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19th July 2023
A series of points to consider to help define the clinical and imaging features of people with psoriasis who transition to psoriatic arthritis (PsA) have been developed by the European Alliance of Associations for Rheumatology (EULAR) in order to identify those who might benefit from a therapeutic intervention.
The fact that psoriasis typically develops some 10 years before PsA, provides an opportunity for clinicians to investigate risk factors and predictors for PsA in those with the skin disease. Now, with the help of both dermatologists and rheumatologists, a EULAR multidisciplinary taskforce of 30 members and from 13 European countries has produced five overarching principles and a total of 10 points to consider.
Published in the Annals of the Rheumatic Diseases, these principles acknowledge that not everyone with psoriasis will go on to develop PsA, and even among those who do develop the arthritis, this can occur at different times. The taskforce also stress the importance of being able to identify specific risk factors for PsA and how these could influence the choice of treatment, which is crucial given that some systemic psoriasis treatments might reduce the risk of transitioning to PsA.
The 10 points highlight that arthralgia, together with abnormalities seen on ultrasound or magnetic resonance imaging scans, represent key elements of subclinical PsA that could serve as short-term predictors. Additionally, the more traditional risk factors for PsA – such as psoriasis severity, obesity and nail involvement – can be seen as more long-term disease predictors.
EULAR suggests standard naming to define the three distinct stages relevant to the prevention of PsA: people with psoriasis at higher risk of PsA, subclinical PsA and clinical PsA. This, the EULAR group felt, was important because in other inflammatory rheumatic musculoskeletal diseases, such as rheumatoid arthritis, the clinical onset is usually preceded by a preclinical phase encompassing arthralgia and immunological or imaging abnormalities, but without a clinical diagnosis.
A definition for early psoriatic arthritis was proposed by EULAR based on the development of joint swelling as a clinical outcome measure for trials of PsA prevention.
EULAR believes that the points to consider will help to define the clinical and imaging features of those with psoriasis that raise the index of suspicion for progression to PsA. Furthermore, these points could be used to identify people who could benefit from a therapeutic intervention to delay or prevent PsA.
An additional and important practice issue, is that clinicians inform patients with psoriasis about the risk of developing PsA and encourage them to report any joint-related symptoms to facilitate early diagnosis. Previous studies have shown that even a diagnostic delay as short as six months can lead to significantly more severe radiographic joint damage, worse physical function and decrease the changes of therapeutic success
3rd December 2021
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28th June 2021
The European Alliance of Associations for Rheumatology (EULAR) is the organisation that represents the people with arthritis/rheumatism, health professions in rheumatology and scientific societies of rheumatology of all the European nations. With immune mechanisms clearly involved in the evolution of more severe COVID-19, there is a potentially important role for immunotherapy in those infected with the virus. As a result, EULAR convened a task force to develop overarching principles (OPs) and points to consider (PtC) on the pathophysiology of COVID-19 from a rheumatological perspective through a systematic review of the available evidence. The task force included 24 members from 8 different countries and comprised rheumatologists, translational immunologists, haematologists, paediatric rheumatologists and a patient representative. Based on the evidence from the literature, a series of statements were prepared and circulated to members, discussed and voted on. Initially EULAR sought at least 75% agreement on statement wording from members but where this did not occur, refinements were made and the revised statement re-circulated and the accepted level of acceptance was set at 67% for this second round.
The task force defined two overarching principles. The first was that the phenotype of COVID-19 infection is heterogenous and ranged from asymptomatic to lethal disease as a result of multi-organ failure. The second highlighted the need for different treatment approaches to manage an infection and that these were required at different stages of the disease.
The task force also approved 14 PtC, with a view to offering guidance on the management COVID-19 with immunotherapy. Six of the PtC covered aspects of the pathophysiology of COVID-19 with the remainder discussing the use of immunotherapy. For example, it was recognised that while cellular and humoral immune responses to COVID-19 were highly variable in patients, there was insufficient evidence to associate these differing responses directly with patient outcomes. The first PtC for immunotherapy noted the absence of evidence supporting a role for this treatment modality among non-hospitalised patients, or for the value of initiating such treatment. In contrast, given the evidence on oral corticosteroids, there was a recommendation to use these drugs (in particular dexamethasone and which has the strongest evidence), in patients receiving supplemental oxygen, non-invasive or mechanical ventilation. While the evidence base continued to change rapidly, another PtC was that it was still inappropriate to offer a formal recommendation for the routine use of tocilizumab in hospitalised COVID-19 patients requiring either supplemental oxygen, non-invasive or mechanical ventilation. The final PtC was that there was a lack of evidence to recommend the use of immunomodulators including convalescent plasma, interferon kappa, interferon beta, lenzilumab, cyclosporin or canakinumab.
An important caveat with the EULAR document is that it is not intended to undermine or override local regulations or guidelines produced by bodies such as the World Health Organization. Rather the purpose is to provide recommendations of good practice to help clinicians analyse their own therapeutic strategy and inspire change were appropriate. The authors concluded that given how knowledge around COVID-19 changes quickly, these PtCs will be updated as and when appropriate.
Aluno A et al. EULAR points to consider on pathophysiology and use of immunomodulatory therapies in COVID-19. Ann Rheum Dis 2021; 80(6): 698-706