Psoriasis and PsA Epidemiology and Classification

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5/15/15 Learning Objectives Psoriasis and PsA Epidemiology and Classification Describe epidemiology of psoriasis Examine impact of psoriasis on quality of life, work productivity, and under-treatment

Content Developers Pre-Activity Question 1 April W.

Health Outcomes Program (COHO) University of Colorado Denver School of Medicine Aurora, Colorado Dafna D.

1 5/15/15 Learning Objectives Psoriasis and PsA Epidemiology and Classification Describe epidemiology of psoriasis Examine impact of psoriasis on quality of life, work productivity, and under-treatment patterns. Describe epidemiology and classification of psoriatic arthritis. Examine factors contributing to disease progression and methods of screening for psoriatic arthritis. Content Developers Pre-Activity Question 1 April W. Armstrong, MD, MPH Vice Chair of Clinical Research Associate Professor of Dermatology Director, Clinical Trials and Outcomes Research Director, Psoriasis Program Department of Dermatology Colorado Health Outcomes Program (COHO) University of Colorado Denver School of Medicine Aurora, Colorado Dafna D. Gladman MD, FRCPC Professor of Medicine, University of Toronto Senior Scientist, Toronto Western Research Institute Director, Psoriatic Arthritis Program University Health Network Toronto, Ontario, Canada Philip Helliwell, MD Leeds Institute of Rheumatic and Musculoskeletal Medicine University of Leeds Chapel Allerton Hospital Leeds, England How confident are you in your ability to discuss the classification of psoriatic arthritis? 1. Very confident. Confident 3. Somewhat confident 4. Not confident Speakers Pre-Activity Question April W. Armstrong, MD, MPH Vice Chair of Clinical Research Associate Professor of Dermatology Director, Clinical Trials and Outcomes Research Director, Psoriasis Program Department of Dermatology Colorado Health Outcomes Program (COHO) University of Colorado Denver School of Medicine Aurora, Colorado How confident are you in your ability to discuss the epidemiology of psoriasis? 1. Very confident. Confident 3. Somewhat confident 4. Not confident Atul Deodhar, MD Professor of Medicine Division of Arthritis and Rheumatic Diseases Medical Director, Rheumatology Clinics Oregon Health and Science University Portland, OR 1

5/15/15 Pre-Activity Question 3 Prevalence of Psoriasis: Africa and Asia Which of the following is NOT a disease activity-related predictor of disease progression for PsA? 1. Number of swollen joints.

% in adults yrs (NHANES) 1 ~5 million adults diagnosed with psoriasis Prevalence of undiagnosed active psoriasis Conservative estimate:.4% (6, adults) Broad definition:.8% (3.6 million adults) NPF: 7.

At 5-6 years 75% have onset before age 4 NHANES = National Health and Nutrition Examination Survey; NPF = National Psoriasis Foundation. 1. Rachakonda TD, et al. J Am Acad Dermatol. 13;7:51-516.

ca/wpcontent/uploads/1/1/cdnpsoriasisguidelines.pdf. Accessed September 16, 14.

2 5/15/15 Pre-Activity Question 3 Prevalence of Psoriasis: Africa and Asia Which of the following is NOT a disease activity-related predictor of disease progression for PsA? 1. Number of swollen joints. Number of tender joints Sri Lanka <.5% China.4% Taiwan <.5% 3. Initial ESR 4. Pain rating of 8 on visual analog scale Africa <.5% United States In 1, prevalence of diagnosed psoriasis was 3.% in adults yrs (NHANES) 1 ~5 million adults diagnosed with psoriasis Prevalence of undiagnosed active psoriasis Conservative estimate:.4% (6, adults) Broad definition:.8% (3.6 million adults) NPF: 7.5 million patients in the US 3 Canada 4 Prevalence of Psoriasis: North America Estimated 5, people affected Psoriasis Epidemiology Equal frequency in both genders Two peaks of occurrence At -3 years At 5-6 years 75% have onset before age 4 NHANES = National Health and Nutrition Examination Survey; NPF = National Psoriasis Foundation. 1. Rachakonda TD, et al. J Am Acad Dermatol. 13;7: Kurd SK, et al. J Am Acad Dermatol. 9;6: National Psoriasis Foundation. Accessed August 9, Canadian Dermatology Association. Accessed September 16, 14. Prevalence of Psoriasis: Europe and Russia Emotional and Physical Impact of Psoriasis in US Patients Emotional and Physical Impact of Psoriasis (N=5,64) Sweden.% 1 Yes No Norway 1.4% United Kingdom 1.48 % 1.87% Denmark.84% Russia.7% Germany.%.53% Psoriasis Patients Impacted (%) Italy.9% Spain 1.43% Emotional Components Physical Components Parisi R, et al. J Invest Dermatol. 13;133: Armstrong AW, et al. PLoS One. 1;7:e

3 5/15/15 Impact of Psoriasis on Work Status among US Patients Work Status among Psoriasis Patients (N=564) Part-time work 11% Not working 1% Retired % Homemaker 5% In school % Full-time work 48% Patients with severe psoriasis were more likely to be unemployed than those with mild disease 9% of those who were unemployed cited their disease as the sole reason not working Of those working, 49% reported missing work due to psoriasis or psoriatic arthritis treatment Data from 5,64 psoriasis and psoriatic arthritis patients in semiannual surveys conducted by the NPF from Armstrong AW, et al. PLoS One. 1;7:e Under-treatment among Patients with Psoriasis in the United States % Receiving No Treatment Proportion of Patients with Psoriasis Receiving No Treatment (N=564) Armstrong A, et al. JAMA Dermatol. 13;149: Mild Psoriasis Moderate Psoriasis Severe Psoriasis Patient Dissatisfaction With Psoriasis Therapy Based on Disease Severity in the United States Learning Objectives % Dissatisfied Patients with Moderate Psoriasis Had the Highest Level of Treatment Dissatisfaction Describe epidemiology of psoriasis Examine impact of psoriasis on quality of life, work productivity, and under-treatment patterns. Describe psoriatic arthritis epidemiology, clinical presentation, and classification. Examine factors contributing to disease progression and methods of screening for psoriatic arthritis. Mild (< 3% BSA) Moderate (3-1% BSA) Severe (> 1% BSA) Disease Severity BSA = body surface area. Armstrong A, et al. JAMA Dermatol. 13;149: MAPP Survey: Treatment Trends for Psoriatic Disease in North America and Europe The Relation between Psoriasis and PsA Current Treatment by BSA in Psoriasis and Psoriatic Arthritis Patients Patients (%) Biologic +/- Topical Oral + Biologic Oral +/- Topical Topical only No Rx Arthritis Before Psoriasis and Arthritis Together 1% 15% 75% Psoriasis Before palm lesions (n = 1) 4-1 palm lesions (n = 393) > 1 palm lesions (n = 166) Body Surface Area PsA patients (n = 71) MAPP = Multinational Assessment of Psoriasis and Psoriatic Arthritis. Lebwohl MG, et al. J Am Acad Dermatol. 14;7: Slide courtesy of Dr Lihi Eder. 3

5/15/15 Population Prevalence of Psoriatic Arthritis Slide Courtesy of Dr Enrique Soriano GDD5 Population Incidence of Psoriatic Arthritis Slide Courtesy of Dr Enrique Soriano.1.5.4.5...1-.1 6.6 8 6.

4 Van Romunde et al 1984 Netherlands Rheumatologist.5 Shbeeb et al USA Arthritis + psoriasis.1 Gelfand et al 5 USA Patient report of PsA.5 Agari et al 13 USA ICD9 codes.7 (.54.

4 5/15/15 Population Prevalence of Psoriatic Arthritis Slide Courtesy of Dr Enrique Soriano GDD5 Population Incidence of Psoriatic Arthritis Slide Courtesy of Dr Enrique Soriano Point prevalence of psoriatic arthritis per 1 persons worldwide Study Year Country Case definition Prevalence % Lomholt et al 1963 Faroe Islands Arthritis + psoriasis.4 Van Romunde et al 1984 Netherlands Rheumatologist.5 Shbeeb et al USA Arthritis + psoriasis.1 Gelfand et al 5 USA Patient report of PsA.5 Agari et al 13 USA ICD9 codes.7 (.54.84) Hellgren et al 1969 Sweden Arthritis + psoriasis. Alamanos et al 3 Greece ESSG criteria.6 Trontzas et al 5 Greece Rheumatologist.17 Madland et al 5 Norway Rheumatologist. Soriano et al 11 Argentina CASPAR.7 ( ) Li et al 1 China Arthritis + psoriasis.1-.1 Lomholt et al. Copenhagen: GEC Gad; 1963.van Romunde LK, et al. Rheumatol Int. 1984;4:55-6; Shbeeb M, et al. J Rheumatol. ;7;147-5; Gelfand JM, et al. J Am Acad Dermatol. 5;53:573. Agari MM, et al. pharmacoepidemiology and drug safety 13; : ; Hellgren L. Acta Rheumatol Scand. 197;16:18-1; Alamanos Y, et al. J Rheumatol. 3;3:641-4; Tronztas P, et al. Rheumatology (Oxford). 6;45: ; Madland TM, et al. J Rheumatol. 5;3:1918-; Soriano ER, et al. Rheumatology (Oxford). 11;5:79-34; Li R, et al. Rheumatology (Oxford). 1;51: Annual incidence of psoriatic arthritis per 1, persons worldwide 7. Annual Incidence cases/1 5 Study Year Country Case definition (95% confidence interval) Kaipianinen-Seppanen et al 1996 Finland Arthritis + psoriasis 6.1 ( ) Shbeeb et al USA Arthritis + psoriasis 6.6 (5. 8.) Hukuda et al 1 Japan Arthritis + psoriasis.1 Soderlin et al Sweden Arthritis + psoriasis 8 (4 15) Alamanos et al 3 Greece ESSG criteria 3. ( ) Savolainen et al 3 Finland Arthritis + psoriasis 3.1 ( ) Wilson et al 9 USA CASPAR 7. (6 8.) Soriano et al 11 Argentina CASPAR 6.3 (4. 8.3) Kaipiainen-Seppänen O. Br J Rheumatol. 1996;35:189-91; Shbeeb M, et al. J Rheumatol. ;7;147-5; Hukuda S, et al. J Rheumatol. 1;8:554-9; Soderlin MK, et al. Ann Rheum Dis. ;61:911-5; Alamanos y, et al. J Rheumatol. 3;3:641-4; Savolainen E, et al. J Rheumatol. 3;3:46-8; Wilson FC. Ann Rheum Dis. 9; 36(): Soriano ER, et al. Rheumatology (Oxford). 11;5: Prevalence of PsA among People with Psoriasis Psoriatic Arthritis Author (yr) Centre No. Psoriasis Patients % PsA Leczinsky (1948) Sweden Vilanova (1951) Barcelona 14 5 Little (1975) Toronto 1 3 Scarpa (1984) Napoli Stern (1985) Boston 185 Zaneli (199) Winston-Salem Barisic-Drusko (1994) Osijek region Salvarani (1995) Regio Emilia 5 36 Shbeeb () Mayo Clinic Brockbank (1) Toronto Alenius () Sweden NPF () US 4.4 m 3 Zachariae (3) Denmark Reich (8) Germany Haroon (13) Dublin 1 9 Walsh (13) Utah Mease (13) International 1 3 An inflammatory musculoskeletal disease associated with psoriasis Usually seronegative for rheumatoid factor Associated Features Spondylitis Enthesitis Dactylitis Iritis Mucous membrane ulcers Urethritis Other extra-articular features of SpA Classified as SpA Incidence of PsA 11 Psoriatic Arthritis Clinical Patterns 1 / 313 psoriasis patients developed PsA within 4 years of follow-up The annual incidence rate was 1.87 PsA cases per 1 psoriasis patients Assuming patients not followed did not develop PsA The incidence rate increased to.53 when only the 53 participants with at least one follow-up were included Probability of Developing PsA Eder E, et al. Arthritis Care Res. 11;63: KM Exp Time from First Visit to Diagnosis of PsA (year) Exponential model shows a constant hazard rate Distal predominant (Distal inter-phalangeal joints of fingers and toes) Oligo-articular (<5 joints) often in an asymmetric distribution Poly-articular ( 5 joints), rheumatoid arthritis-like Spinal Involvement Arthritis Mutilans Moll & Wright. Seminars Arthritis Rheum. 1973;3:181. 4

5 Slide 6 GDD5 Again change the white on the left hand column Gladman, Dr Dafna, 1//14

6 5/15/15 Psoriatic Arthritis Differential Diagnosis of PsA Peripheral arthritis Axial arthritis Peripheral plus Axial Patterns change over time Early PsA 4% oligoarticular 6% polyarticular Manifestation Psoriatic Rheumatoid Arthritis Arthritis Gout Osteoarthritis Age at onset 36 5s Any age Over 5 M : F 1.1:1 1:3 3:1 1:1 Joint affected Any Proximal Toes, knees ankles Weight bearing, DIP Symmetry Asymmetric Symmetric Asymmetric May be symmetric Redness over joint Yes No Yes No Spinal disease Yes No No Degenerative Dactylitis Yes No Podagra No Enthesitis Yes No No No Nodules No Yes Tophi Heberden s,bouchard s Psoriasis 1% 1-3% 1-3% 1-3% Nail lesions 87% No No No Jones SM, et al. Br J Rheum. 1994;33: Khan M, et al. J Rheumatol. 3;3: Kane D, et al. ARD. 3;4: Gladman DD. Targeted Treatment of Rheumatic Disease. 1; Psoriatic Arthritis Domains Differentiating PsA from Other SpA Peripheral arthritis Axial disease Dactylitis Enthesitis Skin Nail Manifestation PsA AS ReA IBD Arthritis Age M : F 1.1 : 1 3: 1 3: 1 : 1 Peripheral joints 96% 3% 9% 3% Axial joints 5% 1% 1% 3% Dactylitis Common No Uncommon No Enthesitis Common Common Uncommon Uncommon Psoriasis 1% 1% 1% 1% Nail lesions 87% Uncommon Uncommon Uncommon HLA-B*7 4-5% 9% 7% 3% Gladman D. Am J Med Sci. 1998;316:34-8. The CASPAR Criteria for Psoriatic Arthritis Inflammatory articular disease that may involve joint, entheseal or axial manifestations (not otherwise defined) Current psoriasis + 1 of the following AND Personal or family history of psoriasis Dactylitis Psoriatic nail dystrophy A negative test for rheumatoid factor Radiological evidence of juxta-articular new bone formation No psoriasis + of the following + 3 of the following Learning Objectives Describe psoriasis epidemiology and clinical presentation Examine impact of psoriasis on quality of life, work productivity, and under-treatment patterns. Describe psoriatic arthritis epidemiology, clinical presentation, and classification. Examine factors contributing to disease progression and methods of screening for psoriatic arthritis. Taylor WJ, Gladman DD, Helliwell PS, Marchesoni A, Mease PJ, Mielants H. Classification criteria for Psoriatic Arthritis: new criteria from a large international study. Arthr Rheum. 6;54(8):

7 5/15/15 PsA Is Much More Serious than Previously Recognized Progression of Joint Damage in PsA % with PsA develop clinical deformities and damage, resulting in functional disability Gladman DD, et al. Quart J Med 1987;6:17-41 After 1 years of follow-up, 55% have 5 deformed joints Gladman DD. Baillière s Clinical Rheumatology 1994;8: % with early PsA had at least 1 erosion at presentation to clinic 47% developed erosive disease within the first years Kane D, et al, Rheumatology, 3; 4:146-8 Proportion Clinical Radiological Time since Clinical Entry (years) Siannis F, et al. Ann Rheum Dis. 6;65: Larsen score Comparing Psoriatic Arthritis to Rheumatoid Arthritis Established secondary care cohort Patients matched for age and sex and date of diagnosis Hand 8 RA PsA 11 Feet 4 Mean value HAQ.9 RA.9 Pain VAS/1 PsA.5.6 EQ5D x 1 SteinB Clinical Predictors of Progression Disease Activity Number of swollen joints Number of tender joints Initial ESR Damage Number of damaged joints Tenderness or swelling of a specific joint predicts subsequent damage to that joint Digits with dactylitis are more likely to have erosive disease than digits without dactylitis Sokoll KB, Helliwell PS. Comparison of disability and quality of life in rheumatoid and psoriatic arthritis. J Rheumatol. 1;8: Bond S, et al. Ann Rheum Dis. 7;66:37-6. Cresswell L, et al. Ann Rheum Dis. 11; 7:35-8. Brockbank J, et al. Ann Rheum Dis. 5;64: HAQ and EQ5D by Psoriasis Severity Genetic Markers for Progression of Damage Mean value HAQ EQ5D.5 RA Mild Moderate Severe.4 Progression of Clinical Damage HLA-B7 antigen (with HLA-DR7), HLA-B*7 allele HLA-B39 antigen, HLA-B*39 allele HLA-DQw3 in the absence of HLA-DR7 KIRDS1 Erosive PsA HLA-DRB1 rheumatoid arthritis shared epitope IL-4 I5V Less Progression HLA-DR7, HLA-DRB1*7 HLA-B HLA-C*6 Sokoll KB, Helliwell PS. Comparison of disability and quality of life in rheumatoid and psoriatic arthritis. J Rheumatol. 1;8: Gladman DD, et al. Arthritis Rheum. 1995;38:845-5; Gladman DD, et al. J Rheumatol. 1998;5:73-3. Rahman P, et al. Arthritis Rheum. 8;58:7-8; Korendowych E, et al. J Rheumatol. 3;3:96-1. Ho PY, et al. Ann Rheum Dis. 7;66:87-11; Chandran V, et al. Hum Immunol. 13;74:1333-8; Chandran V, et al. Rheumatology. 14;53:

8 5/15/15 Multivariate Analysis* of Predictors of Clinical Damage: Effect of Disease Duration Post-Activity Question 1 Variable Relative Rate (95% CI) of Joint Damage Progression P-value Group** (PsA > yrs vs. PsA yrs) 1.6 (1.8,.3) <.1 Age 1. (1.1,1.3) <.1 Sex 1.15 (.93,1.4).173 Clinical Joint Damage at 1st visit 1.3 (1.1,1.5).3 NSAIDS at first visit 1.4 (.84,1.3).69 Biologics at first visit.89 (.54,1.45).63 DMARDS at first visit 1. (.95,1.51).13 NSAIDS after first visit 1. (.89,1.68).3 Biologics after first visit 1.15 (.9,1.46).5 DMARDS after first visit 1.5 (1.16,1.99). How confident are you in your ability to discuss the epidemiology and classification of psoriatic arthritis? 1. Very confident. Confident 3. Somewhat confident 4. Not confident * Using a negative binomial model; ** 641 >y 436 y. Gladman DD, et al. Ann Rheum Dis. 11;7:15-4. Effect of Late Consultation Post-Activity Question Univariate Multivariate Variable OR P OR P Erosions Osteolysis Sacroiliitis Arthritis mutilans Deformed joints # deformed joints DMARDs/TNFi failures Drug free remission HAQ scores Even a 6 month delay in consultation leads to untoward outcomes How confident are you in your ability to discuss the epidemiology and classification of psoriasis? 1. Very confident. Confident 3. Somewhat confident 4. Not confident Haroon M, et al. Ann Rheum Dis. Online 14//7. Mortality in Psoriatic Arthritis Post-Activity Question 3 Standardized Mortality Ratio Overall Male Female PsA patients are at an increased risk of death Overall risk is 1.6 that of Ontario Residents 1.65 for women 1.59 for men Causes of Death are similar to the general population In a survey of working psoriatic patients, what percentage reported missing work (absenteeism) due to psoriasis or psoriatic arthritis treatment? 1. 1%. 38% 3. 49% 4. 8% Risk of death is related to previously active and severe disease Ten-year Rolling Periods from 1978 to 4 Ali Y, et al. A&R. 7;56:

9 5/15/15 Post-Activity Question 4 Which of the following is NOT a disease activity-related predictor of disease progression? 1. Number of swollen joints. Number of tender joints 3. Initial ESR 4. Pain rating of 8 on visual analog scale Questions & Answers 8

EXAMINING THE CRUCIAL COALITION BETWEEN DERMATOLOGY AND RHEUMATOLOGY IN PSORIATIC ARTHRITIS

EXAMINING THE CRUCIAL COALITION BETWEEN DERMATOLOGY AND RHEUMATOLOGY IN PSORIATIC ARTHRITIS ACTIVITY 1: EARLY COLLABORATION IN THE TREATMENT OF PSA Key Slides COMMON COMORBIDITIES OF PSORIATIC DISEASE