PSA Male
 

Sacroiliitis and spondylitis

Prevalence: 25%-70%5,*

Sacroiliitis is an inflammation of one or both sacroiliac joints.5 In PsA, sacroiliitis is usually asymmetrical with non-marginal syndesmophytes and paravertebral ossification occurring more in the cervical spine, whereas sacroiliitis in axSpA is symmetrical with marginal syndesmophytes having more involvement in the lumbar joint.5

Spondylitis is inflammation in the insertion of tendons and ligaments into bone with contiguous inflammation of the substance of bone. Spondylitis affects 7%-32% of patients with PsA and is typically less severe than axSpA.6,7

*Prevalence of axial involvement in PsA.​

Uveitis

Prevalence: 7%-20%1

An inflammation of the uveal tract that features1,2:

  • Dry eyes
  • Redness
  • Pain
  • Floaters
  • Photophobia
  • Blurry vision

The risk of developing uveitis is generally lower in PsA compared with axSpA. Anterior uveitis is more common in patients with PsA compared with posterior uveitis and pan-uveitis and is usually insidious in onset as well as continuous, prolonged, and bilateral.1,3,4

Psoriasis

Prevalence: 90%6

An autoimmune skin disease that features red, itchy, scaly skin on the8,9:

  • Knees
  • Elbows
  • Trunk
  • Scalp

IBD

Prevalence: 4%10

Chronic inflammation of the gastrointestinal tract.4

Symptoms4:

  • Persistent diarrhea
  • Abdominal pain
  • Rectal bleeding
  • Weight loss
  • Fatigue

There is a 1-4-fold increased risk of IBD in PsA compared with the general population, and it is more common in patients with axial PsA than in those with peripheral PsA.4

Nail psoriasis

Prevalence: 80%11

An autoimmune skin condition that includes a spectrum of nail dystrophies and can be associated with the activity and progression of PsA, with symptoms ranging from11:

  • Nail pitting
  • Onycholysis
  • Nail discoloration
  • Subungual hyperkeratosis
  • Splinter hemorrhage

Enthesitis

Prevalence: 35%-50%12

The inflammation of the insertion of ligaments, tendons, or joint capsules into bone, which can be painful.12 This condition is an important manifestation of PsA and typically precedes the development of the skeletal manifestations in these patients.13

Peripheral arthritis

Prevalence: Up to 100%14

Arthritis of the peripheral joints associated with15:

  • Synovial inflammation
  • Bony erosion
  • Pathologic new bone formation

This arthritis can be symmetrical or asymmetrical and oligo- or polyarticular and involves the larger joints of the arms and hands.14 Compared with axSpA, patients with PsA have more peripheral joint involvement and a lower prevalence of HLA-B27.16

Dactylitis

Prevalence: 16%-49%12

Dactylitis is the uniform and extensive swelling of soft tissues surrounding the phalangeal joint, and often occurs early in the PsA disease course.12,17 Dactylitis in PsA is usually asymmetrical and involves the feet more than the hands.12 Also, there is a high prevalence of dactylitis in patients with PsA compared with patients with axSpA.18

axSpA=axial spondyloarthritis. HLA-B27=human leukocyte antigen B27. IBD=inflammatory bowel disease.

1. Fotiadou C, Lazaridou E. Psoriasis (Auckl). 2019;9:91-96. 2. Guly CM, Forrester JV. BMJ. 2010;341:c4976. 3. Fraga NA, et al. An Bras Dermatol. 2012;87(6):877-883. 4. Chia AYT, et al. Front Med (Lausanne). 2021;8:737256. 

5. Poddubnyy D, et al. Semin Arthritis Rheum. 2021;51(4):880-887. 6. Mease PJ, Armstrong AW. Drugs. 2014;74(4):423-441. 7. Ogdie A, Weiss P. Rheum Dis Clin North Am. 2015;41(4):545-568. 8. Dhabale A, et al. Cureus. 2022;14(9):e29536. 
9. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Psoriasis. https://www.niams.nih.gov/health-topics/psoriasis. Accessed September 10, 2024. 10. Bergman M, Zueger P, Song, J, et al. Arthritis Rheumatol. 2018:70(S9). American College of Rheumatology abstract 285. 11. Sobolewski P, et al. Reumatologia. 2017;55(3):131-135. 12. Kaeley GS, et al. Semin Arthritis Rheum. 2018;48(1):35-43. 13. Belasco J, Wei N. Rheumatol Ther. 2019;6(3):305-315. 14. Acosta Felquer ML, FitzGerald O. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S26-S30. 15. Mortezavi M, et al. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S20-S25. 16. Benavent D, et al. Ther Adv Musculoskelet Dis. 2020;12:1-8. 17. Helliwell PS, et al. J Rheumatol. 2005;32(9):1745-1750. 18. López-Medina C, et al. RMD Open. 2021;7(1):e001450.

Burden of Disease in PsA

The prevalence of comorbidities in patients with PsA

PsA is frequently associated with comorbidities that could affect the disease outcome and can impact a patient’s daily functioning and quality of life.1,2 To optimize important patient outcomes, physicians should globally assess disease activity and consider the impact of comorbidities on management decisions.1

70% bar

 

~70%

of patients experience at least one comorbidity1

40% bar

 

~40%

of patients have more than three comorbidities3

 

Common comorbidities in patients 
with PsA include:

Obesity

 Obesity4

Diabetes

 Diabetes5

Depression

Depression6

Cardiovascular Disease

 Cardiovascular 
disease6

Osteoporosis

Osteoporosis6

Metabolic syndrome

Metabolic 
syndrome7

Fibromyalgia

Fibromyalgia8

Recognizing the total burden of disease of PsA

PsA has a negative impact on patients’ quality of life across all disease domains. For example:

Enthesitis

Patients with enthesitis and dactylitis report increased disability from reduced physical functioning, as well as increased sleep disturbances and fatigue.6,9,10

Itching

Patients report itching at the location of skin involvement in psoriasis and pain/swelling of joints as factors contributing the most to disease severity.11

Icon finger 137px

Nail disease and disfiguration
have been associated with 
physical and emotional
distress and decreased
productivity at work.6

The quality of life for patients with PsA is further reduced by experiencing clinical presentations across multiple disease domains, comorbidities, and increased disease severity.12

It is important to consider all aspects of disease activity when managing patients with PsA—from specific measures of the various disease domains to assessing the impact on a patient’s quality of life.1,2

PsA=psoriatic arthritis.

1. Lubrano E, et al. Rheumatol Ther. 2020;7(4):825-836. 2. Gupta S, et al. Rheumatol Int. 2021;41(2):275-284. 3. Husted JA, et al. J Rheumatol. 2013;40(8):1349-1356. 4. Tam LS, et al. Rheumatology (Oxford). 2008;47(5):718-723. 5. Dal Bello G, et al. Rheumatol Ther. 2020;7(2):271-285 6. Lee S, et al. P T. 2010;35(12):680-689. 7. Raychaudhuri SK, et al. Metab Syndr Relat Disord. 2010;8(4):331-334. 8. Magrey MN, et al. Arthritis. 2013;2013:762921.
9. Kaeley GS, et al. Semin Arthritis Rheum. 2018;48(1):35-43. 10. Kavanaugh A, et al. Rheumatol Ther. 2016;3(1):91-102. 11. Lebwohl MG, et al. J Am Acad Dermatol. 2014;70(5):871-881.e830. 12. Ogdie A, et al. J Rheumatol. 2021;48(5):698-706.

PsA Disease Outcomes

Optimal disease outcomes are not being reached in PsA

In clinical practice, many patients with PsA are not reaching optimal
disease outcome goals.1

75%

do not achieve minimal disease activity1,*

80%

do not achieve remission1,†

The decision-making pathway for clinicians is complex, with multiple reasons why patients do not achieve optimal disease activity goals.2-5

PsA disease management challenges include:

  • Disease heterogeneity6
  • No definitive diagnostic tests5
  • No consensus on preferred disease activity measures4
  • Patient and clinician discordance on most important disease outcomes2,3
40%

of clinicians
do not routinely use 
disease activity 
measures in clinical 
practice7

More stringent goals in PsA

Striving for and achieving stringent outcome goals

Studies have shown that patients who achieve more stringent outcome goals, such as MDA and cDAPSA remission, are more likely to experience8,9:

Arrow Up

Improved quality of life8

Improved physical functioning and productivity8

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Reduced risk of structural (radiographic) disease progression9,10

 

GRAPPA and OMERACT guidelines recommend setting goals to achieve remission or low disease activity, with regular monitoring and assessment, for optimal patient outcomes in PsA.4,11

Evaluating PsA disease outcome measures

Measuring disease activity: composite vs individual domain measures

Assessment of patients with PsA requires consideration of all disease domains, as well as the impact on pain, function, quality of life, and structural damage. Comorbidities and related conditions should be considered for their impact on management approaches.11
 

Several different measures of disease activity in PsA have been developed, including composite- and domain-specific assessments6,7,12:

Routine use of disease activity measures in clinical practice needs to be implemented to help more patients achieve personalized disease outcome goals7, 11

 
~90% of clinicians agree on a need for a continuous composite measure for routine practice7

 

 

*Based on MDA index. Based on cDAPSA remission.

cDAPSA=Clinical Disease Activity Index for Psoriatic Arthritis. GRAPPA=Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. MDA=minimal disease activity. OMERACT=Outcome Measures for Rheumatology Clinical Trials. PsA=psoriatic arthritis.

1. Smolen JS, et al. Ann Rheum Dis. 2021;80(11):1419-1428. 2. Dures E, et al. Patient. 2017;10(4):455-462. 3. Richette P, et al. Rheumatol Ther. 2022;9(3):823-838. 4. Ogdie A, et al. Arthritis Care Res (Hoboken). 2020;72 (Suppl 10):82-109. 5. Karmacharya P, et al. Best Pract Res Clin Rheumatol. 2021;35(2):101692. 6. Ogdie A, et al. J Rheumatol. 2021;48(5):698-706. 7. Tillett W, et al. J Rheumatol Suppl. 2020;96:11-18. 8. Coates LC, et al. BMC Rheumatol. 2018;2:24. 9. Smolen JS, et al. Ann Rheum Dis. 2018;77(1):3-17. 10. Coates LC, et al. Ann Rheum Dis. 2010;69(1):48-53. 11. Coates LC, et al. Nat Rev Rheumatol. 2022;18(8):465-479. 12. Orbai AM, et al. Ann Rheum Dis. 2017;76(4):673-680.

Measuring PsA Disease Activity

Composite disease-outcome measures

Composite measures allow for the estimation of overall disease activity and disease burden across several disease domains and often include factors important to both clinicians and patients1,2:

  • Domain severity (arthritis, enthesitis, dactylitis, axial disease, and psoriasis)
  • Patient assessments of pain and fatigue
  • Physical functioning assessments
  • Health-related quality of life scores

Many different composite outcome measures are available, and their use in clinical practice often depends on clinician and patient preference, time available, and ease of use.3

Routine use of DAPSA and the MDA index is recommended by GRAPPA and OMERACT, and PsAID-12 (a patient-reported measure) is commonly used in clinical practice to understand the impact of PsA from the patient perspective.2,4,*

The ACR response criteria is also a domain-specific measure for joint count; however, it is primarily used in clinical trials and is not considered feasible for use in clinical practice.5,6

Composite Disease-Outcome Measures

Disease Activity Index for Psoriatic Arthritis (DAPSA)

DAPSA is a GRAPPA and OMERACT guideline-recommended, validated composite measure consisting of five items: SJC66, TJC68, PtGA VAS, patient pain VAS, and CRP.4-6,†

Considerations

Calculator

 Quick and easy to administer and calculate during the clinic visit3

Measure

 Can measure both current disease activity and treatment response3

Bones

 Useful to assess polyarticular peripheral arthritis3

Minimal Disease Activity Index (MDA)

The MDA index is a GRAPPA and OMERACT guideline-recommended, validated composite measure consisting of seven items: SJC66, TJC68, PtGA VAS, patient pain VAS, enthesitis, function (HAQ), and skin (PASI or BSA).4,7,8

Considerations

Ipad

Simple and easy to administer; paper or electronic applications available3,4

Virus

MDA (and VLDA) criteria are useful measures of good disease control; they are binary and not a continuous measure of disease activity3

Check

Valid in polyarticular and oligoarticular disease3

Psoriatic Arthritis Impact of Disease (PsAID-12)

PsAID-12 is a composite measure used to specifically assess the impact of PsA from the patient’s perspective.9 It includes 12 physical and psychological domains: pain, fatigue, skin, work and/or leisure activities, function, discomfort, sleep, coping, anxiety, embarrassment, social life, and depression, all assessed by patients on an NRS.9

Considerations

Scale

The 12-item scale was developed for clinical practice; it is a quick, self-administered questionnaire in print or in electronic format available from EULAR3 

Handshake

Correlates well with 
MDA/VLDA4,9,10

American College of Rheumatology (ACR) Criteria

The ACR criteria is a binary outcome measuring 20%, 50%, or 70% reduction in tender and swollen joint counts plus three of the following2,11:

  • Physician global
  • Patient global
  • Patient pain
  • Function
  • CRP/ESR

Considerations2,11

Bones

May not perform well in patients with lower joint counts

Stethoscope

May not be feasible for use in clinical practice

*Examples of commonly used disease measures and not an exhaustive list of all available measures. †If CRP is not included, it is called the clinical or cDAPSA (four items).3


BSA=body surface area. CRP=C-reactive protein. ESR=erythrocyte sedimentation rate. EULAR=European Alliance of Associations for Rheumatology. GRAPPA=Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. HAQ=Health Assessment Questionnaire. MDA=minimal disease activity. NRS=numerical rating scale. OMERACT=Outcome Measures for Rheumatology Clinical Trials. PASI=Psoriasis Area Severity Index. PsA=psoriatic arthritis. PtGA=patient global assessment. SJC=swollen joint count. TJC=tender joint count. VAS=visual analog scale. VLDA=very low disease activity.

1. Tillett W, et al. J Rheumatol Suppl. 2020;96:11-18. 2. Tucker LJ, et al. Rheumatol Ther. 2019;6(1):23-32. 3. Ogdie A, et al. Arthritis Care Res (Hoboken). 2020;72 (Suppl 10):82-109. 4. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355. 5. Schoels MM, et al. Ann Rheum Dis. 2016;75(5):811-818. 6. Smolen JS, et al. Ann Rheum Dis. 2018;77(1):3-17. 7. Gossec L, et al. J Rheumatol. 2018;45(1):6-13. 8. Wervers K, et al. Arthritis Care Res (Hoboken). 2018;70(12):1764-1770. 9. Gossec L, et al. Ann Rheum Dis. 2014;73(6):1012-1019. 10. Di Carlo M, et al. J Rheumatol. 2017;44(3):279-285. 11. McGagh D, Coates LC. Rheumatology (Oxford). 2020;59(Suppl 1):i29-i36.

Measuring PsA Disease Activity

Individual domain-specific disease outcome measures

Use of individual domain-specific measures allows for accurate assessment of disease activity in each domain.1

  • These measures may be useful to supplement composite measures, as a composite measure may “dilute” the impact seen in individual domains1
  • They can provide an assessment of often overlooked symptoms, such as fatigue, that can have an important impact on a patient’s life2

Many domain-specific measures have been developed, and their use in clinical practice depends on several factors, such as individual patient needs, time available, and ease of use.3

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For example, there are specific measures available for nail psoriasis (NAPSI), dactylitis (LDI), enthesitis (LEI and the SPARCC index), and psoriasis (PASI).4,*

Domain-Specific Disease Outcome Measures

Nail Psoriasis Severity Index (NAPSI)

NAPSI is a tool used to assess severity of nail psoriasis on the nail bed and nail matrix.4 Evaluations include: onycholysis; splinter hemorrhages; hyperkeratosis; oil-drop dyschromia (for nail bed); and pitting, leukonychia, crumbling, and red spots in the lunula (for nail matrix).4

Considerations

Wrench

A numeric, reproducible, objective tool4

Icon finger

A shorter, modified version (mNAPSI) is available4,5

Magnify

Evidence of nail psoriasis can be a surrogate marker for DIP arthritis6

Leeds Dactylitis Index (LDI)

LDI measures the severity of dactylitis by assessing the circumference of swollen digits at the base of the finger and tenderness of affected fingers (and toes).4

Consideration

Clock

Total administration takes less than 10 minutes, with no patient discomfort4

Leeds Enthesitis Index (LEI)

LEI measures the presence or absence of tenderness in six entheseal sites, developed specifically for use in PsA.4

Considerations

Clock

Takes ~30 seconds to complete, with minimal burden to the patient4

Calendar

Routine assessments of entheses with LEI can define enthesitis, a key indicator of disease activity in patients with PsA7

Spondyloarthritis Research
Consortium of Canada (SPARCC)

SPARCC measures the presence or absence of tenderness in 16 entheseal sites.4

Considerations

Clock

Takes ~2–5 minutes to complete, with minimal burden to the patient4 

Spine

Routine assessments of entheses with SPARCC can define enthesitis, a key indicator of disease activity in patients with PsA7

Psoriasis Area and Severity Index (PASI)

PASI assesses psoriasis lesion burden based on BSA involvement and degree of severity of erythema, induration, and desquamation for four body areas (head, upper and lower extremities, and trunk).4

Considerations

Person

Not typically used in patients with <3% BSA lesional involvement4 

Stethoscope

Can be performed by trained rheumatologists4 

Book

An extensively studied and validated measure of psoriasis severity3,4

*Examples of commonly used disease measures and not an exhaustive list of all available measures.
BSA=body surface area. DIP=distal interphalangeal. mNAPSI=modified Nail Psoriasis Severity Index. PsA=psoriatic arthritis.

1. Tillett W, et al. J Rheumatol Suppl. 2020;96:11-18. 2. Tillett W, et al. J Rheumatol. 2017;44(10):1445-1452. 3. Ogdie A, et al. Arthritis Care Res (Hoboken). 2020;72 (Suppl 10):82-109. 4. Mease PJ. Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S64-S85. 5. Cassell SE, et al. J Rheumatol. 2007;34(1):123-129. 6. Lai TL, et al. Clin Rheumatol. 2016;35(8):2031-2037. 7. Kristensen S, et al. Muscles Ligaments Tendons J. 2016;6(2):241-247.