Diagnostic algorithm for axial involvement in psoriatic arthritis

The aim – to develop a unified diagnostic algorithm for axial psoriatic arthritis (axPsA).

Subjects and methods. 122 patients with psoriatic arthritis (PsA), duration less than 10 years, were included in the study according to CASPAR (The ClASsification for Psoriatic ARthritis) criteria, provided they also had axial involvement. Axial involvement was detected in case of radiographic sacroiliitis ((rSI); bilateral grade ≥2 or unilateral grade ≥3) or SI active according to magnetic resonance imaging (MRI) (MRI-SI), or ≥1 syndesmophyte(s) of the cervical and/or lumbar spine (CS/LS), or facet joints ankyloses of the CS. Patients were evaluated for the presence of inflammatory back pain (IBP) by ASAS (The Assessment of SpondyloArthritis international Society) criteria. Back pain lasting over three months, that did not meet ASAS criteria was considered chronic back pain (chrBP). HLA-B27 antigen status was observed.

Results and discussion. IBP was identified in 87 (71.3%), chrBP – in 35 (28.7%) patients, 49 (40.2%) patients had older age (>40 years) at back pain onset. 120 (98.4%) patients had peripheral arthritis, 75 (61.5%) – dactylitis, 69 (56.6%) – enthesitis, 122 (100%) – psoriasis, 90 (73.8%) – nail psoriasis. Isolated axial disease without peripheral arthritis was found in 2 (1.6%) patients. RSI was detected in 85 (69.7%) patients, in 28 of 85 (32.9%) patients rSI developed without IBP. Spinal lesions of the LS and CS were found in 100 (82.0%) patients, chunky “non-marginal” syndesmophytes – in 60 (49.2%), asymmetrical syndesmophytes of the LS – in 22 of 72 (30.6%), paravertebral ossification – in 5 (4.1%) patients. Isolated spinal lesions without rSI were found in 37 (30.3%), isolated spinal lesions without rSI or MRI-SI – in 21 (17.2%) patients. HLA-B27 was observed in 27 of 86 (31.4%) examined patients. Diagnostic algorithm for axPsA was developed. All PsA patients, regardless whether they experienced IBP/chrBP or not, must undergo diagnostic imaging: pelvis, LS and CS X-ray. In patients without rSI, MRI of the sacroiliac joints should be performed. AxPsA diagnosis must be confirmed by imaging. Axial involvement is detected in case of rSI or MRI-SI, or ≥1 syndesmophyte(s) of the CS/LS, or facet joints ankyloses of the CS.

1. Coates LC, Helliwell PS. Psoriatic arthritis: State of the art review. Clin Med (Lond). 2017;17(1):65-70. doi: 10.7861/clinmedicine.17-1-65

2. Gubar EE, Loginova EYu, Kоrsakova YuL, Korotayeva TV, Glukhova SI, Sedunova MV, et al. Specific features of axial involvement in psoriatic arthritis: Data from real clinical practice. Nauchno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2020;58(4):401-406 (In Russ.). doi: 10.47360/1995-4484-2020-401-406

3. Chandran V. Psoriatic spondylitis or ankylosing spondylitis with psoriasis: Same or different? Curr Opin Rheumatol. 2019;31(4):329-334. doi: 10.1097/BOR.0000000000000609

4. Jadon DR, Sengupta R, Nightingale A, Lindsay M, Korendowych E, Robinson G, 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

5. Feld J, Ye JY, Chandran V, Inman RD, Haroon N, Cook R, Gladman DD. Axial disease in psoriatic arthritis: The presence and progression of unilateral grade 2 sacroiliitis in a psoriatic arthritis cohort. Semin Arthritis Rheum. 2021;51(2):464-468. doi: 10.1016/j.semarthrit.2021.03.007

6. Kwok TSH, Sutton M, Pereira D, Cook RJ, Chandran V, Haroon N, et al. Isolated axial disease in psoriatic arthritis and ankylosing spondylitis with psoriasis. Ann Rheum Dis. 2022;81(12):1678-1684. doi: 10.1136/ard-2022-222537

7. Puche-Larrubia MÁ, Ladehesa-Pineda L, Vázquez-Mellado J, Escudero-Contreras A, Gratacós J, Juanola X, et al. Identification of the first signs or symptoms in different spondyloarthritis subtypes and their association with HLA-B27: Data from REGISPONSER and RESPONDIA registries. RMD Open. 2023;9(3):e003235. doi: 10.1136/rmdopen-2023-003235

8. Mease PJ, Palmer JB, Liu M, Kavanaugh A, Pandurengan R, Ritchlin CT, 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

9. Korotaeva TV, Gubar EE, Loginova EY, Korsakova YL, Vasilenko EA, Ilyevsky IY, et al. Results of a non-interventional observational multicenter study of the management of patients with axial psoriatic arthritis in real-life clinical practice (NiSaXPA). Modern Rheumatology Journal. 2023;17(6):22-30 (In Russ.). doi: 10.14412/1996-7012-2023-6-22-30

10. Poddubnyy D. Managing psoriatic arthritis patients presenting with axial symptoms. Drugs. 2023;83:497-505. doi: 10.1007/s40265-023-01857-w

11. Gossec L, Kerschbaumer A, Ferreira RJO, Aletaha D, Baraliakos X, Bertheussen H, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 update. Ann Rheum Dis. 2024;83(6):706-719. doi: 10.1136/ard-2024-225531

12. Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group. Classification criteria for psoriatic arthritis: Development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665-2673. doi: 10.1002/art.21972

13. Sieper J, van der Heijde D, Landewé R, Brandt J, Burgos-Vagas R, Collantes-Estevez E, 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(6):784-788. doi: 10.1136/ard.2008.101501

14. Jenkinson TR, Mallorie PA, Whitelock HC, Kennedy LG, Garrett SL, Calin A. Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS Metrology Index. J Rheumatol. 1994;21(9):1694-1698.

15. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis: A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27(4):361-368. doi: 10.1002/art.1780270401

16. Maksymowych WP, Lambert RG, Østergaard M, Pedersen SJ, Machado PM, Weber U, et al. MRI lesions in the sacroiliac joints of patients with spondyloarthritis: An update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis. 2019;78(11):1550-1558. doi: 10.1136/annrheumdis-2019-215589

17. Chandran V, Barrett J, Schentag CT, Farewell VT, Gladman DD. Axial psoriatic arthritis: Update on a longterm prospective study. J Rheumatol. 2009;36(12):2744-2750. doi: 10.3899/jrheum.090412

18. Aydin SZ, Kucuksahin O, Kilic L, Dogru A, Bayindir O, Ozisler C, 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

19. Ogdie A, Blachley T, Glynn M, Rebello S, Dube B, Mclean R, et al. Comparison of patients with psoriatic arthritis (PsA) and investigator-defined axial PsA to patients with PsA and elevated patient-reported spine pain: Findings from the Corrona psoriatic arthritis/ spondyloarthritis (PsA/SpA) registry. Ann Rheum Dis. 2020;79 (Suppl 1):34-35. doi: 10.1136/annrheumdis-2020-eular.1072

20. Schmidt CO, Günther KP, Goronzy J, Albrecht K, Chenot JF, Callhoff J, et al. Häufigkeiten muskuloskelettaler Symptome und Erkrankungen in der bevölkerungsbezogenen NAKO Gesundheitsstudie [Frequencies of musculoskeletal symptoms and disorders in the population-based German National Cohort (GNC)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2020;63(4):415-425 (In German). doi: 10.1007/s00103-020-03110-1

21. de Souza IMB, Sakaguchi TF, Yuan SLK, Matsutani LA, do Espírito-Santo AS, Pereira CAB, et al. Prevalence of low back pain in the elderly population: A systematic review. Clinics (Sao Paulo). 2019;74:e789. doi: 10.6061/clinics/2019/e789

22. Poddubnyy D, Weineck H, Diekhoff T, Redeker I, Gobejishvili N, Llop M, et al. Clinical and imaging characteristics of osteitis condensans ilii as compared with axial spondyloarthritis. Rheumatology (Oxford). 2020;59(12):3798-3806. doi: 10.1093/rheumatology/keaa175

23. Wang W, Lee YH, Wei JC, Mease P. Similarities and differences between axial spondyloarthritis and axial psoriatic arthritis. Int J Rheum Dis. 2023;26(3):407-409. doi: 10.1111/1756-185X.14537

24. Clinical recommendations. Arthropathic psoriasis. Psoriatic arthritis. 2021 (In Russ.). URL: https://cr.minzdrav.gov.ru/recomend/562_2 (Accessed: 13th July 2022).

25. Helliwell PS. Axial disease in psoriatic arthritis. Rheumatology (Oxford). 2020;59(6):1193-1195. doi: 10.1093/rheumatology/kez629

26. Gubar EE, Korotaeva TV, Korsakova YuV, Loginova EYu, Smirnov AV, Sukhinina AV, et al. Clinical and instrumental characteristics of axial involvement in psoriatic arthritis in real-life clinical practice. Nauchno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2022;60(4):465-472 (In Russ.). doi: 10.47360/1995-4484-2022-465-472

27. Gubar EE, Korotaeva TV, Korsakova YuL, Loginova EYu, Smirnov AV, Sukhinina AV, et al. Evaluation of the possibility of axial psoriatic arthritis patients meet classification criteria for axial spondyloarthritis and ankylosing spondylitis. Nauchno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2023;61(4):493-500. (In Russ.). doi: 10.47360/1995-4484-2023-493-500

28. Gubar EE, Korotaeva TV, Dubinina TV, Vorobyeva LD, Tremaskina PO, Agafonova EM, et al. Comparative characteristics of axial spondyloarthritis and psoriatic arthritis with axial involvement. Nauchno-Prakticheskaya Revmatologia = Rheumatology Science and Practice. 2024;62(2):168-175 (In Russ.). doi: 10.47360/1995-4484-2024-168-175

29. Poddubnyy D, Jadon DR, van den Bosch F, Mease PJ, Gladman DD. Axial involvement in psoriatic arthritis: An update for rheumatologists. Semin Arthritis Rheum. 2021;51(4):880-887. doi: 10.1016/j.semarthrit.2021.06.006

30. Feld J, Chandran V, Haroon N, Inman R, Gladman D. Axial disease in psoriatic arthritis and ankylosing spondylitis: A critical comparison. Nat Rev Rheumatol. 2018;14(6):363-371. doi: 10.1038/s41584-018-0006-8

31. Feld J, Ye JY, Chandran V, Inman RD, Haroon N, Cook R, Gladman DD. Is axial psoriatic arthritis distinct from ankylosing spondylitis with and without concomitant psoriasis? Rheumatology (Oxford). 2020;59(6):1340-1346. doi: 10.1093/rheumatology/kez457

32. Baraliakos X, Østergaard M, Lambert RG, Eshed I, Machado PM, Pedersen SJ, et al. MRI lesions of the spine in patients with axial spondyloarthritis: An update of lesion definitions and validation by the ASAS MRI working group. Ann Rheum Dis. 2022;81(9):1243-1251. doi: 10.1136/annrheumdis-2021-222081

33. McGonagle D, David P, Macleod T, Watad A. Predominant ligament-centric soft-tissue involvement differentiates axial psoriatic arthritis from ankylosing spondylitis. Nat Rev Rheumatol. 2023;19(12):818-827. doi: 10.1038/s41584-023-01038-9

34. Diaz P, Feld J,Eshed I, Eder L. Characterising axial psoriatic arthritis: Correlation between whole spine MRI abnormalities and clinical, laboratory and radiographic fndings. RMD Open. 2022;8:e002011. doi: 10.1136/rmdopen-2021-002011

35. Poddubnyy D, Baraliakos X, van den Bosch F, Braun J, Coates LC. Axial Involvement in Psoriatic Arthritis cohort (AXIS): The protocol of a joint project of the Assessment of SpondyloArthritis international Society (ASAS) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). Ther Adv Musculoskel Dis. 2021;13:1-11. doi: 10.1177/1759720X211057975

36. Poddubnyy D, Protopopov M. Radiographic progression in non-radiographic axial spondyloarthritis. Expert Rev Clin Immunol. 2018;14(6):525-533. doi: 10.80/1744666X.2018.1477591

37. Coates LC, Baraliakos X, Blanco FJ, Blanco-Morales EA, Braun J, Chandran V, et al. The phenotype of axial spondyloarthritis: Is it dependent on HLA-B27 status? Arthritis Care Res (Hoboken). 2021;73(6):856-860. doi: 10.1002/acr.24174

38. Eder L, Chandran V, Gladman DD. What have we learned about genetic susceptibility in psoriasis and psoriatic arthritis? Curr Opin Rheumatol. 2015;27(1):91-98. doi: 10.1097/BOR.0000000000000136