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OBJECTIVE Assess long-term efficacy and safety of guselkumab, an IL-23p19-subunit inhibitor, in patients with active psoriatic arthritis (PsA) from the Phase-3 DISCOVER-2 trial. METHODS In DISCOVER-2, patients with active PsA (≥5 swollen and ≥5 tender joints; CRP ≥0.6 mg/dL) despite prior nonbiologic therapy were randomized to: guselkumab 100mg every-4-weeks (Q4W); at Week0, Week4, and Q8W; or placebo➔guselkumab Q4W at Week24. Efficacy assessments included ≥20%/50%/70% improvement in ACR components (ACR20/50/70), Investigator's Global Assessment of psoriasis score=0 (IGA=0; indicating complete skin clearance), enthesitis (Leeds Enthesitis Index) and dactylitis (Dactylitis Severity Score) resolution, and changes in PsA-modified van der Heijde-Sharp (vdH-S) radiographic scores. Clinical data (imputed as no response/no change from baseline if missing) and observed radiographic data were summarized through Week100; safety assessments continued through Week112. RESULTS Of 739 randomized and treated patients, 652 (88%) completed treatment through Week100. Across groups of guselkumab-treated patients (including placebo➔Q4W) ACR20 (68%-76%), ACR50 (48%-56%), ACR70 (30%-36%), and IGA=0 (55%-67%) responses and enthesitis (62%-70%) and dactylitis (72%-83%) resolution rates at Week100 indicated amelioration of arthritis signs/symptoms and extra-articular manifestations was durable through 2years. Mean changes in PsA-modified vdH-S scores from Week52-100 (0.13-0.75) indicated the low rates of radiographic progression observed among guselkumab-treated patients at earlier timepoints extended through Week100. Through Week112, 8% (5.8/100 patient-years) and 3% (1.9/100 patient-years) of 731 guselkumab-treated patients had a serious adverse event or serious infection, respectively; one death occurred (road traffic accident). CONCLUSION In biologic-naive PsA patients, guselkumab provided durable improvements in multiple disease domains with no unexpected safety findings through 2years.

Contains fulltext : 287596.pdf (Publisher’s version ) (Open Access) OBJECTIVE: As first-degree relatives (FDRs) of HLA-B27-positive patients with axial spondyloarthritis (SpA) have an increased risk of developing axial SpA, the objectives were 1) to evaluate the presence of highly specific imaging features as well as clinical signs of SpA at baseline and after 1 year of follow-up, and 2) to describe the evolution toward clinical disease within 1 year of follow-up in a cohort of seemingly healthy FDRs of HLA-B27-positive axial SpA patients. METHODS: The Pre-SpA cohort is a 5-year prospective inception cohort of seemingly healthy FDRs of HLA-B27-positive axial SpA patients. Clinical and imaging features were collected and recorded. RESULTS: At baseline, 19% of the FDRs reported inflammatory back pain, 32% current arthralgia, 3% arthritis (ever), 5% enthesitis (ever), and 1% dactylitis (ever), and 3% had an extraarticular manifestation. C-reactive protein level was elevated in 16%, and erythrocyte sedimentation rate was elevated in 7%. On magnetic resonance imaging (MRI) views of sacroiliac joints, 10% had a Spondyloarthritis Research Consortium of Canada score of ≥2, 4% had a score of ≥5, and 4% had deep lesions. In total, 1% fulfilled the modified New York criteria for radiographic sacroiliitis. Clinical, MRI, and acute phase findings were equally distributed between HLA-B27-positive and -negative FDRs. After 1 year of follow-up, clinical parameters did not change on the group level, but 6% of the FDRs were clinically diagnosed with axial SpA, of whom 86% were HLA-B27-positive. CONCLUSION: Features associated with SpA or imaging abnormalities were found in up to 32% of seemingly healthy FDRs, with an equal distribution between HLA-B27-positive and -negative FDRs. Progression to clinical axial SpA within 1 year of follow-up was mainly observed in HLA-B27-positive FDRs.

Psoriatic arthritis (PsA) is a chronic, inflammatory disease characterised by peripheral arthritis, axial disease, dactylitis, enthesitis, skin and nail involvement. Its heterogeneity in presentation along with a lack of widely available biomarkers makes it difficult to diagnose. Furthermore, its varying clinical course, pattern of involvement and common associated co-morbidity lead to challenges in treatment. Precision medicine evidence in PsA remains in its infancy, and a single therapy is elusive. Currently a symptom domain-based strategy is used, but with the currently available there is unmet need in efficacy and patient tolerability. Thus, this article reviews the exciting novel pharmacotherapy with varying modes of action in development including upadacitinib, filgotinib, deucravacitinib, bimekizumab, tildrakizumab and risankizumab. While these drugs show promise and broaden the scope of therapy in PsA, they remain not equally effective in treating all domains as with current therapy.

Objectives To delineate the impact of peripheral musculoskeletal manifestations on stratification of disease phenotype and outcome in new-onset spondyloarthritis (SpA), using a prospective observational nationwide inception cohort, the BelGian Inflammatory Arthritis and spoNdylitis cohorT (Be-Giant). Methods Newly diagnosed adult SpA patients, fulfilling the Assessment of SpondyloArthritis International Society (ASAS) criteria for axial or peripheral SpA, were included in Be-Giant and prospectively followed every six months. Peripheral involvement (defined as arthritis, enthesitis and/or dactylitis) was determined in relation to clinically similar patient subsets at baseline and disease activity patterns during two-year follow-up, identified through K-means cluster analysis and latent class growth analysis. Results From November 2010 to March 2020, 367 patients were enrolled in Be-Giant, of whom 162 (44%) had peripheral manifestations. Two patient clusters [A, axial predominant (n = 248) and B, peripheral predominant (n = 119)] were identified at diagnosis. Longitudinal analysis (n = 115) revealed two trajectories of disease activity in each cluster: one with persistently high disease activity over time (‘High’), the other rapidly evolving to low disease activity (‘Low’). In cluster A patients, peripheral manifestations predisposed to the ‘High’ trajectory [odds ratio (OR) = 2.0, 95% CI: 1.3, 3.1, P = 0.001], despite more rapid initiation of biologics compared with patients without peripheral manifestations (hazard ratio (HR) = 2.1, 95% CI: 1.0, 4.4, P = 0.04 – Cox proportional-hazards model). Conclusion Peripheral musculoskeletal manifestations are major determinants of phenotypical diversity in new-onset SpA. Intriguingly, stratification of axial SpA according to concomitant peripheral involvement identified an endotype with an unfavorable outcome despite more prompt therapeutic intensification with biologics. These observations justify an endotype-tailored approach beyond current ASAS/EULAR management recommendations.

Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disorder that causes chronic pain, primarily in the spine and sacroiliac joints. It is characterized by the presence of type 1 major histocompatibility complex HLA-B27 genetic marker, arthritis in peripheral joints, enthesitis and/or dactylitis and extra-articular manifestations. Current guidelines recommend biological therapy when first-line therapy is not sufficiently effective. The finding that the interleukin (IL)-17 axis is vital for the pathogenesis of axSpA propelled the development of secukinumab, a fully human monoclonal antibody directed against IL-17A. The present review provides evidence on the efficacy and safety of secukinumab in the treatment of radiographic and non-radiographic axSpA from nine randomized controlled phase III trials, as well as evidence from real-world observational analyses. The primary endpoint in six clinical trials was the proportion of patients meeting the Assessment of SpondyloArthritis international Society criteria for either 20% or 40% improvement (ASAS20, ASAS40) at week 16. Significantly more patients achieved the primary endpoint with secukinumab compared with placebo in all the studies except MEASURE 4. Both clinical trials and real-world studies showed significant improvements in the secondary endpoints of disease activity, quality of life, and pain and fatigue relative to placebo. The benefits of secukinumab were generally sustained during longer-term (up to 5 years) treatment. Overall, secukinumab was well tolerated with a low frequency of adverse events and treatment persistence was high in the real-world setting. Although indirect comparisons suggest that secukinumab and adalimumab have comparable efficacy and safety, they are being directly compared in the ongoing SURPASS study. During the current coronavirus disease 2019 (COVID-19) pandemic, it is advisable to continue biological therapy in patients who do not have severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection, but interrupt treatment during an infection, reinitiating once the patient has recovered from the infection. In conclusion, secukinumab is a largely safe and effective treatment for radiographic and non-radiographic axSpA.

Background Psoriasis is a multisystem inflammatory disorder with variable morphology, clinical pattern and multiple comorbidities. Interplay between genetic and environmental factors leading to an aberrant immune response in the skin may contribute to disease development. The assessment for risk factors, signs, and symptoms of potential comorbid diseases is an important component of patient management. The aim of this study is to determine rheumatoid factors (RF) positivity and its levels in psoriasis patients, and describe its relationship with the demographic and clinical characteristics, comorbidities, and disease patterns of psoriasis. Results Rheumatoid factor was positive in psoriatic patients more than control,30% of patients had positive rheumatoid factor while only 10% of control had positive results. Rheumatoid factor level was 63.8 ± 186.7 IU/ml in psoriasis vs. 9.3 ± 12.3 in control. Thirty percent of psoriasis patients have positive rheumatoid factor vs. 10% of control. There was no significant statistical difference between psoriasis patients with or without arthritis as regard rheumatoid factor positivity and titer; rheumatoid factor was positive in 20% in psoriatic patients with arthritis vs. 26% in psoriatic patients without arthritis. In psoriatic patients, the status of rheumatoid factor did not relate to disease severity, onset, course, site of affection, presence of scalp, nail affection, and presence of dactylitis (p value>0.5). Conclusion Psoriasis was associated with higher seropositivity of RF compared to age-matched non-psoriatic healthy controls. Occurrence and level of rheumatoid factor were not associated with severity or clinical pattern of psoriasis.

Objective of the study – to compare, in real clinical practice, according to the data of the Russian Psoriatic Arthritis Registry, characteristics of two groups of psoriatic arthritis (PsA) patients: with and without nail psoriasis.Material and methods. 588 PsA patients (277 males and 311 females) with PsA according to CASPAR criteria were included in the Russian Psoriatic Arthritis Registry. Patients’ age was 48.6±0.5 years, disease duration – 7.0±0.3 years. Patients underwent standard clinical examination of PsA activity. Disease activity measures evaluated in this study included DAPSA (Disease Activity in Psoriatic Arthritis), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and ASDAS-СRP (Ankylosing Spondylitis Disease Activity Score). Enthesitis was measured using LEI (Leeds Enthesitis Index) index. Dactylitis was detected, the number of digits with acute dactylitis was defined. Skin lesion severity was evaluated in terms of BSA (Body Surface Area) affected, and PASI (Psoriasis Area Severity Index); PASI was calculated in case BSA > 3%. The criteria of minimal disease activity (MDA) had been used to assess the treatment efficiency. MDA was achieved if a patient met ≥5 of the 7 following categories: tender joint count (TJC) ≤1, swollen joint count (SJC) ≤1, PASI≤1 or BSA≤3%, patient pain VAS ≤15, patient global activity (PGA) VAS ≤20, Health Assessment Questionnaire Disability Index (HAQ) ≤0.5, and tender entheseal points ≤1. Patients were split into two groups: those with nail psoriasis (group 1), and those without nail psoriasis (group 2).Results. 312 (53.1%) patients had nail psoriasis and 276 (46.9%) did not. Patients’ age in group 1 was 45.7±11.9 years, in group 2 – 48.8±13.2 years (р>0.05). PsA duration in groups 1 and 2 did not differ, it was 7.1±6.6 and 7.0±6.2 years respectively (р>0.05). Higher proportions of patients with nail psoriasis were male, disabled from working and chronic smokers compared to patients without nail psoriasis: 51.9% vs 44.1% (р=0.013), 37.20% vs 26.40% (р0.05), it was mostly methotrexate (MTX); MTX was used in 66.0% and 64.1% of cases respectively (р>0.05). bDMARDs were prescribed to 22.1% and 28.3% (р>0.05) of patients, including tumour necrosis factor (TNF) inhibitors – in 67% and 63% of cases, interleukin (IL) inhibitors – in 33% and 37% of cases (р>0.05 for both comparisons). Taking into account the similar disease duration and equivalent therapy in both groups, it could be concluded that patients with nail psoriasis achieved MDA less frequently due to greater disease severity.Conclusion. Nail involvement is identified in more than half (53%) of PsA patients of the Russian Psoriatic Arthritis Registry. Nail psoriasis is associated with significantly worse disease status as measured by severe peripheral arthritis, enthesitis, dactylitis, spondylitis and skin lesions; higher frequency of erosive arthritis was detected in this category of patients. Patients with nail psoriasis had achieved MDA less frequently compared to patients without nail psoriasis. Nail involvement is associated with worse response to therapy and patients’ disability. These data emphasize the importance of accurate diagnostics of nail psoriasis and optimization of treatment approach, including “targeted” therapy.

To address the diagnostic delay in axial spondyloarthritis (axSpA), we have cross-culturally adapted the Hamilton axSpA questionnaire, a self-administered screening questionnaire, in the Singapore population. In this study, we compared the performance of various scoring methods for this questionnaire in detecting axSpA. The questionnaire was self-administered by eligible subjects. Scoring methods included method A, the original questionnaire scoring, and methods B–E, scoring developed based on the Assessment of SpondyloArthritis International Society (ASAS) criteria for inflammatory back pain (IBP) and the referral, classification and both referral and classification of axSpA, respectively. The reference standard was diagnosis by a rheumatologist. Since the ASAS criteria-based scoring methods were mainly based on clinical axSpA features, self-report and rheumatologist-assessment of clinical axSpA features were also compared in subjects with axSpA. Of 1418 subjects (age: 54 ± 14 years, female: 73%) recruited, 46 were diagnosed with axSpA by a rheumatologist. Sensitivities of methods A–E were 35%, 61%, 63%, 48% and 83%, respectively. Self-report of clinical axSpA features exceeded rheumatologist-assessment for arthritis (83 vs 26%), good response to NSAIDs (37 vs 30%), enthesitis (35 vs 30%), dactylitis (20 vs 2%) and family history for axSpA (13 vs 4%). The reverse was true for IBP (41 vs 63%) and uveitis (4 vs 15%). A self-administered questionnaire using the ASAS referral and classification criteria-based scoring yielded relatively high sensitivity in detecting axSpA in subjects newly referred to rheumatology clinics. This supports its evaluation as a screening and referral tool in the general population in future studies.

Псоріатичний артрит (ПсА) — це хронічне запальне скелетно-м’язове захворювання, асоційоване з псоріазом, яке маніфестує зазвичай з периферичного артриту, дактиліту, ентезиту та/чи спондиліту. Рання ідентифікація та діагностика ПсА, ранній початок терапії важливі для покращення довгострокових наслідків хвороби. Клінічна картина ПсА є гетерогенною, і лікарі досить часто стикаються з проблемами при визначенні стратегій лікування. Метою нашого огляду були надання й інтерпретація рекомендацій Американського коледжу ревматологів (ACR) і Національної організації з псоріазу (NFP) 2018 року з лікування активного ПсА у дорослих з використанням фармакологічних і нефармакологічних методів. Ці рекомендації щодо лікування ПсА можуть допомогти як клініцистам, так і пацієнтам досягти оптимальних рішень щодо менеджменту хвороби. У рекомендаціях наведені стратегії вибору препаратів для лікування активного ПсА при різних клінічних ситуаціях та залежно від проведеної попередньої терапії. Наявність або відсутність коморбідних станів, таких як запальне захворювання кишечника, увеїт, діабет або серйозні інфекції, а також знання попередніх методів лікування є факторами, що дозволяють зробити вибір оптимальної терапії для окремого пацієнта в даний момент часу, застосовуючи індивідуальний підхід. Рекомендації ACR/NFP щодо лікування активного ПсА рекомендують інгібітори фактора некрозу пухлини, а не пероральні низькомолекулярні препарати як препарати першої лінії, саме ці біологічні агенти запобігають прогресуванню захворювання та пошкодженню суглобів. Наголошується на необхідності ранньої та агресивної терапії у пацієнтів з вперше виявленим ПсА.

Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.

Objective: to compare the clinical efficacy in real clinical practice of the targeted synthetic disease-modifying antirheumatic drug (sDMARD) tofacitinib (TOFA) and the biologic DMARD (bDMARD), an inhibitor of tumor necrosis factor alpha (TNFα), adalimumab (ADA) in patients with psoriatic arthritis (PsA), included in the Russian nationwide register of patients with PsA.Patients and methods. The study included 77 patients with PsA (43 men and 34 women) who met the CASPAR criteria and were observed in the Russian nationwide register. Patients were divided into two groups depending on the treatment. Group 1, in which oral TOFA was prescribed, 5 mg 2 times a day, included 41 patients: 24 (58.5%) men and 17 (41.5%) women, the median age was 41 [34; 50] years, the median duration of PsA was 72 [35; 120] months. Group 2, in which subcutaneous ADA was used, 40 mg every 2 weeks, included 36 patients: 19 (52.8%) men and 17 (47.2%) women, the median age was 44 [34; 51] years, the median duration of PsA was 59 [22; 102] months. Combination therapy, including methotrexate (MT), received 80.5% of patients in the TOFA group and 52.8% of patients in the ADA group. At the beginning of the study and every 6 months further, the activity and efficacy of PsA therapy were assessed in all patients according to DAPSA and criteria for minimal disease activity – MDA (number of painful joints ≤1, number of swollen joints ≤1, PASI ≤1 or BSA ≤3 , pain score ≤15, patient's general assessment of disease activity ≤20 mm on a visual analogue scale, HAQ ≤0.5, enthesitis ≤1), dynamics of BASDAI and BSA were also assessed. The number of patients who achieved remission (DAPSA ≤4) or MDA (5 criteria out of 7) during therapy with TOFA and ADA was determined.Results and discussion. Before the start of the therapy in the 1st group, the median DAPSA was 44.2 [37.8; 55.3]: moderate PsA activity was in 5 (12.2%) patients, high in 36 (87.8%) patients. In group 2, the median DAPSA was 35.8 [21.1; 52]: low activity was detected in 3 (8.6%), moderate – in 11 (31.4%), high – in 21 (60%) patients (data from 35 patients was available). 6 months after the start of treatment in patients of the 1st and the 2nd group, there was a significant decrease in all indicators of PsA activity compared to the baseline. The median DAPSA was 11 [4.3; 17.3] and 9.1 [6; 19.6]; remissions according to DAPSA reached 11 (26.8%) and 6 (20.8%) patients, respectively, low activity – 15 (36.6%) and 13 (44.8%), MDA – 16 (40%) and 9 (30%). The number of patients with dactylitis in the 1st and in the 2nd group significantly decreased: from 22 (53.7%) to 5 (13.2%) and from 13 (36.1%) to 6 (20%), respectively. Median HAQ decreased from 1 [0.625; 1.5] to 0.5 [0; 0.875] and from 0.875 [0.5; 1.38] to 0.5 [0; 0.875]; median BASDAI – from 6 [4.2; 7] to 1.4 [0.6; 3.2] and from 4.4 [1.9; 5.8] to 3 [0.8; 4.5], respectively. In group 1, the number of patients with BSA> 3% decreased from 16 (39%) to 8 (26.7%; pConclusion. In real clinical practice TOFA and ADA both had comparable efficacy on all clinical manifestations of PsA: after 6 months of therapy, most patients with PsA achieved MDA, low disease activity and remission according to DAPSA and BASDAI.

Objectives Apremilast monotherapy was evaluated up to 5 years in PALACE 4 (fourth PsA Long-term Assessment of Clinical Efficacy study) DMARD-naïve patients with PsA. Methods Patients with active PsA were randomized (1:1:1) to placebo, apremilast 30 mg or apremilast 20 mg twice a day. Placebo patients were rerandomized to apremilast at week 16 or 24. Double-blind apremilast continued to week 52, with a 4-year open-label extension (≤260 weeks of exposure). Analyses through week 260 were based on observed data. Results A total of 527 patients were treated. Among patients randomized to apremilast 30 mg at baseline, 45.5% completed week 260. At study end, 24.8% reported conventional synthetic DMARD or steroid use for any reason. At week 260, 65.8%/39.0%/20.3% of apremilast 30 mg patients achieved ACR20/ACR50/ACR70 responses, respectively. PsA sign and symptom improvements were sustained up to week 260 with continued treatment, including reductions in swollen (84.8%) and tender (76.4%) joint counts. Among apremilast 30 mg patients with baseline enthesitis or dactylitis, 71.2% achieved a Maastricht Ankylosing Spondylitis Enthesitis Score of 0 and 95.1% achieved a dactylitis count of 0. Over 50% of patients achieved a HAQ Disability Index minimal clinically important difference (≥0.35). In patients with ≥3% baseline psoriasis-involved body surface area, 60.3% and 47.6% achieved ≥50% and ≥75% improvement in Psoriasis Area and Severity Index scores, respectively. Patients continuing apremilast 20 mg also demonstrated consistent, sustained improvements. The most common adverse events were diarrhoea, nausea, headache, upper respiratory tract infection and nasopharyngitis. No new safety concerns were observed long term. Conclusions Apremilast led to sustained PsA efficacy up to 260 weeks and was well tolerated. Trial registration ClinicalTrials.gov (http://clinicaltrials.gov), NCT01307423.

Guselkumab (TREMFYA®), a fully human immunoglobulin G1λ (IgG1λ) monoclonal antibody that selectively targets interleukin (IL)-23, is an effective and generally well-tolerated treatment option for active psoriatic arthritis. Guselkumab is administered subcutaneously and can be used alone or in combination with methotrexate. In randomized, double-blind, placebo-controlled phase 3 trials in adults with active psoriatic arthritis and an inadequate response to or intolerance of standard treatment, guselkumab was effective in reducing disease activity and structural damage progression. Guselkumab conferred improvements in arthritis, enthesitis, dactylitis, psoriasis, axial symptoms, physical function and health-related quality of life. The clinical benefits of guselkumab for the diverse signs and symptoms of psoriatic arthritis increased or were maintained through two years of treatment, with no new safety signals emerging. Psoriatic arthritis is an inflammatory joint disease that commonly occurs in patients with psoriasis. While several drugs are now available for the treatment of psoriatic arthritis, patients often need to switch treatments due to inadequate efficacy or tolerability concerns. Guselkumab (TREMFYA®) treats psoriatic arthritis via a novel mechanism of action. In well-designed clinical trials, guselkumab provided durable improvements in the various signs and symptoms of psoriatic arthritis (including arthritis, joint inflammation and structural damage, skin disease and spinal manifestations). Guselkumab recipients reported gains in physical function and health-related quality of life. Guselkumab is an effective option for the treatment of active psoriatic arthritis and is generally well tolerated, with no new safety concerns identified during longer-term use.

Aim of the work To detect the clinical and laboratory characteristics of psoriatic arthritis (PsA) in sample of Egyptian population. Patients and methods 100 PsA patients were subjected to full medical history, full clinical, musculoskeletal and dermatological examination, routine laboratory investigations and assessment of disease severity. Results Among 100 PsA patients, 79 females and 21 males. The mean age was 44.4 ± 12.9 years. 21% of patients had hypertension, 11% had diabetes and 4% hepatitis C-virus. 14% had family history of other rheumatologic disease. 66% of patients experienced psoriasis onset with mean latency; 11.6 ± 8.2 years, 20% had dual onset of both diseases and 10% experienced PsA first with mean latency 3.6 ± 3.5 years. 86% of the patients had enthesitis, 41% had dactylitis, 39% had axial affection and 18% of patients had uveitis. 90% of patients had current psoriasis and 89% of them had current nail lesion. The most common drug was methotrexate. 38% of patients had axial spondyloarthritis, 33% had symmetric polyarthritis, 26% had asymmetric oligoarthritis, and 3% had predominant distal inter-phalangeal (DIP) involvement. The mean value for serum hemoglobin was 12.1 ± 8.21.6 g/dl, platelets; 278.4 ± 90.3 x103/mm3, the white blood cells 7.2 ± 2.2 x103/mm3, C-reactive protein was 10.9 ± 10.1 mg/dl and erythrocyte sedimentation rate was 49.3 ± 27.5 mm/1st hr. 92% of patients were negative for rheumatoid factor. Conclusion Among the cohort of Egyptian patients, most had axial spondyloarthritis, followed by symmetric polyarthritis and asymmetric oligoarthritis. The least frequent was predominant DIP involvement. The onset of psoriasis precedes arthritis and methotrexate was the most common therapy.

Introduction HLA-B*27 is strongly associated with Ankylosing spondylitis (AS). Its subtypes show considerable geographic and ethnic difference. The main aim of this study was to assess the frequency of subtypes of HLA-B*27 in the Indian Tamil AS patients. Methods and materials Adult AS patients positive for HLA-B*27 were considered for the study. The high-resolution typing to define HLA-B*27 subtypes were done using Invitrogen B kits from One Lambda (SeCore® Sequencing Kits, Thermo Fisher, United States). Results and conclusion Prevalence of subtypes identified were HLA-B*27:04 (52.2%), HLA-B*27:05 (41.6%), HLA-B*27:07 (3.5%) and HLA-B*27:02 (2.7%). All subtypes showed disease predisposition for males. The most common extra articular manifestation seen was enthesitis in HLA-B*27:04 and HLA-B*27:05. Uveitis was mainly associated with HLA-B*27:05 and dactylitis with HLA-B*27:04. A significant peripheral joints involvement for female and axial joint involvement for males was seen in HLA-B*27:04. Our study establishes the prevalence of HLA-B*27 subtypes and the associated clinical phenotypes among the Indian Tamil population. Considering the variability of presentation, organ involvement, and disease course in different subtypes and across ethnicities it is critical to define these associations in the ethnic populations we treat for their appropriate care considering the significant negative health and socioeconomic effects of AS.

ObjectivesTo evaluate efficacy and safety of the anti-interleukin-23p19 monoclonal antibody tildrakizumab in patients with psoriatic arthritis (PsA).MethodsIn this randomised, double-blind, placebo-controlled, phase IIb study, patients with active PsA were randomised 1:1:1:1:1 to tildrakizumab 200 mg every 4 weeks (Q4W); tildrakizumab 200, 100 or 20 mg Q12W; or placebo Q4W. Patients receiving tildrakizumab 20 mg or placebo switched to tildrakizumab 200 mg Q12W at W24; treatment continued to W52. The primary efficacy endpoint was proportion of patients with ACR20 response (≥20% improvement by American College of Rheumatology criteria) at W24. Secondary efficacy endpoints were assessed without adjustment for multiplicity. Safety was evaluated from treatment-emergent adverse events (TEAEs).Results391/500 patients screened were randomised and treated. At W24, 71.4%–79.5% of tildrakizumab-treated versus 50.6% of placebo-treated patients achieved ACR20 (all pConclusionsTildrakizumab treatment significantly improved joint and skin manifestations of PsA other than dactylitis and enthesitis. Treatment was generally well tolerated through W52. Clinicaltrials.gov NCT02980692.

BACKGROUND: Psoriatic arthritis is the most frequent and impactful comorbidity among psoriatic patients and appears in most cases after skin disease. Dermatologists play a key role in its early diagnosis and treatment. OBJECTIVE: To determine the prevalence of psoriatic arthritis and associated variables among patients with plaque psoriasis seen at a reference center for treating psoriasis. DESIGN AND SETTING: Retrospective cross-sectional study conducted among 300 patients at an outpatient clinic in a university center in Juiz de Fora, MG, Brazil. METHODS: Standardized records of 300 patients with plaque psoriasis were examined. Demographic data and medical variables relating to psoriasis (Psoriasis Area and Severity Index (PASI), family history, age at onset and disease progression) and psoriasis arthritis (CASPAR criteria) were evaluated. Laboratory and radiographic tests in the medical records were reviewed. RESULTS: Seventy-three (24.3%) of these 300 patients with plaque psoriasis had psoriatic arthritis. Asymmetric oligoarthritis (58.9%) was the most common clinical form, followed by polyarthritis (20.5%), distal interphalangeal arthritis (15.2%) and spondyloarthritis (5.4%). Dactylitis was present in 21.9% and enthesitis in 35.6% of patients. Compared with patients without arthritis, patients with arthritis had higher average age, higher frequency of positive family history of psoriasis, longer duration of evolution and higher PASI rates. CONCLUSION: Psoriatic arthritis is often underdiagnosed. Since dermatologists perform the initial approach, these professionals need to be trained to diagnose this comorbidity and treat it, together with rheumatologists.

Axial involvement in psoriatic arthritis is quite common. There is no data on the use of tofacitinib, an oral Janus kinase inhibitor, in psoriatic arthritis patients with axial involvement, nor is there any data on its effect on active MRI sacroiliitis.The aim of the study was to assess the effect of tofacitinib therapy on the dynamics of active MRI sacroiliitis in psoriatic arthritis patients.Materials and methods. 41 patients with active psoriatic arthritis fulfilling the CASPAR criteria were included. Median age was 41.0 [34; 50] years old, median disease duration was 6.0 [3; 10] years. Apart from a standard clinical examination, 40 patients underwent sacroiliac joint MRI on scanner Siemens General Electric 1.5 TESLA. Bone marrow edema on MRI (STIR) with one lesion on two consecutive slices or at least two lesions on a single slice, was considered active MRI sacroiliitis. Tofacitinib was given in 5 mg tablets twice a day with a possible dose increase up to 10 mg twice a day after 12 weeks of therapy. At the end of study, over a period of 24 weeks, sacroiliac joint MRI examination was repeated in 35 patients.Results. Prior to tofacitinib therapy, active MRI sacroiliitis was detected in 14 of 40 (35%) patients: bilateral – in 9 patients, unilateral – in 5 patients. At the end of 24 weeks therapy, active MRI sacroiliitis was detected in 4 of 35 (11.4%) patients observed: in 1 patient with baseline bilateral MRI sacroiliitis and in 2 patients with unilateral MRI sacroiliitis. 1 patient showed negative dynamics, that is, development of active MRI sacroiliitis (absent at baseline). The decrease in number of active MRI sacroiliitis patients is statistically significant (p=0.017). At baseline, inflammatory changes were detected in 23 of 80 (28.8%) sacroiliac joints, after 24 weeks of therapy they were found in 5 of 70 (7.1%; p=0.001) sacroiliac joints observed. During the treatment period, there was a significant decrease in the initially high activity of spondylitis. After 24 weeks of treatment, median BASDAI decreased from 6.0 [4.2; 7.0] to 1.4 [0.6; 3.2], median ASDAS-CRP from 3.8 [2.8; 4.4] to 1.5 [1.0; 2.1] (p=0.001 for both comparisons). Prior to tofacitinib therapy, high activity according to BASDAI was observed in 90.2% of patients, low activity – in 9.8%; at the end of study – in 13.5% and 86.5% of patients, respectively (p=0.001). At baseline, very high activity by ASDAS-CRP was detected in 61% of patients, high activity – in 29.2%, low activity – in 9.8% of patients. At the end of study there weren’t any patients with very high activity by ASDAS-CRP (p=0.001), high activity remained in 23.1%, moderate and low activity – in 30.7% and 46.2% of patients, respectively (p=0.001 for both comparisons). Significant differences between baseline symptoms in patients with MRI sacroiliitis and without it were defined by number of digits with dactylitis – 2 [0; 4] and 0 [0; 2] (p=0.04) and by ESR values – 47 [26; 76] and 20 [6; 37] mm/h (p=0.02). These parameters were higher in MRI sacroiliitis subgroup. By the end of study, these differences leveled out: the number of digits with dactylitis decreased to 0 [0; 0] and 0 [0; 0] (р=0.48), ESR – to 12 [6; 16] and 8 [6; 16] mm/h, respectively (p=0.78).Conclusion. Tofacitinib therapy shows high efficacy in reducing active MRI sacroiliitis and decreasing activity of axial involvement in psoriatic arthritis patients. The use of tofacitinib in patients with active MRI sacroiliitis as well as dactylitis and increased ESR levels demonstrated its high efficacy.

To determine the characteristics of the early phase of psoriatic arthritis (PsA), we conducted a subanalysis of a retrospective survey of Japanese patients. In this study, we enrolled patients with early onset within either 2 years or 1 year from onset among the 1282 patients with PsA that had previously been reported. Among the total reported PsA patients, 304 (23.7%) were diagnosed with less than 2 years of onset of joint manifestation. The male : female ratio was 1.9:1, mean age at onset of cutaneous psoriasis 40.2 years, and that of joint manifestation 50.3 years. Age of less than 20 years at cutaneous psoriasis onset was observed in 22 cases, while that at joint manifestation was observed in two cases. Plaque-type psoriasis accounted for 90.1%, followed by psoriasis erythroderma (3.9%), pustular psoriasis (3.9%), and nail psoriasis (1.3%). Polyarthritis was the most common joint manifestation (32.9%), followed by distal interphalangeal (DIP) type (29.6%), oligoarthritis type (27.3%), and ankylosing spondylitis type (4.9%). Enthesitis was observed in 27.3% and dactylitis in 61.8%. Biologics were used in 168 cases (55.3%). By contrast, 199 patients (15.5%) were diagnosed within 1 year of onset of joint manifestation, among whom polyarthritis was the most common (30.7%). Biologics were used in 50.8%. In conclusion, the present study showed that the frequency of early PsA within 2 years of onset accounted for 23.7%, and those within 1 year of onset was 15.5% among the Japanese patients with PsA. Polyarthritis was the most common in early PsA patients.

espanolLas espondiloartritis (EspA) afectan sobre todo al esqueleto axial y, en menor medida, a las articulaciones perifericas. La espondilitis anquilosante (EA) es el prototipo, caracterizado por la tendencia a anquilosis de las articulaciones sacroiliacas y la columna vertebral. El diagnostico y el tratamiento precoces son fundamentales para evitar complicaciones y la progresion de la enfermedad, asi como para mantener una buena calidad de vida en los pacientes. En su patogenia se ven implicados factores geneticos como el HLA-B27, el microbioma intestinal, las interleuquinas proinflamatorias y el estres mecanico. Clinicamente se caracteriza por dolor lumbar inflamatorio, entesitis, dactilitis y en ocasiones oligoartritis de miembros inferiores. Puede ir acompanado de manifestaciones extraarticulares como uveitis, psoriasis o enfermedad inflamatoria intestinal. Aunque no disponemos de criterios diagnosticos validados, los criterios ASAS-EULAR permiten una clasificacion precoz en distintas formas de EspA. Estan basados en la presencia de afectacion de articulaciones sacroiliacas, HLA-B27 y otras caracteristicas asociadas a las EspA. El tratamiento debe contemplar medidas farmacologicas y no farmacologicas. Es importante el ejercicio fisico y evitar el sobrepeso y el habito tabaquico. El tratamiento farmacologico se debe ajustar al tipo de afectacion e incluye el uso de AINE y terapias biologicas, fundamentalmente para las formas axiales. EnglishSpondyloarthritis (SpA) principally affects the axial skeleton and, to a lesser degree, the peripheral joints. Ankylosing spondylitis (AS) is the prototype, characterised by the tendency to present ankylosis of the sacroiliac joints and the spine. Early treatment and diagnosis are essential to prevent complications and disease progress, as well as to retain good quality of life for the patients. Its pathogenesis involves genetic factors such as HLA-B27, the gut microbiome, pro-inflammatory interleukins and mechanical stress. Clinically, it is characterised by inflammatory lower back pain, enthesitis, dactylitis and sometimes oligoarthritis in the lower limbs. It can be accompanied by extra-articular conditions such as uveitis, psoriasis or inflammatory bowel disease. Although no validated diagnostic criteria are available, the Assessments in Ankylosing Spondylitis/European League Against Rheumatism (ASAS/EULAR) criteria permit early classification into different forms of SpA. They are based on the presence of sacroiliac joint affectation, HLA-B27 and other characteristics associated with SpA. Treatment should include both drug and non-drug interventions. Physical exercise and avoiding overweight and smoking are of great importance. Drug treatment must be adjusted to the type of condition, and must include using NSAIDs and biological therapy, fundamentally for the axial forms.

Background Psoriatic arthritis (PsA) is considered the prototype of peripheral spondyloarthritides (SpA) and is associated as skin-bone disease (SkiBo) with typical skin changes and with typical arthritides of the joints, especially of the hands and feet. Objective Systematic review of imaging manual findings patterns in PsA with its typical enthesitic arthritides in context with clinical findings. Materials and methods A review based on the current literature on the subject from a radiological and rheumatological point of view is provided. Results In PsA, inflammatory manifestations in the hands and feet are the most frequently affected regions of the body. Image morphological variability between early and late stages is evident. The projection radiographic characteristic of PsA is the simultaneous coexistence of osteodestructive-rarefactive changes with typical osteoproliferative-proliferative changes, which are part of the Classification of Psoriatic Arthritis (CASPAR) criteria. With the help of magnetic resonance imaging (MRI), the image-morphological spondyloarthritis inflammatory patterns of enthesitis, dactylitis and osteitis can be detected in the hands even in the early stages. Conclusions The basic knowledge of the image morphological changes of this complex autoimmunological skin-bone disease will be imparted in order to gain the necessary confidence in the systematic diagnostic evaluation of hand arthritis patterns typical for PsA in images both at the initial diagnosis and over the course of the disease and in the classification of early and late stages, which serve as a guide for rheumatologists regarding "step-up" treatments.

Netakimab is a humanized anti-interleukin-17А monoclonal antibody approved for the treatment of psoriatic arthritis, ankylosing spondylitis, moderate to severe psoriasis. Herein, we report the accumulated efficacy data and safety findings of 54-week netakimab treatment during the PATERA study. The aim of the study was to assess the long-term efficacy and safety of netakimab in patients with active psoriatic arthritis. Materials and methods. 194 patients with active psoriatic arthritis despite the previous therapy with nonsteroidal anti-inflammatory drugs, conventional or biologic disease-modifying antirheumatic drugs were initially randomized to receive 120 mg netakimab or placebo (1:1) at weeks 0, 1, 2, 4, 6, 8, 10, 14, 18, 22. At week 16 inadequate responders in placebo group were reassigned to netakimab in a blinded manner. From week 24 all patients receive open-label netakimab. The analyzed period includes 54 weeks. Results. Netakimab demonstrated sustained treatment response. 94.9% of patients in the netakimab group achieved ACR20 at week 54; 89.5% achieved PASI75 response. Axial disease, dactylitis, and enthesitis significantly improved with netakimab. A similar pattern was observed for placebo/netakimab treated patients. Netakimab was well tolerated. The majority of adverse events were mild and moderate. The most frequent treatment-related adverse events were lymphopenia, increased alanine aminotransferase, hypercholesterolemia. Adverse events of grade 3–4 were observed in 2%. Conclusion. Netakimab demonstrated sustained efficacy in key psoriatic arthritis domains at week 54 with a favorable longterm safety profile.

In Taiwan, the incidence and prevalence of psoriatic arthritis (PsA) have risen significantly in recent years. Moreover, data from the Taiwan National Health Insurance Research Database (NHIRD) show that more than 85% of PsA patients are treated with just non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Taiwanese clinicians have also expressed concerns regarding uncertainties in the diagnosis of PsA and the delayed, interrupted, and/or tapered use of biologics, as well as differences in therapeutic preferences between and within dermatologists and rheumatologists. To address these issues, the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology jointly convened a committee of 28 clinicians from the fields of rheumatology, dermatology, orthopedics, and rehabilitation, to develop evidence-based consensus recommendations for the practical management of PsA in Taiwan. A total of six overarching principles and 13 recommendations were developed and approved, as well as a treatment algorithm with four separate tracks for axial PsA, peripheral PsA, enthesitis, and dactylitis. Psoriasis (PsO) management was not discussed here, as the Taiwanese Dermatological Association has recently published a comprehensive consensus statement on the management of PsO. Together, these recommendations provide an up-to-date, evidence-based framework for PsA care in Taiwan.

Spondyloarthritis is a common rheumatologic disease, present in up to 2% of the population, characterized by inflammatory arthritis, often with enthesitis, dactylitis, spondylitis, and skin disease. It has historically been characterized as ankylosing spondylitis, psoriatic arthritis, arthritis associated with inflammatory bowel disease, reactive arthritis, and undifferentiated spondyloarthritis. These subsets are now classified as axial-predominant and peripheral-predominant spondyloarthritis. This article provides an updated understanding of disease classification and practical advice about diagnosis to aid in the determination of which patients should be referred to rheumatology. It is important to provide patients the opportunity to have early and effective therapy.

Background Some studies have reported the development of moderate and severe de novo SpA-associated disease under vedolizumab (VDZ) treatment for IBD. Herein, we report a case series who developed severe enthesitis under VDZ therapy from a cohort of 90 treated cases. Methods In a single Italian IBD Unit in which 90 cases were on VDZ therapy, we identified 11 cases who developed severe enthesitis. The onset of disease in relationship to VDZ initiation, clinical and sonographic imaging features, and outcomes (including therapy switches) was described. Results A total of 11 cases, including 8 prior anti-TNF failures, with new-onset entheseal pathology were identified: multifocal (n = 4), unifocal (n = 6), and enthesitis/synovitis/dactylitis (n = 1). The mean duration of symptoms was 46 weeks (range 6–119), the mean CRP was 5.1 mg/dl, and the majority were HLA-B27 negative and showed good clinical response for gut disease. Clinical features and US showed severe enthesitis, including power Doppler change in 7 patients. All patients were initially treated with NSAIDs, and 5 patients underwent local steroid injections. At 12 months, 5/7 cases continued VDZ and 2 were switched to ustekinumab. At 12 months follow-up of 7 cases, 5 patients were in clinical remission and 2 patients had mild enthesitis with minimal increase of power Doppler signal. In addition, 4/7 severe patients developed marked post-inflammatory entheseal calcifications Conclusions A predominant isolated severe enthesitis pattern of SpA may develop under VDZ therapy with severe disease in 8% of cases. Most cases continued VDZ therapy.

AIM Fatigue is commonly associated with psoriatic arthritis (PsA). However, information about its prevalence and associated factors is sparse. The primary objective here was to find the prevalence and magnitude of PsA fatigue. The secondary objective was to explore its associated risk factors, particularly emphasis on the effect of disease activity control. METHODS PsA patients who fulfilled Classification Criteria For Psoriatic Arthritis were consecutively recruited from local rheumatology clinics. Fatigue was assessed by a 13-item self-administered questionnaire (Functional Assessment of Chronic Illness Therapy - Fatigue [FACIT-F]) (0-52). Data collected and analyzed included: demographic data, disease activity data, comorbidities and medications use. RESULTS There were 231 eligible PsA patients recruited. The mean FACIT-F score was 37.5 ± 9.1. Severe fatigue, defined as FACIT-F score

Objectives Treatment with golimumab monotherapy in early peripheral SpA (pSpA) results in higher rates of clinical remission compared with treatment in more longstanding disease. When reaching remission, treat-to-target recommendations suggest tapering of treatment. We therefore explored whether addition of MTX would permit discontinuation of golimumab in patients with pSpA in sustained clinical remission. Methods After a 2-year extension phase with golimumab treatment, patients with pSpA reaching clinical remission in the CRESPA trial were offered a tapering strategy leading to discontinuation of golimumab and replacement by MTX monotherapy. Patients were prospectively followed to assess the rate of sustained biologic-free clinical remission. In case of relapse of arthritis, enthesitis or dactylitis under MTX monotherapy, golimumab was restarted. Results Of the original 60 pSpA patients, 25 entered the step-down strategy. Currently, only 4 patients (16%) are still in sustained remission under MTX monotherapy. In 21 patients (84%), golimumab was reinstalled because of relapse of disease activity (n = 19) or development of adverse events related to MTX (n = 2). Restarting golimumab treatment promptly restored clinical remission in all patients within 12 weeks. Conclusion In patients with early pSpA achieving clinical remission after 2 years of golimumab treatment, step-down therapy to monotherapy with MTX led to high rates of clinical relapse. This underscores the overall weak efficacy of MTX in maintaining clinical remission in pSpA. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT01426815.

Background: Dactylitis is a characteristic feature of psoriatic arthritis (PsA). However, early diagnosis of mild dactylitis is challenging and image examination, such as ultrasonography (US), can be helpful. Objectives: We aimed to compare the clinical diagnosis of dactylitis made by the dermatologist and ultrasonographic diagnosis by the rheumatologist. Methods: Consecutive patients diagnosed with peripheral PsA seen in the dermatologic clinics were referred to the same dermatologist for evaluation of dactylitis. Consecutive patients with and without clinical dactylitis were diagnosed in 19 and 19 patients, respectively, by the referred dermatologist. All patients were then referred to an experienced rheumatologist unaware of the clinical diagnosis for sonographic examination of all 20 digits. Dactylitis under US was diagnosed when both proximal and distal parts of a digit were at least 0.25 mm larger than the contralateral digit. Results: For the clinical dactylitis group, 7 (36.8%) patients had more dactylitis diagnosed by US than clinically, and 2 (10.5%) patients had no dactylitis diagnosed by US. For the clinically no dactylitis group, 4 (21.1%) patients had no diagnosis of dactylitis by US, and most of these patients (78.9%) were diagnosed with dactylitis under US by the rheumatologist. More digits affected by dactylitis were found for both groups, although no statistically significant differences were found, probably due to the small sample size. Conclusion: The results revealed concordance between the dermatologist and rheumatologist for clinical dactylitis but not for patients without dactylitis. For PsA patients, US is more sensitive and useful for early dactylitis diagnosis in a dermatologic clinic.

Chikungunya fever (CF), caused by the Chikungunya virus (CHIKV), is an arboviral disease transmitted by infected Aedes mosquitoes found worldwide. Although CF may trigger chronic arthritis, there are still few reports of patients who have progressed to psoriatic arthritis (PsA). We describe the clinical and ultrasound (US) and magnetic resonance imaging (MRI) findings of the wrist and hands of a 49-year-old man who had peripheral PsA triggered by CHIKV. He had scaly, itchy scalp lesions three months after the diagnosis of CF. The patient had classic synovitis and tenosynovitis secondary to CF. The persistence of inflammatory disease with signs of enthesitis and dactylitis on magnetic resonance imaging (MRI) and US, family history and appearance of skin lesions on the scalp strongly suggest post-CF PsA. Viral infections can be a triggering factor for several diseases with chronic arthritis, such as PsA. Imaging exams are essential methods for both diagnosis and the monitoring of treatment.

Therapeutic approaches for psoriatic arthritis (PsA) include non-pharmacologic therapies, symptomatic treatments, tumor necrosis factor inhibitors, interleukin inhibitors, cytotoxic T lymphocyte antigen 4 immunoglobulin, and Janus kinase inhibitors. This systematic review aimed to provide complete and up-to-date information on efficacy of tofacitinib in the treatment of PsA, giving special attention to non-skin manifestations (peripheral arthritis, axial disease, enthesitis, and dactylitis). A search of studies published between January 2016 and June 2020 was carried out on PubMed and Google Scholar. The number of studies with tofacitinib in PsA is limited and most of them are post hoc analyses from OPAL Broaden and OPAL Beyond. Tofacitinib has been demonstrated to be efficacious for the treatment of all disease manifestations in PsA. Superior effectivity to placebo is achieved at the earliest time point evaluated, and maintained over time. Patients who switch from placebo to tofacitinib show the same improvements; however, the time to initial response is faster in patients who firstly receive tofacitinib, compared with those switching subsequently. Additional data suggest that tofacitinib may be also effective for the treatment of the axial domain. Tofacitinib has been demonstrated to be efficacious for the treatment of peripheral and axial involvement, enthesitis, and dactylitis manifestation in PsA. Further prospective and long-term studies are required to corroborate and complete the present results. Similarly, real-world evidence is also necessary to complement the information obtained in clinical trials, and thereby to have a better overview of real efficacy and safety of the drug.

Objective: Currently, concerning the evaluation of psoriatic arthritis (PsA), there is no agreement on a standardized composite index for disease activity that includes all relevant domains. The present study sought to assess the rates of remission (REM)/low disease activity (LDA) and disease states [minimal disease activity (MDA), very low disease activity (VLDA)] as defined by diverse activity scales (DAPSA, DAS28-ESR) in an attempt to display discrepancies across these assessment tools for peripheral PsA. Methods: The study involved 758 patients (496 females, 262 males; mean age 47,1 years) with peripheral PsA who were registered to the Turkish League Against Rheumatism (TLAR) Network. The patients were assessed using the DAS28-ESR, DAPSA, MDA, and VLDA. The overall yield of each scale was assessed in identifying REM and LDA. The presence or absence of swollen joints was separately analysed. Results: The median disease duration was 4 years (range 0-44 years). According to DAPSA and DAS28-ESR, REM was achieved in 6.9% and 19.5% of the patients, respectively. The rates of MDA and VLDA were 16% and 2.9%, respectively. Despite the absence of swollen joints, a significant portion of patients were not considered to be in REM (296 (39.1%) patients with DAS28-ESR, 364 (48%) with DAPSA, and 394 (52%) with VLDA). Conclusion: Patients with peripheral PsA may be assigned to diverse disease activity levels when assessed with the DAS28-ESR, DAPSA, MDA and VLDA, which would inevitably have clinical implications. In patients with PsA a holistic approach seems to be necessary which includes other domains apart from joint involvement, such as skin involvement, enthesitis, spinal involvement, and patient-reported outcomes. © 2021 Société française de rhumatologie

Objectives: To explore the frequency of ultrasound elementary lesions in dactylitis in psoriatic arthritis (PsA), and the reliability of scoring these lesions in a clinical setting. Methods: In 31 patients with PsA and clinical dactylitis, ultrasound assessment of the affected finger or toe was performed using greyscale and color Doppler mode. One examiner scanned all patients and a second examiner scanned 10 patients for inter-reader reliability. For each digit, the following lesions were evaluated: subcutaneous edema; soft tissue thickening; synovitis of the digital joints; tenosynovitis of the flexor tendon; enthesitis at the deep flexor tendon and the extensor tendon entheses; and paratenonitis of the extensor tendon. A dactylitis sum-score was calculated. Findings in clinically tender and non-tender digits were compared. Results: The most frequent lesions were soft tissue thickening (81%) and subcutaneous edema (74%) followed by synovitis (56-68%) and flexor tenosynovitis (52%). Color Doppler was most frequently found subcutaneously (55%) and around the flexor tendons (45%). All lesions were typically found in combinations, most commonly subcutaneous edema and synovitis (71%), subcutaneous edema and flexor tenosynovitis (52%), and all three in combination (52%). Tender digits had a higher dactylitis sum-score and numerically higher prevalence of most lesions than non-tender digits. Intra- and inter-reader agreements were moderate to excellent, though lower for few components of digital enthesitis, especially hypoechogenicity. Conclusion: Dactylitis in PsA appears to encompass several lesions, most often subcutaneous changes combined with synovitis and/or flexor tenosynovitis. Reliability of scoring established ultrasound lesions of dactylitis in a clinical setting is moderate-excellent.Key Points• Dactylitis in psoriatic arthritis consists of multiple ultrasound lesions• A dactylitis ultrasound sum-score gives an impression of severity by including all lesions• Reliability of ultrasound scoring of dactylitis components is good

ObjectivesTo evaluate the burden of residual disease in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) who achieved low disease activity (LDA) status.MethodsWe used baseline data from a clinic registry of SpA in a tertiary hospital in Singapore. For axSpA, LDA was defined as Ankylosing Spondylitis (AS) Disease Activity Score based on erythrocyte sedimentation rate (ASDAS-ESR) < 2.1 or Bath AS Disease Activity Index (BASDAI) < 3/10. For PsA, LDA was defined by achieving 5/7 cutoffs in the minimal disease activity (MDA) or Clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) ≤ 13.ResultsIn 262 cases of axSpA (21% women; mean ± standard deviation (SD) age 42 ± 14 yrs), 33% and 43% of patients achieved ASDAS-ESR and BASDAI LDA states, respectively, while in 142 cases of PsA (49% women, mean age 51 ± SD 14 yrs), 35% and 63% achieved MDA and cDAPSA LDA, respectively. Both axSpA and PsA patients with LDA had pain scores ranging from 14.0 to 21.4/100 and fatigue scores ranging from 3.1 to 3.6/10. Substantial burden in physical disability and mental well-being were observed, with low physical and mental component summary scores on the 36-item Short Form Health Survey. AxSpa patients in BASDAI LDA had higher ESR and lower disability than those in ASDAS-ESR LDA. cDAPSA classified nearly twice as many PsA patients into LDA than MDA. Compared to PsA patients in MDA LDA, those in cDAPSA LDA had higher active joint counts, dactylitis, enthesitis, pain scores, and patient global assessment.ConclusionDespite being in LDA, patients with axSpA and PsA experienced substantial residual burden in pain, poorer physical function, and mental well-being.

Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

Axial skeletal injury is observed in 25–70% of patients with psoriatic arthritis (PsA). Spondylitis frequently occurs subclinically, which leads to serious structural and functional disorders over time. An update shows that axial skeleton involvement in PsA is characterized by a more severe clinical course: these patients are observed to have a greater severity of peripheral arthritis, enthesitis, and dactylitis, skin and nail psoriasis, a higher CRP level, and worse functional status. In addition, the disease is more severe according to the patients' subjective assessment, as evidenced by questionnaires. Synthetic disease-modifying antirheumatic drugs used to treat peripheral PsA are not recommended for axial injury. When nonsteroidal anti-inflammatory drugs are ineffective, biological drugs (tumor necrosis factor-α inhibitors or interleukin-17A (IL-17A) inhibitors) should be prescribed immediately to patients with psoriatic spondylitis. The paper describes two clinical cases demonstrating the successful use of the IL-17A inhibitor secukinumab (SEC) in patients with axial PsA (axPsA). Given the positive experience with SEC in real clinical practice, it seems reasonable to prescribe it to patients at earlier stages of axPsA.

Updated recommendations of the European League Against Rheumatism (EULAR) on the pharmacological management of psoriatic arthritis (PsA) 2019 were presented in May 2020. The recommendations are compiled in accordance with the standardized EULAR operating procedures, a systematic review of the literature, followed by a consensus meeting of 28 international members of the task force for guideline development.Updated recommendations include 6 general principles and 12 recommendations. General principles relate to the nature of PsA and the diversity of both musculoskeletal and non-musculoskeletal manifestations; emphasizes the need for joint decision-making by the patient and the doctor. The recommendations represent treatment strategies for pharmacological therapy. Nonsteroidal anti-inflammatory drugs and local injections of glucocorticoids are offered as initial therapy; for patients with arthritis and poor prognostic factors, such as polyarthritis or monoarthritis/oligoarthritis, accompanied by dactylitis or joint damage, it is recommended that the usual synthetic disease-modifying antirheumatic drugs (DMARD) be started quickly. If the treatment objective is not achieved using this strategy, biological DMARD (bDMARD) should be initiated, targeting tumor necrosis factor (TNF), interleukin (IL)-17A, or IL-12/23 taking into account skin lesions. If axial disease predominates, an TNF inhibitor or an IL-17A inhibitor should be started as a first-line DMARD.The use of Janus kinase inhibitors is considered primarily after the ineffectiveness of bDMARD. Inhibition of phosphodiesterase-4 is proposed for patients who are not suitable for other drugs, usually in the context of a mild disease. The switching of drugs and dose tapering in the phase of sustained remission are considered. This guideline provides an updated consensus on the pharmacological treatment of PsA based on a combination of evidence and expert opinion.