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Fitz 9th > 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
Q

HLA-B27 haplotypes hold prognostic value through association with disease characteristics

A 
PsA onset within 1 year from psoriasis diagnosis
Axial PsA
Enthesitis
Dactylitis
Uveitis
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26
Q

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

A

PTPN22

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27
Q

_____ locus is common to inflammatory bowel disease, juvenile idiopathic arthritis, and asthma

A

5q31

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28
Q

In addition to the clinical factors, the following environmental and individual factors increase the risk of PsA

A

Physical trauma
Smoking
Overweight
Obese physique

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29
Q

Central to innate immunity in both psoriasis and PsA

A

TNF-induced NF-kbeta signaling

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30
Q

Adaptive immune system responses in PsA are characterized by selective transcription of mediators favoring

A

Th1 and Th17 cells

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31
Q

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

A

Biomechanical stress/synovio-entheseal complex

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32
Q

Unfortunately, screening questionnaires may miss a significant portion of PsA patients and therefore _____ remains key for detecting PsA

A

Dermatologists’ high index of suspicion

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33
Q

Laboratory tests for _____ are important to exclude rheumatoid arthritis

A

Rheumatoid factor

Anticyclic citrullinated peptides (anti-CCP)

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34
Q

Genotyping for _____ has clinical and prognostic value because _____-positive individulals are at higher risk for early PsA, axial PsA, severe enthesitis and uveitis

A

HLA-B27

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35
Q

Recommended to evaluate PsA characteristic joint damage such as juxta-articular bone erosions and new bone formation

A

Radiographs

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36
Q

Can distinguish tissue edema and vascularization

A

Imaging techniques (musculoskeletal ultrasonography and MRI)

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37
Q

Usually positive for rheumatoid factor or anti-CCP

A

Rheumatoid arthritis

38
Q

More likely to occur after a GI or sexually transmitted infection

A

Reactive arthritis

39
Q

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

40
Q

Most common differential diagnosis for PsA because of its high prevalence and overlapping predilection for a similar patient population in terms of comorbidities

41
Q

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

42
Q

For PsA, disease-modifying antirheumatic drugs (DMARDS) _____ are generally recommended first-line agents

A

Methotrexate
Sulfasalazine
Leflunomide

43
Q

Not used in PsA because of the potential for worsening or precipitating development of psoriasis

A

Hydroxychloroquine

44
Q

Daily folic acid supplementation is recommended with

A

Sulfasalazine

Methotrexate

45
Q

Can cause mucosal ulcerations

Kidney function is an important consideration

A

Methotrexate

46
Q

Has been shown to improve psoriatic joint swelling with no effect on psoriasis or enthesitis
Preferred DMARD in peripheral spondyloarthritis

A

Sulfasalazine

47
Q

Effective for both psoriasis and PsA with mild to moderate improvements
Hepatic toxicity and the risk of anemia need to be considered

A

Leflunomide

48
Q

Selective inhibitor of the enzyme phosphodiesterase 4 (PDE4)

Side-effect profile is favorable; however, a 1% risk of depression has been observed

A

Apremilast

49
Q

First-line biologic agents for PsA

A

TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab)

50
Q

TNF inhibitor: also effective for PsA-associated manifestations of uveitis and inflammatory bowel disease

A

Adalimumab

Infliximab

51
Q

TNF inhibitor: also effective for Crohn disease

A

Certolizumab

52
Q

TNF inhibitor: effective for ulcerative colitis

53
Q

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

A

Ustekinumab

54
Q

Most efficacious medication class approved for psoriasis

A

IL17 inhibitors (secukinumab, ixekizumab)

55
Q

JAK/STAT inhibitor recently labeled for psoriatic arthritis and ulcerative colitis

A

Tofacitinib

56
Q

Anti-T cell therapy/CTLA4 inhibitor for psoriatic arthritis

57
Q

New molecule: IgG1 antibody binding the p19 subunit specific to IL23

A

Guselkumab

58
Q

New molecule: IL23 monoclonal antibody

A

Tildrakizumab

59
Q

New molecule: IL23/p19 inhibitor family

A

Risankizumab

60
Q

New molecule: JAK inhibitor

A

Upadacitinib

61
Q

New molecule: IL17 inhibitor

A

Bimekizumab

62
Q

An additional immunologic target being evaluated in psoriasis/PsA is _____, a transcription factor on which IL-17 is dependent

A

RORgamma-t

63
Q

The treatment algorithm for PsA starts with initiation of _____ followed by _____

A

DMARDs

Biologic medications with TNF inhibitors as first-line biologics

64
Q

In the case of enthesitis or spondylitis, the first-line medications becomes _____ as _____ are not effective for these manifestations

A

TNF inhibitors

DMARDs

65
Q

Second-like biologics are

A

IL12/23 inhibitors

66
Q

There is concern for worsening _____ with IL17 inhibitors

A

Inflammatory bowel disease

67
Q

Classical synthetic DMARDs

A

Methotrexate
Sulfasalazine
Leflunomide

68
Q

Targeted synthetic DMARDs

A

Apremilast

Tofacitinib

69
Q

csDMARDS not applicable for

A

Enthesitis

70
Q

tsDMARDS not applicable for

A

Spondylitis

71
Q

Reactive arthritis is formerly referred to as

A

Reiter or Fiessinger-Leroy syndrome

72
Q

Classic triad of symptoms in ReA

A

Urethral
Ocular
Articular inflammation

73
Q

The infectious agents most commonly implicated in reactive arthritis include

A 
GI (Yersinia, Shigella, Salmonella, Campylobacter and Clostridium difficile)
Venereal urogenital (Chlamydia trachomatis)
74
Q

Type of ReA:
Typically presents in younger adults in their third to fifth decade
Male predominance
May be asymptomatic in the majority of patients

A

Post-venereal urogenital type

75
Q

Type of ReA:

Nearly always symptomatic

A

Enteric infections

76
Q

_____ weeks following the triggering infection, the patient will develop an oligoarthritis that is asymmetric

77
Q

The predominant symptom in patients with enteric infection is

78
Q

With urogenital infections, the patient may describe

A

Dysuria with a purulent urethral discharge or may be without symptoms

79
Q

Chronic ReA is considered if symptoms extend beyond

80
Q

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

A

Circinate balanitis

81
Q

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

A

Keratoderma blenorrhagicum

82
Q

Superficial ulcerations or erythematous grayish plaques involving the buccal mucosa, palate and tounge
Painless, though they may bleed

A

Stomatitis

83
Q

Subungual accumulation of debris and potential abscess formation
Onycholysis, nail pitting, transverse ridging, or periungal scaling may be seen in the minority of patients

A

Psoriatic-like nail lesions

84
Q

Typical pattern of joint involvement in ReA

A

Asymmetrical peripheral oligoarthritis

85
Q

In ReA, swelling and discomfort of the heel (“_____”) results from Achilles tendon involvement

A

Lover’s heel

86
Q

Dactylitis is the result of enthesitis involving the toes and fingers leading to a diffuse swelling of the entire digit, sometimes referred to as

A

“Sausage digit”

87
Q

Presenting ocular symptoms typically include

A

Photophobia and visual clouding from inflammatory cells in the anterior chamber

88
Q

Genetic risk factor for the development of ReA

89
Q

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)

A

Lower limb

90
Q

When ReA involves only a few joints, _____ can be administered to provide short-term relief of joint inflammation

A

Intraarticular injection of corticosteroids

91
Q

For more involved articular inflammation, systemic steroid administration can be considered, though this rarely provides sufficient benefits to the symptoms of

A

Axial inflammation

92
Q

Used as initial treatment of many of the extraarticular features of ReA

A

Topical corticosteroids

Fitz 9th (108 decks)

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