EULAR provides hints on progression of psoriasis to PsA

According to one report, clinicians treating patients with psoriasis should pay attention to certain signs that joint involvement may develop. New “Things to Consider” document From the European Union of Rheumatology Societies (EULAR).

In particular, patients with psoriasis who present with persistent pain and imaging abnormalities in their joints are at increased risk of progressing to psoriatic arthritis (PsA), according to the EULAR task force led by Dr. Denis McGonagle MBChB, University of Leeds, UK.

These are in addition to traditional progression risk factors such as family history, obesity, very extensive psoriatic lesions, and nail involvement, the researchers noted. Patients presenting with these signs should be told that they are at increased risk for PsA and encouraged to report new or increasing symptoms promptly, while physicians should periodically review the patient’s risk factors. Need to re-evaluate.

The authors suggest that not only clinicians will benefit from this new document, but it could also be used to establish inclusion criteria for trials testing new ways to prevent the progression of psoriasis to PsA. bottom. So far, they found that “data in this area are limited and controversial due to the lack of established serological markers and a standardized, practical definition of early-stage PsA in PsA prevention studies. is brewing,” he said.

About 3 in 10 people with psoriasis eventually develop enough arthritic features to meet the criteria for PsA. An “incomplete understanding of the immunogenetic and other factors associated with disease progression” means that it is not possible to identify which he three will progress to her PsA. As far as this causes problems, he explained McGonagle et al.

EULAR leaders launched a 30-member task force in early 2021 to begin efforts to bring some consensus to the concept of an “initial PsA.” Most were rheumatologists, including five dermatologists. Other members included methodological and patient research specialists and non-physician health professionals.

The research group sought to classify PsA into three onset stages: high-risk psoriasis, ‘silent PsA’, and full-blown clinical PsA. They did not seek to set formal standards, but rather to establish a research base for materializing the standards, especially for his first two designations. Of course, clinical PsA is already well-defined, but the task force thought it would be useful to consider how to characterize new-onset clinical PsA as an endpoint for prevention trials.

Ultimately they determined that a definite onset of clinical synovitis in a psoriasis patient serves as such an endpoint. However, he emphasized that synovitis may be transient and thus this definition is not appropriate in the setting of routine practice.

Specific Considerations

McGonagle et al. emphasized that clinicians should consider other potential diagnoses and comorbidities, such as osteoarthritis and fibromyalgia, when patients complain of joint pain. The group also noted that the link between joint pain and early PsA in people with psoriasis is ripe for research. Many questions remain unanswered, including whether pain location and duration are important with respect to the risk of developing PsA.

The task force recommends that clinicians should routinely ask patients with psoriasis about musculoskeletal pain and functional limitations during routine clinical examinations. And patients complaining of such symptoms should undergo imaging studies (including standard her x-rays plus ultrasound, MRI scans, or both) to look for “synovial enthesis involvement/abnormalities.” may be worth taking.

Of note, however, imaging abnormalities per se in the absence of symptoms do not indicate increased PsA risk. If found, “should be carefully considered to avoid the risk of inappropriate treatment,” the group wrote. “Symptomatic findings detected by imaging studies may be present in her asymptomatic PsA stage, but there is no evidence that this favors any particular treatment choice in the management of the patient. [psoriasis] Absence of musculoskeletal symptoms or sufficient for diagnosis of PsA. ”

On the other hand, symptoms and imaging abnormalities are considered sufficient to at least enroll patients in clinical prevention trials.

One of the major questions that needs further research is whether disease-modifying treatments for psoriasis, especially biologics, affect the risk of progression to PsA. McGonagle and colleagues found evidence going in both directions. Several studies have shown that such treatment reduces risk, but at least one suggests the opposite. So far, the researchers conclude, there is evidence to support “the use of therapies that can improve both skin and joint symptoms” in patients with risk factors for arthritis progression.

Overall, the study group concluded, “These findings link PsA as a result of prevention studies and joint pain and imaging abnormalities as a tailored strategy associated with PsA cases, many of which require chronic treatment of skin disease.” We have set a position against both regressions.” [psoriasis]. ”