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Stage 2: Inflammation > Psoriatic Arthritis > Flashcards

Psoriatic Arthritis Flashcards

1
Q

What are the types of spondyloarthropathy (SpA)?

A

1) Psoriatic arthritis
2) Axial SpA
3) Ankylosing spondylitis
4) Non-radiographic axial SpA

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2
Q

What percentage of psoriasis patients have psoriatic arthritis?

A

20-30%

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3
Q

What are the clinical symptoms of joint inflammation in psoriatic arthritis?

A

1) PIP and DIP synovitis
2) Asymmetric oligoarthritis
3) Peripheral arthritis - axial (back/sacroiliac) joints
4) Joint erosion
5) Enthesitis (rare in RA)
6) Dactylitis - inflammation/swelling of entire digit (toe), tendon involvement
7) Hyperkeratosis (nail inflammation, pitting appearance)
8) Impaired physical function and QoL

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4
Q

What happens in the joint in psoriatic arthritis (PsA)?

A
  • Thick synovial membrane
  • Pannus consisting of T cells, macrophages, fibroblasts, neutrophils, dendritic cells and mast cells
  • Enthesitis - inflammation of enthesis (CT between tendon and bone - where tendons attach to bone)
  • Inflammation
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5
Q

What are the hallmarks of spondyloarthropathies?

A

1) Enthesitis ( + new bone growth where enthesis is) - in foot may mean can’t walk
2) Dactylitis

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6
Q

What other conditions do people with psoriatic arthritis tend to have?

A
  • Metabolic syndrome
  • High BMI
  • Central obesity
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7
Q

What imaging technique is used to assess inflammation of the joint in psoriatic arthritis?

A

US (red = inflammation)

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8
Q

Why do you want to achieve low disease activity in PsA?

A
  • Improves function and QoL
  • Prevents joint damage
  • May still be one or two holes, not a problem if treat early
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9
Q

What would an MRI scan with gadolinium uptake of the wrist in PsA look like after therapy?

A

White inflammation areas not present anymore

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10
Q

What is the M:F ratio in PsA?

A

1:1

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11
Q

In most cases, does PsA precede or come after the development of psoriasis?

A

Comes after

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12
Q

Is the severity of psoriasis predictive of the severity of PsA?

A

No but it is correlated with occurrence of PsA

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13
Q

What are the main symptoms of inflammatory arthritis?

A
  • Early morning stiffness lasting at least 30 minutes
  • Persistent stiffness (weeks, months)
  • Lower back pain which can wake pt up and gets better with exercise (opposite to degenerative disc disease)
  • Fatigue
  • Often multiple joint involvement
  • Swelling
  • FH of autoimmune disease
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14
Q

What is important to listen to in PsA?

A

The symptoms and history bc the hands often look normal

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15
Q

What are the 3 main types of PsA?

A

1) Polyarticular
2) Oligoarticular
3) Spondyloarthritis

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16
Q

Describe polyarticular PsA

A
  • Involvement of many small joints usually in hands and feet
  • Most common type > 50%
  • Rarely v rapid joint damage leading to arthritis mutilans
17
Q

Describe oligoarticular PsA

A

Affects a few large joints e.g. knee, ankle, elbow

18
Q

Describe spondyloarthritis PsA

A

Involvement of sacroiliac joints and spine, sometimes also with an oligoarticular peripheral arthritis

19
Q

Why does inflammation in the achilles tendon occur in PsA and why does it look white on a scan?

A

Enthesitis - white bc of water/growth of new bone (achilles tendonitis)

20
Q

What score is used to assess severity of ankylosing spondylitis?

A

BASDAI

21
Q

What does ankylosing spondylitis look like in imaging?

A
  • MRI = white, inflammation of spine
  • X ray = sacroiliitis with X ray sign
  • X ray = bamboo spine (new bone, back of spine fuses)
22
Q

Which diseases do the genetics of PsA overlap with?

A

1) Psoriasis
2) IBD (Crohn’s)
3) Ankylosing spondylitis
- NOT RA

23
Q

Does PsA have a strong genetic component?

A

Yes (30-40% heritability in twin studies)

24
Q

What are the challenges in PsA?

A

1) Diversity in clinical manifestations of psoriatic disease
2) Musculoskeletal manifestations and abnormal blood results not so obvious and may be difficult to diagnose
3) Many patients with PsA remain undiagnosed and untreated
4) Delays in diagnosis can lead to progression of disease

25
Q

What disease are PsA patients at increased risk of?

A

CVD (inflammation of arteries)

26
Q

What does joint damage in PsA lead to?

A

Irreversible loss of function

27
Q

What is used to treat to arthritis aspect of PsA?

A

1) Methotrexate
2) ?Sulphasalazine
3) Leflunomide
4) NSAID/coxibs
5) TNF-blockers
6) Secukinumab (anti-IL-17)
7) Ustekinumab (anti-IL-23)
8) Apremilast (PDE4 inhibitor)

28
Q

What is used to treat to psoriasis aspect of PsA?

A

1) Methotrexate
2) Cyclosporine
3) Acetretinate
4) Fumaric acid esters
5) TNF-blockers
6) Secukinumab (anti-IL-17)
7) Ustekinumab (anti-IL-23)
8) Apremilast (PDE4 inhibitor)

29
Q

What are the two key inflammatory cytokines in PsA?

A

IL-17 and IL-23

30
Q

What are the actions of IL-17 in PsA?

A

1) Cutaneous lesions
2) Inflammation
3) Cartilage damage
4) Bone erosion

31
Q

What does IL-23 do?

A

Drive differentiation of naive T helper cells into Th17 cells which release IL-17

32
Q

Which treatment is the best treatment for psoriasis and also good for PsA and ankylosing spondylitis?

A

Anti-IL-17 (secukinumab)

33
Q

What are the 5 clinical types of psoriatic arthritis?

A

1) Asymmetric - small joint involvement, RF negative
2) Symmetric - RA-like but RF negative
3) DIP joint disease - classic, sausage digits
4) Ankylosing spondylitis
5) Arthritis mutilans - osteolysis of small bones of hands and feet

34
Q

How many joints are typically affected in psoriasis?

A

5 or fewer joints (oligoarthritis)

35
Q

What is the difference between pain in ankylosing spondylitis and pain in mechanical back pain?

A

1) Ankylosing spondylitis = back pain radiates to sacroiliac joint (top of butt) but not anywhere else and is made better with exercise
2) Mechanical back pain (disc prolapse, muscle spasm) = muscles pinching off one of the nerves leads to pain that shoots down one leg (sciatica) and is made worse by exercise

36
Q

What are extra-articular manifestations in seronegative spondyloarthropathies?

A
  • Eyes
  • Mouth ulcers
  • GI tract
  • Genitourinary system

Stage 2: Inflammation (39 decks)

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