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In Those With Psoriasis, Treat for Arthritis?


Subclinical Joint Inflammation in Patients With Psoriasis Without Concomitant Psoriatic Arthritis: A Cross-sectional and Longitudinal Analysis

 

Article Summary - Faustini F, Simon D, Oliveira I, et al Ann Rheum Dis. 2016 Feb 25. [Epub ahead of print]

In this study, Faustini and colleagues performed clinical evaluations and imaging with contrasted MRI of the dominant hand in 55 patients with cutaneous psoriasis who were recruited from a dermatology clinic and who did not have inflammatory arthritis or enthesitis on physical examination at baseline. They followed these patients over time to evaluate them for the development of clinically apparent inflammatory arthritis.

At baseline, 26 of 55 (47%) participants had at least one inflammatory finding on MRI in their hands. The most common finding was synovitis (38%), followed by osteitis (11%) and flexor tendon tenosynovitis (4%) The synovitis was overall only mild to moderate according to the psoriatic arthritis (PsA) MRI scoring system and predominately located in the metacarpophalangeal joints and proximal interphalangeal joints (29% and 24%, respectively) and rarely in the distal interphalangeal joints (4%). In contrast, only 4 of 30 (13%) healthy control participants had inflammatory findings.

After a mean follow-up of 426 days, among 41 of the original 55 patients, 12 developed clinically apparent PsA per the Classification of Psoriatic Arthritis criteria. At baseline, those who developed arthritis had higher levels of pain as measured by a visual analog scale, tender joint count, and worse global health and function compared with participants who did not develop arthritis. Of note, no overall differences in MRI findings were seen at baseline between participants who developed PsA and those who did not. However, 56% of patients who had a combination of MRI findings of synovitis and symptoms related to arthralgia progressed to PsA within 1 year. In contrast, only 15% of those who had no MRI synovitis or arthralgia at baseline progressed to PsA.

Viewpoint

The finding that 47% of patients with cutaneous psoriasis had MRI findings of inflammation likely indicates that there is a high rate of inflammation among these patients, even if it is not diagnosed as "synovitis" on a physical examination. This is substantial when considering that only 13% of the control participants had inflammatory findings. One of the biggest take-home points from this study is that physical examination is likely inadequate to detect subtle inflammatory musculoskeletal disease in patients with psoriasis.

It will be interesting to see how these findings will affect the evolution of clinical care. Will we start treating people for inflammatory musculoskeletal disease based on imaging even if we cannot find it on a standard joint examination? Could such an approach lead to prevention of the joint-related morbidity of psoriasis? Something potentially relevant to prevention is that some of the patients in this study were on systemic immunomodulatory therapy for their skin disease at baseline. I am assuming that the small number of participants precluded any meaningful statistical analyses, but one wonders if those medications could have affected arthritis risk. While studies of this nature typically focus on the patients who go on to develop clinical disease, what about those who don't? Studying these patients in depth is likely to lead to insights into what factors are associated with lack of progression to clinical disease. This may be just as important as finding out what leads to disease.

As a final point, these longitudinal studies of disease evolution are crucial to moving the field of rheumatology to the point where we may be able to prevent some rheumatic diseases, or at least prevent them from worsening once known risk factors or early disease states are present. Let's hope that the field keeps up the investigative pressure in these areas and gets us to prevention soon. From: Medscape: Kevin Deane, MD, PhD.

28/03/2016 - Categoria: Farmaci - Da: Sh@wn - 390 letture

 

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