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FD9 > 65 - Psoriatic Arthritis and Reactive Arthritis > Flashcards

65 - Psoriatic Arthritis and Reactive Arthritis Flashcards

1
Q

Most widely accepted and define inclusion of participants in PsA clinical trials

A

Classification criteria for PsA (CASPAR)

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2
Q

A classification of PsA is met if the final score is equal to or more than

A

3 points

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3
Q

Unlike (psoriasis/PsA) which has a bimodal incidence, (psoriasis/PsA) onset is most commonly seen in adulthood

A

Psoriasis

PsA

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4
Q

Clinical predictors of PsA

A

Nail psoriasis
Severe psoriasis
Scalp, intergluteal, or perianal psoriasis
Presence of uveitis

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5
Q

Most common manifestation of clinical nail disease in PsA

A

Nail pitting

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6
Q

Noncutanaeous findings: ______ in the year prior to diagnosis

A

Joint pain
Fatigue
Stiffness

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7
Q

5 distinct phenotypes of PsA

A 
Oligoarticular
Polyarticular/symmetrical
Distal interphalangeal joint predominant
Spondyloarthritis
Arthritis mutilans
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8
Q

Most common phenotype of PsA

A

Oligoarticular (>70%)

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9
Q

Joint inflammation in (rheumatoid arthritis/PsA) is more vascular and less tender than in (rheumatoid arthritis/PsA)

A

PsA

Rheumatoid arthritis

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10
Q

Full-thickness inflammation of a digit (finger or toe)

A

Dactylitis

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11
Q

Anatomical structures formed by tendon, ligament, and joint capsule insertions on bone

A

Entheses

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12
Q

Entheses function together with bone and synovium as the _____ to distribute biomechanical stress

A

Synovio-entheseal complex

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13
Q

Most common sites of involvement in enthesitis

A

Achilles tendon
Plantar fascia
Lateral epicondyles at the elbows

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14
Q

Inflammatory arthritis affecting the axial skeleton leading to spondylitis and/or sacroiliitis

A

Spondyloarthritis

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15
Q

Y/N: More commonly, axial PsA overlaps with peripheral PsA

A

Yes

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16
Q

Risk factors for axial PsA

A 
Onycholysis
Inflammatory back pain symptoms
PsA duration/young age at onset
Positive HLA-B27
Inflammatory bowel disease
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17
Q

Significantly more likely to present with bilateral sacroiliitis, complete ankylosis of the sacroiliac joints, bridging syndesmophytes formed in a caudal to cranial progression, and more severe osteoproliferation than axial PsA

A

Ankylosing spondylitis

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18
Q

More likely to present as isolated spondylitis, manifest with random syndesmophyte formation, isolated involvement of the cervical spine, and although sacroiliitis is also most commonly symmetric, it is less likely so than in AS

A

Axial PsA

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19
Q

Eye involvement manifests in a _____ of people with PsA and about _____% in people with psoriasis

A

Third

10

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20
Q

Uveitis in PsA is much (more/less) than in AS, where uveitis occurs in about 40%

A

Less

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21
Q

In (axial/peripheral) PsA, uveitis is diagnosed at a younger age than in psoriasis, more likely to present in males who are HLA-B27 positive and more likely to involve the anterior segment

A

Axial

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22
Q

Uveitis in (axial/peripheral) PsA is more likely to be insidious, bilateral, and to involve the posterior segment

A

Peripheral

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23
Q

Medical risk factors and comorbidities associated with PsA

A 
Cardiovascular disease
Obesity
Type 2 DM
Nonalcoholic fatty liver disease
Metabolic syndrome
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24
Q

Strongest evidence for being a genetic risk factor for PsA in people with psoriasis

A

HLA-B27

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25
HLA-B27 haplotypes hold prognostic value through association with disease characteristics
``` PsA onset within 1 year from psoriasis diagnosis Axial PsA Enthesitis Dactylitis Uveitis ```
26
Encodes a lymphoid-specific intracellular phosphatase involved in T-cell signaling pathways Has been associated with rheumatoid arthritis, type 1 diabetes, SLE, and Grave disease
PTPN22
27
_____ locus is common to inflammatory bowel disease, juvenile idiopathic arthritis, and asthma
5q31
28
In addition to the clinical factors, the following environmental and individual factors increase the risk of PsA
Physical trauma Smoking Overweight Obese physique
29
Central to innate immunity in both psoriasis and PsA
TNF-induced NF-kbeta signaling
30
Adaptive immune system responses in PsA are characterized by selective transcription of mediators favoring
Th1 and Th17 cells
31
The _____ hypothesis connects damage at entheseal insertion sites in the presence of a genetically susceptible background with erroneous tissue repair responses and self-propagating inflammation leading to PsA
Biomechanical stress/synovio-entheseal complex
32
Unfortunately, screening questionnaires may miss a significant portion of PsA patients and therefore _____ remains key for detecting PsA
Dermatologists' high index of suspicion
33
Laboratory tests for _____ are important to exclude rheumatoid arthritis
Rheumatoid factor | Anticyclic citrullinated peptides (anti-CCP)
34
Genotyping for _____ has clinical and prognostic value because _____-positive individulals are at higher risk for early PsA, axial PsA, severe enthesitis and uveitis
HLA-B27
35
Recommended to evaluate PsA characteristic joint damage such as juxta-articular bone erosions and new bone formation
Radiographs
36
Can distinguish tissue edema and vascularization
Imaging techniques (musculoskeletal ultrasonography and MRI)
37
Usually positive for rheumatoid factor or anti-CCP
Rheumatoid arthritis
38
More likely to occur after a GI or sexually transmitted infection
Reactive arthritis
39
More common in people with psoriasis than in the general population likely due to increased skin turnover and increased association with cardiovascular comorbidities and medications used to treat them
Gout
40
Most common differential diagnosis for PsA because of its high prevalence and overlapping predilection for a similar patient population in terms of comorbidities
OA
41
Usually less inflammatory than PsA, worsening with activities and at the end of the day, and lacking PsA-specific manifestations like dacylitis, enthesitis, and/or spondylitis
OA
42
For PsA, disease-modifying antirheumatic drugs (DMARDS) _____ are generally recommended first-line agents
Methotrexate Sulfasalazine Leflunomide
43
Not used in PsA because of the potential for worsening or precipitating development of psoriasis
Hydroxychloroquine
44
Daily folic acid supplementation is recommended with
Sulfasalazine | Methotrexate
45
Can cause mucosal ulcerations | Kidney function is an important consideration
Methotrexate
46
Has been shown to improve psoriatic joint swelling with no effect on psoriasis or enthesitis Preferred DMARD in peripheral spondyloarthritis
Sulfasalazine
47
Effective for both psoriasis and PsA with mild to moderate improvements Hepatic toxicity and the risk of anemia need to be considered
Leflunomide
48
Selective inhibitor of the enzyme phosphodiesterase 4 (PDE4) | Side-effect profile is favorable; however, a 1% risk of depression has been observed
Apremilast
49
First-line biologic agents for PsA
TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab)
50
TNF inhibitor: also effective for PsA-associated manifestations of uveitis and inflammatory bowel disease
Adalimumab | Infliximab
51
TNF inhibitor: also effective for Crohn disease
Certolizumab
52
TNF inhibitor: effective for ulcerative colitis
Golimumab
53
Inhibitor of the common p40 subunit of both IL12 and IL23 Approved for the treatment of psoriasis and PsA Also approved for Crohn disease in people who failed TNF inhibitors
Ustekinumab
54
Most efficacious medication class approved for psoriasis
IL17 inhibitors (secukinumab, ixekizumab)
55
JAK/STAT inhibitor recently labeled for psoriatic arthritis and ulcerative colitis
Tofacitinib
56
Anti-T cell therapy/CTLA4 inhibitor for psoriatic arthritis
Abatacept
57
New molecule: IgG1 antibody binding the p19 subunit specific to IL23
Guselkumab
58
New molecule: IL23 monoclonal antibody
Tildrakizumab
59
New molecule: IL23/p19 inhibitor family
Risankizumab
60
New molecule: JAK inhibitor
Upadacitinib
61
New molecule: IL17 inhibitor
Bimekizumab
62
An additional immunologic target being evaluated in psoriasis/PsA is _____, a transcription factor on which IL-17 is dependent
RORgamma-t
63
The treatment algorithm for PsA starts with initiation of _____ followed by _____
DMARDs | Biologic medications with TNF inhibitors as first-line biologics
64
In the case of enthesitis or spondylitis, the first-line medications becomes _____ as _____ are not effective for these manifestations
TNF inhibitors | DMARDs
65
Second-like biologics are
IL12/23 inhibitors
66
There is concern for worsening _____ with IL17 inhibitors
Inflammatory bowel disease
67
Classical synthetic DMARDs
Methotrexate Sulfasalazine Leflunomide
68
Targeted synthetic DMARDs
Apremilast | Tofacitinib
69
csDMARDS not applicable for
Enthesitis
70
tsDMARDS not applicable for
Spondylitis
71
Reactive arthritis is formerly referred to as
Reiter or Fiessinger-Leroy syndrome
72
Classic triad of symptoms in ReA
Urethral Ocular Articular inflammation
73
The infectious agents most commonly implicated in reactive arthritis include
``` GI (Yersinia, Shigella, Salmonella, Campylobacter and Clostridium difficile) Venereal urogenital (Chlamydia trachomatis) ```
74
Type of ReA: Typically presents in younger adults in their third to fifth decade Male predominance May be asymptomatic in the majority of patients
Post-venereal urogenital type
75
Type of ReA: | Nearly always symptomatic
Enteric infections
76
_____ weeks following the triggering infection, the patient will develop an oligoarthritis that is asymmetric
1-4
77
The predominant symptom in patients with enteric infection is
Diarrhea
78
With urogenital infections, the patient may describe
Dysuria with a purulent urethral discharge or may be without symptoms
79
Chronic ReA is considered if symptoms extend beyond
6 months
80
Inflammatory skin lesion that develops on the shaft or glans of the penis and more rarely on the scrotum Erythematous lesions that can be both papular and pustular and develop raised borders around the meatus
Circinate balanitis
81
Resembles a pustular psoriasis and is generally found on the palms and soles Initially an erythematous vesicular lesion that develops into pustular keratotic lesions before coalescing into psoriatic-like plaques
Keratoderma blenorrhagicum
82
Superficial ulcerations or erythematous grayish plaques involving the buccal mucosa, palate and tounge Painless, though they may bleed
Stomatitis
83
Subungual accumulation of debris and potential abscess formation Onycholysis, nail pitting, transverse ridging, or periungal scaling may be seen in the minority of patients
Psoriatic-like nail lesions
84
Typical pattern of joint involvement in ReA
Asymmetrical peripheral oligoarthritis
85
In ReA, swelling and discomfort of the heel ("_____") results from Achilles tendon involvement
Lover's heel
86
Dactylitis is the result of enthesitis involving the toes and fingers leading to a diffuse swelling of the entire digit, sometimes referred to as
"Sausage digit"
87
Presenting ocular symptoms typically include
Photophobia and visual clouding from inflammatory cells in the anterior chamber
88
Genetic risk factor for the development of ReA
HLA-B27
89
In ReA, the arthritis should predominantly involve the _____, involve one or only a few joints, and not equally involve both sides of the body (asymmetric)
Lower limb
90
When ReA involves only a few joints, _____ can be administered to provide short-term relief of joint inflammation
Intraarticular injection of corticosteroids
91
For more involved articular inflammation, systemic steroid administration can be considered, though this rarely provides sufficient benefits to the symptoms of
Axial inflammation
92
Used as initial treatment of many of the extraarticular features of ReA
Topical corticosteroids

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