Comprehensive Treatment of Dactylitis in Psoriatic Arthritis

Dactylitis, a hallmark clinical feature of psoriatic arthritis (PsA) and other spondyloarthropathies, may also be a severity marker for PsA and psoriasis. Traditionally, clinicians have used nonsteroidal antiinflammatory drugs and local corticosteroid injections to treat dactylitis, although conventional disease-modifying antirheumatic drugs are also used. We performed a systematic literature review to determine the most efficacious current treatment options for dactylitis in PsA. Effect sizes were greatest for the biologic agents ustekinumab, certolizumab, and infliximab, suggesting that therapy with one of these agents should be initiated in patients with dactylitis. However, the limited data highlight the need for randomized, placebo-controlled trials, with dactylitis as a primary outcome, to determine a valid, reliable, and responsive clinical outcome measure for PsA patients with dactylitis.

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Updated Guidelines for the Management of Axial Disease in Psoriatic Arthritis

The Journal of Rheumatology ◽

10.3899/jrheum.140877 ◽

2014 ◽

Vol 41 (11) ◽

pp. 2286-2289 ◽

Cited By ~ 20

Author(s):

Peter Nash ◽

Ennio Lubrano ◽

Alberto Cauli ◽

William J. Taylor ◽

Ignazio Olivieri ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Axial Spondyloarthritis ◽

Nonsteroidal Antiinflammatory Drugs ◽

Therapeutic Interventions ◽

Limited Data ◽

Spinal Disease ◽

Antiinflammatory Drugs ◽

Axial Disease ◽

Traditional Therapies ◽

Axial Involvement

Axial involvement in patients with psoriatic arthritis (PsA) remains common and can be defined in terms of spinal disease alone or in combination with peripheral manifestations. Diagnosis is based upon inflammatory spinal symptoms or the presence of radiological sacroiliitis and other radiographic signs of spondylitis, or by criteria for axial spondyloarthritis (SpA) defined by ASAS (Assessment of SpondyloArthritis International Society). Although recent data are scarce for efficacy of traditional therapies for axial disease (e.g., nonsteroidal antiinflammatory drugs, methotrexate, etc.), limited data are available for targeted biologics and novel agents. We identify and evaluate the efficacy of therapeutic interventions for treatment of axial disease in PsA. This review is an update of the axial PsA section of the treatment recommendations project by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

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Treatment Options for Rheumatoid Arthritis: Celecoxib, Leflunomide, Etanercept, and Infliximab

Annals of Pharmacotherapy ◽

10.1345/aph.19344 ◽

2000 ◽

Vol 34 (6) ◽

pp. 743-760 ◽

Cited By ~ 19

Author(s):

Brigitte T Luong ◽

Barbara S Chong ◽

Dionne M Lowder

Keyword(s):

Rheumatoid Arthritis ◽

English Language ◽

Data Extraction ◽

Treatment Options ◽

Nonsteroidal Antiinflammatory Drugs ◽

Antiinflammatory Drugs ◽

Safety And Efficacy ◽

Medline Search ◽

Pertinent Data

OBJECTIVE: To review new pharmacologic agents approved for use in the management of rheumatoid arthritis (RA). DATA SOURCES: A MEDLINE search (1966–January 2000) was conducted to identify English-language literature available on the pharmacotherapy of RA, focusing on celecoxib, leflunomide, etanercept, and infliximab. These articles, relevant abstracts, and data provided by the manufacturers were used to collect pertinent data. STUDY SELECTION: All controlled and uncontrolled trials were reviewed. DATA EXTRACTION: Agents were reviewed with regard to mechanism of action, efficacy, drug interactions, pharmacokinetics, dosing, precautions/contraindications, adverse effects, and cost. DATA SYNTHESIS: Traditional pharmacologic treatments for RA have been limited by toxicity, loss of efficacy, or both. Increasing discoveries into the mechanisms of inflammation in RA have led to the development of new agents in hopes of addressing these limitations. With the development of celecoxib, a selective cyclooxygenase-2 inhibitor, the potential exists to minimize the gastrotoxicity associated with nonsteroidal antiinflammatory drugs. Leflunomide has been shown to be equal to or less efficacious than methotrexate, and may be beneficial as a second-line disease-modifying antirheumatic drug (DMARD). The biologic response modifiers, etanercept and infliximab, are alternatives that have shown benefit alone or in combination with methotrexate. However, they should be reserved for patients who fail to respond to DMARD therapy. Further studies should be conducted to evaluate the long-term safety and efficacy of these agents as well as their role in combination therapy. CONCLUSIONS: Celecoxib, leflunomide, etanercept, and infliximab are the newest agents approved for RA. Clinical trials have shown that these agents are beneficial in the treatment of RA; however, long-term safety and efficacy data are lacking.

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Opioid-Sparing Analgesics in Chronic Pain Management

10.2310/anes.15086 ◽

2017 ◽

Author(s):

Maricela Schnur ◽

Michael Fitzsimons ◽

Fangfang Xing

Keyword(s):

Chronic Pain ◽

Treatment Options ◽

Primary Treatment ◽

Opioid Therapy ◽

Nonsteroidal Antiinflammatory Drugs ◽

Prescription Opioid ◽

Antiinflammatory Drugs ◽

Opioid Sparing ◽

Pharmacologic Treatments ◽

Chronic Pain Therapy

Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit. Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.

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Burden and Disease Characteristics of Patients with Psoriatic Arthritis: A Population-based Cross-sectional Study

The Journal of Rheumatology ◽

10.3899/jrheum.180670 ◽

2019 ◽

Vol 46 (7) ◽

pp. 716-720 ◽

Cited By ~ 2

Author(s):

Hasan G. Tekin ◽

Jashin J. Wu ◽

Russel Burge ◽

Julie Birt ◽

Alexander Egeberg

Keyword(s):

Psoriatic Arthritis ◽

Population Based ◽

Cross Sectional Study ◽

Nonsteroidal Antiinflammatory Drugs ◽

Considerable Proportion ◽

Antiinflammatory Drugs ◽

Cross Sectional ◽

Disease Characteristics ◽

Systemic Corticosteroids ◽

Comorbid Diseases

Objective.To describe the prevalence and treatment regimes, disease characteristics, and comorbid diseases among patients with psoriatic arthritis (PsA) in Denmark.Methods.All Danish individuals aged ≥ 18 years with rheumatologist-diagnosed PsA were linked in nationwide administrative registers.Results.Among 4.7 million individuals in Denmark, 10,577 patients with PsA had been diagnosed by a rheumatologist. A female predominance (54.5–59.8%) was seen among patients with PsA, and about half of the patients (53.0%) had received no treatment or treatment only with nonsteroidal antiinflammatory drugs/systemic corticosteroids, while 32.9% had received nonbiological disease-modifying antirheumatic drugs (DMARD) and 14.1% had been treated with biologicals. Cutaneous psoriasis was recorded in 66.2–72.3% of patients with PsA, and patients with severe PsA had the highest prevalences of distal interphalangeal arthropathy, spondylitis, and arthritis mutilans. Smoking and comorbid diseases such as hypertension, diabetes, depression, and anxiety were seen frequently in patients with PsA, but did not significantly differ across severities of PsA.Conclusion.Disease burden appeared to be significant in patients with PsA across all severities. A considerable proportion of patients with PsA did not receive active antipsoriatic treatment, and about 1 out of 3 patients was not diagnosed with psoriasis. Cutaneous symptoms of psoriasis in patients with PsA might be either underreported or undertreated.

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2. Pregnancy and myositis

Rheumatology Advances in Practice ◽

10.1093/rap/rkz030.001 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

Author(s):

Nibha Jain ◽

Shilpa Jagadeesh ◽

Arumugam Moorthy

Keyword(s):

Psoriatic Arthritis ◽

Pulmonary Function ◽

Conflicts Of Interest ◽

Treatment Options ◽

Autoimmune Disorders ◽

Hip Pain ◽

Limited Data ◽

Skin Tightening ◽

Scalp Psoriasis ◽

Activity Measurements

Abstract Introduction Inflammatory disorders can appear as a spectrum and pose diagnostic challenges. Inflammatory myositis affects women of childbearing age. This situation presents challenges in management of disease during pregnancy. Myositis specific antibodies are expected to lead to certain clinical presentation but cases outside known information always occur as we learn from this case report. Case description A 26-year-old Asian lady was referred to rheumatology for inflammatory arthritis and Raynaud’s on a background of scalp psoriasis and family history of psoriatic arthritis. She had hip pain with no spinal inflammation and was commenced on low dose methotrexate. ANA 1:6400 but autoimmune screen negative. She was intolerant to higher doses of methotrexate. She developed severe hip pain which was not septic and eventually developed reduced hip movements and forward flexion of spine. X-ray showed soft tissue calcification around hip methotrexate was stopped due to respiratory symptoms but HRCT and pulmonary function were normal. Unfortunately, she was lost to follow-up. She was then referred after a year with skin tightening (indurated plaque) over loin and chest. CK was elevated without clinical evidence of muscle weakness and ANA 1:1600 positive with negative ENA and normal DsDNA/Compliments. Dermatologists felt that indurated plaque was morphea as the histology was inconclusive. She developed pelvic girdle weakness along with left hip calcification and progression of skin tightening of fingers and forearm. Although biopsy and MRI thigh were negative for myositis, nerve conduction studies showed severe active polymyositis. Her extended myositis panel now showed Mi-2 antibody. As she was intolerant to azathioprine with a progressive illness and was keen to have children soon, she was started on IvIG. Despite being on IvIg she developed refractory calcium discharging sinus over her hip. Rituximab was not licensed for myositis then and she was not keen to start on any other medications recommended by the myositis specialist centre. She had a successful pregnancy after 6 months of disease control under joint care of maternal foetal medicine and rheumatology. On repeat autoimmune testing prior to pregnancy, anti-Ro was equivocal (previously negative) hence antepartum surveillance was carried out.The baby had no evidence of congenital heart block. She has progressive extrarticular calcification with otherwise well controlled disease and prefers to remain on IvIg. Discussion We present the first case of psoriasis with Raynaud’s developing progressive skin and soft calcification resulting in discharging sinuses. She developed myositis scleroderma overlap with suspected cardiac involvement posing challenge due to intended pregnancy. There was limited data to go by on outcomes of pregnancy in dermatomyositis and no there are similar cases in literature. In retrospect, her joint symptoms could have stemmed from extra-articular calcification around hip but does not explain skin tightening around fingers. It makes one wonder if resistant scalp psoriasis initially could be related to dermatomyositis and not true psoriasis. She was managed with regular advice from the myositis specialist unit and declined to go on any drugs which could have an impact on fertility or pregnancy. Hence options for treatment were limited and complicated by intolerance to conventional DMARDS. IvIG was selected based on those preferences due to progressive myositis but there were initial reactions to IvIG infusions at which point use of rituximab was considered. The NICE rituximab in myositis guidelines were not present at that time and the individual funding request was declined. Myositis is an idiopathic inflammatory immune mediated disorder that may be existent in an isolated form or in combination with other autoimmune or connective tissue disorders. It is a T-cell mediated cytotoxic process directed toward unknown muscle antigens. Psoriasis on the other hand is a relapsing skin disease; the diagnosis is of which is made on clinical grounds and can be associated with SpA. In a retrospective review of psoriasis patients seen at the Mayo Clinic the frequency of pathologically confirmed myopathies or inflammation in muscle in patients with psoriasis was estimated to be 0.13%. However, this could be an overestimate, given potential referral bias. Concomitant autoimmune disorders, psoriatic arthritis, and exposure to anti-TNF-α therapy were the proposed associations with increased risk of developing myopathy in psoriasis patients. Most had inclusion of body myositis. Key learning points Evidence suggests that the appropriate treatment with immunosuppressants allows a normal pregnancy without major problems and with no further risk for post-partum relapse. This is presuming the disease is well-controlled for 6 months prior to conception. There is no definite impact of pregnancy on a well-controlled myositis, although case reports have variable outcomes. Pregnancy outcomes are better if the disease is fully controlled preconception and there is no cardiac or respiratory involvement. Hence, preconception work up is done in liaison with maternal foetal medicine and includes disease activity measurements, repeat investigations for systemic involvement (commonly ECHO and pulmonary function test), repeat autoimmune screen and individualised preconception counselling. Poorly controlled disease can increase risk of intrauterine growth retardation, stillbirth or preterm birth. Uncontrolled inflammation is thought to result in poor placental circulation due to inflammatory fibrillin deposition. Autoimmune disorders are conventionally known to flare postpartum but experiences are variable. We observed a slight CK rise postpartum which settled without needing further treatment. Treatment options available for women considering pregnancy include glucocorticoids and intravenous immunoglobulin for induction of remission and remission with azathioprine, cyclosporin or tacrolimus. Data available is from case series and experiences of specialist centres only, hence there is scope for further research. Owing to limited data on the long-term use of intravenous immunoglobulins in myositis, absence of evidence-based treatment options for calcification in myositis and push for switch to rituximab due to cost implications, further management of patients in similar situations will be challenging. Conflicts of interest The authors have declared no conflicts of interest.

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Pharmacy Review: Osteoarthritis: The Pharmacist's Perspective

American Journal of Lifestyle Medicine ◽

10.1177/1559827607302333. ◽

2007 ◽

Vol 1 (4) ◽

pp. 271-273

Author(s):

Rebecca Prevost

Keyword(s):

Pain Relief ◽

Treatment Options ◽

Nonsteroidal Antiinflammatory Drugs ◽

Antiinflammatory Drugs ◽

Osteoarthritis Pain ◽

Pain Scales ◽

Source Of Information

A wide variety of treatment options are available for osteoarthritis pain relief. The pharmacist can serve as a source of information within his or her area of expertise, addressing controversies such as nonsteroidal antiinflammatory drugs versus acetaminophen, glucosamine-chondroitin, topical therapies, and herbals. Patients should be encouraged to use pain scales and diaries as they try different therapies.

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Opioid-Sparing Analgesics in Chronic Pain Management

10.2310/pm.15086 ◽

2017 ◽

Author(s):

Maricela Schnur ◽

Michael Fitzsimons ◽

Fangfang Xing

Keyword(s):

Chronic Pain ◽

Treatment Options ◽

Primary Treatment ◽

Opioid Therapy ◽

Nonsteroidal Antiinflammatory Drugs ◽

Prescription Opioid ◽

Antiinflammatory Drugs ◽

Opioid Sparing ◽

Pharmacologic Treatments ◽

Chronic Pain Therapy

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Psoriatic Arthritis: Current Treatment Options

Psoriasis Forum ◽

10.1177/247553030309a00302 ◽

2003 ◽

Vol 9a (3) ◽

pp. 4-6

Author(s):

Ilana R. Sapadin ◽

Sumedha Lamba ◽

Philip Mease

Keyword(s):

Psoriatic Arthritis ◽

Treatment Options ◽

Current Treatment

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Outcomes of Children Treated for Lyme Arthritis: Results of a Large Pediatric Cohort

The Journal of Rheumatology ◽

10.3899/jrheum.090711 ◽

2010 ◽

Vol 37 (5) ◽

pp. 1049-1055 ◽

Cited By ~ 43

Author(s):

HEATHER O. TORY ◽

DAVID ZURAKOWSKI ◽

ROBERT P. SUNDEL

Keyword(s):

Antibiotic Therapy ◽

Treatment Guidelines ◽

Tertiary Care ◽

Laboratory Data ◽

Current Treatment ◽

Nonsteroidal Antiinflammatory Drugs ◽

Chronic Arthritis ◽

Lyme Arthritis ◽

Joint Involvement ◽

Antiinflammatory Drugs

Objective.Children often develop arthritis secondary to Lyme disease; however, optimal treatment of Lyme arthritis in pediatric patients remains ill-defined. We sought to characterize the outcomes of a large cohort of children with Lyme arthritis treated using the approach recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America.Methods.Medical records of patients with Lyme arthritis seen by rheumatologists at a tertiary care children’s hospital from 1997 to 2007 were reviewed. Patients were classified with antibiotic responsive or refractory arthritis based on absence or presence of persisting joint involvement 3 months after antibiotic initiation. Treatment regimens and outcomes in patients with refractory arthritis were analyzed.Results.Of 99 children with Lyme arthritis, 76 had arthritis that responded fully to antibiotics, while 23 developed refractory arthritis. Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2). Five were lost to followup. Six patients with refractory arthritis were initially treated elsewhere and received additional antibiotic therapy, with no apparent benefit. Three subsequently required DMARD, while 3 had gradual resolution of arthritis without further therapy. Antibiotic responsiveness could not be predicted from our clinical or laboratory data.Conclusion.Lyme arthritis in children has an excellent prognosis. More than 75% of referred cases resolved with antibiotic therapy. Of patients with antibiotic refractory arthritis, none in whom followup data were available developed chronic arthritis, joint deformities, or recurrence of infection, supporting current treatment guidelines.

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Medical management of ankylosing spondylitis

Neurosurgical FOCUS ◽

10.3171/foc/2008/24/1/e4 ◽

2008 ◽

Vol 24 (1) ◽

pp. E4 ◽

Cited By ~ 7

Author(s):

Alexander A. Khalessi ◽

Bryan C. Oh ◽

Michael Y. Wang

Keyword(s):

Ankylosing Spondylitis ◽

Medical Management ◽

Treatment Guidelines ◽

Therapy Response ◽

Current Treatment ◽

Nonsteroidal Antiinflammatory Drugs ◽

Antiinflammatory Drugs ◽

Tuberculosis Screening ◽

Axial Disease ◽

Factor Α

✓ In the following literature review the authors consider the available evidence for the medical management of patients with ankylosing spondylitis (AS), and they critically assess current treatment guidelines. Medical therapy for axial disease in AS emphasizes improvement in patients' pain and overall function. First-line treatments include individualized physical therapy and nonsteroidal antiinflammatory drugs (NSAIDs) in conjunction with gastroprotective therapy. After an adequate trial of therapy with two NSAIDs exceeding 3 months or limited by medication toxicity, the patient may undergo tumor necrosis factor–α blockade therapy. Response should occur within 6–12 weeks, and patients must undergo tuberculosis screening. Evidence does not currently support the use of disease modifying antirheumatic drugs, corticosteroids, or radiotherapy in AS.

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