treatment with TNF inhibitors screening for TB, Hepatitis B, and C should be done.
| |
| **** IL inhibitor therapy: This is considered in patients with severe peripheral arthritis, where TNF therapy is contraindicated or not responding even after switching to different TNF inhibitor.
| |
| ***** Anti-IL-17 therapies :
| |
| ****** Preferred regimen (1): Secukinumab<ref name="pmid26135703">{{cite journal |vauthors=McInnes IB, Mease PJ, Kirkham B, Kavanaugh A, Ritchlin CT, Rahman P, van der Heijde D, Landewé R, Conaghan PG, Gottlieb AB, Richards H, Pricop L, Ligozio G, Patekar M, Mpofu S |title=Secukinumab, a human anti-interleukin-17A monoclonal antibody, in patients with psoriatic arthritis (FUTURE 2): a randomised, double-blind, placebo-controlled, phase 3 trial |journal=Lancet |volume=386 |issue=9999 |pages=1137–46 |date=September 2015 |pmid=26135703 |doi=10.1016/S0140-6736(15)61134-5 |url=}}</ref>: It is a monoclonal antibody against IL-17A. Dosage: 150 mg at weeks 0, 1, 2, 3, and 4 and then every 4 weeks can be given subcutaneously.
| |
| ****** Preferred regimen (2): Ixekizumab<ref name="pmid27553214">{{cite journal |vauthors=Mease PJ, van der Heijde D, Ritchlin CT, Okada M, Cuchacovich RS, Shuler CL, Lin CY, Braun DK, Lee CH, Gladman DD |title=Ixekizumab, an interleukin-17A specific monoclonal antibody, for the treatment of biologic-naive patients with active psoriatic arthritis: results from the 24-week randomised, double-blind, placebo-controlled and active (adalimumab)-controlled period of the phase III trial SPIRIT-P1 |journal=Ann. Rheum. Dis. |volume=76 |issue=1 |pages=79–87 |date=January 2017 |pmid=27553214 |pmc=5264219 |doi=10.1136/annrheumdis-2016-209709 |url=}}</ref> : Dosage: 160 mg initially, then 80 mg every two or four weeks can be given subcutaneously.
| |
| ***** Anti-IL-12/23 therapy:
| |
| ****** Ustekinumab<ref name="pmid23769296">{{cite journal |vauthors=McInnes IB, Kavanaugh A, Gottlieb AB, Puig L, Rahman P, Ritchlin C, Brodmerkel C, Li S, Wang Y, Mendelsohn AM, Doyle MK |title=Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial |journal=Lancet |volume=382 |issue=9894 |pages=780–9 |date=August 2013 |pmid=23769296 |doi=10.1016/S0140-6736(13)60594-2 |url=}}</ref>: It is a IgG1 monoclonal antibody against the shared P40 subunit of human IL-12 and IL-23. Dosage: 45 mg at weeks 0 and 4 and then for every 12 weeks can be given subcutaneously.
| |
| **** Abatacept<ref name="pmid28473423">{{cite journal |vauthors=Mease PJ, Gottlieb AB, van der Heijde D, FitzGerald O, Johnsen A, Nys M, Banerjee S, Gladman DD |title=Efficacy and safety of abatacept, a T-cell modulator, in a randomised, double-blind, placebo-controlled, phase III study in psoriatic arthritis |journal=Ann. Rheum. Dis. |volume=76 |issue=9 |pages=1550–1558 |date=September 2017 |pmid=28473423 |pmc=5561378 |doi=10.1136/annrheumdis-2016-210724 |url=}}</ref>: It is a costimulatory T-cell molecule, blocking signal activation of the CD28 receptor on the T cell inhibiting T-cell activation. Dosage: 125 mg can be given subcutaneously once in a week.
| |
| * '''Axial disease/ spondylitis''':<ref name="pmid25362712">{{cite journal |vauthors=Nash P, Lubrano E, Cauli A, Taylor WJ, Olivieri I, Gladman DD |title=Updated guidelines for the management of axial disease in psoriatic arthritis |journal=J. Rheumatol. |volume=41 |issue=11 |pages=2286–9 |date=November 2014 |pmid=25362712 |doi=10.3899/jrheum.140877 |url=}}</ref>
| |
| ** Mild disease: Non-steroidal anti-inflammatory drugs (NSAIDs), local corticosteroid injections, patient education, exercise and physiotherapy may be recommended to treat mild axial involvement.
| |
| *** Preferred regimen (1): [[Naproxen sodium|Naproxen]]: 375-500 mg/twice a day
| |
| *** Preferred regimen (2): [[Celecoxib]]: 200 mg/twice a day
| |
| ** Moderate to severe disease: TNF inhibitors
| |
| * [[Skin disease|'''Skin disease''']]:<ref name="pmid24566842">{{cite journal |vauthors=Mease PJ, Armstrong AW |title=Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis |journal=Drugs |volume=74 |issue=4 |pages=423–41 |date=March 2014 |pmid=24566842 |pmc=3958815 |doi=10.1007/s40265-014-0191-y |url=}}</ref>
| |
| ** Phototherapy: First line of treatment including UVB, PUVA.
| |
| ** Fumeric esters, retinols, calcipotriol
| |
| ** Conventional DMARDs and TNF inhibitors, and retinoic acid derivatives (eg, acitretin) may be used in combinatination with phototherapy.
| |
| * [[Nail changes|'''Nail disease''']]:<ref name="pmid25471223">{{cite journal |vauthors=Crowley JJ, Weinberg JM, Wu JJ, Robertson AD, Van Voorhees AS |title=Treatment of nail psoriasis: best practice recommendations from the Medical Board of the National Psoriasis Foundation |journal=JAMA Dermatol |volume=151 |issue=1 |pages=87–94 |date=January 2015 |pmid=25471223 |doi=10.1001/jamadermatol.2014.2983 |url=}}</ref>
| |
| ** Topical corticosteroids, calcipotriol creams, DMARDs and TNF inhibitors may be helpful.
| |
|
| |
|
| * '''Enthesitis''':
| | ==Diagnosis== |
| ** Mild disease: NSAIDs, local corticosteroid injection, phycial therapy may be helpful.
| | [[Psoriatic arthritis diagnostic study of choice |Diagnostic study of choice]] | [[Psoriatic arthritis history and symptoms|History and Symptoms]] | [[Psoriatic arthritis physical examination|Physical Examination]] | [[Psoriatic arthritis laboratory tests|Laboratory Findings]] | [[Psoriatic arthritis electrocardiogram|Electrocardiogram]] | [[Rheumatoid arthritis x ray|X ray]] | [[Rheumatoid arthritis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Psoriatic arthritis CT|CT]] | [[Psoriatic arthritis MRI|MRI Findings]] | [[Psoriatic arthritis other imaging findings|Other Imaging Findings]] | [[Psoriatic arthritis other diagnostic studies|Other Diagnostic Studies]] |
| ** Moderate to severe disease: TNF inhibitors
| |
| * [[Dactylitis|'''Dactylitis''']]:<ref name="pmid25362714">{{cite journal |vauthors=Rose S, Toloza S, Bautista-Molano W, Helliwell PS |title=Comprehensive treatment of dactylitis in psoriatic arthritis |journal=J. Rheumatol. |volume=41 |issue=11 |pages=2295–300 |date=November 2014 |pmid=25362714 |doi=10.3899/jrheum.140879 |url=}}</ref>
| |
| ** NSAIDs, steroid injections, conventional DMARDs and TNF inhibitors can be helpful.
| |
| ** Biologic DMARDs can be considered for treatment of dactylitis if, therapy with NSAIDs, steroid injections, conventional DMARDs fails.
| |
| * '''Non pharmacologic therapy''':
| |
| ** [[Physical exercise|Exercise]]
| |
| ** [[Weight]] reduction
| |
| ** [[Physical therapy]]
| |
| ** [[Occupational therapy]]
| |
| ** Educating the [[patient]] about [[disease]] course, [[joint]] protection and [[Comorbidity|comorbid]] conditions.
| |
| ** [[Orthotics]]
| |
|
| |
|
| === Surgery === | | ==Treatment== |
| *Surgery may be indicated in patients of psoriatic arthritis with severe joint damage that limit mobility.<ref name="pmid10782824">{{cite journal |vauthors=Zangger P, Esufali ZH, Gladman DD, Bogoch ER |title=Type and outcome of reconstructive surgery for different patterns of psoriatic arthritis |journal=J. Rheumatol. |volume=27 |issue=4 |pages=967–74 |date=April 2000 |pmid=10782824 |doi= |url=}}</ref>
| | [[Psoriatic arthritis medical therapy|Medical Therapy]] | [[Psoriatic arthritis surgical therapy|Surgical Therapy]] | [[Psoriatic arthritis Primary prevention|Primary prevention]] | [[Psoriatic arthritis secondary prevention|Secondary prevention]] | [[Psoriatic arthritis future or investigational therapies|Future or Investigational Therapies]] |
| *Common procedures include hand joint surgery involving PIP and DIP joints, hip or knee surgery.
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|
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|
| === Prevention === | | ==Case Studies== |
| * There are no established primary preventive measures for psoriatic arthritis.
| | :[[Psoriatic arthritis case study 1|Case #1]] |
| * Patients are monitored regularly for disease activity, drug efficacy, adverse effects and associated comorbid conditions.
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| ==References== | | ==Related Chapters== |
| {{Reflist|2}}
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| [[Category:Pick One of 28 Approved]]
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| | {{Diseases of the musculoskeletal system and connective tissue}} |
| | {{WH}} |
| {{WS}} | | {{WS}} |
| {{WH}}
| | e)|adverse effects]] and associated [[Comorbidity|comorbid conditions]]. |
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| | [[Category:Arthritis]] |
| | [[Category:Autoimmune diseases]] |
| | [[Category:Rheumatology]] |