Bone mineral density and body composition in postmenopausal women with psoriasis and psoriatic arthritis

Areal bone mineral density, trabecular bone score and 3D-DXA analysis of proximal femur in psoriatic disease

Objectives

To evaluate bone mineral density (BMD) and bone quality, with assessment of the cortical and trabecular compartments, in patients with psoriasis (PsO) alone or with psoriatic arthritis (PsA).

Methods

Patients with PsA and patients with PsO alone were evaluated and compared to control subjects matched for age, sex and body mass index category. Areal BMD (aBMD) was determined for the lumbar spine, femoral neck, total hip and total body using dual-energy X-ray absorptiometry (DXA). Bone quality was evaluated by using trabecular bone score (TBS) at the lumbar spine, and by 3D DXA-based analysis (3D Shaper) for the proximal femur.

Results

One hundred ninety-six subjects including 52 patients with PsA and 52 patients with PsO and their respective paired controls were analyzed. Patients with PsA had comparable aBMD, TBS and 3D DXA analysis parameters compared to their paired controls. After adjustment for confounders, patients with PsO alone were characterized by a higher aBMD at the left femur and higher cortical 3D DXA derived parameters (total hip cortical surface BMD and total hip cortical thickness) than their paired controls. TBS was decreased in PsO compared to their controls.

Conclusion

Patients with PsA had normal bone mass and bone quality parameters. Patients with PsO were characterized by higher femoral neck bone density by DXA and cortical parameters by 3D DXA-based analysis, supporting no increased risk for hip fracture. Conversely, bone texture by TBS assessment was decreased in patients with PsO, which may be associated with impaired vertebral bone resistance.

High physical activity in persons with psoriatic arthritis is associated with reduced visceral fat mass and percentage body fat: the Trøndelag Health study

The associations of physical activity (PA) with body composition among persons with psoriatic arthritis (PsA) are not well described. The objective was to investigate associations of PA with visceral fat mass and percentage body fat in persons with PsA of different age groups. Persons with PsA (CASPAR criteria, n = 356), and controls (n = 47,470) from the Trøndelag Health Study (HUNT4, 2017-2019) were included. Visceral fat mass and percentage body fat measured using bioelectrical impedance were primary outcomes in multivariable linear regression analysis. PsA, PA (questionnaire data), and age were explanatory variables, with adjustment for sex, smoking, heart disease, lung disease, and height. An interaction term between PsA and age was included in both models. Persons with PsA had altered body composition, including higher visceral fat mass and percentage body fat, especially those < 40 years of age (p ≤ 0.01). Moderate or high PA was associated with significantly lower values of the primary outcomes. Differences were Moderate compared to low PA: 1.4 kg (95% CI 1.3, 1.5 kg) lower visceral fat mass, and 2.0% (95% CI 1.8, 2.1) lower percentage body fat. Differences were High compared to low PA: 3.2 kg (95% CI 3.1, 3.3) lower visceral fat mass and 5.0% (95% CI 4.8, 5.1%) lower percentage body fat. Persons with PsA had higher visceral fat mass and percentage body fat, especially if < 40 years, and PA was associated with lower values of both endpoints. Changes of body composition in persons with PsA may influence important health outcomes and should be addressed in clinical practice.

The risk of osteopenia/osteoporosis and psoriatic disease: A systematic review

Background

Psoriasis (Ps) is a multisystem inflammatory disease associated with several comorbidities; however, its effect on bone health remains uncertain. This systematic review aimed to evaluate the risks of osteopenia (OPe) and osteoporosis (OP) in psoriasis.

Methods

A systematic search was performed for published studies evaluating cutaneous Ps and psoriatic arthritis (PsA) compared with healthy control groups utilizing a validated bone mineral density (BMD) assessment score. Meta-analysis was performed using a random-effects model; pooled estimates and their confidence intervals (CIs) were calculated. For analysis, Ps and PsA groups were combined due to the small number of studies.

Results

Twenty-one studies were included for final analysis; three Ps only, 15 PsA and three both. There was a significant difference between psoriatic disease (combination Ps and PsA group) compared with controls relating to an association with OP/OPe, with an overall odds ratio (OR) of 1.71 (95% CI 1.07-2.74: p-value = 0.026). The Ps group had significantly lower BMD than the control group at both the lumbar spine and femoral neck (mean difference -0.04; 95% CI -0.090 to 0.002 and -0.03; 95% CI -0.059 to 0.003 respectively).

Conclusion

Putative risks of OPe and OP in both Ps and PsA are supported but not confirmed. Significant heterogeneity of reported data limits definitive conclusions in this meta-analysis. This review contributes to the further understanding of Ps as a multisystem disease and future management of potential comorbidities, but highlights key gaps in the literature. Further studies addressing standardised OP reporting, specific disease group characteristics comparing Ps with PsA, patient characteristics and medication use, are required in order to make more certain conclusions with greater clinical impact.

The cardiometabolic conditions of psoriatic disease

Psoriasis (PsO) and psoriatic arthritis (PsA), together known as psoriatic disease (PsD), are immune-mediated diseases with a chronic and relapsing course that affect the skin, the joints or both. The pathophysiology of PsO is complex and involves abnormal expression of keratinocytes and infiltration of the skin with dendritic cells, macrophages, neutrophils and T lymphocytes. Around 30% of patients with PsO develop arthritis with axial and/or peripheral manifestations. Both PsO and PsA share similar Th1- and Th17-driven inflammation, with increased production of inflammatory cytokines, including TNFα, IFN-γ, IL-17, IL-22, IL-23 in the skin and the synovial membrane. PsD is associated with a high burden of cardiometabolic diseases such as hypertension, diabetes, dyslipidemia, obesity, metabolic syndrome and cardiovascular (CV) complications as compared to the general population. These comorbidities share common immunopathogenic pathways linked to systemic inflammation, and are associated with the extent and severity of the disease. Morever, they can influence treatment outcomes in PsD. In this short review, we summarize the available evidence on the epidemiology, clinical aspects and mechanisms of cardiometabolic conditions in patients with PsD. We also discuss the impact of targeted treatments such as methotrexate and biological agents on these cardiometabolic conditions.

Impact of lean and fat mass on disease activity and function in spondyloarthritis

BACKGROUND AND AIMS

Changes in body mass composition such as reduced lean and fat mass can occur in a patient with rheumatic diseases. However, data about body composition in spondyloarthritis (SpA) showed conflicting results. The aim of the present study was to assess by DXA the distribution of lean and fat mass in SpA patients compared to healthy controls and to investigate the association between body mass composition and disease characteristics.

METHODS

We conducted a cross-sectional case-control study including 50 SpA patients and 50 controls. Sociodemographic data as well as disease characteristics were assessed. Body composition measurements, biochemical and inflammatory serum markers were evaluated. Radiographic data (Bath Ankylosing Radiologic Index and the modified Stroke Ankylosing Spondylitis Spine Score was also recorded.

RESULTS

No statistically significant correlation was found between the two groups regarding bone mineral density, body mass distribution. However, a lower weight was observed in the study group compared to the control group (p=0.043). Male gender and younger age were associated with a higher lean mass (p=0.05). C-reactive protein (CRP) level was positively correlated with lean mass (r=0.38, p=0.023). Similarly, BASFI was higher in patients with lower fat mass (r=-0.42, p=0.024). A longer duration of NSAIDs intake was associated with a lower lean mass and a higher fat mass. However, no correlations were found between body mass composition and BASRI mSASSS scores as well as bone mineral density and calcium intake.

CONCLUSION

Our findings suggest that younger age, male gender, and axial phenotype were associated with higher lean mass.

Osteoporosis and Psoriasis: A Literature Review

Psoriasis is a chronic inflammatory skin disease with complex comorbidities. Recent evidence has revealed how the inflammatory nature of psoriasis affects bone mineral density and may lead to osteoporosis. This review outlines the current understanding and advances on the association between psoriasis and osteoporosis. The current literature suggests an increased risk of osteopenia and osteoporosis in patients with extensive and chronic psoriasis, compounded by other lifestyle and genetic factors. It suggests that prophylactic measures such as vitamin D supplementation and increasing weight‐bearing exercises can help, but in patients with extensive psoriasis, prolonged systemic inflammation may require long‐term management. Although there have been many short‐term RCTs on the efficacy and safety of biologics in psoriasis, clinical studies looking at the long‐term effects of biologics, such as whether they might improve bone mineral density in these patients with psoriasis are yet to be conducted.

Tobacco smoking was positively associated with metabolic syndrome among patients with psoriasis in Shanghai: A cross-sectional study

INTRODUCTION

A number of studies have reported a high correlation between psoriasis and metabolic syndrome (MetS), and tobacco smoking is one independent risk factor accounting for the increased prevalence both for psoriasis and MetS. However, few studies have been conducted to assess the effects of tobacco smoking on co-morbidities of psoriasis and MetS.

METHODS

We conducted a cross-sectional study with 1014 psoriasis patients recruited from January to May 2021. Patients were recruited with a cluster survey method in Yueyang Hospital (affiliated with Shanghai University of Traditional Chinese Medicine) and Shanghai Skin Diseases Hospital (affiliated with Tongji University). Data were collected by face-to-face questionnaire interviews which included basic information, personal life habits, medical history, and clinical examinations. SPSS 24.0 was used for data analysis and a p<0.05 was considered statistically significant.

RESULTS

The 1014 psoriasis patients were predominantly males (65.58%), with an average age of 45.98 years (IQR: 34.00–57.00). Of these, 25.74% (261) of psoriasis had MetS and 31.85% (323) were tobacco smokers. Male psoriasis patients had higher tobacco smoking prevalence than female patients. With increasing age and BMI, the prevalence of tobacco smoking among psoriasis patients increased dramatically (p<0.01). Logistic regression indicated that psoriasis patients with tobacco smoking had 1.78 times (95% CI: 1.21–2.60) the probability to have MetS than those without tobacco smoking, even adjusting for potential confounding factors. Moreover, smoking psoriasis patients with MetS consumed more cigarettes per day, with longer smoking duration, but with an older age of smoking initiation.

CONCLUSIONS

The prevalence of tobacco smoking and MetS among psoriasis patients was high in Shanghai, and tobacco smoking was positively associated with the MetS among psoriasis patients. Clinicians should recommend psoriasis patients to abstain from tobacco smoking and provide tobacco cessation assistance regularly.

Risk factors associated with osteoporosis and fracture in psoriatic arthritis

BACKGROUND

Although there are few studies mentioned there may be some relationship between psoriatic arthritis (PsA) and osteoporosis, clinical data in real world still need to be clarified in China. The aim of this study was to assess the areal and volumetric bone mineral density (BMD), frequency of fracture, and risk factors in patients with PsA.

METHODS

A total of one hundred PsA patients who visited Peking University First Hospital and one hundred age- and sex-matched healthy controls with DXA data were enrolled in the study. Patients with clinical fractures confirmed by X-ray during follow-up were also recorded. Clinical characteristics of the patients were recorded and compared between the abnormal BMD group and the normal BMD group, as well as between the fracture and non-fracture groups. Risk factors for fracture and low BMD were analyzed.

RESULTS

Mean BMD at the total hip and femoral neck was significantly lower in PsA patients than that in healthy controls (0.809 ± 0.193 vs. 0.901 ± 0.152 g/cm2, P  = 0.041; 0.780 ± 0.146 vs. 0.865 ± 0.166 g/cm2, P  = 0.037, respectively). Moreover, lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count and DAS28-CRP (r = -0.503, -0.580, -0.438; P < 0.05). Total hip BMD and femoral neck BMD were negatively correlated with HAQ (r = -0.521, -0.335; P < 0.05). Fractures occurred in 29 patients during the follow-up period. Logistic regression analysis showed that older age (OR 1.132 [95%CI: 1.026-1.248), P < 0.05], higher HAQ score (OR 1.493, 95%CI: 1.214-1.836, P < 0.01), higher disease activity index for psoriatic arthritis (OR 1.033, 95% CI: 1.002-1.679, P < 0.05) and hip joint involvement (OR 6.401, 95% CI: 4.012-44.180, P < 0.05) were risk factors for fracture in the multivariate model.

CONCLUSIONS

Increased risks of osteoporosis and fracture were found in PsA patients compared to healthy controls. Besides age, high disease activity and hip joint involvement were risk factors for decreased BMD and fracture.

Extra-Articular Manifestations and Comorbidities in Psoriatic Disease: A Journey Into the Immunologic Crosstalk

Psoriatic arthritis (PsA) is a chronic inflammatory disease primarily affecting peripheral and axial joints, with the possible presence of extra-articular manifestations (EAMs), such as psoriasis, uveitis, and inflammatory bowel disease. Recently, the concept of psoriatic disease (PsD) has been proposed to define a systemic condition encompassing, in addition to joints and EAMs, some comorbidities (e.g., metabolic syndrome, type II diabetes, hypertension) that can affect the disease outcome and the achievement of remission. EAMs and comorbidities in PsA share common immunopathogenic pathways linked to the systemic inflammation of this disease; these involve a broad variety of immune cells and cytokines. Currently, various therapeutics are available targeting different cytokines and molecules implicated in the inflammatory response of this condition; however, despite an improvement in the management of PsA, comprehensive disease control is often not achievable. There is, therefore, a big gap to fill especially in terms of comorbidities and EAMs management. In this review, we summarize the clinical aspects of the main comorbidities and EAMs in PsA, and we focus on the immunopathologic features they share with the articular manifestations. Moreover, we discuss the effect of a diverse immunomodulation and the current unmet needs in PsD.

Visceral adiposity in patients with psoriatic arthritis and psoriasis alone and its relationship with metabolic and cardiovascular risk

BACKGROUND

Fat mass distribution, especially in the abdominal visceral region, has been rarely evaluated in patients with PsA or psoriasis (PsO).

METHODS

Patients with PsA and patients with PsO alone were evaluated and compared with control subjects (1:1 ratio in each patient group) matched for age, sex and BMI category. Body composition and fat distribution (android and visceral fat) were evaluated by DXA. Anthropometric measurements, disease activity and the systematic coronary risk evaluation (SCORE) cardiovascular risk were assessed. Metabolic parameters (insulin, homeostasis model assessment for insulin resistance), serum adipokines [total and high-molecular-weight adiponectin, leptin, resistin and retinol-binding protein-4 (RBP4)] were measured.

RESULTS

Data for 52 patients with PsA and 52 patients with PsO and their respective paired controls were analysed. Android fat and visceral fat were found to be significantly higher in patients with PsO compared with their controls, while these measurements did not differ between patients with PsA and their controls. By multivariate analysis, after adjusting for age, sex and BMI, visceral fat was higher in PsO patients compared with PsA patients (P = 0.0004) and the whole group of controls (P = 0.0013). Insulin levels and HOMA-IR were increased in both PsA and PsO groups. High-molecular-weight/total adiponectin ratio was decreased in patients with PsO. RBP4 was significantly higher in both PsA and PsO patients. In patients with PsO, visceral fat strongly correlated with SCORE (r = 0.61).

CONCLUSION

Visceral fat accumulates more in PsO alone than in PsA. Visceral adiposity may be a more pressing concern in PsO relative to PsA.

TRIAL REGISTRATION

The ADIPSO study (Évaluation du tissu ADIpeux et des adipokines dans le PSOriasis et le rhumatisme psoriasique et analyse de ses relations avec le risque cardiovasculaire) is a case-control study conducted in Besançon, France, and is registered on ClinicalTrials.gov under the number NCT02849795.

Body composition in patients with psoriatic arthritis and changes during interleukin 12/23 inhibition

OBJECTIVE

Little is known about body composition in patients with PsA. We compared body composition parameters in PsA patients and healthy controls, and then investigated the effects of ustekinumab (UST) on body composition in patients with PsA.

METHODS

At baseline, 30 PsA patients were compared cross-sectionnally with 60 non-PsA healthy controls matched for age, sex, menopausal status and body mass index. Thirty active PsA patients treated with UST were included in a 6-month open follow-up study. Body composition parameters were measured at baseline and 6 months of treatment.

RESULTS

Body composition parameters were different in PsA patients compared to healthy controls: in PsA patients, total and appendicular lean mass were lower (p=0.013 and p=0.010 respectively), whereas total fat mass was higher (p<0.001). In 30% of the PsA patients, skeletal muscle mass was below the cut-off for low muscle quantity (men 7.26 kg/m2, women 5.5 kg/m2), whereas no such change was observed in the control group. After 6 months of treatment with UST, there was no significant change in BMI in 18 of the PsA patients. Total lean mass decreased slightly (p=0.046), whereas fat mass tended to increase, but not significantly. No significant changes in appendicular lean mass and skeletal muscle mass index were observed.

CONCLUSION

In this study, we found that PsA patients had higher fat mass and lower lean mass than healthy controls. At 6-months of treatment, total lean mass decreased slightly, whereas fat mass tended to increase, but not significantly.

Psoriatic arthritis is associated with adverse body composition predictive of greater coronary heart disease and type 2 diabetes propensity - a cross-sectional study

OBJECTIVES

To compare body composition in PsA with metabolic disease free (MDF) controls and type 2 diabetes and assess body-composition predicted propensity for cardiometabolic disease.

METHODS

Detailed MRI body composition profiles of 26 PsA participants from the IMAPA study were compared with 130 age, sex and BMI-matched MDF controls and 454 individuals with type 2 diabetes from UK Biobank. The body-composition predicted propensity for coronary heart disease (CHD) and type 2 diabetes was compared between PsA and matched MDF controls.

RESULTS

PsA participants had a significantly greater visceral adipose tissue (VAT) volume [mean 5.89 l (s.d. 2.10 l)] compared with matched-MDF controls [mean 4.34 l (s.d. 1.83 l)] (P <0.001) and liver fat percentage [median 8.88% (interquartile range 4.42-13.18%)] compared with MDF controls [3.29% (1.98-7.25%)] (P <0.001). These differences remained significant after adjustment for age, sex and BMI. There were no statistically significant differences in VAT, liver fat or muscle fat infiltration (MFI) between PsA and type 2 diabetes. PsA participants had a lower thigh muscle volume than MDF controls and those with type 2 diabetes. Body composition-predicted propensity for CHD and type 2 diabetes was 1.27 and 1.83 times higher, respectively, for PsA compared with matched-MDF controls.

CONCLUSION

Individuals with PsA have an adverse body composition phenotype with greater visceral and ectopic liver fat and lower thigh muscle volume than matched MDF controls. Body fat distribution in PsA is more in keeping with the pattern observed in type 2 diabetes and is associated with greater propensity to cardiometabolic disease. These data support the need for greater emphasis on weight loss in PsA management to lessen CHD and type 2 diabetes risk.

Psoriasis is associated with an increased risk of osteoporosis: follow-up and nested case-control studies using a national sample cohort

A total of 25,306 psoriasis participants were matched to 101,224 controls, and the occurrence of osteoporosis was analyzed. Additionally, 79,212 osteoporosis patients were matched to 79,212 controls and a previous history of psoriasis was analyzed. Psoriasis increased the risk of osteoporosis among participants aged ≥ 40 years.

INTRODUCTION

The aim of the present study was to evaluate the association between psoriasis and osteoporosis using two different studies.

METHODS

Data from the Korean National Health Insurance Service-Health Screening Cohort of participants aged ≥ 40 years were collected from 2002 to 2013. Psoriasis and osteoporosis were included using International Classification of Diseases (ICD)-10 codes. In study I (a follow-up study), a total of 25,306 psoriasis participants were matched to 101,224 controls with respect to age, sex, income, and region of residence, and the occurrence of osteoporosis was analyzed. Crude (simple) and adjusted hazard ratios (HRs) were analyzed using a stratified Cox proportional hazard model. In study II (a nested case-control study), a total of 79,212 osteoporosis patients were matched to 79,212 controls and a previous history of psoriasis was analyzed. Crude and adjusted odds ratios (ORs) were analyzed using a conditional logistic regression analysis. Subgroup analyses were conducted according to age group and sex.

RESULTS

The adjusted HR of osteoporosis was 1.09 (95% confidence interval [CI] = 1.05-1.13, P < 0.001) in study I. In the subgroup analysis according to age and sex, the results were consistent except for ≥ 60-year-old women. The adjusted OR of psoriasis was 1.21 (95% CI = 1.16-1.27, P < 0.001) in study II. All subgroups demonstrated high adjusted ORs of osteoporosis for psoriasis.

CONCLUSIONS

Psoriasis increased the risk of osteoporosis among participants aged ≥ 40 years in Korea.

Adiposity and Physical Activity as Risk Factors for Developing Psoriatic Arthritis: Longitudinal Data From a Population-Based Study in Norway

OBJECTIVE

Adiposity is prevalent among patients with psoriatic arthritis (PsA). However, the temporal relation is unclear. The present study was undertaken to investigate whether adiposity and body fat distribution are related to the risk of developing PsA, and whether physical activity could modify the possible risk.

METHODS

We included 36,626 women and men from the Norwegian Nord-Trøndelag Health Study without diagnosed PsA at baseline from 1995 to 1997. Cox regression analysis was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs) of incident PsA at follow-up from 2006 to 2008.

RESULTS

During follow-up, 185 new cases of PsA were reported. Increases of 1 SD in body mass index (BMI) (4.2 and 3.5 kg/m² for women and men, respectively) and waist circumference (10.8 and 8.6 cm, respectively) were associated with HRs of 1.40 (95% CI 1.24, 1.58) and 1.48 (95% CI 1.31, 1.68), respectively. Compared to individuals of normal weight, obese individuals had an HR of 2.46 (95% CI 1.65, 3.68), and overweight individuals had an HR of 1.41 (95% CI 1.00, 1.99). Comparing extreme quartiles of waist circumference yielded an HR of 2.63 (95% CI 1.73, 3.99). In analyses of combined effects using a BMI of <25 kg/m² and high physical activity as reference, a BMI of ≥25 kg/m² was associated with HRs of 2.06 (95% CI 1.18, 3.58) and 1.53 (95% CI 0.80, 2.91) among those with low and high physical activity levels, respectively. Corresponding HRs for high waist circumference and physical activity were 2.25 (95% CI 1.40, 1.63) and 1.85 (95% CI 0.95, 3.50).

CONCLUSION

The results suggest that adiposity, particularly central obesity, is associated with increased risk of incident PsA. Although there was no clear modifying effect of physical activity, high levels of physical activity reduced the risk of PsA, regardless of BMI.

IL-33/Vitamin D Crosstalk in Psoriasis-Associated Osteoporosis

Patients with psoriasis (Pso) and, in particular, psoriatic arthritis (PsoA) have an increased risk of developing osteoporosis (OP). It has been shown that OP is among the more common pathologies associated with Pso, mainly due to the well-known osteopenizing conditions coexisting in these patients. Pso and OP share common risk factors, such as vitamin D deficiency and chronic inflammation. Interestingly, the interleukin (IL)-33/ST2 axis, together with vitamin D, is closely related to both Pso and OP. Vitamin D and the IL-33/ST2 signaling pathways are closely involved in bone remodeling, as well as in skin barrier pathophysiology. The production of anti-osteoclastogenic cytokines, e.g., IL-4 and IL-10, is promoted by IL-33 and vitamin D, which are stimulators of both regulatory and Th2 cells. IL-33, together with other Th2 cytokines, shifts osteoclast precursor differentiation towards macrophage and dendritic cells and inhibits receptor activator of nuclear factor kappa-B ligand (RANKL)-induced osteoclastogenesis by regulating the expression of anti-osteoclastic genes. However, while the vitamin D protective functions in OP and Pso have been definitively ascertained, the overall effect of IL-33 on bone and skin homeostasis, because of its pleiotropic action, is still controversial. Emerging evidence suggests a functional link between vitamin D and the IL-33/ST2 axis, which acts through hormonal influences and immune-mediated effects, as well as cellular and metabolic functions. Based on the actions of vitamin D and IL-33 in Pso and OP, here, we hypothesize the role of their crosstalk in the pathogenesis of both these pathologies.

Bone Mineral Density, Osteoporosis, and Fracture Risk in Adult Patients with Psoriasis or Psoriatic Arthritis: A Systematic Review and Meta-Analysis of Observational Studies

INTRODUCTION

Awareness of psoriasis-related comorbidities has been established in the current guidelines; however, evidence regarding the association of bone density or bone fragility with psoriatic disease remains inconclusive.

METHODS

We conducted a systematic review and meta-analysis to assess bone mineral density and the risk of osteoporosis and fractures in patients with psoriatic disease, including those with cutaneous psoriasis and psoriatic arthritis. We searched electronic databases for published observational studies. A meta-analysis was performed using the random-effect model. Pooled estimates and their confidence intervals (CIs) were calculated. Small-study effects were examined using the Doi plot and Luis Furuya-Kanamori index.

RESULTS

The analysis of the standardized mean difference in the absolute value of bone mineral density at different measuring sites (lumbar spine, femoral neck, and total hip) revealed no significant difference between patients with psoriatic disease and non-psoriatic controls. The pooled results of the adjusted odds ratios (ORs) demonstrated no increased risk of osteoporosis in patients with psoriatic disease. Notably, patients with psoriatic disease had a higher OR of developing bone fractures (adjusted OR: 1.09; 95% CI: 1.06 to 1.12; I²: 0%).

CONCLUSION

Patients with psoriatic disease may be more likely to develop fractures compared with non-psoriatic controls. This higher risk for fracture may not necessarily be associated with lower bone mineral density nor a higher risk for osteoporosis.

Systemic evaluation of the relationship between psoriasis, psoriatic arthritis and osteoporosis: observational and Mendelian randomisation study

OBJECTIVES AND METHODS

With 432 513 samples from UK Biobank dataset, multivariable linear/logistic regression were used to estimate the relationship between psoriasis/psoriatic arthritis (PsA) and estimated bone mineral density (eBMD)/osteoporosis, controlling for potential confounders. Here, confounders were set in three ways: model0 (including age, height, weight, smoking and drinking), model1 (model0 +regular physical activity) and model2 (model1 +medication treatments). The eBMD was derived from heel ultrasound measurement. And 4904 patients with psoriasis and 847 patients with PsA were included in final analysis. Mendelian randomisation (MR) approach was used to evaluate the causal effect between them.

RESULTS

Lower eBMD were observed in patients with PsA than in controls in both model0 (β-coefficient=-0.014, p=0.0006) and model1 (β-coefficient=-0.013, p=0.002); however, the association disappeared when conditioning on treatment with methotrexate or ciclosporin (model2) (β-coefficient=-0.005, p=0.28), mediation analysis showed that 63% of the intermediary effect on eBMD was mediated by medication treatment (p<2E-16). Patients with psoriasis without arthritis showed no difference of eBMD compared with controls. Similarly, the significance of higher risk of osteopenia in patients with PsA (OR=1.27, p=0.002 in model0) could be eliminated by conditioning on medication treatment (p=0.244 in model2). Psoriasis without arthritis was not related to osteopenia and osteoporosis. The weighted Genetic Risk Score analysis found that genetically determined psoriasis/PsA were not associated with eBMD (p=0.24 and p=0.88). Finally, MR analysis showed that psoriasis/PsA had no causal effect on eBMD, osteoporosis and fracture.

CONCLUSIONS

The effect of PsA on osteoporosis was secondary (eg, medication) but not causal. Under this hypothesis, psoriasis without arthritis was not a risk factor for osteoporosis.

Role of osteodensitometry in osteoporosis and osteopenia in psoriatic arthritis

Dual-energy X-ray Absorptiometry (DEXA) determines the mineral contents for the spine, the proximal femur and the entire body. A group of 36 patients with psoriatic arthritis were chosen, with different types of arthropathy, from the total 82 patients with psoriatic arthritis in the study group, for which bone mineral density (BMD) was measured, using the DEXA technique. The chosen study group comprised 12 men, 12 premenopausal women and 12 menopausal women, with psoriatic joint damage and a group of 36 healthy individuals, divided based on the same criteria: Men, premenopausal and menopausal women. This study did not emphasize an association between the patient type and the presented bone demineralization type (χ² ₍₂₎=4.473, P=0.107) in men. In premenopausal women, there was a significant association between the patient type and the presented bone demineralization type (χ² ₍₂₎=8.778, P=0.012), as the female patients with psoriatic arthritis presented total and partial demineralization to a larger degree, compared with healthy individuals. In menopausal women, this study did not highlight an association between the patient type and the presented bone demineralization type (χ² ₍₂₎=4.523, P=0.104). Bone demineralization was significant in all three patient groups, both total and partial, in patients with psoriatic arthritis compared with healthy patients. Bone demineralization manifested as osteopenia, with T-scores ranging from -2.5 to -1, and not as osteoporosis. Determining B MD by DEXA technique revealed osteopenia to a higher degree within the group of patients with psoriatic arthritis compared with the healthy patients, as well as the absence of osteoporosis in psoriatic arthritis.

Osteoporosis in Skin Diseases

Osteoporosis (OP) is defined as a generalized skeletal disease characterized by low bone mass and an alteration of the microarchitecture that lead to an increase in bone fragility and, therefore, an increased risk of fractures. It must be considered today as a true public health problem and the most widespread metabolic bone disease that affects more than 200 million people worldwide. Under physiological conditions, there is a balance between bone formation and bone resorption necessary for skeletal homeostasis. In pathological situations, this balance is altered in favor of osteoclast (OC)-mediated bone resorption. During chronic inflammation, the balance between bone formation and bone resorption may be considerably affected, contributing to a net prevalence of osteoclastogenesis. Skin diseases are the fourth cause of human disease in the world, affecting approximately one third of the world's population with a prevalence in elderly men. Inflammation and the various associated cytokine patterns are the basis of both osteoporosis and most skin pathologies. Moreover, dermatological patients also undergo local or systemic treatments with glucocorticoids and immunosuppressants that could increase the risk of osteoporosis. Therefore, particular attention should be paid to bone health in these patients. The purpose of the present review is to take stock of the knowledge in this still quite unexplored field, despite the frequency of such conditions in clinical practice.

Fragility fractures in psoriatic arthritis patients: a matched retrospective cohort study

OBJECTIVE

To compare incidental fragility fractures in psoriatic arthritis (PsA) patients with matched controls from a university hospital.

METHODS

Consecutive PsA patients were matched (age and sex) with controls (1:2). Follow-up began at index date, defined as the date of PsA diagnosis for cases and their respective controls, until the last hospital visit, death or the end of the study (31 December 2017). Electronic medical records were reviewed for osteoporotic fractures. Incidence rates per 100,000 persons-years (PY) of distinct types of fractures after index dates were calculated and compared between groups. A multivariate Cox regression analysis was performed to investigate determinants of fractures.

RESULTS

Ninety-two PsA patients and 184 controls were included. No difference was found in the overall fracture incidence rate per 100,000 PY between PsA and controls (1020 95% CI 510-1930, vs 870 95% CI 520-1390, p = 0.36). Vertebral fractures were numerically more frequent in PsA patients with an incidence rate of 1020 (95% CI 510-1930) per 100,000 PY versus 460 (95% CI 240-920), per 100,000 PY in the control group but it did not reach statistical significance (p = 0.06). In the Cox regression analysis, after adjusting for bisphosphonate use, only age (HR 1.10, 1.05-1.16, p < 0.001) and female sex (HR 3.94, 1.11-13.91, p = 0.03) were associated with fractures while PsA diagnosis and use of glucocorticoids were not.

CONCLUSION

In this cohort of PsA patients, no overall increased risk of fractures was found in comparison with matched controls. Key Points • PsA could have different effects on bone, leading to confusing results in bone densitometry readings contributing to the difficulty in establishing the real prevalence of OP in PsA. • Vertebral fractures were more frequent in PsA patients compared to controls, but it did not reach statistical significance. No difference was found in the overall fracture incidence rate.

The Interrelations between Biological and Targeted Synthetic Agents Used in Inflammatory Joint Diseases, and Obesity or Body Composition

Obesity is a comorbidity that plays a role in the development and severity of inflammatory joint diseases, including rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. The relationships between obesity and adipose tissue and the treatments given for inflammatory joint diseases are bidirectional. In fact, biological agents (bDMARDs) and targeted synthetic agents (tsDMARDs) may influence body weight and body composition of treated patients, while obesity in turn may influence clinical response to these agents. Obesity is a prevalent comorbidity mainly affecting patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) with specific phenotypes. Tumour necrosis factor alpha (TNFα) inhibitors have been associated with changes in body composition by improving lean mass, but also by significantly increasing fat mass, which localized toward the abdominal/visceral region. The IL-6 inhibitor tocilizumab is associated with an increase in lean mass without change in fat mass. The clinical response to TNFα inhibitors is attenuated by obesity, an effect that is less pronounced with IL-6 inhibitors and the B-cell depletion agent rituximab. Conversely, body weight has no influence on the response to the costimulation inhibitor abatacept. These effects may be of help to the physician in personalized medicine, and may guide the therapeutic choice in obese/overweight patients.

Higher bodily adiposity, fat intake, and cholesterol serum levels are associated with higher disease activity in psoriatic arthritis patients: is there a link among fat and skin and joint involvement?

Introduction/ objectives

Assuming that there is a link between lipid and glucose metabolism and inflammation in patients with psoriatic arthritis (PsA), our aim was to evaluate the relationships among body composition measurements, food intake, and disease activity in patients with PsA.

Methods

A total of 97 patients with PsA, according to the CASPAR criteria, were included in this cross-sectional study. Body composition measurements (whole-body DXA, GE-Lunar), food intake (3-day registry) and biochemical and inflammatory serum markers were evaluated. Skin and joint disease activity were assessed by using PASI, BSA, DAS28, and minimal disease activity (MDA). The level of significance was set as p < 0.05.

Results

A higher prevalence of obesity, according to the fat mass index (FMI) (92.7%), and metabolic syndrome (MetS) (54%) were found, but no significant changes regarding lean or bone mass were found. Joint disease activity was positively correlated with total body fat (r = 0.4; p < 0.001), FMI (r = 0.33; p < 0.001), body mass index (r = 0.20; p < 0.049) and waist circumference (r = 0.27; p = 0.009). In addition, joint disease activity was negatively associated with muscle mass (r = − 0.38; p < 0.001). Skin disease activity was positively correlated with total cholesterol (r = 0.3; p = 0.003) and LDL-cholesterol (r = 0.28; p = 0.006). After multiple adjustments, patients with severe joint disease activity had higher body adiposity than patients in remission or with low disease activity. Skin disease activity was associated with higher trans-fat intake and lower omega-6 consumption.

Conclusions

Our data suggest a possible harmful link among fat (body adiposity, saturated fat consumption, LDL-cholesterol serum levels) and joint and skin disease activity in patients with PsA.

Could Omega 3 Fatty Acids Preserve Muscle Health in Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by a high prevalence of death due to cardiometabolic diseases. As observed during the aging process, several comorbidities, such as cardiovascular disorders (CVD), insulin resistance, metabolic syndrome and sarcopenia, are frequently associated to RA. These abnormalities could be closely linked to alterations in lipid metabolism. Indeed, RA patients exhibit a lipid paradox, defined by reduced levels of total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol whereas the CVD risk is increased. Moreover, the accumulation of toxic lipid mediators (i.e., lipotoxicity) in skeletal muscles can induce mitochondrial dysfunctions and insulin resistance, which are both crucial determinants of CVD and sarcopenia. The prevention or reversion of these biological perturbations in RA patients could contribute to the maintenance of muscle health and thus be protective against the increased risk for cardiometabolic diseases, dysmobility and mortality. Yet, several studies have shown that omega 3 fatty acids (FA) could prevent the development of RA, improve muscle metabolism and limit muscle atrophy in obese and insulin-resistant subjects. Thereby, dietary supplementation with omega 3 FA should be a promising strategy to counteract muscle lipotoxicity and for the prevention of comorbidities in RA patients.

Osteoporosis and Psoriasis

Psoriasis is a chronic inflammatory disease associated with multiple comorbidities, particularly in patients with arthritis or more severe forms of the disease. The link between all these comorbidities is probably systemic inflammation. Several recent studies have indicated that patients with psoriasis may be at an increased risk of pathologic fractures and osteoporosis. Current guidelines on comorbidities in psoriasis do not recommend assessment of bone health. In this article, we review the available evidence on the association between psoriasis and osteoporosis. We first examine the concept of osteoporosis and the role of vitaminD in bone health and then propose an algorithm for managing and treating this condition in patients with psoriasis.

Impact of obesity on autoimmune arthritis and its cardiovascular complications

Obesity can instigate and sustain a systemic low-grade inflammatory environment that can amplify autoimmune disorders and their associated comorbidities. Metabolic changes and inflammatory factors produced by the adipose tissue have been reported to aggravate autoimmunity and predispose the patient to cardiovascular disease (CVD) and metabolic comorbidities. Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are autoimmune arthritic diseases, often linked with altered body mass index (BMI). Severe joint inflammation and bone destruction have a debilitating impact on the patient's life; there is also a staggering risk of cardiovascular morbidity and mortality. Furthermore, these patients are at risk of developing metabolic symptoms, including insulin resistance resulting in type 2 diabetes mellitus (T2DM). In addition, arthritis severity, progression and response to therapy can be markedly affected by the patient's BMI. Hence, a complex integrative pathogenesis interconnects autoimmunity with metabolic and cardiovascular disorders. This review aims to shed light on the network that connects obesity with RA, PsA, systemic lupus erythematosus and Sjӧgren's syndrome. We have focused on clarifying the mechanism by which obesity affects different cell types, inflammatory factors and traditional therapies in these autoimmune disorders. We conclude that to further optimize arthritis therapy and to prevent CVD, it is imperative to uncover the intricate relation between obesity and arthritis pathology.

Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population

Background

The risk of osteoporosis in patients with psoriatic arthritis (PsA) still remains unclear. The aim of this study was to investigate bone mineral density (BMD) at the hip and lumbar spine measured by dual-energy X-ray absorptiometry in patients with PsA.

Methods

From an outpatient clinic in southern Norway, 140 patients with PsA were consecutively recruited and assessed for osteoporosis as part of a prospective study from January 2013 to May 2014. An extensive data collection was performed including demographic data and measures reflecting disease activity and health status.

Results

Mean age was 52.4 years and 71 (50.7%) were women. Median disease duration was 7.8 years. The proportion of patients with low BMD (defined as Z score≤-1.0 SD) was comparable to the expected value of 16%, according to the normal distribution of the Z score in the population. Osteoporosis was only found in 6.4% (95% CI3% to 11%) of the patients. No significant associations were found between BMD and disease activity measures.

Conclusion

The prevalence of PsA patients with osteoporosis or low BMD was low and in the range seen in the reference population. This supports that patients with PsA are not at high risk for osteoporosis compared with the general population. Therefore, clinicians may follow the general population guidelines for monitoring of osteoporosis for patients with PsA.

Addressing comorbidities in psoriatic disease

Psoriasis and PsA are associated with comorbidities including cardiovascular disease, obesity, metabolic syndrome and depression. The purpose of this study was to examine if patients recognize that they are being monitored for comorbidities associated with their condition, and to determine which physicians are managing these comorbidities. Patients with psoriasis without arthritis (PsC) and patients with PsA were recruited from the University of Toronto Psoriasis Cohort and Psoriatic Arthritis Clinic, respectively. A comorbidity questionnaire was developed through a literature review and patients completed the questionnaire at clinic visits or over the telephone. PsA patient responses were compared with information recorded by physicians at clinic visits. A total of 268 patients (103 PsC and 164 PsA) were included. Patients indicated having their blood pressure (96.3%), weight (94.4%), blood sugar (75%) and cholesterol (79.5%) levels checked, with PsA patients indicating being checked more frequently than PsC patients. PsA patients were most uncertain about whether their blood sugar and cholesterol levels were checked by physicians. The highest correlation between patient responses and physician records occurred for medications for diabetes, depression and hypercholesterolemia. Patients indicated their family physician were most responsible in monitoring the comorbidities. Overall, patients documented being moderately well screened for most comorbidities and were most unsure about having their blood sugar and cholesterol levels monitored. Patient education and records should be improved at clinic visits, as there are discrepancies between patient responses and physician records regarding the presence and treatment of comorbidities.

Bone mineral density in patients with psoriatic arthritis: data from the Nord-Trøndelag Health Study 3

Background

The risk of osteoporosis in patients with psoriatic arthritis (PsA) remains unclear. The aim of this study was to compare bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) in patients with PsA and controls.

Patients and methods

Patients with PsA and controls were recruited from the Nord-Trøndelag Health Study (HUNT) 3.

Results

Patients with PsA (n=69) and controls (n=11 703) were comparable in terms of age (56.8 vs 55.3 years, p=0.32), gender distribution (females 65.2% vs 64.3%, p=0.87) and postmenopausal status (75.6% vs 62.8%, p=0.08). Body mass index (BMI) was higher in patients with PsA compared with controls (28.5 vs 27.2 kg/m², p=0.01). After adjusting for potential confounding factors (including BMI), BMD was higher in patients with PsA compared with controls at lumbar spine 1–4 (1.213 vs 1.147 g/cm², p=0.003) and femoral neck (0.960 vs 0.926 g/cm², p=0.02), but not at total hip (1.013 vs 0.982 g/cm², p=0.11). Controls had significantly higher odds of having osteopenia or osteoporosis based on measurements of BMD in both the femoral neck (p=0.001), total hip (p=0.033) and lumbar spine (p=0.033).

Conclusion

Our population-based data showed comparable BMD in patients with PsA and controls. This supports that the PsA population is not at increased risk of osteoporosis.

The relevance of serum vitamin D in psoriasis: a review

Observational research has identified low serum levels of 25-hydroxyvitamin D (25[OH]D) in many non-skeletal diseases. Whether this is causal or due to underlying illness is unknown. Low serum 25[OH]D levels are also reported in the general population. Observational and experimental studies identify that vitamin D supplementation may be beneficial in reducing all-cause mortality in elderly women, as well as cancer mortality. Our aim was to review the literature to identify the relevance of serum 25[OH]D levels in psoriasis. Forty-five studies were included in our analysis. Most of these studies identified low serum 25[OH]D levels in psoriasis patients. Evidence of causality is lacking. Treatment with phototherapy leads to an increase in serum 25[OH]D. There is little evidence that the increase in 25[OH]D after phototherapy correlates with improved disease severity. Multiple studies report an improvement in psoriasis with vitamin D supplementation. These data are predominantly from small observational or non-randomised interventional studies. Randomised controlled trials to date have had small numbers and short follow-up periods. The optimal dose of supplementation is unknown and dosing is not standardised across different studies. The definition of vitamin D insufficiency varies across studies. Low serum 25[OH]D levels may be associated with comorbidities in psoriasis patients, including metabolic syndrome and cardiovascular risk. Evidence of causation is absent. Until further high-quality evidence is available, the relevance of low serum 25[OH]D levels in psoriasis patients is unknown, as is the benefit of supplementation on disease control. Supplementation in patients with low 25[OH]D is of benefit to those at risk of impaired bone health.

Psoriasis, fracture risk and bone mineral density: the HUNT Study, Norway

BACKGROUND

An association between psoriasis and osteoporosis has been reported.

OBJECTIVES

To investigate, in a large prospective population-based Norwegian study, whether psoriasis is associated with increased risk of forearm or hip fracture; to investigate the cross-sectional association between psoriasis and bone mineral density (BMD) T-score in a subpopulation.

METHODS

Hospital-derived fracture data from Nord-Trøndelag County (1995-2013) were linked to psoriasis information, BMD measurements and lifestyle factors from the third survey of the Nord-Trøndelag Health Study 2006-08 (HUNT3); socioeconomic data from the National Education Database; and use of medication from the Norwegian Prescription Database.

RESULTS

Among 48 194 participants in HUNT3, we found no increased risk of forearm or hip fracture in 2804 patients with self-reported psoriasis [overall age- and sex-adjusted hazard ratio 1·03, 95% confidence interval (CI) 0·82-1·31]. No clear association was found between psoriasis and mean BMD T-score; overall age- and sex-adjusted differences in total hip, femoral neck and lumbar spine BMD T-scores were 0·02 (95% CI -0·11 to 0·14), 0·05 (95% CI -0·06 to 0·17) and 0·07 (95% CI -0·09 to 0·24), respectively. No clear association was found between psoriasis and prevalent osteoporosis in either total hip, femoral neck or lumbar spine; overall age- and sex-adjusted odds ratio was 0·77 (95% CI 0·54-1·10). Associations did not change substantially after adjustment for education, smoking, systemic steroid use and body mass index.

CONCLUSIONS

We found no association between psoriasis and risk of fracture. The study did not indicate reduced BMD T-score or higher prevalence of osteoporosis among patients with psoriasis.

Imaging in osteoporosis in rheumatic diseases

Osteoporosis is a common comorbidity of all major rheumatic diseases, and manifests itself both systemically and locally. Systemic bone loss manifests because of several factors, primarily inflammation, immobility, and commonly used medical treatment for rheumatic diseases. Local bone loss manifests as periarticular demineralization and bone erosion due to local release of inflammatory agents and cytokines, which promote bone resorption. All these factors contribute to the phenomenon of arthritis-associated osteoporosis. This review summarized the currently available and used methods that play a role in the diagnosis and monitoring of osteoporosis and in the detection of osteoporotic fractures.

Carotid plaque and bone density and microarchitecture in psoriatic arthritis: the correlation with soluble ST2

Psoriatic arthritis (PsA) patients have increased risk of both atherosclerosis and osteoporosis. Previous studies revealed that IL-33/ST2 axis may be related to both conditions; however, these associations were never evaluated in a single patients’ group. Here we explored the association among plasma levels of IL-33 and its decoy receptor soluble ST2 (sST2), carotid plaque determined by ultrasound, and volumetric bone mineral density (vBMD)/microstructure of distal radius measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 80 PsA patients (55% male; 53.0 ± 10.1 years). Plasma sST2 levels were significantly higher in 33 (41%) patients with carotid plaques (11.2 ± 4.5 vs 7.7 ± 3.7 ng/ml, P < 0.001). In multivariate analysis, sST2 was an independent explanatory variable associated with carotid plaques (OR = 1.296, 95% CI: [1.091,1.540]; P = 0.003). After adjustment for the osteoporotic risk factors, sST2 was significantly associated with higher cortical porosity (β = 0.184, [0.042,0.325]; P = 0.012) and cortical pore volume (2.247, [0.434,4.060]; P = 0.016); and had a trend to be associated with lower cortical vBMD (−2.918, [−6.111,0.275]; P = 0.073). IL-33 was not associated with carotid plaque or vBMD/microstructure. In conclusion, plasma sST2 levels were independently correlated with both carotid plaque and compromised cortical vBMD/microstructure in PsA patients. IL-33/ST2 axis may be a link between accelerated atherosclerosis and osteoporosis in PsA.

Environmental Risk Factors in Psoriasis: The Point of View of the Nutritionist

Psoriasis is a common, chronic, immune-mediated skin disease with systemic pro-inflammatory activation, where both environmental and genetic factors contribute to its pathogenesis. Among the risk factors for psoriasis, evidence is accumulating that nutrition plays a major role, per se, in psoriasis pathogenesis. In particular, body weight, nutrition, and diet may exacerbate the clinical manifestations, or even trigger the disease. Understanding the epidemiological relationship between obesity and psoriasis is also important for delineating the risk profile for the obesity-related comorbidities commonly found among psoriatic patients. Moreover, obesity can affect both drug’s pharmacokinetics and pharmacodynamics. Additionally, the overall beneficial effects on the obesity-associated comorbidities, clinical recommendations to reduce weight and to adopt a healthy lifestyle could improve the psoriasis severity, particularly in those patients with moderate to severe disease, thus exerting additional therapeutic effects in the conventional treatment in obese patients with psoriasis. Education regarding modifiable environmental factors is essential in the treatment of this disease and represents one of the primary interventions that can affect the prognosis of patients with psoriasis. The goal is to make psoriatic patients and health care providers aware of beneficial dietary interventions. The aim of this review is to assess the relevance of the environmental factors as modifiable risk factors in psoriasis pathogenesis, with particular regard to the involvement of obesity and nutrition in the management of psoriasis, providing also specific nutrition recommendations.

Psoriasis: new comorbidities

Psoriasis is a chronic inflammatory disease associated with several comorbidities. A few decades ago, it was considered an exclusive skin disease but today it is considered a multisystem disease. It is believed that 73% of psoriasis patients have at least one comorbidity. Studies have demonstrated the association of psoriasis with inflammatory bowel disease, uveitis, psychiatric disorders, metabolic syndrome and its components and cardiovascular diseases. The systemic inflammatory state seems to be the common denominator for all these comorbidities. This work aims at presenting a review of the current literature on some new comorbidities that are associated with psoriasis as osteoporosis, obstructive sleep apnea and chronic obstructive pulmonary disease. While there is still controversy, many studies already point to a possible bone involvement in patients with psoriasis, especially in the male group, generally less affected by osteoporosis. Psoriasis and chronic obstructive pulmonary disease present some risk factors in common as obesity, smoking and physical inactivity. Besides, both diseases are associated with the metabolic syndrome. These factors could be potential confounders in the association of the two diseases. Further prospective studies with control of those potential confounders should be developed in an attempt to establish causality. Existing data in the literature suggest that there is an association between obstructive sleep apnea and psoriasis, but studies performed until now have involved few patients and had a short follow-up period. It is, therefore, premature to assert that there is indeed a correlation between these two diseases.

The prevalence of vertebral fractures in spondyloarthritis: relation to disease characteristics, bone mineral density, syndesmophytes and history of back pain and trauma

Introduction

An increased risk of vertebral fracture (VF) is one of the extra-articular manifestations of spondyloarthropathy (SpA). The prevalence of moderate to severe VFs visualized by radiography (Rx) in patients with SpA in daily practice is unknown until imaging of the full spine is available, as most VFs do not present with clinical signs and symptoms of an acute fracture.

Methods

We evaluated the prevalence of VFs (>25 % loss in height) on available Rx and dual-energy X-ray absorptiometry (DXA) images in 390 consecutive patients with SpA in daily practice. We assessed their association with disease characteristics, bone mineral density, the modified Stoke Ankylosing Spondylitis Spinal Score, and history of trauma.

Results

Forty-six patients (11.8 %) had Rx VF (56.4 % men, 93.5 % in the thoracic spine), and 44.5 % had multiple VFs. Compared with patients without VF, patients with VF were older (52.2 vs. 47.3 years, p < 0.01; range 25–84 years), had lower femoral neck T-scores (−1.1 vs. −0.7; p < 0.05), and had a marginally higher modified Stoke Ankylosing Spondylitis Spinal Score (11.7 vs. 7.0; p = 0.06). Among patients with VFs, 15.2 % had a history of trauma with acute back pain (p < 0.001 vs. no VF). The reliability of DXA for diagnosing radiographic VFs was high (κ 0.90).

Conclusions

Moderate to severe VFs are found in more than 10 % of patients with SpA before the age of 40 years in 5 % of women and 9 % in men. Most VFs are located in the thoracic region, are related to low femoral neck bone mineral density and to stiffening of the spine, and are only rarely related to trauma history. DXA is a useful alternative for diagnosing VFs.

Quantitative and Qualitative Changes of Bone in Psoriasis and Psoriatic Arthritis Patients

Psoriatic arthritis (PsA) is a chronic inflammatory disease characterized by periarticular bone loss and new bone formation. Current data regarding systemic bone loss and bone mineral density (BMD) in PsA are conflicting. The aim of this study was to evaluate bone microstructure and volumetric BMD (vBMD) in patients with PsA and psoriasis. We performed HR-pQCT scans at the ultradistal and periarticular radius in 50 PsA patients, 30 psoriasis patients, and 70 healthy, age- and sex-related controls assessing trabecular bone volume (BV/TV), trabecular number (Tb.N), inhomogeneity of the trabecular network, cortical thickness (Ct.Th), and cortical porosity (Ct.Po), as well as vBMD. Trabecular BMD (Tb.BMD, p = 0.021, 12.0%), BV/TV (p = 0.020, -11.9%), and Tb.N (p = 0.035, 7.1%) were significantly decreased at the ultradistal radius and the periarticular radius in PsA patients compared to controls. In contrast, bone architecture of the ultradistal radius and periarticular radius was similar in patients with psoriasis and healthy controls. Duration of skin disease was associated with low BV/TV and Tb.N in patients with PsA. These data suggest that trabecular BMD and bone microstructure are decreased in PsA patients. The observation that duration of skin disease determines bone loss in PsA supports the concept of subclinical musculoskeletal disease in psoriasis patients.

Recognizing and managing comorbidities in psoriatic arthritis

PURPOSE OF REVIEW

Many patients with psoriatic arthritis (PsA) have additional medical problems that can have an impact on morbidity and mortality. The goal of this review is to summarize the available evidence to date on the association of medical comorbidities with PsA and the implications these comorbidities have on prognosis, therapy selection and treatment response.

RECENT FINDINGS

Cardiovascular disease, metabolic syndrome, obesity, diabetes, fatty liver disease Crohn's disease, ophthalmic disease, depression and anxiety are common comorbidities associated with PsA. Additional comorbidities may include an elevated risk for malignancy and osteoporosis; however, fewer studies have addressed these issues and the data available are sometimes conflicting.

SUMMARY

All clinicians caring for patients with PsA should be aware of the relevant comorbidities affecting patients with PsA and should have an understanding of how these comorbidities affect management.

The Epidemiology of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by joint and entheseal inflammation with a prevalence of 0.05% to 0.25% of the population and 6% to 41% of patients with psoriasis. PsA is a highly heterogeneous inflammatory arthritis. In this review, current knowledge is discussed regarding the epidemiology of PsA, including disease manifestations, classification criteria for adult and juvenile PsA, methods for recognizing early PsA, including use of screening tools and knowledge of risk factors for PsA, and medical comorbidities associated with PsA.

Comorbidities in Psoriatic Arthritis

Epidemiologic studies have shown that, in patients with psoriatic arthritis (PsA), associated comorbidities may occur more frequently than expected. This article discusses related comorbidities in patients with PsA. Identifying these comorbidities may affect the management and treatment decisions for these patients to ensure an optimal clinical outcome. All health care providers caring for patients with PsA should be aware of the relevant comorbidities and should have an understanding of how these comorbidities affect management. The common comorbidities include cardiovascular disease, metabolic syndrome, obesity, diabetes, fatty liver disease, inflammatory bowel disease, ophthalmic disease, kidney disease, osteoporosis, depression, and anxiety.

Psoriasis: classical and emerging comorbidities

Psoriasis is a chronic inflammatory systemic disease. Evidence shows an association of psoriasis with arthritis, depression, inflammatory bowel disease and cardiovascular diseases. Recently, several other comorbid conditions have been proposed as related to the chronic inflammatory status of psoriasis. The understanding of these conditions and their treatments will certainly lead to better management of the disease. The present article aims to synthesize the knowledge in the literature about the classical and emerging comorbidities related to psoriasis.

Vitamin D status in men with psoriatic arthritis: a case-control study

We determined hypovitaminosis D prevalence in men with psoriatic arthritis. This is a cross-sectional, analyst blinded, age- and sex-matched, case-control study. Men with psoriatic arthritis have significantly lower 25-hydroxyvitamin D levels. Men with psoriatic arthritis are at increased odds of suffering from hypovitaminosis D.

INTRODUCTION

Skeletal manifestations as a result of abrupted bone metabolism may be predominant in psoriatic arthritis (PsA). Vitamin D plays a vital role in maintenance of skeletal health and is known to modulate the immune system in various autoimmune diseases including PsA. The aim of the present study was to determine the prevalence of hypovitaminosis D in a treatment naïve, de novo psoriatic arthritis male cohort in a cross-sectional, analyst blinded, age- and sex-matched, case-control study.

METHODS

25 hydroxyvitamin D (25OHD), parathyroid (PTH), osteocalcin (OC) and C-terminal telopeptides of type-I collagen (CTx) levels, and lumbar spine and femoral neck bone mineral density were compared between 53 PsA and controls.

RESULTS

The prevalence of hypovitaminosis D (25 hydroxyvitamin D (25OHD) levels <75 nmol/L) was 81 and 57 % in the PsA and control groups, respectively. Compared to the healthy controls, 25OHD (67.2 (12-137) nmol/L vs. 51.9 (15-95) nmol/L; p = 0.001) was significantly lower, and osteocalcin (13.6 (5-33) μg/L vs. 18.2 (6-35) μg/L; p = 0.003) and C-terminal telopeptides of type-I collagen (0.20 (0.01-0.71) μg/L vs. 0.28 (0.06-0.69) μg/L; p = 0.008) were significantly higher in the PsA group. A significant association was found between hypovitaminosis D and PsA; the odds for patients with PsA of having hypovitaminosis D was 3.297 (95 % confidence interval 1.372 to 7.922).

CONCLUSION

The results of this study suggest that men with PsA have significantly lower 25-hydroxyvitamin D levels, and furthermore, men with PsA are at statistically significant increased odds of suffering from hypovitaminosis D.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9-9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.