Can Early Aggressive Treatment of Psoriasis Prevent Psoriatic Arthritis? A Debate at the GRAPPA Annual Meeting.

In recent years, a number of studies have examined risk factors for development of psoriatic arthritis (PsA) among patients with PsO. Most recently, 5 studies have examined the effect of biologic therapy on the development of PsA. However, the results have been mixed, with 3 studies suggesting a lower risk for PsA among those using a biologic therapy and 2 suggesting a higher risk for PsA. At the 2022 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) meeting, Drs. Enrique Soriano and Alexis Ogdie conducted a debate to discuss the arguments for and against the use of biologic therapies in PsO for the purpose of preventing PsA.

Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica / Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

La artritis psoriásica (APs) es una enfermedad inflamatoria sistémica crónica que afecta a la piel, las estructuras musculoesqueléticas y otros órganos y sistemas, comprometiendo la funcionalidad, la calidad de vida y reduciendo la expectativa de vida de los pacientes. Es una enfermedad compleja que requiere atención y manejo especializado y oportuno. Las alternativas para el tratamiento de las manifestaciones de la APs se han incrementado y, adicionalmente, el efecto de los distintos agentes sobre manifestaciones específicas ha sido aclarado en estudios recientes, por lo tanto, es conveniente incorporar la evidencia disponible para construir una estrategia en el tratamiento de estos pacientes. El Colegio Mexicano de Reumatología seleccionó una comisión para evaluar estas distintas alternativas y generar recomendaciones. Métodos: El grupo de estudio incluyó a 16 reumatólogos y tres dermatólogos certificados, que fueron seleccionados de diferentes instituciones de salud y regiones del país. Se conformó un comité ejecutivo que coordinó las reuniones y un comité de expertos que seleccionó los criterios de búsqueda en la literatura, elaboró las preguntas de investigación, calificó la calidad de la evidencia y generó las recomendaciones en los distintos dominios de la enfermedad con base en la metodología GRADE. Resultados: Se generaron 24 recomendaciones actualizadas para el tratamiento de pacientes con APs. Las recomendaciones establecen el papel de los medicamentos disponibles actualmente en nuestro país. Se enfatiza la importancia del control adecuado de la enfermedad, individualizando el perfil de involucramiento de cada paciente en cada uno de los seis dominios potencialmente afectados por la enfermedad. Además, se establece la secuencia en la elección de los tratamientos disponibles para cada dominio, basada en su eficacia, perfil de seguridad y accesibilidad.(AU)

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. Methods: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. Results: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. Conclusions: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.(AU)

Retraso y recorrido diagnóstico de pacientes con artritis psoriásica en España / Delay and Diagnostic Pathway of Patients with Psoriatic Arthritis in Spain

Introducción y objetivos: El retraso diagnóstico condiciona un peor pronóstico en pacientes con artritis psoriásica. Nuestro objetivo es determinar el tiempo de retraso diagnóstico, las especialidades consultadas y los puntos de derivación de pacientes con artritis psoriásica en nuestro medio. Pacientes y métodos: Distribuimos una encuesta entre los miembros de la asociación española Acción Psoriasis indagando sobre los objetivos del estudio. Resultados: Se analizaron 503 encuestas. El tiempo de retraso diagnóstico fue de 4,01±1,42 años. La proporción de pacientes que habían consultado, antes del diagnóstico, con atención primaria fue del 79,9%, con traumatología, del 33,8% y por urgencias, del 30,2%. La proporción de derivaciones que finalmente condujeron al diagnóstico provinieron de atención primaria en el 29,3% de los casos, de traumatología en el 15,8% y de urgencias en el 3,5%. Discusión y conclusiones: El retraso diagnóstico detectado supera extensamente otros resultados europeos. Los servicios de urgencias ocupan un lugar importante de tránsito de estos pacientes, sin embargo, la proporción de derivaciones es muy bajo. Entendemos que incidir en este gremio médico en particular sobre la importancia del diagnóstico precoz podría resolver gran parte del retraso diagnóstico.(AU)

Introduction and objectives: Delayed diagnosis results in a worse prognosis in patients with psoriatic arthritis. Our objective is to determine the diagnostic delay, the specialties consulted and the referral points of patients with psoriatic arthritis in our environment. Patients and methods: We distributed a survey to members of the Spanish association Acción Psoriasis inquiring about the objectives of the study. Results: A total of 503 surveys were analysed. The diagnostic delay was 4.01±1.42 years. The proportion of patients who had consulted, before diagnosis, primary care was 79.9%, traumatology 33.8% and the emergency department was 30.2%. The proportion of referrals that eventually led to diagnosis came from primary care in 29.3% of cases, traumatology 15.8% and the emergency department 3.5%. Discussion and conclusions: The delay in diagnosis far outweighs other European results. Emergency departments are an important transit point for these patients, but the proportion of referrals is very low. We believe that focusing on the importance of early diagnosis in this particular medical sector could resolve a large part of diagnostic delay.(AU)

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Consensus terminology for preclinical phases of psoriatic arthritis for use in research studies: results from a Delphi consensus study.

The concept of psoriatic arthritis (PsA) prevention is gaining increased interest owing to the physical limitation, poor quality of life and low remission rates that are achieved with current therapies for PsA. The psoriasis-to-PsA transition offers a unique opportunity to identify individuals at increased risk of developing PsA and to implement preventive strategies. However, identifying individuals at increased risk of developing PsA is challenging as there is no consensus on how this population should be defined. This Consensus Statement puts forward recommended terminology from the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN) for defining specific subgroups of individuals during the preclinical and early clinical phases of PsA to be used in research studies. Following a three-round Delphi process, consensus was reached for three terms and definitions: 'increased risk for PsA', 'psoriasis with asymptomatic synovio-entheseal imaging abnormalities' and 'psoriasis with musculoskeletal symptoms not explained by other diagnosis'. These terms and their definitions will enable improved identification and standardization of study populations in clinical research. In the future, as increasing evidence emerges regarding the molecular and clinical features of the psoriasis-to-PsA continuum, these terms and definitions will be further refined and updated.

Short-Term Western Diet Intake Promotes IL-23‒Mediated Skin and Joint Inflammation Accompanied by Changes to the Gut Microbiota in Mice.

We previously showed that exposure to a high-sugar and moderate-fat diet (i.e., Western diet [WD]) in mice induces appreciable skin inflammation and enhances the susceptibility to imiquimod-induced psoriasiform dermatitis, suggesting that dietary components may render the skin susceptible to psoriatic inflammation. In this study, utilizing an IL-23 minicircle-based model with features of both psoriasiform dermatitis and psoriatic arthritis, we showed that intake of WD for 10 weeks predisposed mice not only to skin but also to joint inflammation. Both WD-induced skin and joint injuries were associated with an expansion of IL-17A‒producing γδ T cells and increased expression of T helper type 17 cytokines. After IL-23 minicircle delivery, WD-fed mice had reduced microbial diversity and pronounced dysbiosis. Treatment with broad-spectrum antibiotics suppressed IL-23‒mediated skin and joint inflammation in the WD-fed mice. Strikingly, reduced skin and joint inflammation with a partial reversion of the gut microbiota were noted when mice switched from a WD to a standard diet after IL-23 minicircle delivery. These findings reveal that a short-term WD intake‒induced dysbiosis is accompanied by enhanced psoriasis-like skin and joint inflammation. Modifications toward a healthier dietary pattern should be considered in patients with psoriatic skin and/or joint disease.

Modifiable lifestyle and environmental factors associated with onset of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational studies.

BACKGROUND: Psoriatic arthritis (PsA) is a progressive joint disease associated with psoriasis. OBJECTIVES: To investigate the association of modifiable lifestyle and environmental factors with PsA risk among people with psoriasis. METHODS: We conducted a systematic search of PubMed, Embase, and Cochrane Library through May 2, 2020, for observational studies reporting lifestyle or environmental factors for PsA onset in patients with psoriasis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were combined using a random-effects model. RESULTS: We included 16 studies comprising 322,967 individuals. Obesity and being overweight were associated with an increased PsA risk in patients with psoriasis (OR, 1.75 [95% CI, 1.42-2.16] and OR, 1.50 [95% CI, 1.08-2.09], respectively), with an increase of approximately 6% for each kg/m2 rise in body mass index (OR, 1.06; 95% CI, 1.03-1.10). The presence of PsA was associated with a history of physical trauma (OR, 1.33; 95% CI, 1.16-1.54) or fracture (OR, 1.46; 95% CI, 1.22-1.74). No significant associations were observed regarding alcohol consumption (OR, 0.99; 95% CI, 0.88-1.13), smoking (OR, 0.89; 95% CI, 0.75-1.06), female hormonal exposure (OR, 1.45; 95% CI, 0.95-2.20), and psychologically traumatic events. LIMITATIONS: Inherent limitations in the included observational studies. CONCLUSIONS: Several lifestyle and environmental factors are associated with PsA onset among patients with psoriasis. These findings indicate that such risk may be modified with lifestyle changes or avoidance of physical trauma in people with psoriasis.

Aiming for Cure and Preventive Initiatives in Psoriatic Disease: Building Synergy at NPF, GRAPPA, and PPACMAN.

PURPOSE OF REVIEW: To provide a general overview of the organizations dedicated to advance clinical and translational research in the field of psoriatic disease and to describe the current and future opportunities for team science approaches to overcome unmet needs in the field. Descriptions of initiatives from the NPF, PPACMAN, and GRAPPA are summarized. RECENT FINDINGS: Program projects have recently identified areas of knowledge gaps in diagnosis, treatment, and prevention of psoriasis and psoriatic arthritis (PsA). NPF's Psoriasis Prevention Initiative aims to identify interventions that can prevent the onset and relapse of psoriatic disease or related comorbidities. The Psorcast Study is a joint venture between PPACMAN and Sage Bionetworks based on patient-generated smartphone measurements of psoriatic disease. Similarly, GRAPPA is involved in a number of projects related to axial PsA, enthesitis prevalence, and biomarker discoveries. As important initiatives bring new targets for diagnosis and therapeutics in psoriatic disease, supra-endeavors such as the NIH-Accelerating Medicines Partnership (AMP) and the European Innovative Medicines Initiative (IMI) are promising public-private partnerships that can significantly catapult the field forward.

Effect of biologics on radiographic progression of peripheral joint in patients with psoriatic arthritis: meta-analysis.

OBJECTIVES: To determine the efficacy of biologics in preventing radiographic progression in peripheral joints of PsA patients. METHODS: Studies were searched in MEDLINE, Web of Science, and abstracts from the last three EULAR and ACR meetings up to 31 December 2019. Primary and secondary endpoints were the proportion of patients without radiographic progression and the mean change in total radiographic score at week 24. RESULTS: Eleven studies, involving 5382 patients, 9 drugs and 18 treatments, were included. Patients receiving biologics were more likely to achieve radiographic non-progression compared with placebo [odds ratio: pooled: 2.40, 95% CI: 2.00, 2.87; TNF inhibitors (TNFi): 2.94, 95% CI: 2.38, 3.63; IL inhibitors (ILi): 2.15, 95% CI: 1.69, 2.74; abatacept: 1.54, 95% CI: 1.03, 2.28] and have significantly lower radiographic progression [standardized mean difference (SMD): pooled: -2.16, 95% CI: -2.91, -1.41; TNFi: -2.82, 95% CI: -4.31, -1.33; ILi: -1.60, 95% CI: -2.49, -0.72; abatacept: -0.40, 95% CI: -0.59, -0.21]. Concomitant MTX therapy was not superior to monotherapy (SMD: pooled: 0.01, 95% CI: -0.07, 0.08; biologics: 0.01, 95% CI: -0.09, 0.11; placebo: -0.01, 95% CI: -0.13, 0.12). The effect of ustekinumab and secukinumab on radiographic progression was not influenced by prior anti-TNF therapy (SMD: -0.08, 95% CI: -0.25, 0.10). CONCLUSION: Biologic agents may retard radiographic progression in PsA patients in terms of bone erosion and joint space narrowing compared with placebo. MTX seems to have no added effect. Prior anti-TNF therapy seems to not influence the radiographic efficacy of IL blockers.

Evidence that systemic therapies for psoriasis may reduce psoriatic arthritis occurrence.

OBJECTIVES: Contemporary biologic therapies for psoriasis are independently licensed for psoriatic arthritis (PsA). Since skin disease generally predates PsA and PsA has a subclinical phase, we investigated the pattern of PsA evolution in psoriasis treated with biologic agents compared to other medications including oral therapy, topical agents or no treatments. METHODS: A retrospective chart review was performed in psoriasis patients with musculoskeletal symptoms referred for rheumatological assessment. Patients who had a final diagnosis of PsA were identified. The frequency and clinical features of PsA were compared for biologics versus the other strategies. RESULTS: Between 2015-18, 203 psoriasis patients were referred for musculoskeletal symptoms with 25 on biologics, 31 on non-biologic systemic therapies and 147 on topical/no therapies. A final diagnosis of PsA was similar in all groups (biologics: 36%; non-biologic systemic treatments: 35.4%; none/local treatments: 37.4%). Most patients had musculoskeletal symptoms before systemic therapy initiation but new onset PsA was evident in 12% (3/25) biologics treated patients, 9.6% (3/31) in non-biologic systemic therapy patients and was significantly higher in patients on topical/no therapy (55/147; 37.4%, p<0.001). Among patients with PsA, none of the patients on biologics exhibited dactylitis compared to 28.6% of other systemic treatments and 48.6% of none/local treatments (p=0.046). CONCLUSIONS: New symptoms and signs leading to PsA diagnosis appear to decrease with systemic treatments. The characteristic PsA dactylitis lesion was not evident in the biologic therapy group.

Evaluation of the expression of the stromal cell-derived factor-1 alpha (CXCL 12) in psoriatic patients after treatment with Methotrexate.

BACKGROUND: CXCL12 has an important role in skin homeostasis and inflammation. OBJECTIVE: In this work, the expression of CXCL12 was evaluated in psoriasis vulgaris, psoriatic arthritis (PsA) patients in relation to disease activity and methotrexate (MTX) therapy. METHODS: Skin biopsies were obtained from 10 psoriasis vulgaris patients, 10 PsA patients, and 20 controls. The biopsies were repeated 6 weeks after MTX therapy. The biopsies were stained immunohistochemically by stromal dermal factor 1 alpha (CXCL 12) antibody. RESULTS: Psoriatic arthritis showed significantly more expression of CXCL 12 than psoriasis vulgaris patients before treatment but not after treatment. There was significant decrease in CXCL 12 expression in the keratinocytes of psoriasis vulgaris patients after MTX therapy than before treatment, P-value was 0.009. There was no significant difference between pre- and post-treatment in the CXCL 12 expression of keratinocytes of PsA patients, P-value was 0.093. The percentage decrease of PASI score after treatment showed a moderate correlation with the percentage decrease of CXCL12 expression of the keratinocytes of the total psoriasis patients, r = 0.484, P-value was 0.015. CONCLUSION: CXCL12 might be involved in the progression of psoriasis vulgaris to PsA. MTX therapy downregulated the expression of CXCL12 of the keratinocytes of psoriasis patients. This downregulation was paralleled by decrease in the PASI score. CXCL12 can be used as a biological marker of disease severity of psoriasis patients.

Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition.

Psoriasis is one of the most common chronic inflammatory skin diseases, affecting 3% of the world's population, and approximately one-third of patients with psoriasis will eventually transition to having psoriatic arthritis (PsA). The evolution from cutaneous to synovio-entheseal inflammation in these patients presents an opportunity to investigate the critical events linked to arthritis development. The events responsible for progression to PsA are currently unclear. Genetic and clinical-demographic risk factors (most notably familial aggregation and psoriasis sub-phenotypes) provide relevant insights into the variables that promote transition. The specific underlying molecular and cellular mechanisms, however, remain poorly defined. Intriguingly, although targeting the IL-23-IL-17 axis substantially improves psoriasis outcomes, this strategy is not more effective than TNF inhibitors in improving musculoskeletal symptoms in PsA. Major unmet needs in the field of PsA include defining those patients with psoriasis at increased risk of developing arthritis, improving our understanding of the natural history of disease and characterizing the immune, environmental and molecular subclinical events preceding PsA onset. Improving our knowledge of this transition is essential for designing clinical trials with treatments that can delay, attenuate or even prevent the development of PsA in patients with psoriasis.

Efectos del tabaco sobre la psoriasis y la artritis psoriásica / Effects of tobacco on psoriasis and psoriatic arthritis

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Inflammatory Arthritis Prevalence and Health Services Use in the First Nations and Non-First Nations Populations of Alberta, Canada.

OBJECTIVE: To estimate prevalence of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic disease (PsD), and crystal-related arthritis and health care use for inflammatory arthritis in First Nations and non-First Nations patients in Alberta, Canada. METHODS: Population-based cohorts of adults with RA, AS, PsD, and crystal-related arthritis were defined, with First Nations determination by premium payer status, to estimate prevalence rates. Rates of outpatient primary care, specialist visits, and hospitalizations (all-cause, inflammatory-arthritis specific) were estimated. RESULTS: RA affected 3 times as many First Nations residents compared to non-First Nations residents (standardized rate ratio [SRR] 3.2, 95% confidence interval [95% CI] 2.9-3.4). AS and PsD were more prevalent in First Nations (AS 0.6 per 100 residents; SRR 2.7, 95% CI 2.3-3.2 and PsD 0.3 per 100 residents; SRR 1.5, 95% CI 1.3-1.9), whereas crystal-related arthritis was less prevalent (SRR 0.7, 95% CI 0.6-0.7). First Nations patients were more likely to have primary care visits (SRR 1.7, 95% CI 1.6-1.8) and less likely to have specialist visits (SRR 0.6, 95% CI 0.6-0.7) for RA relative to non-First Nations individuals. In PsD and crystal-related arthritis, First Nations people had higher rates of cause-specific hospitalizations. CONCLUSION: The estimated prevalence of RA, AS, and PsD was higher in the First Nations population, while crystal-related arthritis was less prevalent compared to the non-First Nations population. First Nations people were more likely to see primary care physicians and were less likely to see specialists for inflammatory arthritis care.

Bloque 1: Actualización/la industria informa / No disponible

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Bloque 3: Talleres y Reunión del Grupo Español de Psoriasis / No disponible

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Bloque 5: Comunicaciones orales presentadas / No disponible

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Diet and psoriasis, part I: Impact of weight loss interventions.

One of the most frequently asked questions by patients with psoriasis is whether dietary changes can improve their condition. Included in this discussion is whether dietary weight loss can benefit their skin disease. Obesity has been associated with a proinflammatory state and several studies have demonstrated a relationship between body mass index and psoriasis severity. However, the question of whether weight loss interventions can impact psoriasis outcome is less clear. Here, we review the literature to examine the efficacy of weight loss interventions, both dietary and surgical, on psoriasis disease course.