Psoriatic Arthritis and Connection to Diet

Psoriatic Arthritis and Connection to Diet

1. 1. Psoriatic Arthritis and Diet:an Individualized ApproachDr. Alexander Shikhman MD, PhD, FACR Institute for Specialized Medicine.
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3. 2. Psoriatic Arthritis Inflammatory joint disease found in up to 30% of patients with psoriasis Stiffness, pain, swelling and tenderness of the joints and surrounding ligaments and tendons Early recognition, diagnosis and treatment can help prevent progressive joint involvement and damage Skin symptoms usually appear before joint symptoms, but not always.

1. 3. Psoriatic ArthritisSymptoms to be aware of: Back pain/stiffness Pain in heel or bottom of foot Morning stiffness lasting longer than 30 minutes Generalized fatigue Reduced range of motion Swollen fingers and/or toes
2. 4. Psoriatic ArthritisIf you have psoriasis and are experiencing any symptomsof psoriatic arthritis, it is a good idea to: Tell your health care provider Consider seeing a rheumatologist Not wait for your symptoms to get worse before seeking medical advice and/or treatment

1. 5. Psoriatic Arthritis is a Part of Spondyloarthropathies Ankylosing Spondylitis Reactive arthritis (Reiters syndrome) Enteropathic spondylitis or spondylitis associated with inflammatory bowel disease (including Crohns disease and ulcerative colitis) Psoriatic arthritis Isolated acute anterior uveitis Undifferentiated spondyloarthropathy (USpA)
2. 6. Psoriatic Arthritis is a Part of SpondyloarthropathiesThe hallmark of thespondyloarthropathies, includingpsoriatic arthritis, is theinflammatory process affectingthe junction betweenligaments/tendons and theanchor bone called enthesitis
3. 7. Genetics of Psoriatic ArthritisHigh prevalence of:HLA B27 (subtypes B*2701-2759)HLA DQ8.1 (DQA1*0301:DQB1*0302)
4. 8. Diagnosing Psoriatic Arthritis There is no single test to diagnose psoriatic arthritisTypically, the diagnosis of psoriatic arthritis is based on acombination of: Patient’s history Physical examination Imaging of the joints (x-rays, ultrasound, MRI etc) Laboratory test results
5. 9. Subtypes of Psoriatic Arthritis Asymmetrical mono- and oligoarticular arthritis (30-50% of cases) is the most common presentation of psoriatic arthritis Dactylitis presents as the so- called "sausage digit", diffuse swelling of the entire digit likely due to a combination of both arthritis and tenosynovitis.
7. 10. Subtypes of Psoriatic ArthritisSymmetrical polyarticular arthritis(20-40% of cases) is the secondmost common form of psoriaticarthritis
8. 11. Subtypes of Psoriatic Arthritis Distal interphalangeal (DIP) joint involvement (20-30% of cases) is nearly always associated with nail manifestations Nail involvement may be manifested as pitting, ridging, separation from the nail bed (onycholysis) or yellow-orange discoloration ("oil drop" sign)
9. 12. Subtypes of Psoriatic Arthritis Axial arthritis (20-30% of cases) may be different in character from ankylosing spondylitis, the prototypical HLA-B27-associated spondyloarthropathy It may present as sacro-iliitis, which may be asymmetrical and asymptomatic, or spondylitis, which may occur without sacro-iliitis and may affect any level of the spine in "skip" fashion
10. 13. Subtypes of Psoriatic Arthritis Arthritis mutilans (5% of cases) is characterized by resorption of the phalangeal bones
11. 14. Psoriatic Arthritis: Satellite Problems Extra-Cutaneous and Overlapping ProblemsArticular Manifestations  Conjunctivitis  Gout  Uveitis  Pseudogout (calcium pyrophosphate deposition  Aortitis (inflammation of aorta) disease)  Pulmonary fibrosis
12. 15. Psoriasis, Psoriatic Arthritis and InfectionTHE FOLLOWING INFECTIOUS AGENTS HAVE BEEN ASSOCIATED WITH ACTIVATION OF PSORIASIS AND PSORIATIC ARTHRITIS  Streptococcus pyogenes group A  Candida albicans  Helicobacter pylori  Atypical mycobacteria  Mycoplasma pneumonia  Human immunodeficiency virus (HIV)  Hepatitis C

1. 16. Psoriasis, Psoriatic Arthritis and Streptococcal Infection Early studies on T cells in the skin revealed the presence of oligoclonal T-cells which could indicate the presence of a common antigen as a major target of the psoriatic immune response. HLA-Cw*-0602 protein product binds peptide motifs that are shared between the M proteins of Streptococci and the keratins K16 and K17 in the skin. This provides a mechanism for psoriasis where Streptococcal infection leads to T cell activation.
2. 17. Treatments for Psoriatic Arthritis Symptomatic Therapy Nonsteroidal anti-inflammatory drugs (NSAIDs) Over-the-counter (OTC) medications such as aspirin, naproxen and ibuprofen Prescription strength products (diclophenac, indomethacin, sulindac etc)
3. 18. Treatments for Psoriatic Arthritis Disease-modifying Antirheumatic Drugs(DMARDs) may relieve more severe symptoms and attempt to slow orstop joint/tissue damage and the progression of psoriatic arthritis. Methotrexate (oral and injection) Leflunomide (oral) Sulfasalizine (oral)
4. 19. Treatments for Psoriatic ArthritisBiologics approved by FDA for psoriatic arthritis:Etanercept (Enbrel®) Administered as a self injection once or twice weeklyAdalimumab (Humira®) Administered as a self injection with a pre-filled syringe typically once every other weekGolimumab (Simponi®) Administered as a self injection once a monthInfliximab (Remicade®) Administered as a self injection once or twice weekly
5. 20. Most Advanced Drugs in Pipeline for Psoriatic Arthritis Name Sponsor Mechanism Route Development phase Apremilast Celgene Anti- Oral III inflammatory (PDE4 inihibitor) Cimzia UCB TNF blocker Injecta III (Certolizumab) ble Tofacitinib Pfizer Anti- Oral III inflammatory (JAK3 inhibitor) Stelara Centocor IL-12/-23 Injecta III (Ustekinumab) blocker ble Secukinumab Novartis IL-17 blocker Injecta II (AIN457) ble
6. 21. Psoriasis, Psoriatic Arthritis and Diet Generic ApproachAvoid  alcohol  refined carbohydrates  foods high in saturated fats  processed foods  gluten, dairy products, citrus, eggs, cornRestrict  red meat consumptionConsume  fresh fruits and vegetables  moderate amounts of protein from fish and fowl  fiber
7. 22. Psoriasis, Psoriatic Arthritis and Diet Individualized Approach There are various diagnostic systems focused on determining of food intolerances and food allergies:Detection of Food Specific Detection of Food Specific Cell Antibodies ResponsesBLOOD  Food based neutrophil activation Serum IgG Serum IgG4 Nontraditional Screening Systems Serum IgE  Electrodermal screening  VAS reflex based screeningSALIVA  Applied kinesiology based screening Salivary IgA
8. 23. Psoriasis, Psoriatic Arthritis and Diet Individualized Approach LAB: Institute for Specialized Medicine IgG4 Food Intolerance Screen (FIS-20) RESPONSE 0 - negative 1 - borderline 2 - mild 3 - moderate 4 - severe 0 1 2 3 4
9. 24. Psoriasis, Psoriatic Arthritis and Diet Individualized ApproachInstitute forSpecializedMedicine:ElectrodermalScreening
10. 25. Psoriasis, Psoriatic Arthritis and Diet Individualized Approach Most of the systems available for food intolerance testing have specificity around 75-80% Introduction of overlapping systems significantly increases reliability of the results The ultimate answer is based on foods elimination with their subsequent reintroduction (challenge test)
11. 26. Psoriasis, Psoriatic Arthritis and Food Supplements Commonly Used Remedies Orphan Remedies Omega-3 polyunsaturated fatty  Sea cucumber extract acids  Indigo extract Black currant seed oil Vitamin D3 - do not use with  Oregon grape (Mahonia Calcipotriene (Dovonex) aquifolium) extact Calcium  Yucca Schidigera extract Turmeric  Coleus forskohlii Boswellia Devil’s claw N-acetylglucosamine Probiotics

1. 27. Psoriasis and Heart Attack Recent studies show that psoriasis, in and of itself, can cause cardiovascular risk The greater the psoriasis severity, the greater the risk Controlling inflammation associated with psoriasis and psoriatic arthritis shows promising results for reducing cardiovascular risk
2. 28. Atherosclerosis and Other Vascular Diseases Psoriasis is associated with increased risk of:  Ischemic heart disease - 78%  Cerebrovascular disease - 70%  Peripheral vascular disease - 98% * after controlling for age, sex, hypertension, diabetes mellitus, dyslipidemia, and tobacco
3. 29. Possible Causes for Increased Risk of Heart Attack in Psoriasis Uncontrolled inflammation leading to blood vessel dysfunction, altered blood lipids and vascular disease The use of drugs such as corticosteroids, acitretin, and cyclosporine that alter blood lipid levels The increased prevalence other risk factors: obesity, hypertension.