K Wervers

Influence of Disease Manifestations on Health-related Quality of Life in Early Psoriatic Arthritis

Objective. Psoriatic arthritis (PsA) is a multifaceted disease. Affecting joints, skin, entheses, and dactylitis, its effect on health-related quality of life (HRQOL) could be substantial. We aim to assess HRQOL in patients newly diagnosed with PsA and analyze its associations with disease manifestations. Methods. Data collected at time of diagnosis from patients with PsA included in the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR) study were used. HRQOL was assessed using 8 domains of the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Patients were classified based on primary manifestation in arthritis subtypes (i.e., mono-, oligo-, or polyarthritis) and other subtypes (i.e., enthesitis, dactylitis, and axial disease). In all patients, presence of arthritis, enthesitis, dactylitis, psoriasis, and chronic inflammatory back pain was determined. Multivariable linear regression was used to determine associations of PsA manifestations with HRQOL. Results. Of 405 patients, primary manifestation was peripheral arthritis in 320 (78 monoarthritis, 151 oligoarthritis, and 91 polyarthritis), enthesitis in 37, axial disease in 9, and dactylitis in 39. Mean scores of SF-36 domains were lower than the Dutch reference population and similar across arthritis subtypes. A higher number of enthesitis locations and tender joints, and presence of chronic back pain, were independently associated with worse SF-36 scores. Psoriasis and dactylitis were not associated with worse scores. Conclusion. HRQOL was diminished in PsA at time of diagnosis compared to the Dutch reference population, and tender joints, enthesitis at clinical examination, and back pain as indicators of pain affected HRQOL.

Modification of a sonographic enthesitis score to differentiate between psoriatic arthritis and young healthy volunteers

Objectives: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison. Method: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI. Results: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002). Conclusions: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volunteers. After recoding of PD severity and excluding thickness of knee entheses, marked differences between PsA patients and healthy controls were observed.

Burden of Psoriatic Arthritis in different definitions of disease activity: comparing Minimal Disease Activity and Disease Activity index for Psoriatic Arthritis

Treat‐to‐target strategies have improved outcomes in rheumatic diseases. In psoriatic arthritis (PsA), the proposed targets are the multidimensional target minimal disease activity (MDA) and the articular target Disease Activity index for PsA (DAPSA). The aim of this study was to compare the disease burden of PsA in patients with low disease activity according to the 2 definitions, MDA and DAPSA low disease activity (DAPSA‐LDA), 1 year after diagnosis.

THU0289 Burden of psoriatic arthritis in different definitions of disease activity: comparing minimal disease activity and disease activity index for psoriatic arthritis

Background Treat-to-target strategies have improved outcomes in rheumatic diseases. In psoriatic arthritis (PsA), the proposed targets are the multidimensional target Minimal Disease Activity (MDA) and the articular target Disease Activity index for PsA (DAPSA). Objectives We aimed to compare burden of PsA in patients with low disease activity according to the two definitions MDA and DAPSA-Low Disease Activity (DAPSA-LDA), one year after diagnosis. Methods We obtained data on MDA, DAPSA-LDA and disease burden one year after diagnosis from patients included in the Dutch southwest early PsA cohort. Disease burden was assessed in two domains: ‘Body Functions’, including Short Form 36 Bodily Pain (SF36-BP), and ‘Activity’, including Health Assessment Questionnaire (HAQ). Results Of the 292 patients included, 48% achieved MDA and 64% DAPSA-LDA. Average ‘Body Functions’ and ‘Activity’ were similar in patients in MDA and patients in DAPSA-LDA. However the scores were significantly better in the 44% of patients in both MDA and DAPSA-LDA than in the 20% of patients only in DAPSA-LDA. The average SF36-BP was higher in patients achieving both targets (74.7, 95% CI 72.0–77.4) than in patients only in DAPSA-LDA (58.7, 95% CI 54.8–62.6). Similarly, mean HAQ scores measuring ‘Activity’ were 0.19 (95%CI 0.14–0.25) and 0.61 (95%CI 0.48–0.73) respectively.Abstract THU0289 – Figure 1 SF36-BP and HAQ scores in MDA and DAPSA subgroups. Conclusions Of patients newly diagnosed with PsA, 48% achieved MDA and 64% DAPSA-LDA after one year receiving usual care. Average disease burden was similar in patients in MDA and in patients in DAPSA-LDA. However, those that only achieved DAPSA-LDA reported worse outcomes than those also achieving MDA. Disclosure of Interest None declared

FRI0497 What choices do rheumatologist make in escalating dmard therapy in early psa

Background Psoriatic arthritis (PsA) is a multifaceted disease. Objectives We aimed to evaluate change in medication over time guided by joints, skin, enthesis, low back pain and dactylitis in newly diagnosed PsA patients Methods Newly diagnosed PsA patients were included in the Dutch Early south-west Psoriatic Arthritis cohoRt (DEPAR) study between August 2013 and March 2016. Initial drug treatment and escalation of therapy were described for all patients. Drivers of treatment changes in the first year were evaluated by mixed ordered ordinal regression with outcome treatment change and variables joints (66/68 count), skin (PASI), entheses (LEI and MASES), dactylitis (LDI) and axial disease (BASDAI) Results 323 patients had had baseline assessment in March 2016. Their average age was 50.0 years (SD 13.8) and 49% were male. 80% patients had arthritis (19% monoarthritis, 39% oligoarthritis and 23%polyarthritis), 9% had an enthesitis subtype, 2% axial disease and 9% dactylitis. Initial treatment consisted of methotrexate (MTX) (52%), in 7% of other synthetic disease modifying antirheumatic drugs (sDMARDs) and due to treatment of psoriasis 3% biologicals. Within the different phenotypes MTX was most frequently started in polyarthritis (84%) followed by oligoarthritis (63%), monoarthritis (33%) and other phenotypes (5%). At 12 months 70% (n=148) stayed on the initial drug. Of those switched, 9 started MTX, within the initial MTX users (n=74) almost equal percentages stopped, switched to metoject or biological (4%). A smaller percentage (2%) switch to leflunomide. Changes in medication were driven by swollen joint count and the presence of dactylitis (Table 1) Conclusions MTX was initiated in about half of the early PsA patients. The majority of patients were kept on the initial treatment strategy in first year. Failure on initial drug led to variation in subsequent drugs with additional start of other sdmards, switch subcutaneuous MTX, to other sdmards or to biological dmards. Treatment change was driven by Swollen Joint Count and presence of Dactylitis. Skin, Enthesis and Axial disease did not play a role in escalating treatment. Disclosure of Interest None declared

AB0769 Sonographic signs of enthesitis in established psoriatic arthritis and healthy volunteers

Background Previous research in our group showed that sonographic signs of enthesitis are present in early and established PsA, but in young healthy volunteers as well. The Madrid Sonographic Enthesitis Index (MASEI) was only able to differentiate between patients and healthy volunteers after excluding knee enthesis thickness from the score and semi-quantitative scoring of Power Doppler (PD) signal (1). Objectives We aim to validate the modified MASEI in a larger cohort of established PsA patients and healthy volunteers. Methods Established PsA patients and healthy volunteers aged 35–55 were asked to participate in this cross-sectional study, irrespective of presence of enthesitis complaints. The triceps, quadriceps, proximal and distal patellar and Achilles tendon and plantar fascia (i.e. the locations of the MASEI) and the common extensor insertion at the lateral epicondyle of the elbow were evaluated sonographically for structural changes (i.e. erosions, calcifications and structure) and active inflammation (thickness, bursitis and PD). Results 84 established PsA patients and 25 healthy volunteers participated. Sonographic structural changes and one or two spots of PD signal were common in both groups. The modified MASEI was significantly higher in PsA patients (median 12 (IQR 7.25–17) vs. 7.5 (5–9), P<0.001), while the original MASEI did not differ significantly (Table 1). Confluent PD over a larger area was only seen in 8% of the established PsA patients. Structural damage on ultrasound was more pronounced in the patients compared to the healthy volunteers. Number of PD locations and PD score did not distinguish the two groups.Table 1. Participant characteristics and sonographic enthesitis scores PsA patients (n=84) Healthy Volunteers (n=25) Male, n (%) 45 (54) 12 (48) Age, mean (SD) 55 (11) 47 (6)* Disease duration, median years (IQR) 8.0 (4.9–12.3) LEI, median (IQR) 0.5 (0–2) 0 (0–0)** Ultrasound MASEI, median (IQR) 15.5 (11–22) 13 (9–18) Modified MASEI, median (IQR) 12 (7.25–17) 7.5 (5–9)** structural components 7 (3–10) 3 (1–6)** inflammatory components 6 (3.5–8.5) 3.5 (2–5.5) Power Doppler in any enthesis, n (%) 74 (88) 22 (88) score 3, n (%) 7 (8%) 0 (0%) locations, median (IQR) 2 (1–3) 2 (1–3) if positive, median (IQR) 1.5 (1.25–1.75) 1.5 (1.25–1.5) PsA: Psoriatic Arthritis; SD: standard deviation, IQR: interquartile range; LEI: Leeds Enthesitis Index; MASEI: Madrid Sonographic Enthesitis Score; modified MASEI: MASEI with new PD scoring method (1: one spot of PD, 1.5: some spots of PD, 2: confluent signal, 3: severe signal) and without knee entheses thickness. Structural components: erosions, calcifications, structure. Inflammatory components: bursitis, thickness and PD signal. PD: Power Doppler. *P<0.01, **P<0.001 (Wilcoxon rank sum test). Conclusions Inflammatory and structural changes of the enthesis measured with ultrasound are common in both unselected PsA patients and healthy volunteers, but more pronounced in established PsA patients. References Wervers K, Rasappu N, Vis M, Tchetverikov I, Kok MR, Gerards AH, et al. AB0733 Masei Shows Substantial Changes in The Entheses of Young Healthy Volunteers – Amending Its PD Score and Excluding Knee Entheses Thickness Provides Better Discrimination of Enthesitis in Psoriatic Arthritis Patients. Ann Rheum Dis 2016;75:1155. Disclosure of Interest None declared

AB0733 Masei Shows Substantial Changes in The Entheses of Young Healthy Volunteers – Amending Its PD Score and Excluding Knee Entheses Thickness Provides Better Discrimination of Enthesitis in Psoriatic Arthritis Patients

Background Tendon complaints are common in both healthy adults and patients with psoriatic arthritis (PsA). Ultrasound (US) could be used to investigate whether these are located at the enthesis and of inflammatory origin, as it is able to detect structural changes and inflammatory changes using Power Doppler. Objectives We aim to describe the difference in ultrasound abnormalities in the entheses of patients with recently diagnosed PsA, patients with established PsA and young healthy volunteers (20–30 years). using the MASEI US score Methods Consecutively newly diagnosed PsA patients participating in the Dutch south west Psoriatic Arthritis Registry (DEPAR), patients with >2 years PsA and healthy volunteers (aged 20–30 years) were asked to participate. An ultrasound was performed by one examiner unaware of clinical findings using an Esoate Mylab 60 (probe LA-435 and LA-523). The triceps, quadriceps, proximal and distal patellar and Achilles tendon insertion, plantar fascia (i.e. the locations of the Madrid Sonographic Enthesis Index; MASEI) and the tendon insertion at the lateral epicondyle of the elbow were investigated (1). In each location structural changes, erosions, calcifications, increased thickness and Power Doppler signal and is some locations bursitis were evaluated, resulting in a total score (range 0–158). Results In total, 25 newly diagnosed PsA patients (A), 25 established PsA patients (B) and 25 healthy volunteers (C) participated. The median of the MASEI+ score was for A 18 (IQR 15–30), for B 22 (IQR 15–27) and for C 10 (IQR 5–15) (Table 1). Of note, the reference values for thickness of the Quadriceps tendon at the superior pole (6.1 mm), the inferior pole (4.0 mm) and the insertion at the tuberosity of the tibia (4.0 mm) were exceeded by 50%, 58% and 70% of the entheses of healthy volunteers (50 tendons). Also the degree of Power Doppler signal varied from one spot of signal to a confluent signal in large section of the enthesis, suggesting different levels of inflammation or possibly even false-positive findings. The images were re-evaluated for PD signal (assigning 1 point for one spot of signal, 1.5 for 2 or 3 spots, 2 for confluent small area or 3 points for confluent large area). When excluding increased thickness of knee entheses and using the re-evaluated PD scores the median MASEI was resp. 13 (IQR 10–22.5), 13.5 (IQR 9.5–18) and 3 (IQR 1.5–8) (Table 1). Conclusions US structural changes and inflammation in the entheses are common in both early and established PsA patients using the MASEI. In healthy young adults US enthesitis was only observed around the knee. MASEI ultrasound score differentiated PsA patients from healthy volunteers when dropping the knee tendon enthesis thickness and applying a refined Power Doppler score. Our findings need to be confirmed in a larger cohort of healthy controls and patients. References de Miguel E, Cobo T, Munoz-Fernandez S, Naredo E, Uson J, Acebes JC, et al. Validity of enthesis ultrasound assessment in spondyloarthropathy. Ann Rheum Dis. 2009;68(2):169–74. Disclosure of Interest None declared

FRI0465 Does Skin Matter in Incident Psoriatic Arthritis

Background Psoriatic arthritis (PsA) is a disease with musculoskeletal and skin inflammation (psoriasis). Attempts are being made to develop comprehensive disease measures to capture global disease activity. However very little is known on how much psoriasis actually affects quality of life (QOL) in patients with PsA. Objectives In this study we aim to determine to what extent psoriasis affects quality of life in incident Psoriatic Arthritis patients. Methods Data collected at baseline in the Dutch south west Psoriatic Arthritis Registry (DEPAR) study were used. The DEPAR includes newly diagnosed PsA patients from 8 hospitals in the South-West of the Netherlands. PsA core measurements were collected: Swollen and Tender join count (66/68), enthesitis (LEI and MASES), dactylitis (LDI) and psoriasis (PASI). In addition 3 patient reported measures of quality of life were administered. Short Form-36 (SF-36) is a self-administered 36-item health survey questionnaire. The items are assigned to eight scales grouped in two factors: physical component summary (PCS) and mental component summary (MCS, score 0–100). Skindex-17 is a self-administered 17-item dermatology questionnaire that explores functioning, emotions and symptoms in a Symptoms Subscale (SS; range 0–10) and a Psychosocial Subscale (PS; range 0–24).The DLQI is a self-administered 10-item questionnaire, score 0–30 with higher scores resulting in poorer quality of life. It covers Symptoms and feelings, Daily activities, Leisure, Work and school, Personal relationships and Treatment Results In total 281 patients were included: mean age was 50.6 (SD 13.6) and 50.5% were male. In terms of arthritis subtypes, 56 (20%) had mono-arthritis, 108 (39%) oligo-arthritis, 80 (29%) poly-arthritis and 35 (12%) were diagnosed with axial disease, dactylitis or enthesitis only. The Median PASI score was 2.3, ranging from 0 to 22.5. Divided in PASI categories (1) this resulted for 12% in no skin disease, 72% mild (>0–7), 11% moderate (7–12) and 5% had severe (>12) psoriasis. Median PASI scores were different for mono, oligo to polyarthritis group: 2.7 (0–12.3), 3.4 (0–22.5) and 4.4 (0–21). Skin related quality of life measured by DLQI showed a median 1 (QR 0–5) and the two subscales of the skindex resulted in a median SS 4 (IQR 2–6) and a PS of 2 (IQR 0–8), and a SF-36 PCS of 40.3 (8.3) and SF-36 MCS of 47.7 (10.4).(table 1) Comparing none and mild psoriasis to moderate and sever psoriasis resulted in median scores for DLQI: 1 vs 5 (p<0.01) and Skindex-17 SS: 4 vs 7 and skindex-17 PS: 2 vs 7 (p<0.01)while significant difference was observed for the bodily pain an emotional role subscales of the SF-36. (P<0.05) Conclusions Skin involvement in incident Psoriatic Arthritis is in the majority of patients mild with median PASI score of 2.3. About 15% suffered from moderate to severe psoriasis. Skin quality of life measures showed poorer health states for these patients, which was also reflected in the emotional role and bodily pain subscale of more generic QOL questionnaire: SF-36. Disclosure of Interest None declared

AB0734 Quality of Life at Baseline in Early Psoriatic Arthritis Related To Initial Presentation of Mono-, Oligo-, and Polyarthritis and Tender Enthesis: Results from The Depar Study

Background Little data is available on quality of life in newly diagnosed psoriatic arthritis (PsA) patients and its relation to the extent of the disease. Objectives To describe quality of life in newly diagnosed PsA related to the extent of the disease as defined by the number of swollen joints and the presence or absence of tender enthesis. Methods Baseline data of consecutively recruited incident PsA patients was used from the Dutch south west Psoriatic Arthritis Registry (DEPAR) study between August 2013 to November 2015. Health-related quality-of-life (HRQoL) was assessed by the 8 subscales of the Short-Form 36 (SF-36) questionnaire (0–100, higher score represents a better HRQL) and the PsA-specific quality-of-life (PsAQoL) questionnaire (0–20, lower score represents a better HRQL). Patients were classified in the three arthritis subtypes (i.e. mono-, oligo- or polyarthritis) based on evaluation of the rheumatologist. A tender enthesis was defined as having at least one tender enthesis using the Leeds Enthesitis Index (LEI) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Results 209 patients with arthritis at time of inclusion completed the SF-36 questionnaire. Average age was 51.4 years (SD 13.7) and 55% were male. Of these patients 49 had monoarthritis, 92 oligoarthritis and 68 polyarthritis. At least one tender enthesis was present in 45%, 38% and 53% of the patients. Mean scores of the subdomains in the SF-36 were similar across the different arthritis-groups, with better scores for monoarthritis compared to oligo and polyarthritis. However, when separating the groups based on the presence of a tender enthesis HRQoL decreased substantially for all groups across all subdomains of the SF-36, with a mean difference of 15 points (Figure 1). Mean scores of all subdomains were significantly lower in the tender enthesis group (n=106) compared to the non-tender enthesis group (n=131). Comparable results were observed for the PsAQoL scores (mono: 7.09 (SD 6.24) vs. 2.15 (SD 2.85); oligo: 7.11 (5.21) vs 4.18 (5.65) and 8.52 (6.04) vs 2.16 (2.90) Conclusions Stratifying the HRQoL for the presence of tender enthesis, present in about half of newly diagnosed PsA patients, showed lower levels of health-related quality-of-life across both physical and mental scales, independent of arthritis classification, emphasizing the importance of the enthesis in PsA. Disclosure of Interest None declared