Psoriatic Arthritis Clinical Features and Epidemiology Dafna D. Gladman MD, FRCPC Director, Psoriatic Arthritis Program, University Health Network Centre for Prognosis Studies in the Rheumatic Diseases Toronto Western Hospital Toronto Western Hospital
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Psoriatic Arthritis Clinical Features and Epidemiology Dafna D. Gladman MD, FRCPC Director, Psoriatic Arthritis Program, University Health Network Centre.
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Psoriatic ArthritisClinical Features and
Epidemiology
Dafna D. Gladman MD, FRCPC
Director, Psoriatic Arthritis Program,
University Health Network
Centre for Prognosis Studies in the Rheumatic Diseases
Toronto Western Hospital
Toronto Western Hospital
Psoriatic Arthritis
An inflammatory arthritis Associated with psoriasis Usually seronegative for
rheumatoid factor
Definition
Psoriatic Arthritis Clinical Patterns
Distal predominant (Distal inter-phalangeal joints of fingers and toes).
Oligo-articular (<5 joints) often in an asymmetric distribution.
Progression of damage defined by a change in damage state:– State 1 = 0 damaged joints– State 2 = 1-4 damaged joints– State 3 = 5-9 damaged joints– State 4 = 10 damaged joints
Analysis by model for rate of transition between damage states.
Clinical Indicators of Progression
Gladman DD et al. J Rheumatology 1995;22:675.
Prognostic Indicators in PsA
Relative Risk Variable 1 to 2 2 to 3 3 to 4 2 P value > 4 Effusions 1.6 1.6 1.6 5.7 0.017 ESR < 15 0.61 0.61 - 6.68 0.01
Rx 1.78 1.78 1.78 7.8 0.005
Steroids 1.55 1.55 1.55 5.46 0.019
Multivariate model for Clinical Indicatorsof Clinical Progression*
Gladman DD et al. J Rheumatology 1995;22:675.
*Based on clinical features at presentation
Prognostic Indicators in PsA
Variable Relative Risk X2 P value 1 to 2 2 to 3 3 to 4 B22 0.19 0.19 0.19 0.002
Final Multivariate Model for Time Varying Clinical Indicators
Gladman DD, Farewell VT. J Rheumatol 1999;26:2409
Outcome in Psoriatic arthritis
PsA patients are at an increased risk of death.
Overall risk is 1.62 that of Ontario Residents.
» 1.66 for women, 1.59 for men
Causes of Death are similar to general population.
Risk of death is related to previously active and severe disease.
Wong K, et al. Arthritis Rheum 1997;40:1868-7.Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Mortality Studies
Mortality in Psoriatic Arthritis
Primary Cause N (%) Circulatory system 17 (36.2)
Myocardial Infarction 13 (27.6)
Cerebrovascular accident 2 ( 4.3)
CHF/arteriosclerosis 2 ( 4.3)
Respiratory system 10 (21.3)
Pneumonia 7 (14.9)
COPD 3 ( 6.4)
Digestive system (liver) 4 ( 8.5)
Malignant neoplasms 8 (17.0)
Injuries/poisoning 7 (14.9)
Other 1 ( 2.1)
Total known cause 47 ( 100)
Primary causes of death in 53 patients
Survival in Psoriatic Arthritis
Time Since Clinic Entry (Years)
Su
rviv
al P
rob
abili
ty
0 5 10 15 20
0.5
0.6
0.7
0.8
0.9
1.0
All patients
Mortality in Psoriatic Arthritis
Factor Relative risk
Confidence interval
P value
Prior Medication
1.83
0.93, 3.60
0.079
Radiological damage 3.88 1.32,11.35 0.014
ESR > 15 3.77 1.31,10.83 0.013
Nail changes 0.33 0.14, 0.76 0.009
Prognostic Factors: Final Multivariate Model
Gladman DD, et al. Arthritis Rheum 1998;41:1103-10.
Remission in Psoriatic Arthritis
Summary Remission occurred in 17.6% of our PsA
patients. Male gender and less active and severe
arthritis at presentation to Clinic were associated with remission.
Only 6 (8.7%) of the PsA patients sustained “true remission”,
35 (52%) had subsequent flares.
Gladman DD et al. J Rheumatol 2001;28:1045-8.
Psoriatic Arthritis Prognostic Factors
Progression of Damage: High effusion count at presentation High joint count at each visit High medication level at presentation Low ESR is “protective”
Death: Elevated ESR High prior medication level Radiological Damage
Remission Male Gender Low joint count at presentation
Psoriatic Arthritis
Not just skin and joints! An inflammatory arthritis associated with
psoriasis. More common than previously thought. About one fifth of the patients have a
severe debilitating disease, although some patients achieve remission.
Earlier studies suggesting that PsA was a mild disease included patients with early disease.
Psoriatic Arthritis Program
Cathy Schentag MsC Research AssociateCPSRD, TWH
Richard Cook, PhDBiostatisticianWaterloo, Ontario
Vern Farewell, PhDBiostatisticianMRC, Cambridge, UK