Skip to main content
SpringerLink
Log in

Axial Psoriatic Arthritis

Current Rheumatology Reports Aims and scope Submit manuscript

Cite this article

Abstract

Purpose of Review

To review current understanding of the prevalence, clinical features, outcome measures and recent therapeutic trials in axial psoriatic arthritis (axPsA).

Recent Findings

The prevalence of axPsA is estimated at 40–50%. However, the definition of axPsA remains unclear, therefore these estimates may be inaccurate. Ax PsA appears to be distinct from ankylosing spondylitis in demographic, clinical, genetic and therapeutic features. Because of the lack of widely accepted definition of axPsA it has been difficult to design therapeutic trials for this domain of PsA.

Summary

Several studies have demonstrated the uniquness of axPsA. Few recent trials suggest that therapies that work for peripheral arthritis also work for axPsA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Moll JMH, Wright V. Psoriatic arthritis. Seminars Athritis Rheum. 1973;3:55–78.

    Article  CAS  Google Scholar 

  2. Gladman DD, Shuckett R, Russell ML, Thorne JC, Schachter RK. Psoriatic arthritis - clinical and laboratory analysis of 220 patients. Quart J Med. 1987;62:127–41.

    CAS  PubMed  Google Scholar 

  3. Gladman DD. Axial disease in psoriatic arthritis. Curr Rheumatol Rep. 2007;9:455–60.

    Article  Google Scholar 

  4. •• Chandran V. Psoriatic spondylitis or ankylosing spondylitis with psoriasis: same or different? Curr Opin Rheumatol. 2019;31:329–34 An excellent review of the question posed. Highlights the difficulty in classification of the two conditions.

    Article  Google Scholar 

  5. •• Feld J, Chandran V, Haroon N, Inman R, Gladman D. Axial disease in psoriatic arthritis and ankylosing spondylitis: a critical comparison. Nat Rev Rheumatol. 2018;14:363–71 This is a critical review of the literature addressing the question whether axial disease in psoriatic arthritis is different from that of ankylosing spondylitis and highlights some clinical, imaging, genetic, and therapeutic differences.

    Article  Google Scholar 

  6. Ritchlin CT, Kavanaugh A, Gladman DD, Mease PJ, Helliwell P, Boehncke WH, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68:1387–94.

    Article  CAS  Google Scholar 

  7. •• Feld J, Ye JY, Chandran V, et al. Is axial psoriatic arthritis distinct from ankylosing spondylitis with and without concomitant psoriasis? Rheumatology (Oxford). 2020;59:1340–6 This study was triggered by the literature review noted above which identified cross-sectional studies but no longitudinal studies comparing the axial disease in PsA to that of AS with or without psoriasis. Patients with AS and PsA were followed by the same protocol in a single centre. Axial PsA was clearly different from AS with or without psoriasis suggesting that it is a distinct entity.

    Article  Google Scholar 

  8. van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27:361–8.

    Article  Google Scholar 

  9. Hanly JG, Russell ML, Gladman DD. Psoriatic spondyloarthropathy: a long term prospective study. Ann Rheum Dis. 1988;47:386–93.

    Article  CAS  Google Scholar 

  10. Jadon DR, Sengupta R, Nightingale A, Lindsay M, Korendowych E, Robinson G, et al. Axial disease in psoriatic arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017;76:701–7.

    Article  Google Scholar 

  11. Ikumi K, Kobayashi S, Tamura N, Tada K, Inoue H, Osaga S, et al. HLA-B46 is associated with severe sacroiliitis in Japanese patients with psoriatic arthritis. Mod Rheumatol. 2019;29:1017–22.

    Article  Google Scholar 

  12. •• Yap KS, Ye JY, Li S, et al. Back pain in psoriatic arthritis: defining prevalence, characteristics and performance of inflammatory back pain criteria in psoriatic arthritis. Ann Rheum Dis. 2018;77:1573–7 This study demonstrated that the definition of inflammatory back pain developed for ankylosing spondylitis may not be appropriate for patients with PsA.

    Article  Google Scholar 

  13. Calin A, Porta J, Fries JF, Schurman DJ. Clinical history as a screening test for ankylosing spondylitis. JAMA. 1977;237:2613–4.

    Article  CAS  Google Scholar 

  14. Sieper J, van der Heijde D, Landewé R, et al. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis International Society (ASAS). Ann Rheum Dis. 2009;68:784–8.

    Article  CAS  Google Scholar 

  15. Rudwaleit M, Metter A, Listing J, Sieper J, Braun J. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006;54:569–78.

    Article  Google Scholar 

  16. • Haroon M, Gallagher P, FitzGerald O. Inflammatory back pain criteria perform well in a subset of patients with active axial psoriatic arthritis but not among patients with established axial disease. Ann Rheum Dis. 2019;78:1003–4 This study looked specifically at patients with axial PsA who had spinal pain and in them the inflammatory back pain criteria developed for AS worked.

    Article  Google Scholar 

  17. • Mease PJ, Palmer JB, Liu M, Kavanaugh A, Pandurengan R, Ritchlin CT, et al. Influence of axial involvement on clinical characteristics of psoriatic arthritis: analysis from the Corrona psoriatic arthritis/Spondyloarthritis registry. J Rheumatol. 2018;45:1389–96 In this report from the Corrona registry axial involvement defined by physician without any specific criteria imparted a greater disease burden among patients with PsA.

    Article  Google Scholar 

  18. Aydin AZ, Kucuksahin O, Kilic L, et al. Axial psoriatic arthritis: the impact of underdiagnosed disease on outcomes in real life. Clin Rheumatol. 2018;37:3443–8.

    Article  Google Scholar 

  19. • Nas K, Erkan K, Tekeoglu I, et al. The effect of gender on disease activity and clinical characteristics in patients with axial psoriatic arthritis. Mod Rheumatol. 2020. https://doi.org/10.1080/14397595.2020.1812870This is one of few studies addressing the effect of gender on the expression of axial psoriatic arthritis. It demonstrates that women have more pain and higher scores on patients reported outcomes while men have more severe sacroiliitis.

  20. Benavent D, Plasencia-Rodriquez C, Franco-Gómez K, et al. Axial spondyloarthritis and axial psoriatic arthritis: similar or different disease spectrum? Ther Adv Muscoloskel Dis. 2020;12:1–8.

    Google Scholar 

  21. Liu V, Fong W, Kwan YH, Leung YY. Residual disease burden in axial spondyloarthritis and psoriatic arthritis patients despite low disease activity states in a multi-ethnic Asian population. J Rheumatol. 2020.

  22. • Coates LC, Baraliakos X, Blanco FJ, et al. The phenotype of axial spondyloarthritis: is it dependent on HLA-B27 status? Arthritis Care Res. 2020. This study investigated the phenotype of axial Spondyloarthritis as it relates to HLA-B27. Patients who were HLA-B27 positive had higher radiographic scores than those who were negative.

  23. Gladman DD, Inman R, Cook R, van der Heijde D, Landewé RB, Braun J, et al. International Spondyloarthritis Inter-Observer Reliability Exercise – the INSPIRE Study: I. Assessment of Spinal Measures. J Rheumatol. 2007;34:1733–9.

    PubMed  Google Scholar 

  24. Chandran V, O'shea FD, Schentag CT, et al. Relationship between spinal mobility and radiographic damage in ankylosing spondylitis and psoriatic spondylitis: a comparative analysis. J Rheumatol. 2007;34:2463–5.

    PubMed  Google Scholar 

  25. Wakhlu A, Chandran V, Phumethum V, Shen H, Cook RJ, Gladman D. Comparison between INSPIRE and Domjan method for measuring lumbar lateral flexion in patients with psoriatic arthritis (PsA) and correlation with radiographic damage. Clin Rheumatol. 2019;38:1063–6.

    Article  Google Scholar 

  26. Biagioni B, Gladman DD, Cook RJ. Reliability of radiographic scoring methods in axial psoriatic arthritis. Arthritis Care Res. 2014;66:1417–22.

    Article  Google Scholar 

  27. Ibrahim A, Gladman DD, Thavaneswaran A, Eder L, Helliwell P, Cook RJ, et al. Radiographic scoring instruments have moderate sensitivity but high specificity for detecting change in axial psoriatic arthritis. Arthritis Care Res. 2017;69:1700–5.

    Article  Google Scholar 

  28. Sieper J, Rudwaleit M, Baraliakos X, et al. The assessment of spondyloarthritis international society (ASA) hand book: a guide to assess Spondyloarthritis. Ann Rheum Dis. 2009;68:ii1–44.

    Article  Google Scholar 

  29. Taylor WJ, Harrison AA. Could the Bath ankylosing spondylitis disease activity index (BASDAI) abe a valid measure of disease activity in patients with psoriatic arthritis? Arthritis Rheum (Arthritis Care Res). 2004;51:311–5.

    Article  Google Scholar 

  30. Fernandez-Sueiro JL, Willisch A, Pertega-Diaz S, et al. Validity of the bath ankylosing spondylitis disease activity index for the evaluation of disease activity in axial psoriatic arthritis. Arthritis Care Res. 2010;62:78–85.

    Article  Google Scholar 

  31. Eder L, Chandran V, Shen H, Cook RJ, Gladman DD. Is ASDAS better than BASDAI as a measure of disease activity in Axial Psoriatic Arthritis? Ann Rheum Dis. 2010;69:2160–4.

    Article  Google Scholar 

  32. Kilic G, Kilic E, Nas K, et al. Comparison of ASDAS and BASDAI as a measure of disease activity in axial psoriatic arthritis. Clin Rheumatol. 2015;34:515–21.

    Article  Google Scholar 

  33. Coates LC, Kavanaugh A, Mease PJ, et al. Group for research and assessment of psoriasis and psoriatic arthritis: treatment recommendations for psoriatic arthritis 2015. Arthritis Rheum. 2016;68:1060–71.

    Google Scholar 

  34. Gossec L, Baraliakos X, Kerschbaumer A, de Wit M, McInnes I, Dougados M, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020;79:700–12.

    PubMed  Google Scholar 

  35. • Helliwell PS, Gladman DD, Chakravarty SD, et al. Effects of ustekinumab on spondylitis-associated endpoints in TNFi-naive active psoriatic arthritis patients with physician-reported spondylitis: pooled results from two phase 3, randomised, controlled trials. RMD Open. 2020;6(1):e001149 This analysis of patients including in the PSUMMIT 1 and 2 studies investigating the effect of ustekinumab in PsA demonstrated improvement in spinal endpoint in the subgroup of patients who had axial disease defined by a physician. The study is relevant since it suggests that IL-12/23 inhibition may work in axial PsA although it did not work in AS.

    Article  Google Scholar 

  36. • Helliwell PS, Gladman DD, Poddubnyy D, et al. Efficacy of guselkumab, a monoclonal antibody that specifically binds to the p19-subunit of IL-23, on endpoints related to axial involvement in patients with active PsA with imaging-confirmed sacroiliitis: week-24 results from two phase 3, randomized, double-blind, placebo-controlled studies. Ann Rheum Dis. 2020;79(supplement 1):36 (Submitted for publication). This analysis of patients including in the DISCOVER 1 and 2 studies investigating the effect of guselkumab in PsA demonstrated improvement in spinal endpoint in the subgroup of patients who had axial disease confirmed by imaging. The study is relevant since it suggests that IL-23 p19 inhibition may work in axial PsA although it did not work in AS.

    Article  Google Scholar 

  37. •• Baraliakos X, Gossec L, Poumara E, et al. Secukinumab improves clinical and imaging outcomes in patients with psoriatic arthritis and axial manifestations with inadequate response to NSAIDs: week 52 results from the MAXIMISE trial. Ann Rheum Dis. 2020;79(supplement 1):36 (Submitted for publication). This is the first study designed specifically to assess axial disease in PsA. Although the patient selection was based on physician definition of axial disease, at least half the patients had inflammatory changes on MRI. Both clinical and imaging responses were noted with secukinumab.

    Google Scholar 

Download references

Availability of Data and Material

Not applicable.

Funding

Dr. Gladman’s research is supported by the Krembil Foundation, the Canadian Institutes of Health Research, and the National Psoriasis Foundation.

Author information

Authors and Affiliations

  1. Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, 1E-410B, Canada

    Dafna D. Gladman

Authors
  1. Dafna D. Gladman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dafna D. Gladman.

Ethics declarations

Ethics Approval

Not applicable.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Conflict of Interest

Dr. Gladman has received trial grants and or consulting fees from AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB.

Additional information

Key Points

• Ankylosing spondylitis and axial psoriatic arthritis are both part of the spectrum of spondyloarthritis and have overlapping features but also differ in their genetic, clinical, radiographic, and prognostic characteristics.

• HLA-B*27 occurs less frequently in axial psoriatic arthritis than in ankylosing spondylitis but is a genetic risk factor for both diseases.

• Axial psoriatic arthritis develops at an older age, is less symptomatic, and is associated with distinct radiographic features compared with ankylosing spondylitis.

• The majority of comparative studies to date have had a cross-sectional design, which captures patients at different stages of disease and hampers the true comparison of these two diseases.

• The lack of a universally accepted definition of axial psoriatic arthritis needs to be addressed.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Spondyloarthritis

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gladman, D.D. Axial Psoriatic Arthritis. Curr Rheumatol Rep 23, 35 (2021). https://doi.org/10.1007/s11926-021-00999-8

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11926-021-00999-8

Keywords

search

Navigation