What is Spondyloarthritis? What is Psoriatic Arthritis?

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What is Spondyloarthritis? What is Psoriatic Arthritis?

  1. 1. 2011 Juvenile Arthritis Conference Bob Colbert MD, PhD Senior Investigator Chief, Pediatric Translational Research Branch NIAMS/NIH Juvenile Spondyloarthritis and Psoriatic Arthritis
  2. 2. Disclosures: <ul><li>No financial relationships to disclose </li></ul>
  3. 3. Objectives: <ul><li>Provide overview of symptoms, diagnosis, current treatment options and disease-management for Juvenile Spondyloarthritis and Psoriatic Arthritis </li></ul>
  4. 4. What is Spondyloarthritis? What is Psoriatic Arthritis? <ul><li>Spondyloarthritis (SpA) </li></ul><ul><ul><ul><li>Usually involves the back or spine, but does not always cause back pain </li></ul></ul></ul><ul><ul><ul><li>Tender and painful ‘entheses’ </li></ul></ul></ul><ul><ul><ul><li>Patients may have eye and bowel inflammation </li></ul></ul></ul><ul><ul><ul><li>Major long-term problem is excessive bone formation and fusion of the spine </li></ul></ul></ul><ul><li>Psoriatic Arthritis (PsA) </li></ul><ul><ul><ul><li>Psoriasis – rash due to inflammation of the skin </li></ul></ul></ul><ul><ul><ul><li>Sausage digits (dactylitis), nail pitting, arthritis </li></ul></ul></ul>
  5. 5. What is Spondyloarthritis?
  6. 6. Sacroiliac Joints
  7. 7. Dactylitis
  8. 8. Psoriatic Skin Rash
  9. 9. Psoriatic Nail Changes
  10. 10. Eye Inflammation (Acute Anterior Uveitis) <ul><li>Pain </li></ul><ul><li>Redness </li></ul><ul><li>One eye or both eyes </li></ul><ul><li>Photophobia </li></ul><ul><li>Blurred vision </li></ul>
  11. 11. How are JSpA and JPsA diagnosed ? <ul><li>Medical history </li></ul><ul><li>Physical examination </li></ul><ul><li>Laboratory tests of blood </li></ul><ul><ul><li>Autoantibodies - Anti-nuclear antibody (ANA); Rheumatoid factor (RF) </li></ul></ul><ul><ul><li>Markers of inflammation – erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) </li></ul></ul><ul><ul><li>Genetic marker - HLA-B27 </li></ul></ul><ul><li>There are several forms of JIA distinguished by number of joints involved, presence of fever, rash, lab tests </li></ul>
  12. 12. JIA Subtypes Few Joints (less than 5) = Oligoarticular Many Joints (5 or more) = Polyarticular Fever/rash = Systemic SpA (spine) = ERA With Psoriasis = PsA ?
  13. 13. Juvenile Spondyloarthritis (Enthesitis-Related Arthritis) <ul><li>Arthritis and Enthesitis OR Arthritis or Enthesitis </li></ul><ul><li>With two or more of following: </li></ul><ul><ul><li>Sacroiliac tenderness or inflammatory lumbosacral pain </li></ul></ul><ul><ul><li>HLA-B27 </li></ul></ul><ul><ul><li>Family history of HLA-B27-associated disease </li></ul></ul><ul><ul><li>Acute anterior uveitis </li></ul></ul><ul><ul><li>Male, age >7 years </li></ul></ul><ul><li>Exclusions: psoriasis in patient or family, RF, systemic JIA </li></ul>
  14. 14. Juvenile Psoriatic Arthritis <ul><li>Arthritis and Psoriasis OR…. </li></ul><ul><li>Arthritis two features: </li></ul><ul><ul><li>Dactylitis </li></ul></ul><ul><ul><li>Nail changes (pitting or onycholysis) </li></ul></ul><ul><ul><li>Psoriasis in first degree relative </li></ul></ul><ul><li>Exclusions: RF, systemic JIA, classification as another form of JIA </li></ul>
  15. 15. Two Subgroups of JPsA <ul><li>Younger age at onset </li></ul><ul><li>Peak 2-3 years </li></ul><ul><li>More girls, ANA+ </li></ul><ul><li>More like early onset oligo/poly JIA </li></ul><ul><li>More small joint and wrist arthritis </li></ul><ul><li>Older age at onset </li></ul><ul><li>Peak 10-12 years </li></ul><ul><li>Girls = boys </li></ul><ul><li>More enthesitis and axial involvement </li></ul><ul><li>More like SpA </li></ul>
  16. 16. How common is juvenile arthritis ? <ul><li>Occurs in 1 child in every 1,000 each year </li></ul><ul><li>Close to 294,000 children in the US have arthritis or another rheumatic disease </li></ul><ul><li>One of the most common chronic inflammatory diseases of childhood </li></ul>Lawrence RA, et al. , Arth Rheum 1998; 41:778-799 Sacks J et al ., Arth Rheum 2007; 57:1439-1455
  17. 17. How do we treat JIA ?
  18. 18. Management of JIA <ul><li>Goals </li></ul><ul><li>Control/eliminate disease activity – pain and inflammation </li></ul><ul><li>Preserve joint function </li></ul><ul><li>Prevent long-term consequences of disease and therapy </li></ul>
  19. 19. Treatment Pyramid NSAIDS, PT/OT GLUCOCORTICOIDS Methotrexate, Corticosteroid injections Biologics (anti-TNF, anti-IL-1, anti-IL-6) EXP
  20. 20. Management of JIA <ul><li>NSAIDs </li></ul><ul><ul><li>Used frequently but no longer mainstay of therapy </li></ul></ul><ul><ul><li>Naproxen, ibuprofen, tolectin, indomethacin, celebrex, oxaprozin approved for use in children </li></ul></ul><ul><ul><li>Generally well tolerated in children, but not effective enough for majority of patients </li></ul></ul><ul><li>Methotrexate </li></ul><ul><ul><li>Important ‘anchor’ drug known to improve symptoms and modify underlying course of disease; well tolerated </li></ul></ul><ul><ul><li>Most effective when given as a shot - subcutaneously </li></ul></ul><ul><li>Oral steroids </li></ul><ul><ul><li>Low doses may help control disease – should not be used long-term </li></ul></ul><ul><li>Joint Injections </li></ul><ul><ul><li>Long-lasting benefit in significant proportion (triamcinolone hexacetamide) </li></ul></ul><ul><ul><li>Multiple joints often done to quickly squelch disease; often done asleep </li></ul></ul>
  21. 21. Biologics Frequently Used in Juvenile Arthritis <ul><li>Anti-TNF </li></ul><ul><li>Etanercept * (Enbrel) </li></ul><ul><li>Infliximab (Remicade)- also effective for JIA uveitis </li></ul><ul><li>Adalimumab * (Humira) – also effective for JIA uveitis </li></ul><ul><li>Anti-IL-1 </li></ul><ul><li>Anakinra (Kineret; IL-1RA) (approved for CAPS) </li></ul><ul><li>Rilonacept (Arcalyst, IL-1 TRAP) (approved for CAPS) </li></ul><ul><li>Canakinumab (Ilaris; anti-IL-1  ) (approved for CAPS) </li></ul><ul><li>* FDA approved for poly, extended oligo and systemic JIA with poly course disease. </li></ul>
  22. 22. Biologics Frequently Used in Juvenile Arthritis <ul><li>Anti-IL-6 (blocks soluble IL-6 receptor) </li></ul><ul><li>Tocilizumab (Actemra, RoActemra) (recently approved for sJIA) </li></ul><ul><li>CTLA4 Ig (blocks T cell activation) </li></ul><ul><li>Abatacept (Orencia) (approved for poly JIA) </li></ul><ul><li>Anti-CD20 (depletes B cells) </li></ul><ul><li>Rituximab (Rituxan) (case reports effective in poly and systemic JIA) </li></ul><ul><li>Anti-Others </li></ul><ul><li>Anti-IL-17, anti-IL-23/12, anti-IL-22 </li></ul>
  23. 23. Why is it important to do research in children ? To practice evidence-based medicine If we don’t do research, every treatment becomes a poorly controlled experiment
  24. 24. Observational Studies <ul><li>Retrospective chart review </li></ul><ul><ul><li>Often missing data; potential for bias </li></ul></ul><ul><ul><li>Not rigorous; ?quality of data </li></ul></ul><ul><li>Prospective – “registry” – collect specific information on large numbers of patients </li></ul><ul><ul><li>Can be used to collect information on patients treated a specific way, but not randomized </li></ul></ul>
  25. 25. Translational Studies <ul><li>Patient gives one or more samples </li></ul><ul><ul><li>Blood, urine, tissue </li></ul></ul><ul><ul><li>Analysis for biomarkers: RNA, DNA, inflammatory proteins </li></ul></ul><ul><li>Information about the patient is collected at the same time </li></ul><ul><ul><li>Disease characteristics/Medications </li></ul></ul><ul><li>Long-term goal of personalized medicine </li></ul>
  26. 26. Spondyloarthritis
  27. 27. Thank you for your attention! National Institute of Arthritis and Musculoskeletal and Skin Diseases

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