A multidisciplinary care unit approach for the management of psoriatic arthritis: an Italian experience.

BACKGROUND: Psoriatic arthritis (PsA) is a chronic inflammatory disease that can produce disabling joint symptoms, adding significantly to the physical and psychosocial burden of psoriasis. Early detection is important to allow the development of an appropriate care plan to delay the onset of PsA and maximize the patient's quality of life. Our aim was to present the criteria, based on evidence and expert opinion, for a multidisciplinary approach to the management of PsA in a patient already characterized by skin manifestation. METHODS: An expert panel from the principal psoriatic care units of the Campania region of Italy met to discuss their mutual experience of the multidisciplinary approach to the management of psoriatic disease and to describe an integrated dermatologic/rheumatologic approach focused on the early diagnosis, management, and treatment of PsA. RESULTS: Two types of consultation modalities were considered most relevant to the care of patients with psoriatic disease in Italy: the parallel approach and the face-to-face care unit approach. Screening criteria for multidisciplinary care unit admission were described, with dermatologists, as the primary managers of the majority of patients with psoriasis, playing a critical role in introducing patients early on to therapy. CONCLUSIONS: An integrated management approach may enhance patient care by ensuring early diagnosis and treatment, with the potential to achieve better outcomes for both skin and musculoskeletal manifestations of psoriasis. The multidisciplinary care unit model is an effective and satisfying collaborative approach, not only optimizing outcomes and satisfaction for the patient but strengthening collaboration between the specialties.

Metabolic syndrome in psoriatic arthritis: the interplay with cutaneous involvement. Evidences from literature and a recent cross-sectional study.

The aim of this study was to evaluate the prevalence of MetS and its components and the level of serum uric acid in patients with PsA and in those with PsA sine psoriasis. A secondary aim of the study was to investigate on correlations of MetS in all study population. Consecutive PsA patients underwent assessment of disease activity and metabolic parameters. Blood samples were collected after 12 h of overnight fasting and analyzed for glucose, lipid profile, serum uric acid, and acute-phase reactants. The NCEP-ACT III criteria were used to identify subjects with MetS. Forty-two patients (52.5%) were classified as having PsA with clinically evident psoriasis (group 1) and 38 (47.5%) as having PsA sine psoriasis (group 2). Group 1, when compared to group 2, showed a significant increase for the frequency of MetS (p = 0.006) and for mean values of diastolic blood pressure (p = 0.0116) and of serum uric acid (p = 0.04). We then aimed at defining determinants of MetS in the entire study population. In the multivariate analysis, three variables reached statistical significance: presence of psoriasis (OR 0.14; p = 0.01), increase of one unit of BMI (OR 1.26; p = 0.001), and smoking habit (OR 5.93; p = 0.02). In our study, the occurrence of MetS and mean levels of serum uric acid were higher in PsA patients with clinical evident psoriasis compared to sine psoriasis PsA. The results also show the potential role of BMI, psoriasis, and smoking as important determinants in the development of MetS in PsA patients.

Progress in understanding and utilizing TNF-α inhibition for the treatment of psoriatic arthritis.

The improved recognition of pathogenetic molecular mechanisms has led to the use of drugs targeting cytokines in different inflammatory arthropathies as well psoriatic arthritis (PsA). In particular, the progress in knowledge on tumor necrosis factor (TNF)-α in the pathogenesis of PsA has changed the therapeutic approach by use of direct and receptor cytokine antagonists. Currently, infliximab (IFX), adalimumab, etanercept, golimumab and certolizumab pegol represent the five anti-TNF-α available for the treatment of PsA. This review describes evidence on treatment aimed at neutralizing TNF-α in PsA patients, from the first study in 2000 until today, mainly derived from randomized clinical trials. In comparison with traditional therapies, anti-TNF-α agents have shown to have more efficacy both in treating clinical aspects, including enthesitis, dactylitis, joint pain and swelling, axial involvement, nail and skin lesions, and in reducing radiographic progression. Moreover, anti-TNF-α agents have been demonstrated to be reasonably safe in PsA, as confirmed by data derived by different registries.

Fragility Fractures in Patients with Psoriatic Arthritis.

Psoriatic arthritis (PsA) can have peculiar effects on bone, including mechanisms of bone loss such as erosions, but also of bone formation, such as ankylosis or periostitis. The aim of the present study was to describe the prevalence of fractures in patients with PsA as compared to healthy controls and to investigate determinants of fractures among cases. For both cases and controls, radiographs were read to identify vertebral fractures (VF), and the presence of femoral neck or other nonvertebral fractures was obtained from patients' medical history. The prevalence of fragility fractures on radiographic readings did not differ between cases and controls. The number of subjects showing a VF was 33 (36%) among PsA patients and 36 (36%) among controls, with a prevalence of severe VF of 8% among cases and 4% among controls. Controlling for covariates in a logistic model, the only variables showing a significant correlation with the presence of nonvertebral fractures (NVF) were disease duration (p=0.02), age (p=0.03), and bone mineral density at femoral neck (inverse correlation, p=0.04). Fractures should be carefully considered when evaluating the global picture of the patient with PsA for their contribution to the "fragility" profile.

Osteoporosis and psoriatic arthritis.

Osteoporosis (OP) is a skeletal disorder characterized by compromised bone strength that predisposes to an increased risk of fracture. The prevalence of OP in the general population is very high as established in several studies, and OP represents one of the possible aspects of bone involvement in arthritis. In psoriatic arthritis this involvement is particularly complex because it affects not only mechanisms of bone loss but also of bone formation. We will discuss these aspects and the available epidemiological data.

Prevalence of thyroid autoimmunity in patients with spondyloarthropathies.

OBJECTIVE: To evaluate the prevalence of chronic autoimmune thyroiditis or Hashimoto's thyroiditis (HT) in a group of patients with spondyloarthritis (SpA). METHODS: We evaluated serum levels of thyroid-stimulating hormone, free triiodothyronine, and free thyroxine, and titers of antithyroglobulin and antithyroid peroxidase (anti-TPO) antibodies in 357 consecutive patients with SpA. We also recruited 318 healthy age-matched controls. Ultrasonography of the thyroid gland was performed in all subjects and rheumatic activity was evaluated. RESULTS: Indices of thyroid autoimmunity were significantly more frequent in patients with SpA than in controls (24.09% vs 10.69%, respectively; p < 0.05). In the SpA group, a higher prevalence of HT was found in patients with an active disease than in those with low-moderate disease levels. Also in the SpA group, patients with a disease duration > 2 years had a higher prevalence of HT and anti-TPO antibodies positivity than patients with a disease duration ≤ 2 years. Ultrasonography detected a significantly higher frequency of thyroid nodules and hypoechoic pattern in patients with SpA than in controls. Among patients with SpA, HT and anti-TPO antibodies positivity were significantly more frequent in patients with peripheral involvement (68.6%) than in patients with axial involvement (31.4%; p < 0.05). CONCLUSION: Our study shows a significantly higher prevalence of thyroid autoimmunity in patients with SpA as compared to controls. Thyroiditis occurs more frequently in patients with longer disease duration and active rheumatic disease. We suggest that thyroid function tests be part of the clinical evaluation in patients with SpA.