What is Psoriatic Arthritis (PsA)?

Psoriatic arthritis (PsA) is an immune mediated, inflammatory arthritis.

• Psoriasis precedes the arthritis in approximately 67 percent of patients.
• Arthritis precedes the psoriasis in 33 percent of patients, especially in children and the elderly.
• If untreated, 67 percent of patients will develop erosive disease.

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Subtypes of PsA

1. Polyarthritis: 50–60 percent
   • Commonly affects PIPs, MTPs, ankles, MCPs, and wrists
2. Asymmetric oligoarthritis: 15–20 percent
   • Commonly affects DIPs, PIPs, MTPs, ankles, knees, hips, and MCPs
3. DIP arthritis: 2–5 percent
   • Commonly affects DIPs
4. Axial involvement: 2–5 percent
   • Commonly affects sacroiliac joints, cervical, thoracic, and lumbar spine
5. Arthritis mutilans: 5 percent
   • Commonly affects DIPs and PIPs

Differential Diagnosis

• Inflammatory/erosive osteoarthritis
• Crystalline arthropathy (gout or calcium pyrophosphate deposition disease (CPPD)
• Septic joint
• Other seronegative spondyloarthropathy (ankylosing spondylitis, reactive arthritis, enteric arthritis)
• Autoimmune diseases (rheumatoid arthritis, lupus)

Diagnostic Pearls and Clinical Features Characteristic of PsA

Click to view and print a handy infographic for your office.

• Family history (first degree relative with psoriasis)
• Morning stiffness > 1 hour
• Psoriasis
• Nail pitting
• Asymmetric joint involvement
• Dactylitis (“sausage digit”)
• Enthesitis that may not respond to conventional therapy (Achilles tendon, plantar fascia insertion)
• Negative rheumatoid arthritis and other autoantibodies
• X-rays with central erosions (pencil-in-cup deformity) with lack of periarticular osteopenia
• Asymmetric sacroiliac joint involvement

Treatment

Treatment focuses on management of symptoms and stopping disease activity/joint damage.

Symptomatic Management

• Non-medical treatment for mechanical issues (orthotics, bracing, physical therapy)
• Non-steroidal anti-inflammatory drugs (NSAIDs)—Click to view a handy infographic for your office.
  • Improves pain, swelling and stiffness
  • No single NSAID has been shown to be superior to another in terms of efficacy
  • Celecoxib has been shown in prospective trials to be better than many other NSAIDs on GI safety but none are clearly safer than any other in terms of cardiovascular and renal safety.
  • Selection is based on various factors including ability to adhere to therapy (dosing regimen), cost, prior patient experience, and class of NSAID since switching from one class to another may result in differences in individual efficacy and side effects.

*Non-acetylated Salicylates

• Pain medications (acetaminophen, duloxetine, tramadol, etc.)

Disease Modification/Prevention of Joint Damage

• Disease modifying anti-rheumatic drugs (DMARDs) slow and even stop disease progression and joint damage
  • Methotrexate
  • Leflunomide (Arava)
  • Sulfasalazine
  • Tofacitinib (Xeljanz)
  • Otezla
• Biologic DMARDs
  • Humira, Enbrel, Remicade, Simponi, Cimzia
  • Taltz, Cosentyx
  • Stelara
  • Tremfya
  • Orencia

Perioperative Management

• Minimize psoriatic arthritis flares and perioperative complications
• Consult with rheumatologist or dermatologist for perioperative management of DMARDs
• Discontinue aspirin 7–10 days (lifespan of platelets) prior to surgery
• Discontinue NSAID 4–5 half-lives prior to surgery
• Stress dose steroids as indicated

APMA received an independent medical education grant from Pfizer to support development of these materials. APMA and those involved in the development of these materials have no financial relationships or potential conflicts of interest to disclose.

APMA wishes to acknowledge Christopher Parker, DO, and Thomas Rennie, MD, for their contributions.