Vinod Chandran, MBBS, MD, DM, PhD

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). 
5.    Walscheid K et al. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15).

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). 
5.    Walscheid K et al. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15).

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). 
5.    Walscheid K et al. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15).

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴ demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). doi: 10.1093/aje/kwac009. Epub ahead of print. PMID: 35029650.
5.    Walscheid K, Rothaus K, Niewerth M, Klotsche J, Minden K, Heiligenhaus A. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15). doi: 10.3899/jrheum.210755. Epub ahead of print. PMID: 35034000.
 

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴ demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). doi: 10.1093/aje/kwac009. Epub ahead of print. PMID: 35029650.
5.    Walscheid K, Rothaus K, Niewerth M, Klotsche J, Minden K, Heiligenhaus A. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15). doi: 10.3899/jrheum.210755. Epub ahead of print. PMID: 35034000.
 

The influence of sex and gender on psoriatic arthritis (PsA) continues to be of interest. Using data from the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR), Passia et al¹assessed sex-related differences in demographics, disease characteristics, and evolution over 1 year in 273 men and 294 women newly diagnosed with PsA. They found that at baseline, women had a significantly longer duration of symptoms, higher tender joint count and enthesitis, higher disease activity, higher levels of pain, more severe limitations in function and worse quality of life. During the 1 year follow up, composite measures of disease activity declined in men and women, but women continued to have higher levels than men. At the end of 1 year, fewer women achieved the criteria for minimal disease activity (MDA). Thus, the disease burden of PsA was higher in women vs. men at all time points and even after 1 year of standard-of-care treatment. Sex-specific treatment strategies might help a higher proportion of women achieve MDA.

Although, enthesitis is believed to be a primary pathogenetic lesion in PsA, the relationship between active enthesitis and disease severity as measured by the presence of joint erosions is less well studied. In a cross-sectional study of 104 PsA patients, Smerilli et al² explored the association between ultrasound (US) entheseal abnormalities and the presence of US detected bone erosions in PsA joints. At least 1 joint bone erosion was found in 45.2% of patients and was associated with power Doppler signal at enthesis (odds ratio [OR] 1.74; P < .01), entheseal bone erosions (OR 3.17; P = .01), and greyscale synovitis (OR 2.59; P = .02). Thus, Doppler signal and bone erosions at entheses indicate more severe PsA and patients with such abnormalities should therefore be treated aggressively.

Comorbidities and associated conditions were a focus of several publications last month. Venous thromboembolism (VTE) is associated with inflammatory diseases, including PsA. In a retrospective cohort study including 5,275 patients with newly diagnosed PsA, Gazitt et al³ assessed the association between PsA and VTE events using a large population-based database in Israel. During follow-up, 1.2% vs. 0.8% patients in the PsA vs. control group were diagnosed with VTE, but this association was not statistically significant after adjusting for demographic factors and comorbidities (adjusted hazard ratio [aHR] 1.27; P = .16) with only older age (aHR 1.08; P < .0001) and history of VTE (aHR 31.63; P < .0001) remaining associated with an increased risk for VTE. Thus, VTE in patients with PsA may be associated with underlying comorbidities rather than PsA per se. In another study, Harris et al⁴ demonstrated that PsA was associated with increased risk of endometriosis. In an analysis of 4112 patients with laparoscopically confirmed endometriosis from the Nurses’ Health Study II, they found that psoriasis with concomitant PsA was associated with increased risk for subsequent endometriosis (HR 2.01; 95% CI 1.23-3.30), which persisted even after adjusting for comorbidities. Finally, in a cross-sectional study using data from 1862 juvenile PsA (jPsA) patients (122 [6.6%] of whom developed uveitis) in the German National Pediatric Rheumatological Database, Walscheid et al⁵ showed that patients with jPsA were more likely to develop uveitis if they were diagnosed with PsA at a younger age or were antinuclear antibody positive, with higher disease activity being the only factor significantly associated with the presence of uveitis.

References

1.    Passia E et al. Sex-specific differences and how to handle them in early psoriatic arthritis. Arthritis Res Ther. 2022;24(1):22 (Jan 11). 
2.    Smerilli G et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol. 2022 (Feb 1). 
3.    Gazitt T et al. The association between psoriatic arthritis and venous thromboembolism: a population-based cohort study. Arthritis Res Ther. 2022;24(1):16 (Jan 7). 
4.    Harris HR et al. Endometriosis, psoriasis and psoriatic arthritis: A prospective cohort study. Am J Epidemiol. 2022 (Jan 13). doi: 10.1093/aje/kwac009. Epub ahead of print. PMID: 35029650.
5.    Walscheid K, Rothaus K, Niewerth M, Klotsche J, Minden K, Heiligenhaus A. Occurrence and risk factors of uveitis in juvenile psoriatic arthritis: Data from a population-based nationwide study in Germany. J Rheumatol. 2022 (Jan 15). doi: 10.3899/jrheum.210755. Epub ahead of print. PMID: 35034000.
 

Identifying risk factors associated with transition from cutaneous psoriasis to arthritic psoriasis remains a hot area of research. In a retrospective nested case-control study using the resources of the Rochester Epidemiology Project, Karmacharya et al¹ identified 164 patients with incident PsA between 2000 and 2017. Among the 158 total patients satisfying study criteria, 64 (41%) had concurrent psoriasis and PsA and 94 (59%) had onset of psoriasis before PsA. The median time from psoriasis diagnosis to the incidence of PsA was 35.5 months with age at psoriasis onset (odds ratio [OR] per 10-year decrease 1.63; 95% CI 1.26-2.11) and its severity (OR for severe vs. mild 3.65; 95% CI 1.18-11.32) being associated with having a psoriasis diagnosis >1 year prior to incident PsA. Early onset as well as severe psoriasis is associated with the HLA- C*06 allele as is longer psoriasis-PsA latency. Although not evaluated in this study, this genetic factor, or other factors such as detection bias, may underly these observations.

Once diagnosed, stratification of PsA severity is important for planning treatment. Towards this goal, Dubash et al² demonstrated that the presence of dactylitis indicates a more severe PsA phenotype. In a study of 177 disease-modifying antirheumatic drug (DMARD)-naive patients with early PsA, they found that those with dactylitis (46%) had significantly higher tender and swollen joint counts and C-reactive protein than those with non-dactylitic PsA. Ultrasound synovitis and erosions were also significantly more prevalent in dactylitic PsA. Thus, the presence of dactylitis indicates a more severe phenotype, and patients with dactylitis should be treated aggressively to improve long-term outcomes.

Novel therapies are being frequently evaluated in PsA and a recent target is interleukin (IL)-23, a key cytokine in the T-helper 17 (Th17) pathway and in the pathogenesis of psoriatic disease. Risankizumab is a novel monoclonal antibody targeting IL-23. In the double-blind phase 3 KEEPsAKE 1 study including 964 patients with active PsA and inadequate response to one or more conventional synthetic (cs) DMARDs. They were randomly assigned to receive 150 mg risankizumab or placebo, Kristensen et al³ demonstrated that, at week 24, at least a 20% improvement in the American College of Rheumatology score (ACR20) was achieved by a significantly higher proportion of patients receiving risankizumab vs. placebo (57.3% vs. 33.5%; P < .001). Treatment-emergent adverse events were mild-to-moderate and reported at similar frequencies in the risankizumab (40.4%) and placebo (38.7%) groups. Thus, risankizumab was efficacious in reducing clinical manifestations of PsA in patients with inadequate response to csDMARDs with no new adverse events. An important question when treating patients with PsA with targeted therapies is the need for concomitant therapy with csDMARDs. In a pooled analysis of 2 phase 3 trials, SELECT-PsA 1 and SELECT-PsA 2,  1,916 patients with active PsA with an inadequate response to ≥1 non-biologic (nb) DMARDs or biologic DMARDs were randomly assigned to placebo, 15 mg upadacitinib, or 30 mg upadacitinib as monotherapy or in combination with ≤2 nbDMARDs for 24 weeks, Nash et al⁴ demonstrated that at week 12, ACR20 response was achieved by a similar proportion of patients receiving 15 mg upadacitinib or 30 mg upadacitinib as monotherapy (15 mg: 33.7%; 95% CI 24.4%-43.1%; 30 mg: 45.7%; 95% CI 36.9%-54.5%) or combination therapy (15 mg: 34.0%; 95% CI 27.9%-40.1%; 30 mg: 39.6%; 95% CI 33.7%-45.5%). Adverse events were generally similar between monotherapy and combination therapy. Although, we don’t have information regarding the sustainability of the response, these data indicate that upadacitinib may be used without concomitant csDMARDs in PsA.

References

1. Karmacharya P et al. Time to transition from psoriasis to psoriatic arthritis: A population-based study. Semin Arthritis Rheum. 2021(Dec 31):S0049-0172(21)00230-4.
2. Dubash S et al. Dactylitis is an indicator of a more severe phenotype independently associated with greater SJC, CRP, ultrasound synovitis and erosive damage in DMARD-naive early psoriatic arthritis. Ann Rheum Dis. 2021(Dec 10):annrheumdis-2021-220964.
3. Kristensen LE et al. Efficacy and safety of risankizumab for active psoriatic arthritis: 24-week results from the randomised, double-blind, phase 3 KEEPsAKE 1 trial. Ann Rheum Dis. 2022(Feb);81(2):225-231.
4. Nash P et al. Upadacitinib as monotherapy and in combination with non-biologic disease-modifying antirheumatic drugs for psoriatic arthritis. Rheumatology (Oxford). 2021(Dec 3):keab905.

Identifying risk factors associated with transition from cutaneous psoriasis to arthritic psoriasis remains a hot area of research. In a retrospective nested case-control study using the resources of the Rochester Epidemiology Project, Karmacharya et al¹ identified 164 patients with incident PsA between 2000 and 2017. Among the 158 total patients satisfying study criteria, 64 (41%) had concurrent psoriasis and PsA and 94 (59%) had onset of psoriasis before PsA. The median time from psoriasis diagnosis to the incidence of PsA was 35.5 months with age at psoriasis onset (odds ratio [OR] per 10-year decrease 1.63; 95% CI 1.26-2.11) and its severity (OR for severe vs. mild 3.65; 95% CI 1.18-11.32) being associated with having a psoriasis diagnosis >1 year prior to incident PsA. Early onset as well as severe psoriasis is associated with the HLA- C*06 allele as is longer psoriasis-PsA latency. Although not evaluated in this study, this genetic factor, or other factors such as detection bias, may underly these observations.

Once diagnosed, stratification of PsA severity is important for planning treatment. Towards this goal, Dubash et al² demonstrated that the presence of dactylitis indicates a more severe PsA phenotype. In a study of 177 disease-modifying antirheumatic drug (DMARD)-naive patients with early PsA, they found that those with dactylitis (46%) had significantly higher tender and swollen joint counts and C-reactive protein than those with non-dactylitic PsA. Ultrasound synovitis and erosions were also significantly more prevalent in dactylitic PsA. Thus, the presence of dactylitis indicates a more severe phenotype, and patients with dactylitis should be treated aggressively to improve long-term outcomes.

Novel therapies are being frequently evaluated in PsA and a recent target is interleukin (IL)-23, a key cytokine in the T-helper 17 (Th17) pathway and in the pathogenesis of psoriatic disease. Risankizumab is a novel monoclonal antibody targeting IL-23. In the double-blind phase 3 KEEPsAKE 1 study including 964 patients with active PsA and inadequate response to one or more conventional synthetic (cs) DMARDs. They were randomly assigned to receive 150 mg risankizumab or placebo, Kristensen et al³ demonstrated that, at week 24, at least a 20% improvement in the American College of Rheumatology score (ACR20) was achieved by a significantly higher proportion of patients receiving risankizumab vs. placebo (57.3% vs. 33.5%; P < .001). Treatment-emergent adverse events were mild-to-moderate and reported at similar frequencies in the risankizumab (40.4%) and placebo (38.7%) groups. Thus, risankizumab was efficacious in reducing clinical manifestations of PsA in patients with inadequate response to csDMARDs with no new adverse events. An important question when treating patients with PsA with targeted therapies is the need for concomitant therapy with csDMARDs. In a pooled analysis of 2 phase 3 trials, SELECT-PsA 1 and SELECT-PsA 2,  1,916 patients with active PsA with an inadequate response to ≥1 non-biologic (nb) DMARDs or biologic DMARDs were randomly assigned to placebo, 15 mg upadacitinib, or 30 mg upadacitinib as monotherapy or in combination with ≤2 nbDMARDs for 24 weeks, Nash et al⁴ demonstrated that at week 12, ACR20 response was achieved by a similar proportion of patients receiving 15 mg upadacitinib or 30 mg upadacitinib as monotherapy (15 mg: 33.7%; 95% CI 24.4%-43.1%; 30 mg: 45.7%; 95% CI 36.9%-54.5%) or combination therapy (15 mg: 34.0%; 95% CI 27.9%-40.1%; 30 mg: 39.6%; 95% CI 33.7%-45.5%). Adverse events were generally similar between monotherapy and combination therapy. Although, we don’t have information regarding the sustainability of the response, these data indicate that upadacitinib may be used without concomitant csDMARDs in PsA.

References

1. Karmacharya P et al. Time to transition from psoriasis to psoriatic arthritis: A population-based study. Semin Arthritis Rheum. 2021(Dec 31):S0049-0172(21)00230-4.
2. Dubash S et al. Dactylitis is an indicator of a more severe phenotype independently associated with greater SJC, CRP, ultrasound synovitis and erosive damage in DMARD-naive early psoriatic arthritis. Ann Rheum Dis. 2021(Dec 10):annrheumdis-2021-220964.
3. Kristensen LE et al. Efficacy and safety of risankizumab for active psoriatic arthritis: 24-week results from the randomised, double-blind, phase 3 KEEPsAKE 1 trial. Ann Rheum Dis. 2022(Feb);81(2):225-231.
4. Nash P et al. Upadacitinib as monotherapy and in combination with non-biologic disease-modifying antirheumatic drugs for psoriatic arthritis. Rheumatology (Oxford). 2021(Dec 3):keab905.

Identifying risk factors associated with transition from cutaneous psoriasis to arthritic psoriasis remains a hot area of research. In a retrospective nested case-control study using the resources of the Rochester Epidemiology Project, Karmacharya et al¹ identified 164 patients with incident PsA between 2000 and 2017. Among the 158 total patients satisfying study criteria, 64 (41%) had concurrent psoriasis and PsA and 94 (59%) had onset of psoriasis before PsA. The median time from psoriasis diagnosis to the incidence of PsA was 35.5 months with age at psoriasis onset (odds ratio [OR] per 10-year decrease 1.63; 95% CI 1.26-2.11) and its severity (OR for severe vs. mild 3.65; 95% CI 1.18-11.32) being associated with having a psoriasis diagnosis >1 year prior to incident PsA. Early onset as well as severe psoriasis is associated with the HLA- C*06 allele as is longer psoriasis-PsA latency. Although not evaluated in this study, this genetic factor, or other factors such as detection bias, may underly these observations.

Once diagnosed, stratification of PsA severity is important for planning treatment. Towards this goal, Dubash et al² demonstrated that the presence of dactylitis indicates a more severe PsA phenotype. In a study of 177 disease-modifying antirheumatic drug (DMARD)-naive patients with early PsA, they found that those with dactylitis (46%) had significantly higher tender and swollen joint counts and C-reactive protein than those with non-dactylitic PsA. Ultrasound synovitis and erosions were also significantly more prevalent in dactylitic PsA. Thus, the presence of dactylitis indicates a more severe phenotype, and patients with dactylitis should be treated aggressively to improve long-term outcomes.

Novel therapies are being frequently evaluated in PsA and a recent target is interleukin (IL)-23, a key cytokine in the T-helper 17 (Th17) pathway and in the pathogenesis of psoriatic disease. Risankizumab is a novel monoclonal antibody targeting IL-23. In the double-blind phase 3 KEEPsAKE 1 study including 964 patients with active PsA and inadequate response to one or more conventional synthetic (cs) DMARDs. They were randomly assigned to receive 150 mg risankizumab or placebo, Kristensen et al³ demonstrated that, at week 24, at least a 20% improvement in the American College of Rheumatology score (ACR20) was achieved by a significantly higher proportion of patients receiving risankizumab vs. placebo (57.3% vs. 33.5%; P < .001). Treatment-emergent adverse events were mild-to-moderate and reported at similar frequencies in the risankizumab (40.4%) and placebo (38.7%) groups. Thus, risankizumab was efficacious in reducing clinical manifestations of PsA in patients with inadequate response to csDMARDs with no new adverse events. An important question when treating patients with PsA with targeted therapies is the need for concomitant therapy with csDMARDs. In a pooled analysis of 2 phase 3 trials, SELECT-PsA 1 and SELECT-PsA 2,  1,916 patients with active PsA with an inadequate response to ≥1 non-biologic (nb) DMARDs or biologic DMARDs were randomly assigned to placebo, 15 mg upadacitinib, or 30 mg upadacitinib as monotherapy or in combination with ≤2 nbDMARDs for 24 weeks, Nash et al⁴ demonstrated that at week 12, ACR20 response was achieved by a similar proportion of patients receiving 15 mg upadacitinib or 30 mg upadacitinib as monotherapy (15 mg: 33.7%; 95% CI 24.4%-43.1%; 30 mg: 45.7%; 95% CI 36.9%-54.5%) or combination therapy (15 mg: 34.0%; 95% CI 27.9%-40.1%; 30 mg: 39.6%; 95% CI 33.7%-45.5%). Adverse events were generally similar between monotherapy and combination therapy. Although, we don’t have information regarding the sustainability of the response, these data indicate that upadacitinib may be used without concomitant csDMARDs in PsA.

References

1. Karmacharya P et al. Time to transition from psoriasis to psoriatic arthritis: A population-based study. Semin Arthritis Rheum. 2021(Dec 31):S0049-0172(21)00230-4.
2. Dubash S et al. Dactylitis is an indicator of a more severe phenotype independently associated with greater SJC, CRP, ultrasound synovitis and erosive damage in DMARD-naive early psoriatic arthritis. Ann Rheum Dis. 2021(Dec 10):annrheumdis-2021-220964.
3. Kristensen LE et al. Efficacy and safety of risankizumab for active psoriatic arthritis: 24-week results from the randomised, double-blind, phase 3 KEEPsAKE 1 trial. Ann Rheum Dis. 2022(Feb);81(2):225-231.
4. Nash P et al. Upadacitinib as monotherapy and in combination with non-biologic disease-modifying antirheumatic drugs for psoriatic arthritis. Rheumatology (Oxford). 2021(Dec 3):keab905.

Research published in November has provided us with insights on the impact of psoriatic arthritis (PsA) as well as treatment outcomes. Although PsA often affects women of child-bearing age, data on pregnancy outcomes in PsA is scarce. To evaluate pregnancy outcomes in patients with severe PsA, Remaeus et al¹ conducted a Swedish nationwide register-based cohort study of births from Jul 1 2007 to Dec 31 2017. A total of 921 PsA- pregnancies and 9210 non-PsA-pregnancies (matched on maternal age, year, and parity) were identified. Pregnancy in PsA vs. non-PsA women were associated with increased risk for preterm birth (adjusted odds ratio [aOR] 1.69; 95% CI 1.27-2.24), elective cesarean delivery (CD; aOR 1.77; 95% CI 1.43-2.20), and emergency CD (aOR 1.42; 95% CI 1.10-1.84) with the risk even more pronounced in pregnancies in women with PsA with exposure to antirheumatic treatment any time before or during pregnancy (surrogate for disease severity- preterm birth: aOR 1.98; 95% CI 1.27-2.86; elective CD: aOR 1.96; 95% CI 1.47-2.63; and emergency CD: aOR 1.67; 95% CI 1.18-2.36). Thus, pregnant women with PsA, particularly those requiring antirheumatic treatment, are at increased risk for adverse pregnancy outcomes and therefore should be counselled appropriately.

Depression is a well-known comorbidity of PsA. However, little is known about the impact of the COVID-19 pandemic on the prevalence of depressive symptoms in PsA patients. Engelbrecht et al² evaluated 89 patients with PsA participating in the German multicenter RheumaDatenRhePort registry. Symptoms of depression were assessed using the Patient Health Questionnaire-2 (PHQ-2). The majority of patients scored <2 on the PHQ-2 indicating that they did not have depressive symptoms during (85.39%) and prior to (83.15%) the pandemic. The prevalence of depressive symptoms was not significantly different before and during the pandemic, irrespective of disease activity. Thus, contrary to expectations, the COVID-19 pandemic did not increase the occurrence of depressive symptoms among patients with PsA.

With regard to longer-term treatment efficacy and safety of recently approved advanced therapies for PsA, McInnes et al reported 2-year results from the from the Phase-3 DISCOVER-2 trial that included 739 biologic-naive patients with active PsA. At week 100, ACR20 response was achieved by 76%, 74%, and 68% of patients who initially were randomized to receive guselkumab every 4 weeks, every 8 weeks, or placebo, respectively, indicating a durable response. No new safety signals were identified. The 56-week efficacy and safety results from SELECT-PsA 1 trial with upadacitinib reported by McInnes et al^4,5 showed that of 1705 patients randomized, 1419 (83.2%) completed 56 weeks of treatment. A higher proportion of patients achieved ACR20 response with upadacitinib (15 mg, 74.4%; 30 mg, 74.7%) vs. adalimumab (68.5%; P = .046) at week 56. No new safety signals were identified.

Safety, especially risk of infection, remains a significant concern when treating patients with biologics, especially tumor necrosis factor inhibitors (TNFi). Patients with rheumatoid arthritis (RA) are known to have a higher risk of infection, but data are scarce regarding the risk of serious infections in patients with PsA treated with TNFi and the comparative risk of infection in TNFi-treated RA patients versus patients with PsA. Using data from 1,352 and 1,007 patients with RA and PsA, respectively, followed in the prospective multi-center NORwegian-Disease Modifying Anti-Rheumatic Drug (NOR-DMARD) registry, Christensen et al report that patients with PsA vs. RA had a lower risk of contracting serious infections (adjusted hazard ratio 0.65; P = .025).

References

1. Remaeus K et al. Pregnancy outcomes in women with psoriatic arthritis with respect to presence and timing of antirheumatic treatment. Arthritis Rheumatol. 2021(Oct 20).
2. Englbrecht M et al. Prevalence of depressive symptoms in patients with psoriatic arthritis: have numbers changed during the COVID-19 pandemic? Front Med (Lausanne). 2021(Nov 1);8:74826
3. McInnes IB et al. Long-term efficacy and safety of guselkumab, a monoclonal antibody specific to the p19 subunit of interleukin-23, through 2 years: results from a phase 3, randomized, double-blind, placebo-controlled study conducted in biologic-naïve patients with active psoriatic arthritis. Arthritis Rheumatol. 2021(Nov 1).
4. McInnes IB et al. Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study.  RMD Open. 2021;7:e001838 (Oct 18).
5. Christensen IE et al. Serious infections in patients with rheumatoid arthritis and psoriatic arthritis treated with tumour necrosis factor inhibitors: data from register linkage of the NOR-DMARD study. Ann Rheum Dis. 2021(Oct 8). Correction: Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study. RMD Open. 2021 Nov;7(3):e001838corr1.

Research published in November has provided us with insights on the impact of psoriatic arthritis (PsA) as well as treatment outcomes. Although PsA often affects women of child-bearing age, data on pregnancy outcomes in PsA is scarce. To evaluate pregnancy outcomes in patients with severe PsA, Remaeus et al¹ conducted a Swedish nationwide register-based cohort study of births from Jul 1 2007 to Dec 31 2017. A total of 921 PsA- pregnancies and 9210 non-PsA-pregnancies (matched on maternal age, year, and parity) were identified. Pregnancy in PsA vs. non-PsA women were associated with increased risk for preterm birth (adjusted odds ratio [aOR] 1.69; 95% CI 1.27-2.24), elective cesarean delivery (CD; aOR 1.77; 95% CI 1.43-2.20), and emergency CD (aOR 1.42; 95% CI 1.10-1.84) with the risk even more pronounced in pregnancies in women with PsA with exposure to antirheumatic treatment any time before or during pregnancy (surrogate for disease severity- preterm birth: aOR 1.98; 95% CI 1.27-2.86; elective CD: aOR 1.96; 95% CI 1.47-2.63; and emergency CD: aOR 1.67; 95% CI 1.18-2.36). Thus, pregnant women with PsA, particularly those requiring antirheumatic treatment, are at increased risk for adverse pregnancy outcomes and therefore should be counselled appropriately.

Depression is a well-known comorbidity of PsA. However, little is known about the impact of the COVID-19 pandemic on the prevalence of depressive symptoms in PsA patients. Engelbrecht et al² evaluated 89 patients with PsA participating in the German multicenter RheumaDatenRhePort registry. Symptoms of depression were assessed using the Patient Health Questionnaire-2 (PHQ-2). The majority of patients scored <2 on the PHQ-2 indicating that they did not have depressive symptoms during (85.39%) and prior to (83.15%) the pandemic. The prevalence of depressive symptoms was not significantly different before and during the pandemic, irrespective of disease activity. Thus, contrary to expectations, the COVID-19 pandemic did not increase the occurrence of depressive symptoms among patients with PsA.

With regard to longer-term treatment efficacy and safety of recently approved advanced therapies for PsA, McInnes et al reported 2-year results from the from the Phase-3 DISCOVER-2 trial that included 739 biologic-naive patients with active PsA. At week 100, ACR20 response was achieved by 76%, 74%, and 68% of patients who initially were randomized to receive guselkumab every 4 weeks, every 8 weeks, or placebo, respectively, indicating a durable response. No new safety signals were identified. The 56-week efficacy and safety results from SELECT-PsA 1 trial with upadacitinib reported by McInnes et al^4,5 showed that of 1705 patients randomized, 1419 (83.2%) completed 56 weeks of treatment. A higher proportion of patients achieved ACR20 response with upadacitinib (15 mg, 74.4%; 30 mg, 74.7%) vs. adalimumab (68.5%; P = .046) at week 56. No new safety signals were identified.

Safety, especially risk of infection, remains a significant concern when treating patients with biologics, especially tumor necrosis factor inhibitors (TNFi). Patients with rheumatoid arthritis (RA) are known to have a higher risk of infection, but data are scarce regarding the risk of serious infections in patients with PsA treated with TNFi and the comparative risk of infection in TNFi-treated RA patients versus patients with PsA. Using data from 1,352 and 1,007 patients with RA and PsA, respectively, followed in the prospective multi-center NORwegian-Disease Modifying Anti-Rheumatic Drug (NOR-DMARD) registry, Christensen et al report that patients with PsA vs. RA had a lower risk of contracting serious infections (adjusted hazard ratio 0.65; P = .025).

References

1. Remaeus K et al. Pregnancy outcomes in women with psoriatic arthritis with respect to presence and timing of antirheumatic treatment. Arthritis Rheumatol. 2021(Oct 20).
2. Englbrecht M et al. Prevalence of depressive symptoms in patients with psoriatic arthritis: have numbers changed during the COVID-19 pandemic? Front Med (Lausanne). 2021(Nov 1);8:74826
3. McInnes IB et al. Long-term efficacy and safety of guselkumab, a monoclonal antibody specific to the p19 subunit of interleukin-23, through 2 years: results from a phase 3, randomized, double-blind, placebo-controlled study conducted in biologic-naïve patients with active psoriatic arthritis. Arthritis Rheumatol. 2021(Nov 1).
4. McInnes IB et al. Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study.  RMD Open. 2021;7:e001838 (Oct 18).
5. Christensen IE et al. Serious infections in patients with rheumatoid arthritis and psoriatic arthritis treated with tumour necrosis factor inhibitors: data from register linkage of the NOR-DMARD study. Ann Rheum Dis. 2021(Oct 8). Correction: Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study. RMD Open. 2021 Nov;7(3):e001838corr1.

Research published in November has provided us with insights on the impact of psoriatic arthritis (PsA) as well as treatment outcomes. Although PsA often affects women of child-bearing age, data on pregnancy outcomes in PsA is scarce. To evaluate pregnancy outcomes in patients with severe PsA, Remaeus et al¹ conducted a Swedish nationwide register-based cohort study of births from Jul 1 2007 to Dec 31 2017. A total of 921 PsA- pregnancies and 9210 non-PsA-pregnancies (matched on maternal age, year, and parity) were identified. Pregnancy in PsA vs. non-PsA women were associated with increased risk for preterm birth (adjusted odds ratio [aOR] 1.69; 95% CI 1.27-2.24), elective cesarean delivery (CD; aOR 1.77; 95% CI 1.43-2.20), and emergency CD (aOR 1.42; 95% CI 1.10-1.84) with the risk even more pronounced in pregnancies in women with PsA with exposure to antirheumatic treatment any time before or during pregnancy (surrogate for disease severity- preterm birth: aOR 1.98; 95% CI 1.27-2.86; elective CD: aOR 1.96; 95% CI 1.47-2.63; and emergency CD: aOR 1.67; 95% CI 1.18-2.36). Thus, pregnant women with PsA, particularly those requiring antirheumatic treatment, are at increased risk for adverse pregnancy outcomes and therefore should be counselled appropriately.

Depression is a well-known comorbidity of PsA. However, little is known about the impact of the COVID-19 pandemic on the prevalence of depressive symptoms in PsA patients. Engelbrecht et al² evaluated 89 patients with PsA participating in the German multicenter RheumaDatenRhePort registry. Symptoms of depression were assessed using the Patient Health Questionnaire-2 (PHQ-2). The majority of patients scored <2 on the PHQ-2 indicating that they did not have depressive symptoms during (85.39%) and prior to (83.15%) the pandemic. The prevalence of depressive symptoms was not significantly different before and during the pandemic, irrespective of disease activity. Thus, contrary to expectations, the COVID-19 pandemic did not increase the occurrence of depressive symptoms among patients with PsA.

With regard to longer-term treatment efficacy and safety of recently approved advanced therapies for PsA, McInnes et al reported 2-year results from the from the Phase-3 DISCOVER-2 trial that included 739 biologic-naive patients with active PsA. At week 100, ACR20 response was achieved by 76%, 74%, and 68% of patients who initially were randomized to receive guselkumab every 4 weeks, every 8 weeks, or placebo, respectively, indicating a durable response. No new safety signals were identified. The 56-week efficacy and safety results from SELECT-PsA 1 trial with upadacitinib reported by McInnes et al^4,5 showed that of 1705 patients randomized, 1419 (83.2%) completed 56 weeks of treatment. A higher proportion of patients achieved ACR20 response with upadacitinib (15 mg, 74.4%; 30 mg, 74.7%) vs. adalimumab (68.5%; P = .046) at week 56. No new safety signals were identified.

Safety, especially risk of infection, remains a significant concern when treating patients with biologics, especially tumor necrosis factor inhibitors (TNFi). Patients with rheumatoid arthritis (RA) are known to have a higher risk of infection, but data are scarce regarding the risk of serious infections in patients with PsA treated with TNFi and the comparative risk of infection in TNFi-treated RA patients versus patients with PsA. Using data from 1,352 and 1,007 patients with RA and PsA, respectively, followed in the prospective multi-center NORwegian-Disease Modifying Anti-Rheumatic Drug (NOR-DMARD) registry, Christensen et al report that patients with PsA vs. RA had a lower risk of contracting serious infections (adjusted hazard ratio 0.65; P = .025).

References

1. Remaeus K et al. Pregnancy outcomes in women with psoriatic arthritis with respect to presence and timing of antirheumatic treatment. Arthritis Rheumatol. 2021(Oct 20).
2. Englbrecht M et al. Prevalence of depressive symptoms in patients with psoriatic arthritis: have numbers changed during the COVID-19 pandemic? Front Med (Lausanne). 2021(Nov 1);8:74826
3. McInnes IB et al. Long-term efficacy and safety of guselkumab, a monoclonal antibody specific to the p19 subunit of interleukin-23, through 2 years: results from a phase 3, randomized, double-blind, placebo-controlled study conducted in biologic-naïve patients with active psoriatic arthritis. Arthritis Rheumatol. 2021(Nov 1).
4. McInnes IB et al. Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study.  RMD Open. 2021;7:e001838 (Oct 18).
5. Christensen IE et al. Serious infections in patients with rheumatoid arthritis and psoriatic arthritis treated with tumour necrosis factor inhibitors: data from register linkage of the NOR-DMARD study. Ann Rheum Dis. 2021(Oct 8). Correction: Upadacitinib in patients with psoriatic arthritis and an inadequate response to non-biological therapy: 56-week data from the phase 3 SELECT-PsA 1 study. RMD Open. 2021 Nov;7(3):e001838corr1.

There have been quite a few papers published in October that have provided further insights into psoriatic arthritis (PsA). Understanding risk factors for developing PsA in patients with psoriasis is of ongoing interest, but there is limited data on the relationship between the severity of psoriasis and the risk of developing PsA especially in the USA population. Using the Optum electronic health records (EHR) database, Merola et al¹ assessed the incidence, prevalence, and predictors of PsA among 114,868 patients with psoriasis between January 1, 2009, and March 31, 2019. The severity of psoriasis was determined by treatment received during the 1 year after psoriasis diagnosis as follows: mild (89.3%) topicals and phototherapy only; moderate (5.5%) nonbiologic systemic therapies (acitretin, apremilast, cyclosporine, methotrexate), and severe (5.2%) biologic therapies (adalimumab, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, secukinumab, ustekinumab). They found that the overall incidence of PsA was 2.9 (95% CI 2.9-3.0) events per 100 patient-years of follow up (PY). The incidence (100 PY, 95% CI) by severity was lowest (2.1 [95% CI 2.1-2.1]) in the mild, higher in the moderate (9.9 [95% CI 9.5-10.4]), and highest (17.6 [95% CI 16.9-18.3]) in the severe psoriasis category. The study thus confirms that patients with more severe psoriasis have higher risk of developing PsA.

The effect of treatment of psoriasis on the development of PsA is also have great interest. Recent studies² have indicated that biologic treatment of psoriasis may reduce the incidence of PsA. However, Meer et al³ in a retrospective cohort study using of 1,93,709 patients with psoriasis without PsA in the Optum Insights EHR database report that biologic use was associated with the development of PsA among patients with psoriasis. After propensity score matching, the hazard ratio was 2.14 (95% CI 2.00-2.28) for patients on biologics compared to those on oral therapy or phototherapy. Such studies are influenced by confounding factors ,by indication, and protopathic bias and hence prospective studies are warranted.

Better treatment outcomes are likely if patient priorities are taken into account when choosing a therapy. However, there are few studies addressing this issue. Sumpton et al⁴ conducted a discrete choice experiment in patients with PsA in Sydney, Australia, to assess preferences for different attributes of biologics. They identified the following attributes in order of preference: oral route (compared to subcutaneous and intravenous routes), avoiding severe side effects, increasing ability to attend to normal activities, avoiding infections, improvement in enthesitis pain, improvement in psoriasis, increasing chance of remission and improvement in joint pain. Thus, patients valued ease of administration, avoiding side effects, and physical function more when choosing a therapy. With increased availability of treatment choices, developing decision support systems that facilitate shared decision making between patients and clinicians is required to improve care of PsA patients.

Ultrasound is increasingly being used at the point of care in rheumatology, but until now ultrasound was not used as a primary outcome in a clinical trial. In the first randomized, placebo-controlled, phase III study using power Doppler ultrasound (PDUS) D’Agostino et al⁵ demonstrated that treatment with secukinumab (dosed according to psoriasis severity) led to statistically significant improvement in synovitis measured using the Global European League Against Rheumatism and Outcome Measures in Rheumatoid Arthritis Clinical Trials Synovitis Score (GLOESS) compared to placebo. Thus, secukinumab, an IL-17A inhibitor, reduces synovitis as detected by ultrasound as well as symptoms and clinical signs of PsA.

References

1. Merola JF et al. Incidence and Prevalence of Psoriatic Arthritis in Patients With Psoriasis Stratified by Psoriasis Disease Severity: Retrospective Analysis of a US Electronic Health Records Database. J Am Acad Dermatol. 2021(Sep 18):S0190-9622(21)02494-4.
2. Acosta Felquer ML et al. Treating the skin with biologics in patients with psoriasis decreases the incidence of psoriatic arthritis. Ann Rheum Dis. 2021 (Jul 19):annrheumdis-2021-220865.
3. Meer E et al. Does biologic therapy impact the development of PsA among patients with psoriasis? Ann Rheum Dis. 2021(Oct 6):annrheumdis-2021-220761.
4. Sumpton D et al. Preferences for biologic treatment in patients with psoriatic arthritis: a discrete choice experiment. Arthritis Care Res (Hoboken). 2021(Sep 13):acr.24782
5. D'Agostino MA et al. Response to secukinumab on synovitis using power Doppler ultrasound in psoriatic arthritis: 12-week results from a phase III study, ULTIMATE. Rheumatology (Oxford). 2021(Sep 16):keab628.

There have been quite a few papers published in October that have provided further insights into psoriatic arthritis (PsA). Understanding risk factors for developing PsA in patients with psoriasis is of ongoing interest, but there is limited data on the relationship between the severity of psoriasis and the risk of developing PsA especially in the USA population. Using the Optum electronic health records (EHR) database, Merola et al¹ assessed the incidence, prevalence, and predictors of PsA among 114,868 patients with psoriasis between January 1, 2009, and March 31, 2019. The severity of psoriasis was determined by treatment received during the 1 year after psoriasis diagnosis as follows: mild (89.3%) topicals and phototherapy only; moderate (5.5%) nonbiologic systemic therapies (acitretin, apremilast, cyclosporine, methotrexate), and severe (5.2%) biologic therapies (adalimumab, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, secukinumab, ustekinumab). They found that the overall incidence of PsA was 2.9 (95% CI 2.9-3.0) events per 100 patient-years of follow up (PY). The incidence (100 PY, 95% CI) by severity was lowest (2.1 [95% CI 2.1-2.1]) in the mild, higher in the moderate (9.9 [95% CI 9.5-10.4]), and highest (17.6 [95% CI 16.9-18.3]) in the severe psoriasis category. The study thus confirms that patients with more severe psoriasis have higher risk of developing PsA.

The effect of treatment of psoriasis on the development of PsA is also have great interest. Recent studies² have indicated that biologic treatment of psoriasis may reduce the incidence of PsA. However, Meer et al³ in a retrospective cohort study using of 1,93,709 patients with psoriasis without PsA in the Optum Insights EHR database report that biologic use was associated with the development of PsA among patients with psoriasis. After propensity score matching, the hazard ratio was 2.14 (95% CI 2.00-2.28) for patients on biologics compared to those on oral therapy or phototherapy. Such studies are influenced by confounding factors ,by indication, and protopathic bias and hence prospective studies are warranted.

Better treatment outcomes are likely if patient priorities are taken into account when choosing a therapy. However, there are few studies addressing this issue. Sumpton et al⁴ conducted a discrete choice experiment in patients with PsA in Sydney, Australia, to assess preferences for different attributes of biologics. They identified the following attributes in order of preference: oral route (compared to subcutaneous and intravenous routes), avoiding severe side effects, increasing ability to attend to normal activities, avoiding infections, improvement in enthesitis pain, improvement in psoriasis, increasing chance of remission and improvement in joint pain. Thus, patients valued ease of administration, avoiding side effects, and physical function more when choosing a therapy. With increased availability of treatment choices, developing decision support systems that facilitate shared decision making between patients and clinicians is required to improve care of PsA patients.

Ultrasound is increasingly being used at the point of care in rheumatology, but until now ultrasound was not used as a primary outcome in a clinical trial. In the first randomized, placebo-controlled, phase III study using power Doppler ultrasound (PDUS) D’Agostino et al⁵ demonstrated that treatment with secukinumab (dosed according to psoriasis severity) led to statistically significant improvement in synovitis measured using the Global European League Against Rheumatism and Outcome Measures in Rheumatoid Arthritis Clinical Trials Synovitis Score (GLOESS) compared to placebo. Thus, secukinumab, an IL-17A inhibitor, reduces synovitis as detected by ultrasound as well as symptoms and clinical signs of PsA.

References

1. Merola JF et al. Incidence and Prevalence of Psoriatic Arthritis in Patients With Psoriasis Stratified by Psoriasis Disease Severity: Retrospective Analysis of a US Electronic Health Records Database. J Am Acad Dermatol. 2021(Sep 18):S0190-9622(21)02494-4.
2. Acosta Felquer ML et al. Treating the skin with biologics in patients with psoriasis decreases the incidence of psoriatic arthritis. Ann Rheum Dis. 2021 (Jul 19):annrheumdis-2021-220865.
3. Meer E et al. Does biologic therapy impact the development of PsA among patients with psoriasis? Ann Rheum Dis. 2021(Oct 6):annrheumdis-2021-220761.
4. Sumpton D et al. Preferences for biologic treatment in patients with psoriatic arthritis: a discrete choice experiment. Arthritis Care Res (Hoboken). 2021(Sep 13):acr.24782
5. D'Agostino MA et al. Response to secukinumab on synovitis using power Doppler ultrasound in psoriatic arthritis: 12-week results from a phase III study, ULTIMATE. Rheumatology (Oxford). 2021(Sep 16):keab628.

There have been quite a few papers published in October that have provided further insights into psoriatic arthritis (PsA). Understanding risk factors for developing PsA in patients with psoriasis is of ongoing interest, but there is limited data on the relationship between the severity of psoriasis and the risk of developing PsA especially in the USA population. Using the Optum electronic health records (EHR) database, Merola et al¹ assessed the incidence, prevalence, and predictors of PsA among 114,868 patients with psoriasis between January 1, 2009, and March 31, 2019. The severity of psoriasis was determined by treatment received during the 1 year after psoriasis diagnosis as follows: mild (89.3%) topicals and phototherapy only; moderate (5.5%) nonbiologic systemic therapies (acitretin, apremilast, cyclosporine, methotrexate), and severe (5.2%) biologic therapies (adalimumab, certolizumab pegol, etanercept, golimumab, guselkumab, infliximab, ixekizumab, secukinumab, ustekinumab). They found that the overall incidence of PsA was 2.9 (95% CI 2.9-3.0) events per 100 patient-years of follow up (PY). The incidence (100 PY, 95% CI) by severity was lowest (2.1 [95% CI 2.1-2.1]) in the mild, higher in the moderate (9.9 [95% CI 9.5-10.4]), and highest (17.6 [95% CI 16.9-18.3]) in the severe psoriasis category. The study thus confirms that patients with more severe psoriasis have higher risk of developing PsA.

The effect of treatment of psoriasis on the development of PsA is also have great interest. Recent studies² have indicated that biologic treatment of psoriasis may reduce the incidence of PsA. However, Meer et al³ in a retrospective cohort study using of 1,93,709 patients with psoriasis without PsA in the Optum Insights EHR database report that biologic use was associated with the development of PsA among patients with psoriasis. After propensity score matching, the hazard ratio was 2.14 (95% CI 2.00-2.28) for patients on biologics compared to those on oral therapy or phototherapy. Such studies are influenced by confounding factors ,by indication, and protopathic bias and hence prospective studies are warranted.

Better treatment outcomes are likely if patient priorities are taken into account when choosing a therapy. However, there are few studies addressing this issue. Sumpton et al⁴ conducted a discrete choice experiment in patients with PsA in Sydney, Australia, to assess preferences for different attributes of biologics. They identified the following attributes in order of preference: oral route (compared to subcutaneous and intravenous routes), avoiding severe side effects, increasing ability to attend to normal activities, avoiding infections, improvement in enthesitis pain, improvement in psoriasis, increasing chance of remission and improvement in joint pain. Thus, patients valued ease of administration, avoiding side effects, and physical function more when choosing a therapy. With increased availability of treatment choices, developing decision support systems that facilitate shared decision making between patients and clinicians is required to improve care of PsA patients.

Ultrasound is increasingly being used at the point of care in rheumatology, but until now ultrasound was not used as a primary outcome in a clinical trial. In the first randomized, placebo-controlled, phase III study using power Doppler ultrasound (PDUS) D’Agostino et al⁵ demonstrated that treatment with secukinumab (dosed according to psoriasis severity) led to statistically significant improvement in synovitis measured using the Global European League Against Rheumatism and Outcome Measures in Rheumatoid Arthritis Clinical Trials Synovitis Score (GLOESS) compared to placebo. Thus, secukinumab, an IL-17A inhibitor, reduces synovitis as detected by ultrasound as well as symptoms and clinical signs of PsA.

References

1. Merola JF et al. Incidence and Prevalence of Psoriatic Arthritis in Patients With Psoriasis Stratified by Psoriasis Disease Severity: Retrospective Analysis of a US Electronic Health Records Database. J Am Acad Dermatol. 2021(Sep 18):S0190-9622(21)02494-4.
2. Acosta Felquer ML et al. Treating the skin with biologics in patients with psoriasis decreases the incidence of psoriatic arthritis. Ann Rheum Dis. 2021 (Jul 19):annrheumdis-2021-220865.
3. Meer E et al. Does biologic therapy impact the development of PsA among patients with psoriasis? Ann Rheum Dis. 2021(Oct 6):annrheumdis-2021-220761.
4. Sumpton D et al. Preferences for biologic treatment in patients with psoriatic arthritis: a discrete choice experiment. Arthritis Care Res (Hoboken). 2021(Sep 13):acr.24782
5. D'Agostino MA et al. Response to secukinumab on synovitis using power Doppler ultrasound in psoriatic arthritis: 12-week results from a phase III study, ULTIMATE. Rheumatology (Oxford). 2021(Sep 16):keab628.

In almost 80% of cases, cutaneous psoriasis predates the onset of arthritic psoriasis. Therefore, identifying risk factors for the development of psoriatic arthritis (PsA) in patients with skin psoriasis is of significant clinical and research interest. One such risk factor that has previous been described is the severity of psoriasis. In a prospective population-based cohort study performed within The Health Improvement Network in the UK, Ogdie et al demonstrated that in a cohort of 8881 patients aged 25–60 years with a code for psoriasis randomly selected between 2008 and 2011, the extent of psoriasis as measured by the body surface area affected (BSA) was a strong predictor of developing PsA. Comorbidities, such as obesity and depression, were additive risk factors. In this cohort, after a mean follow-up time of 4.2 years (SD 2.1), the incidence of PsA was 5.4 cases per 1000 person-years. After adjusting for age and sex, BSA > 10% [hazard ratio (HR) 2.01, 95% CI 1.29, 3.13], BSA 3–10% (HR 1.44, 95% CI 1.02, 2.03), obesity (HR 1.64, 95% CI 1.19, 2.26) and depression (HR 1.68, 95% CI 1.21, 2.33) were associated with incident PsA. Thus, patients with these risk factors should be carefully evaluated at each visit for signs of PsA.

One important question is whether treatment of psoriasis with targeted therapies reduces the risk of incident PsA. In a retrospective cohort study using the electronic medical records of the Maccabi Healthcare Services in Israel, Rosenthal et al, using propensity score matching compared patients who had received biological treatment for psoriasis and were not diagnosed with PsA before or at the time of biologic treatment initiation to controls not on such treatment. Patients were matched by age at diagnosis, gender, time until treatment initiation, maximum body mass index (BMI), and smoking. Multivariable Cox regression analysis showed that the control group had a significantly higher risk for PsA compared to patients treated with biologics (adjusted HR 1.39; 95%CI 1.03-1.87). Thus, there is increasing evidence that biologic therapy may decrease the risk of developing PsA.

Management of comorbidities remain an ongoing challenge in the management of psoriatic disease. In a cross-sectional multi-center study conducted by the Turkish League Against Rheumatism involving 1033 patients with PsA, 383 (37.1%) of whom were obese, Gok et al report that obesity was significantly associated with higher disease activity, lower quality of life scores, anxiety, depression, and fatigue. Comorbidities including obesity must be addressed for holistic management of PsA.

But counseling about modifiable risk factors remains low. Taylor et al reported that counseling or education for modifiable lifestyle risk factors were rare during psoriatic disease outpatient visits. Using data from the National Ambulatory Medical Care Survey (2002-2016) and the National Hospital Ambulatory Medical Care Survey (2002-2011) conducted in the United States, they demonstrate low rates of counseling for any modifiable lifestyle risk factor (11.1%; 95% CI 7.9%-15.3%), tobacco (4.8%; 95% CI 2.8%-8.0%), and obesity (2.8%; 95% CI 1.7%-4.5%). Thus, in addition to counseling about medications, an effort must be made to counsel about modifiable risk factors and comorbidities to improve quality of life of patients with psoriatic disease.

References

Ogdie A, Shin DB, Love TJ, Gelfand JM. Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study. Rheumatology (Oxf). 2021:Sep 11:keab622 (in press). doi: 10.1093/rheumatology/keab622 PMID: 34508558.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Gok K, Nas K, Tekeoglu I, Sunar I, Keskin Y, Kilic E, Sargin B, Acer Kasman S, Alkan H, Sahin N, Cengiz G, Cuzdan N, Albayrak Gezer İ, Keskin D, Mulkoglu C, Resorlu H, Bal A, Duruoz MT, Kucukakkas O, Yurdakul OV, Alkan Melikoglu M, Aydin Y, Ayhan FF, Bodur H, Calis M, Capkin E, Devrimsel G, Ecesoy H, Hizmetli S, Kamanli A, Kutluk O, Sen N, Sendur OF, Tolu S, Toprak M, Tuncer T. Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2021:Aug 28. doi: 10.1007/s00296-021-04971-8. Epub ahead of print. PMID: 34453579.

Taylor MT, Keller M, Barbieri JS. Lifestyle risk factor counseling at visits for psoriasis and psoriatic arthritis in the United States. J Am Acad Dermatol. 2021:Aug 25:S0190-9622(21)02376-8. doi: 10.1016/j.jaad.2021.08.034. Epub ahead of print. PMID: 34450204

In almost 80% of cases, cutaneous psoriasis predates the onset of arthritic psoriasis. Therefore, identifying risk factors for the development of psoriatic arthritis (PsA) in patients with skin psoriasis is of significant clinical and research interest. One such risk factor that has previous been described is the severity of psoriasis. In a prospective population-based cohort study performed within The Health Improvement Network in the UK, Ogdie et al demonstrated that in a cohort of 8881 patients aged 25–60 years with a code for psoriasis randomly selected between 2008 and 2011, the extent of psoriasis as measured by the body surface area affected (BSA) was a strong predictor of developing PsA. Comorbidities, such as obesity and depression, were additive risk factors. In this cohort, after a mean follow-up time of 4.2 years (SD 2.1), the incidence of PsA was 5.4 cases per 1000 person-years. After adjusting for age and sex, BSA > 10% [hazard ratio (HR) 2.01, 95% CI 1.29, 3.13], BSA 3–10% (HR 1.44, 95% CI 1.02, 2.03), obesity (HR 1.64, 95% CI 1.19, 2.26) and depression (HR 1.68, 95% CI 1.21, 2.33) were associated with incident PsA. Thus, patients with these risk factors should be carefully evaluated at each visit for signs of PsA.

One important question is whether treatment of psoriasis with targeted therapies reduces the risk of incident PsA. In a retrospective cohort study using the electronic medical records of the Maccabi Healthcare Services in Israel, Rosenthal et al, using propensity score matching compared patients who had received biological treatment for psoriasis and were not diagnosed with PsA before or at the time of biologic treatment initiation to controls not on such treatment. Patients were matched by age at diagnosis, gender, time until treatment initiation, maximum body mass index (BMI), and smoking. Multivariable Cox regression analysis showed that the control group had a significantly higher risk for PsA compared to patients treated with biologics (adjusted HR 1.39; 95%CI 1.03-1.87). Thus, there is increasing evidence that biologic therapy may decrease the risk of developing PsA.

Management of comorbidities remain an ongoing challenge in the management of psoriatic disease. In a cross-sectional multi-center study conducted by the Turkish League Against Rheumatism involving 1033 patients with PsA, 383 (37.1%) of whom were obese, Gok et al report that obesity was significantly associated with higher disease activity, lower quality of life scores, anxiety, depression, and fatigue. Comorbidities including obesity must be addressed for holistic management of PsA.

But counseling about modifiable risk factors remains low. Taylor et al reported that counseling or education for modifiable lifestyle risk factors were rare during psoriatic disease outpatient visits. Using data from the National Ambulatory Medical Care Survey (2002-2016) and the National Hospital Ambulatory Medical Care Survey (2002-2011) conducted in the United States, they demonstrate low rates of counseling for any modifiable lifestyle risk factor (11.1%; 95% CI 7.9%-15.3%), tobacco (4.8%; 95% CI 2.8%-8.0%), and obesity (2.8%; 95% CI 1.7%-4.5%). Thus, in addition to counseling about medications, an effort must be made to counsel about modifiable risk factors and comorbidities to improve quality of life of patients with psoriatic disease.

References

Ogdie A, Shin DB, Love TJ, Gelfand JM. Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study. Rheumatology (Oxf). 2021:Sep 11:keab622 (in press). doi: 10.1093/rheumatology/keab622 PMID: 34508558.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Gok K, Nas K, Tekeoglu I, Sunar I, Keskin Y, Kilic E, Sargin B, Acer Kasman S, Alkan H, Sahin N, Cengiz G, Cuzdan N, Albayrak Gezer İ, Keskin D, Mulkoglu C, Resorlu H, Bal A, Duruoz MT, Kucukakkas O, Yurdakul OV, Alkan Melikoglu M, Aydin Y, Ayhan FF, Bodur H, Calis M, Capkin E, Devrimsel G, Ecesoy H, Hizmetli S, Kamanli A, Kutluk O, Sen N, Sendur OF, Tolu S, Toprak M, Tuncer T. Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2021:Aug 28. doi: 10.1007/s00296-021-04971-8. Epub ahead of print. PMID: 34453579.

Taylor MT, Keller M, Barbieri JS. Lifestyle risk factor counseling at visits for psoriasis and psoriatic arthritis in the United States. J Am Acad Dermatol. 2021:Aug 25:S0190-9622(21)02376-8. doi: 10.1016/j.jaad.2021.08.034. Epub ahead of print. PMID: 34450204

In almost 80% of cases, cutaneous psoriasis predates the onset of arthritic psoriasis. Therefore, identifying risk factors for the development of psoriatic arthritis (PsA) in patients with skin psoriasis is of significant clinical and research interest. One such risk factor that has previous been described is the severity of psoriasis. In a prospective population-based cohort study performed within The Health Improvement Network in the UK, Ogdie et al demonstrated that in a cohort of 8881 patients aged 25–60 years with a code for psoriasis randomly selected between 2008 and 2011, the extent of psoriasis as measured by the body surface area affected (BSA) was a strong predictor of developing PsA. Comorbidities, such as obesity and depression, were additive risk factors. In this cohort, after a mean follow-up time of 4.2 years (SD 2.1), the incidence of PsA was 5.4 cases per 1000 person-years. After adjusting for age and sex, BSA > 10% [hazard ratio (HR) 2.01, 95% CI 1.29, 3.13], BSA 3–10% (HR 1.44, 95% CI 1.02, 2.03), obesity (HR 1.64, 95% CI 1.19, 2.26) and depression (HR 1.68, 95% CI 1.21, 2.33) were associated with incident PsA. Thus, patients with these risk factors should be carefully evaluated at each visit for signs of PsA.

One important question is whether treatment of psoriasis with targeted therapies reduces the risk of incident PsA. In a retrospective cohort study using the electronic medical records of the Maccabi Healthcare Services in Israel, Rosenthal et al, using propensity score matching compared patients who had received biological treatment for psoriasis and were not diagnosed with PsA before or at the time of biologic treatment initiation to controls not on such treatment. Patients were matched by age at diagnosis, gender, time until treatment initiation, maximum body mass index (BMI), and smoking. Multivariable Cox regression analysis showed that the control group had a significantly higher risk for PsA compared to patients treated with biologics (adjusted HR 1.39; 95%CI 1.03-1.87). Thus, there is increasing evidence that biologic therapy may decrease the risk of developing PsA.

Management of comorbidities remain an ongoing challenge in the management of psoriatic disease. In a cross-sectional multi-center study conducted by the Turkish League Against Rheumatism involving 1033 patients with PsA, 383 (37.1%) of whom were obese, Gok et al report that obesity was significantly associated with higher disease activity, lower quality of life scores, anxiety, depression, and fatigue. Comorbidities including obesity must be addressed for holistic management of PsA.

But counseling about modifiable risk factors remains low. Taylor et al reported that counseling or education for modifiable lifestyle risk factors were rare during psoriatic disease outpatient visits. Using data from the National Ambulatory Medical Care Survey (2002-2016) and the National Hospital Ambulatory Medical Care Survey (2002-2011) conducted in the United States, they demonstrate low rates of counseling for any modifiable lifestyle risk factor (11.1%; 95% CI 7.9%-15.3%), tobacco (4.8%; 95% CI 2.8%-8.0%), and obesity (2.8%; 95% CI 1.7%-4.5%). Thus, in addition to counseling about medications, an effort must be made to counsel about modifiable risk factors and comorbidities to improve quality of life of patients with psoriatic disease.

References

Ogdie A, Shin DB, Love TJ, Gelfand JM. Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study. Rheumatology (Oxf). 2021:Sep 11:keab622 (in press). doi: 10.1093/rheumatology/keab622 PMID: 34508558.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Shalev Rosenthal Y, Schwartz N, Sagy I, Pavlovsky L. Psoriatic arthritis incidence among patients receiving biologic medications for psoriasis: A nested case control study. Arthritis Rheumatol. 2021:Aug 23. doi: 10.1002/art.41946. Epub ahead of print. PMID: 34423909.

Gok K, Nas K, Tekeoglu I, Sunar I, Keskin Y, Kilic E, Sargin B, Acer Kasman S, Alkan H, Sahin N, Cengiz G, Cuzdan N, Albayrak Gezer İ, Keskin D, Mulkoglu C, Resorlu H, Bal A, Duruoz MT, Kucukakkas O, Yurdakul OV, Alkan Melikoglu M, Aydin Y, Ayhan FF, Bodur H, Calis M, Capkin E, Devrimsel G, Ecesoy H, Hizmetli S, Kamanli A, Kutluk O, Sen N, Sendur OF, Tolu S, Toprak M, Tuncer T. Impact of obesity on quality of life, psychological status, and disease activity in psoriatic arthritis: a multi‑center study. Rheumatol Int. 2021:Aug 28. doi: 10.1007/s00296-021-04971-8. Epub ahead of print. PMID: 34453579.

Taylor MT, Keller M, Barbieri JS. Lifestyle risk factor counseling at visits for psoriasis and psoriatic arthritis in the United States. J Am Acad Dermatol. 2021:Aug 25:S0190-9622(21)02376-8. doi: 10.1016/j.jaad.2021.08.034. Epub ahead of print. PMID: 34450204

Identifying risk factors for onset of Psoriatic Arthritis (PsA) is a major unmet need. Comparing potential risk factors for the diagnosis of PsA, rheumatoid arthritis (RA), and ankylosing spondylitis (AS) is of interest. Such studies may help us identify shared and unique risk factors of onset of chronic inflammatory arthritis. Meer E et al compared potential risk factors for the diagnosis of PsA, psoriasis, RA, and AS. They conducted four parallel case-control studies using data collected between 1994 and 2015 in The Health Improvement Network, an anonymized longitudinal patient dataset collected at primary care clinics throughout the United Kingdom. PsA was associated with obesity, pharyngitis, skin infections, moderate alcohol intake, gout, and uveitis. As expected, PsA and AS were associated with uveitis. Interestingly, PsA and RA were associated with preceding gout. Smoking was a risk factor for all disease and statin use was inversely associated with all 4 diseases. This study has identified potential risk factors for inflammatory diseases including PsA and may help in early identification as well as risk mitigation.

Most patients develop psoriatic arthritis (PsA) after or simultaneously with cutaneous psoriasis. The mechanisms underlying progression from cutaneous psoriasis to arthritis psoriasis are currently unclear. An important question is whether modern targeted treatment of cutaneous psoriasis reduces the risk of developing PsA. To address this, Acosta Felquer ML et al  conducted a retrospective cohort study to compare the incidence of PsA in 1719 patients with psoriasis (14,721 patient/years of follow up) grouped according to different treatments for their skin psoriasis: topicals, phototherapy or no treatment (n= 1387), conventional disease-modifying antirheumatic drugs (cDMARDs) or biological DMARDs (bDMARDs). During follow-up, 239 patients (14%) developed PsA. The risk of developing PsA in patients treated with bDMARDs was significantly lower (incidence rate ratio (IRR)=0.26; 95% CI 0.03 to 0.94), compared with topicals, but not compared with cDMARDs (IRR=0.35; 95% CI 0.035 to 1.96). Male sex, nail involvement and higher body mass index were associated with increased risk of developing PsA, while bDMARD use was protective. Thus, this study provides some evidence that systemic treatment might ‘protect’ against development if PsA. Appropriately designed prospective studies are required.

One important clinical question is whether patients with oligoarthritis (involvement of <5 joints) progress to polyarthritis. In an observational study Gladman DD et al  reported that in 407 patients evaluated within 12 months of diagnosis, 192 (47%) presented with oligoarthritis. More patients with polyarthritis presented with dactylitis, enthesitis, higher HAQ and lower SF-36 scores. Of the 192 patients with oligoarthritis, 75 (39%) progressed to polyarthritis. Lower SF-36 mental component summary score was the predictor for progressing to polyarthritis. Thus, except for the burden of musculoskeletal involvement, oligoarticular PsA resembles polyarticular PsA and therefore the two PsA subclasses should simply be classified together as peripheral arthritis.

Identifying risk factors for onset of Psoriatic Arthritis (PsA) is a major unmet need. Comparing potential risk factors for the diagnosis of PsA, rheumatoid arthritis (RA), and ankylosing spondylitis (AS) is of interest. Such studies may help us identify shared and unique risk factors of onset of chronic inflammatory arthritis. Meer E et al compared potential risk factors for the diagnosis of PsA, psoriasis, RA, and AS. They conducted four parallel case-control studies using data collected between 1994 and 2015 in The Health Improvement Network, an anonymized longitudinal patient dataset collected at primary care clinics throughout the United Kingdom. PsA was associated with obesity, pharyngitis, skin infections, moderate alcohol intake, gout, and uveitis. As expected, PsA and AS were associated with uveitis. Interestingly, PsA and RA were associated with preceding gout. Smoking was a risk factor for all disease and statin use was inversely associated with all 4 diseases. This study has identified potential risk factors for inflammatory diseases including PsA and may help in early identification as well as risk mitigation.

Most patients develop psoriatic arthritis (PsA) after or simultaneously with cutaneous psoriasis. The mechanisms underlying progression from cutaneous psoriasis to arthritis psoriasis are currently unclear. An important question is whether modern targeted treatment of cutaneous psoriasis reduces the risk of developing PsA. To address this, Acosta Felquer ML et al  conducted a retrospective cohort study to compare the incidence of PsA in 1719 patients with psoriasis (14,721 patient/years of follow up) grouped according to different treatments for their skin psoriasis: topicals, phototherapy or no treatment (n= 1387), conventional disease-modifying antirheumatic drugs (cDMARDs) or biological DMARDs (bDMARDs). During follow-up, 239 patients (14%) developed PsA. The risk of developing PsA in patients treated with bDMARDs was significantly lower (incidence rate ratio (IRR)=0.26; 95% CI 0.03 to 0.94), compared with topicals, but not compared with cDMARDs (IRR=0.35; 95% CI 0.035 to 1.96). Male sex, nail involvement and higher body mass index were associated with increased risk of developing PsA, while bDMARD use was protective. Thus, this study provides some evidence that systemic treatment might ‘protect’ against development if PsA. Appropriately designed prospective studies are required.

One important clinical question is whether patients with oligoarthritis (involvement of <5 joints) progress to polyarthritis. In an observational study Gladman DD et al  reported that in 407 patients evaluated within 12 months of diagnosis, 192 (47%) presented with oligoarthritis. More patients with polyarthritis presented with dactylitis, enthesitis, higher HAQ and lower SF-36 scores. Of the 192 patients with oligoarthritis, 75 (39%) progressed to polyarthritis. Lower SF-36 mental component summary score was the predictor for progressing to polyarthritis. Thus, except for the burden of musculoskeletal involvement, oligoarticular PsA resembles polyarticular PsA and therefore the two PsA subclasses should simply be classified together as peripheral arthritis.

Identifying risk factors for onset of Psoriatic Arthritis (PsA) is a major unmet need. Comparing potential risk factors for the diagnosis of PsA, rheumatoid arthritis (RA), and ankylosing spondylitis (AS) is of interest. Such studies may help us identify shared and unique risk factors of onset of chronic inflammatory arthritis. Meer E et al compared potential risk factors for the diagnosis of PsA, psoriasis, RA, and AS. They conducted four parallel case-control studies using data collected between 1994 and 2015 in The Health Improvement Network, an anonymized longitudinal patient dataset collected at primary care clinics throughout the United Kingdom. PsA was associated with obesity, pharyngitis, skin infections, moderate alcohol intake, gout, and uveitis. As expected, PsA and AS were associated with uveitis. Interestingly, PsA and RA were associated with preceding gout. Smoking was a risk factor for all disease and statin use was inversely associated with all 4 diseases. This study has identified potential risk factors for inflammatory diseases including PsA and may help in early identification as well as risk mitigation.

Most patients develop psoriatic arthritis (PsA) after or simultaneously with cutaneous psoriasis. The mechanisms underlying progression from cutaneous psoriasis to arthritis psoriasis are currently unclear. An important question is whether modern targeted treatment of cutaneous psoriasis reduces the risk of developing PsA. To address this, Acosta Felquer ML et al  conducted a retrospective cohort study to compare the incidence of PsA in 1719 patients with psoriasis (14,721 patient/years of follow up) grouped according to different treatments for their skin psoriasis: topicals, phototherapy or no treatment (n= 1387), conventional disease-modifying antirheumatic drugs (cDMARDs) or biological DMARDs (bDMARDs). During follow-up, 239 patients (14%) developed PsA. The risk of developing PsA in patients treated with bDMARDs was significantly lower (incidence rate ratio (IRR)=0.26; 95% CI 0.03 to 0.94), compared with topicals, but not compared with cDMARDs (IRR=0.35; 95% CI 0.035 to 1.96). Male sex, nail involvement and higher body mass index were associated with increased risk of developing PsA, while bDMARD use was protective. Thus, this study provides some evidence that systemic treatment might ‘protect’ against development if PsA. Appropriately designed prospective studies are required.

One important clinical question is whether patients with oligoarthritis (involvement of <5 joints) progress to polyarthritis. In an observational study Gladman DD et al  reported that in 407 patients evaluated within 12 months of diagnosis, 192 (47%) presented with oligoarthritis. More patients with polyarthritis presented with dactylitis, enthesitis, higher HAQ and lower SF-36 scores. Of the 192 patients with oligoarthritis, 75 (39%) progressed to polyarthritis. Lower SF-36 mental component summary score was the predictor for progressing to polyarthritis. Thus, except for the burden of musculoskeletal involvement, oligoarticular PsA resembles polyarticular PsA and therefore the two PsA subclasses should simply be classified together as peripheral arthritis.

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

In most patients with psoriatic arthritis (PsA), the musculoskeletal manifestations occur after the onset of cutaneous manifestations. The mechanisms underlying the triggering of joint disease is still not well understood, one burning question is whether early and effective treatment of cutaneous psoriasis will reduce the incidence of PsA. In a retrospective non-randomised study, Gisondi et al compared the incidence rates of PsA in patients with chronic plaque psoriasis receiving either continuous treatment with a biologic disease modifying anti-rheumatic drugs (bDMARD- infliximab, etanercept, adalimumab, ustekinumab and secukinumab) for at least 5 years (n=234, 1584 person-year of follow-up) or at least three courses of narrow band ultraviolet B (nb-UVB) phototherapy (n=230, 1478 person-year of follow-up). bDMARDs treatment was associated with a lower risk of incident PsA (adjusted hazard ratio 0.27, 95% Confidence Interval 0.11–0.66). However, analysis after propensity score matching found no significant difference between treatment with bDMARDs and nb-UVB phototherapy and the risk of incident PsA. Prospective studies are required to answer this important question. Interestingly, nail psoriasis was associated with higher risk of PsA, confirming previous observations.

Due to lack of disease activity biomarkers clinical assessment of disease activity in PsA patients with concomitant fibromyalgia can be challenging. Ultrasound (US) may however be useful in providing objective assessment of disease activity. Polachek et al compared 42 patients with PsA and coexisting fibromyalgia syndrome (FMS) (satisfying CASPAR criteria and the 2016 fibromyalgia classification criteria) to 114 PsA patients without FMS (satisfying CASPAR criteria alone). All patients underwent detailed US evaluation including 52 joints, 40 tendons and 14 entheses, and a scores for synovitis, tenosynovitis and enthesitis were summed to obtain a final US disease activity score for each patient. Those with FMS had higher scores of composite clinical disease activity indices. However, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with composite indices in PsA patients without FMS but not in PsA patients with FMS. Thus, US is a tool that can be employed to determine PsA disease activity in patients with concomitant FMS. However, the scanning protocol as described is time consuming. A shortened protocol as well as training of rheumatologists and radiologists for reliably assessing synovitis, tenosynovitis and enthesitis is required before US can be feasibly and reliably used in clinical practice.

IL-23 inhibitors were not found to be efficacious in the treatment of axial spondyloarthritis. It is not clear whether these inhibitors improve axial disease in PsA patients, and if indeed axial PsA is distinct from primary axial spondyloarthritis. In a post-hoc analyses of the DISCOVER 1 and DISCOVER 2 studies that included 312 patients with PsA with imaging-confirmed sacroiliitis randomly assigned to either placebo (n=118), guselkumab Q4 (n=103), or Q8 (n=91), Mease et al demonstrated that at week 24, guselkumab Q4 and Q8 groups vs placebo showed higher least-squares mean changes in BASDAI (−2.7 and −2.7 vs −1.3; P less than .0001) and ASDAS (−1.4 and −1.4 vs −0.7; P less than .0001) scores, which were maintained until week 52. Thus, Guselkumab may improve axial PsA. However, axial PsA has not yet been formally defined, and BASDAI and ASDAS are not specific for axial PsA. Once axial PsA is defined, prospective randomised clinical trials with associated MRI studies will be required to determine if IL-23 inhibitors improve symptoms of axial PsA.

Most research published on psoriatic arthritis (PsA) in the month of June 2021 were related to treatment. Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and anti-tumour necrosis factor (TNF) remain the most used drugs to treat PsA worldwide. However, the benefits of combining csDMARDs and anti-TNF therapies have been less well studied. Lindström et al studied this question using data from 15,332 patients with PsA from 13 European countries participating in the EuroSpA collaboration who initiated a first anti-TNF treatment in 2006–2017.  Sixty-two percent of the patients were on combined therapy, while 38% were no anti-TNF monotherapy. Overall, combined treatment was associated with better remission rates, pooled odds ratio (OR) 1.25 (1.12–1.41). Methotrexate (MTX) comedication was associated with improved rates of remission with adalimumab (OR 1.45 [1.23–1.72]) and infliximab (OR 1.55 [1.21–1.98]) and improved drug retention with infliximab. No effect of comedication could be demonstrated for etanercept. Thus, in clinical practice there may be an advantage to combine MTX with infliximab or adalimumab.

Biosimilars provide similar efficacy and safety to originator biologics at lower cost. Many jurisdictions are mandating nonmedical switch from a biologic to a biosimilar but concerns about such administrative switches remain among patients and physicians. Giunta et al report their observations in patients undergoing nonmedical switch from originator adalimumab to biosimilar adalimumab (ABP 501/ adalimumab-atto). In this retrospective study of 94 patients, 46 of whom underwent nonmedical switch from originator adalimumab to ABP 501, they found no significant differences in PASI or DAS-28 ESR at before and after switch in patients undergoing nonmedical switch from adalimumab originator to ABP 501. This study, although small and observational, adds to the growing body of literature on the effectiveness and safety of biosimilars including nonmedical switching.

About newer therapies, Mease et al reported the 52-week results of the phase 2b trial with tildrakizumab (an anti-IL23 biologic) in PsA. In this study, 391 patients with PsA who were randomly assigned to tildrakizumab 200 mg every 4 weeks (Q4W), tildrakizumab 200 mg, 100 mg, or 20 mg every 12 weeks or placebo Q4W. At week 24, the proportion of patients achieving at least 20% improvement in the American College of Rheumatology response was significantly higher for any dose of tildrakizumab vs placebo (71.4%-79.5% vs 50.6%; all P ≤.0125). However, improvement in dactylitis and enthesitis was not observed. No new safety signals were observed through W52. Tildrakizumab may be another option for the management of PsA but requires further evaluation in phase 3 trials.

About gender differences, Prior-Español et al using the Spanish BIOBADASER III registry demonstrated that women with PsA were at greater risk of discontinuing DMARDs because of both lack of efficacy and adverse events. Finally, Ferguson et al reported results from a prospective, open label study of adults receiving apremilast 30 mg as part of routine care for psoriatic disease. They show that in addition to reduction in disease activity, apremilast treatment was significantly associated with a mean weight loss of 2.2 kg and a mean body mass index decrease of 0.8 kg/m² (both P < .001). Improvement in disease activity did not correlate with weight change.

Most research published on psoriatic arthritis (PsA) in the month of June 2021 were related to treatment. Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and anti-tumour necrosis factor (TNF) remain the most used drugs to treat PsA worldwide. However, the benefits of combining csDMARDs and anti-TNF therapies have been less well studied. Lindström et al studied this question using data from 15,332 patients with PsA from 13 European countries participating in the EuroSpA collaboration who initiated a first anti-TNF treatment in 2006–2017.  Sixty-two percent of the patients were on combined therapy, while 38% were no anti-TNF monotherapy. Overall, combined treatment was associated with better remission rates, pooled odds ratio (OR) 1.25 (1.12–1.41). Methotrexate (MTX) comedication was associated with improved rates of remission with adalimumab (OR 1.45 [1.23–1.72]) and infliximab (OR 1.55 [1.21–1.98]) and improved drug retention with infliximab. No effect of comedication could be demonstrated for etanercept. Thus, in clinical practice there may be an advantage to combine MTX with infliximab or adalimumab.

Biosimilars provide similar efficacy and safety to originator biologics at lower cost. Many jurisdictions are mandating nonmedical switch from a biologic to a biosimilar but concerns about such administrative switches remain among patients and physicians. Giunta et al report their observations in patients undergoing nonmedical switch from originator adalimumab to biosimilar adalimumab (ABP 501/ adalimumab-atto). In this retrospective study of 94 patients, 46 of whom underwent nonmedical switch from originator adalimumab to ABP 501, they found no significant differences in PASI or DAS-28 ESR at before and after switch in patients undergoing nonmedical switch from adalimumab originator to ABP 501. This study, although small and observational, adds to the growing body of literature on the effectiveness and safety of biosimilars including nonmedical switching.

About newer therapies, Mease et al reported the 52-week results of the phase 2b trial with tildrakizumab (an anti-IL23 biologic) in PsA. In this study, 391 patients with PsA who were randomly assigned to tildrakizumab 200 mg every 4 weeks (Q4W), tildrakizumab 200 mg, 100 mg, or 20 mg every 12 weeks or placebo Q4W. At week 24, the proportion of patients achieving at least 20% improvement in the American College of Rheumatology response was significantly higher for any dose of tildrakizumab vs placebo (71.4%-79.5% vs 50.6%; all P ≤.0125). However, improvement in dactylitis and enthesitis was not observed. No new safety signals were observed through W52. Tildrakizumab may be another option for the management of PsA but requires further evaluation in phase 3 trials.

About gender differences, Prior-Español et al using the Spanish BIOBADASER III registry demonstrated that women with PsA were at greater risk of discontinuing DMARDs because of both lack of efficacy and adverse events. Finally, Ferguson et al reported results from a prospective, open label study of adults receiving apremilast 30 mg as part of routine care for psoriatic disease. They show that in addition to reduction in disease activity, apremilast treatment was significantly associated with a mean weight loss of 2.2 kg and a mean body mass index decrease of 0.8 kg/m² (both P < .001). Improvement in disease activity did not correlate with weight change.

Most research published on psoriatic arthritis (PsA) in the month of June 2021 were related to treatment. Conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and anti-tumour necrosis factor (TNF) remain the most used drugs to treat PsA worldwide. However, the benefits of combining csDMARDs and anti-TNF therapies have been less well studied. Lindström et al studied this question using data from 15,332 patients with PsA from 13 European countries participating in the EuroSpA collaboration who initiated a first anti-TNF treatment in 2006–2017.  Sixty-two percent of the patients were on combined therapy, while 38% were no anti-TNF monotherapy. Overall, combined treatment was associated with better remission rates, pooled odds ratio (OR) 1.25 (1.12–1.41). Methotrexate (MTX) comedication was associated with improved rates of remission with adalimumab (OR 1.45 [1.23–1.72]) and infliximab (OR 1.55 [1.21–1.98]) and improved drug retention with infliximab. No effect of comedication could be demonstrated for etanercept. Thus, in clinical practice there may be an advantage to combine MTX with infliximab or adalimumab.

Biosimilars provide similar efficacy and safety to originator biologics at lower cost. Many jurisdictions are mandating nonmedical switch from a biologic to a biosimilar but concerns about such administrative switches remain among patients and physicians. Giunta et al report their observations in patients undergoing nonmedical switch from originator adalimumab to biosimilar adalimumab (ABP 501/ adalimumab-atto). In this retrospective study of 94 patients, 46 of whom underwent nonmedical switch from originator adalimumab to ABP 501, they found no significant differences in PASI or DAS-28 ESR at before and after switch in patients undergoing nonmedical switch from adalimumab originator to ABP 501. This study, although small and observational, adds to the growing body of literature on the effectiveness and safety of biosimilars including nonmedical switching.

About newer therapies, Mease et al reported the 52-week results of the phase 2b trial with tildrakizumab (an anti-IL23 biologic) in PsA. In this study, 391 patients with PsA who were randomly assigned to tildrakizumab 200 mg every 4 weeks (Q4W), tildrakizumab 200 mg, 100 mg, or 20 mg every 12 weeks or placebo Q4W. At week 24, the proportion of patients achieving at least 20% improvement in the American College of Rheumatology response was significantly higher for any dose of tildrakizumab vs placebo (71.4%-79.5% vs 50.6%; all P ≤.0125). However, improvement in dactylitis and enthesitis was not observed. No new safety signals were observed through W52. Tildrakizumab may be another option for the management of PsA but requires further evaluation in phase 3 trials.

About gender differences, Prior-Español et al using the Spanish BIOBADASER III registry demonstrated that women with PsA were at greater risk of discontinuing DMARDs because of both lack of efficacy and adverse events. Finally, Ferguson et al reported results from a prospective, open label study of adults receiving apremilast 30 mg as part of routine care for psoriatic disease. They show that in addition to reduction in disease activity, apremilast treatment was significantly associated with a mean weight loss of 2.2 kg and a mean body mass index decrease of 0.8 kg/m² (both P < .001). Improvement in disease activity did not correlate with weight change.

Several important studies on psoriatic arthritis (PsA) were published in the month of May 2021. Although, 50% of patients with PsA are women, many of them being in the child-beaing age, few studies have investigated pregnancy outcomes in women with psoriatic disease. Xie et al, report the results of their systematic review and meta-analysis of observational studies evaluating the impact of psoriasis and PsA on pregnancy outcomes. They retrieved 16 articles that met their study criteria. They demonstrate that pregnant women with psoriatic disease have significantly higher risk of adverse maternal outcomes (caesarean delivery, preterm birth, (pre)eclampsia, gestational diabetes, or gestational hypertension) compared with general population. However, no increased risk of fetal complications was observed. The authors recommend close monitoring of the mothers’ clinical status before and during pregnancy.

Despite availability of multiple targeted therapies, only about 60% of patients achieve a meaningful response to therapy in randomized trials and only a quarter of patients achieve a state of minimal disease activity. The assessment of musculoskeletal inflammation is heavily dependent on assessment of tender and swollen joints. However, whether tender or swollen joints, especially tender joints, truly reflect joint inflammation is a matter of debate. Felbo et al investigated the association between clinical joint tenderness and intra- and periarticular inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) in patients with active PsA. They found that tender joints poorly reflect intra- and periarticular inflammation assessed by imaging. The association between swollen joints and ultrasound and MRI assessed inflammation was stronger but still only low-to-moderate. The agreement between joint tenderness and imaging assessed inflammation was even weaker in patients with high overall pain scores, high disability scores, or nonerosive disease. Therefore, it is recommended that imaging be used to supplement clinical examination in patients with PsA and high overall pain, disability, and/or nonerosive disease.

With regard to PsA treatment, Rahman et al reported the pooled safety results through one year of two phase 3 trials with guselkumab in PsA. This drug inhibits IL-23, has proven efficacy in PsA and psoriasis, and was recently approved for the treatment of PsA. No active tuberculosis, opportunistic infections, or inflammatory bowel disease, and low rates of malignancy and major adverse cardiovascular events, were observed in guselkumab-treated patients. In another study, using data from 2 large US claims databases, MarketScan and Optum’s De-identified Clinformatics® Data Mart, Jin et al demonstrated that other biologics and apremilast were associated with 1.4- to 3-times higher risk of hospitalized serious infections in patients with psoriatic disease when compared with ustekinumab. Ustekinumab is a biologic agent that inhibits IL-12 and IL-23 and is approved for the treatment of psoriasis, PsA, and ulcerative colitis. The two studies speak to the safety of targeting IL-23 with biologics in psoriatic disease.

Finally, an exploratory, proof-of-concept study explored whether fecal microbiota transplantation (FMT) improves the signs and symptoms of PsA. Kragsnaes et al conducted a double-blind, parallel-group, placebo-controlled, superiority trial, randomly allocating adults with active PsA despite ongoing treatment with methotrexate to one gastroscopic-guided FMT (15 patients) or sham transplantation (16 patients) into the duodenum. Surprisingly, treatment failure occurred more frequently in the FMT group than in the sham group (9 [60%] vs 3 [19%]; risk ratio, 3.20; 95% CI 1.06 to 9.62; P = 0.018). Improvement in HAQ-DI favoured sham treatment. There was no difference in the proportion of ACR20 responders between groups. No serious adverse events were observed. This study highlights that such studies are feasible but indicates that such interventions may not provide significant benefit. Further investigations including careful selection of donors, patients and concomitant therapy is required.

Several important studies on psoriatic arthritis (PsA) were published in the month of May 2021. Although, 50% of patients with PsA are women, many of them being in the child-beaing age, few studies have investigated pregnancy outcomes in women with psoriatic disease. Xie et al, report the results of their systematic review and meta-analysis of observational studies evaluating the impact of psoriasis and PsA on pregnancy outcomes. They retrieved 16 articles that met their study criteria. They demonstrate that pregnant women with psoriatic disease have significantly higher risk of adverse maternal outcomes (caesarean delivery, preterm birth, (pre)eclampsia, gestational diabetes, or gestational hypertension) compared with general population. However, no increased risk of fetal complications was observed. The authors recommend close monitoring of the mothers’ clinical status before and during pregnancy.

Despite availability of multiple targeted therapies, only about 60% of patients achieve a meaningful response to therapy in randomized trials and only a quarter of patients achieve a state of minimal disease activity. The assessment of musculoskeletal inflammation is heavily dependent on assessment of tender and swollen joints. However, whether tender or swollen joints, especially tender joints, truly reflect joint inflammation is a matter of debate. Felbo et al investigated the association between clinical joint tenderness and intra- and periarticular inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) in patients with active PsA. They found that tender joints poorly reflect intra- and periarticular inflammation assessed by imaging. The association between swollen joints and ultrasound and MRI assessed inflammation was stronger but still only low-to-moderate. The agreement between joint tenderness and imaging assessed inflammation was even weaker in patients with high overall pain scores, high disability scores, or nonerosive disease. Therefore, it is recommended that imaging be used to supplement clinical examination in patients with PsA and high overall pain, disability, and/or nonerosive disease.

With regard to PsA treatment, Rahman et al reported the pooled safety results through one year of two phase 3 trials with guselkumab in PsA. This drug inhibits IL-23, has proven efficacy in PsA and psoriasis, and was recently approved for the treatment of PsA. No active tuberculosis, opportunistic infections, or inflammatory bowel disease, and low rates of malignancy and major adverse cardiovascular events, were observed in guselkumab-treated patients. In another study, using data from 2 large US claims databases, MarketScan and Optum’s De-identified Clinformatics® Data Mart, Jin et al demonstrated that other biologics and apremilast were associated with 1.4- to 3-times higher risk of hospitalized serious infections in patients with psoriatic disease when compared with ustekinumab. Ustekinumab is a biologic agent that inhibits IL-12 and IL-23 and is approved for the treatment of psoriasis, PsA, and ulcerative colitis. The two studies speak to the safety of targeting IL-23 with biologics in psoriatic disease.

Finally, an exploratory, proof-of-concept study explored whether fecal microbiota transplantation (FMT) improves the signs and symptoms of PsA. Kragsnaes et al conducted a double-blind, parallel-group, placebo-controlled, superiority trial, randomly allocating adults with active PsA despite ongoing treatment with methotrexate to one gastroscopic-guided FMT (15 patients) or sham transplantation (16 patients) into the duodenum. Surprisingly, treatment failure occurred more frequently in the FMT group than in the sham group (9 [60%] vs 3 [19%]; risk ratio, 3.20; 95% CI 1.06 to 9.62; P = 0.018). Improvement in HAQ-DI favoured sham treatment. There was no difference in the proportion of ACR20 responders between groups. No serious adverse events were observed. This study highlights that such studies are feasible but indicates that such interventions may not provide significant benefit. Further investigations including careful selection of donors, patients and concomitant therapy is required.

Several important studies on psoriatic arthritis (PsA) were published in the month of May 2021. Although, 50% of patients with PsA are women, many of them being in the child-beaing age, few studies have investigated pregnancy outcomes in women with psoriatic disease. Xie et al, report the results of their systematic review and meta-analysis of observational studies evaluating the impact of psoriasis and PsA on pregnancy outcomes. They retrieved 16 articles that met their study criteria. They demonstrate that pregnant women with psoriatic disease have significantly higher risk of adverse maternal outcomes (caesarean delivery, preterm birth, (pre)eclampsia, gestational diabetes, or gestational hypertension) compared with general population. However, no increased risk of fetal complications was observed. The authors recommend close monitoring of the mothers’ clinical status before and during pregnancy.

Despite availability of multiple targeted therapies, only about 60% of patients achieve a meaningful response to therapy in randomized trials and only a quarter of patients achieve a state of minimal disease activity. The assessment of musculoskeletal inflammation is heavily dependent on assessment of tender and swollen joints. However, whether tender or swollen joints, especially tender joints, truly reflect joint inflammation is a matter of debate. Felbo et al investigated the association between clinical joint tenderness and intra- and periarticular inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) in patients with active PsA. They found that tender joints poorly reflect intra- and periarticular inflammation assessed by imaging. The association between swollen joints and ultrasound and MRI assessed inflammation was stronger but still only low-to-moderate. The agreement between joint tenderness and imaging assessed inflammation was even weaker in patients with high overall pain scores, high disability scores, or nonerosive disease. Therefore, it is recommended that imaging be used to supplement clinical examination in patients with PsA and high overall pain, disability, and/or nonerosive disease.

With regard to PsA treatment, Rahman et al reported the pooled safety results through one year of two phase 3 trials with guselkumab in PsA. This drug inhibits IL-23, has proven efficacy in PsA and psoriasis, and was recently approved for the treatment of PsA. No active tuberculosis, opportunistic infections, or inflammatory bowel disease, and low rates of malignancy and major adverse cardiovascular events, were observed in guselkumab-treated patients. In another study, using data from 2 large US claims databases, MarketScan and Optum’s De-identified Clinformatics® Data Mart, Jin et al demonstrated that other biologics and apremilast were associated with 1.4- to 3-times higher risk of hospitalized serious infections in patients with psoriatic disease when compared with ustekinumab. Ustekinumab is a biologic agent that inhibits IL-12 and IL-23 and is approved for the treatment of psoriasis, PsA, and ulcerative colitis. The two studies speak to the safety of targeting IL-23 with biologics in psoriatic disease.

Finally, an exploratory, proof-of-concept study explored whether fecal microbiota transplantation (FMT) improves the signs and symptoms of PsA. Kragsnaes et al conducted a double-blind, parallel-group, placebo-controlled, superiority trial, randomly allocating adults with active PsA despite ongoing treatment with methotrexate to one gastroscopic-guided FMT (15 patients) or sham transplantation (16 patients) into the duodenum. Surprisingly, treatment failure occurred more frequently in the FMT group than in the sham group (9 [60%] vs 3 [19%]; risk ratio, 3.20; 95% CI 1.06 to 9.62; P = 0.018). Improvement in HAQ-DI favoured sham treatment. There was no difference in the proportion of ACR20 responders between groups. No serious adverse events were observed. This study highlights that such studies are feasible but indicates that such interventions may not provide significant benefit. Further investigations including careful selection of donors, patients and concomitant therapy is required.