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EVALUARE SI MONITORIZARE INARTROPATIA PSORIAZICA
Codrina Ancuta
MD, PhD, CCDSef lucrari
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§Criterii de diagnostic si clasificare§Domenii de evaluare§Evaluare reumatologica & raspuns terapeutic
§Evaluare dermatologica & raspuns terapeutic§Evaluare functionala§Evaluare imagistica
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CRITERII DE DIAGNOSTIC
§Criterii Moll si Wright§artrita inflamatorie (periferica/ sacroiliita/ spondilita)§prezenta psoriazis§absenta factorului reumatoid
§ Alte seturi criterii: Vasey si Espinoza; McGonagle;Bennett; Fournie
§Criterii ESSG modificate:§durere axiala inflamatorie sau sinovita asimetrica,
predominant membre inferioare
si una din:
§antecedente familiale de psoriazis§psoriazis
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CLASSIFICATION CRITERIA FOR
PSORIATIC ARTHRITIS 2006§Artrita (periferica + entezita, sacroiliita sau
spondilita) 3 luni (3 pcte)
!i minim 3 /5:
§Psoriazis cutanat (în prezent =2, în trecut=1,familial =1)
§Psoriazis unghial tipic (1 pct)
§Factor reumatoid seric (de regul$) absent (1 pct)§Dactilita (în prezent sau ca APP) (1 pct)§radiologic: apozi'ie osoasa juxtaarticulara (artic
mici) (1 pct)
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SUBTIPURI CLINICE APsSUBTIPURI CLINICE APs
• Oligoartrita asimetrica cu dactilita
• Poliartrita simetrica ( AR
• APs clasica interesand IFD de la maini si
picioare
– Afectarea IFD⇔ afectare unghiala
• SA +/- artrita periferica
– Sacroiliita asimptomatica asimetrica
• Artrita mutilans
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GRAPPA (Group for Research and
Assessment of Psoriasis and PsoriaticArthritis)
OMERACT (Outcome Measures inRheumatology)
§set de criterii pentru definirea APs§
validarea si standardizarea instrumentelor deevaluare in APs
§ghiduri terapeutice APs
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DOMENII DE EVALUARE –OMERACT8
REUMATOLOGIC
§articulatii periferice§dactilita
§entezita§afectarea axiala
DERMATOLOGIC
§cutanat
§ungheal
FUNCTIONALCALITATEA VIETII
FATIGABILITATE
RADIOLOGIC
§scor Sharpmodificat§scor eroziuni§pensare spatiu artic
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EVALUARE REUMATOLOGICA§Afectare articulara periferica
§Afectare axiala
§Entezita§Dactilita
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AFECTARE ARTICULARA PERIFERICA
§Numar articulatii afectate(ACR)
• NAD = 78• NAT = 76
§Evaluare globala apacientului
§Evaluare globala medic• scala Likert 0-5
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DACTILITA
§“sausage finger” = “deget in carnat” tenosinovitflexori + sinovita interfalangiene
§ Acuta (tumefactie + roseata + durere) / cronica§Dactilita = 1 articulatie tumefiata!§Cuantificare: 0 = absenta/ 1 = prezenta
§LDI (Leeds Dactylitis Instrument)
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ENTEZITA
§Newcastle Enthesitis Index (NEI) – 66 pct§Maunder Enthesis Index (MEI) – 66 pct; cotat 0–
3 – durere la palpare
§Maastricht Ankylosing Spondylitis EnthesisScore (MASES) - 13 pct§Spondyloarthritis Research Consortium ofCanada (SPARCC) – 8 pct
§Leeds Enthesitis Index (LEI) – 6 pct:
–Epicondilii laterali 2 –Epicondilii mediali 2
–Insertia tendoanelor Achille 2
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EVALUARE RASPUNS LA
TRATAMENT
§PsARC
§ ACR
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PSORIATIC ARTHRITIS RESPONSE
CRITERIA (PsARC) – Clegg 1996criterii
§NAD (0-78)§NAT (0-76)
§Evaluare globalapacient (Likert 0-5)
§Evaluare globalamedic (Likert 0-5)
Ameliorare:
NAD, NAT > 30%
crestere 1 unitate Likert
Inrautatire:
NAD, NAT < 30%
scadere 1 unitate Likert
Raspuns PsARC Ameliorare in 2 din cele 4 crt, macar unul articular
Fara inrautatire in nici unul din criterii
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CRITERII ACR
parametri§NAD (0-78)§NAT (0-76)§durere (SAV 0-10 cm)§evaluare globala pacient§evaluare globala medic§VSH§CRP§HAQ
RASPUNS ACR
20%; 50%; 70%ameliorare NAD, NAT
20%; 50%; 70%
ameliorare in 3 din 5
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REMISIUNE
Criterii Gladman
• NAT = 0
• NAD = 0minim 3 vizite consecutive fara modificare
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EVALUAREA DERMATOLOGICA
§Leziunea cutanata
§Leziunea ungheala
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CRT DE EVALUARE – CUTANAT
PASI
Psoriasis Area and Severity
Index
§aria implicata >3%
§severitate: eritem,induratie, descuamare
§ Intindere pe 4 ariipicioare; trunchi;
brate; cap§scor = 0-72
§> 10 à psoriazis sever
§ Target Lesion Score(aria implicata
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EVALUAREA GLOBALA A PACIENTULUI
STATIC
• F. sever
• Sever • Moderat• Mediu• Minim
• Fara leziune
DINAMICA
• Inrautatire
• Neschimbat• Ameliorare usoara• Ameliorare medie• Ameliorare buna
• Ameliorare excelenta• Fara leziune
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CRT DE EVALUARE – UNGHEAL
NAPSI (Nail Psoriasis Severity Index) – pitting
– leukonichia
– casarea unghiilor plate – spoturi rosii in lunula
– onicoliza
– hiperkeratoza patului unghial
– hemoragii in aschie – decolorarea in picatura de ulei
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EVALUAREA FUNCTIONALA
CALITATEA VIETIIFATIGABILITATE
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EVALUARE FUNCTIONALA SI ACALITATII VIETII
§HAQ = dizabilitate + durere§ HAQ-S (+ domeniu vertebral) (SA)§ HAQ-SK (+ domeniu tegument) (APs)
§Minimal Clinical ImportantDifference (MCID)
§ PR = 0.22§ APs=0.3-0.4§AIMS, AIMS-2§NU BASFI!
§ Psoriatic Arthritis Quality ofLife (PSaQoL) - specific§ European Quality of Life (EQ-
5D)
§ SF-36
§Dermatology Life QualityIdex (DLQI)
§Dermatology Quality of
Life Scale (DQoLS)§Koo-Menter PsoriasisInstrument (KMPI)
§ Psoriasis Disability Index(PDI)
§ Psoriasis Quality of LifeInstrument (PsoriQoL)§ Salford Psoriasis Index
(SPI)
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EVALUARE FUNCTIONALA SI A
CALITATII VIETIIParticipation/ participarea = abilitatea de a
desfasura o activitate + performanta reala
(implicarea pacientului)
boala ) dizabilitate ) participare ) factori
ambientali si personali
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FATIGABILITATEA
§scale simple – SAV§scale multidimensionale (fatigabilitate
fizica + emotionala)§Multidimentional Fatigue Inventory (MFI)§Krup Fatigue Severity Score (FSS)§Functional Assessment of Chronic
Illness Therapy (FACIT)§Multidimensional Assessment of Fatigue(MAF) Index
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EVALUARE RADIOLOGICA
§Scor Sharp modificat
§Scorul eroziunilor §Pensarea spatiului articular
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Modificarile radiologice APs
• 40–50% dintre APs⇒ artrite erozive,
progresive, cu modificari radiologice detectabile
• Severitatea modificarilor radiologice la maini sipicioare a fost comparabila3
• Eroziuni semnificative chiar in stadii precoce4
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Modificari radiologiceModificari radiologice
• Osteopenia juxta-articulara rara
• Pastrarea spatiu articular
• Eroziuni asimetrice – IFD, IFP, MTF, MCF
• Eroziuni mari excentrice
• Rezorbtia falangei distale
• Aspect “pencil-in-cup”
• Periostita
• Tendinta la anchiloza osoasa
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FACTORI PROGNOSTIC NEGATIVFACTORI PROGNOSTIC NEGATIV
• Afectare poliarticulara periferica (artrita mutilans, poliartrita simetrica)• Sindrom biologic inflamator intens la debut
• Factori genetici
• Antecedente heredo-colaterale de APs
• HLA-B27, B39 in prezenta HLA-DR7⇒ SEVER!
• HLA-DQw3, B22 in prezenta HLA-DR7⇒ BUN!
• Pacientii cu forme severe
• Varsta tanara la debutul artritei
• Sexul feminin
• Debutul acut al artritei
• Afectare cutanata extensiva
• Lipsa de raspuns la AINS
• Asocierea cu SIDA (# PR!)
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CONCLUZII
• Domenii de evaluare – reumatologic sidermatologic
• Raspuns la tratament
• Progresie radiologica
• Afectarea functionala
• Criterii/ scoruri specifice + comune/
adaptate• Putine sunt validate