Evidence that systemic therapies for psoriasis may reduce psoriatic arthritis occurrence

Abstract

ObjectiveContemporary biologic therapies for psoriasis are independently licensed for psoriatic arthritis (PsA). Since skin disease generally predates PsA and PsA has a subclinical phase, we investigated the pattern of PsA evolution in psoriasis treated with biologic agents compared to other medications including oral therapy, topical agents or no treatments. Methods A retrospective chart review was performed in psoriasis patients with musculoskeletal symptoms referred for rheumatological assessment. Patients who had a final diagnosis of PsA were identified. The frequency and clinicalfeatures of PsA were compared for biologics versus the other strategies. ResultsBetween 2015 and 2018, 203 psoriasis patients were referred for musculoskeletal symptoms with 25 on biologics, 31 on non-biologic systemic therapies and 147 on topical/no therapies. A final diagnosis of PsA was similar in all groups (biologics: 36%; non-biologic systemic treatments: 35.4%; none/local treatments: 37.4%). Most patients had musculoskeletal symptoms before systemic therapy initiation but new onset PsA was evident in 12% (3/25) biologics treated patients, 9.6% (3/31) in non-biologic systemic therapy patients and was significantly higher in patients on topical/no therapy (55/147; 37.4%, p<0.001). Among patients with PsA, none of the patients on biologics exhibited dactylitis compared to 28.6% of other systemic treatments and 48.6% of none/local treatments (p=0.046). Conclusion New symptoms and signs leading to PsA diagnosis appear to decrease with systemic treatments.The characteristic PsA dactylitis lesion was not evident in the biologic therapy group.

Reducing the Risk of Developing Psoriatic Arthritis in Patients with Psoriasis

“…The control group had a significantly higher risk for PsA compared to the biologic treatment group within 10 years of follow-up, aHR 1.39 (95% CI 1.03-1.87). 57 Conversely, Meer et al in a retrospective cohort study of 193,709 patients with psoriasis without PsA found that, contrary to the study hypothesis, biologic use was associated with the development of PsA among patients with psoriasis. 58 This may be related to confounding by indication and protopathic bias, ie, when a pharmaceutical agent is inadvertently prescribed for an early manifestation of a disease that has not yet been diagnostically detected.…”

“…The control group had a significantly higher risk for PsA compared to the biologic treatment group within 10 years of follow-up, aHR 1.39 (95% CI 1.03–1.87). 57 …”

“…53 Furthermore, four recent studies found a decreased incidence of PsA in cohorts of patients receiving systemic therapy compared with skin directed therapies (ie, phototherapy and topical therapy). [54][55][56][57] We found an annual incidence rate of PsA of 1.20 cases (95% CI 0.77 to 1.89) versus 2.17 (95% CI 1.53 to 3.06) per 100 patients/year in patients with psoriasis receiving biologics versus those treated with phototherapy. 52 Notably, treatment with biologics was associated with a lower risk of incident PsA (adjusted HR 0.27, 0.11-0.66).…”

Unravelling the complexity of psoriatic arthritis on a journey towards precision medicine

“…(7,89) In patients with SSc (26%), pSS (14%) and extra-articular RA (> 30%), circulating C1q antibodies are also detected. (89,90) Complement deficiency can reduce B cell tolerance as follows (88,91): first, C1q deficiency specifically intervenes with effective negative selection of autoreactive B cells in bone marrow (89); and secondly, via insufficient elimination of immune complexes, apoptotic and necrotic cell material. (92) Under healthy conditions debris is opsonized by immunoglobulins and complement factors, and then rapidly cleared from the circulation via binding to CR1 on erythrocytes and through engulfment by phagocytes.…”

“…This time window offers the opportunity to study the critical factors that drive musculoskeletal disease, to facilitate early diagnosis and to investigate prevention of PsA (88,89). PsA prevention has gained interest over recent years, since multiple studies found evidence that DMARD initiation in psoriasis patients reduces the risk of transition to PsA (90)(91)(92)(93)(94). Although large prospective studies are necessary to confirm the results, these data suggest that it is possible to delay, attenuate or even prevent PsA by initiating biologic treatment.…”