SlideShare ist ein Scribd-Unternehmen logo
1 von 50
Downloaden Sie, um offline zu lesen
Tutorial presentation

Psoriatic arthropathy

Moderator:- Dr. Deepak K.
Mathur
INTRODUCTION TO PSORIATIC ARTHRITIS (PSA)









Chronic progressive, inflammatory disorder of the joints and skin1
 Characterized by osteolysis and bony proliferation1
 Clinical manifestations include dactylitis, enthesitis,
osteoperiostitis, large joint oligoarthritis, arthritis mutilans,
sacroiliitis, spondylitis, and distal interphalangeal arthritis1
PsA is one of a group of disorders known as the
spondyloarthropathies2
Males and females are equally affected3
PsA can range from mild nondestructive disease to a severely
rapid and destructive arthropathy3
 Usually Rheumatoid Factor negative3
Radiographic damage can be noted in up to 47% of patients at a
median interval of two years despite clinical improvement with
standard DMARD therapy4
1Taylor

WJ. Curr Opin Rheumatol. 2002;14:98–103.
1Taylor
P. Curr OpinWJ. Curr Opin Rheumatol. 2002;14:98–103.
Rheumatol. 2004;16:366–370.
2Mease P. Curr Opin Rheumatol. 2004;16:366–370.
3Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511–1522.
43Brockbank J,Rheumatology. 2003;42:1460–1468.
Kane D, et al. et al. Exp Opin Invest Drugs. 2000;9:1511–1522.
4Kane D, et al. Rheumatology. 2003;42:1460–1468.
2Mease
SPONDYLOARTHRITIS, PSORIASIS AND PSA
Spondyloarthritis (SpA)

The prevalence of SpA is comparable to that of RA (0.5–1.9%)1,2
Psoriasis (Pso)

Psoriasis affects 2% of population
Juvenile SpA
3

7% to 42% of patients with Pso will develop arthritis

Undifferentiated
SpA (uSpA)
PsA
Ankylosing
spondylitis (AS)

Arthritis

Psoriatic Arthritis
Reactive
associated with
arthritis
IBD

A chronic and inflammatory arthritis in association with skin psoriasis4

Usually rheumatoid factor (RF) negative and ACPA negative5
 Distinct from RA

Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies
 Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail
psoriasis4

1Rudwaleit

RA: Rheumatoid arthritis

M et al. Ann Rheum Dis 2004;63:535-543; 2Braun J et al. Scand J Rheumatol 2005;34:178-90;
3 Fitzgerald ―Psoriatic Arthritis‖ in Kelley’s Textbook of Rheumatology, 2009;
4Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77–i84. doi:10.1136/ard.2010.140582;
5Pasquetti et al. Rheumatology 2009;48:315–325
PSORIATIC ARTHRITIS

ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994.
Data on file, Centocor, Inc.
EPIDEMIOLOGY OF PSA
•

Recent review undertaken to 20061,2
− Incidence



Europe+North America: 3 to 23.1 cases/105
Japan
0.1 case/105

− Prevalence



•

Europe+North America 20 and 420 cases/105
Japan
1 case/105

Population-based study/Minnesota (CASPAR criteria)2,3
− Incidence


7.2 cases/105 (men 9.1, female 5.4)

− Prevalence


158 cases/105

The prevalence of PsA is assumed to be larger than expected, since
enthesitis associated with PsA can develop without symptoms or
signs that are recognizable by patients themselves or the physicians4
1

Alamos et al. J Rheumatol 2008;35:1354-8;
F et al. J Rheumatol 2009;36:361-7;
3Editorial by Chaudran. J Rheumatol 2009;36:213-5;
4Takata et al. J Dermatol Sci. 2011 Nov;64(2):144-7
2Wilson
ETIOLOGY




Genetic Factors
Immunologic Mechanisms
Environmental




Trauma – Koebner phenomenon: psoriatic lesions arising
at site of trauma (24-52%); development of PsA after
trauma to joint.
Bacterial infections - association between guttate
psoriasis and streptococcal pharyngitis; up to 30% of PsA
synovial tissue-derived T cells proliferate following
exposure to group A strep
GENETIC FACTORS
Has been known to occur in families
 Up to 40% psoriasis or PsA have a family
history in first degree relative
 The disease is 50 times more likely to occur
in first degree relative than controls
 Tends to be concordant among monozygotic
twins more commonly than dizygotic

GENETICS AND HLA ANTIGENS








Concordance rate monozygotic twins of 35-70%, 1220% for dizygotic twins.
HLA-B27 in the presence of HLA-DR7, HLA-DQ3 in
the absence of HLA-DR7, and HLA-B39 are predictors
for disease progression, HLA-B22 is protective.
HLAB27 less than AS or Reiter’s; some psoriasis and
SpA are HLA B27 (-)
PsA and HLA B27 who do not have SpA
Some patients with HLA DR4: PsA with polyarthritis
ROLE OF TNF
Released predominantly by cells of the
monocyte/macrophage lineage
 Accumulation of T-cells, infiltration of
synovium: TNF-mediated production of
factors that attract T-cells – monocyte
chemoattractant protein-1 and macrophage
inflammatory protein 3 alpha
 Induces lymphocyte and neutrophil migration
into synovium

TNF IN PSA










High levels of TNF-α in PsA synovium
Marked upregulation of TNF-α in PsA synovial
membrane
Inflammation of synovium, enthesis and bone
TNF-α transgenic mice – bone destruction
Promotes release of matrix-degrading
metalloproteinases
Enhances secretion of pro-inflammatory cytokines
(IL-1, IL-6, IL-8)
Potentiates osteoclastic bone resorption
DIFFERENTIAL DIAGNOSIS


Rheumatoid Arthritis
Symmetric
 PIP, MCP, not distal
 Ulnar deviation,
swan neck
deformities
 Rheumatoid
nodules




Ankylosing Spondylitis
Strong HLA B27
association
 Male predominance
 Axial skeletal
involvement –
sacroilitis
 Bamboo spine
 Schober test
demonstrating limited
flexion


Uptodate.com
DIFFERENTIAL DIAGNOSIS


Reactive Arthritis Bowel
 Inflammatory
Disease Associated
 LE arthritis



 weeks after an
1-4 Crohn’s
infection
 LE distribution
Infectious agents:

Shigella
 Salmonella
 Yersinia
 Campylobacter
 Chlamydia






Triad: urethritis,
conjunctivitis, arthritis
Keratoderma
Blennorhagicum
AAFP
How to diagnose PsA?

CLASSIFICATION CRITERIA OF PSA
CLASSICAL DESCRIPTION OF PSA USING THE
DIAGNOSTIC CRITERIA OF MOLL AND WRIGHT


Including 5 clinical patterns:







Asymmetric mono-/oligoarthritis (~30% [range 12-70%])1-4
Symmetric polyarthritis (~45% [range 15-65%])1-4
Distal interphalangeal (DIP) joint involvement (~5%)1
Axial (spondylitis and Sacroiliitis) (HLA-B27) (~5%)1,3
Arthritis Mutilans (<5%)1,3

• However patterns may change over time and are therefore not useful for
classification 5
HLA: Human leucocytes antigen

References see notes
ASYMMETRICAL OLIGOARTICULAR ARTHRITIS












MC type (70%)
Asymmetrical similar
to low grade gout.
Sausage like swelling
of one or more digit
(dactylitis).
A large joint, such as
the knee, is also
commonly involved.
Usually, <5 joints are
affected at any one
time.
Enthesitis
Flexor sheath
synovitis
HALLMARK CLINICAL FEATURES IN PSA

P so ria tic A rth ritis

D a ctylitis

E n th e sitis

Ritchlin C. J Rheumatol. 2006;33:1435–1438.
Helliwell PS. J Rheumatol. 2006;33:1439–1441.
DACTYLITIS
• Diffuse swelling of a digit may be acute, with painful
inflammatory changes, or chronic wherein the digit remains
swollen despite the disappearance of acute inflammation1
• Also referred to as
―sausage digit‖1
• Recognized as one
of the cardinal
features of PsA,
occurring in up
to 40% of patients1,2
• Feet most commonly
affected1
• Dactylitis involved
digits show more
radiographic damage1

ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994.
1Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190.
2Veale D, et al. Br J Rheumatol. 1994;33:133–38.
DEFINITION OF ENTHESITIS
 Entheses

are the regions at
which a tendon, ligament, or
joint capsule attaches to
bone1
 Inflammation at the
entheses is called enthesitis
and is a hallmark feature of
PsA1,2
 Pathogenesis of enthesitis
has yet to be fully
elucidated2
 Isolated peripheral
enthesitis may be the only
rheumatologic sign of PsA in
a subset of patients3
1McGonagle

D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60.
2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343.
3Salvarani C. J Rheumatol. 1997;24:1106–1140.
SYMMETRICAL POLYARTHRITIS




-

-

-

Rheumatoid like pattern.
15%
Hands, wrists, ankles, and feet
may be involved.
D/D from RA by
DIP joint involvement,
Morning stiffness
Fusiform deformity
Wind swept deformity
Relative asymmetry,
Subcutaneous nodules absent.
RF negative.
Milder, with less deformity.
DISTAL INTERPHALANGEAL ARTHROPATHY






Classical form
Less common 16%
Involvement of the nail with significant inflammation of the
paronychia and swelling of the digital tuft may be
prominent,
30 pits with inflammatory arthritis of DIP joints considered
diagnostic.
Psoriatic arthritis involving the distal phalangeal joint.
ARTHRITIS MUTILANS









Rare form
1-5%
Some reports suggest up to 16% of patients.
Resorption of bone (osteolysis), with dissolution of the
joint, is observed as the "pencil-in-cup" radiographic
finding and leads to redundant, overlying skin with a
telescoping motion of the digit.
This "opera-glass hand" is M>F and is more frequent
in early-onset disease.
ARTHRITIS MUTILANS, A TYPICALLY
PSORIATIC PATTERN OF ARTHRITIS,
WHICH IS ASSOCIATED WITH A
CHARACTERISTIC "PENCIL-IN-CUP"
RADIOGRAPHIC APPEARANCE OF
DIGITS.

Arthritis mutilans (ie,
"pencil-in-cup"
deformities).
SPONDYLITIS WITH OR WITHOUT SACROILIITIS



-

-





Affect 5% of patients and has a male predominance.
Can occur in conjunction with other subgroups of PA.
Spondylitis may occurWithout radiologic evidence of sacroiliitis, which
frequently tends to be asymmetrical,
May appear radiologically without the classic
symptoms of morning stiffness in the lower back.
Thus, the correlation between symptoms and
radiologic signs of sacroiliitis can be poor.
Vertebral involvement differs from that observed in AS.





-

-

Vertebrae are affected
asymmetrically, and the
atlantoaxial joint may be
involved with erosion of the
odontoid and subluxation
(with attendant neurologic
complications).
Therapy may limit
subluxation-associated
disability.
Unusual radiologic feature
nonmarginal asymmetrical
syndesmophytes
(characteristic),
paravertebral ossification,
and,
less commonly, vertebral
fusion with disk calcification.

Lateral radiograph of the cervical spine
shows syndesmophytes at the C2-3 and
C6-7 levels, with zygapophyseal joint fusio
PATTERNS MAY CHANGE OVER TIME AND ARE
THEREFORE NOT USEFUL FOR CLASSIFICATION
Clinical subgroups at baseline and follow-up:
Monoarthritis

Monoarthritis

Oligoarthritis

Oligoarthritis

DIP

DIP

Polyarthritis

Polyarthritis

Spondyloarthritis

Spondyloarthritis

Mutilans

Mutilans
No clinical evidence of
joint disease
McHugh et al. Rheum 2003;42:778-783
CASPAR CRITERIA FOR THE CLASSIFICATION OF
PSA



Inflammatory articular disease (joint, spine, or
entheseal)
With 3 points from following categories:
− Psoriasis: current (2), history (1), family history (1)
− Nail dystrophy (1)
− Negative rheumatoid factor (1)
− Dactylitis: current (1), history (1) recorded by a
rheumatologist
− Radiographs: (hand/foot) evidence of juxta-articular new
bone formation



Specificity 98.7%, Sensitivity 91.4%

Taylor et al. Arthritis & Rheum 2006;54: 2665-73
SIGNS AND SYMPTOMS










Morning stiffness lasting >30 min in 50% of patients1
Ridging, pitting of nails, onycholysis – up 90% of patients vs
nail changes in only 40% of psoriasis cases2,3
Patients may present with less joint tenderness than is
usually seen in RA1
Dactylitis may be noted in >40% of patients2,4
Eye inflammation (conjunctivitis, iritis, or uveitis) — 7–33%
of cases; uveitis shows a greater tendency to be bilateral
and chronic when compared to AS2
Distal extremity swelling with pitting edema has been
reported in 20% of patients as the first isolated manifestation
of PsA5
1Gladman

DD. In: Up To Date. Available at: www.uptodate.com. Accessed December 3, 2004.
2Taurog JD. In: Harrison's Online McGrawHill. Available at:
http://www3.accessmedicine.com/popup.aspx?aID=94996&print=yes. Accessed January 2,2005.
3Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844.
4Veale D, et al. Br J Rheumatol. 1994;33:133–38.
5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296.
MAIN FEATURES OF PSA

*Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA
***Spinal disease occurs in 40-70% of PsA patients
Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8
Fitzgerald ―Psoriatic Arthritis‖ in Kelley’s Textbook of Rheumatology, 2009
MAIN FEATURES AND THEIR FREQUENCY

Back involvement (50%)1
Skin Involvement

In nearly 70% of patients,
cutaneous lesions precede
the onset of joint pain, in
20% arthropathy starts
before skin manifestations,
and in 10% both are
concurrent. 6

DIP involvement (39%)2

Nail psoriasis (80%)4, 5
Dactyilitis (48%)3

Enthesopathy (38%)2
DIP: Distal interphalangeal

1Gladman

D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-1468
3 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67
5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6
COMORBIDITIES IN PSA PATIENTS
Ocular inflammation1
(Iritis/Uveitis/ Episcleritis)

IBD2

Pso patients6-8

• Psychosocial burden
• Reactive depression
• Higher suicidal ideation
• Alcoholism


Metabolic Syndrome3-5
• Hyperlipidemia
• Hypertension
• Insulin resistent
• Diabetes
• Obesity
Higher risk of
Cardiovascular disease (CVD)

Nail pitting, transverse depressions,
and subungual hyperkeratosis
1Qieiro

et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355;
et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6:383-392;
7Naldi et al. Br J Dermatol 1992;127:212-217; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319

4Neimann
Staging of psoriatic arthritis
Outcomes measurements

TREATMENT OF PSA
Psoriatic arthropathy
Psoriatic arthropathy
Dosing schedule, monitoring and
side effects of disease modifying drugs
Pharmaceutical treatments for psoriatic arthritis: corticosteroid
Generic Name

Manufacturer U.S.
Trade Name(s)*

How Supplied

Usual Adult Dose

Methyl-prednisolone

Multiple
®
Medrol , Depo®
Medrol , Solu®
Medrol

Acetate - Injectable
IM—20, 40, and 80
mg/ml
Sodium succinate Injectable:
IM—40, 125, and 500
mg, 1 and 2 g vials
Oral:
Tabs—2, 4, 8, 16, and
32 mg

•Acetate:IM—10 to 80
mg every 1 to 2
weeks
•Intra-articular,
intralesional —4 to 80
mg every 1 to 5
weeks
•Sodium
succinate:IM—10 to
80 mg daily
•IV—10 to 40 mg
every 4 to 6 hours; up
to 30 mg/kg every 4
to 6 hours
•Oral:2 to 60 mg in 1
to 4 divided doses to
start, followed by
gradual reduction

Prednisone

Multiple
®
Deltasone ,
®
Sterapred ,
®
LiquiPred

Oral Solution—1 and
5 mg/ml
Tabs—1, 2.5, 5, 10,
20, and 50 mg

Use lowest effective
dose (5–60 mg/day)

Prednisolone

Multiple
®
Orapred ,

Oral Solution/Syrup—
5, 15, and 20 mg/5 ml

Use lowest effective
dose (5 to 7.5

®
Efficacy of drugs in psoriatic arthritis
Indications for biologic agents in psoriatic arthritis
Mechanism of action, dosing schedule and
major risks with the biologic therapies
Generic Name

Manufacturer
U.S. Trade
Name(s)*

Injectable Supply

Usual Adult Dose

Abatacept

Bristol
Myers
Squibb
®
Orencia

250 mg vial

IV—Dosed according to body weight
(<60 kg=500 mg; 60–100 kg=750 mg;
>100 kg=1,000 mg); dose repeated at 2
weeks and 4 weeks after initial dose, and
every 4 weeks thereafter
SQ—may give weight-based IV loading
dose, then 125 mg SQ once weekly

Adalimuma
b

Abbott
®
Humira

40 mg/0.8 ml, 20
mg/0.4 ml prefilled
syringe

SQ—40 mg every other week alone or in
combination with other DMARDs

Anakinra

Amgen
®
Kineret

100 mg/0.67 ml
syringe

SQ—100 mg/day; dose should be
decreased to 100 mg every other day in
renal insufficiency

Certolizuma
a
bPegol

UCB
®
Cimzia

200 mg powder for
reconstitution, 200
mg/ml solution

SQ—initial dose of 400 mg (as 2 SQ
injections of 200 mg), repeat dose 2 and
4 weeks after initial dose; Maintenance
dose is 200 mg every other week (may
consider maintenance dose of 400 every
4 weeks)

Etanercept

Amgen
Pfizer
Immunex
®
Enbrel

50 mg/ml in 25 mg
or 50 mg single
use prefilled
syringe

SQ—50 mg once weekly with or without
MTX
Golimuma
b

Centocor
Ortho
Biotech
®
Simponi

50 mg/0.5
ml syringe

Infliximab

Centocor
Ortho
Biotech
®
Remicade

100 mg in a IV—5 mg/kg at 0, 2 and 6 weeks
20 ml vial
followed by maintenance every 8
weeks thereafter; may be given with
or without MTX

Rituximab

Biogen
Idec /
Genentech
®
Rituxan

100 mg/10
ml and 500
mg/50 ml
vial

Tocilizuma
b

Genentech
/ Roche
®
Actemra ,
RoActemra

80 mg/4 ml, IV—4 mg/kg every 4 weeks; increase
200 mg/10
to 8 mg/kg every 4 weeks based on
ml, 400
clinical response
mg/20 ml
vial

®

SQ—50 mg once per month, alone or
in combination with MTX

IV—1,000 mg IV infusion separated by
2 weeks (one course) every 24 weeks
or based on clinical evaluation, but
not sooner than every 16 weeks
OTHER AGENTS








Several other agents have been tried, including vitaminD3, bromocriptine, peptide T, and fish oils, but their
efficacy remains to be proven.
Antimalarials, particularly hydroxychloroquine
(Plaquenil), are usually avoided in patients with psoriasis
for fear of precipitating exfoliative dermatitis or
exacerbating psoriasis.
However, 2 studies showed that these reactions did not
occur in patients who were treated with
hydroxychloroquine; therefore, this drug is occasionally
used to treat PA.
Systemic corticosteroids are usually avoided because of
possible rebound of the skin disease upon withdrawal.
SURGICAL CARE IN PSORIATIC ARTHRITIS







Arthroscopic synovectomy has been effective in treating
severe, chronic, monoarticular synovitis.
Joint replacement and forms of reconstructive therapy
are occasionally necessary.
Patients in severe pain or with significant contractures
may be referred for possible surgical intervention;
however, high rates of recurrence of joint contractures
have been noted after surgical release, especially in the
hand.








Hip and knee joint replacements have been
successful.
Arthrodesis and arthroplasty have also been used on
joints, such as the thumb PIP joint.
The wrist often spontaneously fuses, and this may
relieve the patient's pain without surgical intervention.
For arthritis mutilans, surgical intervention is usually
directed toward salvage of the hand; combinations of
arthrodesis, arthroplasty, and bone grafts to lengthen
the digits may be used.
CONSULTATIONS AND MONITORING IN PSORIATIC
ARTHRITIS










If the patient's physiatrist feels uncomfortable with
prescribing medications for PA, referral to a
rheumatologist with more experience with these agents
may be advisable.
The physiatrist may then concentrate on functional
restoration of the patient.
Referral to a surgeon should be considered for
appropriate patients.
Children with juvenile PA should be examined by an
ophthalmologist annually to check for the several forms
of eye inflammation usually associated with various
forms of juvenile arthritis.
In addition, consultation with an orthopedic surgeon is
warranted for individuals who may benefit from joint
replacement, arthrodesis, or contracture release.
DIETARY CONSIDERATIONS








For people who have morning stiffness, the optimal
time for taking an NSAID may be after the evening
meal and again upon awakening.
Taking NSAIDs with food can reduce stomach
discomfort.
Any NSAID can damage the mucous layer and cause
ulcers and GI bleeding when taken for long periods.
Cyclooxygenase (COX)–2 selective inhibitors are
associated with a lower prevalence of gastric ulcer
formation.
PHYSICAL THERAPY IN PSORIATIC ARTHRITIS










The rehabilitation treatment program should be
individualized and should be started early in the
disease process. Such a program should consider the
use of the following:
Rest - Local and systemic
Exercise - Passive, active, stretching, strengthening,
and endurance
Modalities - Heat, cold
Orthotics - Upper and lower extremities, spinal
DETERRENCE AND PREVENTION











Lithium and withdrawal from systemic corticosteroids are
well known to cause disease flare-ups.
Other drugs that have been implicated include beta
blockers, antimalarials (although, as previously
mentioned, evidence suggests that hydroxychloroquine
does not exacerbate skin lesions), and NSAIDs.
If skin lesions worsen with an NSAID, switch to a
different family of NSAID.
Prevention includes rest and exercise.
Joint protection, including splints, braces, and other
supports, may be helpful.
No definitive prevention exists, because this is a chronic
disease that can wax and wane.
Thanks

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Ankylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesisAnkylosing spondylitis pathogenesis
Ankylosing spondylitis pathogenesis
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Psoriatic arthritis
Psoriatic arthritis Psoriatic arthritis
Psoriatic arthritis
 
Dermatomyositis
DermatomyositisDermatomyositis
Dermatomyositis
 
Septic arthritis
Septic arthritisSeptic arthritis
Septic arthritis
 
Seronegative spondyloarthropathies
Seronegative spondyloarthropathiesSeronegative spondyloarthropathies
Seronegative spondyloarthropathies
 
Still's disease
Still's diseaseStill's disease
Still's disease
 
Osteoarthritis knee
Osteoarthritis  kneeOsteoarthritis  knee
Osteoarthritis knee
 
Tb spine
Tb spineTb spine
Tb spine
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
 
Seminar approach to joint pain
Seminar approach to joint painSeminar approach to joint pain
Seminar approach to joint pain
 
Systemic sclerosis
Systemic sclerosisSystemic sclerosis
Systemic sclerosis
 
Septic Arthritis
Septic ArthritisSeptic Arthritis
Septic Arthritis
 
Rheumatology
RheumatologyRheumatology
Rheumatology
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritis
 
Ankylosing spondylitis,Causes,symptoms,diagnosis,management
Ankylosing spondylitis,Causes,symptoms,diagnosis,managementAnkylosing spondylitis,Causes,symptoms,diagnosis,management
Ankylosing spondylitis,Causes,symptoms,diagnosis,management
 
SERO-NEGATIVE ARTHRITIS
SERO-NEGATIVE ARTHRITISSERO-NEGATIVE ARTHRITIS
SERO-NEGATIVE ARTHRITIS
 
Psoriatric arthritis
Psoriatric arthritisPsoriatric arthritis
Psoriatric arthritis
 
Polymyalgia rheumatica
Polymyalgia rheumaticaPolymyalgia rheumatica
Polymyalgia rheumatica
 

Andere mochten auch

Psoriasis-The best Presentation
Psoriasis-The best PresentationPsoriasis-The best Presentation
Psoriasis-The best PresentationDr.Shahidul Islam
 
Psoriatic Arthritis and Connection to Diet: an Individualized Approach
Psoriatic Arthritis and Connection to Diet: an Individualized ApproachPsoriatic Arthritis and Connection to Diet: an Individualized Approach
Psoriatic Arthritis and Connection to Diet: an Individualized ApproachIFSMED
 
reactive arthritis
reactive arthritisreactive arthritis
reactive arthritistodam1
 
Seronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSeronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSri Harsha Gutta
 
Approach to case of arthritis
Approach to case of arthritisApproach to case of arthritis
Approach to case of arthritisSarath Menon
 
Rheumatoid arthritis for undergraduates
Rheumatoid arthritis for undergraduatesRheumatoid arthritis for undergraduates
Rheumatoid arthritis for undergraduatesDhananjaya Sabat
 
applied aspects of shoulder joint
applied aspects of shoulder jointapplied aspects of shoulder joint
applied aspects of shoulder jointmrinal joshi
 
Juvenile Idiopathic Arthritis (2012)
Juvenile Idiopathic Arthritis  (2012)Juvenile Idiopathic Arthritis  (2012)
Juvenile Idiopathic Arthritis (2012)Dr Padmesh Vadakepat
 
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...cmid
 
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011Gianfranco Tammaro
 
stroke rehabilitation
stroke rehabilitationstroke rehabilitation
stroke rehabilitationmrinal joshi
 
Psoriasis evidence based treatment
Psoriasis evidence based treatmentPsoriasis evidence based treatment
Psoriasis evidence based treatmentDr Daulatram Dhaked
 
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...QIAGEN
 
Juvenile idiopathic arthritis
Juvenile idiopathic arthritisJuvenile idiopathic arthritis
Juvenile idiopathic arthritisAriyanto Harsono
 
Multiple sclerosis rehab
Multiple sclerosis rehabMultiple sclerosis rehab
Multiple sclerosis rehabmrinal joshi
 

Andere mochten auch (20)

Psoriasis-The best Presentation
Psoriasis-The best PresentationPsoriasis-The best Presentation
Psoriasis-The best Presentation
 
Psoriatic arthritis clinical features & epidemiology.
Psoriatic arthritis clinical features & epidemiology.Psoriatic arthritis clinical features & epidemiology.
Psoriatic arthritis clinical features & epidemiology.
 
Psoriatic Arthritis and Connection to Diet: an Individualized Approach
Psoriatic Arthritis and Connection to Diet: an Individualized ApproachPsoriatic Arthritis and Connection to Diet: an Individualized Approach
Psoriatic Arthritis and Connection to Diet: an Individualized Approach
 
reactive arthritis
reactive arthritisreactive arthritis
reactive arthritis
 
Seronegative arthropathies
Seronegative arthropathiesSeronegative arthropathies
Seronegative arthropathies
 
Spondyloarthropathy
SpondyloarthropathySpondyloarthropathy
Spondyloarthropathy
 
Seronegative Spondyloarthropathies
Seronegative SpondyloarthropathiesSeronegative Spondyloarthropathies
Seronegative Spondyloarthropathies
 
Approach to case of arthritis
Approach to case of arthritisApproach to case of arthritis
Approach to case of arthritis
 
Rheumatoid arthritis for undergraduates
Rheumatoid arthritis for undergraduatesRheumatoid arthritis for undergraduates
Rheumatoid arthritis for undergraduates
 
applied aspects of shoulder joint
applied aspects of shoulder jointapplied aspects of shoulder joint
applied aspects of shoulder joint
 
Juvenile Idiopathic Arthritis (2012)
Juvenile Idiopathic Arthritis  (2012)Juvenile Idiopathic Arthritis  (2012)
Juvenile Idiopathic Arthritis (2012)
 
Cicatricisial alopecia
Cicatricisial alopeciaCicatricisial alopecia
Cicatricisial alopecia
 
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...
Titta giulio diagnosi precoce reumatismo articolare-torino gennaio 2011-14° c...
 
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011
Bizzi Emanuele. Inquadramento delle spondiloartriti. ASMaD 2011
 
stroke rehabilitation
stroke rehabilitationstroke rehabilitation
stroke rehabilitation
 
Psoriasis evidence based treatment
Psoriasis evidence based treatmentPsoriasis evidence based treatment
Psoriasis evidence based treatment
 
Exercise guide 1
Exercise guide 1Exercise guide 1
Exercise guide 1
 
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...
Studying the Adaptive Immune Response - Tools for T & B Cell Research: Host D...
 
Juvenile idiopathic arthritis
Juvenile idiopathic arthritisJuvenile idiopathic arthritis
Juvenile idiopathic arthritis
 
Multiple sclerosis rehab
Multiple sclerosis rehabMultiple sclerosis rehab
Multiple sclerosis rehab
 

Ähnlich wie Psoriatic arthropathy

What further tx in ps a
What further tx in ps aWhat further tx in ps a
What further tx in ps aKailen Tsai
 
Rhematoid arthritis by dr shyam sunder sharma
Rhematoid arthritis by dr shyam sunder sharmaRhematoid arthritis by dr shyam sunder sharma
Rhematoid arthritis by dr shyam sunder sharmadrshyamsundersharma
 
Rheumatoid arthritis
Rheumatoid arthritis Rheumatoid arthritis
Rheumatoid arthritis EDWINjose43
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritisPratap Tiwari
 
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016cardilogy
 
Approach to and recent advances in management of rheumatoid arthritis
Approach to and recent advances in management of rheumatoid arthritisApproach to and recent advances in management of rheumatoid arthritis
Approach to and recent advances in management of rheumatoid arthritisChetan Ganteppanavar
 
Approach to and recent advances in the management of rheumatoid arthritis
Approach to and recent advances in the management of rheumatoid arthritisApproach to and recent advances in the management of rheumatoid arthritis
Approach to and recent advances in the management of rheumatoid arthritisChetan Ganteppanavar
 
Rheumatoid arthritis 2019
Rheumatoid arthritis 2019Rheumatoid arthritis 2019
Rheumatoid arthritis 2019AdesewaPearl
 
rheumatoid arthritis,gout & osteoarthritis
rheumatoid arthritis,gout & osteoarthritisrheumatoid arthritis,gout & osteoarthritis
rheumatoid arthritis,gout & osteoarthritisdr.shameer basha
 
RHEUMATOID ARTHRITIS.pptx
RHEUMATOID ARTHRITIS.pptxRHEUMATOID ARTHRITIS.pptx
RHEUMATOID ARTHRITIS.pptxAmeena Kadar
 
Psoriatic arthropathy
Psoriatic arthropathyPsoriatic arthropathy
Psoriatic arthropathyarnab ghosh
 
RHEUMATOID ARTHRITIS by ershard ali.pptx
RHEUMATOID ARTHRITIS by ershard ali.pptxRHEUMATOID ARTHRITIS by ershard ali.pptx
RHEUMATOID ARTHRITIS by ershard ali.pptxershadali534
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritisDiana Girnita
 
Rheumatoid arthritis.ppt
Rheumatoid arthritis.pptRheumatoid arthritis.ppt
Rheumatoid arthritis.pptKeyaArere
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritisERIC GENERAL
 

Ähnlich wie Psoriatic arthropathy (20)

What further tx in ps a
What further tx in ps aWhat further tx in ps a
What further tx in ps a
 
Inflammatory arthritis an overview
Inflammatory arthritis an overviewInflammatory arthritis an overview
Inflammatory arthritis an overview
 
Inflammatory arthritis an overview
Inflammatory arthritis an overviewInflammatory arthritis an overview
Inflammatory arthritis an overview
 
Rhematoid arthritis by dr shyam sunder sharma
Rhematoid arthritis by dr shyam sunder sharmaRhematoid arthritis by dr shyam sunder sharma
Rhematoid arthritis by dr shyam sunder sharma
 
ra-2013-final.pptx
ra-2013-final.pptxra-2013-final.pptx
ra-2013-final.pptx
 
Rheumatoid arthritis
Rheumatoid arthritis Rheumatoid arthritis
Rheumatoid arthritis
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritis
 
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016
RHEUMATOID ARTHRITIS --DR MAGDI SASI 2016
 
Approach to and recent advances in management of rheumatoid arthritis
Approach to and recent advances in management of rheumatoid arthritisApproach to and recent advances in management of rheumatoid arthritis
Approach to and recent advances in management of rheumatoid arthritis
 
Approach to and recent advances in the management of rheumatoid arthritis
Approach to and recent advances in the management of rheumatoid arthritisApproach to and recent advances in the management of rheumatoid arthritis
Approach to and recent advances in the management of rheumatoid arthritis
 
Rheumatoid arthritis 2019
Rheumatoid arthritis 2019Rheumatoid arthritis 2019
Rheumatoid arthritis 2019
 
rheumatoid arthritis,gout & osteoarthritis
rheumatoid arthritis,gout & osteoarthritisrheumatoid arthritis,gout & osteoarthritis
rheumatoid arthritis,gout & osteoarthritis
 
RHEUMATOID ARTHRITIS.pptx
RHEUMATOID ARTHRITIS.pptxRHEUMATOID ARTHRITIS.pptx
RHEUMATOID ARTHRITIS.pptx
 
Psoriatic arthropathy
Psoriatic arthropathyPsoriatic arthropathy
Psoriatic arthropathy
 
Ra
RaRa
Ra
 
RHEUMATOID ARTHRITIS by ershard ali.pptx
RHEUMATOID ARTHRITIS by ershard ali.pptxRHEUMATOID ARTHRITIS by ershard ali.pptx
RHEUMATOID ARTHRITIS by ershard ali.pptx
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritis
 
Rheumatoid arthritis.ppt
Rheumatoid arthritis.pptRheumatoid arthritis.ppt
Rheumatoid arthritis.ppt
 
Sarcoidosis
SarcoidosisSarcoidosis
Sarcoidosis
 
Rheumatoid arthritis
Rheumatoid arthritisRheumatoid arthritis
Rheumatoid arthritis
 

Mehr von Dr Daulatram Dhaked (20)

Treponema pallidum tutorial
Treponema pallidum tutorial Treponema pallidum tutorial
Treponema pallidum tutorial
 
Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.
 
Physiotherapy in dermatology ppt
Physiotherapy in dermatology pptPhysiotherapy in dermatology ppt
Physiotherapy in dermatology ppt
 
Pruritus targated treatment- a look into future
Pruritus  targated treatment- a look into futurePruritus  targated treatment- a look into future
Pruritus targated treatment- a look into future
 
Ppt scar
Ppt scarPpt scar
Ppt scar
 
Methotrexate
MethotrexateMethotrexate
Methotrexate
 
Melasma treatment
Melasma treatmentMelasma treatment
Melasma treatment
 
Melanocyte culture technique
Melanocyte culture techniqueMelanocyte culture technique
Melanocyte culture technique
 
Leprosy nlep & currents trends
Leprosy nlep & currents trendsLeprosy nlep & currents trends
Leprosy nlep & currents trends
 
Isotretinoin in acne
Isotretinoin in acneIsotretinoin in acne
Isotretinoin in acne
 
Gonorrhoea
GonorrhoeaGonorrhoea
Gonorrhoea
 
Genital ulcer
Genital ulcerGenital ulcer
Genital ulcer
 
Female hair loss
Female hair lossFemale hair loss
Female hair loss
 
Dermal filler sminar
Dermal filler sminarDermal filler sminar
Dermal filler sminar
 
Dapsone, colchicine
Dapsone, colchicineDapsone, colchicine
Dapsone, colchicine
 
Cutaneous features of endocrine diseases
Cutaneous features of endocrine diseasesCutaneous features of endocrine diseases
Cutaneous features of endocrine diseases
 
Cutaneous pseudolymphoma
Cutaneous pseudolymphomaCutaneous pseudolymphoma
Cutaneous pseudolymphoma
 
Clinicl aproch to blistering dissorder
Clinicl aproch to blistering dissorderClinicl aproch to blistering dissorder
Clinicl aproch to blistering dissorder
 
Clinical patterns of adverse drug reactions ppt
Clinical patterns of adverse drug reactions pptClinical patterns of adverse drug reactions ppt
Clinical patterns of adverse drug reactions ppt
 
Cheilitis
CheilitisCheilitis
Cheilitis
 

Kürzlich hochgeladen

Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptxClinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptxraviapr7
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapitolTechU
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptxmary850239
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17Celine George
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfMohonDas
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsEugene Lysak
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRATanmoy Mishra
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17Celine George
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesMohammad Hassany
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptxSandy Millin
 
The Singapore Teaching Practice document
The Singapore Teaching Practice documentThe Singapore Teaching Practice document
The Singapore Teaching Practice documentXsasf Sfdfasd
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICESayali Powar
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxMYDA ANGELICA SUAN
 
Philosophy of Education and Educational Philosophy
Philosophy of Education  and Educational PhilosophyPhilosophy of Education  and Educational Philosophy
Philosophy of Education and Educational PhilosophyShuvankar Madhu
 
CAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxCAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxSaurabhParmar42
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxiammrhaywood
 

Kürzlich hochgeladen (20)

Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptxClinical Pharmacy  Introduction to Clinical Pharmacy, Concept of clinical pptx
Clinical Pharmacy Introduction to Clinical Pharmacy, Concept of clinical pptx
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptx
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptx
 
How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17How to Add a many2many Relational Field in Odoo 17
How to Add a many2many Relational Field in Odoo 17
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdf
 
The Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George WellsThe Stolen Bacillus by Herbert George Wells
The Stolen Bacillus by Herbert George Wells
 
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRADUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
DUST OF SNOW_BY ROBERT FROST_EDITED BY_ TANMOY MISHRA
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17
 
Human-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming ClassesHuman-AI Co-Creation of Worked Examples for Programming Classes
Human-AI Co-Creation of Worked Examples for Programming Classes
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
 
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdfPersonal Resilience in Project Management 2 - TV Edit 1a.pdf
Personal Resilience in Project Management 2 - TV Edit 1a.pdf
 
The Singapore Teaching Practice document
The Singapore Teaching Practice documentThe Singapore Teaching Practice document
The Singapore Teaching Practice document
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICE
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptx
 
Philosophy of Education and Educational Philosophy
Philosophy of Education  and Educational PhilosophyPhilosophy of Education  and Educational Philosophy
Philosophy of Education and Educational Philosophy
 
CAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxCAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptx
 
Prelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quizPrelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quiz
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
 

Psoriatic arthropathy

  • 2. INTRODUCTION TO PSORIATIC ARTHRITIS (PSA)      Chronic progressive, inflammatory disorder of the joints and skin1  Characterized by osteolysis and bony proliferation1  Clinical manifestations include dactylitis, enthesitis, osteoperiostitis, large joint oligoarthritis, arthritis mutilans, sacroiliitis, spondylitis, and distal interphalangeal arthritis1 PsA is one of a group of disorders known as the spondyloarthropathies2 Males and females are equally affected3 PsA can range from mild nondestructive disease to a severely rapid and destructive arthropathy3  Usually Rheumatoid Factor negative3 Radiographic damage can be noted in up to 47% of patients at a median interval of two years despite clinical improvement with standard DMARD therapy4 1Taylor WJ. Curr Opin Rheumatol. 2002;14:98–103. 1Taylor P. Curr OpinWJ. Curr Opin Rheumatol. 2002;14:98–103. Rheumatol. 2004;16:366–370. 2Mease P. Curr Opin Rheumatol. 2004;16:366–370. 3Brockbank J, et al. Exp Opin Invest Drugs. 2000;9:1511–1522. 43Brockbank J,Rheumatology. 2003;42:1460–1468. Kane D, et al. et al. Exp Opin Invest Drugs. 2000;9:1511–1522. 4Kane D, et al. Rheumatology. 2003;42:1460–1468. 2Mease
  • 3. SPONDYLOARTHRITIS, PSORIASIS AND PSA Spondyloarthritis (SpA)  The prevalence of SpA is comparable to that of RA (0.5–1.9%)1,2 Psoriasis (Pso)  Psoriasis affects 2% of population Juvenile SpA 3  7% to 42% of patients with Pso will develop arthritis Undifferentiated SpA (uSpA) PsA Ankylosing spondylitis (AS) Arthritis Psoriatic Arthritis Reactive associated with arthritis IBD  A chronic and inflammatory arthritis in association with skin psoriasis4  Usually rheumatoid factor (RF) negative and ACPA negative5  Distinct from RA  Psoriatic Arthritis is classified as one of the subtypes of spondyloarthropathies  Characterized by synovitis, enthesitis, dactylitis, spondylitis, skin and nail psoriasis4 1Rudwaleit RA: Rheumatoid arthritis M et al. Ann Rheum Dis 2004;63:535-543; 2Braun J et al. Scand J Rheumatol 2005;34:178-90; 3 Fitzgerald ―Psoriatic Arthritis‖ in Kelley’s Textbook of Rheumatology, 2009; 4Mease et al. Ann Rheum Dis 2011;70(Suppl 1):i77–i84. doi:10.1136/ard.2010.140582; 5Pasquetti et al. Rheumatology 2009;48:315–325
  • 4. PSORIATIC ARTHRITIS ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994. Data on file, Centocor, Inc.
  • 5. EPIDEMIOLOGY OF PSA • Recent review undertaken to 20061,2 − Incidence   Europe+North America: 3 to 23.1 cases/105 Japan 0.1 case/105 − Prevalence   • Europe+North America 20 and 420 cases/105 Japan 1 case/105 Population-based study/Minnesota (CASPAR criteria)2,3 − Incidence  7.2 cases/105 (men 9.1, female 5.4) − Prevalence  158 cases/105 The prevalence of PsA is assumed to be larger than expected, since enthesitis associated with PsA can develop without symptoms or signs that are recognizable by patients themselves or the physicians4 1 Alamos et al. J Rheumatol 2008;35:1354-8; F et al. J Rheumatol 2009;36:361-7; 3Editorial by Chaudran. J Rheumatol 2009;36:213-5; 4Takata et al. J Dermatol Sci. 2011 Nov;64(2):144-7 2Wilson
  • 6. ETIOLOGY    Genetic Factors Immunologic Mechanisms Environmental   Trauma – Koebner phenomenon: psoriatic lesions arising at site of trauma (24-52%); development of PsA after trauma to joint. Bacterial infections - association between guttate psoriasis and streptococcal pharyngitis; up to 30% of PsA synovial tissue-derived T cells proliferate following exposure to group A strep
  • 7. GENETIC FACTORS Has been known to occur in families  Up to 40% psoriasis or PsA have a family history in first degree relative  The disease is 50 times more likely to occur in first degree relative than controls  Tends to be concordant among monozygotic twins more commonly than dizygotic 
  • 8. GENETICS AND HLA ANTIGENS      Concordance rate monozygotic twins of 35-70%, 1220% for dizygotic twins. HLA-B27 in the presence of HLA-DR7, HLA-DQ3 in the absence of HLA-DR7, and HLA-B39 are predictors for disease progression, HLA-B22 is protective. HLAB27 less than AS or Reiter’s; some psoriasis and SpA are HLA B27 (-) PsA and HLA B27 who do not have SpA Some patients with HLA DR4: PsA with polyarthritis
  • 9. ROLE OF TNF Released predominantly by cells of the monocyte/macrophage lineage  Accumulation of T-cells, infiltration of synovium: TNF-mediated production of factors that attract T-cells – monocyte chemoattractant protein-1 and macrophage inflammatory protein 3 alpha  Induces lymphocyte and neutrophil migration into synovium 
  • 10. TNF IN PSA        High levels of TNF-α in PsA synovium Marked upregulation of TNF-α in PsA synovial membrane Inflammation of synovium, enthesis and bone TNF-α transgenic mice – bone destruction Promotes release of matrix-degrading metalloproteinases Enhances secretion of pro-inflammatory cytokines (IL-1, IL-6, IL-8) Potentiates osteoclastic bone resorption
  • 11. DIFFERENTIAL DIAGNOSIS  Rheumatoid Arthritis Symmetric  PIP, MCP, not distal  Ulnar deviation, swan neck deformities  Rheumatoid nodules   Ankylosing Spondylitis Strong HLA B27 association  Male predominance  Axial skeletal involvement – sacroilitis  Bamboo spine  Schober test demonstrating limited flexion  Uptodate.com
  • 12. DIFFERENTIAL DIAGNOSIS  Reactive Arthritis Bowel  Inflammatory Disease Associated  LE arthritis    weeks after an 1-4 Crohn’s infection  LE distribution Infectious agents: Shigella  Salmonella  Yersinia  Campylobacter  Chlamydia    Triad: urethritis, conjunctivitis, arthritis Keratoderma Blennorhagicum AAFP
  • 13. How to diagnose PsA? CLASSIFICATION CRITERIA OF PSA
  • 14. CLASSICAL DESCRIPTION OF PSA USING THE DIAGNOSTIC CRITERIA OF MOLL AND WRIGHT  Including 5 clinical patterns:      Asymmetric mono-/oligoarthritis (~30% [range 12-70%])1-4 Symmetric polyarthritis (~45% [range 15-65%])1-4 Distal interphalangeal (DIP) joint involvement (~5%)1 Axial (spondylitis and Sacroiliitis) (HLA-B27) (~5%)1,3 Arthritis Mutilans (<5%)1,3 • However patterns may change over time and are therefore not useful for classification 5 HLA: Human leucocytes antigen References see notes
  • 15. ASYMMETRICAL OLIGOARTICULAR ARTHRITIS        MC type (70%) Asymmetrical similar to low grade gout. Sausage like swelling of one or more digit (dactylitis). A large joint, such as the knee, is also commonly involved. Usually, <5 joints are affected at any one time. Enthesitis Flexor sheath synovitis
  • 16. HALLMARK CLINICAL FEATURES IN PSA P so ria tic A rth ritis D a ctylitis E n th e sitis Ritchlin C. J Rheumatol. 2006;33:1435–1438. Helliwell PS. J Rheumatol. 2006;33:1439–1441.
  • 17. DACTYLITIS • Diffuse swelling of a digit may be acute, with painful inflammatory changes, or chronic wherein the digit remains swollen despite the disappearance of acute inflammation1 • Also referred to as ―sausage digit‖1 • Recognized as one of the cardinal features of PsA, occurring in up to 40% of patients1,2 • Feet most commonly affected1 • Dactylitis involved digits show more radiographic damage1 ACR Slide Collection on the Rheumatic Diseases; 3rd edition. 1994. 1Brockbank J, et al. Ann Rheum Dis. 2005;64:188–190. 2Veale D, et al. Br J Rheumatol. 1994;33:133–38.
  • 18. DEFINITION OF ENTHESITIS  Entheses are the regions at which a tendon, ligament, or joint capsule attaches to bone1  Inflammation at the entheses is called enthesitis and is a hallmark feature of PsA1,2  Pathogenesis of enthesitis has yet to be fully elucidated2  Isolated peripheral enthesitis may be the only rheumatologic sign of PsA in a subset of patients3 1McGonagle D. Ann Rheum Dis. 2005;64(Suppl II):ii58–ii60. 2Anandarajah AP, et al. Curr Opin Rheumatol. 2004;16:338–343. 3Salvarani C. J Rheumatol. 1997;24:1106–1140.
  • 19. SYMMETRICAL POLYARTHRITIS     - - - Rheumatoid like pattern. 15% Hands, wrists, ankles, and feet may be involved. D/D from RA by DIP joint involvement, Morning stiffness Fusiform deformity Wind swept deformity Relative asymmetry, Subcutaneous nodules absent. RF negative. Milder, with less deformity.
  • 20. DISTAL INTERPHALANGEAL ARTHROPATHY     Classical form Less common 16% Involvement of the nail with significant inflammation of the paronychia and swelling of the digital tuft may be prominent, 30 pits with inflammatory arthritis of DIP joints considered diagnostic.
  • 21. Psoriatic arthritis involving the distal phalangeal joint.
  • 22. ARTHRITIS MUTILANS      Rare form 1-5% Some reports suggest up to 16% of patients. Resorption of bone (osteolysis), with dissolution of the joint, is observed as the "pencil-in-cup" radiographic finding and leads to redundant, overlying skin with a telescoping motion of the digit. This "opera-glass hand" is M>F and is more frequent in early-onset disease.
  • 23. ARTHRITIS MUTILANS, A TYPICALLY PSORIATIC PATTERN OF ARTHRITIS, WHICH IS ASSOCIATED WITH A CHARACTERISTIC "PENCIL-IN-CUP" RADIOGRAPHIC APPEARANCE OF DIGITS. Arthritis mutilans (ie, "pencil-in-cup" deformities).
  • 24. SPONDYLITIS WITH OR WITHOUT SACROILIITIS    - -   Affect 5% of patients and has a male predominance. Can occur in conjunction with other subgroups of PA. Spondylitis may occurWithout radiologic evidence of sacroiliitis, which frequently tends to be asymmetrical, May appear radiologically without the classic symptoms of morning stiffness in the lower back. Thus, the correlation between symptoms and radiologic signs of sacroiliitis can be poor. Vertebral involvement differs from that observed in AS.
  • 25.    - - Vertebrae are affected asymmetrically, and the atlantoaxial joint may be involved with erosion of the odontoid and subluxation (with attendant neurologic complications). Therapy may limit subluxation-associated disability. Unusual radiologic feature nonmarginal asymmetrical syndesmophytes (characteristic), paravertebral ossification, and, less commonly, vertebral fusion with disk calcification. Lateral radiograph of the cervical spine shows syndesmophytes at the C2-3 and C6-7 levels, with zygapophyseal joint fusio
  • 26. PATTERNS MAY CHANGE OVER TIME AND ARE THEREFORE NOT USEFUL FOR CLASSIFICATION Clinical subgroups at baseline and follow-up: Monoarthritis Monoarthritis Oligoarthritis Oligoarthritis DIP DIP Polyarthritis Polyarthritis Spondyloarthritis Spondyloarthritis Mutilans Mutilans No clinical evidence of joint disease McHugh et al. Rheum 2003;42:778-783
  • 27. CASPAR CRITERIA FOR THE CLASSIFICATION OF PSA   Inflammatory articular disease (joint, spine, or entheseal) With 3 points from following categories: − Psoriasis: current (2), history (1), family history (1) − Nail dystrophy (1) − Negative rheumatoid factor (1) − Dactylitis: current (1), history (1) recorded by a rheumatologist − Radiographs: (hand/foot) evidence of juxta-articular new bone formation  Specificity 98.7%, Sensitivity 91.4% Taylor et al. Arthritis & Rheum 2006;54: 2665-73
  • 28. SIGNS AND SYMPTOMS       Morning stiffness lasting >30 min in 50% of patients1 Ridging, pitting of nails, onycholysis – up 90% of patients vs nail changes in only 40% of psoriasis cases2,3 Patients may present with less joint tenderness than is usually seen in RA1 Dactylitis may be noted in >40% of patients2,4 Eye inflammation (conjunctivitis, iritis, or uveitis) — 7–33% of cases; uveitis shows a greater tendency to be bilateral and chronic when compared to AS2 Distal extremity swelling with pitting edema has been reported in 20% of patients as the first isolated manifestation of PsA5 1Gladman DD. In: Up To Date. Available at: www.uptodate.com. Accessed December 3, 2004. 2Taurog JD. In: Harrison's Online McGrawHill. Available at: http://www3.accessmedicine.com/popup.aspx?aID=94996&print=yes. Accessed January 2,2005. 3Gladman DD. Rheum Dis Clin N Amer. 1998;24:829–844. 4Veale D, et al. Br J Rheumatol. 1994;33:133–38. 5Cantini F, et al. Clin Exp Rheumatol. 2001;19:291–296.
  • 29. MAIN FEATURES OF PSA *Low levels of RF and ACPA can be found in 5-16% of patients; **To a lesser degree than in RA ***Spinal disease occurs in 40-70% of PsA patients Helliwell PS & Taylor WJ. Ann Rheum Dis 2005;64(2:ii)3-8 Fitzgerald ―Psoriatic Arthritis‖ in Kelley’s Textbook of Rheumatology, 2009
  • 30. MAIN FEATURES AND THEIR FREQUENCY Back involvement (50%)1 Skin Involvement In nearly 70% of patients, cutaneous lesions precede the onset of joint pain, in 20% arthropathy starts before skin manifestations, and in 10% both are concurrent. 6 DIP involvement (39%)2 Nail psoriasis (80%)4, 5 Dactyilitis (48%)3 Enthesopathy (38%)2 DIP: Distal interphalangeal 1Gladman D et al. Arth & Rheum 2007;56:840; 2 Kane. D et al. Rheum 2003;42:1460-1468 3 Gladman D et al. Ann Rheum Dis 2005;64:188–190; 4Lawry M. Dermatol Ther 2007;20:60-67 5Jiaravuthisan MM et al. JAAD 2007;57:1-27; 6Yamamoto Eur J Dermatol 2011;21:660-6
  • 31. COMORBIDITIES IN PSA PATIENTS Ocular inflammation1 (Iritis/Uveitis/ Episcleritis) IBD2 Pso patients6-8 • Psychosocial burden • Reactive depression • Higher suicidal ideation • Alcoholism  Metabolic Syndrome3-5 • Hyperlipidemia • Hypertension • Insulin resistent • Diabetes • Obesity Higher risk of Cardiovascular disease (CVD) Nail pitting, transverse depressions, and subungual hyperkeratosis 1Qieiro et al. Semin Arth Rheum 2002;31:264; 2Scarpa et al. J Rheum 2000;27:1241; 3Mallbris et al. Curr Rheum Rep 2006;8:355; et al. J Am Acad Derm 2006;55:829; 5Tam et al. 2008;47:718; 6Kimball et al. Am J Clin Dermatol 2005;6:383-392; 7Naldi et al. Br J Dermatol 1992;127:212-217; 8Mrowietz U et al. Arch Dermatol Res 2006;298(7):309-319 4Neimann
  • 32. Staging of psoriatic arthritis
  • 36. Dosing schedule, monitoring and side effects of disease modifying drugs
  • 37. Pharmaceutical treatments for psoriatic arthritis: corticosteroid Generic Name Manufacturer U.S. Trade Name(s)* How Supplied Usual Adult Dose Methyl-prednisolone Multiple ® Medrol , Depo® Medrol , Solu® Medrol Acetate - Injectable IM—20, 40, and 80 mg/ml Sodium succinate Injectable: IM—40, 125, and 500 mg, 1 and 2 g vials Oral: Tabs—2, 4, 8, 16, and 32 mg •Acetate:IM—10 to 80 mg every 1 to 2 weeks •Intra-articular, intralesional —4 to 80 mg every 1 to 5 weeks •Sodium succinate:IM—10 to 80 mg daily •IV—10 to 40 mg every 4 to 6 hours; up to 30 mg/kg every 4 to 6 hours •Oral:2 to 60 mg in 1 to 4 divided doses to start, followed by gradual reduction Prednisone Multiple ® Deltasone , ® Sterapred , ® LiquiPred Oral Solution—1 and 5 mg/ml Tabs—1, 2.5, 5, 10, 20, and 50 mg Use lowest effective dose (5–60 mg/day) Prednisolone Multiple ® Orapred , Oral Solution/Syrup— 5, 15, and 20 mg/5 ml Use lowest effective dose (5 to 7.5 ®
  • 38. Efficacy of drugs in psoriatic arthritis
  • 39. Indications for biologic agents in psoriatic arthritis
  • 40. Mechanism of action, dosing schedule and major risks with the biologic therapies
  • 41. Generic Name Manufacturer U.S. Trade Name(s)* Injectable Supply Usual Adult Dose Abatacept Bristol Myers Squibb ® Orencia 250 mg vial IV—Dosed according to body weight (<60 kg=500 mg; 60–100 kg=750 mg; >100 kg=1,000 mg); dose repeated at 2 weeks and 4 weeks after initial dose, and every 4 weeks thereafter SQ—may give weight-based IV loading dose, then 125 mg SQ once weekly Adalimuma b Abbott ® Humira 40 mg/0.8 ml, 20 mg/0.4 ml prefilled syringe SQ—40 mg every other week alone or in combination with other DMARDs Anakinra Amgen ® Kineret 100 mg/0.67 ml syringe SQ—100 mg/day; dose should be decreased to 100 mg every other day in renal insufficiency Certolizuma a bPegol UCB ® Cimzia 200 mg powder for reconstitution, 200 mg/ml solution SQ—initial dose of 400 mg (as 2 SQ injections of 200 mg), repeat dose 2 and 4 weeks after initial dose; Maintenance dose is 200 mg every other week (may consider maintenance dose of 400 every 4 weeks) Etanercept Amgen Pfizer Immunex ® Enbrel 50 mg/ml in 25 mg or 50 mg single use prefilled syringe SQ—50 mg once weekly with or without MTX
  • 42. Golimuma b Centocor Ortho Biotech ® Simponi 50 mg/0.5 ml syringe Infliximab Centocor Ortho Biotech ® Remicade 100 mg in a IV—5 mg/kg at 0, 2 and 6 weeks 20 ml vial followed by maintenance every 8 weeks thereafter; may be given with or without MTX Rituximab Biogen Idec / Genentech ® Rituxan 100 mg/10 ml and 500 mg/50 ml vial Tocilizuma b Genentech / Roche ® Actemra , RoActemra 80 mg/4 ml, IV—4 mg/kg every 4 weeks; increase 200 mg/10 to 8 mg/kg every 4 weeks based on ml, 400 clinical response mg/20 ml vial ® SQ—50 mg once per month, alone or in combination with MTX IV—1,000 mg IV infusion separated by 2 weeks (one course) every 24 weeks or based on clinical evaluation, but not sooner than every 16 weeks
  • 43. OTHER AGENTS     Several other agents have been tried, including vitaminD3, bromocriptine, peptide T, and fish oils, but their efficacy remains to be proven. Antimalarials, particularly hydroxychloroquine (Plaquenil), are usually avoided in patients with psoriasis for fear of precipitating exfoliative dermatitis or exacerbating psoriasis. However, 2 studies showed that these reactions did not occur in patients who were treated with hydroxychloroquine; therefore, this drug is occasionally used to treat PA. Systemic corticosteroids are usually avoided because of possible rebound of the skin disease upon withdrawal.
  • 44. SURGICAL CARE IN PSORIATIC ARTHRITIS    Arthroscopic synovectomy has been effective in treating severe, chronic, monoarticular synovitis. Joint replacement and forms of reconstructive therapy are occasionally necessary. Patients in severe pain or with significant contractures may be referred for possible surgical intervention; however, high rates of recurrence of joint contractures have been noted after surgical release, especially in the hand.
  • 45.     Hip and knee joint replacements have been successful. Arthrodesis and arthroplasty have also been used on joints, such as the thumb PIP joint. The wrist often spontaneously fuses, and this may relieve the patient's pain without surgical intervention. For arthritis mutilans, surgical intervention is usually directed toward salvage of the hand; combinations of arthrodesis, arthroplasty, and bone grafts to lengthen the digits may be used.
  • 46. CONSULTATIONS AND MONITORING IN PSORIATIC ARTHRITIS      If the patient's physiatrist feels uncomfortable with prescribing medications for PA, referral to a rheumatologist with more experience with these agents may be advisable. The physiatrist may then concentrate on functional restoration of the patient. Referral to a surgeon should be considered for appropriate patients. Children with juvenile PA should be examined by an ophthalmologist annually to check for the several forms of eye inflammation usually associated with various forms of juvenile arthritis. In addition, consultation with an orthopedic surgeon is warranted for individuals who may benefit from joint replacement, arthrodesis, or contracture release.
  • 47. DIETARY CONSIDERATIONS     For people who have morning stiffness, the optimal time for taking an NSAID may be after the evening meal and again upon awakening. Taking NSAIDs with food can reduce stomach discomfort. Any NSAID can damage the mucous layer and cause ulcers and GI bleeding when taken for long periods. Cyclooxygenase (COX)–2 selective inhibitors are associated with a lower prevalence of gastric ulcer formation.
  • 48. PHYSICAL THERAPY IN PSORIATIC ARTHRITIS      The rehabilitation treatment program should be individualized and should be started early in the disease process. Such a program should consider the use of the following: Rest - Local and systemic Exercise - Passive, active, stretching, strengthening, and endurance Modalities - Heat, cold Orthotics - Upper and lower extremities, spinal
  • 49. DETERRENCE AND PREVENTION       Lithium and withdrawal from systemic corticosteroids are well known to cause disease flare-ups. Other drugs that have been implicated include beta blockers, antimalarials (although, as previously mentioned, evidence suggests that hydroxychloroquine does not exacerbate skin lesions), and NSAIDs. If skin lesions worsen with an NSAID, switch to a different family of NSAID. Prevention includes rest and exercise. Joint protection, including splints, braces, and other supports, may be helpful. No definitive prevention exists, because this is a chronic disease that can wax and wane.

Hinweis der Redaktion

  1. #### PLEASE DO NOT DELETE CONTENT BELOW THIS LINE ! ############### Presentation &apos;GLM_OPT02_GLM Optimize PsA_r00_05AUG10.ppt&apos; created on Wednesday, 4 August, 2010 ###########Author: GIB1 Purpose: Optimize slide decks QA: 04-Aug-10 Review By: 04-Feb-11Review Type: Scientific, Reference Check, Compliance Review and HCC Office Slide: 9/108 Golimumab-Specific Deck: Yes
  2. #### PLEASE DO NOT DELETE CONTENT BELOW THIS LINE ! ############### Presentation &apos;GLM_OPT02_GLM Optimize PsA_r00_05AUG10.ppt&apos; created on Wednesday, 4 August, 2010 ###########Author: GIB1 Purpose: Optimize slide decks QA: 04-Aug-10 Review By: 04-Feb-11Review Type: Scientific, Reference Check, Compliance Review and HCC Office Slide: 9/108 Golimumab-Specific Deck: Yes
  3. #### PLEASE DO NOT DELETE CONTENT BELOW THIS LINE ! ############### Presentation &apos;GLM_OPT02_GLM Optimize PsA_r00_05AUG10.ppt&apos; created on Wednesday, 4 August, 2010 ###########Author: GIB1 Purpose: Optimize slide decks QA: 04-Aug-10 Review By: 04-Feb-11Review Type: Scientific, Reference Check, Compliance Review and HCC Office Slide: 14/108 Golimumab-Specific Deck: Yes
  4. Two important features of PsA that cause significant problems for PsA patetients. Data to be shared later will show significant benefit of anti-tnf therapy in this regard.
  5. #### PLEASE DO NOT DELETE CONTENT BELOW THIS LINE ! ############### Presentation &apos;GLM_OPT02_GLM Optimize PsA_r00_05AUG10.ppt&apos; created on Wednesday, 4 August, 2010 ###########Author: GIB1 Purpose: Optimize slide decks QA: 04-Aug-10 Review By: 04-Feb-11Review Type: Scientific, Reference Check, Compliance Review and HCC Office Slide: 17/108 Golimumab-Specific Deck: Yes