AUSTRALIAN PODIATRY ASSOCIATION NSW & ACT Friday 29TH April 2016

Advances, assessment and approaches for management in psoriatic arthritis

Professor in Podiatric Medicine Debbie Turner WESTERN SYDNEY UNIVERSITY

Governance • Funded by Arthritis Research UK (ref: 17832) • Funded by Arthritis Research UK (ref: 18374) • Funded by Arthritis Research UK (ref: 18884) • NRES approval (West Glasgow Ethics Committee 2. Ref 09/S0704/14 No Conflicts of interest to declare

Aims of presentation • • • • •

Background on PsA Foot involvement in PsA Imaging Features Typical functional impairments Management

Spondylarthropathies - PsA • Seronegative! • Sacroiliitis • Anodular peripheral arthritis • Psoriaform skin lesions • Ocular inflammation (iritis, uveitis) • Enthesitis • Familial aggregation

• Shared comorbidity – Aortic regurgitation – Pulmonary fibrosis – Inflammatory bowel disease – Amyloidosis

Diagnosis • Concept of spondylarthropathy was introduced by Moll et al. 1974 • Classification based on clinical and / or pathological findings • 2 main sets of classification proposed by the European Spondylarthropathy Study Group (ESSG) – Dougados et al 1991 – Amor et al 1990

ESSG Preliminary criteria for classification of SpA Inflammatory spinal pain

or

Synovitis (asymmetric often in lower limb)

One or more of the following

Positive family history Inflammatory bowel disease Urethritis, cervicitis or acute diarrhoea (1 month before arthritis) Buttock pain alternating between right and left Enthesopathy Sacroiliitis

Amor criteria for classification of SpA (≥ 6 for SpA) A

Past or current clinic manifestations

Points

1

Back pain at night and or stiffness in the morning

1

2

Asymmetric oligoarthritis

2

3

Gluteal pain without other details

1 or

Alternating gluteal pain

2

4

Sausage digit or toe

2

5

Heel pain or other enthesopathy

2

6

Iritis

2

7

Non-gonoccal urethritis or cervicitis within 1 month onset of arthritis

1

8

Diarrhoea within 1 month onset of arthritis

1

9

Past or current psoriasis and /or inflammatory bowel disease

2

B

Roentgenographic changes

10

Sacroiliitis (stage 2 or more if bilateral, stage 3 or more if unilateral)

C

Predisposing genetic factors

11

Presence of HLA-B27 antigen and / or positive family Hx of AS, ReA, psoriasis, uveitis or chronic bowel disease

D

Responsiveness to treatment

12

Improvement within 48 hrs after initiated NSAIDs

3 2

1

Classification of PsA CASPAR criteria Inflammatory articular disease (peripheral, spine, enthesis)

• Plus >= 3 points from the following • Psoriasis: current (2) / history (1) / family history (1) • Nail dystrophy (1) • Negative rheumatoid factor (1) • Dactylitis: current (1) / history of (1) • Radiographs: (hand / foot) juxta-articular new bone formation (1) • Taylor W et al Arth & Rheum August 2006

Psoriatic Arthritis • PSA often a neglected area of rheumatology practice • Often considered a benign arthropathy • 50% patients go on to develop progressive arthritis, with impairment of joint function, deformity and impact on quality of life 1-3 1- Gladman D., 1994. 2-Brockbank J. & Gladman D., et al. 2000. 1992.

3- Alonso J.C.T., et al.

Psoriatic Arthritis • Peripheral enthesitis is considered to be a hallmark feature

Psoriatic Arthritis • Peripheral enthesitis is considered to be a hallmark feature • Dactylitis • Synovitis

Psoriatic Arthritis • Peripheral enthesitis is considered to be a hallmark feature • Dactylitis • Synovitis • Nail pathology

Psoriatic Arthritis • Peripheral enthesitis is considered to be a hallmark feature • Dactylitis • Synovitis • Nail pathology • Deformity • Podiatrists well placed to screen for PSA • Manage foot problems

Diagnosis of PsA – Clinical red flag • A clue to the diagnosis of PsA is diffuse swelling of a single digit – ‘sausage toe’ or ‘sausage finger’ due to dactylitis • A number of components are at work simultaneously joint synovitis/periostitis/tendonitis

Nail involvement in PsA – Clinical red flag • Approximately 80% of patients with PSA have nail involvement (4). • Associated with pain, functional impairment of manual dexterity and psychological stress(5). • Nail involvement is a visible indicator of disease activity and a precursor of PSA (7). 4- Williamson., et al. 2004. 5- Wilson., et al. 2009. 6- Reich., et al. 2009.

Nail involvement in PsA – Clinical red flag

Figure taken from Reich K. 2009. Approach to managing patients with nail psoriasis. JEADV 23 (Suppl 1), 15-21

Nail anatomy

Figure taken from McGonagle D. 2009. Enthesitis: an auto inflammatory lesion linking nail and joint involvement in psoriatic disease. JEADV 23 (Suppl 1), 9-13.

Screening for PsA in patients with psoriasis

Free educational resources online

https://www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Screening for PsA in patients with psoriasis

Outcome domains in PsA - GRAPPA • Tender / swollen joint counts • Psoriasis area severity index (PASI) Lesion score, Body Surface Area • Pain VAS • HAQ, SF-36 • PsAQoL

Disease activity in PsA

Systemic disease or localised disease? Global Disease Factors

Local Disease Factors

Foot Structure and Function

 Global  Local  S&F impairment  Global  Local  S&F impairment

 Global  Local  S&F impairment

Measuring disease activity - Skin • • • • •

Body surface area (BSA) Psoriasis Area and Severity Index (PASI) Physician's Global Assessment (PGA) Self-Administered PASI (SAPASI) Salford Psoriasis Index (SPI)

• Surface area of skin involvement and Lesion Severity – • 4 domains (surface area, erythema,thickness and scale) Head, trunk and upper and lower extremities. Score 0-72 Response is classed as a 75% improvement in PASI

Measuring disease activity - Nails The Nail Pso- riasis Severity Index (NAPSI) is the most comprehensive assessment of nail disease used in psoriasis clinical trials The nail is divided into four quadrants and 1 point is awarded if there is any finding of nail matrix and 1 point is awarded for nail bed change that is seen, per quadrant, or 0-8 per nail. This yields a potential total score of 80 in the feet or 160 if hands and feet are inlcuded

Measuring disease activity - Nails

Nail plate

Figure taken from McGonagle D. 2009. Enthesitis: an auto inflammatory lesion linking nail and joint involvement in psoriatic disease. JEADV 23 (Suppl 1), 9-13.

Nail plate

Figure taken from McGonagle D. 2009. Enthesitis: an auto inflammatory lesion linking nail and joint involvement in psoriatic disease. JEADV 23 (Suppl 1), 9-13.

Measuring disease activity - Dactylitis • Found in 6- 48% of reported PsA cases • Present / absent • 0-3 scale where 0 is no swelling or pain and 3 is severe swelling and pain) • Leeds Dactylitis Index (LDI)

Measuring disease activity - Enthesitis Several enthesitis scoring measures have been developed: • Mander Enthesis Index (MEI) • MASES - Maastricht Ankylosing Spondylitis Entheses Score the Major Enthesitis Index • SPARCC Enthesitis Index, Spondyloarthritis Research Consortium of Canada • Leeds Enthesitis Index (LEI) The LEI is relatively simple and consists only of six sites: • Bilateral Achilles tendon insertions • Bilateral medial femoral condyles • Bilateral lateral epicondyles of the humerus. • Tenderness on examination is recorded as either; present (1) or absent (0) for each of the six sites Score range of 0-6.

In a study comparing the LEI, MEI, MASES, modified SPARCC (eight sites), and Major indices in PsA patients commencing diseasemodifying therapy, the clinical parameters of disease activity correlated most consistently with the LEI

Quality of Life - PsAQoL • Self administered 20- item questionnaire (McKenna et al. 2004) • True / false statements • Qualitative patient interviews • Rasch analysis • High score indicates lower quality of life • I cant do the things I want to • I am unable to join in activities with friends and family

Foot impairments and disease burden in PsA • Evidence base? Limited clinical foot related studies (Bezza et al. 2004) Focus on imaging of foot enthesitis MR Imaging features in patients with psoriasis (Ghanem et al 2007) • Clinical survey (Hyslop et al. 2010) Self-reported foot pain Enthesitis Burden (impairment / related disability (FISRA) Skin / nail dystrophy Dactylitis Provision of foot care

Foot impairments – Clinical survey n=104 Enthesitis

Dactylitis (24%) Skin psoriasis (8%) Nail dystrophy (13%)

Posterior Tibial Tendon 40%

Achilles Tendon 24% SJC (0-14): 0 (1) TJC (0-14): 3 (3)

Plantar Fascia 30%

Forefoot deformity (95%) Rearfoot deformity (65%)

Self-reported foot pain (62%) FIS-RA (0-21)IF: 10 (5) FIS-RA (0-30)AP: 15 (9)

Foot impairments – Forefoot PAIN

STIFFNESS

Newly diagnosed

Dactylitis IP joint synovitis, erosions Lesser toe deformity HAV Nail Pathology MTP joint synovitis, erosions and dislocation Inter-metatarsal bursitis Plantar callosities and bursa Dorsal toe callosities

DEFORMITY

Forefoot typical plantar pressure profiles

Forefoot and ultrasound metrics – combined knowledge Bur

Ph Met

Figure 1A – B mode image of a longitudinal scan of plantar aspect of fifth metatarsal head showing joint erosion and formation of overlying plantar bursa. Met= metaratsal head; Ph= proximal phalanx; E= erosion; Bur= plantar bursa. 1B- The corresponding peak plantar pressure distribution showing high focal pressures over the fifth metatarsal head. Figure taken from Turner D E. et al (2014). Metatarsalphalangeal joint pain in psoriatic arthritis : a cross sectional study. Rheumatology; 53(4):737-40.

Assessment of enthesitis • Detected clinically by swollen and tender joints / soft-tissue (tendon, bursae, enthesis) • Clinical examination is not sensitive and lacks pathological specificity (4).

• Clinical confidence increased by further imaging (7-9).

1- Achilles insertional tendinopathy 2- Achilles mid-portion tendinopathy 3-Retrocalcaneal bursitis 4- Ankle / STJ synovitis

7- Wakefield, R. J., et al. 2008. 8-D'Agostino, et al. 2005.

9- Bàlint, P. V.,et al. 2003.

Assessment of enthesitis

Assessment of enthesitis Enthesitis Scoring Systems

Tendon thickness ≥5.29mm + +

+ +

Power Doppler Ultrasound Signal

Retrocalcaneal Bursitis

Erosion

Enthesophyte

Assessment of enthesitis

Assessment of enthesitis

Assessment of enthesitis

Kager’s fat pad

Achilles tendonosis

Assessment of enthesitis

Extended field of view image – Dr Anna Ciechomska

Assessment of enthesitis Enthesitis Scoring Systems

PF thickness ≥4.4mm + +

+ +

Power Doppler Ultrasound Signal

Erosion

Enthesophyte

Elaine Hyslop, PhD student, GCU

Enthesitis • Hypothesis: AT enthesitis localisation associated with abnormal mechanics in PsA – Insertional angle – Increased ankle-complex dorsiflexion

Hyslop et al 2010; Hyslop et al 2012; Woodburn et al

Assessment of enthesitis Insertional angle

Ankle complex dorsiflexion

AT force

+ +

+

p=0.05 (Trend: More eversion in the healthy adult control group ) +

p=0.59 (Trend: None)

p=0.003 (Trend: Smaller AT force in PsA enthesitis group )

Enthesitis

GUESS Tendon thickness ≥5.29mm

Retrocalcaneal Bursitis

Erosion

Enthesophyte

+ +

PsA 

Healthy control Χ

PsA  Healthy control

PsA 



PsA 

Healthy control Χ Healthy control

Plantar pressure profiles - PsA

Arch well preserved – focal localisation in lateral border around 30% of patients

Treatment guidelines

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment guidelines for psoriatic arthritis.

Treatment guidelines

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment guidelines for psoriatic arthritis.

Biologics and Infection – lessons form RA Systemic Manifestations & Adverse Events

• Foot ulcer prevalence 9.7% (Firth et al. 2008) • Retrospective audit foot ulceration (Davys et al. 2006): – Female – Long-standing disease – Pressure vulnerable sites in forefoot – One-third on biologic therapy • Single case infected foot ulceration with septic arthritis (Otter et al. 2005). • Case series of 9 infected onychocryptosis (Davys et al. 2006).

Podiatry Management Goals Targeted Care Patient Assessment Peripheral Arthritis

Dactylitis

Skin and nail disease

Enthesitis

Medical referral (multidisciplinary team care) Initiate IA steroids Self-management Immobilisation Orthotics Footwear Physical therapies Surgery

Foot hygiene advice Self-management Orthotics Footwear

Initiate IA steroids Orthotics Footwear

Initiate IA steroids Immobilisation Orthotics Footwear Physical therapies Surgery

Reassess response to therapy

↓Foot pain

↑Physical function

↑ HRQoL

PSA Podiatry Management Goals (1) Zero tolerance of active foot disease Residual Disease ???

Optimised medical care Change in drug class / escalating dose

Monitor and Assess Outcome Targeted IA / soft tissue injections

Address Biomechanics

Casting

+/-

US-guided

Targeted intervention

Case history example

Case history example

Case history example

Case history example

Summary • Assessment of disease activity • Enthesitis, Skin, Nails, Joints • Quality of life • Targeted approach • Active inflammation • Biomechanics • Combination • Pharmacology - biologics

Any Questions? [email protected]. au