Spondyloarthopathies - Current classification
- Axial Spondyloarthritis
- With radiographic sacroileitis
- Without radiographic sacroiletis
- MRI positive
- HLA B27 positive
- Peripheral sondyloarthritis
- With Psoriasis
- With IBD
- With preceding infection
- Without IBD, Psoriasis, or Preceding infection
- 4 Major Groups (classic classification)
- Reactive Arthritis
- Ankylosing Spondylitis
- Psoriatic Arthritis
- Enteropathic Arthritis (IBD associated)
Common C/F- Both Axial or Peripheral Arthritis can occur
- Enthesitis
- Dactylitis
1. Reactive Arthritis - Skin Manifestations:
- Keratoderma Blenorrhagica
2. Ankylosing Spondylitis
3. Psoriatic Arthritis
- Clinical Features
- Psoriatic Patients are at risk of
- Gout (due to increase turn over of skin)
- Skin : When PsA is suspected examine the skin around extensor surfaces, scalp posterior auricular area, gluteal cleft, umbilicus (15 % of patients will eventually develop Psoriasis)
- OA
- PsA: 30% of patients with Posriasis develop PsA; 5 Patterns of joint involvement
- Asymmetric Oligoarthritis (m/c type of PsA, 30 - 50%)
- Symmetric Polyarthritis (3rd m/c manifestation; Like RA)
- DIP (3rd m/c manifestation, 10-15%)
- Nail changes are common: Examine for 4 types of nail manifestations
- Pitting
- Onycholysis
- Subungal Keratosese
- Oil drop like staining
- Spondylitis
- Arthritis Mutilans (osteolysis of digits with significant deformity)
- Note: Enthesisits is seen as Dactilytis (sausage digit)
- Lab:
- RF and Anti-CCP ab can be present in around 10 of these patients
- Xray: Pencil in Cup
- Treatment:
- Anti-TNF
- 5 FDA approved Anti-TNF medications for Psoriasis
- Monoclonal ab against IL-12/23: Ustekinumab (Stelara) Medscape 2015
- IL-12 leads to Th1 pathway
- IL-23 leads to Th17 pathway
- Ustekinumab (UST), an mAb directed against the p40 subunit of IL-12 and IL-23
- PDE-4 (Phosphodiesterase 4) Inhibitor: Apremilast
- Downstream in the TNF pathway
- Increases expression of IL-10
- IL - 17A: Secukinumab (Cosentyx™) - monoclonal antibody against 17 A
- 2 other drugs are in Phase II/III that inhibit 17A and / or 17 F
- References:
4. Enteropathic Arthritis (IBD associated)
Clinical Trials on
Psoriatic arthritis - ACR20
- ACR50
- ACR70
- Health Assessment Questionnaire Disability Index (HAQ-DI
Ankylosing Spondylitis - Bath Ankylosing Spondylitis Disease Activity Index (BASDAI),
- Functional ability measured by the Bath Ankylosing Spondylitis Functional Index (BASFI), and
- mobility of the spine measured by the Bath Ankylosing Spondylitis Metrology Index (BASMI)
- Assessment in Ankylosing Spondylitis (ASAS) criteria
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