Arane Thavaneswaran

Cardiovascular and other comorbidities in patients with psoriatic arthritis: A comparison with patients with psoriasis

To determine whether the presence of psoriatic arthritis (PsA) is associated with greater comorbidity, in particular cardiovascular morbidity, compared to psoriasis without arthritis.

Patients with psoriatic arthritis have worse quality of life than those with psoriasis alone

OBJECTIVE PsA is an inflammatory arthritis present in ∼30% of people with psoriasis (PsC). Both conditions have a significant impact on quality of life (QoL). Our objective was to test the hypothesis that people with PsA have poorer QoL than patients with PsC because of the added burden of arthritis, age and comorbidities. METHODS Consecutive patients with PsA (CASPAR criteria) and PsC were approached to participate in this study. Patients with PsC were examined by a rheumatologist using a standardized protocol to exclude PsA. Patients completed the HAQ, Medical Outcome Study 36-item Short Form Health Survey, Dermatology Life Quality Index (DLQI), EuroQoL 5 domains (EQ-5D) and Fatigue Severity Scale (FSS). Mean scores were compared and multivariate analyses were conducted to compare the QoL measures between the two patient groups. RESULTS Two hundred and one patients with PsC and 201 patients with PsA were studied. A significant decrease in QoL for patients with PsA compared with those with PsC was identified by all questionnaires except for the DLQI. This skin-specific questionnaire revealed a lower QoL in patients with PsC. Multivariate analyses for each QoL measure confirmed the results of these analyses. After adjusting for age, sex, duration of PsC, comorbidities, DMARDs and biologic therapy, HAQ and DLQI were independently associated with PsA in a logistic regression. CONCLUSION Patients with PsA have a poorer QoL compared with those with PsC as measured by all questionnaires except the DLQI.

Obesity is associated with a lower probability of achieving sustained minimal disease activity state among patients with psoriatic arthritis

Aim To assess whether overweight and obese patients with psoriatic arthritis (PsA) are less likely to achieve sustained minimal disease activity (MDA) state compared to patients with normal weight. Methods A cohort of patients was assessed at the University of Toronto PsA clinic at 6–12-month intervals according to a standard protocol from 2003 to 2012. Patients were categorised into the following groups according to their body mass index (BMI): normal (<25), overweight (25–30), and obese (>30). Sustained MDA was defined as achieving low disease activity state in five or more of the following domains for at least 1 year: skin, enthesitis, tender and swollen joint counts, pain, patient global assessment and function. Proportional odds discrete time to event analysis was used to investigate the association between BMI category and the achievement of sustained MDA. Results Of the 557 patients included in the study, 36.2% were classified as overweight and 35.4% were obese. Overall, 66.1% of the patients achieved sustained MDA during the follow-up period. A dose–response association was found between obesity and the probability of achieving sustained MDA in the multivariate regression analysis. Patients in the higher BMI categories were less likely to achieve sustained MDA compared those in the lowest BMI category (overweight: OR 0.66 p=0.003; obese: OR 0.53 p<0.0001) after adjusting for potential confounding variables. Conclusions Overweight and obese patients with PsA are less likely to achieve sustained MDA compared to those of normal weight.

Depression and Anxiety in Psoriatic Disease: Prevalence and Associated Factors

Objective. (1) To determine the prevalence of depression and anxiety in patients with psoriatic arthritis (PsA) and to identify associated demographic and disease-related factors. (2) To determine whether there is a difference in the prevalence of depression and anxiety between patients with PsA and those with psoriasis without PsA (PsC). Methods. Consecutive patients attending PsA and dermatology clinics were assessed for depression and anxiety using the Hospital Anxiety and Depression Scale. Patients underwent a clinical assessment according to a standard protocol and completed questionnaires assessing their health and quality of life. T tests, ANOVA, and univariate and multivariate models were used to compare depression and anxiety prevalence between patient cohorts and to determine factors associated with depression and anxiety. Results. We assessed 306 patients with PsA and 135 with PsC. There were significantly more men in the PsA group (61.4% vs 48% with PsC) and they were more likely to be unemployed. The prevalence of both anxiety and depression was higher in patients with PsA (36.6% and 22.2%, respectively) compared to those with PsC (24.4% and 9.6%; p = 0.012, 0.002). Depression and/or anxiety were associated with unemployment, female sex, and higher actively inflamed joint count as well as disability, pain, and fatigue. In the multivariate reduced model, employment was protective for depression (OR 0.36) and a 1-unit increase on the fatigue severity scale was associated with an increased risk of depression (OR 1.5). Conclusion. The rate of depression and anxiety is significantly higher in patients with PsA than in those with PsC. Depression and anxiety are associated with disease-related factors.

The association between smoking and the development of psoriatic arthritis among psoriasis patients

Aim To investigate the association between smoking and psoriatic arthritis (PsA) among patients with psoriasis and its interaction with the HLA-C*06 allele. Methods In this exploratory case–control study, smoking status was determined at the time of the diagnosis of arthritis for PsA patients and at their first study visit for psoriasis patients, when they were confirmed not to have PsA. The proportions of patients exposed to smoking were compared in patients with PsA to those with psoriasis alone. A logistic regression model was constructed to test the independent association of smoking and PsA after adjusting for potential confounders. The statistical interaction between HLA-C*06 and smoking was tested through a regression model. Results The proportions of current and past smokers were higher in the psoriasis group compared with the PsA group (30.2% vs 23.4% and 26.7% vs 22.3%, p=0.001, respectively). On multivariate analysis being a current smoker versus a lifetime non-smoker remained inversely associated with PsA (OR 0.57, p=0.002), while past smoker versus lifetime non-smoker status was no longer significant. In a subgroup analysis, smoking remained inversely associated with PsA only among patients who were HLA-C*06 negative. Regression analysis revealed that the interaction between smoking status (ever smoked vs lifetime non-smoker) and HLA-C*06 was statistically significant (p=0.01). Conclusion Smoking may be inversely associated with PsA among psoriasis patients. This association is not present among HLA-C*06-positive individuals.

The burden of carotid artery plaques is higher in patients with psoriatic arthritis compared with those with psoriasis alone

Aim To compare the extent of atherosclerosis in patients with psoriatic arthritis (PsA) and patients with cutaneous psoriasis without arthritis (PsC). Methods In this cross-sectional study the authors compared patients with PsA with PsC patients. Psoriasis patients underwent a rheumatological assessment to exclude inflammatory arthritis. Ultrasonographic measurements of carotid total plaque area (TPA) and carotid intima-media thickness (cIMT) were performed. t Test was used to compare the imaging findings between the two groups. Multivariate linear regression analysis was used to assess the association between disease status and imaging findings after adjusting for potential confounders. Results Overall, 125 PsA and 114 PsC patients were compared. There were no significant differences in age, gender or cardiovascular risk factors between the two groups. Patients with PsA exhibited greater TPA than did PsC patients (TPA (square root of area in mm2) 3.33±3.34 vs 2.43±2.72, p=0.03). This difference remained statistically significant in the multivariate regression analysis after adjusting for potential confounders (p=0.03). The difference in cIMT between the groups did not achieve statistical significance (p=0.09). The following disease-related variables were associated with increase in TPA in multivariate regression analysis among PsA patients: duration of PsA (p=0.04), highest Psoriasis Area and Severity Index recorded in the first 3 years of follow-up (p=0.02) and erythrocyte sedimentation rate (p=0.005). Conclusions PsA patients suffer from more severe subclinical atherosclerosis compared with patients with PsC. This difference is independent of traditional cardiovascular risk factors and correlates with PsA disease duration, more severe skin disease and increased inflammatory markers.

Increased burden of inflammation over time is associated with the extent of atherosclerotic plaques in patients with psoriatic arthritis

Aim To investigate whether a higher burden of inflammation is associated with more severe atherosclerosis in patients with psoriatic arthritis (PsA). Methods Patients from a large PsA cohort were analysed. The cumulative effect of inflammation was measured by a time-adjusted arithmetic mean of all measurements from the first visit to the clinic. The following variables were considered as predictors: Psoriasis Activity and Severity Index (PASI), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, tender and swollen joint counts, C-reactive protein, Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity for PsA (DAPSA). Vascular ultrasound of the carotid arteries was performed, and total plaque area was measured. This measure represented the extent of atherosclerosis and was considered the outcome of interest. The association between inflammation over time and atherosclerosis was assessed by regression models adjusted for age, sex and cardiovascular risk factors. Results A total of 235 patients with PsA were analysed. Patients with more severe atherosclerosis were older (p<0.001), more likely to be obese (p=0.01), smokers (p=0.008) and have hypertension (p=0.001), diabetes (p<0.0001) and dyslipidaemia (p<0.0001). In a multivariate regression model adjusted for age and sex, higher ESR (p=0.009), WBC count (p=0.015) and DAPSA (p=0.04) were associated with more severe atherosclerosis. These associations were not significant after adjustment for traditional cardiovascular risk factors. No association was found between disease duration and atherosclerosis. Conclusions Exposure to an increased burden of inflammation is associated with more severe atherosclerosis in patients with PsA. This association may be mediated by traditional cardiovascular risk factors.

Factors Explaining the Discrepancy Between Physician and Patient Global Assessment of Joint and Skin Disease Activity in Psoriatic Arthritis Patients

To assess the extent and determinants of discordance in scoring between patient global assessment (PtGA) and physician global assessment (PhGA) in patients with psoriatic arthritis (PsA).

Minimal Disease Activity and Anti–Tumor Necrosis Factor Therapy in Psoriatic Arthritis

A state of minimal disease activity (MDA) was defined and validated as target for treatment in psoriatic arthritis (PsA). We aimed to identify disease characteristics, outcome, and predictors of MDA in patients treated with tumor necrosis factor α (TNFα) blockers.

Tumour necrosis factor α blockers are more effective than methotrexate in the inhibition of radiographic joint damage progression among patients with psoriatic arthritis

Aim To determine whether tumour necrosis factor α (TNFα) blockers are more effective than methotrexate in inhibiting the progression of radiographic joint damage in patients with psoriatic arthritis (PsA). Methods A cohort analysis of patients followed prospectively in a large PsA clinic was conducted. Patients who received a TNFα blocker were compared to those treated with methotrexate. Patients who had records of at least 12 months of treatment with either medication for active peripheral PsA and had radiographic bone erosions were analysed. Radiographs of the hands and feet were performed at baseline, 1–2 years (time 1) and 3–4 years (time 2). Radiographic joint damage was scored according to the modified Steinbrocker score. The outcome of interest was the occurrence of radiographic progression. Multivariate logistic regression analysis using generalised estimating equations for repeated measures was used to compare progression in radiographic joint damage between the two treatment groups. Results 65 patients treated with TNFα blockers and 70 patients treated with methotrexate were analysed. The proportion of patients who demonstrated progression of radiographic damage score at time 1 and time 2 was higher in the methotrexate group compared to the TNFα blockers group (at time 1: 80% vs 58.9% p=0.005; at time 2: 88% vs 61% p=0.005). In the multivariate regression analysis methotrexate treatment was associated with an increase in radiographic damage compared to TNFα blockers (p=0.001). Conclusions In a clinic setting, patients with erosive PsA receiving TNFα blockers had a better radiographic outcome compared to those treated with methotrexate.