Specific features of axial involvement in psoriatic arthritis: data from real clinical practice

Objective. To compare clinical features in psoriatic arthritis (PsA) patients with and without axial involvement.
Subjects and methods. 385 PsA patients (172 males and 213 females) from National PsA Register were examined, their diagnosis verified according to CASPAR criteria. Patients’ median age was 45 [35; 54] years, median disease duration – 5,1 [0; 8] years. Pelvis X-ray and HLA-B27 levels in addition to physical examinations were obtained in all patients. Sacroiliitis (SI) was established based on radiographic findings (rSI) including bilateral changes corresponding to at least stage II, or unilateral – corresponding to at least stage III of Kellgren-Lawrence radiographic grading scale. Patients’ radiographs were evaluated by an independent radiologist. Disease activity was assessed using the DAS28 (Disease activity score 28), DAS (Disease activity in psoriatic arthritis) and BASDAI (Bath ankylosing spondylitis disease activity index) scales. 100 mm visual analog scale (VAS) was used for assessment of pain intensity (PI) and the Patient’s Global Assessment of Disease Activity (PtGA). Patients were distributed into two groups: Group 1 included rSI(+) patients, Group 2 – patients without radiologically confirmed SI – rSI (-).
Results. Group 1 included 214 (55,6%) patients with axial involvement, 106 males and 108 females, Group 2 rSI (-) – 171 (44,4%) patients, 66 males and 105 females Proportion of men was significantly higher in RSi(+) group – 49,5% vs 38,6% in rSi(-) group (Odds Ratio, OR – 1,56, 95% CI 1,6-2,4; р = 0,0324). Patient’s median age was 45 [35; 54] and 46 [34; 56] years, respectively (p=0,911). Higher rates of HLA-В27 positivity were found in group rSI(+) patients, than in rSI(-), respectively in 62 out of 126 and in 26 out of 78 patients (OR 1,9, 95% CI 1,1-3,5). Patients from RSI(+) group had more severe erosive peripheral arthritis. Median tender joint counts (TJC) were 9 [14; 18] and 6 [3; 12] (р=0,02), while radiographic feet bone erosions were found in 58 (27,1%) and 29 (17%) patients, respectively (OR 1,8, 95% CI 1,1-3,0). Disease activity was higher in rSI(+) group. Median DAS28 score was 4,3 [3,3; 5,6] and 4,05 [3,03; 4,88] (р=0,02), DAPSA – 28,40 [15,65; 43,65] and 20,0 [12,45; 30,0], (р < 0,01), BASDAI – 1,6 [0; 5,1] and 0 [0; 4,5] (р < 0,01), C-reactive protein (CRP) – 0,9 [0,4; 2,2] mg/dl and 0,8 [0,3; 1,3] mg/dl, respectively (р=0,029). PtGA VAS values were 56,5 [42,3; 70,0] mm and 50,0 [30,0; 60,0] mm (р < 0,01); physicians global assessment (PGA) – 54,0 [40,0; 69,5] mm and 40,0 [25,5; 50,0] mm (р < 0,01); PI VAS values were 50,0 [40,0; 70,0] mm and 50,0 [20,5; 58,8] mm, respectively (р < 0,01). Higher rates of entheses involvement based on the Leeds Enthesitis Index (LEI) and dactylitis were documented in rSI(+) group. Median LEI score was 0 [0; 2] and 0 [0; 1] (p=0,02), while dactylitis was established in 71 (31,2%) and 32 (18,7%) patients, respectively (OR 2,2, 95% CI 1,3-3,5). More severe cutaneous involvement was also found in rSI(+) patients as compared to rSI (-). BSA (Body Surface Area) > 3% involvement was established in 94 (43,9%) and 57 (33,3%) patients, respectively (OR 1,7, 95% CI 1,03-2,4). Axial involvement was associated with more pronounced functional impairment. Median HAQ was 1,0 [0,6; 1,5] and 0 [0-2,2] (р=0,02).
Conclusion. Axial involvement in PsA patients is associated with more severe articular damage, higher enthesitis and dactylitis rates, more severe psoriasis, which should be considered when planning treatment.

1. Baraliakos X, Coates LC, Braun J. The involvement of the spine in psoriatic arthritis. Clin Exp Rheumatol. 2015;33( Suppl 93):S31-5

2. Mease PJ, Palmer JB, Liu M, et al. Influence of Axial Involvement on Clinical Characteristics of Psoriatic Arthritis: Analysis from the Corrona Psoriatic Arthritis/Spondyloarthritis Registry. J Rheumatol. 2018;45(10):1389-1396. doi:10.3899/jrheum.171094

3. Aydin SZ, Kucuksahin O, Kilic L, et al. Axial psoriatic arthritis: the impact of underdiagnosed disease on outcomes in real life. Clin Rheumatol. 2018;37(12):3443-3448. doi: 10.1007/s10067-018-4173-4

4. Fernandez-Sueiro JL. The Challenge and Need of Defining Axial Psoriatic Arthritis. J Rheumatol. 2009 Dec;36(12):2633-4. doi: 10.3899/jrheum.091023

5. Jadon DR, Sengupta R, Nightingale A, et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017;76(4):701-707. doi: 10.1136/annrheumdis-2016-209853

6. Губарь ЕЕ, Логинова ЕЮ, Смирнов АВ и др. Клиникоинструментальная характеристика аксиального поражения при раннем периферическом псориатическом артрите. (Данные исследования РЕМАРКА). Научно-практическая ревматология 2018;56(1):34-40 [Gubar EE, Loginova EYu, Smirnov AV, et al. Clinical and instrumental characteristics of axial lesion in early peripheral psoriatic arthritis (DATA of REMARCA study). Nauchno-Prakticheskaya Revmatologiya= Rheumatology Science and Practice. 2018;56(1):34-40. (In Russ.)]. doi:10.14412/1995-4484-2018-34-40

7. Haroon M, Winchester R, Giles JT et al. Clinical and genetic associations of radiographic sacroiliitis and its different patterns in psoriatic arthritis. Clin Exp Rheumatol. 2017; 35 (2): 270-276

8. Van den Bosch F, Coates L. Clinical management of psoriatic arthritis. Lancet. 2018;391(10136):2285-2294. doi:10.1016/S0140-6736(18)30949-8

9. Van der Heijde D, Ramiro S, Landewé R et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978-991. doi: 10.1136/annrheumdis-2016-210770

10. Taylor W, Gladman D, Helliwell P et al. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665-73. doi::10.1002/art.21972

11. Healy PJ, Helliwell PS. Measuring clinical enthesitis in psoriatic arthritis: assessment of existing measures and development of an instrument specific to psoriatic arthritis. Arthritis Care and Research. 2008;59(5):686–691. doi: 10.1002/art.23568

12. Fredriksson T, Pettersson U. Severe psoriasis-oral therapy with a new retinoid. Dermatologica.1978;157(4):238-44

13. Амирджанова ВН, Койлубаева ГМ, Горячев ДВ и др. Валидация русско-язычной версии HAQ. Научнопрактическая ревматология. 2004;2:59-65. [Amirdzhanova VN, Koilubaeva GM, Gorjachev DV et al. Validation of the Russian language version of HAQ. Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2004;2:59-65. (in Russ)]

14. Sze JT, Packham JC, Milica K et al. The prevalence of axial involvement in psoriasis or psoriatic arthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2019; 58(3) kez107.068, https://doi.org/10.1093/rheumatology/kez107.068

15. Aydin SZ, Kilic L, Kucuksahin O et al. 2017 Performances of inflammatory back pain criteria in axial psoriatic arthritis. Rheumatology (Oxford). 2017;56(11):2031-2032. doi: 10.1093/rheumatology/kex307

16. Haroon M, Gallagher P, FitzGerald O. Inflammatory back pain criteria perform well in subset of patients with active axial psoriatic arthritis but not among patients with established axial disease. Ann Rheum Dis. 2019;78(7):1003-1004. doi: 10.1136/annrheumdis-2018-214583

17. Насонов ЕЛ, Коротаева ТВ, Лила АМ, Кубанов АА. Можно ли предотвратить развитие псориатического артрита у пациентов с псориазом? Научно-практическая ревматология. 2019;57(3):250–254 [Nasonov EL, Korotaeva TV, Lila AM, Kubanov A. Can the development of psoriatic arthritis be prevented in patients with psoriasis? Nauchno-Prakticheskaya Revmatologiya= Rheumatology Science and Practice. 2019;57(3):250-254. (In Russ.)]. Doi:10.14412/1995-4484-2019-250-254

18. Feld J, Ye JY, Chandran V, et al. Is axial psoriatic arthritis distinct from ankylosing spondylitis with and without concomitant psoriasis? Rheumatology (Oxford). 2019 doi:10.1093/rheumatology/kez457

19. Glintborg B, Sørensen IJ, Østergaard M. Ankylosing Spondylitis versus Nonradiographic Axial Spondyloarthritis: Comparison of Tumor Necrosis Factor Inhibitor Effectiveness and Effect of HLA-B27 Status. An Observational Cohort Study from the Nationwide DANBIO Registry. J Rheumatol. 2017;44(1):59-69. doi: 10.3899/jrheum.160958

20. Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care Res (Hoboken). 2019;71(1):2-29. doi: 10.1002/acr.23789