Псориатический артрит: классификация, клиническая картина, диагностика, лечение

В лекции приведены основные сведения о псориатическом артрите (ПсА) – хроническом воспалительном заболевании суставов, позвоночника и энтезисов из группы спондилоартритов. Описана эпидемиология заболевания, рассмотрены современные представления о его патогенезе, факторы, влияющие на развитие ПсА у больных псориазом. Приведены классификация и клинические формы ПсА. Указано, что к основным клиническим проявлениям заболевания относят: периферический артрит, энтезит, дактилит, спондилит. Отмечено, что диагноз заболевания устанавливают на основании выявления типичных клинических и рентгенологических признаков с использованием критериев CASPAR. Скрининг ПсА осуществляют дерматолог, ревматолог, врач общей практики путем активного выявления жалоб, характерных клинических и рентгенологических признаков поражения суставов, и/или позвоночника, и/или энтезисов, а также с использованием скрининговых опросников. Приведены сведения о том, что у больных ПсА отмечается повышенный риск развития ряда заболеваний: сахарного диабета 2-го типа, гипертонической болезни, ишемической болезни сердца, ожирения, метаболического синдрома, воспалительных заболеваний кишечника и др. Цель современной фармакотерапии ПсА – достижение ремиссии или минимальной активности клинических проявлений заболевания, замедление или предупреждение рентгенологического прогрессирования, увеличение продолжительности и качества жизни пациентов, а также снижение риска коморбидных заболеваний. Рассмотрены группы лекарственных средств, применяемых при лечении заболевания, в частности приведены сведения о генно-инженерных биологических препаратах (ГИБП), зарегистрированных в Российской Федерации для лечения ПсА. Указано, что большинство пациентов демонстрируют хороший ответ на этот вариант терапии уже через 3–6 мес от начала лечения, однако у части из них развивается первичная неэффективность. В этом случае рекомендуется смена одного ГИБП на другой. У некоторых пациентов при применении ГИБП развивается вторичная неэффективность лечения, что в первую очередь обусловлено появлением нейтрализующих антител и снижением концентрации препарата в крови. Отмечено, что сопутствующая терапия метотрексатом повышает приверженность пациентов с ПсА терапии ГИБП.

1. Olivieri I, Padula A, D'Angelo S, Cutro MS. Psoriatic arthritis sine psoriasis. J Rheumatol. 2009;Suppl 83:28–9.

2. Mease PJ. Psoriatic arthritis: update on pathophysiology, assessement and management Ann Rheum Dis. 2011;70 (Suppl):77–84. DOI: http://dx.doi.org/10.1136/ard.2010.140582.

3. Love TJ, Zhu Y, Zhang Y, et al. Obesity and the risk of psoriatic arthritis: a population-based study. Ann Rheum Dis. 2012;71:1273–7. DOI: http://dx.doi.org/10.1136/annrheumdis- 2012-201299.

4. Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum. 1973;3:55–78. DOI: http://dx.doi.org/10.1016/0049-0172(73)90035-8.

5. Коротаева ТВ. Псориатический артрит: клиника, диагностика, патогенез, лечение, маркеры кардиоваскулярного риска. Под ред. Е.Л. Насонова. Москва: НПО «Медиа-Графика»; 2013. 309 с. [Korotaeva TV. Psoriaticheskii artrit: klinika, diagnostika, patogenez, lechenie, markery kardiovaskulyarnogo riska [Psoriatic arthritis: clinic, diagnostics, pathogenesis, treatment, markers of cardiovascular risk]. Nasonov EL, editor. Moscow: NPO «Media-Grafika»; 2013. 309 p.]

6. Gladman DD, Antoni C, Mease P, et al. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005;64(Suppl 2):14–7.

7. Chandran V, Barrett J, Schentag NC, et al. Axial Psoriatic Arthritis: update on a longterm prospective study. J Rheumatol. 2009;36;2744–50. DOI: http://dx.doi.org/10.3899/jrheum.090412.

8. Taylor WJ, Gladman DD, Helliwell PS, et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54:2665–73. DOI: http://dx.doi.org/10.1002/art.21972.

9. Sieper J, van der Heijde D, Landewe R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis International Society (ASAS). Ann Rheum Dis. 2009;68:784–8. DOI: http://dx.doi.org/10.1136/ard.2008.101501.

10. Kane D, Pathare S. Early psoriatic arthritis. Rheum Dis Clin North Am. 2005;31(4):641–57. DOI: http://dx.doi.org/10.1016/j.rdc.2005.07.009.

11. Qureshi AA, Husni ME, Mody E. Psoriatic arthritis and psoriasis: need for a multidisciplinary approach. Semin Cutan Med Surg. 2005;24:46–51. DOI: http://dx.doi.org/10.1016/j.sder.2005.01.006.

12. Prey S, Paul C, Bronsard V, et al. Assessment of risk of psoriatic arthritis in patients with plaque psoriasis: a systematic review of the literature. J Eur Acad Dermatol Venereol. 2010;24(Suppl 2):31–5. DOI: http://dx.doi.org/10.1111/j.1468-3083.2009.03565.x.

13. Gottlieb A, Korman N, Gordon K, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58:851–64. DOI: http://dx.doi.org/10.1016/j.jaad.2008.02.040.

14. Mease PJ. Assessing the impact of psoriatic arthritis on patient function and quality of life: lessons learned from other rheumatologic conditions. Semin Arthritis Rheum. 2009;38:320–35. DOI: http://dx.doi.org/10.1016/j.semarthrit.2008.01.003.

15. Raychaudhuri SK, Chatterjee S, Nguyen C, et al. Increased prevalence of the metabolic syndrome in patients with psoriatic arthritis. Metab Syndr Relat Disord. 2010;8:331–4. DOI: http://dx.doi.org/10.1089/met.2009.0124.

16. Li W-Q, Han J-L, Chan TA. Psoriasis and psoriatic arthritis and increased risk of incedent Crohn's disease in US women. Ann Rheum Dis. 2013;72:1200–5. DOI: http://dx.doi.org/10.1136/annrheumdis-2012-202143.

17. Gossec L, Smolen J, Gaujoux-Viala C, et al. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann Rheum Dis. 2012;71(1):4–12. DOI: http://dx.doi.org/10.1136/annrheumdis-2011-200350.

18. Buckley C, Cavill C, Taylor G, et al. Mortality in psoriatic arthritis – a single-center study from the UK. J Rheumatol. 2010;37:2141–4. DOI: http://dx.doi.org/10.3899/jrheum.100034.

19. Tam LS, Tomlinson B, Chu TT, et al. Cardiovascular risk proile of patients with psoriatic arthritis compared to controls – the role of inlammation. Rheumatology (Oxford). 2008;47:718–23. DOI: http://dx.doi.org/10.1093/rheumatology/ken090.

20. Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735–41. DOI: http://dx.doi.org/10.1001/jama.296.14.1735.

21. Lin HW, Wang KH, Lin HC. Increased risk of acute myocardial infarction in patients with psoriasis: a 5-year population-based study in Taiwan. J Am Acad Dermatol. 2011;64(3):495–501. DOI: http://dx.doi.org/10.1016/j.jaad.2010.01.050.

22. Bhole VM, Choi HK, Burns LC, et al. Differences in body mass index among individuals with PsA, psoriasis, RA and the general population. Rheumatology (Oxford). 2012;51:552–6. DOI: http://dx.doi.org/10.1093/rheumatology/ker349.

23. Gisondi P, Del Giglio M, Di Francesco V, et al. Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr. 2008;88:1242–7.

24. Scottish Intercollegiate Guidelines Network (SIGN) publication no 121. Diagnosis and management of psoriasis and psoriatic arthrits in adult: a national clinical guideline. October 2010. Available from: http://www.sign.ac.uk

25. Mease PJ. Assessment tools in psoriatic arthritis. J Rheumatol. 2008;35:1426–30.

26. Coates LC, Helliwell PS. Validation of minimal disease activity criteria for psoriatic arthritis using interventional trial data. Arthritis Care Res (Hoboken). 2010;62:965–9. DOI: http://dx.doi.org/10.1002/acr.20155.

27. Saber TP, Ng CT, Renard G, et al. Remission in psoriatic arthritis: is it possible and how can it be predicted? Arthritis Res Ther. 2010;12(3):94–8. DOI: http://dx.doi.org/10.1186/ar3021.

28. Eder L, Chandran V, Shen H, et al. Is ASDAS better than BASDAI as a measure of disease activity in axial psoriatic arthritis? Ann Rheum Dis. 2010;69:2160–4. DOI: http://dx.doi.org/10.1136/ard.2010.129726.

29. Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68:1387–94. DOI: http://dx.doi.org/10.1136/ard.2008.094946.

30. Kavanaugh AF, Ritchlin CT. Systematic review of treatments for psoriatic arthritis: an evidence based approach and basis for treatment guidelines. J Rheumatol. 2006;33:1417–21.

31. Sarzi-Puttini P, Santandrea S, Boccasini L, et al. The role of NSADI in psoriatic arthritis: evidence from a controlled study with nimesulide. Clin Exper Rheumatol. 2001;19 Suppl 22:17–20.

32. Ritchlin CT. Therapies for psoriatic enthesopathy. A systematic review. J Rheumatol. 2006;33:1435–8.

33. Abu-Shakra M, Gladman DD, Thorne JC, et al. Longterm methotrexate therapy in psoriatic arthritis: clinical and radiological outcome. J Rheumatol. 1995;22:241–5.

34. Kalb RE, Strober B, Weinstein G, Lebwohl M. Methotrexate andpsoriasis: 2009 National Psoriasis Foundation Consensus Conference. J Am Acad Dermatol. 2009;60:824–37. DOI: http://dx.doi.org/10.1016/j.jaad.2008.11.906.

35. Salvarani C, Macchioni P, Olivieri I, et al. A comparison of cyclosporine, sulfasalazine, and symptomatic therapy in the treatment of psoriatic arthritis. J Rheumatol. 2001;28:2274–82.

36. Madan V, Griffiths CE. Systemic cyclosporine and tacrolimus in dermatology. Dermatol Ther. 2007;20:239–50. DOI: http://dx.doi.org/10.1111/j.1529-8019.2007.00137.x.

37. Fernandez Sueiro JL, Juanola Roura X, Canete Crespillo JD, et al. Consensus statement of the Spanish Society of Rheumatology on the management of biologic therapies in psoriatic arthritis. Rheumatol Clin. 2011;7:179–88.

38. Antoni CE, Kavanaugh A, Kirkham B, et al. Sustained beneits of inliximab therapy for dermatologic and articular manifestations of psoriatic arthritis: results from the inliximab multinational psoriatic arthritis controlled trial (IMPACT). Arthritis Rheum. 2005;52(4):1227–36. DOI: http://dx.doi.org/10.1002/art.20967.

39. Gladman DD, Sampalis JS, Illouz O, Guerette B. Responses to adalimumab in patients with active psoriatic arthritis who have not adequately responded to prior therapy: effectiveness and safety results from an open-label study. J Rheumatol. 2010;37(9):1898–906. DOI: http://dx.doi.org/10.3899/jrheum.100069.

40. Kavanaugh A, McInnes I, Mease P, et al. Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: twenty- four-week efficacy and safety results of a randomized, placebocontrolled study. Arthritis Rheum. 2009;60(4): 976–86. DOI: http://dx.doi.org/10.1002/art.24403.

41. McInnes I, Kavanaugh A, Gottlieb A, et al. Ustekinumab in patients with active psoriatic arthritis: Results of the phase 3, multicenter, double-blind, placebo-controlled PSUMMIT I study. Ann Rheum Dis. 2012;71:107–10. DOI: http://dx.doi.org/10.1136/annrheumdis-2012-eular.1841.

42. Gottlieb A, Menter A, Mendelsohn A, et al. Ustekinumab, a human interleukin 12/23 monoclonal antibody, for psoriatic arthritis: randomised, double-blind, placebo-controlled, crossover trial. Lancet. 2009;373:633–40. DOI: http://dx.doi.org/10.1016/S0140-6736(09)60140-9.

43. Fonseca JE, Lucas H, Canhao H, et al. Recommendations for the diagnosis and treatment of latent and active tuberculosis in inflammatory joint diseases candidates for therapy with tumor necrosis factor alpha inhibitors: March 2008 update. Acta Reumatol Port. 2008;33:77–85.

44. Van der Heijde D, Kivitz A, Schiff MH, et al. Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2006;54:2136–46. DOI: http://dx.doi.org/10.1002/art.21913.

45. Inman RD, Davis JC, Heijde D, et al. Efficacy and safety of golimumab in patients with ankylosing spondylitis: results of a randomized, double-blind, placebo-controlled, phase III trial. Arthritis Rheum. 2008;58:3402–12. DOI: http://dx.doi.org/10.1002/art.23969.

46. Papp K, Langley R, Lebwohl M, et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double- blind, placebo-controlled trial (PHOENIX 2). Lancet. 2008;371:1675–8. DOI: http://dx.doi.org/10.1016/S0140- 6736(08)60726-6.

47. McInnes I, Kavanaugh A, Gottlieb A, et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet. 2013;382(9894):780–9. DOI: http://dx.doi.org/10.1016/S0140-6736(13)60594-2.

48. Atteno M, Peluso R, Costa L, et al. Comparison of effectiveness and safety of ifliximab, etanercept, and adalimumab in psoriatic arthritis patients who experienced an inadequate response to previous disease-modifying antirheumatic drugs. Clin Rheumatol. 2010;29(4):399–403. DOI: http://dx.doi.org/10.1007/s10067-009-1340-7.

49. Glintborg B, Ostergaard M, Dreyer L, et al. Treatment response, drug survival, and predictors thereof in 764 patients with psoriatic arthritis treated with anti-tumor necrosis factor alpha therapy: results from the nationwide Danish DANBIO registry. Arthritis Rheum. 2011;63:382–90. DOI: http://dx.doi.org/10.1002/art.30117.

50. Dougados M, Combe B, Braun J, et al. A randomized, multicentre, double-blind, placebo-controlled trial of etanercept in adults with refractory heel enthesitis in spondyloarthritis: the HEEL trial. Ann Rheum Dis. 2010;69:1430–5. DOI: http://dx.doi.org/10.1136/ard.2009.121533.

51. Heilwell PS. Therapies for dactylitis in psoriatic arthritis. A systematic review. J Rheumatol. 2006;33:1439–41.

52. Van der Heijde D, Sieper J, Maksymowych WP, et al. 2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis. Ann Rheum Dis. 2011;70:905–8. DOI: http://dx.doi.org/10.1136/ard.2011.151563.

53. Salvarany C, Boiardi L, Macchioni P, et al. Multidisciplinary focus on Cyclosporin A. J Rheumatol. 2009;83:52–5.