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Psoriatic arthritis

Prevalence of PsA in the clinic

PsA=psoriatic arthritis; THIN=The Health Improvement Network; UK=United Kingdom.
1. Savage L, et al. J Clin Med. 2020;9(10):3262.
2. Krakowski P et al. Arch Med Sci. 2019;15(3):580–589.
3. Perez-Chada LM, et al. Nat Rev Rheumatol. 2021;17(4):238–243.
4. Ogdie A, et al. Rheumatology (Oxford). 2013;52(3):568−575.

PsA differs from other arthritic diseases¹

PsA vs RA
•The peripheral polyarticular pattern of PsA may share several features with RA.
•Clinical features are important to differentiate seronegative (rheumatoid factor negative) RA with coincidental psoriasis from patients with peripheral PsA.
•The presence of psoriatic plaques or nail psoriasis helps to establish a diagnosis of PsA.
•Patients who display other characteristic signs of RA (i.e. rheumatoid nodules, extra-articular involvement, and high titers of rheumatoid factor) should not begiven the diagnosis of PsA.
•Involved joints in PsA are usually less tender and swollen and less symmetric in distribution than in RA.
•Dactylitis, enthesitis, and DIP joint involvement common in PsA are uncommon in RA.

PsA vs OA
•In the hands, there may be distal interphalangeal (DIP) involvement in both PsA and osteoarthritis but the classic DIP-related Heberden’s nodes in osteoarthritis are bone spurs whereas in PsA the DIP involvement is joint inflammation.
•Enthesitis, dactylitis, and sacroiliitis are generally not present in patients with osteoarthritis.

PsA vs AS
•Axial disease in PsA may present as clinically similar to AS. However, patients with PsA are often less symptomatic, have asymmetric disease, and tend to have less severe disease.
•In addition, the psoriatic plaques or nail changes present in patients with psoriatic spondylitis are absent in patients with AS.
•Axial involvement is often secondary in PsA, however PsA may present either as sacroiliitis, often asymmetric and asymptomatic, or spondylitis affecting any level of the spine in a ‘‘skip’’ fashion.
•When compared with patients with AS, patients with PsA seldom have impaired mobility or progress to ankylosis (total loss of joint space).

It is important for dermatologists to draw on both history and physical findings in making a diagnosis of an inflammatory arthritis like PsA.

1. Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851–864.
2. Myasoedova E, et al. Ann Rheum Dis. 2020;79(4):440–444.
3. Xia B, et al. Calcif Tissue Int. 2014;95(6):495–505.
4. Exarchou S, et al. Arthritis Res Ther. 2015;17(1):118.

Differentiation amongst arthritis types

N/A=not assessed.

Ritchlin CT, et al. N Engl J Med. 2017;376(10):957–970.

PsA and RA differ clinically¹

DIPJ=distal interphalangeal joint; RA=rheumatoid arthritis; PsA=psoriatic arthritis.

1. Merola JF, et al. RMD Open. 2018;4(2):e000656.
2. Tan EST, et al. Am J Clin Dermatol. 2012;13(6):375−388.
3. Sudoł-Szopińska I, et al. J Ultrason. 2016;16(64):65–77.
4. Kivelevitch D, et al. Biologics. 2014;8:169−182.
5. Brockbank JE, et al. Ann Rheum Dis. 2005;64(2):188−190.
6. Lories RJU, et al. Ann Rheum Dis. 2004;63(5):595−598.
7. Mańczak M, Gasik R. Reumatologia. 2017;55(4):201–207.
8. Radiopaedia. Rheumatoid arthritis (musculoskeletal manifestations). https://radiopaedia.org/articles/rheumatoid-arthritis-musculoskeletal-manifestations-2. Accessed 18 October 2021.
9. RheumatoidArthritis. Rheumatoid Nodules: Are Rheumatoid Nodules Dangerous? https://www.rheumatoidarthritis.org/ra/symptoms/rheumatoid-nodules/. Accessed 18 October 2021.

PsA is a multi-system disease

•PsA causes swelling, pain and stiffness in joints, and in areas where tendons and ligaments connect to bone¹
•Mild PsA is sometimes referred to as oligoarticular, meaning it affects ≤4 joints in the body, whereas more severe PsA is often called polyarticular, meaning it affects ≥5 joints¹
•PsA can involve the peripheral joints or, less commonly, the axial skeleton (spine, hips and shoulders)¹
•The clinical domains of PsA include peripheral arthritis, axial disease, enthesitis, dactylitis, skin disease and nail disease²

PsA=psoriatic arthritis; PsO=psoriasis.

1. National Psoriasis Foundation. Locations and Types: https://www.psoriasis.org/locations-and-types/. Accessed 18 October, 2021.

2. Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060−1071.

Multiple disease domain involvement in patients with PsA in real-world clinical practice (CorEvitas registry) (1)¹

•A total of 2617 patients with PsA were enrolled in the Corrona PsA/SpA Registry at the time of this analysis, of whom 354 (13.5%) initiated a biologic at registry enrolment

•Of the 2617 patients in the overall population, 2315 (88.5%) had ≥ 1 active domain presentation at enrolment; 1814 (69.3%) presented with skin disease, 1523 (58.2%) with PA, 1042 (39.8%) with nail psoriasis, 539 (20.6%) with enthesitis, 319 (12.2%) with axial disease, and 235 (9.0%) with dactylitis.

•Regarding the frequency of active PsA domain presentations by number of domains affected among all patients with PsA, 1698 patients (64.9%) had ≥2 domain presentations, 617 (23.6%) had single-domain presentations and 302 (11.5%) had no active presentations. The most common disease presentations were skin disease only (12.7%), peripheral arthritis + skin disease (11.7%), and peripheral arthritis + nail psoriasis + skin disease (10.3%); overall, 6.8% of patients were reported to have peripheral arthritis only

•In real-world clinical practice, patients with PsA frequently presented with disease manifestations in multiple domains (most often skin, peripheral arthritis or nail), demonstrating that PsA is a heterogenous disease

The CORRONA registry was rebranded as the CorEvitas registry in March 2021.2

PsA=psoriatic arthritis.
1. Ogdie A, et al. J Rheumatol. 2021;48(5):698–706.
2. Rheumatoid arthritis registry. CorEvitas. https://www.corevitas.com/registry/rheumatoid-arthritis. Accessed 19 October 2021.

Comorbidities associated with PsA

•Patients with PsA exhibit high levels of systemic comorbidities, including cardiovascular disease, metabolic syndrome, osteoporosis and psychologic dysfunction; these associations may relate to the disease or its treatment

•A study by Khraishi M, et al. showed that the prevalence of hypercholesterolaemia, obesity, hypertension, diabetes mellitus, anxiety/depression and coronary heart disease was 61.6%, 59.7%, 32.7%, 13.8%, 13.8% and 8.7%, respectively, in patients with PsA^1. Increased frequency of smoking and alcohol consumption in patients with PsA does not seem to account for their increased risk of cardiovascular disease

•PsA is associated with gastrointestinal inflammatory diseases. In 1 study by Makredes M, et al., higher prevalence ratios were reported for CD (2.1 [95% CI: 1.3–3.3]), UC (2.0 [95% CI: 1.3–3.1]) and IBD (1.8 [95% CI 1.3-2.5]) in patients with PsA compared with patients with cutaneous psoriasis²
•Dreiher J, et al. showed an increased occurrence of COPD in patients with psoriasis (after controlling for confounders: OR: 1.27 [95% CI: 1.13–1.42])3

•Zeboulon N, et al. demonstrated a mean prevalence of uveitis (n=1341) of 25.1% among patients with PsA.4 Uveitis in patients with PsA is more likely insidious in onset, continuous, posterior, and active bilaterally compared with uveitis in patients with spondyloarthropathy^5. Patients with uveitis may experience a decrease in visual acuity. The prevalence of uveitis varies with disease duration. The HLA-B27+ haplotype is associated with an increased prevalence of uveitis, compared to HLA-B27- people

•Depression is 1.4- to 1.5-fold more likely in patients with psoriasis compared with the general population; other psychiatric diagnoses are also more common in patients with psoriasis^6. In addition, the rate of anxiety and depression is significantly higher in patients with PsA than in those with psoriasis without PsA (36.6% vs 24.4%, P=0.012 for anxiety; 22.2% vs 9.6%, P=0.002 for depression)⁷
•Dermatologists have an important role in screening their psoriasis patients for PsA and in assessing them for psychological and CV comorbidities.8 In most cases, however, patients should be referred for specialist management if other comorbidities are detected⁶

1.Khraishi M, et al. Clin Rheumatol. 2014;33(10):1495–1500.

2.Makredes M, et al. J Am Acad Dermatol. 2009;61:405–410.

3.Dreiher J, et al. Br J Dermatol. 2008;159:956–960.

4.Zeboulon N, et al. Ann Rheum Dis. 2008;67:955–959.

5.Paiva ES, et al. Ann Rheum Dis. 2000;59:67–70.

6.Strohal R, et al. J Eur Acad Dermatol Venereol. 2014;28(12):1661–1669.

7.McDonough E, et al. J Rheumatol. 2014;41:887-896.

8.National Institute for Health and Care Excellence (NICE). Psoriasis: assessment and management [CG153]. October 2012. https://www.nice.org.uk/guidance/cg153. Accessed 18 October 2021.

PsA comorbidities

Higher prevalence of Cardiovascular Risk Factors in PsA compared to RA or control patients (1/2)

PsA=psoriatic arthritis; RA=rheumatoid arthritis.

Jafri K, et al. Arthritis Care Res (Hoboken). 2017;69:51–57 (including supplementary appendix).

Find out more about Xeljanz as a treatment option for PsA

Xeljanz brand site

Diagnosis and scoring systems

PsA=psoriatic arthritis.

1. Mease P, et al. J Eur Acad Dermatol Venerol. 2019;33:886–892.
2. Rech J, et al. Rheumatol Adv Pract. 2020 Jul 10;4(2):rkaa033.
3. Gottlieb AB, Merola JF. J Dermatolog Treat. 2020;31(7):662–679.
4. Dures E, et al. Rheum Adv Prac. 2019;3(2):rkz022.
5. Giannelli A. Rheumatol Ther. 2019;6(1):5–21.

Early diagnsosis & diagnostic delay

PsA=psoriatic arthritis.

Gottlieb AB, Merola JF. J Dermatolog Treat. 2020;31(7):662–679.

DMARD=disease-modifying anti-rheumatic drug; NEIAA=National Early Inflammatory Arthritis Audit; PsA=psoriatic arthritis; RA=rheumatoid arthritis.

1. Dures E, et al. Rheum Adv Prac. 2019;3(2):rkz022.
2. Karmacharya P, et al. J Rheumatol. 2021;201199 [Epub ahead of print].
3. Holland R, et al. Ann Rheum Dis 2017;76:685.

Delayed diagnosis of PsA - poorer long term outcomes

Clinical features recorded as percentages, unless otherwise stated.

Clinical features in bold were also significantly increased (p≤0.05 level), compared to patients who did not experience diagnostic delay, in patients who experienced a 1- and 2- year delay in diagnosis
BMI=body mass index; CI=confidence interval; DMARD=disease-modifying antirheumatic drug; HAQ=health assessment questionnaire; PsA=psoriatic arthritis; TNF=tumour necrosis factor.

Haroon M, et al. Ann Rheum Dis. 2015;74:1045–1050.

Classification of PsA and the disease activity assessment

Caspar criteria for PsA

One benefit of these criteria is that they permit the diagnosis of PsA despite RF positivity or the absence of psoriasis, as long as other typical features of PsA are present.

CASPAR=Classification Criteria for Psoriatic Arthritis; PsA=psoriatic arthritis; RF=Rheumatoid Factor.

Taylor W, et al. Arthritis Rheum. 2006;54:2665–2673.

PASDAS scoring

PASDAS is scored from 0 to 10 and is composed of the following measures: patient global assessment of PsA VAS; physician’s global assessment of PsA VAS; tender and swollen joint counts; Leeds Enthesitis Index; tender dactylitis count; SF-36v2 physical component summary score; and C‑reactive protein measurement. Each component is weighted before contributing to the final score.

PASDAS=Psoriatic Arthritis Disease Activity Score; PsA=psoriatic arthritis; SF-36 PCS=Short Form-36 version 2 – Physical Component Summary; SJC=swollen joint count; TJC=tender joint count; VAS=visual analogue scale.
Coates LC, et al. Arthritis Res Ther. 2021;23(1):94.

Role of CRP in PsA

•CRP levels are often normal in patients with PsA (~40–50% show elevated ESR/CRP levels), making it less useful in the diagnosis of PsA, unlike in patients with RA where CRP levels are often elevated^1-3
•Also, most individuals with PsA are seronegative for RF and ACPA³
•In a recent study, CRP levels were low/normal in most domains, despite active disease and inflammation²
•This suggests that a subset of patients with PsA show elevated CRP (not those with skin or entheseal disease)

Images adapted from Sokolova MV, et al. 2020.

ACPA=anti-citrullinated antibodies; CRP=C-reactive protein; ESR=erythrocyte sedimentation rate; CRP=C-reactive protein; N/A=not applicable; PsA=psoriatic arthritis; RA=rheumatoid arthritis; RF=rheumatoid factor.

1. Juneblad K, et al. Int J Immunol Immunother. 2018,5:033.
2. Sokolova MV, et al. Arth Res Ther. 2020;22(1):26.
3. Ritchlin C. N Engl J Med. 2017;376(10):957–970.

Assessing the many manifestations of PsA

ACR20=≥20% improvement in American College of Rheumatology score; ASDAS=Ankylosing Spondylitis Disease Activity Score; BASDAI=Bath Ankylosing Spondylitis Disease Activity Index; CPDAI=Composite Psoriatic Disease Activity Index; DAPSA=Disease Activity Index for Psoriatic Arthritis; DAS28=Disease Activity Score in 28 joints; EQ-5D=EuroQOL five dimensions questionnaire; GRACE=GRAPPA Composite Exercise; GRAPPA=Group for Research and Assessment of Psoriasis and PsA; HAQ=Health Assessment Questionnaire; HRQoL=health-related quality of life; LDI=Leeds Dactylitis Index; LEI=Leeds Enthesitis Index; MASES=Maastricht Ankylosing Spondylitis Enthesitis Score; mNAPSI=modified Nail Psoriasis Severity Index; PASI=Psoriasis Area and Severity Index; PGA=physician global assessment; PsAQoL=psoriatic arthritis quality of life; PsA=psoriatic arthritis; SPARCC=Spondyloarthritis Research Consortium of Canada.

1. McGagh D, Coates LC. Rheumatology (Oxford). 2020;59:i29–i36.
2. Eder L, et al. Ann Rheum Dis. 2010;69(12):2160–2164.
3. Wong PC, et al. Int J Rheumatol. 2012;2012:839425.

Whats important to patients?

Which domains are important to patients?

Important domains were those patients scored as ≥8 on an 11-point numerical rating scale from 0 (‘not important at all’) to 10 (‘very important’).

PsA=psoriatic arthritis.

Orbai AM, et al. Ann Rheum Dis. 2017;76:673–680.

Discrepancies between patient-physician in PsA perception

•Patients whose satisfaction with their level of disease control was not aligned with that of their physicians report greater work impairment, greater impact of PsA on daily activities and higher disease burden compared with patients who are aligned with their physicians
(all P≤0.0001)¹
•The discrepancy between patients and physicians may be determined by factors such as pain and fatigue
•This can have a major impact on shared decision‑making

PD/ND refers to the percentage of discrepancy between patients and physicians reporting more severe/less severe disease activity.

DLQI=Dermatology Life Quality Index; HAQ-DI=health assessment questionnaire – disability index; ND=negative discrepancy; PASI=Psoriasis Area and Severity Index;
PD=positive discrepancy; PsA=psoriatic arthritis; SJC=swollen joint count; TJC=tender joint count.

1. Sacristán JA, et al. PLoS One. 2020;15(6):e0234705.
2. Eder L, et al. Arthritis Care Res (Hoboken). 2015;67(2):264–272.
3. Desthieux C, et al. Arthritis Care Res (Hoboken). 2017;69(10):1606–1611.
4. Furst DE, et al. Clin Rheumatol. 2017;36(9):2045–2054.

PsA impact on mental health

HRQoL=health-related quality of life; PsA=psoriatic arthritis.

1. Kamalaraj N, et al. Int J Rheum. 2019;22(6):967-73. 2. Ogdie A, et al. RMD Open. 2020;6(3):e001321.

Mental health comorbidities negatively impact remission rates in patients with PsA

All comparisons are between depressed/anxious and non-depressed/non-anxious patient groups.

*P≤0.05, **P≤0.01.

ACR=American College of Rheumatology; CDAI=RA/PsA: Clinical Disease Activity Index; CI=confidence interval; DAPSA=Disease Activity in Psoriatic Arthritis; DAS28(ESR)=Disease Activity Score in 28 joints, erythrocyte sedimentation rate; EQ-5D-3L=EuroQOL 5 dimensions questionnaire-three-level version; EULAR=European League against Rheumatism; MH=mental health; MCS=mental component summary; OR=odds ratio; PsA=psoriatic arthritis; SDAI=Simple Disease Activity Index;
SF-36=36-Item Short Form Health Survey.

Michelsen B, et al. Ann Rheum Dis. 2017;76:1906–1910.

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