Clinical remission of psoriatic arthritis in patients receiving continuous biological therapies for 1 year: the experience of an outpatient dermatological clinic for psoriasis

Difficult to treat psoriatic arthritis - how should we manage?

Psoriatic arthritis (PsA) is a chronic, multi-domain immune-mediated inflammatory arthritis with a high disease burden. PsA patients have significant co-morbidities like obesity, depression, fibromyalgia which can impact disease activity assessment. The management of PsA has undergone a paradigm shift over the last decade due to the availability of multiple biologic and targeted synthetic disease modifying anti-rheumatic drugs. Despite the availability of multiple therapeutic agents, it is not uncommon to find patients not responding adequately and continuing to have active disease and/or high disease burden. In our review, we propose what is "difficult to treat PsA", discuss differential diagnosis, commonly overlooked factors, co-morbidities that affect treatment responses, and suggest a stepwise algorithm to manage these patients.

Is pain associated with premature mortality in patients with psoriatic arthritis? A nested case-control study using the DANBIO Register

OBJECTIVES

It has been hypothesized that the presence of chronic pain causes excess mortality. Since chronic pain is prevalent among patients with PsA this potential association should be explored. We aimed to investigate whether higher cumulative pain intensity is associated with an excess mortality risk in patients with PsA.

METHODS

A nested case-control study using data from the nationwide DANBIO Register (Danish Database for Biological Therapies in Rheumatology) Register and Danish healthcare registers. Cases were patients who died and corresponding to the date of death, matched on sex, year of birth and calendar period at the time of death with up to five controls. Exposure of interest was mean pain intensity reported during the time followed in routine rheumatology practice. Pain intensity was measured using a visual analogue scale from 0 to 100 and conditional logistic regression was used to calculate odds of mortality per 5 unit increase in pain while adjusting for confounders.

RESULTS

The cohort consisted of 8019 patients. A total of 276 cases were identified and matched with 1187 controls. Higher mean pain intensity was associated with increased odds of mortality [odds ratio 1.06 (95% CI 1.02, 1.10)] in the crude model, but there was no association [odds ratio 0.99 (95% CI 0.95, 1.03)] when adjusting for additional confounders. Factors shown to increase the odds of mortality were recent glucocorticoid use, concomitant chronic obstructive pulmonary disease, diabetes mellitus, cancer and cardiovascular disease.

CONCLUSION

These results indicate that experienced pain in itself is not associated with premature mortality in patients with PsA. However, recent glucocorticoid use and concurrent comorbidities were.

Fibromyalgia in patients with psoriatic arthritis: Impact on disease activity indices, fatigue and health-related quality of life

OBJECTIVE

To assess the frequency of fibromyalgia (FM) in patients with psoriatic arthritis (PsA) and its impact on disease activity indices, fatigue and health-related quality of life (QOL).

METHODS

This cross-sectional study randomly recruited patients with PsA attending an outpatient clinic between June 2017 and December 2018. Disease activity, functional ability, fatigue, and QOL were assessed for all patients. The recruited PsA patients were screened for concomitant FM, then classified into group Ι, patients with PsA only, and group ΙI, patients with FM-PsA. The severity and impact of FM were assessed for group II patients.

RESULTS

A total of 60 patients with PsA were assessed with a mean age of 49.30 ± 11.69 years, of which 43.3% were female. A total of 23 PsA patients had concomitant FM (38.3%). Patients with FM-PsA showed a statistically higher disease activity in all aspects of PsA except for C-reactive protein, swollen joint count (SJC) and dactylitis count. Patients in both groups had similar functional levels, while fatigue and QOL were statistically worse in patients with FM-PsA than in patients with PsA only.

CONCLUSION

These results might highlight the importance of considering FM as a contextual factor in disease activity assessment in patients with PsA, especially in those with discrepancies in tender joint count/patient-reported outcomes vs SJC/inflammatory markers and those with persistently high disease activity indices.

The impact of coexisting fibromyalgia syndrome on disease activity in patients with psoriatic arthritis and rheumatoid arthritis: A cross-sectional study

BACKGROUND/OBJECTIVE

This study aims to assess the coexistence of fibromyalgia syndrome (FMS) and impact of possible FMS on disease activity in patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA).

METHODS

A total of 126 patients, aged 18-65 years old, who were being followed up with PsA (n = 64) and RA (n = 62) diagnoses were included. The Fibromyalgia Rapid Screening Tool (FiRST) was administered for screening FMS. Patients were divided according to the presence of FMS; PsA patients with FMS, patients with PsA without FMS, patients with both RA and FMS and patients with RA without FMS. Disease Activity Score 28 (DAS28) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were recorded.

RESULTS

FMS was detected in 26.5% of the patients with PsA and 17.7% of the patients with RA (p = .04). A statistically significant higher DAS28 and BASDAI scores were found in patients with FMS (p < .05). There was statistically significant correlation between FiRST with DAS28 and BASDAI scores (p < .001, p = .03, respectively) in PsA patients. No significant correlation was found between FiRST score with age, disease duration, CRP and DAS28 in patients with RA (p > .05).

CONCLUSION

The patients with concomitant FMS had higher disease activity parameters (DAS28 and BASDAI) than those without FMS.

Evaluating Inflammatory Versus Mechanical Back Pain in Individuals with Psoriatic Arthritis: A Review of the Literature

Psoriatic arthritis (PsA) is a chronic immune-mediated disease characterized by psoriatic skin and nail changes, peripheral joint inflammation, enthesitis, dactylitis, and/or axial involvement, either alone or in combination with each other. The presence of axial involvement has been shown to be a marker of PsA severity; however, there is no widely accepted definition of axial involvement in PsA (axPsA) or consensus on how or when to screen and treat patients with suspected axPsA. Chronic back pain is a prominent feature of axPsA and is thought to have a relevant role in early identification of disease. Chronic back pain can be caused by inflammatory back pain (IBP) or mechanical back pain (MBP). However, MBP can complicate recognition of IBP and delay diagnosis of axPsA. While MBP can also be associated with chronic back pain of ≥ 3 months in duration that is typical of IBP, IBP is characterized by inflammation of the sacroiliac joint and lower spine that is differentiated from MBP by key characteristic features, including insidious onset at age < 40 years, improvement with exercise but not with rest, and nighttime pain. This review discusses the differences in identification and management of IBP and MBP in patients with PsA with axPsA. The summary of available evidence highlights the importance of appropriate and timely screening, difficulties and limitations of differential diagnoses and treatment, and unmet needs in axPsA.

Psoriatic arthritis (PsA) is a long-term disease that may lead to psoriatic changes in skin and nails; inflammation of some joints, including finger and toe joints (dactylitis); inflammation of sites where tendons and ligaments connect to bone (enthesitis); and/or problems in the spine (axial involvement). Approximately 25–70% of patients with PsA have axial involvement (axPsA); this number varies because there is no widely accepted definition for axPsA. Chronic (long-lasting) back pain is a major feature of axSpA and can help doctors recognize axPsA early. Chronic back pain can be caused by inflammatory back pain (IBP) or mechanical back pain (MBP). IBP is described by back pain lasting ≥ 3 months, gradual onset at age < 40 years, improvement with exercise, no improvement with rest, pain at night (with improvement upon getting up), and changes in some laboratory test results. On the other hand, MBP is caused by a physical injury to the lower back. Both IBP and MBP can occur in patients with PsA, but they are treated in different ways. Being able to tell the difference between IBP and MBP is important to make sure that patients receive the right treatment. This review looks at the differences between IBP and MBP, screening for IBP, the difficulties and limitations of diagnosing and treating axPsA, and the needs of patients with axPsA for better diagnosis and treatment.

Fibromyalgia interferes with disease activity and biological therapy response in inflammatory rheumatic diseases

Fibromyalgia is one of the numerous comorbidities that may accompany inflammatory rheumatic diseases. Concomitant fibromyalgia in inflammatory rheumatic conditions can interfere with symptomatology, disease activity and overall management plan. The aim of the present narrative review article was to discuss the current evidence on (i) the prevalence/frequency of comorbid fibromyalgia in inflammatory rheumatic conditions, (ii) the role of fibromyalgia on disease activity, (iii) the impact of concomitant fibromyalgia on biological disease-modifying antirheumatic treatment outcomes and (iv) potential effectiveness of biological disease-modifying antirheumatic drugs on fibromyalgia-related symptoms among patients with inflammatory rheumatic diseases. A literature search was conducted through PubMed/MEDLINE Cochrane and Web of Science databases by using relevant keywords and their combinations. Studies representing different geographical areas of the world revealed that frequency rates of fibromyalgia are higher in inflammatory rheumatic diseases than those in the general population. Comorbid fibromyalgia interferes not only with the disease activity scores but also with the treatment outcomes and management plan. Further evidence is warranted in order to determine the potential benefits of biological disease-modifying antirheumatic drugs on fibromyalgia-related symptoms in patients with inflammatory rheumatic diseases.

The impact of the presence of fibromyalgia on fatigue in patients with psoriatic arthritis: comparison with controls

Background

Coexisting fibromyalgia (FM) to psoriatic arthritis (PsA) has been identified and it has been associated with more severe symptoms, impaired function, and greater disability. It was aimed to explore the effect of the presence of FM on fatigue in patients with PsA comparing with controls.

Methods

Fifty patients with PsA and 34 sex-age matched controls were enrolled. In patients; pain was assessed by Visual Analogue Scale, disease activity by DAS-28, enthesitis by The Leeds Enthesitis Index. Fatigue level of all participants was evaluated by Multidimensional Assessment of Fatigue. In all participants, FM was determined according to 2010 American College of Rheumatology criteria.

Results

Seventeen patients with PsA (34%) and 4 controls (11.8%) were diagnosed with FM and all of them were women. There was significant difference between the patients and controls in terms of presence of FM (p < 0.05). Patients’ fatigue scores were significantly higher than controls’ (p = 0.001). There were significant differences between the PsA patients with and without FM with regard to gender, enthesitis, DAS-28 and pain scores (p < 0.05); fatigue scores (p < 0.001). The significant effect of the presence of FM on fatigue was found by univariate analysis of variance in patients (p < 0.001).

Conclusion

It was observed that FM presence and fatigue were more common in PsA patients than controls and comorbid FM had significant effect on fatigue in these patients. Physicians should be aware of the possibility of concomitant FM in patients with PsA.

The Impact of Fibromyalgia in Spondyloarthritis: From Classification Criteria to Outcome Measures

The term spondyloarthritis (SpA) encompasses a broad clinical spectrum characterized by chronic inflammatory conditions affecting the sacroiliac joints, the spine but also peripheral joints and tendons and being additionally associated with the involvement of organs, such as bowel, eye and skin (1). Musculoskeletal pain is a key symptom in SpA. However, although low back pain and/or joint pain are characteristic for SpA, undifferentiated pain at different enthesial sites may also be a concomitant or even the first clinical presentation in some patients (2). In addition, fatigue is another important symptom often reported by patients with SpA, which substantially affects the quality of life (QoL) (3). Fibromyalgia (FM) is the most common diagnosis in patients complaining of chronic diffuse pain with fatigue and may occur alone or in association with chronic inflammatory diseases (4). The prevalence of FM ranges from 2 to 8% in the general population and it can reach up to over 50% in patients with other rheumatic and musculoskeletal diseases (RMDs) (5-7). FM has been identified as the most disabling RMD, based on the patients' perception that their medical condition is not properly recognized (8). This is also due to the poor knowledge about its pathogenesis, and therefore the lack of reliable biomarkers reveals a major unmet need requiring to be addressed in further research studies. Over the last decade, an increasing body of evidence described the impact of FM in SpA highlighting the pitfalls for correct classification, appropriate differential diagnosis and assessment of outcome measures in both conditions. The purpose of this review is to provide an overview of currently available data with regard to the coexistence and reciprocal features of FM and SpA.

Concomitant fibromyalgia complicating chronic inflammatory arthritis: a systematic review and meta-analysis

Objectives

This systematic review and meta-analysis will describe the prevalence of concomitant FM in adults with inflammatory arthritis and quantify the impact of FM on DAS.

Methods

Cochrane library, MEDLINE, Psychinfo, PubMed, Scopus and Web of Science were searched using key terms and predefined exclusion criteria. As appropriate, proportional and pairwise meta-analysis methods were used to pool results.

Results

Forty articles were identified. In RA the prevalence of FM ranged from 4.9 to 52.4% (21% pooled). In axSpA the range was 4.11–25.2% (13% pooled in AS only). In PsA the range was 9.6–27.2% (18% pooled). The presence of concomitant FM was related to higher DAS in patients with RA and AS (DAS28 mean difference 1.24, 95% CI: 1.10, 1.37 in RA; BASDAI mean difference 2.22, 95% CI: 1.86, 2.58 in AS). Concomitant FM was also associated with higher DAS in existing PsA studies. Self-reported, rather than objective, components of DAS appear to be raised in the presence of FM (e.g. tender joint count and Visual Analogue Scale (VAS) pain scores).

Conclusion

FM is common in RA, AxSpA and PsA. Comorbid FM appears to amplify DAS and could therefore influence management of these rheumatic conditions.

The Effect of the Presence of Fibromyalgia on Common Clinical Disease Activity Indices in Patients with Psoriatic Arthritis: A Cross-sectional Study

Objective.

To study the effect of the presence of fibromyalgia (FM) on common clinical disease activity indices in patients with psoriatic arthritis (PsA).

Methods.

Seventy-three consecutive outpatients with PsA (mean age 51.7 yrs; 42 females, 57.5%) were enrolled in a prospective cross-sectional study. FM was determined according to American College of Rheumatism criteria (2010 and 1990). All patients underwent clinical evaluation of disease activity and completed the Health Assessment Questionnaire (HAQ), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Dermatology Life Quality Index, and the Leeds Enthesitis Index (LEI). Disease activity was evaluated using the Composite Psoriatic Disease Activity Index (CPDAI), minimal disease activity (MDA), and the Disease Activity Index for Psoriatic Arthritis (DAPSA) scores.

Results.

The overall prevalence of FM was 17.8% (13 patients), and all but 1 were women (12 patients, 92.3%, p = 0.005). CPDAI and DAPSA scores were significantly higher in patients with coexisting PsA and FM (9.23 ± 1.92 and 27.53 ± 19.23, respectively) than in patients with PsA only (4.25 ± 3.14 and 12.82 ± 12.71, respectively; p < 0.001 and p = 0.003). None of the patients with FM + PsA met the criteria for MDA, whereas 26 PsA-only patients did (43.3%, p = 0.003). HAQ, BASDAI, and LEI scores were significantly worse in patients with PsA and associated FM.

Conclusion.

Coexisting FM is related to worse scores on all tested measures in patients with PsA. Its influence should be taken into consideration in the treatment algorithm to avoid unnecessary upgrading of treatment.