How to evaluate the disease activity of psoriatic arthritis?

*It is only for medical professionals to read for reference.
It is impossible to give up the evaluation.
Maybe there is a lazy method available! For many rheumatic immune diseases, clinical cure is still the same as the existence of water and moon-visible but elusive
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Therefore, low disease activity has become a goal pursued by doctors and patients
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The question is, how to evaluate disease activity more effectively in clinical practice? Professor Philip Helliwell from the United Kingdom took the disease activity assessment of psoriatic arthritis (PsA) as an example at the Asia Pacific Rheumatism Alliance (APLAR) Annual Meeting in 2021, and introduced how to carry out disease activity assessment in clinical practice
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There are many subtypes, how to evaluate the PsA disease activity? PsA complex clinical manifestations, including the common involvement of the distal interphalangeal joint, the end (toe) osteolysis, damage arthritis, extensive destruction of bone proliferative reaction, sausage (toe), small and large joints and the like dislocation
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Some studies have also divided PsA into single joint and oligoarthritis similar to reactive arthritis with tendinitis, symmetrical polyarthritis similar to rheumatoid arthritis (RA), and ankylosing spondylitis similar to the central axis.
Spine type (spondylitis, sacroiliac arthritis and hip arthritis) dominated by joint disease
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With the support of complex and chaotic clinical manifestations, the clinical evaluation of PsA disease activity needs to cover the following: evaluation of tenderness and swelling of joints; evaluation of skin and nails; evaluation of enthesitis and finger inflammation; evaluation of the spine if necessary; patient description The disease activity, physical function and quality of life.
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seems to be a smooth path of clinical thinking, but when doctors start to put it into practice, they will find that the evaluation of disease activity is full of doubts
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■ Doubt 1: How many joints are evaluated? In RA disease evaluation, doctors often only need to evaluate the tenderness and swelling of 28 joints, while the number of joints that PsA patients need to evaluate may be 44, 66/68, or even 76/78! How many joints are evaluated in patients with different joints? A study showed (unpublished) that in oligoarthritis subjects, whether it was swollen or tender joints, the more joints examined, the fewer involved joints were missed
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For PsA patients with significant enthesitis, inflammation of the Achilles tendon, plantar fascia, elbow joint, costal cartilage joint, patellar ligament and other parts are generally prone to inflammation.
However, there are hundreds of similar parts throughout the body, which is obviously impossible Check all parts
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How to evaluate PsA enthesitis? Professor Helliwell recommends using the Leeds Attachment Inflammation Score (LEI), which only needs to assess the 6 locations of the bilateral external epicondyle of the elbow, the bilateral medial femoral condyle, and the attachment point of the Achilles tendon, which can greatly reduce the evaluation workload
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■ Doubt 2: How to press the joints? When evaluating joint tenderness, the doctor needs to press the corresponding joint, but in practice many people do not know how much effort is required to press the joint
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Some people think that it is necessary to use about 4kg of gravity to press
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4kg or 40N, it seems difficult to accurately grasp the strength, but in fact this strength is equivalent to the strength that can be used to press the nail bed to whiten, so finding a more feasible method in practice will also make PsA disease assessment more efficient
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■ Doubt 3: Is the enthesitis assessment scale reliable? Although there are many evaluation tools for enthesitis of PsA, such as enthesitis clinical score (MASES), the Spine and Joint Research Association of Canada (SPARCC), LEI, IMPACT scores, etc.
, in the evaluation of PsA, LEI and SPARCC The evaluation performance is better than other scales
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Nonetheless, the several scales mentioned have undergone rigorous clinical trial design and practical testing.
In the dimension of reliability, there are still several scales that are worth recommending
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It has been found in practice that these types of scales play a leading role in the assessment of ankylosing spondylitis and peripheral PsA enthesitis.
In practice, measures must be taken according to the disease
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No matter how complicated the assessment is, don’t forget how these subtle details are.
Just a general understanding of the assessment of PsA disease is enough to upset people? Don't be discouraged, many minutiae in PsA disease assessment also need attention! ■ Detail 1: Little pinky/toe inflammation, can’t be ignored.
Studies have pointed out that dactylitis/toe inflammation is very common in patients with PsA, accounting for 57% of patients with polyarticular involvement, and even 45% of patients with non-polyarticular involvement.
Proportion [1]
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Dendritis/toe inflammation often presents as a spindle.
When patients with PsA have acute dactylitis/toe inflammation, it often means that the disease is aggravated, and some researchers believe that this is an independent sign of disease recurrence
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In addition, dactylitis/toe inflammation is also one of the classification diagnostic criteria in the new PsA classification standard (CASPAR)
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In practice, the change in the circumference of the finger/toe caused by dactylitis is not easy to find.
Therefore, the University of Leeds has developed a tool called "Dactylometer" for the measurement of finger/toe circumference, and this tool can also be used Give a definition of joint tenderness
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Figure 1: The manifestations of digit/toe inflammation Figure 2: Dactylometer ■ Detail 2: The disease is abnormal, and there must be something strange.
In some cases, the patient has widespread psoriasis as the main manifestation
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If the condition persists after dermatological treatment, PsA needs to be taken into consideration
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In addition, overweight or other patients can also show PsA characteristics in details, especially those similar to tuberculosis and gout.
The initiator may be the PsA that is not easy to think of
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■ Detail 3: See the big from the small, but keep it simple.
Because of the peculiarities of PsA, skin evaluation is very necessary
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If you want to fully evaluate all skins, it is obviously not easy
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Previously, doctor-patient overall scores (PGA and PtGA) and psoriasis area and severity index (PASI) were recommended skin assessment tools in many literatures, but in reality, these tools are not practical because of their complexity
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Although some researchers believe that if patients with PsA are not fully evaluated, the disease cannot be effectively treated, but a simpler quantitative grading scale (likert scale) is used, which divides skin involvement into non-involved, mildly affected, moderately affected, and severely affected ), it can also generally reflect the condition of skin involvement
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In addition, try to observe the patient's palm and other easy-to-observe places and make a judgment.
These subtle skin involvements may occur in the nails, behind the occiput, tongue, ear canal, gluteal groove and other places that are not easily detectable
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Among them, the manifestations of nail involvement in PsA patients are relatively abundant, such as nail detachment, nail punctate erosion, drop-like change of subnail oil, white nails, and cracked nails
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PsA assessments are very specific, I want them all! So many methods are important for PsA disease assessment, how to choose? Smart scholars tell you: No need to choose, use compound evaluation methods! As mentioned earlier, PsA cannot be effectively treated without an overall assessment
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Therefore, scholars have begun to consider scales or tools for omni-directional and holistic assessment-the compound assessment method, including but not limited to 28 joint disease activity assessment (DAS28), minimum disease activity (MDA), and extremely low disease activity (VLDA), PsA disease activity score (PASDAS), modified psoriatic arthritis disease activity index (DAPSA), and 4 times visual analog pain method (4VAS)
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■ DAS28 Although DAS28 is still used as an assessment tool in many clinical practices of PsA, it contains too few joints, so it is not recommended as an assessment tool for PsA disease activity
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■ MDA/VLDAMDA and VLDA are the outcome indicators or treatment goals of many clinical trials, mainly involving 7 aspects (MDA must meet 5 items, VLDA must meet 7 items): the number of tender joints ≤ 1 (68 in total); swelling Number of joints ≤ 1 (68 in total); PASI ≤ 1 or body surface area ≤ 3%; PGA-VAS ≤ 2 cm; Pain-VAS ≤ 1.
5 cm; Health Assessment Questionnaire (HAQ) ≤ 0.
5 points; number of attachment point tenderness ≤1; this method is both practical and comprehensive, and the evaluation process is still complicated and can be used as appropriate
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■ PASDASPASDAS involves 8 aspects including inflammation index, physical sign score, joint involvement, etc.
The calculation formula is extremely complicated, and the procedure required to collect all the information is complicated, so the clinical practicality is not strong
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■ DAPSADAPSA includes 5 aspects such as 68 joint tenderness, 66 joint swelling, PGA-VAS and inflammation indicators.
It is relatively complicated and time-consuming, and clinical practice is not feasible
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■ 4VAS 4VAS is composed of 4 parts: PGA-VAS, PtGA pain VAS, joint VAS and skin VAS.
Its evaluation effect can compete with complex methods such as PASDAS.
It is currently becoming a popular research object because it is simple and feasible and evaluates efficiency.
High and recommended for clinical practice [2]
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Summary: PsA is a complex disease with numerous clinical manifestations
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Therefore, a reasonable assessment of PsA disease activity requires consideration of every aspect of the definition of PsA in clinical practice, but this expectation obviously reduces the efficiency and feasibility of clinical practice
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If the disease is not assessed as a whole, there is no clear understanding of the disease activity
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Therefore, a simple and feasible "lazy man's method" without sacrificing value and efficiency-the 4VAS method came into being, and it is hopeful that it will emerge in clinical and scientific research in the future
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Experts comment that PsA is one of the spondyloarthropathy with skin lesions and joint lesions as the main clinical manifestations.
The diversity and complexity of its skin manifestations and joint symptoms often make clinical work how to carry out accurate disease activities for such diseases Degree evaluation has become a difficult point
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The past assessment methods for PsA disease activity are very complicated.
For example, the examination and assessment of many joints often takes a lot of time, and it is even prone to missed or misdiagnosed situations
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In actual clinical work, it is indeed unrealistic to allow clinicians who have been robbed of their own skills to perform such a detailed and time-consuming evaluation of patients
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How to simplify disease assessment to a certain extent without increasing the risk of missed diagnosis and misdiagnosis has always been a very challenging topic.
Professor Philip Helliwell from the United Kingdom took the PsA disease activity assessment as an example at the APLAR annual meeting in 2021.
Introduced how to evaluate the disease activity in clinical practice.
It is recommended to use the Leeds Enclosure Inflammation Score (LEI) to evaluate PsA Enclosure Inflammation, which can greatly reduce the evaluation workload.
At the same time, the 4VAS evaluation method is equivalent to its effectiveness.
Other complex methods, simple and efficient, are more conducive to clinical application
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All of these have opened up our clinical thinking, provided more clinical options, and provided references for further optimization or improvement of PsA disease activity methods.
We also hope that there will be more efficient, simpler, and easier-to-use evaluation methods for clinicians in the future.
Widely used in clinical practice
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 Expert Profile: Associate Professor Wu Xin, Associate Chief Physician, Associate Professor, and Postgraduate Tutor of the Department of Rheumatology and Immunology, Shanghai Changzheng Hospital Member and Secretary of the Academic Branch Member of the Shanghai Medical Association Rheumatology and Immunology Physician Branch Member of the Youth Committee of the Shanghai Medical Association Internal Medicine Branch Member of the Shanghai Medical Association Rheumatology Branch Vasculitis Group Deputy Leader of the Psychosomatic Rheumatology Collaboration Group of the Chinese Medical Association Psychosomatic Medicine Branch Member and Secretary The Second Rheumatology Professional Committee of the Cross-Strait Medical and Health Exchange Association.
Member of the Precision Medicine Branch of the Chinese Medical Biotechnology Association.
He studied at the University of Queensland in Australia
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He has successively won the National Natural Science Foundation of China Youth Project, the National Natural Science Foundation of China General Project, the Second Military Medical University "Outstanding Young Scholar" Fund, and the main academic backbone of the 973 project
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Won the Outstanding Speaker Award of the 3rd China-Japan-Korea Rheumatism Summit Forum in the Asia-Pacific region, the first prize of the second and third Shanghai Annual Conference on Rheumatism, the first prize of Shanghai Medical Science and Technology Award, and the first prize of Shanghai Science and Technology Progress Award.
One reference for the award: [1]Helliwell PS,Porter G,Taylor W J.
Polyarticular psoriatic arthritis is more like oligoarticular psoriatic arthritis,than rheumatoid arthritis[J].
Annals of the rheumatic diseases,2007,66(1): 113-117.
[2]Tillett W,FitzGerald O,Coates LC,et al.
Composite measures for routine clinical practice in psoriatic arthritis:testing of shortened versions in a UK multicenter study[J].
The Journal of Rheumatology Supplement,2021, 97:45-49.