SPECIFIC FEATURES OF AXIAL SKELETON INVOLVEMENT IN EARLY PSORIATIC ARTHRITIS (The REMARCA TRIAL)

Objective: to optimize the diagnosis of spinal column involvement in early psoriatic arthritis (ePsA).

Subjects and methods. 40 ePsA patients (17 men and 23 women) fulfilling the respective CASPAR criteria were examined. Their median age was 36.5 [28.5; 49.5] years; median PsA duration  – 13.5 [5; 24] months. The activity of ePsA was assessed using DAS and DAS28. Presence of inflammatory back pain (IBP) according to ASAS criteria and HLA-B27 was evaluated in all the patients; 38 of them underwent  pelvic X-ray to reveal significant sacroiliitis (SSI) (Stage II bilateral or Stage III–IV unilateral SSI) and 37 had magnetic resonance imaging (MRI)  of sacroiliac joints. A radiologist determined  blindly the presence of active sacroiliits (ASI) as bone marrow edema/osteitis.

Results and discussion. In ePsA, median DAS and DAS28 were 3.99 [2.99; 4.92] and 4.22 [3.37; 4.8], respectively. IBP was detected in 22 (55%) patients; it was prolonged in 12 (54.5%); IBP episodes were noted in 10 (45.5%). MRI revealed ASI n 15 (40.5%) of the 37 patients; SSI in 11 (28.9%); 17 (42.5%) patients were HLA-B27 positive. In ePsA, there was a very high association of ASI and SSI with IBP (Q = 0.91, р<0.002 and Q=0.83,  р<0.002). No significant relationship was found between ASI and HLA-B27. There was no correlation  between ASI and DAS (Q=0.06,  р>0.9) and SSI and DAS (Q=0.42,  р>0.3). A significant association was revealed between ASI and SSI (Q=0.67,  р<0.002). Conclusion. In ePsA, ASI and SSI are identified in 40.5 and 28.9% of cases, respectively. ASI and SSI are closely related to IBP rather than to HLA-B27. The activity of peripheral arthritis does not affect the rate of ASI detected on MRI and SSI in patients with ePsA.

1. Насонов ЕЛ, редактор. Ревматология: Клинические рекомендации. 2-е изд. Москва: ГЭОТАР-Медиа; 2010. 752 c. [Nasonov EL, editor. Revmatologiya: Klinicheskie rekomendatsii. [Rheumatology: Clinical guidelines]. 2nd ed. Moscow: GEOTARMedia; 2010. 752 p.].

2. Bennett AN, McGonagle D, O’Connor P, et al. Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLAB27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years. Arthritis Rheum. 2008;58:3413-8. doi: 10.1002/art.24024

3. Oostveen J, Prevo R, den Boer J, van de Laar M. Early detection of sacroiliitis on magnetic resonance imaging and subsequent development of sacroiliitis on plain radiography. A prospective, longitudinal study. J Rheumatol. 1999;26:153-8.

4. Docherty P, Mitchell MJ, MacMillan L, et al. Magnetic resonance imaging in the detection of sacroiliitis. J Rheumatol. 1992;19:393-401.

5. Blum U, Buitrago-Tellez C, Mundinger A, et al. Magnetic resonance imaging (MRI) for detection of active sacroiliitis – a prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI. J Rheumatol. 1996;23:2107-15.

6. 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: 10.1136/ard.2008.101501

7. Rudwaleit M, Jurik AG, Hermann K-GA, et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann Rheum Dis. 2009;68:1520-7. doi: 10.1136/ard.2009.110767

8. Chandran V, Tolusso DC, Cook RJ, Gladman DD. Risk factors for axial inflammatory arthritis in patients with psoriatic arthritis. J Rheumatol. 2010;37:809-15. doi: 10.3899/jrheum.091059

9. Hanly JG, Russell ML, Gladman DD. Psoriatic spondyloarthropathy: A long term prospective study. Ann Rheum Dis. 1988;47:386-93. doi: 10.1136/ard.47.5.386

10. Scarpa R, Oriente P, Pucino A, et ai. The clinical spectrum of psoriatic spondylitis. Br J Rheumatol. 1988;27:133-7. doi: 10.1093/rheumatology/27.2.133

11. Helliwell PS, Hickling P, Wright V. Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis? Ann Rheum Dis. 1998;57:135-40. doi: 10.1136/ard.57.3.135

12. Perez Alamino R, Maldonado Cocco JA, Citera G, et al. Differential features between primary ankylosing spondylitis and spondylitis associated with psoriasis and inflammatory bowel disease. J Rheumatol. 2011;38:1656-60. doi: 10.3899/jrheum.101049

13. Lindqvist U, Alenius G-M, Husmark T, et al. The Swedish Early Psoriatic Arthritis Register – 2-years follow-up: a comparison with early rheumatoid arthritis. J Rheumatol. 2008;35(4):668-73.

14. Gladman DD, Brubacher B, Buskila D, et al. Differences in the expression of spondyloarthropathy: A comparison between ankylosing spondylitis and psoriatic arthritis. Clin Invest Med. 1993;16:1-7.

15. Weber U, Maksymowych WP. Sensitivity and specificity of magnetic resonance imaging for axial spondyloarthritis. Am J Med Sci. 2011;341:272-7. doi: 10.1097/MAJ.0b013e31820f8c59

16. Der Hooge M, van der Berg R, Navarro-Compan V. Patients with chronic back pain of short duration from SPACE cohort: which MRI structural lesions in the sacroiliac joints and inflammatory and structural lesions in the spine are most specific for axial spondyloarthritis? Ann Rheum Dis. 2015 Aug 18. doi: 10.1136/annrheumdis-2015-207823 [Epub ahead of print].

17. Williamson L, Dockerty JL, Dalbeth N, et al. Clinical assessment of sacroiliitis and HLA-B27 are poor predictors of sacroiliitis diagnosed by magnetic resonance imaging in psoriatic arthritis. Rheumatology. 2004;43:85-8. doi: 10.1093/rheumatology/keg475

18. Castillo-Gallego C, Aydin SZ, Emery P, et al. Brief Report: Magnetic Resonance Imaging Assessment of Axial Psoriatic Arthritis: Extent of Disease Relates to HLA-B27. Arthritis Rheum. 2013 Sep;65(9):2274-8. doi: 10.1002/art.38050

19. Gladman DD. Inflammatory spinal disease in psoriatic arthritis: A Report from the GRAPPA 2010 Annual Meeting. J Rheumatol. 2012;39:2. doi: 10.3899/jrheum.111238

20. Gossec L, Smolen JS, Ramiro S. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2015;0:1-12. doi: 10.1136/annrheumdis-2015-208337.