Identification of Psoriatic Arthritis and Ankylosing Spondylitis Early Detection to Facilitate Appropriate Care

Transcription

1 Identification of Psoriatic Arthritis and Ankylosing Spondylitis Early Detection to Facilitate Appropriate Care Joy Schechtman D.O. Professor Midwestern University 64C

2 Disclosures None 3 64C

3 Learning Objectives Understand the evolving concept of spondyloarthritis (SpA) Recognize the signs and symptoms of psoriatic arthritis (PsA) Recognize the signs and symptoms of ankylosing spondylitis (AS) Understand how to screen and when to refer to a rheumatologist for further evaluation 3 64C

4 PsA and AS: Part of the Spondyloarthritides (SpA) Psoriatic Arthritis Enteropathic Arthritis Reactive Arthritis Spondyloarthritis Ankylosing Spondylitis Undifferentiated SpA Khan MA. Ankylosing Spondylitis. 2009; Rudwaleit M. In: Rheumatology. 5th ed. 2011: C

5 Two Subtypes of SpA Predominantly Axial Disease Ankylosing spondylitis (radiographic SpA) Nonradiographic axial SpA Predominantly Peripheral Disease Psoriatic arthritis Reactive arthritis Inflammatory bowel disease-associated arthritis Undifferentiated SpA Rudwaleit M. Ann Rheum Dis. 2009;68(6): Rudwaleit M. Ann Rheum Dis. 2011;70(1): Zochling J et al. Rheumatology (Oxford). 2005;44(12): C

6 Co-management of the AS/PsA Patient Continued coordination and communication Primary caregivers Perform baseline screening with history, examination +/- testing Recognize the signs and symptoms of AS/PsA Refer to specialist to ensure appropriate diagnosis and management Rheumatologist Confirm diagnosis Educate patient Prescribe and monitor therapy Coordinate SpA care with other providers when appropriate (PCP, ophthalmologist, physical therapy, et cetera) Monitor patient s progress and adjust therapy when appropriate ACR Subcommittee on RA Guidelines. Arthritis Rheum. 2002;46(2): Graydon SL et al. J Rheumatol. 2008;35(7): Kountz DS et al. J Fam Pract. 2007;56(suppl 10A):59A-74A. Weinblatt ME et al. J Fam Pract. 2007;56(suppl 4):S1-S C

7 Psoriatic Arthritis (PsA) 7 64C

8 What Is PsA? An inflammatory spondyloarthropathy associated with psoriasis Characterized by inflammation in joints and surrounding bone, ligaments, and tendons Plaque psoriasis 2012 ASSH; used with permission ACR; used with permission. Fitzgerald O. In: Kelley s Textbook of Rheumatology. 8th ed. 2008: Gladman DD. In: Primer on the Rheumatic Diseases. 13th ed. 2008: Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): Haroon M et al. Ann Rheum Dis. 2013;72(5): C

9 Who Does PsA Affect? PsA affects females and males in equal ratio The most typical age of onset is from 30 years old, but it may occur at any age The prevalence is estimated to range from 0.1% to 1.0% of the general population, with an incidence of about 3 to 23 new cases per 100,000 people Up to 42% of patients with psoriasis will develop PsA In about 84% of patients, skin disease precedes joint disease Fitzgerald O. In: Kelley s Textbook of Rheumatology. 8th ed. 2008: Gladman DD. In: Primer on the Rheumatic Diseases. 13th ed. 2008: Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): C

10 Importance of Early Diagnosis and Appropriate Management Early recognition and appropriate management of PsA are important to: Reduce symptoms such as pain, stiffness, and skin lesions Prevent further joint damage and improve physical function In one study, up to 47% of PsA patients with disease duration of 2 years had evidence of radiographic damage Ahlehoff O et al. J Intern Med. 2011;270(2): Kane D et al. Rheumatology. 2003;42(12): Mease PJ et al. Int J Adv Rheumatol. 2006;4(2): C

11 What Are the Most Common Manifestations of PsA? Recognizing some of the most common signs, symptoms, and manifestations of PsA can improve early recognition Psoriatic skin lesions Peripheral arthritis Axial disease Dactylitis Enthesitis Nail disease Elevated acute phase reactants Gladman DD. In: Primer on the Rheumatic Diseases. 13th ed. 2008: Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): C

12 Psoriasis Chronic inflammatory disease of the skin Occurs in approximately 2% of the population Plaque psoriasis characterized by raised plaques with scale Common locations include: Scalp Knees/elbows Hands/feet Lower back/buttocks 2012 American Academy of Dermatology. Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): Menter A et al. J Am Acad Dermatol. 2008;58(5): AAD C

13 Peripheral Arthritis Pain and swelling in any joint outside of the spine and pelvis Occurs in 95% of patients with PsA Fluctuating course of flares and improvement May cause joint damage and deformities Distal interphalangeal (DIP) involvement can help distinguish PsA from other types of inflammatory arthritis, but may not always be present About 5% may develop arthritis mutilans with substantial bone loss and deformities 2013 ACR; used with permission. Bruce IN. In: Rheumatology. 5th ed. 2011: Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): Kane D et al. Rheumatology. 2003;42(12): C

14 Peripheral Arthritis (cont d) X-rays may be normal Erosive bone loss may cause irreversible joint damage Fusion with bone growth across joints (ankylosis) can occur 2013 ACR; used with permission. Note the ankylosis of all interphalangeal joints, except for the thumb Bruce IN. In: Rheumatology. 5th ed. 2011: Husni ME. In: Rheumatology. 5th ed. 2011: ACR; used with permission. Subchondral bone resorption of the distal interphalangeal joint of the thumb and middle fingers has resulted in the pencil-incup appearance. 64C

15 Axial Involvement in PsA Inflammation in sacroiliac joints and/or spine 20% to 50% have both peripheral and axial disease 5% have axial disease without peripheral disease Inflammatory back pain (more to come in AS review) Gottlieb A et al. J Am Acad Dermatol. 2008;58(5): C

16 Dactylitis Inflammation of tendons in fingers and toes Occurs in approximately 30% to 40% of PsA patients Differs from arthritis on exam in that there is tenderness and swelling between the joints as well as around the joints Causes the digit to have sausage appearance Most commonly involves 1 or 2 digits at a time Brockbank JE et al. Ann Rheum Dis. 2005;64(2): Bruce IN. In: Rheumatology. 5th ed. 2011; ACR; used with permission C

17 Enthesitis Inflammation where tendons and ligaments insert into bone Symptomatic enthesitis occurs in 20% to 40% of patients with PsA Most common sites are Achilles and plantar fascia insertions Usually presents similarly to mechanical enthesopathy, but more refractory and often at more than one site Characterized by tenderness on examination, swelling may not be apparent on examination Bruce IN. In: Rheumatology. 5th ed. 2011: Gladman DD. In: Primer on the Rheumatic Diseases. 13th ed. 2008: C

18 Nail Disease in PsA Fingernail pitting 2013 ACR; used with permission. Fingernail pitting and onycholysis 60% to 80% of patients with PsA have psoriatic nail diseases Characterized by: Pitting Thickening of nails (hyperkeratosis) Separation of nails from nail bed (onycholysis) The nail thickening and separation in PsA can be indistinguishable from fungal infections on examination 2013 ACR; used with permission. Bruce IN. In: Rheumatology. 5th ed. 2011: Kacar N et al. Clin Exp Dermatol. 2007;32(1): C

19 PsA: Laboratory Measures Acute phase reactants have value in assessing active inflammation in peripheral joints Increased CRP* levels are less commonly observed in PsA vs RA, but are associated with poorer outcomes in PsA 5% to 9% of patients with PsA can be rheumatoid factor (RF) positive *CRP=C-reactive protein. Kavanaugh A et al. Clin Exp Rheum. 2005;23(suppl 39):s142-s C

20 Flags for Referral You should refer all patients with any of the following to a rheumatologist for suspected PsA: Psoriasis or a family history of psoriasis with a suspicion for inflammatory arthritis Psoriasis or a family history of psoriasis with a suspicion for enthesitis Psoriasis or a family history of psoriasis and either swollen or painful joints Suspicion for dactylitis Suspicion for inflammatory spine disease Salisbury NHS Foundation Trust. Referral pathway for psoriatic arthritis. ICALM AN AGEM EN T/RH EUM ATOLOG Y/P ages/psa.aspx 20 64C

21 Sample Screening Questions The following screening questions can be used to identify appropriate candidates for referral: Have you had swelling in your joints for no apparent reason? Do you have a history of psoriasis? Do you experience morning stiffness for longer than 30 minutes? Do you have chronic pain in your back that improves with exercise, not with rest? Have you had tenderness or swelling in your heel(s) for no apparent reason? Have you had a finger or toe that became completely swollen from tip to base for no apparent reason? Do you have pits in your nails? 21 64C

22 PsA Case Study 22 64C

23 Case Study: Presentation FK, a 32-year-old female, is a dedicated long-distance runner She presents in the office with a 1-year history of left ankle pain and a 2-month history of right knee pain No history of psoriasis, but has had dandruff for 3 months 23 64C

24 Case Study: Clinical Assessment Cutaneous exam Nail dystrophy of the right 2nd and 3rd digits Scaling plaque, right occiput Peripheral articular exam Right knee swelling DIP swelling of the right 2nd and 3rd digits Labs Test CBC ESR CRP RF Result Normal Normal Mildly elevated Negative 24 64C

25 Case Study: Conclusion Provisional diagnosis: psoriatic arthritis Prescribe naproxen 500 mg BID Refer to rheumatologist for an early appointment and consider dermatology referral for skin management 25 64C

26 Therapeutic Management of PsA Goals of therapy: To improve signs and symptoms Prevent progression of joint damage Improve physical function Kavanaugh A et al. J Rheumatol. 2006;33(7): C

27 Ankylosing Spondylitis (AS) 27 64C

28 What Is AS? AS is a chronic inflammatory disease Most commonly affected sites: Axial skeleton (sacroiliac joints and the spinal column) Entheses (sites where the tendons and ligaments attach to bones) Peripheral joints Over time, in severe cases, may cause progressive, vertebral fusion (ankylosis) van der Heijde D. In: Primer on the Rheumatic Diseases. 13th ed. 2008: van der Linden S et al. In: Kelley s Textbook of Rheumatology. 8th ed. 2008: C

29 Who Does AS Affect? Age of onset, AS vs RA German rheumatological database: disease duration 5 years; 1993 to 1998 data. Used with permission. Symptoms usually start between 20 and 30 years of age (rarely after age 40) Unfortunately, most patients with AS are either diagnosed late or already compromised upon diagnosis Traditionally, AS has been a disease thought to be more prevalent in males than in females, with a ratio of about 2 to 3:1. However, data suggest that the percentage of women with AS is dependent on the year of diagnosis, and in recent years the gender ratio has approached 1:1 Feldtkeller E et al. Curr Opin Rheumatol. 2000;12(4): Khan MA. Ann Intern Med. 2002;136(12): van der Linden SM et al. In: Kelley s Textbook of Rheumatology. 8th ed. 2008: Zink A et al. Ann Rheum Dis. 2001;60(3): C

30 Prevalence of Axial SpA, Including AS, vs RA The age-adjusted prevalence of axial SpA varies from 0.9% to 1.4% Approximately 1.7 million to 2.7 million patients with axial SpA Estimate based on adults aged 20 to 69 years examined in the US NHANES who fulfilled the Amor or ESSG criteria The estimated reported prevalence of AS is 0.52% Estimates based on moderate or severe radiographic sacroiliitis on pelvic radiographs in men, aged 25 to 74 years, and women, aged 50 to 74 years Questions regarding inflammatory back pain were not asked; therefore, the exact prevalence of AS cannot be ascertained The estimated prevalence of rheumatoid arthritis (RA) is 0.6% Estimated Prevalence in US a a The age-adjusted prevalence of axial SpA varies from 0.9% to 1.4% Note: Prevalence figures were derived from differing populations and studies Helmick CG et al. Arthritis Rheum. 2008;58(1): Reveille JD et al. Arthritis Care Res doi: /acr C

31 Age at First Symptoms and at First Diagnosis in AS Patients Average delay in diagnosis: 9 years There was a significantly longer delay in diagnosis in women compared to men (9.8 vs 8.4 years; P<0.01) Feldtkeller E et al. Curr Opin Rheumatol. 2000;12(4): (with permission) C

32 Barriers to Early Diagnosis: A Survey of 127 AS Patients Patients slow to seek care: 35% delayed consulting a health care professional for >12 months after symptom onset 71% assumed that their symptoms would resolve AS is difficult for providers to recognize: Prior to diagnosis: 68% consulted a physical therapist (3 or more: 16%) 44%, a chiropractor (3 or more: 9%) Diagnosis of SpA was suspected in <2% Grigg SE et al. Arthritis Rheum. 2011;63(suppl 10): C

33 Importance of Early Diagnosis and Appropriate Management in AS Early diagnosis and appropriate management are important for several reasons: Appropriate treatment can help improve symptoms Patients in the early course of disease have a similar burden of disease to those in later stages An early diagnosis avoids unnecessary diagnostic procedures and inappropriate treatment Brandt HC et al. Ann Rheum Dis. 2007;66(11): Braun J et al. Ann Rheum Dis. 2011;70(6): Rudwaleit M et al. Arthritis Rheum. 2005;52(4): Sieper J et al. Ann Rheum Dis. 2005;64(5): C

34 Evolution of AS Nonradiographic stage of Axial SpA Nonradiographic stage of Axial SpA Back pain Back pain Radiographic sacroiliitis Radiographic stage (AS) Modified New York Criteria 1984 Back pain Syndesmophytes Time (years) It is not yet known if every patient in the nonradiographic stage of axial SpA will progress Rudwaleit M et al. Arthritis Rheum. 2005;52(4): Rudwaleit M et al. Arthritis Rheum. 2009;60(3): C

35 Classification Criteria for Ankylosing Spondylitis (AS): 1984 Modified New York Criteria A: Diagnosis Clinical criteria: Low back pain and stiffness for >3 months, which improve with exercise but are not relieved by rest Limitation of motion of the lumbar spine in both the sagittal and frontal planes Limitation of chest expansion relative to normal values correlated for age and sex Radiologic criterion: Sacroiliitis (grade 2 bilaterally or grade 3 4 unilaterally) B: Grading Definite AS = radiological criterion present + 1 clinical criterion Probable AS = 3 clinical criteria present or radiologic criterion present without any signs or symptoms satisfying the clinical criteria van der Linden et al. Arthritis Rheum. 1984;27(4): C

36 What Does AS Look Like? Recognizing the common manifestations of AS can improve early recognition: Axial disease Inflammatory back pain Sacroiliitis Range of motion limitations and postural changes Peripheral arthritis Enthesitis Uveitis van der Heijde D. In: Primer on the Rheumatic Diseases. 13th ed. 2008: C

37 Inflammatory Back Pain (IBP) Not all back pain is the same: The character of SpA back pain is different than mechanical back pain in that it is of inflammatory origin 1 out of every 3 chronic back pain patients has IBP What does IBP look like? Onset before the age of 40 Worse at night or early morning after prolonged immobility Improves with exercise or activity, not relieved by rest Morning stiffness for >30 minutes Alternating buttock pain Weisman MH et al. Ann Rheum Dis. 2013;72(3): C

38 Sacroiliitis Normal sacroiliac joint Joint space widening Joint space narrowing Sclerosis Erosion Sacroiliitis on imaging is considered the hallmark of AS Imaging is not generally suggested for screening in primary care settings due to costs, radiation exposure, and difficulties in interpretation. However, if available, an imaging result showing clear sacroiliitis warrants immediate referral to a rheumatologist Rudwaleit M et al. Nat Rev Rheumatol. 2012;8(5): van der Heijde D. In: Primer on the Rheumatic Diseases. 13th ed. 2008: C

39 Range of Motion Limitations and Postural Changes Fusion of vertebrae restricts spinal motion This feature is more evident in later stages of disease, thus is less useful in identifying early AS Patients often complain about difficulty looking upward and over their shoulder Over time patients may stoop forward OVER TIME In one study of patients with AS, radiographs were scored according to disease duration. Complete spinal fusion occurred in 28% of patients with disease duration >30 years and 43% with disease duration >40 years Jang JH et al. Radiology. 2011;258(1): van der Linden SM et al. In: Kelley s Textbook of Rheumatology. 8th ed. 2008: Ankylosis of all cervical joints from the second cervical vertebrae downward 64C

40 Peripheral Arthritis Classically oligoarticular, large joints of lower extremities, but may affect any joint Inflammatory hip disease occurs in 30% to 50% of AS patients and is associated with more severe disease Can cause erosive bone loss or bony fusion across joints, similar to PsA 2013 ACR; used with permission. Advanced narrowing of the entire hip joint space characteristic of inflammatory arthritis. Hamdi W et al. Joint Bone Spine. 2012;79(1): C

41 Enthesitis May occur anywhere tendons and ligaments attach to bone, but occurs most often in Achilles and plantar fascia Diagnosed by applying enough pressure to blanch your fingernail Diagnosis can be confirmed with ultrasound or MRI Oliveri I et al. Rheumatology (Oxford). 2006;45(10) van der Heijde D. In: Primer on the Rheumatic Diseases. 13th ed. 2008: Common sites for pain associated with enthesitis 41 64C

42 Acute Anterior Uveitis Uveitis occurs in about one-third of AS patients Sudden onset pain, redness, and blurred vision Although uveitis rarely precedes the clinical onset of AS, it is often the first clue to the recognition that low back pain is inflammatory 80% of HLA-B27+ people with recurrent uveitis have SpA Diagnosis requires slit lamp exam Patients suspected of having uveitis should be referred to an ophthalmologist for further evaluation Monnet D et al. Ophthalmology. 2004;111(4): van der Heijde D. In: Primer on the Rheumatic Diseases. 13th ed. 2008: C

43 HLA-B27 Estimates from 2009 National Health and Nutrition Examination Survey (NHANES) demonstrated a 6.1% prevalence rate of HLA-B27 in adults aged 20 to 69 years The strength of disease association varies among the different forms of SpA and the many ethnic and racial groups worldwide Among whites, 4% to 13% of the general population possess HLA-B27, but more than 90% of the patients with AS possess this gene Among African Americans, 2% to 4% of the general population possess HLA-B27, whereas 50% to 60% of patients with AS possess this gene HLA-B27 testing is diagnostically useful only in combination with other features of SpA For example, axial SpA diagnosis occurs in 58% of patients with both HLA-B27 and inflammatory back pain Brandt HC et al. Ann Rheum Dis. 2007;66: Braun J. In: Primer on the Rheumatic Diseases. 13th ed. 2008; Khan MA. Atlas of Rheumatology. 2005; Reveille JD et al. Arthritis Rheum. 2012;64(5): C

44 Improving Early Recognition of AS Chronic inflammatory back pain is the leading symptom in patients with axial SpA, including AS, and should serve as a key screening parameter No incremental cost for assessment Sensitivity of inflammatory back pain for AS is 75% Sieper J et al. Ann Rheum Dis. 2005;64(5): C

45 Recognizing Inflammatory Back Pain Assessment in SpondyloArthritis International Society (ASAS), criteria for IBP present a standard framework for screening patients In patients with chronic back pain (>3 mo), IBP criteria are fulfilled if at least 4 out of 5 parameters are present* *Sensitivity of 79.6% and specificity of 72.4% based on expert clinical judgment from ASAS Validation Study; n=648. Mnemonic ipain and ipain are copyrighted (Ozgocmen S et al. J Rheumatol. 2010;37(9): ). Ozgocmen S et al. J Rheumatol. 2010;37(9): Sieper J et al. Ann Rheum Dis. 2009;68(suppl II):ii1-ii C

46 IBP Ascertainment Tool The following screening questions can be used to help identify patients with inflammatory back pain: Adapted from Development and Validation of a Case Ascertainment Tool for AS Question item What is your gender? Rationale Historically there has been a 2:1 male to female ratio in the diagnosis of AS, however, recent data suggest the ratio is approaching 1:1 Have you experienced pain or stiffness that lasted for at least 3 months? If so, please indicate the location(s). Approximately how old were you when you first had pain or stiffness in your back that lasted for at least 3 months? ASAS IBP criteria are to be applied to patients with chronic back pain lasting for at least 3 months. Presence of neck and/or hip pain has a significant positive association with AS Based on IBP criteria, age of onset is <40 years old with a duration of back pain >3 months Approximately how long have you had back pain or stiffness? Have you felt numbness or tingling that spread into or down your leg(s) that you think or have been told might have been caused by your back pain or stiffness? If answer is Yes, back pain is likely mechanical vs inflammatory Is the pain or stiffness due to fall, sprain, or other incidents, such as twisting or lifting? How does exercise affect the pain or stiffness in your lower back or buttocks? How does daily physical activity affect the pain or stiffness in your lower back or buttocks? Do you take any NSAID medication(s)? If so, do they help reduce your back pain or stiffness within 48 hours? Have you been diagnosed with iritis? Exercise typically alleviates IBP/stiffness IBP/stiffness tends to decrease with daily physical activity Patients with IBP/stiffness generally have a good response to NSAIDs within 48 hours Uveitis is a common extra-articular manifestation, occurring in 25%-40% of AS patients Weisman MH et al. Arthritis Care Res (Hoboken). 2010;62(1): C

47 A Guide to Referring for AS Evaluation Patients with chronic low back pain with the onset of symptoms <45 years old should be referred to a rheumatologist in the presence of: IBP HLA-B27 Sacroiliitis Chronic diarrhea, enthesitis, uveitis and psoriasis are also considered valuable clues for identifying patients that should be referred to a rheumatologist for further assessment Chronic low back pain >3 months First symptoms <45 years old IBP Sensitivity 75%; specificity 76% If positive, about 1/5 patients has axial SpA OR OR HLA-B27 Sensitivity 80-90%; specificity 90% If positive, about 1/3 patients has axial SpA Refer to rheumatologist for further evaluation Sacroiliitis Only if available (Not recommended for screening) By X-ray or MRI Sieper J et al. Ann Rheum Dis. 2005;64(5): C

48 AS Case Study 48 64C

49 Case Study: Presentation JD, a 28-year-old male, is a mechanic He comes into your office complaining of worsening back pain and stiffness for >2 years History of neck spasms since age 18 Regularly sees a chiropractor for his lower back pain 49 64C

50 Case Study: Clinical Assessment Signs and symptoms Back pain that is worse at night and often awakens him from sleep Marked early morning stiffness that improves after walking around for about 45 minutes His heel has been sore for months Physical exam Reduced forward flexion at the waist Tenderness at the Achilles insertion of R heel 2012 ACR; used with permission. Lab Test Result CBC Normal ESR CRP RF Mildly elevated Normal Negative 50 64C

51 Case Study: Conclusion Provisional diagnosis: inflammatory back pain and enthesitis Prescribe indomethacin 50 mg BID and physical therapy Refer to a rheumatologist, suggest early appointment 51 64C

52 2010 ASAS/EULAR Recommendations for the Management of AS The optimal management of patients with AS requires a combination of nonpharmacological and pharmacological treatments. Some nonpharmacological options include physical therapy/rehabilitation, exercise, and patient help groups NSAIDs recommended as first line of therapy for AS patients with pain and stiffness Extra-articular manifestations, such as psoriasis, uveitis and IBD, should be managed in collaboration with appropriate specialists Biologic therapy should be given to appropriate patients with persistently high disease activity despite conventional therapies according to the updated ASAS recommendations Braun J et al. Ann Rheum Dis. 2011;70(6): C

53 Conclusions Spondyloarthritis includes heterogeneous diseases that are challenging to diagnose. Early diagnosis and treatment are important. Psoriasis patients should be screened for PsA risk and educated about PsA symptoms. Chronic back pain patients should be screened for and educated about inflammatory back pain (consider referring to back pain project website). Refer to a rheumatologist early if you suspect any type of SpA AbbVie Inc. North Chicago, IL November 2016 Printed in U.S.A. 64C